Blended Learning in Healthcare: A Toolkit for a Blended Learning Approach in Clinical Training

In this article, you will learn:

• Code Blue: Blended Learning To The Rescue
• First Things First: Defining Your Learning Goal
• Toolkit For A Blended Learning Approach In Clinical Training
• Blended Learning Magic 
• Blending It All Together With A Learning Management System

Code Blue: Blended Learning To The Rescue

Code Blue is a code every healthcare clinician, and most healthcare visitors, know. It is an immediate call to action, leveraging a protocol to bring the right clinicians quickly to the scene of a possible cardiac arrest. When they arrive, these clinicians know what to do, who is going to do it, and what role needs to be played when they arrive.

Lives are saved because this information is taught, practiced, and drilled into the care teams. Training clinicians need to respond to whatever the situation may be, emergent or otherwise, which is the foundation for effective and consistent care. You can imagine how much learning and training must happen to be ready for anything you might encounter. It is a circular process where clinicians learn, practice, debrief and repeat.

So how can an industry filled with clinicians that are the very definition of “busy professionals” make this work? Blended learning offers a solution that streamlines the training process and leverages the best technologies for each part of the learning journey.

“Blended learning” typically includes a mix of online learning, simulation, team training, one-on-one coaching, and even in-person seminars. The value of each piece fits a specific need for the outcome desired at the end of the learning journey. As Marc Rosenberg said in 2001, “the question is not if we should blend… [but rather] what are the ingredients?”¹. Let’s take a look at what some of the ingredients are for blended learning in Healthcare and how they can best be utilized for effective blended solutions.

First Things First: Defining Your Learning Goals

The first step to mixing the optimal blend of ingredients is, of course, to know your goal. Here are some of the questions to consider:

• What do you want to achieve at the end of the training?
• Does the learning population need to have an understanding of a protocol?
• Does this protocol require practice?
• Does it require practice as a team?
• Is it a hands-on responsibility they must learn to execute?

Whatever the goal, identify it and state it clearly using action-based language so you know what approach is needed to effectively teach the outcome. Using action based language, try to decipher whether or not the learning outcome is to describe or demonstrate, to use or to respond. Each outcome verb will point to a different piece of the Blended Learning solution as you mix and match the right types of tasks to achieve your goals.

Toolkit For A Blended Learning Approach In Clinical Training

Online Learning

In situations where the learning population needs to first establish a base line of knowledge, online learning is a very effective tool. To develop understanding, outcomes typically include information-based learning, demonstration through testing, or practice and perfection of the thinking process in safe or introspective spaces.

Even participating in a 15 or 30-minute online module prior to a face-to-face session can increase the outcome of a face-to-face session by bringing all participants up to the same level of understanding before they walk through the door². This is only the beginning of the impact that online learning can have in a blended setting. In healthcare, online learning can include materials and activities that supplement face-to-face environments, as well as prepare for the time together as a group. Such materials may include:

• 3-D animation models that can be used to simulate damage to diseased organs over time.
• Case-based practice to explore the decision tree necessary for patients with different comorbidities in a treatment setting.
• Review of responses in a learner’s decision making, and communication in an environment that is safe and provides immediate feedback based on the choice selected.

Another online learning feature that is becoming readily more available is the ability to compare your choices or your performance in an online environment against the scores achieved by “other people who look like me”. In a culture like healthcare, finding personal and private ways to benchmark against other clinicians in my care facility, my healthcare system, my geographic region, or my country—allows me to see what areas are falling short and where my performance is strong.³

Online learning can also be a powerful way to followup after the face-to-face portion of a blended event.

Community tools, reference tools, and a learning management system that presents clinicians with additional training options after an initial event, can help to combat the expected knowledge degradation. By using the aforementioned technologies, knowledge degradation can be combatted overtime as learners are continually engaged in discussion and practice around the topic.

Simulations

Simulation is defined by the Society for Simulation in Healthcare as “the imitation or representation of one act or system by another”. In healthcare, simulation is a technique, not a technology, and provides clinicians with the opportunity to develop knowledge and skills—even decision making skills— in an environment that is either entirely separate from patient care, or in one that protects patients from unnecessary risk⁴. Many of the simulation techniques use simulators which can be as advanced as the medical manikins used during surgical and obstetrical simulations, with an actual pulse, body temperature, and EKG reading. Even the skin feels real on some of these manikins!

But simulators can also be as simple as a set of holes in a stretchy sheet of plastic, through which a trocar and other laparoscopic equipment can be inserted to practice the general operations of the trocar during different procedures. Following the examples set in the aviation industry, which was the first industry to use simulators for training—healthcare now relies on simulators and simulations to train more than 70% of the procedures in many clinical focus areas⁵.

The benefits of simulation are simple— they allow for the practice and repetition necessary to perfect new skills in a safe environment. Simulations are especially powerful in situations where heuristics and muscle memory are necessary to react quickly in high-stress situations. A simulation approach in training can increase the success of repeating a trained movement or set of activities significantly. The Academy of Medicine reported in 2011, that simulation-based medical education with deliberate practice “is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals.”⁶

A simulation approach in training can increase the success of repeating a trained movement or set of activities significantly.

Simulations for Team Training

Simulations are also very effective for team training. As the name implies, team-based simulations move away from individual skills training and focuses on team based drills, especially communication in high stress situations. Teams deliver a large majority of care in clinical settings, with very few activities directly tied to the performance of only one clinician. Relatedly, the number of adverse outcomes attributed to the failure of team communication, performance, or underlying systems that teams rely upon is significant; which underlines the importance of team-based simulations.

Examples of Simulations for Team-based Training

Effective team training exercises in communication can challenge teams to accomplish tasks entirely unrelated to health care – the Institute for Simulation and Interprofessional Studies (ISIS) uses a paper chain challenge to engage teams and encourage them to communicate effectively during a race to create a paper chain longer than the team next to them. By focusing on an outcome of clear and effective communication—while under pressure to perform a task—the ISIS team has found an effective way to simulate and practice communication skills.

In other team training exercises, like ones used in the Code Blue training mentioned earlier, teams rehearse in clinical environments with the actual clinical equipment they need to use in real life situations. During team-based simulation training, sounds and protocol triggers are used just like real-life settings so that clinicians to respond correctly and immediately. This repetitive training as a team is very much like rehearsing for a play. For example, in suicide prevention training with gate keepers, community members are trained using simulations to identify signs of risk. Research shows that using repetitive role-playing techniques in team training settings is an effective way to increase gate keeper skills.⁷ The study also showed that there was, like in all situations, degradation in skill overtime as gate keepers returned to their primary roles and used their new found skills less frequently over time. The take-away then is to ensure that simulation training happens often if the skill being taught is seldom used. Another method to curb knowledge and skill degradation is coaching and mentoring.

Coaching and Mentoring

One-on-one coaching is a great way to curb skill degradation—especially in those skill areas that are imperative to keep sharp and focused. Though not frequently considered part of a blended learning approach in the past, coaching is becoming a more recognized approach to keeping the momentum of learning over time. As an underrated component of any blended learning offering, we cannot stress this enough. Coaches are a vital part of ensuring that learners are surrounded by people who will push them to grow, hold them accountable for the goals they set, and act as a mirror by reflecting back an outside perspective that helps to truly gauge where they are effective and where there are gaps to address. Atul Gawande highlighted the very same concept in his New Yorker article in 2011, Personal Best, when he said “Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short.”

Dr. Gawande recommends that every physician find themselves a coach to help them avoid the plateaus in skill development that can creep into any career. We would go further, and challenge all clinicians to find a trusted peer or professional coach to play this role for them. Far from being a source of advice, coaches are most effective as sounding boards and story tellers. By pulling from their own experiences they shed light on new ways to push learning forward, and help keep critical skills sharp. In a family medicine publication from 1994, two physicians reported that their peer coaching relationship gave them increased self-awareness, the ability to improve specific skills, and the rewards of a collaborative relationship between colleagues⁸. The benefits of coaching are still as powerful, and the advances in technology make coaching even more accessible as video technology and connection is readily available.

Classroom Learning

Classroom Learning is traditionally thought of as the act of sitting a large group of learners down in front of a teacher who tells them what they need to know. The learners scramble to take notes, absorb new concepts, and build all of the new information into their existing body of knowledge. To bring a unit up-to-speed on a new compliance requirement or protocol, the classroom can sometimes be the fastest way to gather and educate a group of people. There is also value in hearing the questions that others ask when digesting new knowledge, a feature that is replicated in self-paced study or online courses via discussion forums.

That said, the traditional “sage on the stage” approach to traditional classroom learning is an old training model, and one that is not favoured by busy professionals. However, it does have its place. This is how we encourage you to think of it – as a place for interaction and face-to-face learning so that learners can collaborate. In healthcare, classrooms can often contain the simulator equipment needed for the simulation techniques we discussed above. The classroom can also become a place to gather and use the team training techniques mentioned above, or to engage in open and seminar-like discourse around a topic that has been prepared for in advance.

Also, check out this blog post to find out the difference between blended learning and flipped classrooms (a very handy !

Blended Learning Magic

So what is the magic in blending these approaches together? And what are the best practices for walking a learner population through the parade of curriculum pieces as you accomplish your outcomes? First, let’s talk about the magic. Blended learning benefits from the advantages of all of these approaches to provide a very holistic learning experience. Select the right approach for each of the outcomes you want and string them all together. The active learning model, which shifts the responsibility of learning from the teacher to the student, is easier to accomplish when you blend activities into your approach that engage and empower a learner. The blend of the activities is truly where the magic happens.

In Barcelona, a study to measure the impact that a blended learning approach had on students learning anatomy showed a statistically significant increase in test scores for those students who were taught using a blended learning approach⁹. The variety of activities engage areas of the brain that are not able to reinforce each other when learning happens in only one way. Certainly, based on the evidence found in scores of case specific blended learning results, the fact that blended learning allows you to chose the teaching modality that best fits the outcome you are hoping to achieve has undeniable benefits over trying to accomplish all of your goals through one teaching approach.

When we look at the barriers to effective blended learning (also read our blog post: Why Blended Learning is Effective), they seem to focus in on two areas – keeping momentum in the learning journey across the different learning components (especially when the components are separated from one another by significant time) and adjusting the components of the curriculum to reflect recent changes in context or role.

Using these technologies to streamline the learning experience, blended learning is a powerful tool in the clinical training toolbox.

The active learning model, which shifts the responsibility of learning from the teacher to the student, is easier to accomplish when you blend activities into your approach that engage and empower a learner.

Blending It All Together With A Learning Management System

While blended learning has proven to be a superior approach in achieving learning outcomes that stick—it is a tad trickier to manage given all the activities that take place. If using the full plethora of tools we’ve outlined for a blended learning approach in clinical training—online learning, classroom learning, simulations, and coaching and mentoring—it is crucial to be able to track, record, and report on the learning that takes place. Why is this so important? Because learning needs to be tied to measureable performance outcomes so that training and development managers can see what is working and what is not. It is also important because managers need to justify the time and money that is allocated to learning. Let’s take a look at the specific functionalities of a learning management system that make a Blended Learning approach not just possible but efficient.

1. Visibility into the Learning Journey

With an open source learning management system such as Totara Learn LMS, administrators and managers can easily peer into the learning journeys of groups and individual employees to see the learning that has been completed and that progress that has been achieved. Reporting and dashboards allow administrators to peer into the time spent learning both in-class and online.

2. Scheduling Classroom Learning Sessions

A learning management system such as Totara Learn also makes it easy for administrators or managers to schedule in class training or simulation sessions. With automated workflows, Totara Learn makes it easy for employees to browse on-site workshop and training opportunities and directly book online. Registration confirmations will automatically be sent and managers can easily review and approve bookings. Better yet, Totara Learn enables administrators to record attendance within the system so that reporting is seamless.

3. Setting Goals and Managing Performance

A learning management system also enables mentors, coaches and managers to set goals and record progress made. With Totara’s flexible tiered approach, goals can be connected to high level organizational objectives so that employee performance is directly related to the overarching mission. In order to monitor performance, Totara Learn provides a system for 360 degree feedback by making it easier for managers to ask a wider group of participants for feedback.

4. Competency Management

In the clinical setting, competencies are highly related to patient care and in the same respect, learning and training is highly related to competencies. Using Totara Learn LMS, administrators have the ability to link learning activities to competencies to automatically populate learning paths. 

Download this white paper to find out what healthcare organizations stand to gain from competency based learning:

References:

1. Rosenberg, Marc Jeffrey. E-learning: Strategies for delivering knowledge in the digital age. Vol. 9. New York: McGraw-Hill, 2001.
2. Driscoll, Margaret. “Blended learning: Let’s get beyond the hype.” E-learning1.4 (2002).
3. http://www.aps-web.com/research-and-analytic-insights
4. Lateef, Fatimah. “Simulation-based learning: Just like the real thing.” Journal of Emergencies, Trauma and Shock 3.4 (2010): 348.
5. Passiment, M., H. Sacks, and G. Huang. “Medical simulation in medical education: Results of an AAMC survey.” Association of American Medical Colleges. Washington DC (2011): 1-48.
6. McGaghie, William C., et al. “Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence.” Academic medicine: journal of the Association of American Medical Colleges 86.6 (2011): 706.
7. Cross, Wendi F., et al. “Does practice make perfect? A randomized control trial of behavioral rehearsal on suicide prevention gatekeeper skills.” The journal of primary prevention 32.3-4 (2011): 195-211.
8. Flynn, S. P., et al. “Peer coaching in clinical teaching: a case report.” Family medicine 26.9 (1994): 569-570.
9. Pereira, Jose A., et al. “Effectiveness of using blended learning strategies for teaching and learning human anatomy.” Medical education 41.2 (2007): 189-195.