Healthcare organisations currently face multiple challenges in delivering safe, effective nursing care in environments that are becoming increasing complex (Draper et al, 2014). Acute tertiary hospitals require knowledgeable, skilled registered nurses to care for patients in specialist areas (Ryder et al, 2018); thus, continuing professional education (CPE) is fundamental in ensuring that frontline nurses are able to practise safely and effectively (Manley et al, 2018). Although much of the literature calls for empirical evidence in relation to the impact and outcomes of CPE (Hegney et al, 2015; Lee, 2011; Clark et al, 2015), it is also essential that an understanding of the process for the development and delivery of effective CPE is established. There is little empirical evidence in relation to the outcomes of CPE, so further evidence is required into the key roles of stakeholders in the process of development and delivery of effective CPE (Draper et al, 2014).
This article sets out to understand the perceptions of stakeholders about a new curriculum design, and its development and delivery for continuing e-learning education for nurses in an acute environment. It reports on stage 5 of an action research project from focus groups that involved key stakeholders. The overall project was developed for the purpose of redesigning and restructuring CPE courses for nurses in an acute academic teaching hospital in the Republic of Ireland. Stage 1 of the action research project has been reported in Ryder et al (2018) and involved the initial evaluation of existing CPE courses.
The action research cycle used in this project is outlined in Figure 1. Stage 2 involved the development of a template for e-learning content underpinned by constructive alignment theory (Biggs and Tang, 2011) and instructional design principles that were aligned with the concept of a flipped classroom. Stage 3 involved initial implementation and observation with stakeholders, while stage 4 involved full implementation of the redesigned and restructured CPE courses.
Methodology
CPE is a collaborative process involving management, and clinical and education staff. Participatory action research was identified as a suitable methodology because it facilitates a collaborative relationship involving stakeholders as participants in a process of inquiry about change (Froggatt and Hockley, 2011; Stringer, 2013). Evaluation is fundamental to action research through the process of data gathering and comparing the situations before and after a change of current workplace practices as they relate to the design, development and delivery of CPE (Froggatt and Hockley, 2011; Crozier et al, 2012).
Recruitment and sampling
Purposeful sampling was used to select participants (Creswell, 2017). A total of 48 nurses from across the organisation were invited to participate in the study. Those invited had all been involved in the development, delivery and support of the CPE courses. Three focus groups were held, with a total of 20 nurses taking part in the interviews. Participants were drawn from a range of roles across the organisation: education and practice development, clinical facilitation, clinical nurse managers, and clinical nurse specialists. Details of the focus groups and participants are presented in Table 1.
| Description | Number | Gender | Job position of focus group participants | Duration of focus group | |||
|---|---|---|---|---|---|---|---|
| Group 1 | Education staff | 7 | Female | (7) | Director of education and practice development | (1) | 66 min 50 s |
| Assistant director of nursing | (1) | ||||||
| Nurse tutors | (4) | ||||||
| Nurse manager | (1) | ||||||
| Group 2 | Facilitators and authors of the learning units | 8 | Female | (8) | Clinical nurse specialist | (1) | 56 min 13 s |
| Advanced nurse practitioner | (1) | ||||||
| Clinical facilitators | (6) | ||||||
| Group 3 | Managers | 5 | Female | (4) | Assistant director of nursing | (1) | 47 min |
| Male | (1) | Ward managers | (4) | ||||
Data collection
The research design ultimately guided how the focus groups were constructed. Each group was made up of homogeneous participants in terms of the nature of their experience of the change process. Ground rules for the conduct of the focus group were outlined to participants in order to ensure that each felt secure in sharing their experiences and to help make them feel at ease (Jayasekara, 2012: Krueger and Casey, 2015). Data were collected from all three focus groups.
Focus groups are widely acknowledged as a useful and effective mechanism, whereby a group jointly constructs meaning about a topic (Bryman, 2012; Jayasekara, 2012). The primary goal of focus groups is to use interaction resulting from discussion among participants to increase the depth of the enquiry and reveal aspects of the phenomenon assumed to be otherwise less accessible (Doody et al, 2013a). The use of focus groups with key stakeholders completed the action research process, whereby stakeholders were seen as equals to the researcher, participating in a process of inquiry and change through continual alteration between practical decision-making and reflective evaluation (Froggatt and Hockley, 2011; Stringer, 2013; Winter and Munn-Giddings, 2013).
The focus groups were conducted by a moderator external to the organisation (MC) and the principal investigator (MR). The external moderator assisted in establishing neutrality regarding the change process and also reduced the potential for coercion or conflict of interest (Shaha et al, 2011). The moderators were experienced researchers, and were skilled at interviewing and managing groups, group dynamics and group discussion (Doody et al, 2013b). The duration of the focus groups was between 47 minutes and 66 minutes 50 seconds, and all focus groups were completed in one sitting. The duration of the focus groups was sufficient to address the required topic areas in order to answer the research question, while ensuring that it was within the general physical and psychological limits for participants (Krueger and Casey, 2015).
A semistructured interview guide, which was based on teaching, learning and outcomes, was used for the focus groups (Box 1). The three topic headings had been previously used in stage 1 of this study in the format of a self-assessment questionnaire. The schedule was used as a guide to stimulate discussion, however the moderator also probed responses and asked specific questions related to responses that were not specifically included in the interview guide (Doody et al, 2013b). The moderators were responsible for creating a safe environment and facilitated discussion whereby all participants were enabled to share their opinions while maintaining the topic based on the interview guide (Shaha et al, 2012). All focus group interviews were digitally recorded, downloaded and securely transmitted via email for transcription.
Data analysis
Thematic analysis was used to identify themes that emerged as being important (Creswell, 2017). Data were analysed using MAXQDA, a data management software package.
Ethical considerations
Ethical approval was obtained from the nursing research and innovation committee of the organisation where the study took place. All participants were assured of confidentiality and anonymity in reporting. Prior to commencement of the focus group interviews, the purpose of the study and the ground rules for the focus group were reviewed and each participant completed a consent form.
Results
Data analysis yielded four main themes:
Theme 1. The process of change
Participants reflected on their experience of engaging with a new way of delivering CPE courses (including the development of e-learning units) as a process of change and spoke freely about their personal journey, highlighting the importance of feeling and being supported through the process, particularly by education staff.
‘Again, it was a bit of a learning curve, engaging with it. And I had to do it within, you know, a time frame, obviously. But the nurse tutor I worked with, it was a very different situation. She worked hand in hand with me.’
‘From a content perspective, she [education staff member] approached me and I approached my clinical colleagues, who were the clinical facilitators also, to peer review it. And some of the clinical managers as well … And I got a lot of support, actually. And it felt like collaboration …'
Some participants voiced their concerns regarding a feeling of isolation and being left to work on content development without sufficient support, which was attributed to continued staff challenges, particularly skill mix in areas of high acuity.
‘It definitely felt, like, we did all the work, without it being planned or, you know, this is what we're going to do. It was definitely done on top of our other work, and this is happening, and because we are so short staffed.'
Overall, the participants in all the focus groups were keen to speak openly about their experience of the change process and the personal and professional impact it had had.
Theme 2. Lightbulb moments
Participants across all focus groups reflected on their personal experience of engaging with the development of education materials and facilitating learning. For many, this engagement brought with it what is best described as ‘lightbulb moments’, when participants began to sense a greater personal and group responsibility and understanding of the nature of the education development and its impact—mostly positive—on themselves, the organisation and, ultimately, on patient care.
‘… I think, as the whole group, we're kind of on the same page. There's so many variables involved and definitely educational background. I mean, I was dealing with one or two people who'd … they were working so autonomously, maybe in the role … that they were actually able to do this with very little guidance.’
‘So in the area where I work, with several facilitators, it's been quite revolutionary. It's really a structured education. Whereas before … in the last year or so, we've had an influx of new junior nurses. There was a real need to structure the education, whereby it was clear to all senior staff who was on what pathway and on what stage. So having a structured orientation, where we have now, like, an Excel sheet, where we can quickly access who is … and [a] flag even for staff on allocation, [to see] who is at what stage, has been revolutionary.’
While acknowledging the difficulties inherent with change in an acute clinical environment, participants were keen to articulate a sense of ownership of continuing education development, design and delivery.
Theme 3. Learner focused
Participants spoke positively about the impact on staff who had participated in the newly developed CPE courses. There was an overall feeling that the newly developed courses, both online content and related workshops, were more learner focused, clinically relevant and competence driven than previous CPE education offerings.
‘So, before, it was just delivering education, no tricks, no underhand, nothing. And then … you left them in a classroom and you gave them an exam. Or you gave them blended learning … So that's another thing to get your head around. It's not a trick: you present the information, they seek it out and then they answer the question. So that's another thing to change.'
‘… the purpose of the learning units is to kind of enhance their knowledge. And then the purpose of the workshops, or the scenarios, is to develop clinical skills. And combined together, with the workshops and the scenarios and the enhanced knowledge, you should see clinical skills improving. So, you know, just to be clear with what the purpose of each part of it is. And my experience with the feedback, significantly from senior staff, is that there is a hugely increased level of standardised competence emerging … I'm trying to think about four groups through now. So you can, they can, see the difference, but it's standardised as well … you know what I mean.'
One group did express concern about the amount of material that was being delivered and thought it was important that student overload would be avoided, while ensuring that competence was firmly addressed.
‘Like we just overloaded our group, though. And we tend to anyway; they were doing, maybe, four learning units and a couple of workshops in one week … of brand new concepts. Like mechanical ventilation … so, you know, on Monday we'd expect them to start their learning and we're doing a workshop on Friday … Maybe it was just about the level of information.'
Notwithstanding some of the concerns, participants were clear in their appreciation that the new delivery format had changed to a more learner-focused model.
Theme 4. Future opportunities
Participants were keen to explore the future of education development and delivery and the need to continue to use the process that had been implemented. Doing so they felt would help nurses who have been working for a long period feel more able to access ongoing development.
‘Some of the older staff … we have a lot of older staff who would love to have some access to the units … so if that could be something that could be looked at, and I do understand that you have to have a security thing … I would have a number of people that are working in the unit.’
Further opportunities in the future were considered, one being the potential to explore the possibility of increasing simulation to enhance learning.
‘I just thought … one thing we had kind of talked about doing … it'll be a little bit further down the line. It's like a full team, like simulated scenarios, so that will draw in the expertise in a non-didactic way … but bring very good examples and cases for, like, our specialised kind of critical areas.’
A key aspect for the future was to ensure greater communication across the organisation so that positive developments in education are shared at all levels. This would have the potential to positively increase the uptake and completion of CPE.
‘From a communication, organisational point of view I think there needs to be more communication from nurses, what's going on in different areas … what positive stuff is happening, initiatives, where are we now from where we were last year. I know the nurse managers see it at meetings, but that's not filtering, it's all right saying that you know your team, but it's not really filtering down.’
Participants anticipated an exciting future for CPE and also the opportunities it presented for staff who have worked in the organisation for a long time.
Discussion
Change of any kind is difficult, but within a clinical environment with significant acuity the process can be even more difficult (Lumbers, 2018). Participants had to engage with a new way of designing and delivering education using a new theoretical framework, which required a shift of focus from the educator to the learner. It is understandable that such a change to e-learning can cause uncertainty because clinical educators were faced with a new set of circumstances that may challenge their role concept (Koch, 2014). In addition, clinical educators were themselves engaged in a personal journey developing skills for the design and delivery of e-learning. It also marks a significant change in the role of the teacher, with a move from knowledge provider to knowledge facilitator (Biggs and Tang, 2011; Koch, 2014). This was significant because evidence indicates that a number of factors need to be considered when education for nurses is being restructured for e-learning (Schnetter et al, 2014; Stott and Mozer, 2016).
The importance of communication throughout the change process is paramount. At the outset of CPE course development communication regarding expectations of participants, the intended outcomes, time frames and resources must be clearly articulated (Lee, 2011). The use of the action research process in this study clearly facilitated communication between all stakeholders. It has been recognised that there is often a lack of integration between practice and education (Allan and Smith, 2010) and that effective partnerships need to be formed between key stakeholders, where a mutual understanding of each other's perspectives, aspirations and constraints is established (Clark et al, 2015). Draper et al (2016) also identified the need for managers and educators to develop ‘symbiotic relationships’ and work collectively on curriculum development. The shared journey for all the participants reflected a genuinely collaborative partnership between educators and clinicians in the design, development and delivery of learner-focused e-learning.
Participants in this study acknowledged in their 'lightbulb moment' that they now saw the benefits of implementing the new CPE curriculum and their personal contribution to the process. This is an achievement to be celebrated, because the attitudes within an organisation and the attitudes of staff can be particularly hard to change (Lee, 2011). The focus groups were made up of key stakeholders from the clinical, education and managerial section of the organisation, and thus the gatekeepers for the success or failure of the new CPE curricula. Managers have previously been identified as playing a central role in developing and maintaining positive organisational cultures (Draper et al, 2016) and therefore how new knowledge and skills are implemented (or not) in practice (Gould et al, 2007; Tame 2011). Positive change and transfer of skills into the practice environment was identified in this study. This reflects previous findings which reported examples of CPE leading to practice enchantments and knowledge transfer into daily practice (Lahti et al, 2014). This is a significant finding in our study because there is a dearth of evidence to identify the impact on practice of CPE courses (Gijbels et al, 2010).
Participants in the study identified that, by combining online content supported by workshops, the CPE courses resulted in a learner-focused, clinically pertinent and competence course. This finding provides evidence to support the strategies used in the redesigned curriculum to achieve the predetermined CPE course learning outcomes.
Future opportunities identified by participants included the potential to incorporate other technology-enhanced teaching and learning methods, such as simulation, and to embed it into CPE curricula. The use of simulation as an educational tool is becoming increasingly prevalent in nursing education (Shin et al, 2015). The introduction of further simulation had not been identified as a key feature in the original action research project. The potential to integrate it with existing strategies will need to be explored further by the action research team.
Improving access to CPE through the effective use of e-learning has the potential to support the availability of education for all staff to access meeting personal and professional demands (Ousey and Roberts, 2013). It also has the potential to assist participants to learn in a manner that is adaptable to their workplace and promotes lifelong learning by development of independence (Jonas and Burns, 2010).
Conclusion
To date, the impact of CPE courses has mostly been evaluated from the student's perspective, with little consideration to the course leaders or service providers (Gijbels et al, 2010). This paper contributes to the limited evidence of the impact of CPE from the perspective of key stakeholders. It reports on the perceptions of key stakeholders on the development, design and delivery of a new model of CPE education. By doing so, it has explored the ‘journey through’ (Pawson, 2013) the change of CPE design and delivery. This is a process that is not often explored, but it is essential to understand in order to achieve a positive outcome from any CPE intervention (Clark et al, 2015). The process of change reported by the stakeholders was, as expected, difficult for some, but for the majority it was worth the effort because positive outcomes for staff and patients were evident. The benefits of engaging with innovative ways for staff to access and undertake ongoing education for professional development were demonstrated.