Research
Evaluating a self-directed palliative care learning package for rural aged care workers: a pilot study
Abstract
Aim: To evaluate the effectiveness of a self-directed learning package in increasing palliative care knowledge and confidence for aged care workers in Rural New South Wales, Australia. Method: Participants piloted a palliative care self-directed learning package and completed pre- and post-package knowledge and confidence questionnaires with a 6-month follow-up. The data was then analysed via paired two-tailed T-tests. Results: There was a statistically significant mean increase in knowledge and confidence after completion of the self-directed learning package. Knowledge but not confidence increases were retained after 6 months. Conclusion: Self-directed learning packages can play a part in increasing knowledge and confidence in palliative care for rural aged care workers. Questions remain regarding the role of ongoing support, education, and mentoring. Key words: Palliative care l Education l Self-directed learning l Aged care l Rural care
T
Steven Pitman is Clinical Nurse Consultant, Mercy Health, 550 Poole Street, Albury, 2640 New South Wales, Australia Email: Steven.Pitman@gsahs. health.nsw.gov.au
290
he number of people aged 85 and over in Australia is expected to increase from 0.4 to 1.8 million between 2010 and 2050, effectively increasing demand for aged care services fourfold over the next 40 years (Productivity Commission, 2011). Meeting the increasing demand for adequate care for an ageing population is dependent on having a well resourced and adequately skilled workforce. Research suggests that among the Australian residential aged care workforce in 2007, 19.8% had no formal postsecondary school education (Martin and King, 2008). The high expectations of physically and emotionally demanding work roles with poor remuneration, inadequately defined training, and inadequately defined career pathways create issues of staff retention in the aged care workforce (Productivity Commission, 2011). Rural health professionals often have multiple roles in delivering health care to their communities. This requirement for multi-skilled approaches can be due to minimal access to specialist services, isolation from resource opportunities, and lower capacities of rural infrastructure
(Ricketts, 2005; Fisher and Fraser, 2010; Fragar and Depczynski, 2011). Provision of palliative care is one of the key elements of the multiple requirements placed on many rural health-care workers. The need to increase the palliative care capacity of rural health professionals is recognized in Australia as well as overseas (Noble et al, 2001; Kelley et al, 2004). Providing equitable access to education and resources in palliative care for rural and remote health-care workers is problematic owing to geographical isolation and to shortages both in the workforce and in education providers and resources (McConigley et al, 2001; Rosenberg and Canning, 2004). The question of how to meet the aged and palliative care capacitybuilding needs of health professionals is a considerable source of discussion in Western policy development contexts (United States Senate, 2008; Commission on Funding of Care and Support, 2011; Productivity Commission, 2011). Targeted palliative care education is important in aged care facilities (Parker et al, 2005; Allen et al, 2008). In Australia, where the adoption of a palliative approach in aged care facilities is established in policy, there is evidence of a gap in transforming this policy stance into practice owing to a lack of education provision and intentional support mechanisms (Allen et al, 2008; Andrews et al, 2009). Self-directed learning in health care has been used for mandatory education or fact-based learning, such as in the reading of electrocardiographs and hand washing. A literature review conducted for this study identified self-directed learning research that dealt with packages focusing on factual knowledge. These research projects did not explore learning that incorporated reflection on practice and care approaches in the context of personal values and complex skills required such as communication (Jang et al, 2005; Bloomfield et al, 2010). Some health-care domains, such as palliative care, require a broad skill set. For example,
© 2013 MA Healthcare Ltd
Steven Pitman
International Journal of Palliative Nursing 2013, Vol 19, No 6
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 28, 2015. For personal use only. No other uses without permission. . All rights r
Research
pain assessment may require a rudimentary understanding of pain physiology, a critical understanding of personal values in regard to pain, and adequate communication skills. The multi-factorial learning need in some domains of health care arguably requires complex approaches to curriculum development and pedagogy (Bankert and Kozel, 2005; Mikol, 2005; Earle and Myrick, 2009). There is a gap in the literature in regard to self-directed learning packages that aim to deliver multi-factorial knowledge that deviates from the purely factual.
Aims The aims of this study were to investigate the impact of a self-directed learning package on Australian rural aged care workers’ knowledge and confidence in the provision of palliative care.
Setting
Methodology
Aged care facilities in southern New South Wales, Australia, were considered as potential sites to approach for sampling. Facilities in towns with a Rural, Remote and Metropolitan Areas classification of R3 (indicating a population less than 10 000) were selected as they have been identified as areas with considerable resource limitation (Productivity Commission, 2011; Australian Institute of Health and Welfare, 2012). Towns with multi-purpose health care services were excluded in order to focus on staff with dedicated aged care employment.
Sample Staff at three dedicated aged care facilities in three rural towns were approached to participate. These facilities incorporated a mixture of lowcare and high-care residential aged care services. The total study population for the three services was 93 aged care employees. The response rate to the initial stages of the research was a sample of 33 employees—36% of the study population. Comparisons were made between the demographics of the sample, the study population, and residential aged care workers in Australia as a whole. There was considerable congruence between these groups with regard to occupation, gender, and age (Tables 1–3).
© 2013 MA Healthcare Ltd
Ethical considerations Ethics approval for this research was received from The Human Research Ethics Committee of the former Greater Southern Area Health Service. A letter explaining the nature of the research was provided to participants. Participation was voluntary and written consent was obtained.
International Journal of Palliative Nursing 2013, Vol 19, No 6
Table 1. Comparison between study sample, study population and Australian aged care workers as a whole—occupation Occupation
Sample (n=33)
Study population (n=93)
Australia*
Registered nurses
9%
9%
18%
Enrolled nurses
3%
9%
13%
Patient care assistants
88%
83%
69%
*Martin and King (2008)
Table 2. Comparison between study sample and Australian aged care workers as a whole—age group Age group
Sample (n=33)
Australia*
16–24
6%
6%
25–34
3%
11%
35–44
25%
22%
45–54
42%
38%
55–64
24%
21%
>65
0%
2%
*Martin and King (2008)
Table 3. Comparison between study sample and Australian aged care workers as a whole—gender Gender
Sample (n=33)
Australia*
Male
3%
7%
Female
97%
93%
*Martin and King (2008)
Learning package content The self-directed learning package was developed by Albury Wodonga Regional GP Network (now Hume Medicare Local), as a part of the Rural Palliative Care Project 2008–2011. It was adapted, with permission, from a package put together by Palliative Care Australia (2006). The adaptation adjusted the language of the package so that the education provided was not exclusive to aged care and could be used by community nursing as well as acute care staff. Although the adapted package was not made publically available during this research project, the original self-directed learning package from Palliative Care Australia is publically available. The package provided written information on evidence-based assessment and intervention in the context of the palliative approach. Case studies were presented throughout, encouraging the grounding of education experience in real-life scenarios. Three modules of the package were selected for the present study, including palliative care philosophy, pain assessment, and bowel management. Participants were provided with a
291
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 28, 2015. For personal use only. No other uses without permission. . All rights r
Research
292
printable learning journal with prompts throughout the package to encourage reflection on personal values and professional practice. Exposure to and completion of the learning package occurred in one 2-hour session in each facility. The content of the first module considered definitions and approaches to palliative care, including: ●●The World Health Organization (WHO, 2013a) definition of palliative care ●●Different contexts of palliative care including the palliative approach in primary health settings, specialist palliative care, and end-of-life care ●●Identification of when it would be appropriate to engage specialist palliative care teams ●●Potential benefits of the palliative approach and common concerns or misconceptions that the community may have ●●Consideration of how the palliative approach may be similar to or different from other forms of health care. The second module examined the subject area of pain and incorporated the following elements, with the last two elements creating a division-one, registered nurse extension: ●●Subjective experiences and objective assessment of pain. This element highlighted individual perceptions and understanding of pain and the requirement for attentive and non-judgmental exploration of the pain experience ●●Different presentations of pain including acute and chronic pain ●●Descriptors of pain, which may point to a possible aetiology and effect on the chosen treatment ●●Factors that can either lower or increase the pain threshold ●●Non-pharmacological measures for addressing pain, with critical consideration to ensure that further damage is not caused by the intervention ●●Recognition that effective pharmacological management uses both sustained-release and PRN breakthrough medications ●●Explanation of how the WHO (2013b) pain ladder can assist in determining the most effective approach in managing pain ●●Exploration of some myths of opioid use among patients, families, and health professionals. The third and final module selected was bowel management, inclusive of the following: ●●Negative health impacts of constipation ●●Means of preventing constipation ●●Factors causing constipation ●●Assessment and ongoing monitoring of bowel function ●●When to alert other members of the healthcare team to bowel issues
●●A division-one registered nurse extension looking at aperients, assessment of faecal impaction, and bowel obstruction.
Data collection Knowledge and confidence in delivering palliative care were measured via a combination questionnaire that included elements from the Rural Palliative Care Program Evaluation Toolkit, University of Wollongong (Eagar et al, 2004), the Palliative Care Quiz for Nurses, University of Ottawa (Ross et al, 1996), and the End of Life Nursing Education Consortium (ELNEC) Test (Takenouchi et al, 2011). Questions were selected from these resources according to their relevance to the self-directed learning package. The combination questionnaire was peer reviewed by two clinical nurse consultants in palliative care. Knowledge scores were aggregated according to correct responses. Confidence scores were generated from a self-rated appraisal according to the following criteria: ●●Need further basic instruction ●●Confident to perform with close supervision/ coaching ●●Confident to perform with minimal consultation ●●Confident to perform independently. The confidence self-appraisal was applied to the following domains: ●●Describing what palliative care is ●●Reacting to reports of pain from the patient ●●Reacting to and coping with reports of constipation. The combination questionnaire was applied at three time intervals: ●●Pre-package (questionnaire placed in envelope and given to researcher prior to use of the learning package) ●●Post-package (questionnaire completed again after completion of the learning package) ●●6-month follow-up (no additional exposure to the learning package, questionnaire completed and posted to researcher).
Results Differences in the scores between the testing periods were analysed via histograms, Jarque– Bera testing, and the three-sigma rule, and the data was deemed normally distributed. After completion of the self-directed learning package, there was a statistically significant increase in mean knowledge and confidence immediately post-package. Pre-package knowledge increased by a mean of 1.3 points post-package, and confidence increased by a mean of 0.9 points. The knowledge increase was retained and in fact was even greater after 6 months, at a
© 2013 MA Healthcare Ltd
❛This pilot study demonstrated that self-directed learning opportunities can increase knowledge and confidence in palliative care provision for rural aged care workers.❜
International Journal of Palliative Nursing 2013, Vol 19, No 6
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 28, 2015. For personal use only. No other uses without permission. . All rights r
Research
Table 4.Two-tailed paired T-tests Measure
Questionnaire results comparison
Mean difference
Standard deviation
T score
P value
Confidence score
Post-test compared to pre-test (n=33)
0.939
1.519
3.552
0.001
6-month follow-up compared to pre-test (n=20)
0.7
2.536
1.234
0.232
Knowledge score
Post-test compared to pre-test (n=33)
1.303
2.404
3.113
0.003
6-month follow-up compared to pre-test (n=20)
2.1
1.944
4.831
0.001
© 2013 MA Healthcare Ltd
Statistical significance was set at P
Evaluating a self-directed palliative care learning package for rural aged care workers: a pilot study
Abstract
Aim: To evaluate the effectiveness of a self-directed learning package in increasing palliative care knowledge and confidence for aged care workers in Rural New South Wales, Australia. Method: Participants piloted a palliative care self-directed learning package and completed pre- and post-package knowledge and confidence questionnaires with a 6-month follow-up. The data was then analysed via paired two-tailed T-tests. Results: There was a statistically significant mean increase in knowledge and confidence after completion of the self-directed learning package. Knowledge but not confidence increases were retained after 6 months. Conclusion: Self-directed learning packages can play a part in increasing knowledge and confidence in palliative care for rural aged care workers. Questions remain regarding the role of ongoing support, education, and mentoring. Key words: Palliative care l Education l Self-directed learning l Aged care l Rural care
T
Steven Pitman is Clinical Nurse Consultant, Mercy Health, 550 Poole Street, Albury, 2640 New South Wales, Australia Email: Steven.Pitman@gsahs. health.nsw.gov.au
290
he number of people aged 85 and over in Australia is expected to increase from 0.4 to 1.8 million between 2010 and 2050, effectively increasing demand for aged care services fourfold over the next 40 years (Productivity Commission, 2011). Meeting the increasing demand for adequate care for an ageing population is dependent on having a well resourced and adequately skilled workforce. Research suggests that among the Australian residential aged care workforce in 2007, 19.8% had no formal postsecondary school education (Martin and King, 2008). The high expectations of physically and emotionally demanding work roles with poor remuneration, inadequately defined training, and inadequately defined career pathways create issues of staff retention in the aged care workforce (Productivity Commission, 2011). Rural health professionals often have multiple roles in delivering health care to their communities. This requirement for multi-skilled approaches can be due to minimal access to specialist services, isolation from resource opportunities, and lower capacities of rural infrastructure
(Ricketts, 2005; Fisher and Fraser, 2010; Fragar and Depczynski, 2011). Provision of palliative care is one of the key elements of the multiple requirements placed on many rural health-care workers. The need to increase the palliative care capacity of rural health professionals is recognized in Australia as well as overseas (Noble et al, 2001; Kelley et al, 2004). Providing equitable access to education and resources in palliative care for rural and remote health-care workers is problematic owing to geographical isolation and to shortages both in the workforce and in education providers and resources (McConigley et al, 2001; Rosenberg and Canning, 2004). The question of how to meet the aged and palliative care capacitybuilding needs of health professionals is a considerable source of discussion in Western policy development contexts (United States Senate, 2008; Commission on Funding of Care and Support, 2011; Productivity Commission, 2011). Targeted palliative care education is important in aged care facilities (Parker et al, 2005; Allen et al, 2008). In Australia, where the adoption of a palliative approach in aged care facilities is established in policy, there is evidence of a gap in transforming this policy stance into practice owing to a lack of education provision and intentional support mechanisms (Allen et al, 2008; Andrews et al, 2009). Self-directed learning in health care has been used for mandatory education or fact-based learning, such as in the reading of electrocardiographs and hand washing. A literature review conducted for this study identified self-directed learning research that dealt with packages focusing on factual knowledge. These research projects did not explore learning that incorporated reflection on practice and care approaches in the context of personal values and complex skills required such as communication (Jang et al, 2005; Bloomfield et al, 2010). Some health-care domains, such as palliative care, require a broad skill set. For example,
© 2013 MA Healthcare Ltd
Steven Pitman
International Journal of Palliative Nursing 2013, Vol 19, No 6
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 28, 2015. For personal use only. No other uses without permission. . All rights r
Research
pain assessment may require a rudimentary understanding of pain physiology, a critical understanding of personal values in regard to pain, and adequate communication skills. The multi-factorial learning need in some domains of health care arguably requires complex approaches to curriculum development and pedagogy (Bankert and Kozel, 2005; Mikol, 2005; Earle and Myrick, 2009). There is a gap in the literature in regard to self-directed learning packages that aim to deliver multi-factorial knowledge that deviates from the purely factual.
Aims The aims of this study were to investigate the impact of a self-directed learning package on Australian rural aged care workers’ knowledge and confidence in the provision of palliative care.
Setting
Methodology
Aged care facilities in southern New South Wales, Australia, were considered as potential sites to approach for sampling. Facilities in towns with a Rural, Remote and Metropolitan Areas classification of R3 (indicating a population less than 10 000) were selected as they have been identified as areas with considerable resource limitation (Productivity Commission, 2011; Australian Institute of Health and Welfare, 2012). Towns with multi-purpose health care services were excluded in order to focus on staff with dedicated aged care employment.
Sample Staff at three dedicated aged care facilities in three rural towns were approached to participate. These facilities incorporated a mixture of lowcare and high-care residential aged care services. The total study population for the three services was 93 aged care employees. The response rate to the initial stages of the research was a sample of 33 employees—36% of the study population. Comparisons were made between the demographics of the sample, the study population, and residential aged care workers in Australia as a whole. There was considerable congruence between these groups with regard to occupation, gender, and age (Tables 1–3).
© 2013 MA Healthcare Ltd
Ethical considerations Ethics approval for this research was received from The Human Research Ethics Committee of the former Greater Southern Area Health Service. A letter explaining the nature of the research was provided to participants. Participation was voluntary and written consent was obtained.
International Journal of Palliative Nursing 2013, Vol 19, No 6
Table 1. Comparison between study sample, study population and Australian aged care workers as a whole—occupation Occupation
Sample (n=33)
Study population (n=93)
Australia*
Registered nurses
9%
9%
18%
Enrolled nurses
3%
9%
13%
Patient care assistants
88%
83%
69%
*Martin and King (2008)
Table 2. Comparison between study sample and Australian aged care workers as a whole—age group Age group
Sample (n=33)
Australia*
16–24
6%
6%
25–34
3%
11%
35–44
25%
22%
45–54
42%
38%
55–64
24%
21%
>65
0%
2%
*Martin and King (2008)
Table 3. Comparison between study sample and Australian aged care workers as a whole—gender Gender
Sample (n=33)
Australia*
Male
3%
7%
Female
97%
93%
*Martin and King (2008)
Learning package content The self-directed learning package was developed by Albury Wodonga Regional GP Network (now Hume Medicare Local), as a part of the Rural Palliative Care Project 2008–2011. It was adapted, with permission, from a package put together by Palliative Care Australia (2006). The adaptation adjusted the language of the package so that the education provided was not exclusive to aged care and could be used by community nursing as well as acute care staff. Although the adapted package was not made publically available during this research project, the original self-directed learning package from Palliative Care Australia is publically available. The package provided written information on evidence-based assessment and intervention in the context of the palliative approach. Case studies were presented throughout, encouraging the grounding of education experience in real-life scenarios. Three modules of the package were selected for the present study, including palliative care philosophy, pain assessment, and bowel management. Participants were provided with a
291
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 28, 2015. For personal use only. No other uses without permission. . All rights r
Research
292
printable learning journal with prompts throughout the package to encourage reflection on personal values and professional practice. Exposure to and completion of the learning package occurred in one 2-hour session in each facility. The content of the first module considered definitions and approaches to palliative care, including: ●●The World Health Organization (WHO, 2013a) definition of palliative care ●●Different contexts of palliative care including the palliative approach in primary health settings, specialist palliative care, and end-of-life care ●●Identification of when it would be appropriate to engage specialist palliative care teams ●●Potential benefits of the palliative approach and common concerns or misconceptions that the community may have ●●Consideration of how the palliative approach may be similar to or different from other forms of health care. The second module examined the subject area of pain and incorporated the following elements, with the last two elements creating a division-one, registered nurse extension: ●●Subjective experiences and objective assessment of pain. This element highlighted individual perceptions and understanding of pain and the requirement for attentive and non-judgmental exploration of the pain experience ●●Different presentations of pain including acute and chronic pain ●●Descriptors of pain, which may point to a possible aetiology and effect on the chosen treatment ●●Factors that can either lower or increase the pain threshold ●●Non-pharmacological measures for addressing pain, with critical consideration to ensure that further damage is not caused by the intervention ●●Recognition that effective pharmacological management uses both sustained-release and PRN breakthrough medications ●●Explanation of how the WHO (2013b) pain ladder can assist in determining the most effective approach in managing pain ●●Exploration of some myths of opioid use among patients, families, and health professionals. The third and final module selected was bowel management, inclusive of the following: ●●Negative health impacts of constipation ●●Means of preventing constipation ●●Factors causing constipation ●●Assessment and ongoing monitoring of bowel function ●●When to alert other members of the healthcare team to bowel issues
●●A division-one registered nurse extension looking at aperients, assessment of faecal impaction, and bowel obstruction.
Data collection Knowledge and confidence in delivering palliative care were measured via a combination questionnaire that included elements from the Rural Palliative Care Program Evaluation Toolkit, University of Wollongong (Eagar et al, 2004), the Palliative Care Quiz for Nurses, University of Ottawa (Ross et al, 1996), and the End of Life Nursing Education Consortium (ELNEC) Test (Takenouchi et al, 2011). Questions were selected from these resources according to their relevance to the self-directed learning package. The combination questionnaire was peer reviewed by two clinical nurse consultants in palliative care. Knowledge scores were aggregated according to correct responses. Confidence scores were generated from a self-rated appraisal according to the following criteria: ●●Need further basic instruction ●●Confident to perform with close supervision/ coaching ●●Confident to perform with minimal consultation ●●Confident to perform independently. The confidence self-appraisal was applied to the following domains: ●●Describing what palliative care is ●●Reacting to reports of pain from the patient ●●Reacting to and coping with reports of constipation. The combination questionnaire was applied at three time intervals: ●●Pre-package (questionnaire placed in envelope and given to researcher prior to use of the learning package) ●●Post-package (questionnaire completed again after completion of the learning package) ●●6-month follow-up (no additional exposure to the learning package, questionnaire completed and posted to researcher).
Results Differences in the scores between the testing periods were analysed via histograms, Jarque– Bera testing, and the three-sigma rule, and the data was deemed normally distributed. After completion of the self-directed learning package, there was a statistically significant increase in mean knowledge and confidence immediately post-package. Pre-package knowledge increased by a mean of 1.3 points post-package, and confidence increased by a mean of 0.9 points. The knowledge increase was retained and in fact was even greater after 6 months, at a
© 2013 MA Healthcare Ltd
❛This pilot study demonstrated that self-directed learning opportunities can increase knowledge and confidence in palliative care provision for rural aged care workers.❜
International Journal of Palliative Nursing 2013, Vol 19, No 6
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on November 28, 2015. For personal use only. No other uses without permission. . All rights r
Research
Table 4.Two-tailed paired T-tests Measure
Questionnaire results comparison
Mean difference
Standard deviation
T score
P value
Confidence score
Post-test compared to pre-test (n=33)
0.939
1.519
3.552
0.001
6-month follow-up compared to pre-test (n=20)
0.7
2.536
1.234
0.232
Knowledge score
Post-test compared to pre-test (n=33)
1.303
2.404
3.113
0.003
6-month follow-up compared to pre-test (n=20)
2.1
1.944
4.831
0.001
© 2013 MA Healthcare Ltd
Statistical significance was set at P
