Effectiveness of Blended Learning in Healthcare Training



Effectiveness of Blended Learning in Healthcare TrainingSophie L. RadlowskiAbstractThe topic researched was the effectiveness of blended learning in healthcare training. Literature that was reviewed concluded that blended learning, of any topic, by any learner, was at least as effective as instructor-led-training and in most cases, was more effective than instructor-led training. Literature specific to healthcare training was also reviewed. These studies concluded that clinical training was more effective when blended learning was the method of training used as compared to instructor-led-training alone. IntroductionIn the healthcare arena, hospital communities, as well as the health system where I’m employed, there is much debate and difference of opinion as to the most effective method for training and which solution yields the best return for patients, staff, community, as well as the hospital facility itself. Currently, there are several different methods being employed for staff training. Each method has a specific goal. The current methods available include computer-based learning modules (e-Learnings), instructor-led classroom training (ILT), live and recorded sessions of webinars, open labs, one-on-one tutoring, lunch-n-learns, seminars, tip sheets, and quick start guides. This list is not exhaustive but encompasses the major training vehicles. With the cost of healthcare skyrocketing, and government regulation looming, training resources are being strained. It is incumbent upon us to look for the most cost effective, yet consistently reliable method of keeping our staff up to date on matters of patient care, safety and in compliance with Joint Commission requirements. The training method we choose needs to address the needs of the clinical staff as well as the non-clinical support personnel and fit within the compressed timelines and budget constraints of the administration.Instruction for annual regulatory, refresher courses, such as fire safety, privacy rules, basic patient handling and hospital alarm codes is disseminated through computer-based learning (CBL) modules or e-Learnings that are hosted and tracked on the hospitals’ learning management system (LMS), HealthStream. These modules are assigned to each hospital employee, clinical and non-clinical, and completion is tracked through HealthStream. It is self-directed learning, as the employee is notified when the lessons have been assigned to them and they are given a deadline, usually several weeks later, to have them completed. There is a short quiz given after each module to confirm that the employee understood the material that was presented in the e-Learning. The hospital, based on past practice and industry best practice, has determined that using these custom designed e-Learnings and industry authored pre-recorded e-Learnings represent a cost efficient and effective way to train. The topics that are covered are factual in nature and require only short periods of time, usually less than 15 minutes, to teach. The unknown factor to be determined is whether these types of modules are appropriate and effective for more involved topics or topics that involve inference as a method of understanding. The reason this is of paramount importance is that several clinical processes and pieces of functionality require critical thinking skills and a grasp of conceptual information when new material is presented to the clinician. These processes and procedure differ greatly from factual memorization that the majority of the annual regulatory learning requires. Epic, an electronic medical record (EMR) software, was originally introduced to the entire staff using instructor-led classroom training as the primary vehicle in a blended learning approach. At the end of class, a multiple choice proficiency exam was administered in HealthStream and the grade was recorded on the employee’s transcript. There were CBL modules (e-Learnings) assigned to staff, that were to be completed before they came to class, as a prelude to the subject matter. After class follow-up practice sessions included open labs, one-on-one tutoring, the distribution of printed tip sheets and quick start guides. Throughout the initial rollout of the Epic software installation, a blended-learning approach was used to train the hospital staff. An outside audit firm conducted audits of patient records after each hospital began using Epic software, to ensure compliance with government regulations on meaningful use and patient safety. Each hospital and clinic had achieved the minimum standards necessary for compliance with regulations, within the 90-day window after implementation. This was the benchmark used for validating training effectiveness.Currently, all staff have been trained on the basic use of the EMR software. At this point, we are adding new features and new updates to the software, some of which will require training. There are three distinct schools of thought as to the best way to approach training approximately 14,000 people in a short, 3 week timeframe and do it effectively, and cost efficiently. Each plan has advantages and disadvantages that need to be considered.The first method under consideration is to train the staff using instructor-led classroom settings. ILT is the preferred method of the Epic training team. Instructor-led training is, by far, the most costly of the alternatives. Instructor-led classrooms involve a cadre of trainers, a large number of training rooms that will need to be equipped with computers and scanners, and stacks of instructional materials printed. ILT will be no small undertaking given the time constraints that will be faced. ILT will also require staff be given significant amounts of paid time off to attend classes. Budget concerns surround this option as these costs have not been allocated in the current fiscal year education allotment.The second method under consideration is to train the staff using CBL modules exclusively. Computer-based training is the preferred method of the hospital administration as it causes the least disruption to employee workloads and patient care. It is perceived as being the most cost effective. There are several drawbacks to this method that need to be factored into the decision. The first is that the pre-recorded e-Learning modules that Epic provides may not be in sync with the workflows that are unique to this organization. Secondly, the Epic provided e-Learning modules do not cover every single change or new feature that needs to be trained. The most prohibitive feature of this option is the amount of time it takes for a principal trainer to create a new e-Learning module from scratch. Epic estimates that it takes approximately 40 hours for a principal trainer to create a 15 minute e-Learning module. That is a significant amount of time to devote to creating a library of e-Learning modules needed to cover all of the changes, improvements or enhancements that will be installed with the software upgrade. The issue of effectiveness of this training for all types of materials is at the heart of issues that need to be considered in regard to this choice as a method of staff training.The third method under consideration is to train the staff using a blended method of training. A blended approach would involve the use of webinars, lunch-n-learns, as well as CBL modules. Webinars appear to offer the best of both worlds. Webinars or synchronous shared learning could probably be most closely compared with traditional classroom learning experience. The learners and instructor are all logged on to a live, web-based collaborative learning environment and are participating in the class at the same time.” CITATION Rut00 \l 1033 (Ruttenbur, Spickler, & Lurie, 2000) The employee does not need to leave their desk or workstation, and the trainer does not need to be at the front of a classroom to illustrate new functionality. The employee can see and hear the trainer describe in detail how the new feature works and also can ask questions for clarity. This method would minimize staff interruptions, but ensure that more complicated training was handled in a face-to-face manner allowing for a question and answer period should clarification be needed. This study is designed to explore the effectiveness of a blended method of training as compared to either instructor-led or computer-based training.Addressing the ProblemMy research is a dual-pronged approach to the issue. The first prong will be used to determine the effectiveness of CBT. I believe that CBT is effective primarily for certain types of material or subject matter that is data- or fact- oriented. The result of this research would provide me with the basis for when it would be appropriate to use computer-based training, keeping in mind that there are disadvantages to this method.The other prong would be to collect data on the effectiveness of a blended-learning approach. The information to be gathered include decisions about when a blended-learning approach appropriate to use, and what teaching methods should be included in a blended-learning approach. A blended approach would, in theory, minimize disruption of patient care to train employees and lower the training cost, based on fewer classroom hours and instructors.The searches that have been conducted using the following keywords:Effectiveness of blended learningIs CBT more effective than ILTCBT vs Online learningBlended learning in healthcareCost effective trainingJust-in-time trainingThe Effectiveness of Computer Based TrainingThe definition of computer-based training (CBT) that will be used for the purposes of this paper is asynchronous, self-directed, interactive, computer-based instruction. The advantages to CBT are numerous. It can be used as just-in-time training, which by definition should be more effective than other types of training because it is delivered just as the employee needs the knowledge or information to adequately perform his/her job. Secondly, it is flexible in the respect that it can be administered without regard to a trainer being available or minimum class size being met. Additionally, a geographically diverse population can be addressed with a single CBT as it is not dependent on students being all in the same location at the same time. CBT can also accommodate a different schedule for each of the trainees as it is on-demand instruction. One of the most significant advantages to CBT is the consistency of training. All employees see, hear and need to respond to the same delivery of information. Using this method of instruction ensures that all employees are given the same message, in the same manner and removes any possibility of information being overlooked or not covered in other types of training methods. It is learner-centered instruction and can be designed to be self-paced and have branching capabilities to meet the needs of learners at all stages of development. It is cost effective for learners as there is usually no travel or minimal travel involved, and usually no time lost from work as these modules can be viewed on demand. CBT is archival in nature and can be reused as often as necessary. CITATION Zha04 \l 1033 (Zhang, Zhao, Zhou, & Nunamaker, 2004)CBT is far from the perfect format for learning. There are significant costs associated with the start-up of a computer-based training program. The initial preparation time for a computer-based training module is far greater than creating a lesson plan for an instructor-led class. CITATION Wel03 \l 1033 (Welsh, Wanberg, Brown, & Simmering, 2003) Software necessary to create the e-Learning modules will need to be purchased and then mastered by the trainers. Also, there are hardware and networking systems that need to be purchased, installed and have training conducted on the use of these tools such as a learning management system (LMS) prior to any computer-based training taking place. CBT does not allow for immediate feedback or the trainee to ask questions. For staff members that are not comfortable or well-versed in the use of technology, there is an added stress level to the training process. CITATION Zha04 \l 1033 (Zhang, Zhao, Zhou, & Nunamaker, 2004).Johnson and Rubin CITATION Joh11 \p 64-71 \n \t \l 1033 (2011, pp. 64-71) conducted a comprehensive review of studies regarding the effectiveness of computer-based instruction published between 1995 and 2007. For the purposes of this paper, computer-based instruction and computer-based training are used interchangeably. The results included data from 71 different published studies. The studies that are of particular interest are those that covered CBT that was classified as training. Training was used to designate the CBT that was designed to facilitate performance in currently held jobs. The studies of interest also were CBT’s that were considered primary or designed to be used as a stand-alone module. These studies compared the following types of training:Interactive CBT to non-interactive CBTInteractive CBT to other instructional formatsInteractive CBT with lecture style instruction Hybrid interactive CBT along with lecture as compared to lecture aloneThe criteria for determining the effectiveness of the training was comprehensive in the number of factors that were used in the comparisons. These factors included, but not limited to:Paced – machine or studentMastery criteriaResponse InteractionFeedback typeSupplemental incentivesOutcomesThe results of the comparisons are as follows:Interactive CBT to other instructional formats – Interactive CBT was found to be at least as good, if not better, than instructional alternatives 95.2% of the time.Interactive CBT to non-interactive CBT – Fourteen of twenty studies favored interactive CBT over non-interactive CBTInteractive CBT with lecture style instruction – Eight of the ten comparisons demonstrated superior results for interactive CBTHybrid interactive CBT along with lecture as compared to lecture alone – Two of the four comparisons found that adding the CBT component improved the lecture formatThe vast majority of the studies concluded that interactive computer-based training was found to be at least as good and in some cases better then instructional alternatives. This conclusion was drawn by a vast array of researchers over a twelve-year period. What Johnson and Rubin did not review in their study was the subject matter of the CBT and whether or not the subject matter made a significant difference in the effectiveness of computer-based training.Another summary study, this one by Welsh, Wanberg, Brown & Simmering CITATION Wel03 \p 245-258 \n \t \l 1033 (2003, pp. 245-258) four questions were addressed regarding the issue of the effectiveness of CBT. The questions and the responses follow:Can adults learn from classes conducted through technology? – First, research suggests that people can and do learn from technology-delivered instruction. This research covered a wide spectrum of industries ranging from manufacturing, trucking, the U.S. Military and included an equally diverse subject matter training portfolio.Are classes conducted through technology equally effective for everyone? - The research indicates that there is no significant difference in the outcomes of e-Learnings based on learning style or gender.Are classes conducted through technology equally effective for all types of courses? – The research indicates that CBT would be effective for almost all types of courses with the exception of soft skills that would require interaction and feedback. The other classes that may not be as effective are those requiring advanced simulations. Note; this study, is nine years old, and technology has advanced to where simulations are now commonplace.Are such classes better than or at least as good as classroom training? – The conclusion drawn by the authors was that CBT can be better and have more effective outcomes than classroom training.Effectiveness of Blended LearningA blended learning approach would encompass the best of both worlds, the face-to-face interaction of an instructor-led class along with an interactive, learner-centered instruction of a computer-based training module. Traditional physical classrooms with instructors have been the dominant method of teaching for decades. CITATION Sin \l 1033 (Singh & Reed, 2001) The effectiveness of the face-to-face method of teaching is the standard against which all other methods will be judged. The simplest definition of a blended learning environment is one that includes face-to-face instruction and on-line instruction. CITATION Gra06 \l 1033 (Graham, 2006) It can also be categorized as any training that involves multiple delivery methods. According to CITATION Joh11 \l 1033 (Johnson & Rubin, 2011), the hybrid approach increased the effectiveness of an instructor-led class. Reasons for using a blended learning approach include improved pedagogy, easy access to knowledge, more interaction among learners, personal presence, cost effectiveness and ease of revision of learning content. CITATION Lim07 \l 1033 (Lim, Morris, & Kupritz, 2007).Clinical education is the subject matter that is being considered when discussing the effectiveness and viability of a blended learning approach to training hospital staff. Rowe, Frantz and BozalekCITATION Row12 \p 216-221 \n \t \l 1033 (2012, pp. 216-221) evaluated studies that centered on the role of blended learning in the clinical education of healthcare students. Their findings confirm that integrating technology-enhanced teaching with traditional approaches has the potential to improve clinical competencies among health students. There is another definition of blended learning that is far more characteristic of the structure of training that is more closely aligned with the proposed method. Singh and ReedCITATION Sin \p 1-11 \n \t \l 1033 (2001, pp. 1-11) suggest that the definition is: “Blended learning focuses on optimizing achievement of learning objectives by applying the “right” learning technologies to match the “right” personal learning style to transfer the “right” skills to the “right” person at the “right” time.”All of the studies, as noted above, consistently have determined that a blended approach to training yields to greatest results in terms of knowledge transfer, employee satisfaction and retention. A blended approach can include face-to-face training or mentoring support after completion of computer-based training. Either approach was equally effective.ConclusionAll studies that have been reviewed have indicated that computer-based training is effective. Studies have also noted that instructor-led training can be enhanced with the use of CBT. The basic premise is that CBT is a viable training tool as it is cost effective and easily updated once the initial investment in hardware and software have been taken into account. The benefits of CBT, at first glance, certainly outweigh any disadvantages.My contention is that computer-based training is not the panacea that it is touted to be. The ability to easily and quickly update a computer-based training module is a fallacy. The more interactive and involved with branching and other pieces of technology the module is, the longer it will take to update the module, particularly if there is audio attached to it. In some cases, updating may not even be feasible. The module may need to be completely redone from scratch. Rework is a time-consuming process, even after a trainer has become proficient at the use of the software that is necessary to author an e-Learning. e-Learning is at it best when used with discreet pieces of knowledge or the lesson is “chunked” into smaller segments for ease of viewing and better retention of information when presented in this fashion. Smaller segments create a much larger task for the trainer than simply creating an e-Learning module to correspond to a class. There may be a series of e-Learnings that need to be created in order to cover all of the material that is required. A significant amount of time and resources will need to be expended to create the initial e-Learning library necessary to accommodate the upgrade training as part of a blended learning strategy. Once the library is complete, keeping it up-to-date may be an onerous task depending on how often updates need to be made.My ideal blended, collaborative e-Learning program would resemble that of the IBM model. CITATION Sin \l 1033 (Singh & Reed, 2001)Interactive online opportunities before the employee starts work to introduce them tolearning resources and their team, and enable them to be better prepared for successA physical classroom kick-off event for acculturation and teambuildingA series of self-paced, online tutorials covering the company’s product or serviceAn asynchronous, online discussion forum created to allow participants to share customer-case studies or scenariosA series of live, collaborative coaching sessions where the new employees talk withmembers of the management teamAn online, Web-based post-test that certifies the competency of new employeesAn online survey that allows participants to provide their feedback about the learningprogram for future improvementsUnder the current model, new employees are indoctrinated during a new hire process that includes several days of classroom-based Epic training. I believe that this is ineffective as it is information overload and the retention of key pieces of functionality is minimal at best. A blended-learning approach over a slightly longer period would allow for greater knowledge transfer to occur and for the new staff member to be incorporated into the clinical setting much sooner and be more proficient at key clinical workflows in a shorter time frame. A study of the effectiveness of this approach needs to be undertaken as soon as feasible to minimize the waste of resources and manpower and improve clinical training efforts.References BIBLIOGRAPHY Ali, G. E., & Magalhaes, R. (2008). Barriers to implementing e‐learning: a Kuwaiti case study. International journal of training and development, 12(1), 36-53.Alonso, F., Lopez, G., Manrique, D., & Vines, J. M. (n.d.). An instructional model for web‐based e‐learning education with a blended learning process approach. 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