One in two people will be diagnosed with cancer in their lifetime (Cancer Research UK, 2018) and it is predicted there will be over five million cancer survivors in the UK in 2040 (Maddams et al, 2012). To sustain and secure the cancer care workforce, it is vital that pre-registration programmes prepare healthcare students to care for people affected by cancer (Armoogum, 2023). However, provision of cancer and end of life care education can be limited in nursing and allied health professionals' programmes (Flood and Shepherd, 2021; Nilsson et al, 2022).
In the UK, the Aspirant Cancer Career and Education Development programme (ACCEND) Framework outlines nationally agreed cancer-focused learning outcomes and core cancer capabilities in practice (CiPs) for pre-registration healthcare students (Potter and Taylor, 2022; Health Education England (HEE), 2023). To increase access to cancer education for pre-registration healthcare students, and support implementation of the ACCEND framework, nine e-learning modules, collectively called ‘The Foundations of Cancer Care’, have been developed. This article outlines the development and peer review evaluation of the modules.
Development
Following review of existing e-learning resources, a programme called Cancer Nursing Careers was identified on the HEE e-Learning for Healthcare (e-LfH) platform. Cancer Nursing Careers consists of eight modules aligned to the Royal College of Nursing (2022) Career and Education Framework for Cancer Nursing. With permission from the original authors, the Cancer Nursing Careers modules were revised, renewed and rewritten for a pre-registration audience to meet the learning outcomes outlined in the ACCEND Framework (HEE, 2023). This was undertaken by a team of UK nurses and allied health professionals who work in higher education institutions and are cancer specialists in pre-registration curricula and pedagogy.
Modules were adapted to include perspectives of nursing and allied health professionals and to develop learning at an appropriate level for pre-registration students. This included the development of reflective questions and recommended workplace learning scenarios to help students understand how they could link theory to practice.
Peer review method
Peer review and quality assurance was undertaken with students, health professionals and technology enhanced learning experts to ensure the learning was relevant and fit for purpose.
Twenty five third-year BSc nursing students at one English university were invited to complete the first three modules and an evaluation e-survey. Ethical advice was obtained from the university ethics committee and the committee chair confirmed that no ethical approval was required, and the evaluation could take place within standard module evaluation procedures. The evaluation e-survey consisted of eight questions adapted from the Kirkpatrick model of evaluation (Kirkpatrick and Kirkpatrick, 2019). This included Likert scale responses to elicit views on the modules and free text responses about what participants liked and thought could be improved. Finally, participants were asked to rate their overall opinion of the modules as very poor, poor, neutral, good, or very good.
Health professionals with an interest in cancer care and pre-registration education were also asked to review the modules. The health professionals were sent links to the modules and the evaluation e-survey.
Peer review results
Student survey
In total, 19 students completed the survey. Seven (37%) indicated no clinical experience of cancer care and seven (37%) had experienced a clinical placement in a cancer setting (Table 1).
Table 1. Student nurse participant characteristics
| Descriptors | n | % | |
|---|---|---|---|
| Clinical experience of cancer care (participants were allowed to check more than one option) | None | 7 | 37 |
| I have had a clinical placement in a cancer service setting during my course | 7 | 37 | |
| I have not had a cancer specific placement during my course, but I have cared for people with cancer during my clinical placements | 7 | 37 | |
| I have worked as a healthcare assistant in cancer services | 2 | 11 | |
| I have cared for people with cancer while working as a healthcare assistant in a non-cancer setting | 3 | 16 | |
Overall, 18 (95%) students rated the modules as very good (n=10, 53%) or good (n=8, 42%) and one (5%) did not answer. Almost all (n=18, 95%) agreed or strongly agreed the modules could increase pre-registration healthcare students' knowledge and understanding of cancer and its treatment and could increase pre-registration healthcare students' confidence about cancer care in practice (Table 2). All students (n=19, 100%) agreed or strongly agreed the learning objectives were relevant to pre-registration healthcare students. Almost three-quarters (n=14, 74%) agreed or strongly agreed the content was written at the right level for pre-registration healthcare students, two (11%) disagreed and three (16%) did not agree or disagree (Table 3).
Table 2. Levels of agreement regarding modules' content
| Pre-registration students | Health professionals | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Please state your level of agreement with the following statements. Do you think these modules could support pre-registration healthcare students to … | Strongly disagree/disagree | Neither agree or disagree | Strongly agree/agree | Strongly disagree/disagree | Neither agree or disagree | Strongly agree/agree | ||||||
| n | % | n | % | n | % | n | % | n | % | n | % | |
| Increase knowledge and understanding of cancer and its treatment | 0 | 0 | 1 | 5 | 18 | 95 | 0 | 0 | 0 | 0 | 6 | 100 |
| Examine current national policies, guidance and local healthcare processes influencing organisation of cancer services and care for people affected by cancer | 0 | 0 | 2 | 11 | 17 | 90 | 0 | 0 | 0 | 0 | 6 | 100 |
| Explore public and professional attitudes to cancer | 0 | 0 | 3 | 16 | 16 | 84 | 0 | 0 | 0 | 0 | 6 | 100 |
| Describe the biological basis of cancer and examine how this informs practices relating to risk reduction, early detection, screening, diagnosis, staging and grading of cancer, personalised treatment decisions | 0 | 0 | 0 | 0 | 19 | 100 | 0 | 0 | 0 | 0 | 6 | 100 |
| Analyse the physical, psychological, emotional and social impact of cancer and its treatment across the spectrum of cancer care | 0 | 0 | 2 | 11 | 17 | 90 | 0 | 0 | 0 | 0 | 6 | 100 |
| Examine the range of support (a) informational, (b) emotional, (c) esteem, (d) social network support, and (e) tangible support needs of people living with and beyond cancer, palliative and end-of-life care | 0 | 0 | 1 | 5 | 18 | 95 | 0 | 0 | 0 | 0 | 6 | 100 |
| Analyse models of communication and psychological support for addressing the emotional concerns of patients and/or their caregivers | 0 | 0 | 1 | 5 | 18 | 95 | 0 | 0 | 0 | 0 | 6 | 100 |
| Examine own professional role as part of multi-professional team contributing to person-centred assessment and care for people affected by cancer including self-care, self-management and rehabilitation/reablement | 0 | 0 | 1 | 5 | 18 | 95 | 0 | 0 | 0 | 0 | 6 | 100 |
| Explore own support and development needs and identifying opportunities for clinical supervision, support and development | 0 | 0 | 2 | 11 | 17 | 90 | 0 | 0 | 0 | 0 | 6 | 100 |
Table 3. Levels of agreement regarding modules' level
| Pre-registration students | Health professionals | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Please state your level of agreement with the following statements: | Strongly disagree/disagree | Neither agree or disagree | Strongly agree/agree | Strongly disagree/disagree | Neither agree or disagree | Strongly agree/agree | ||||||
| n | % | n | % | n | % | n | % | n | % | n | % | |
| The learning objectives are relevant to pre-registration healthcare students | 0 | 0 | 0 | 0 | 19 | 100 | 0 | 0 | 0 | 0 | 6 | 100 |
| The content is written at the right level for pre-registration healthcare students | 2 | 11 | 3 | 16 | 14 | 74 | 0 | 0 | 0 | 0 | 6 | 100 |
| The content is appropriately challenging for pre-registration healthcare students | 1 | 5 | 4 | 21 | 14 | 74 | 0 | 0 | 0 | 0 | 6 | 100 |
| The content is too basic for pre-registration healthcare students | 16 | 84 | 2 | 11 | 1 | 5 | 6 | 100 | 0 | 0 | 0 | 0 |
| The suggested workplace activities are helpful and relevant to pre-registration healthcare students | 0 | 0 | 2 | 11 | 17 | 90 | 0 | 0 | 0 | 0 | 6 | 100 |
| These modules could increase pre-registration healthcare students' confidence about cancer care in practice | 0 | 0 | 1 | 5 | 18 | 95 | 0 | 0 | 0 | 0 | 6 | 100 |
From the qualitative comments, when asked what they liked about the modules, students highlighted: modules are interactive, informative, and easy to navigate; helpful for learning about cancer and cancer care; perceived link and continuity with post-registration resources; and pitched correctly at learner's level. Exemplar quotes are presented in Table 4.
Table 4. What students liked about the modules
| Area | Exemplar quotes |
|---|---|
| Modules are interactive, informative, and easy to navigate | ‘The revision activities were helpful’‘They are engaging and go into just the right amount of detail. I like how the information is delivered, its interactive and so keeps me engaged.’‘They were engaging and informative. Easy to navigate and follow-up information is relevant, and information is separated into different categories to be understandable.’‘I like that they have interactive parts to them to keep you interested and involved.’ |
| Helpful for learning about cancer and cancer care | ‘I liked that they provided lots of useful information surrounding the topic’‘It increased my knowledge around cancer vastly and I found it an effective way of learning.’‘They cover cancer care in all aspects and the assessment section is very helpful in recounting what you've learnt.’‘I enjoyed learning about cancer care.’ |
| Perceived link and continuity with post-registration resources | ‘Provides good basic overall grounding of context. I also feel that if the post-reg training is similar then it would be very useful to review again once qualified and working in practice.’ |
| Pitched correctly at learner's level | ‘I liked that they were written in a way that allowed me to understand the science and complexity of cancer in the body but also explained in a way that made it easy to follow.’‘I thought the content was well laid out. It provided a lot of information which was all broken down making it easier to comprehend as a pre-reg nurse. I also really liked how there was a good chunk of detail on each subject, not just a one-line definition.’ |
Areas of improvement were identified by students in the free text comments. These include:
- Reinforce online learning with live lectures
- Simplify the science of cancer module
- A lot of new information to learn
- Improve navigation of virtual platform.
These are listed on Table 5 with exemplar quotes provided.
Table 5. Areas for improvement identified by students
| Area | Exemplar quotes |
|---|---|
| Reinforce online learning with live lectures | ‘I think the e-learning modules are useful, but I also feel that some of that content should be taught in the live teaching sessions … As for someone who's not had any experience with cancer care, it would have been nice to have this information at the start.’ |
| Simplify the science of cancer module | ‘The scientific side was a lot to learn in a short period of time although it was well explained.’‘The science of cancer module was exceptional, rich in medical information; it was quite hard to fully take in.’ |
| A lot of new information to learn | ‘Unsure if I will remember any of this content before being able to use it within practice.’‘I thought it was quite hard to remember a range of difficult information.’‘There is a lot of information to take in, so if this was given as an optional module with no credits assigned to it students may find it overwhelming.’ |
| Improve navigation of virtual platform | ‘The registering of the answers didn't always work, but the modules were very good.’‘Key words or important information should be in bold or colour.’‘Maybe make it a bit easier to navigate.’‘Reflections and typing answers took too long’ |
Health professional survey
In total, six health professional participants – four allied health professionals and two nurses – completed the evaluation questionnaire. Of the participants, three said that more than 75% of their role involved patients living with and beyond cancer, and the others ranged from 25% to 75%. Length of experience working with people who may be living with or beyond cancer was spread across 10 years or less (n=2), between 11 and 20 years (n=2), and more than 20 years (n=2).
Overall, health professional participants found the modules either very good (n=5) or good (n=1). All professionals agreed or strongly agreed the learning objectives were relevant to pre-registration healthcare students and written at the right level (Table 3). All agreed or strongly agreed the modules could: increase pre-registration healthcare students' knowledge and understanding of cancer and its treatment, increase confidence about cancer care in practice, support students to describe the biological basis of cancer, support students to examine the range of support for people living with and beyond cancer, analyse models of communication and psychological support and examine their own professional role (Table 2).
Health professionals particularly liked the ‘interactive nature’ of the module with ‘work activities’ for the learner. They also highlighted the importance of providing a ‘range of relevant resources’ with links for ‘further evidence searching’. They found the ‘workplace questions’ and ‘overview of policy context’ very good and useful for students. They mentioned that the module was an ‘excellent resource’ that was ‘logical and easy to follow’.
Areas identifed for improvement included:
- Simplify the science of cancer module
- Improve site navigation
- Review representation – eg, genders of case examples
- Include a self-assessment at the end of the personalised treatment section
- Ensure acronyms/abbreviations are spelled out or avoided
- Ensure links and data are recent Actions taken following the review are highlighted in Table 6.
Table 6. Modifications following evaluation and peer review
| Suggestion | Actions taken |
|---|---|
| Some content too advanced for pre-registration students | All content reviewed to ensure appropriate for pre-registration audience. The science of cancer module was simplified |
| Include self-assessment within each module | Self-assessment and reflective questions have been included in all modules |
| Review gender representation | All representation reviewed by team and by technology enhanced learning quality assurance team |
| Avoid acronyms | All acronyms removed where appropriate or full explanations given |
| Ensure links and references are up-to-date | All links checked to ensure accuracy and relevance. All references updated to within 5 years unless seminal work |
| Improve site navigation | Digital platform has migrated to a revised platform with improved navigation |
Final online modules
From Spring 2023, The Foundations of Cancer Care online modules will be able on the NHS Learning Hub (https://learninghub.nhs.uk) and will be freely accessible to all those with an NHS or UK university email address, or with an Open Athens account. Modules include:
- The context of cancer
- The science of cancer
- Personalised treatment and care for cancer
- Understanding the impact of cancer on the individual, families and health professionals
- Living with and beyond cancer
- Palliative and end-of-life care
- Self-care, ethics and clinical leadership in cancer
- Communication and team working in cancer care
- Evidence-based practice and applied research in cancer care.
Modules include factual content supported by suggested workplace activities, reflective practices and self-assessments. Each incorporates text, figures, diagrams, links to patient experience videos, podcasts, policies and charity websites. Every module summarises the key points and students are signposted to additional e-learning opportunities and further reading.
Discussion
Over a third of students in this review had no cancer experience at all and almost two-thirds had not experienced a clinical placement in a cancer setting. Lack of clinical placements is a recognised issue and novel approaches, such as simulation and virtual placements, have been adopted for cancer care to good effect (Croxford et al, 2021). However, access to such placements remains limited. In addition, due to pressures to meet all standards set out by professional regulatory and statutory bodies, pre-registration curricula can include limited opportunity for in-depth study of any speciality (Collier-Sewell et al, 2023), including cancer. This lack of exposure to cancer during pre-registration programmes can lead to students feeling ill-prepared to care for people affected by cancer. This reinforces the need for resources such as The Foundations of Cancer Care.
Feedback from both students and health professionals suggested simplifying the module on the science of cancer. Globally, there are recognised challenges in teaching biosciences and pathophysiology in health care. Although nursing students recognise the need to understand bioscience (Taylor et al, 2015; Barton et al, 2021) it can be perceived as harder and more difficult to learn and apply than other aspects of healthcare knowledge (Craft et al, 2013; Barton et al, 2021). Furthermore, education providers can find it challenging to convey the significance of learning about anatomy and physiology (Satoh et al, 2023). However, bioscience knowledge can help to contextualise and tailor holistic nursing care to individual patient needs (Montayre et al, 2021). In response to the feedback on the science of cancer module, the team felt it was appropriate to simplify the content, especially as the module may be used as stand-alone learning by students and students may not have opportunity to ask questions to deepen their understanding.
Conclusions
Peer review has demonstrated that The Foundations of Cancer Care e-learning provides a useful resource for pre-registration healthcare students to learn about cancer care. The review was limited by the small number of student participants and, if repeated, it would be advantageous to include allied health professionals and students from more than one higher education institution. However, it provided opportunity for the modules to be modified in response to the feedback ahead of final release to students.
Although these modules provide a comprehensive foundation for cancer education, students would benefit if they were used in conjunction with additional reading, face-to-face sessions, and specialist cancer education to facilitate their learning and understanding. Guidelines to support higher education institutions to increase cancer education into their programmes would be helpful. Evaluation of the impact of the modules on students' learning and clinical practice is underway.
KEY POINTS
- Pre-registration healthcare students can have limited access to specialist cancer education and cancer clinical placements during their pre-registration programmes and can, therefore, feel unprepared to care for people affected by cancer
- E-learning modules can be an effective method to increase students' knowledge and understanding of cancer
- The use of e-learning in conjunction with additional learning opportunities, such as supplementary reading, face-to-face sessions, discussions, action learning sets and mentorship are advocated to deepen students' knowledge and understanding
CPD reflective questions
- How is cancer education delivered in your pre-registration programme and how does this align to the Foundations of Cancer Care module in the ACCEND Framework?
- How can this learning enhance your practice to support the care you deliver to people affected by cancer?
- What are the challenges of integrating this learning in your delivery of cancer care education?
- How could this eLearning support experiential and/or reflective learning for students?