the expectations and experiences of blended learning approaches to patient safety education

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The expectations and experiences of blended learning approaches to patient safety education Ann B. Wakefield a, * , Caroline Carlisle b , Andrew G. Hall c , Moira J. Attree a a School of Nursing Midwifery and Social Work, The University of Manchester, Coupland Building 3, Coupland Street, Manchester M13 9PL, United Kingdom b School of Nursing Midwifery and Social Work, The University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, United Kingdom c School of Nursing Midwifery and Social Work, The University of Manchester, Gateway House, Piccadilly South, Manchester M60, United Kingdom Accepted 4 April 2007 Summary E-learning facilitates access to educational programmes via electronic asynchronous or real time communication without the constraints of time or place. However, not all skills can be acquired via e-learning, thus blended approaches have emerged, where traditional academic processes have been combined with e-learn- ing systems. This paper presents qualitative findings from a study evaluating a blended approach to patient safety education. The 3-day face-to-face training in Root Cause Analysis supported by e-learning resources was designed by the National Patient Safety Agency. The study evaluated the efficacy of the blended learning approach, and explored how operational practices in NHS organisations supported staffs’ skill in using electronic resources. Data collection techniques included pre and post-course Confidence Logs, Individual Interviews, Focus Groups and Evaluation Questionnaires. Students’ views on blended learning varied. Some were positive, while others felt e-learning did not suit their preferred learning style, or the subject matter. Many stu- dents did not engage with the e-learning resources. Lack of awareness regarding the e-learning component, combined with inconsistent access to computing facilities may have contributed to this. For this reason a series of recommendations are outlined to guide those wishing to adopt blended learning approaches in the future. c 2007 Elsevier Ltd. All rights reserved. KEYWORDS E-learning; Blended learning; Patient safety 1471-5953/$ - see front matter c 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2007.04.007 * Corresponding author. Tel.: +44 0161 275 7007; fax: +44 0161 275 7566. E-mail address: ann.b.wakefi[email protected] Nurse Education in Practice (2008) 8, 54–61 www.elsevierhealth.com/journals/nepr Nurse Education in Practice

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Page 1: The expectations and experiences of blended learning approaches to patient safety education

Nurse Education in Practice (2008) 8, 54–61

Nurse

www.elsevierhealth.com/journals/nepr

Educationin Practice

The expectations and experiences of blendedlearning approaches to patient safety education

Ann B. Wakefield a,*, Caroline Carlisle b, Andrew G. Hall c,Moira J. Attree a

a School of Nursing Midwifery and Social Work, The University of Manchester, Coupland Building 3,Coupland Street, Manchester M13 9PL, United Kingdomb School of Nursing Midwifery and Social Work, The University of Manchester, Williamson Building,Oxford Road, Manchester M13 9PL, United Kingdomc School of Nursing Midwifery and Social Work, The University of Manchester, Gateway House,Piccadilly South, Manchester M60, United Kingdom

Accepted 4 April 2007

Summary E-learning facilitates access to educational programmes via electronicasynchronous or real time communication without the constraints of time or place.However, not all skills can be acquired via e-learning, thus blended approaches haveemerged, where traditional academic processes have been combined with e-learn-ing systems.

This paper presents qualitative findings froma study evaluating a blended approachto patient safety education. The 3-day face-to-face training in Root Cause Analysissupported by e-learning resources was designed by the National Patient SafetyAgency. The study evaluated the efficacy of the blended learning approach, andexplored how operational practices in NHS organisations supported staffs’ skill inusing electronic resources. Data collection techniques included pre and post-courseConfidence Logs, Individual Interviews, Focus Groups and Evaluation Questionnaires.

Students’ views on blended learning varied. Some were positive, while others felte-learning did not suit their preferred learning style, or the subject matter. Many stu-dents did not engage with the e-learning resources. Lack of awareness regarding thee-learning component, combinedwith inconsistent access to computing facilitiesmayhave contributed to this. For this reason a series of recommendations are outlined toguide those wishing to adopt blended learning approaches in the future.

�c 2007 Elsevier Ltd. All rights reserved.

KEYWORDSE-learning;Blended learning;Patient safety

1d

2

471-5953/$ - see front matter �c 2007 Elsevier Ltd. All rights reserved.oi:10.1016/j.nepr.2007.04.007

* Corresponding author. Tel.: +44 0161 275 7007; fax: +44 016175 7566.E-mail address: [email protected]

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The expectations and experiences of blended learning approaches to patient safety education 55

Introduction

Courses of study increasingly involve electronicand/or blended learning components, which needto be evaluated if they are to result in active learning(Cox et al., 2004). This paper presents qualitativefindings from a study evaluating the use of a blendedlearning approach to patient safety education forNHS staff within the UK. The paper examines currentliterature related to electronic and blended learningtechniques, and outlines the methodological anddata analysis frameworks used. Recommendationsare made, which will assist future educators imple-ment e-learning within their respective educationalprogrammes.

Background

E-learning provides access to educational pro-grammes without the usual constraints of timeand place (Finn and Bucceri, 2004). Learners accessmaterials electronically, facilitating personal andprofessional development by making it easier toaccommodate not only busy work schedules butindividual learning styles (Ally, 2004). E-learningenables employers and education providers to re-duce the need for costly study sessions (Finn andBucceri, 2004), as there is no need to gather largegroups of people together in one venue. Learnersare provided with the opportunity to communicatewith each other either as part of an asynchronousor real time event (Frydenberg, 2002). This cantake place either as part of a learner-led discussionor one facilitated by an e-learning moderator ableto support and direct learners (Anderson, 2004).

E-learning moderators can monitor learner pro-gress via the integration of course managementsystems (Belyk et al., 2005). Monitoring can beachieved either by tracking and reviewing the num-ber and type of messages learners post to eachother or by tracking their use of the e-learningmaterials (Anderson, 2004). Monitoring an individ-ual’s progress is more precise than can be achievedduring face-to-face interactions. For example, it ispossible to see changes in an individual’s thinkingfrom the messages posted on discussion boardsand to monitor what an individual has focused onas part of their learning by noting those location(s)within the e-learning site that a learner has ac-cessed. This latter activity affords the moderatorthe opportunity to access training scores or otherlearning related activities in the form of electronicreports across a local and if necessary global popu-lation of users (Strother, 2002).

Within facilitated discussions the moderator’sexpertise in creating an interactive, approving, so-cial, and communicative atmosphere is crucial tocollaborative e-learning (Karppinen, 2005; King,2002). Instructors are no longer the centre ofattention, as learning revolves around each individ-ual’s interactions, collaboration, and engagementwith the materials through a process of discovery(Juntunen and Heikkinen, 2004). Educators needhowever, to help learners see the relationship be-tween the virtual learning environment and theirdomain of practice. There is a need to provide linksfor learners to identify how e-learning materials re-late to practice as an integral part of the learningprocess (Wiecha and Barrie, 2002).

Blended learning

Not all skills can be learned via e-learning, nor is itpossible to deliver all educational content via re-mote means. Consequently individuals may feelthe need to meet and communicate with each otherface-to-face in order to engage in open interactivedebate, share their ideas and challenge each other.For this reason, blended learning approaches haveemerged, where technology-supported educationis combined with more conventional educationalschema (Berke and Wiseman, 2003). Recently therehas been a move towards merging technologies andeducational techniques designed to support differ-ent forms of teaching to achieve more effectivelearning. Blended learning is defined as the ‘‘effec-tive integration of various learning techniques,technologies, and delivery modalities to meet spe-cific communication, knowledge sharing, and infor-mational needs’’. (Finn and Bucceri, 2004, p. 2).Similarly, Whitelock and Jelfs (2003) argue blendedlearning should integrate and combine traditionallearning methods with e-learning approaches. Forthis reason, blended learning needs to make useof a variety of media as part of an e-learning envi-ronment whilst simultaneously exploiting addi-tional educational avenues such as enquiry-basedlearning (Kubicek, 2005). Consequently blendedlearning needs to be structured in such a way asto take account of both the type of learningadopted and the educational approaches selected(Whitelock and Jelfs, 2003).

Twigg (2003) has attempted to move these def-initions on further by subdividing blended learninginto four paradigms, which she termed: supple-mental, replacement, emporium and buffet modelsof blended learning (see Fig. 1).

The key differentiator between the paradigms iswhere they each lie on the fully face-to-face versus

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Supplemental Model Traditional course structures are retained supported by e-learning materials and activities

Replacement Model A number of face-to-face contacts are substituted with e-learning activities and communication

Emporium Model Formal lectures are replaced by e-learning activities supported by an open access learning resource centre which actively encourages students to use enquiry-based learning strategies.

Buffet Model Learners are provided with a flexible learning pathway allowing them to graze their way through a range of learning environments and/or activities.

Figure 1 Twigg’s (2003) model of Blended learning.

FullyFace-to-Face Learning E-Learning

Fully

Figure 2 E-learning continuum.

56 A.B. Wakefield et al.

fully e-learning educational continuum as shown inFig. 2.

Blended learning does not simply representassimilation of new or increasingly sophisticatedtechnologies within the learning context. It alsohas a direct impact on the type of teaching andlearning styles employed, enabling learners to ac-cess educational materials in their own time, attheir own pace (Dean et al., 2001; Finn and Buc-ceri, 2004; Karppinen, 2005); encouraging en-quiry-based learning which places greateremphasis on autonomy (Kubicek, 2005).

Twigg’s (2003) model of blended learningemphasises the relationship between learners andfacilitators, and the way individuals learn. Theunderpinning feature of all four of Twigg’s para-digms is the notion of ‘learning space’, which isboth a physical and virtual concept. For this reason,blended learning has an incremental impact on anorganisation’s physical space. For example, themore learning is located within an electronic envi-ronment the less physical space is needed. Insteaddifferent forms of space are required that allowmoderators and students to ‘‘meet’’ and communi-cate without having to be in the same physical loca-tion. For this reason, when attempting to introducee-learning, educational establishments need tocreate what is known as a virtual space or virtuallearning environment to allow learning activitiesto take place remotely (Koskela et al., 2005).

Whilst blended learning methods can help createflexible routes for people to learn, it is not alwaysapparent from the literature which forms of learn-ing suit individuals best or enable them to attainmaximum benefit from the learning experience(Koskela et al., 2005). Face-to-face, electronicand blended learning interventions need to be fully

evaluated before they are integrated within anorganisation’s educational strategy to ensure ac-tive learning is achieved (Cox et al., 2004). Hence,the impact of introducing a blended learning pack-age, as part of a 3-day root cause analysis (RCA)training programme, was examined in a study,which aimed to evaluate the:

� Effectiveness of the National Patient SafetyAgency’s (2004) RCA training programme, involv-ing 3-day face-to-face training, supported by ane-learning RCA toolkit.�Ways in which organisational and operationalpractices affected access to and skill in usingthe electronic resources available to supportRCA.� Extent to which organisational and operationalsystems enabled and promoted the use of thepatient safety e-learning programmes amongstclinical and non-clinical study participants.

The RCA tool kit referred to above is a free stand-ing, web-based, open access 6-module e-learningprogramme (NPSA, 2004). The modules were pro-duced in Macromedia Flash and required partici-pants to respond to preset questions; feedbackwas also preset and text based. The modules didnot facilitate peer-to-peer or tutor-to-student com-munication as asynchronous discussion boards ortext chat facilities were not included in the learningdesign. The learning programme evaluated here,adopted a supplemental approach (Twigg, 2003),whereby the RCA tool kit was designed to supportand reinforce the 3-day face-to-face training.

Methods

This study examined the efficacy of the 3-day RCAprogramme using Impact Evaluation, a research ap-proach designed to examine the impact of an edu-cational programme and the extent to which it

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The expectations and experiences of blended learning approaches to patient safety education 57

realises its intended outcomes (Rossi et al., 2004).Impact Evaluation allowed us to evaluate the edu-cational intervention, in terms of its ability to bringabout enhanced knowledge and/or behaviourchange (Torres et al., 1996; Tuckman, 1999). It isa flexible research approach permitting the use ofboth quantitative and qualitative data collectiontechniques (Rossi et al., 2004). If Impact Evaluationis to be effective it needs to be undertaken byindependent professional peers (International FoodPolicy Research Institute, 2002). As we were not in-volved in the design or execution of the pro-gramme, and independent of the respectiveclinical settings, it was possible to achieve a moreobjective stance to the evaluation of the blendedlearning approach.

Sample

Participants who took part in the individual and fo-cus group interviews were RCA-course participants.Key Organisational Stakeholders participated in fo-cus group interviews located in each of the threecase study sites. These were Acute, Mental Healthand Primary Care NHS Trusts located across theNorth of England (See Fig. 3). Most participantswere managers or clinicians, representing Medi-cine, Nursing and Allied Heath Professions, em-ployed at band 6 or above, as well as HealthService Administrators.

Ethics

The study was approved by an NHS Multi-centre Re-search Ethics Committee before commencement.Participants were sent an information sheet outlin-ing what was expected and asked to sign a consentform.

Post-Course One-to-Course Participa

Post-course FocInterviews Key Stak

Post-CourseFocus Group

Interviews Course

Participants(n=18)

Figure 3 Sample of participants contrib

Data collection

Although data were collected using both quantita-tive and qualitative methods, this paper reportson the qualitative findings. The quantitative mea-sures used are listed here for completeness andto illustrate the flexible approach recommendedby Rossi et al. (2004). Quantitative measures in-cluded Confidence Logs and Questionnaires; forfurther details see Project report (Carlisle et al.,2006) at: http://www.nursing.manchester.ac.uk/projects/rca.

Qualitative data were collected via semi-struc-tured individual interviewswith course participants’before and after the training (n = 12). Focus groupinterviews were conducted post-course with courseparticipants (n = 16) and key organisational stake-holders (n = 18) from the three case study sites.Interview schedules were piloted to establishwhether the questions elicited relevant, credibledata and had resonance with participants (Politand Beck, 2006). Interview questions explored read-iness to learn, learning experience and impact oflearning on the individual and theorganisation, in or-der to reflect the research aims. Focus groups wereused to enable people from the sameTrust to debateissues pertinent to them and to reach consensus.Examples of questions asked during the individualand focus group interviews are shown in Table 1.

Data analysis

Qualitative data from the individual and focusgroup interviews were fully transcribed and contentanalysed (Polit and Beck, 2006). The content analy-sis was performed independently by two of theresearchers (MA & AW). Themes generated fromthe content analysis were mapped against the re-

One Interviewsnts (n=12)

EvaluationQuestionnaires

CourseParticipants

(n=16)Facilitators

(n=3)

us Groupeholders(n=16)

uting to each Data collection method.

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Table 1 Examples of the interview themes for the individual and focus group interviews

What was your experience of the programme, in particular the structure of the course and the study pattern?What are your thoughts on how the face-to-face and the e-learning worked?What do you think was the most valuable aspect of the programme?Thinking about people who attended the programme, were you able to get together as a group and learn andwork on things in between?Do you think the organisation has the technological facilities? What about support for people who maybe don’thave the skills or the confidence to use the technology?Do you think that the course effectively prepared you for the cascade training?What impact do you think has the training had firstly on you as individuals and secondly on the organisation

58 A.B. Wakefield et al.

search aims. Inter-researcher consistency waschecked by a third member of the research team(CC) to ensure that the findings were accurate,credible and trustworthy (Polit and Beck, 2006).

Findings

During the interviews and focus group discussionsdiverse experiences and expectations about thee-learning element of the programme were identi-fied. Selected quotations from the interviews arepresented to illustrate these themes; quotes fromcourse participants are identified by (CP) and keystakeholders (FS); from focus groups (FG). Casestudy sites are signified by the letters A, B or C.

Experiences of blended learning

The majority of the 34 participants who took part inthe individual and focus group interviews reportedhaving limited or no previous experience of interact-ing with e-learning technologies. A minority ex-pressed feeling at ease with e-learningtechnologies from the outset. Some participantsknew about the e-learning in advance, were familiarwith the approach, and were positive about its use.

Access is something the NPSA should be quite proudof really. It’s . . . VERY user friendly and very useraccessible in terms of being able to quickly . . .get information . . . the tool kit is readily available. . . very beneficial to ALL healthcare professionals’CP4272

Whilst others were unaware of the e-learningcomponent and expressed more negative views:

I didn’t really understand even anticipate that (e-learning) would be part of it, so maybe if peoplehad made me more aware prior to it. . .however Ihave to be honest . . . I just don’t use that sort ofthing.CP30105

Some participants identified e-learning was nottheir preferred learning style:

I know personally . . . e-learning. . . I like to beinvolved in discussion and that’s how I learn by lis-tening to people. . . dilemmas and discussion . . .practically using things. So I would say e-learningwouldn’t be my preferenceCP5863I don’t think it would suit everybody. My experi-ence is that people learn in different ways.CPFGRSB

Patterns of e-learning usage

The range of e-learning usage included: no accessto computers or the e-learning materials; full com-puter access but still no use of the material; occa-sional access of the e-learning material and workbased computers, and regular access of both thework based computers and e-learning material.Those who did use the materials responded posi-tively, commenting that it complemented theface-to-face sessions

I did find the pack was easy to use it was userfriendly and it was nice to go back there as arefresherCP4263

Interestingly, the majority of participants re-ported not having accessed the e-learning. How-ever, lack of awareness regarding the relationshipbetween the face-to-face training and the e-learn-ing resources may have led to the latter componentnot being utilised in the blended manner originallyenvisaged by the programme designers. As high-lighted by the following comment:

I don’t think the e-learning was sold enough fromthe content prior to going to the courseCPFGRSA

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The expectations and experiences of blended learning approaches to patient safety education 59

Participants who did use the e-learning materi-als rated them as less effective than the face-to-face training and felt there was a lack of supportfor this type of learning. Some saw e-learning asan individual or passive activity with no opportu-nity for discussion to support their learning be-tween the taught sessions: a factor reinforced byone key stakeholder:

it’s a one-to-one type interaction. I don’t thinkwe’d’ve been able to do a group interaction. Wehaven’t got the facilities at the present time.KSFGCH2

Accessibility of computing facilities

Many participants felt the potential for e-learningand asynchronous discussion was constrained bylack of access to computer facilities. Levels of ac-cess ranged from open access via an on-site inter-net cafe, to a maximum of 30-min internet accessper day.

. . .at X (hospital) they have a quota time of half anhour and once they’ve used that half an hour it cutsthem off and won’t let them use the internet. . .CPFGRSB

One participant felt in reality accessing e-learn-ing materials was not as easy to achieve as manyorganisations thought.

Organisations make that assumption. . .they (clini-cal staff) can neatly fit that into half an hour. . .people can’t do that. . . staff would have to go toa sister’s office or something. . .even though wehave moved on with people and their opinion ofcomputers in the workplace I still don’t think weare where its at electronicallyCP2059

This could explain why participants who did ac-cess the e-learning materials tended to print themoff:

I think the online acts as a library . . . to give you all. . .reference material . . . support and tools . . . Iwould not normally just use my PC to act on a lotof that information. I would take a lot of it awayand use it on a ward visit and introduce it that wayrather than just sitting in front of the computer.CP4272

Discussion

Although there is growing evidence supporting theuse of e-learning environments (Piccoli et al.,

2001; Marandi and Luik, 2003), they need to beintroduced with caution (Koskela et al., 2005). Thisstudy reinforces Twigg’s (2003) assertion that re-stricted access to computing facilities can be a ma-jor obstacle to successful implementation of thesupplemental model of blended or e-learning aspart of a workplace learning strategy. Course par-ticipants in this study appeared to have limitedawareness of the blended e-learning approach.Use of the e-learning materials appeared to beinfluenced by participants’ own perceptions, expe-riences of e-learning, and whether it suited theirpreferred learning style. Additional reasons whye-learning materials were not used related specifi-cally to accessibility, time availability and levels ofsupport for e-learning. Hence, if organisations wishto use a supplemental blended learning model thelearning design needs to reflect the programmeaims and the learning strategy should be clearlycommunicated. The necessary technical and learn-ing resources should also be in place and individu-als’ allocated sufficient time to acquire the skillsthey need to use them properly (Burgess, 2003; Si-lius and Tervakari, 2003; Twigg, 2003; JISC, 2004).If institutions are to take blended learning seriouslythey also need to develop dedicated learning re-sources or study areas furnished with the necessarycomputer equipment which permits access to thesoftware.

Blended learning requires the same level of con-sideration be given to the notion of time and spaceas that given to fully electronic or face-to-facemod-els of learning (Twigg, 2003). Hence, the design andimplementation of virtual ‘learning spaces’ needcareful consideration, particularly if they are tomeet the requirements of the organisation, learnersand educational facilitators (Burgess, 2003; Siliusand Tervakari, 2003; Twigg, 2003; JISC, 2004). Par-ticipants in our study were unable to engage in asyn-chronous discussions to facilitate networking andgroup support as this facility was not part of thelearning design. Consequently the communicationpotential of e-learning, which is seen as one of itsstrengths (Kubicek, 2005), was not realised.

If learners are to be encouraged to use blendedand e-learning technologies as part of their educa-tion and development, specific information abouthow, where and when to access the learning mate-rials might encourage them to use the resourcesmore frequently. However, educators need toacknowledge that placing greater emphasis onblended or e-learning aspects of a course mayunsettle those who conceptualise e-learning asnot only unfamiliar, but challenging (Ryan, 2001;Juntunen and Heikkinen, 2004). For this reason,the following recommendations are offered for

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60 A.B. Wakefield et al.

educators and organisations thinking of developingblended learning programmes in the future.

� Make explicit to participants the type of learningapproach to be adopted.� Develop a clear strategy for using blendedlearning.� Actively involve participants in using e-learningand ensure that they have open access to thenecessary computer hardware.� Integrate and embed blended learning withinprogrammes.� Encourage course participants to engage with e-learning educational modalities whilst on a pro-gramme of study to help sustain their activeinvolvement in this form of learning.� Advocate communication technologies as ameans of enhancing inter and intra-agency com-munication and networking.� Make full use of the potential that learning tech-nologies have for enhancing student to studentand staff to student communication and support.� Design programmes using a blended approachfrom the outset and ensure that the design ofthe e-learning materials matches the pro-grammes structure and aims.

Limitations of the study

Study limitations included the small sample sizeand limited scope – three case study sites andshort timescale. The qualitative study data is alsopotentially limited by self-report bias; for exampleparticipants’ reports of experiences, perceptions,actions and reactions to the use of e-learningmaterials could be subject to recall, social desir-ability and interpretation bias (Polit and Beck,2006). To enhance the credibility of the findingsa longitudinal follow-up study is recommended toestablish whether opinions regarding the blendedor e-learning technologies changed over time.Similarly a longitudinal study would also have en-abled us to establish whether the healthcareorganisations had developed new protocolsregarding staff access to technology in order tofacilitate networking and enhanced intra-agencycommunication.

Conclusions

In order to implement the above recommenda-tions organisations need to consider the struc-tures and processes required to support blendedlearning; including the need for appropriate

technology, dedicated learning resources andtechnical support. In addition, organisations plan-ning to use blended learning approaches need toexplain the concept and its advantages to learn-ers from the outset and actively engage them inany new developments. Moreover, learners notonly need to be prepared to use blended learn-ing, but it is vital they have the necessary tech-nical skills, as well as time to access thematerials. Additionally, learners need to under-stand the purpose of the educational strategybeing developed so that they can appreciatehow these might support their individual learn-ing. Finally, learners need to discover how to ac-cess increasingly diverse learning materials, so asto interact with broader educational learningcommunities, and share their enhanced knowl-edge and ability to engage with new educationaldelivery modalities.

Acknowledgements

This study was commissioned by the North WestStrategic Health Authorities E-learning Strategygroup, the National Patient Safety Agency (NPSA)and the NHS Modernisation Agency (now ClinicalGovernance Support Team).

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