The Organ Donation (Deemed Consent) Act 2019—known as Max and Keira's law—has passed through the final legislative process, becoming law in England on 20 May 2020. This law saw organ donation change to an opt-out system. This means that, unless a person has recorded a decision to opt out, is in an excluded group or has nominated someone to make a donation decision for them, it will be considered ‘deemed’ that the individual has agreed to donate their organs.
In order to educate staff involved in organ donation in England on the legislation change, a tri-modular, blended learning approach was developed by NHS Blood and Transplant (NHSBT). Module 1 training began in November 2019 and was completed and evaluated at the beginning of January 2020 (Miller et al, 2020). Module 2 training began in January, with plans to run until the beginning of April 2020. However, the COVID-19 pandemic disrupted the planned training activities.
During a House of Lords debate on 18 May 2020, Lord Bethell acknowledged that deemed consent might not come into practice straight away because of the pandemic, the need to ensure transplants go ahead when it is safe, and when training for returning specialist nurses had been completed (Bethell, 2020). Therefore, specialist nurses could apply deemed consent in practice only once they had completed their legislation training. Despite the pandemic, NHSBT staff were able to redesign and deliver the training to the specialist nurse workforce in just 8 weeks.
The introduction of deemed consent legislation requires changes to the organ and tissue donation conversation specialist nurses have with the family in cases where consent can be deemed. The change in the law means that, when someone dies, if they have not recorded or expressed a decision and are not in an excluded group, the default position will be that consent to donate will be deemed.
The aim of the tri-modular approach to education and training for the legislation change is to meet NHSBT's commitment to the Department of Health and Social Care (DHSC) for 100% of specialist nurses participating on the on-call rota to be trained and supported through participation in three legislation modules. The training will enable the specialist nurses to recognise a potential deemed conversation, support hospital staff and adapt their conversations with families to reflect the deemed legislation.
The education and training plan was designed as a tri-modular approach, covering:
The training is being delivered by seven members of the NHSBT Legislative Change Team (LCT), seconded into specific roles for this fundamental and historically ground-breaking project. The specialist nurses—organ donation (SNODs), specialist requesters (SRs), specialist nurses—tissue donation (SNTDs) and all staff members closely involved in the donation process are therefore required to participate in education and training that will further enhance their understanding of deemed consent and how to apply the legislation in clinical practice (Hubner et al, 2020).
Module 2
A report on the evaluation of module 1 was published in March (Miller et al, 2020). Since then, training on module 2 has been completed and evaluated. The LCT reviewed how well the delegates perceived the module objectives had been met and any lessons to be learnt to shape the implementation of future modules.
Design
Module 2 training was designed as a face-to-face module. However, close to completion of delivery by this method, COVID-19 forced NHSBT to adjust plans. Efforts focused on keeping the workforce safe. The redeployment of specialist nurses to frontline NHS services, and restrictions placed on travel and social distancing meant the final training sessions were adapted and delivered via video conferencing. An exploration of the impact of these changes will be considered in this article.
The design of the education and training in module 2 was built on module 1, using an evidence base of research findings and experiences following the implementation of the Human Transplantation (Wales) Act (2013), which saw the introduction of deemed consent in Wales in 2015 (Noyes et al, 2019).
Training for modules 1 and 2, were designed using adult learning theory (andragogy) (Knowles, 1980). Training incorporated:
Feedback from critical friends
In order to test the design and build of the materials before delivering module 2, two ‘critical friend’ days were hosted. On day 1 colleagues (n=24) from NHSBT's Organ and Tissue Donation and Transplantation (OTDT) Professional Development Team (PDT) and legislation project teams were invited to critique the content for its learning potential and provide real-time feedback because of their education knowledge and skills. On the second day, education specialists from complementary areas of health care such as palliative care, and professionals working in end-of-life care, were invited to critique the module, as well as an organ donor family member. Both of the ‘critical friend’ days allowed us to obtain vital feedback regarding the legislation content and the educational value to delegates. The following quotes are a selection from those who attended a critical friend day.
‘It is clear that you are very good communicators … there are no hidden agendas … only that you want to be successful and are working as a team to ensure that the project is successful. I will be using forum theatre in my own teaching.’
‘Good to see complex situations being dealt with compassionately and by experts.’
‘Good use of different media, building on the narrative throughout. Inclusive facilitation. Acknowledged learning from what didn't go so well previously. Be human, be kind—the story is changing but humans are not—connect and influence. So good to hear specialist nurses ask what faith means to the person.’
‘Good to be involved to know that donor families are in safe hands.’
‘Brilliant to know that you are saying what you are seeing with the family. Compassion and rapport building evident. Great to be involved.’
Content
Module 2 aimed to:
Module 2 began with 15 face-to-face sessions and, in response to the pandemic, nine virtual sessions. These were hosted by the LCT with the same expectation that all team managers (TMs), SNODs, SNTDs and SRs would attend a session. The delegates were mixed to enable a richness of shared practice; the maximum attending from one regional team was six people. Where possible, specialist nurses from either the South Wales region or the North West region (which includes North Wales), were in each session to share their experiences and knowledge of working in deemed legislation in Wales.
The principle of sharing practice was replicated from the annual Shared Professional Practice Course (SPPC) (Scales and Bentley, 2020), which all on-call specialist nurses attend to share practice and receive updates to current practice. Forum theatre is also used in the SPPC.
There were no mop-up sessions arranged, which meant strict booking measures and monitoring of staff attendance was key and undertaken by a business support officer in conjunction with the legislation champions in each regional team. These champions are experienced specialist nurses who help embed the legislation in each of the regional teams.
Learning from module 1
LCT members were fortunate in having the evaluation from attendees in module 1 and could apply what was learnt to module 2, to continue ensure it was high quality.
The vlogs used in module 1 were well received, but there were some problems with the technology, which sometimes failed. With support from digital learning colleagues, videos were developed depicting deemed consent conversations, with actors role-playing family members and specialist nurses applying the deemed legislation to various scenarios. The videos were filmed and edited by a professional videographer, which meant the picture quality and sound was excellent and transferable as a future learning resource to be held on NHSBT's digital learning platform.
Testing the training materials that were developed as part of module 1 with critical friends in the education and project team was helpful, as was the module 2 feedback from critical friends.
Building module 1 training based on draft codes of practice had been challenging. Some of the specialist nurses said that this created uncertainty in some aspects of the legislation. Using this feedback, the LCT worked with the Human Tissue Authority to help shape the codes of practice in readiness for module 2 (HTA, 2020).
Format
Each training session ran for 4.5 hours. The morning session comprised recapping module 1, shared practice and groupwork focusing on deemed consent scenarios. The afternoon session incorporated forum theatre using potential deemed consent scenarios. This was used to encourage audience interaction from the specialist nurses. Each session was facilitated by two professional development specialist (PDS) facilitators from the LCT.
Virtual training
Owing to the social distancing restrictions brought about by the COVID-19 pandemic, all non-essential travel was restricted during March 2020. Therefore, the remainder of module 2 was redesigned to be facilitated on an online platform. Virtual training was devised by adapting the face-to-face training but without the forum theatre element. Four online sessions were held on the same dates as the planned face-to-face modules, with one extra date added. Delegates were divided into morning and afternoon sessions lasting 2.5 hours each and facilitated by two of the LCT members who had delivered the face-to-face training.
Results
This evaluation will consider the data separately and draw comparisons between face-to-face and virtual training. The results are displayed below using headings based on the evaluation questions attendees answered after completing their training and are split between face-to-face and virtual training.
Attendees trained by job role
In total, 303 people received module 2 education and training. Of those, 228 (75%) received face-to-face training and 75 (25%) virtual training. Of the face-to-face delegates, 224 (98%) completed an evaluation whereas 41 (55%) did so following virtual training.
NHSBT was able to train 100% of the specialist nurses who were working on the on-call rota at that time. Fifteen members of staff were unable to attend the on-line module 2, due to redeployment to priority NHS services, family bereavement, sickness or social isolation and on-call commitments. These people were given the opportunity of watching a pre-recorded virtual module 2 to enable them to experience module 2 in preparation for the final module 3. This watching of the video equated to their training.
In Tissue and Eye Services, NHSBT trained 100% (16/16) of the staff taking consent—69% face to face and 31% via the digital platform.
The face-to-face training was attended predominantly by SNODs/SRs/TMs, SNTDs, PDSs and other staff. The average number of people on each face-to-face training course was 14, ranging from 5 to 21. Virtual training was attended predominantly by SNODs, SNTDs, SRs and PDSs. The average number of people on each virtual training course was 8,.
Overall rating for the education and training
For face-to-face module 2, the overall rating for education and training was 9.1/10, and for the virtual module 2 it was slightly lower at 8.3/10, giving an overall score of 8.53.
Was there a wide range of course materials and media?
See Figure 2. Of those who completed an evaluation of the face-to-face education and training (n=224), the majority (n=218; 97%) reported there to be a wide range of course materials and media that were appropriate to meet their individuals learning needs. While 5 people (2%) felt this was slightly true, only 1 person disagreed.
In respect of the virtual education and training 39 people (95%) of those who evaluated the module (n=41), reported there was a wide range of course materials and media to meet their learning requirements; 2 people (5%) stated that was slightly true, no one disagreed.
Did the course increase your knowledge and understanding of the legislation change and relevance to practice?
See Figure 3. Most people (n=213; 95%) evaluating the face-to-face education and training indicated that the course had increased their understanding of the deemed consent legislation changes and the relevance this had for discussing organ donation with potential donor families. Three per cent (n=7) felt this was slightly true, and just 4 people (2%) disagreed.
Everyone (n=41; 100%) evaluating the virtual education and training indicated that the course had increased their understanding of the deemed consent legislation changes and the relevance this had for discussing organ donation with potential donor families.
What went well?
Feedback from the face-to-face sessions was unanimously positive, particularly regarding the use of forum theatre, having the opportunity to practise the deemed consent conversation, share practice with fellow colleagues and feel involved and able to contribute. The videos were evaluated as excellent activators and enhanced the blended learning experience.
People appreciated the recap from module 1 and found the videos ‘powerful’ and ‘thought provoking’, especially one depicting an intensive care consultant's experience of implementing the deemed consent legislation in Wales.
Facilitation of the sessions was considered good, with a typical comment being:
‘Delivered well and in a clear and concise manner, with relevant information to the job role.’
Virtual feedback was also positive and evaluated the trainers as ‘enthusiastic’ and praised their ability to ‘remain interactive despite not being face to face as originally intended’. It was ‘interactive’ and ‘well paced’. The ‘creativity in getting people involved and working differently’ was also noted. Overall, module 2:
‘… was delivered very well, considering it had to be done virtually and at such short notice.’
What could be better?
Feedback from the face-to-face sessions for areas of improvement, included a request for:
‘More engagement from the attendees in forum theatre, but that wasn't anything that the PDSs could have improved as it was very engaging.’
‘Maybe slightly more time for discussions, as it felt there could have been even more that was shared.’
Another attendee said:
‘Having some hard copies of the consent form available for those less familiar with parts A, B [and] C would have been beneficial, along with some factsheets and reference guides.’
Where deemed consent applies, section C of the consent form is to be completed. Before the introduction of deemed legislation in England, this section of the form was used only in Wales and Jersey, which operated under deemed consent legislation, so many attendees working in England would be unfamiliar with it. Although the consent form was projected on the screen, a hard copy would have been beneficial. Some people also wanted more examples of practical communication strategies and suggested phrases to use in conversations.
In the evaluation of the virtual training sessions, attendees acknowledged that the use of forum theatre would have been useful but understood why this was not possible during the pandemic because of the rules on travel and social distancing. One attendee stated:
‘Training would obviously be better face to face. It felt like we missed out on practising the approach scenarios.’
Would attendees recommend the training to other colleagues?
See Figure 4. Of the respondents evaluating the face-to-face training, 210 (94%) stated that they would recommend the training to colleagues. Although there were 11 (5%) people who said they might recommend the training to colleagues, just 3 (1%) said they would not.
In comparison, 38 (93%) of the respondents who attended the virtual training would recommend it. Although there were 3 (7%) who said they might recommend the training, no one suggested that they would not recommend it.
Conclusion
In conclusion, module 2 was received face to face by 75% of the workforce (n=228) and by virtual means by the remaining 25% (n=75) of the workforce, including the 15 people who for various reasons missed module 2 but were able to access an online video of module 2 and bring themselves up to speed, prior to module 3.
The face-to-face elements of the training, with the use of forum theatre, were the highlight of this module and were much missed by those who received the virtual training.
On a positive note, the virtual version was well received and considered to be paced appropriately by enthusiastic trainers, which is reassuring because this is the proposed method of delivery for the final module, module 3, due to COVID-19 restrictions around travel and social distancing still being in place.