|ORIGINAL RESEARCH PAPER
|Year : 2007 | Volume
| Issue : 3 | Page : 85
Learning Education Solutions for Caregivers in Long-Term Care (LTC) Facilities: New Possibilities
CJ MacDonald, R Walton
University of Ottawa, Ottawa, Canada
|Date of Submission||17-Jul-2007|
|Date of Acceptance||08-Sep-2007|
|Date of Web Publication||14-Nov-2007|
C J MacDonald
Faculty of Education, University of Ottawa, 145 Jean Jacques Lussier, Ottawa Ontario, K1N 6N5
Source of Support: None, Conflict of Interest: None
Context: Online learning (referred to as e-learning throughout this article) has proved to be a useful tool for delivering accessible and convenient education to busy clinical healthcare workers. The ABS Management Company specifically designed a program to provide nurses and caregivers with the necessary knowledge and skills to improve the quality of care and the quality of life for the geriatric population in long-term care (LTC) facilities.
Objectives: The purpose of the "Online Solutions: Quality Education for Quality Care in Long-Term Care" program is to use new educational pedagogies and innovative ways to conceptualise and deliver healthcare education to meet the complex issues and concerns of caregivers in LTC facilities.
Methods: During the one-year period that data were collected for this study, 881 caregivers completed the eight (one-hour) modules in the program. Of these, 753 (85%) completed the optional assessment (both the pre and post tests) for one or more of the eight modules. Therefore, of the 881 employees who reviewed all eight modules (881x8 = 7048 modules), 1046 modules (15%) had both pre-post test data upon which to build the analysis.
Findings: Information from the evaluation revealed learner improvement in pre-post test scores in excess of 10%, suggesting an increase in new and relevant skills and knowledge related to abuse and neglect, elopement, infection control, nutrition and hydration, pressure ulcers, provision of basic care and restraints. Moreover, the data indicated a reduction in the use of restraints and occurrence of pressure ulcers, suggesting that learners applied new knowledge and skills in the workplace. Finally, staff turnover rates decreased more than 20% suggesting greater job satisfaction after participating in the program.
Conclusions: The research findings point to an urgent and unmet need to provide more accessible just-in-time, just-for-you education programs for caregivers in LTC facilities to ensure quality and efficient services to residents and their families.
Keywords: Online learning, long-term care facilities, healthcare education, nurse, quality standards, education solutions
|How to cite this article:|
MacDonald C J, Walton R. Learning Education Solutions for Caregivers in Long-Term Care (LTC) Facilities: New Possibilities. Educ Health 2007;20:85
Lifelong learning and constant professional upgrading have become the norm in the healthcare industry. Today’s healthcare providers are expected and sometimes required to participate in professional education courses that provide up-to-date clinical techniques and relevant information enabling healthcare workers to improve residents’ quality of care and quality of life. However, the vulnerable state of long-term care (LTC) residents makes it difficult for healthcare providers to justify time away from caregiving to participate in continuing education programs. New approaches to education and training are being demanded by both caregivers struggling to be efficient and effective in their current jobs, and by employers who want to offer the best service to their patients but who have limited resources to support the time away from work required by traditional program courses (MacDonald et al., 2000; MacDonald et al., 2006).
Planning long-term healthcare education
Planning an education program for healthcare workers in LTC facilities requires consideration of a number of complex concerns and issues (MacDonald et al., 2004). Increased workloads, shift work, high staff turnover, an aging workforce and limited expert resources are challenges in providing continuing education to this population. The diversity of the continuing care and LTC workforce, including assorted professional backgrounds and differing levels of educational aptitude, literacy, experience and seniority further complicate this process. The large number of LTC sites and their distribution across urban, rural and remote areas present additional challenges for effectively and efficiently educating and supporting this workforce. E-Learning has proved to be an appropriate and useful tool to deliver accessible and convenient education that addresses many of the constraints of busy clinical healthcare workers (MacDonald et al., 2006).
E-Learning: Moving toward an education solution
ABS Management designed the “Online Solutions: Quality Education for Quality Care in Long-Term Care” program to meet the complex educational issues and concerns of caregivers in LTC. The purpose of the Online Solutions program is to use new educational pedagogies and innovative ways to conceptualize and deliver flexible convenient healthcare education. ABS Management specifically designed an online program to provide gerontological nurses and caregivers in LTC with the necessary knowledge and skills to improve the quality of care and quality of life of their residents.
Despite the growing prevalence of e-learning in all aspects of our society, there are still some concerns regarding the quality and effectiveness of education offered online (Carstens & Worsfold, 2000; Noble, 2002). The problem is that there is a plethora of online learning courses and programs with few standards to ensure the quality of their content, delivery and service (MacDonald & Thompson, 2005). Consequently, there is variance in the quality of online courses and programs that are advertised and delivered on the internet and it is difficult for an organization, consumer or learner to choose a program that is both of high quality and will meet their needs.
One quality measure for online learning is an external evaluation of the program. The dearth of online evaluation efforts may be in part, a result of competing priorities. Funding for the development and deployment of novel programs may be emphasized, while resources are not tagged to support expertise for evaluation (Breithaupt & MacDonald, 2003; Wills & Alexander, 2000). In an effort to ensure quality in their program, Online Solutions underwent an external evaluation to facilitate continual improvement.
Online Solutions: The program
ABS Management is an LTC management company serving geriatric populations in the Southern Illinois and Chicago areas. It is a family owned and operated corporation that has been involved in LTC for over 25 years. ABS hired a Chicago-based instructional designer to create the “Online Solutions: Quality Education for Quality Care in Long-Term Care” program modules in 2004-2005. Subject matter experts who collaborated with the designer were ABS corporate quality assurance leaders. All the LTC facilities that participated in this project are licensed by the State of Illinois Department of Public Health as either skilled or intermediate LTC facilities. All of the locations offer medicare services, therapies, activity programs, specialized diets and assistance with activities of daily living.
The modules were innovative in at least two ways. First, the modules were designed specifically to take advantage of universally available communication technologies (modules were accessible over the internet 24x7). Second, the modules addressed the specific needs of LTC frontline workers (for example, the content was designed to be relevant to the various professional backgrounds and to be appropriate for the differing levels of educational aptitude, literacy and experience of LTC frontline workers). At the time, there was no alternative available that was a commercial learning resource to address these LTC industry constraints. The modules have not been used beyond this project.
All employees at the participating LTC facilities were required to complete the modules as a condition for continued employment, according to a government compliance agreement. This is an important observation in light of recent reports in the popular press on the abuse many residents are suffering at the hands of healthcare workers and professionals in some LTC facilities (MacDonald et al., 2004). The learners were not reimbursed for their participation and there was extensive follow-up by local and corporate management to ensure that the modules were completed by all employees. Learners participated in the modules as time permitted during, before, or after their shifts (for example, during their lunch hour or when the residents were sleeping).
Although all employees working in the facilities were required to complete the eight modules, participation in the evaluation associated with each module was not mandatory. During the one-year period that data were collected for this study, 881 caregivers completed the eight (one hour) modules in the program. Of these, 753 (85%) completed the optional assessment (both the pre and post tests) for one or more of the eight modules. Therefore, of the 881 employees who reviewed all eight modules (881x8 = 7,048 modules), 1,046 modules (15%) had both pre-post test data upon which to build the analysis.
Participants in the educational program ranged in age from 18 to over 70 years of age and represented all occupations in the LTC healthcare facility. Representation of the various occupations that participated in the pre-post test exercises varied in overall percentage, ranging from 100% of the administration and office staff to 50% for the occupational therapy aids. Since participation in the evaluation was voluntary, it is difficult to explain why some occupations are better represented than others without further investigation such as, conducting follow-up interviews with employees. Employee participation in the program is provided in Table 1.
Table 1: Employee Participation in the LTC Education Program
Data collection and analysis
Upstairs Solutions LTC, a sister company of ABS Management, discovered a publication on the Internet reporting the findings of an online program being offered for healthcare workers in LTC facilities in Canada. Upstairs Solutions contacted the author of this paper for permission to reprint the article. Communication between Upstairs Solutions and the author lead to the evaluation of the ABS initiative. ABS hired the authors of this paper as external evaluators to: (1) analyze the data collected during the 2005-2006 delivery phase of the program, (2) make recommendations on how to improve the modules and, (3) recommend directions for future initiatives.
This study evaluated the overall effectiveness of an LTC educational program designed and delivered by ABS Management during 2005. The program is comprised of a suite of eight online modules related to healthcare issues in LTC facilities. The module numbers and descriptions are presented in Table 2. Data for the evaluation were collected by using quantitative research methodology from a variety of sources in order to understand the impact that this kind of education had on learners in the workplace. The quantitative pre-post tests were collaboratively designed by the pedagogy team (instructional designer and subject matter experts) to assess whether the learning objectives of each module had been met. The tests were administered before and after learners participated in each of the eight modules. The types of questions on the tests included choosing true or false and multiple-choice answers and took approximately ten minutes to complete. The pre-post tests were built into the learning resource in order to make it easily accessible for participants (learners were directed to the assessment tool before and after the modules). Participation in the pre-post tests was optional for learners. Demographic information came from the LTC facilities’ personnel records. Quality indicator data were taken from the LTC resident clinical records.
Table 2: Modules for the LTC Education Program
Descriptive statistics were calculated for the demographic information, and data were averaged for the sites under discussion. Comparisons of learners’ scores on the pre and post tests and on the clinical quality indicators from the two years were conducted to find out if learning and quality of care improved over time.
There was a downward trend in employee turnover indicated from the year previous to the implementation of the educational program (2004) and the year during the delivery of the program (2005) illustrated in Figure 1. The data indicate an overall decrease of approximately 17 percent, including the most significant decrease in turnover of 36 percent at one location, and decreases of 22 percent and 30 percent at two other locations.
Figure 1: Employee Turnover for All Locations 2004/2005
Quality Indicators Quality Indicators (QI) are statistics used by the United States federal government to compare the quality of care in nursing homes. For each LTC facility, there is a monthly QI measurement for care areas that is related to the subjects that were addressed in the ABS Management educational program. Quality Indicators are percentiles that rate the actual prevalence of problems in the facility to other nursing homes in Illinois. For example, an indicator of 40% means that things were ‘worse’ in 60% of the other LTC facilities in the state; therefore, a decrease in QI is indicative of improvement. Analyses indicate that several of the care areas for which education was provided showed improvements over the course of the year. Quality Indicators for seven of the eight sites (one site was not included because it is not a nursing home) are depicted in Figures 2 and 3 below. The t-test results in this study discussed below support the training program knowledge transfer. These results are represented by a small sample size and caution should be taken in interpreting the results of these findings so that the positive outcomes are not overstated.
Figure 2 illustrates the success of education in Pressure Ulcers Prevention and Treatment (module 6), as represented by the notable decrease in monthly Quality Indicators for prevalence of high risk and low risk ulcers at the seven sites during 2005.
Figure 2: Quality Indicators for Pressure Ulcers Prevention and Treatment (2005)
A notable improvement was demonstrated after the program at the seven sites on the use of restraints. Quality Indicators decreased from more than 70% to less than 40% immediately following completion of module 8 in the education program. This decrease in QI represents a significant improvement in staff performance. The rate of decrease in QI is illustrated in Figure 3.
Figure 3: Quality Indicators for Prevalence of Restraints (2005)
Comparison of scores between modules
A comparison of pre and post test scores between the eight education modules is illustrated in Figure 5. The data indicate a positive knowledge transfer in all modules, averaging more than 10% overall. The statistical significance of this knowledge transfer is supported by a t-test critical value of t=2.30 and p<.001. The p value for all modules was .05, indicating a probability of 95% that the performance improvement data were attributed to the knowledge transfer in the training program.
Figure 4: Pre-test and Post-test Average Score Comparisons between Modules with Number of Cases (n) for Each
Generally, information from a variety of sources in this evaluation revealed learner improvement in pre and post test scores in all modules in excess of 10%, suggesting an increase in new and relevant skills and knowledge. Moreover, the data indicated a reduction in the use of restraints and prevalence of pressure ulcers, suggesting that learners are applying new knowledge and skills in the workplace. The consistent improvements in all areas that were the subject of the training and lack of change in those that were not covered (e.g., falls), suggests that these changes may be a result of the educational program. Finally, staff turnover rates decreased by as much as 36% during and after participation in the educational program, suggesting that there was greater job satisfaction after participating in the educational program.
However, additional research is required to further establish the extent to which the educational program is responsible for this downward trend. For example, follow-up qualitative interviews with learners would be helpful to find out if there are other possible explanations. Several authors have pointed out that designing an evaluation plan to establish a link between training and improved patient care outcomes is difficult, if not impossible to demonstrate. This is because the outcomes of training in such a complex system may be a function of many non-training factors including a range of experiences, contexts, audiences, cultural and local and individual situations (Glouverman & Zimmerman, 2001; Phelps & Hase, 2002; McDonald & Kay, 2007). Further investigation might indicate if other factors also contributed to the change in behavior and positive results as well as if there is a link between the training program and long-term patterns, trends and impact on healthcare practice.
Additionally, further research is needed to evaluate the quality of the modules with regard to the theoretical basis and design. There was also variance in improvements among sites and more data needs to be collected to explain why some sites performed better than others.
The diversity of the LTC workforce provides challenges for educating this sector. It appears that an effective learning approach for these adult healthcare workers is one that provides relevant, practical information that is easily accessible in terms of understanding and convenience and is simple and easy to use. From an employer’s perspective, programs that do not take learners away from their work for long periods of time are necessary, and e-learning is a viable means for achieving these objectives. Furthermore, the economy of scale is significant. The number of healthcare workers who could benefit from online education programs makes its delivery through e-learning extremely attractive.
When an e-learning program is designed and deployed appropriately, education is effective and organizations may realize significant time and cost savings. The research findings point to an urgent and unmet need to provide more accessible just-in-time, just-for-you programs for caregivers in LTC facilities to ensure quality and efficient services for patients and their families.
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