End of Life Care Education: A Service evaluation.

Abstract

EXECUTIVE SUMMARY Introduction and scope of report Following a successful pilot programme which combined End of Life Care (EoLC) education with leadership skills, St Wilfred’s Hospice Chichester, in partnership with Sue Nash from Action Learning Teams were awarded a grant from the Frances and Augustus Newman Foundation to fund a follow-up programme and independent evaluation. The action learning and education development programme for care home leaders focused on improving End of Life Care provision in a care home setting and was delivered over one year. Bournemouth University (BU) undertook the independent service evaluation on behalf of the project team. This report concerns the evaluation element of the project. Evaluation questions Following consultation with the education facilitators, two questions were determined to guide the evaluation: • What are the care home managers’ perceptions of the impact of the educational programme on their leadership role in the provision of end of life care in their workplace? • Has confidence and competence in delivering and facilitating the delivery of end of life care changed over the course over the programme? Evaluation design As the evaluation questions sought to explore the effectiveness of learning as well as the relevance of the action learning approach, the evaluation was designed on the basis of a mixed methods approach. Quantitative methods utilised three questionnaires to explore; • Demographic data • Assessment of Training Needs using the Hennessey & Hicks Training Needs Analysis (TNA) Tool (with permission). • Assessment of Confidence using an adapted questionnaire developed by the Advanced Connected Advanced Communication Skills Programme offered under the auspices of the NHS End of Life Care Programme. Scores from competency documents were also collated. Qualitative methods involved focus groups, a type of group interview that stimulates interaction between participants in order to generate data. A member of the BU team acted as a facilitator using prepared trigger questions with the goal of eliciting perceptions and attitudes about the programme and its impact on participants’ practice. Participants were encouraged to share their views, to expand on these and others invited to comment. The interaction was audio-recorded (with permission). Data Analysis Completed questionnaires were managed and analysed using SPSS (V18.0) for Windows and descriptive statistical analysis was utilised. Reliability analysis (Cronbach’s Alpha) was used to screen the TNA and Confidence elements (and sub-categories) ahead of generating scores for these domains. The threshold for reliability was set at 0.7 or above. The focus groups were analysed using a process of thematic and content analysis. This technique is used with qualitative data and involves a process of systematically searching for themes or patterns in the data related to the evaluation questions. Subsequently, these themes are able to provide small thematic case study examples of how the professional development programme has impacted on practice. Findings - questionnaires TNA tool (n=6) The integration of the EoLC competencies indicates the tool has good internal face and content validity. Overall there was an improved perception of performance in role but the results are limited given the numbers of participants and the very slight degree of change evident. However, the results were confirmed and elaborated upon within the focus group data. Confidence questionnaire (n=6) Use of the confidence questionnaire indicates that the managers’ perceptions of confidence in a range of their abilities related to EoLC increased in all sections. However, given the managers’ desire to undertake the programme, perceived confidence in their knowledge and skills pre-programme was surprisingly high. An over-assessment of abilities seems likely resulting in a smaller extent of change post-programme. This conclusion is supported by the frequency and strength of comments concerning increased levels of knowledge and confidence as a result of the programme captured within the focus group data. Competency profile document (n=5) The competency profile appeared to be a very useful educational tool as it was so closely linked to the programme content. From the perspective of the evaluation however it yielded limited information. Nevertheless, the competency rating provides confirmation of the scores related to the corresponding areas of the confidence questionnaire. Findings – focus groups The perceptions of the focus group participants indicates that the programme offered a valuable opportunity for the development of interpersonal and management skills related to EoLC. Three themes emerged. First communication abilities in terms of leading and managing staff in the provisions of informed EoLC were reported to have significantly developed, alongside an increased sense of self-confidence. Second the style of the programme, which used action learning, resulted in the sharing of practice knowledge and a valuing of actively engaging in support networks. These ways of working were new to the participants. Finally the data indicated that the programme resulted in a sustainable model of education for this particular professional group, firstly perceived more effective management of staff to cascade best practice; second, the skills taught in action learning motivated the participants to continue to meet and share experiences post-programme on a self-managed basis. Discussion The evaluation has indicated increased confidence in care home managers knowledge and skills related to end of life care via a number of measures: the confidence questionnaire (CQ), the competency profile and the focus group feedback. The TNA questionnaire also showed some positive movement towards perceived increase in role performance in most domains. As the TNA, CQ and competency profile were linked with the EoLC competencies (DoH, 2009), it is reasonable to assume that improved confidence and perception of competence will have positively impacted on EoLC for residents. In addition, the focus groups provide examples and case studies of improved inter-professional liaison, cascading of knowledge and more proactive communication with residents and families when making decisions about EoLC. This data also indicates that for most participants this educational experience has been both personally and professionally effective, and even for some, life changing. The evaluation provides support for the link between excellent communication skills, effective leadership ability and better quality provision (Shaw et al, 2007; Thomas and Noble, 2007; King et al, 2008; Shaw et al, 2010; Seymour et al, 2011; Badger et al, 2012). The findings show that this educational strategy appeared to have a positive influence on communication both within the specialty and in general teams when working with colleagues and residents. Further the link between evidence-based care and confidence to deliver has emerged as very significant factor (Badger et al, 2012). The action-learning model appeared to be a sustainable approach as participants carried on appreciating the benefits of this, with the only cost being staff time. However, the programme length and small group size could be perceived as expensive. Conclusions In order to enable high quality EoLC, professional development should equip participants to be able to positively influence not just the individual’s immediate team, but also resident’s family members, care home owners, and other external stakeholders such as general practitioners (GP) and emergency departments in hospitals. This evaluation provides compelling evidence that an action learning approach to EoLC education can be used to empower middle managers to have positive impacts on EoLC provision through not only increasing specialist knowledge but also enhancing their capability to engage in a confident and informed manner with a diverse range of stakeholders. Recommendations Evidence from this evaluation suggests that • Expertly taught EoLC knowledge and skills is essential for care home managers to fulfil their role effectively • An action learning approach enables the embedding of specialist knowledge in practice through the enhancement of leadership skills linked to increased self-confidence. • The EoLC action learning education model leads to sustainable educational outcomes