The Government recently passed the Organ Donation (Deemed Consent) Act 2019, a new law to change the mode of consent for organ and tissue donation in England from 2020 (Hubner et al, 2020). The introduction of deemed consent legislation means that we need to modify the way that the organ and tissue donation conversation with families is conducted. The new law for consent for organ and tissue donation means that in the future when someone dies, if they have not recorded or expressed a decision, the default position will be that consent to donate will be ‘deemed’.
Education
The aim of the modular approach to education and training for the legislation change is to meet the Department of Health and Social Care's (DHSC) commitment for 100% of all specialist nurses/specialist requesters participating on the on-call rota to be trained and supported through participation in four legislation modules.
The education and training plan from NHS Blood and Transplant (NHSBT) has a modular approach, covering:
The training is being delivered by seven members of the Legislative Change Team (LCT), seconded into specific roles for this fundamental and historically ground-breaking project. The specialist nurses—organ donation, specialist requesters, specialist nurses—tissue donation, 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.
Module 1, on the new legislation, was delivered in autumn 2019.
Purpose of module 1
The purpose of module 1 was to cover the theoretical aspects of the legislation, explaining the inclusion and exclusion criteria for potentially deeming consent lawfully for organ and tissue donation. Participants should be able to understand the tenets of the deemed consent legislation in England and how this transfers to clinical practice. The main objectives of the education and training were to build on current knowledge, develop an understanding of the inclusion and exclusion for deemed consent criteria and know where to find the necessary resources.
Evaluation of module 1
An evaluation of module 1 was completed to review how well the delegates felt that the module objectives have been met and to see what lessons can be learnt, so that subsequent modules can be improved, if necessary, while there is time to do so.
Method
The design of the education and training for module 1, was based on evidence from the experience of introducing the Welsh deemed consent legislation (Noyes et al, 2019). Adult learning theory (andragogy) (Knowles, 1980) was applied, as adults learners tend to be more self-directed, internally motivated, and ready to learn by relating theory to clinical practice and building on existing knowledge.
The module was designed to deliver theoretical information based on the Organ Donation (Deemed Consent) Act 2019 and the draft Human Tissue Authority (HTA) Code of Practice(F: Donation of solid organs and tissue for transplantation) (2017). The module design incorporated shared practice through digital learning, such as video logs (vlogs), to encourage dialogue and critical thinking and an interactive quiz to consolidate learning. To test the design and build of the materials, a ‘critical friend’ day was hosted, to which 24 colleagues from the Organ Donation and Transplantation (ODT) Professional Development Team (PDT) and legislation project teams were invited. They had the education knowledge and skills to critique the content for its learning potential and provide real-time feedback.
The content for module 1 comprised:
Further to the critical friend's day, 14 more sessions were hosted within regional operational team meetings, with the expectation that all team managers, specialist nurses in organ and tissue donation and specialist requesters would attend their own regional team meeting or a neighbouring team meeting. Slots on routine team meeting days were secured to minimise the operational burden. To ensure all staff received the education and training, we factored in three extra face-to-face mop-up sessions, geographically split between the north and south of England.
The sessions ran for 3 hours and were facilitated by two professional development specialist facilitators from the Legislation Change Team (LCT). A back-up facilitator from the LCT was assigned to each training date in case of competing on-call priorities, sickness or unanticipated absence.
Results
In total, 333 people received module 1 education and training. Of those, 298 people completed the evaluation (this included 24 of the internal ‘critical friends’). The majority of those attending the training were specialist nurses—organ donation (n=173) (Table 1). The average number of people at each training session was 17. However, numbers ranged between 4 and 33 people at each session.
| Attendees trained by job role | Number |
|---|---|
| Specialist nurses—organ donation | 173 |
| Specialist requester | 43 |
| Team managers | 29 |
| Other staff | 20 |
| Professional development team staff | 17 |
| Specialist nurses—tissue donation | 8 |
| Regional managers | 7 |
| Specialist nurses—organ donation (family care) | 1 |
Whether attendance numbers were small or large did not appear to detract from the learning experience. What was apparent was that the final three face-to-face mop-up sessions attracted the largest numbers of participants. In theory, if people were able to attend their team meeting dates or neighbouring regional dates, there would not be a need for further mop-up sessions. However, on-call commitments and unplanned absences prevented staff from attending. This was the first taught module on the new legislation and, possibly, people may not have appreciated the importance of prioritising booking the training. For future modules, the booking system has been amended to mitigate the need for further mop-up dates.
Despite building in the mop-up sessions, two extra Skype calls were required, to capture the remaining 8 people. However, these learners did not find this approach engaging, primarily due to the poor sound quality of the vlogs.
Overall rating
The overall rating for module 1 was almost 9 out of 10 (Figure 1).
Range of course materials and media
The majority of people (n=290) evaluating the education and training reported there to be a wide range of course materials and media that were appropriate to meet their individuals learning needs. Although 8 people felt this was only slightly true, nobody disagreed (Table 2).
| Course materials and media was appropriate and met learning needs | Number |
|---|---|
| Extremely true | 213 |
| Somewhat true | 77 |
| Slightly true | 8 |
| Not true | 0 |
| Training increased understanding of the legislation change and relevance to practice | Number |
| Extremely true | 205 |
| Somewhat true | 71 |
| Slightly true | 21 |
| Not true | 1 |
| I would recommend the training to other colleagues | Number |
| Yes | 281 |
| No | 3 |
| Maybe | 14 |
Knowledge and understanding of the legislation change and relevance to practice
Most (n=276) people 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. Although 21 people felt this was only slightly true, just one person disagreed (Table 2).
What went well?
Overall, the feedback was positive, citing excellent delivery and good interaction. People reported that the quiz and vlogs helped consolidate their learning. The training was viewed as extremely relevant and engaging. Some typical comments included:
‘Great facilitation, highly knowledgeable and delivered the training at a great pace.’
‘Extremely relevant and interesting.’
‘Vlog scenarios to bring the legislation to life. There were varied formats of content …’
‘Excellent delivery. Good interaction and range of materials to support the delivery of the course. Particularly enjoyed the quiz as consolidation for the information delivered.’
‘Great engagement and informative.’
What could be better?
Respondents reported a few shortcomings of the training. As the module was developed from the draft HTA Code of Practice, some questions could not be fully answered at this stage of the training. On occasion there was a problem with the technology. Audio for the vlogs was compromised due to poor IT systems both internally and externally and when this happened, evaluation was consistent that this should be an area for improvement. Typical comments from trainees included:
‘Some conflicting messages as some of the legislation not finalised. May have been better to have training when final HTA Code of Practice available so answers to queries are correct.’
‘It would have been better had IT been more successful, otherwise a really good introduction to the legislation.’
‘If the volume in the video clips were louder.’
‘A couple of the scenarios could have been slightly more complex or have a hidden situation to make delegates think more.’
Would you recommend the training to other colleagues?
Some 94% of the respondents would recommend the training to other colleagues, 5% said they might recommend the training to other colleagues and just 1% said they would not (Table 2).
Any other comments?
In total, 125 people responded in the any other comments section, which was not a mandatory field. Comments included:
‘The “car park” board [a flip chart where any questions could be added] is a good idea. Educators willing to research unusual and/or difficult questions and feedback answers to the group. Thanks for a really worthwhile session.’
‘Perhaps more helpful to those teams not working with deemed consent already.’
‘Really good to discuss queries in a “safe environment” with colleagues.’
‘The quiz was fun.’
‘Really enjoyed the training and very informative. Looking forward to module 2.’
Conclusion
The education and training for legislation module 1 was well received and viewed by the majority as an excellent and engaging module with the added benefit of digital technology such as the vlogs and an interactive quiz.
In South Wales, where deemed consent legislation has been in place since 1 December 2015, a tailored approach by the PDT facilitator from the LCT based in South Wales has been undertaken. The South Wales team just needed to know what was different in England as they cross-cover into England.
Although there was 100% attendance on module 1, this was not achieved without challenges and the numbers on the face-to-face mop-up sessions created very large groups—one mop-up session had 33 attendees whereas an earlier course had just four people attending.
As a result, a more a proactive approach has been taken for modules 2, 3 and 4, with ‘real time’ monitoring of the course bookings. The business support officer in conjunction with the legislation champions and team managers are required to report back to the legislation change team manager with an update of those who are booked on for modules 2 and 3 so that a current tally can be kept, in order to capture any outliers in good time and ensure, where possible, everyone is booked in for training.
Those attending the two mop-up Skype sessions faced problems with the technology. The facilitators overcame the problem of poor-quality sound on the vlog by reading the vlog script, rather than relying on sound from the vlog. A new microphone has been purchased so that future vlogs can be made with optimum sound quality.
The LCT has learnt that face-to-face training is the best mode for the legislation training due to the benefits of sharing practice and group work. The LCT will continue to look at innovative methods for teaching, including digital technologies and ensure testing is carried out to ensure audio quality.
Forward planning in conjunction with the business support officer, legislation champions and team managers in booking people on to module 2 (national training dates) and module 3 (regional and three cluster training dates), is being planned to avoid a last-minute rush and extra mop-up sessions being provided unnecessarily.
Having a ‘critical friends’ day was invaluable to test the training materials. The feedback was overwhelmingly positive from the ODT PDT and project team. For module 2 the approach was taken to extend the invite to external critical friends from the wider NHS end-of-life and palliative care environments, external to NHSBT, including a donor family representative. In preparation, a feedback form has been designed to collate specific feedback on course content and generate a knowledge base of shared learning from our critical friends.
To bolster support for our PDT LCT members, particularly those new to education and training and facilitating training, each course in module 2 will have two LCT PDT members, one of whom will have previous forum theatre experience. In forum theatre, professional actors play family members and simulate donation conversations with specialist nurses/requesters as a way of practising conversations about organ donation and deemed consent in a safe environment
Feedback on module 1 was overwhelmingly positive, and all feedback will be used to make improvements in future training. This is an exciting time and we are constantly evaluating and assessing our educational input into supporting the legislation change to improve consent rates and ensure there are more organs available for transplantation.