DEVELOPING AN ONLINE CONTINUING EDUCATION CLASS FOR HEALTH CARE
PROFESSIONALS: PROVIDING CONTENT
TO INFLUENCE LEARNING
The Practicum – DHS 8140
Barbara Duffy
Daytona State College
Dr. Sherry A. Robins
Nova Southeastern University
A practicum report presented to the College of Allied Health and Nursing
in partial fulfillment of the requirements for the degree of
Doctor of Health Science
Nova Southeastern University
March 2011
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Abstract of a practicum report presented to the College of Allied Health and Nursing
in partial fulfillment of the requirements for the degree of
Doctor of Health Science
DEVELOPING AN ONLINE CONTINUING EDUCATION CLASS FOR HEALTH CARE
PROFESSIONALS: PROVIDING CONTENT
TO INFLUENCE LEARNING
by
Barbara Duffy
March 2011
Online learning is becoming an increasingly more common medium in which to provide
learning. The purpose of this practicum was to create and implement an effective online class at
Daytona State College to meet the continuing education needs of health care professionals.
Prevention of Medical Errors was presented as a two-hour asynchronous, instructor-led online
continuing education class on February 28, 2011. The challenge was to choose, adapt, and
perfect educational activities and opportunities that maximize the advantages of online learning
and determine what influences learning and instructor effectiveness within an asynchronous,
instructor-led online continuing education class for health care professionals.
An extensive review of literature was conducted. Topics included the online learner and
instructor, constructivist theory, problem-based learning, the online environment, instructional
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design, special challenges, feedback, and evaluation among others. The material was categorized
as assessment, teaching and learning strategies, content, and the evaluation process. Details and
examples of influences on learning and teaching effectiveness were provided throughout the text.
Methods included an extensive review of literature pertaining to effective learning and
instruction in the online environment. Information pertinent solely to online college-credit
classes without application to online continuing education classes was excluded. Additionally,
content from the campus-placed class pertaining to the prevention of medical errors was
modified, added to, and adapted to the online format. Formative and summative committees
were formed as well as significant work conducted with technology and management personnel
at Daytona State College to create, coordinate, and implement this class.
This first online continuing education class resulted in all learners completing discussion
questions, viewing content, and passing the final quiz. Feedback from learners stated they were
very satisfied with the content and method of instruction and learned something valuable and
applicable to their work. Further learner outcomes and satisfaction were determined by the
amount of interaction and comprehensiveness of responses to discussion items. The practicum
also resulted in identifying unique characteristic of online continuing education classes and
learners.
In conclusion, the short nature of continuing education classes limits the opportunity for
interactivity and establishing a sense of community among the learners. Instructors must be
adept at promoting these essential elements of effective online learning. In addition, it is
important to address the needs of learners new to the environment and simplify navigation within
the classroom. While the prevention of medical errors is a topic of interest for most health care
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professionals, this online medium can easily be adapted to accommodate a wide range of career
develop classes.
Finally, to assist those wanting to know more, three addendums are included. This includes
information pertaining to the different types of online classes and instructor attributes. Lastly, a
summary of examples to help shift instruction to a learner-centered approach to learning is
provided.
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TABLE OF CONTENTS
Chapter Page
1. INTRODUCTION ......................................................................................................................7
Nature of the Problem.............................................................................................................8
Purpose of the Study ...............................................................................................................9
Significance to the Health Care Profession ..........................................................................10
Research Question ................................................................................................................10
2. REVIEW OF LITERATURE ...................................................................................................11
Assessment of the Online Learner ........................................................................................11
Teaching and Learning Strategies.........................................................................................13
Consideration Toward Content .............................................................................................19
The Evaluation Process.........................................................................................................25
3. METHODOLOGY AND PROCEDURES...............................................................................27
Methodology .........................................................................................................................27
Procedures.............................................................................................................................27
Assumptions..........................................................................................................................28
Limitations ............................................................................................................................29
4. RESULTS .................................................................................................................................30
5. DISCUSSION, CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS ..........33
Discussion .............................................................................................................................33
Conclusions...........................................................................................................................35
Implications...........................................................................................................................36
Recommendations.................................................................................................................36
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TABLE OF CONTENTS (Cont.)
REFERENCES ..............................................................................................................................39
APPENDIXES ...............................................................................................................................43
A. Types of Online Classes..................................................................................................44
B. Instructor Attributes ........................................................................................................45
C. Shifting to an Online Learner-Centered Approach .........................................................46
D. Class Introduction Screen ...............................................................................................47
E. Table of Contents Screen.................................................................................................48
F. Example of Articles to Read............................................................................................49
G. Audio-visual Presentation Prevention of Medical Errors ...............................................52
H. Examples of Discussion Questions .................................................................................57
I. Examples of Learner Interaction Responses ...................................................................58
J. Average Time per Lesson................................................................................................59
K. Feedback Survey .............................................................................................................60
L. Learner Narrative Comments ..........................................................................................61
M. Frequently Asked Questions ...........................................................................................62
N. Formative Committee .....................................................................................................63
O. Summative Committee....................................................................................................64
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Chapter 1
INTRODUCTION
During the past several decades, facilitating learning has increasingly involved the use of
technology. However, unlike audiotapes, radio, television, and multimedia CD-ROMs, online
education via the Internet is steadily proving to be more resilient, adaptable, and innovative.
Because of its ability to accommodate individual learners, encourage interactivity, and provide
information, learning, and communication without consideration to geography or time zones,
online learning is increasingly meeting the educational needs of a mobile society (Weller, n.d.).
Not only is it a cost-effective means to serve a widely dispersed population of learners, one study
showed nearly 70% of students preferred the autonomy of online learning to traditional
classroom courses (Hannay & Newvine, 2006).
To meet the increasing demand for online college classes, Daytona State College (DSC)
has provided college-credit classes online for several years. Utilizing the Desire2Learn platform,
thousands of students are currently enjoying the convenience offered by online classes. DSC has
acknowledged the current increase in college enrollment will likely subside in the near future and
continuing education (CE) is a future source of continuous enrollment. However, the Institute
for Health Services (IHS) at DSC was conducting all of their CE classes for health care
professionals on the college campus. DSC saw online CE classes as an opportunity to attract a
new market of busy health care professionals and adjusted processes (registration, marketing,
etc.) to accommodate online CE classes utilizing the college-credit online platform.
This practicum developed and implemented the first online CE class for health care
professionals utilizing the online DSC platform and best practices for online instruction. The
class pertained to the prevention of medical errors. It was an asynchronous, instructor–led class
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to allow flexibility for learner interaction, yet with the support of instructor guidance and
availability. The online CE class required significant interaction with the instructor and other
learners and differed from computer-based models in which the learner reads PowerPoint
presentations without interaction among others. It also differs from strictly synchronous classes,
which require all learners to be present and online at the same time. College credit was not
available for this class and as such, grades (other than pass or fail) were not provided (See
Appendix A).
The online CE class focused on developing interactive learning and addressed multiple
learning styles. It utilized active learning via problem-solving skills, engaged learner interaction,
and the application of new learning to real-life situations. The class provided two contact hours
toward the continuing professional development for a wide variety of health care providers.
This online CE class was intended to supplement the classes offered on campus and to
provide health care professionals with another option to obtain CE credit. This should attract
learners who would otherwise be unable to attend CE classes conducted on campus.
Nature of the Problem
The Prevention of Medical Errors class is required for licensure or certification for many
health care disciplines. As such, it is a well-attended class when held on campus. Increasingly,
however, health care professionals are in need of convenient educational opportunities that
accommodate diverse needs and schedules. An asynchronous, instructor-led online class that
offers pertinent interactive learning and CE credit for health care professionals more easily
adjusts to growing educational mandates, constantly changing information, and busy schedules
(Hannay & Newvine, 2006).
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Additionally, the rapid advances in health care have provided an increasing specialization
and segmentation of knowledge and information. As a result, new health-related jobs,
disciplines, and sub disciplines are created frequently. To cope with the massive expansion of
information, people in the workforce are focusing on smaller areas of knowledge. Out of
necessity, this has created health care professionals with narrower and more acute interests
(Draves, 2002). This further specialization prompted the need for detailed education targeted at
these newly formed occupations.
Purpose of the Study
The purpose of this practicum was to create and implement an effective online class to
meet the CE needs of health care professionals. To accomplish this, it was necessary to explore
teaching strategies that were effective in enhancing learner participation and interaction while
integrating adult learning principles addressing multiple types of learners. The challenge was to
choose, adapt, and perfect educational activities and opportunities that maximize the advantages
of online learning for a specific population (Anderson, 2004). The creation of this online class
considered the ADDIE (analyze, design, develop, implement, and evaluate) instructional design
model, learning-centered content, and a simplified internal navigation for novice online learners
within the learning environment.
The target audience consisted of working licensed or certified health care professionals
who are older than typical college students are. These adults often had multiple outside
obligations, and may have lacked previous online learning experience. They worked in a variety
of locations including home health care, hospitals, skilled nursing facilities, prisons, and private
practice. Nurses, physical therapists, psychological services, respiratory care practitioners, and
occupational therapists were included. Additionally, as there was no faculty at DSC experienced
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with creating non-college credit online CE classes, this practicum was also created to provide
guidance for future instructors and online CE class creation.
Significance to the Health Care Profession
As health care professionals have an ongoing need for updated information and learning
to keep current with best practice, online learning provides many convenient advantages to
traditional classroom learning. Data indicate that learners prefer online education because it
permits them to balance learning with other commitments. These learners also stated that online
learning achieved higher quality outcomes (Hannay & Newvine, 2006). Additionally, this
learning method allows health care professionals to learn from one another as they share
pertinent experiences across the spectrum of health care services and settings. It also permits the
application of new knowledge immediately to the work environment.
Research Question
There is one question directing this practicum, “How should class content be provided to
influence learning in an asynchronous, instructor-led online CE class for health care
professionals pertaining to the prevention of medical errors?”
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Chapter 2
REVIEW OF LITERATURE
Assessment of the Online Learner
The Online Learner
Russell (2006) describes adult learning as a process of self-directed inquiry. Adult
learners are characterized as autonomous, knowledgeable, goal-oriented, and require relevancy
of the new learning and respect (Russell, 2006). The author states active participation in learning
is also a principle of adult learning. According to Russell, active learning results in improved
long-term recall, synthesis, and problem solving skills over other methods of learning or
instruction. Additionally, this author adds adults also have established a visual, auditory, or
kinesthetic preferred learning style. Also importantly, Gaumer Erickson and Noonan (2010)
point out that older adults, in particular, have grown as a market niche in education. These
authors recommend institutes identify the needs, interests, and necessary online supports of these
learners to remain competitive.
A study in 2007 reported there were 100,000 nurses over the age of 50 in 1980 and that
number had increased to 400,000 by 2007 (Hill, 2010). Furthermore, the author states within the
health care environment, nursing knowledge is moving from a skill-based need to a knowledge-
based framework supported by evidence and the application of knowledge. Hill concludes that
CE classes are necessary to help health care professionals keep abreast of these rapid advances in
the health care industry.
Per Gaumer Erickson and Noonan (2010) adults over the age of 50 are increasingly
pursuing online instructional modalities of higher education coursework. They add that while
research shows late career adults typically prefer traditional instruction (face-to-face), some are
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embracing the flexibility and convenience of online instruction. These two authors go on to state
results of the study demonstrate that late career adults are satisfied with the online delivery and
find the experience to be more rewarding than their younger peers. Gaumer Erickson and
Noonan also cite results that reveal older adults are successful in online classes, but may require
more technology support at the onset of class. However, they add, after receiving technical
assistance, older learners perform as well or better than younger learners.
Additionally, information from the United States Census Bureau (2010) reveals that in
the next few decades the fastest-growing segment of the population will be older adults. This
report finds the number of workers over the age of 55 is increasing at a higher rate than any other
group. Additionally, the economy and workforce demands lifelong learners who continually
update their knowledge and skills (Gaumer Erickson & Noonan, 2010). As it is expected online
learning modalities will become more prevalent in the next decade, Gaumer Erickson and
Noonan add older adults will have little choice but to attempt online coursework to maintain
credentials and lifelong learning.
According to Gaytan (2007), learners state the scheduling convenience and quality of
instructional design are important aspects of effective online classes. Other advantages cited by
Gaytan included the ability to control the pace of the lesson. Furthermore, online learners
included the importance to reflect upon their own thinking as this enhanced the ability to transfer
knowledge of unfamiliar context and develop new knowledge structures (Anderson, 2004).
Finally, Anderson states the Internet allowed the learner to plunge more deeply into knowledge
resources and provided a means for learners to individualize their learning.
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Teaching and Learning Strategies
The Online Instructor
To establish an engaging environment for online learning, the roles of instructors in an
online classroom take on four dimensions: (a) pedagogical, (b) social, (c) managerial, and (d)
technical.
The pedagogical role involves facilitating educational processes of critical concepts,
principles, and skills for the learner. This includes knowledge sharing through interactive
discussion and a variety of educational experiences including feedback and referral to external
resources. Instructors weave effective online discussions into relevant concepts and identify
controversial topics, encourage discussion on both sides of the issue, and provide additional
evidence and counterexamples to raise learner debates to more engaging levels (Liu, Bonk,
Magjuka, Lee, & Su, n.d.).
The social role of the instructor promotes a friendly environment and feeling of
community among learners. The goal is to develop group cohesiveness and collective identity
among the learners. This is accomplished by nurturing skills that encourage participation,
providing ample feedback, attending to individual concerns, and using a friendly, personal tone.
Establishing a strong sense of belonging encourages learners to contribute to the knowledge
building. Studies have shown that a weak sense of social cohesiveness within an online
classroom results in an increasing dropout rate of learners who feel isolated and stressed (Lui et
al., n.d.). Therefore, it is important the instructor avoids negativity and provides encouragement
as timely, respectful, and positive feedback (Draves, 2002).
Managerial roles of the instructor include the organizational, procedural, and
administrative tasks associated with the online learning environment. This includes rotating
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assignments, managing online discussion forums, and handling the overall class structure. For
example, instructors can shape online interaction by setting clear agendas, objectives, and
timetables (Lui et al., n.d.).
Finally, within the technical role, online instructors attempt to make learners comfortable
within the system and software program. Learners are directed to support services to address
technical concerns and allowed sufficient time to learn the navigation within the environment.
When the instructor facilitates the smooth use of technology, the learner is better able to
concentrate on class participation and learning (Lui et al., n.d.).
Furthermore, Lui et al. (n.d.) add online instructors promote three types of interactions:
learner to content, learner to learner, and learner to instructor. Gaytan (2007) contributes that
online instructors must also address the different learning styles of learners. According to
Gaytan, translating the benefits of face-to-face interaction in a traditional classroom setting is
essential to develop effective online instruction. Unlike traditional classroom settings, Lui et al.
find facilitation does not rely upon verbal and non-verbal cues to initiate ongoing
communication. The online classes instead rely upon written language without paralinguistic
cues (Lui et al., n.d.).
Again quite unlike the traditional classroom, Hislop (2000) mentions the culture within
the online learning environment has moved from teacher-centered instruction and toward
learner-directed learning. The teaching requires interactions that are more informal (Hislop,
2000). Multiple authors confirm this new construct also requires instructors to become resource
people who provide the intellectual guidance and act as a coach to learners (Henry & Meadows,
2008; Levy, 2003; Lui et al., n.d.; Stick & Ivankova, 2004). Knowles, Holton, and Swanson
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(2005) described this learner-centered approach as instructors contributing resources as a co-
learner in the spirit of mutual inquiry.
Wagner, Vanevenhoven, and Bronson (2010) recommend learners be provided with what
to expect from instructors. In return, instructors must provide clear attention to detail, and an
intense focus on what is being communicated (Smith, 2008; Wagner et al., 2010). Finally, to
prevent the sense of learner isolation, instructors should respond to e-mails quickly, even if to
say a detailed response may not be possible for another day or two (Wagner et al., 2010; See
Appendix B).
Sense of Community and Social Presence
Johnson-Curiskis (2006) states the single most important element of successful online
education is interaction among participants. Research links higher levels of interactivity with
increased satisfaction of online learning (Wagner, Khaled, & Head, 2008). Similarly, Anderson
(2004) adds to be interactive, learners need to share a sense of belonging, trust, expectation, and
commitment. Along those same lines, social presence explains, Steinweg, Trujillo, Jeffs, and
Warren (2006) is the impersonal nature of online classes and describes the measure of the feeling
of community in an online environment.
Online instructors, cite Steinweg et al. (2006), must design activities to stimulate a sense
of community and social presence. For example, these authors suggest a class might begin with
light topics or introductions among the participants. This enables learners to become
comfortable with the medium and each other (Steinweg et al., 2006). According to the authors,
the online instructor can also enhance relationships with learners by personalizing e-mails and
feedback using a conversational writing style. As typical non-verbal communication cues are
absent within the online environment, learners mirror the language and style illustrated by the
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instructor (Steinweg et al., 2006). In addition, the authors note, differences between spoken and
written communication emphasize the importance of having a command of the written language
and its potential effect and comprehension by others. For example, Steinweg et al. claim writing
class materials in a learner friendly language (used during face-to-face interactions) helps to
convey human interaction and reflect “talking” with the learner.
Constructivist Theory
According to Bristol and Zerwekh (2011), constructivism relies upon cognitive styles,
transfer of learning, and social construction of knowledge. A constructivist-based class assists
learners to develop into responsible, self-directed learners (Ruey, 2010). The constructivist style
of instructional strategy facilitates adult learning and helps learners to learn in a more
collaborative, authentic, and responsible manner cites Ruey. This author goes on to state a
constructivist online learning environment is better able to provide active learning than a passive
learning environment.
Ruey further comments that within the constructivist theory, knowledge is socially
situated and constructed through connection to one’s own thoughts and experiences. This
instructional approach focuses on the why and how of learning (Ruey, 2010). Learners, the
author adds, are encouraged to actively engage in learning by discussing ideas and
collaboratively solving problems. The goal, according to the author is to assist learners to
become independent thinkers rather than passive knowledge receivers. Therefore, the class
curriculum is tailored to individual learning needs, interests, and experiences (Ruey, 2010).
Additionally, the author recommends the six instructional principles to be considered
when designing constructivist pedagogy for adult learners: (a) interactive learning, (b)
collaborative learning, (c) facilitating learning in a safe positive environment for sharing ideas,
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(d) authentic learning where content is connected to real-life experiences, (e) learning
emphasizing self-directed and experiential learning, (f) and high quality learning stressing
critical thinking skills and learner reflection. Ruey warns the instructor should be aware that
constructivist type of learning might be new to learners. Therefore, learners may need to be
taught the necessity of taking responsibility for their own learning (Ruey, 2010; See Appendix
C).
Problem-Based Learning and Critical Thinking Skills
Derived from constructivist epistemology, Bristol and Zerwekh (2011) and Nelson
(2010) agree that problem-based learning (PBL) is a learner-centered instructional approach.
These authors also concur that PBL is based upon instructional design that integrates relevant,
real-life problems to stimulate and strengthen critical thinking and problem-solving skills
(Bristol & Zerwekh, 2011; Nelson, 2010). This approach shifts the role of the instructor to a
facilitator who guides learners through the process of discovery, inquiry, analysis, and reporting
(Nelson, 2010). Not only is PBL one of the best-described methods of interactive learning, it
may be more effective than traditional methods in terms of lifelong learning skills (Smits,
Verbeek, & de Buisonje, 2002). Bristol and Zerwekh conclude that PBL allows learners to
integrate cognitive, psychomotor, and affective learning.
As it relates to constructivism, Nelson (2010) states PBL aids learners to understand by
their interactions with the environment. Learning is thereby tested, according to this author,
through the process of social negotiation and existing concepts as they relate to personal
experience. Furthermore, the author includes, PBL supports the tenets of adult learning
principles in that learners utilize their prior knowledge as a basis for new learning and are
actively involved and responsible for their own learning.
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Nelson (2010) states the problem presented must be authentic and based in the subject
matter of the class. Additionally, the author adds, the problem should be compelling, complex,
open-ended, and with more than one correct solution. Ideally, Nelson continues, it should
contain components of more than one discipline. The author goes on to state the outcome should
produce multiple hypotheses and require creative thinking, knowledge, and skills that meet class
objectives. Afterward, learners must reflect upon the successes and failures of their efforts to
make progress in future endeavors (Nelson, 2010). Fortunately, Bristol and Zerwekh (2011) find
these conditions can be provided within the online learning environment.
Oldenberg and Wei-Chen (2010) conclude that PBL also helps learners acquire critical
thinking skills. Critical thinking is a purposeful reflective process in which learners engage in
actively conceptualizing, applying, analyzing, and synthesizing in order to evaluate information
gathered from, or generated by, observation, experience, reflection, reasoning, or communication
(Alexander, Commander, Greenberg, & Ward, 2010). A strong body of research cited by
Alexander et al. shows critical thinking is enhanced through instructional strategies that promote
active learning. Additionally, Alexander, Commander, Greenberg, and Ward recommend online
learning techniques incorporate reflective and collaborative properties to foster critical thinking
skills in learners.
The goal of the instructor within online classroom discussions therefore is to ensure that
learners continually make progress towards critical thinking cite DeLoach and Greenlaw (2007).
For example, these authors recommend the instructor comments to discussion posts in a manner
to help learners make the transition to increasing cognitive complexity. Furthermore, they state
interactions should facilitate a deeper understanding of the material and include follow-up
questions to encourage learners to think more critically about the issue. DeLoach and Greenlaw
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recommend the instructor moves the discussion to higher levels of thinking in an active but
unobtrusive manner by posting probing questions directed at the entire group. This article
summarizes that since the online classroom environment does not have the time constraints
found in traditional classroom settings, the online discussions can last longer than a single class
period. These extended discussions allow online learners to explore more complex and
controversial issues, practice critical thinking skills, and develop a deeper understanding of the
issues (DeLoach & Greenlaw, 2007).
Consideration Toward Content
Instructional Design
The ability to interact with the instructor and other learners is one of the key activities of
the online approach that separates it from technologies such as computer-based training (Hislop,
2000). Likewise, Davis (2010) states an important aspect of online instructional design is
establishing a connection between the strategies and activities to learning outcomes or goals.
Davis further recommends content direct learners toward achieving the objectives.
Shelton and Saltsman (2007) cite the ADDIE model as a systematic approach to
instructional development. The authors state this model provides a basic path for developing an
instructional class by analyzing the objectives and audience, designing and developing materials
and activities, implementing the class materials, and evaluating the effectiveness of the
experience. From the onset, Shelton and Saltsman state an analysis of the learners and the class
is necessary. They also recommend analyzing the online delivery medium, as content cannot
simply be moved from the traditional classroom and into the online environment without regard
for capabilities of the medium.
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The authors then compare strategies and goals in the design phase to a blueprint of the
class. Within this phase they state, learner expectations and directions are clearly defined and
described. Class goals and objectives, orientation, communication practices, technology
policies, and overall class design are defined (Shelton & Saltsman, 2007).
The development stage provides content development, learning activities, and learner
assessment as according to Shelton and Saltsman (2007), each lesson is created with the class
objectives in mind. The authors add the implementation of the instruction where it is important
to create a welcoming and warm first impression to establish a learning community. They
suggest an introductory class session may include a scavenger hunt that teaches learners how to
navigate within the class and a personal introduction. Finally, the authors conclude evaluation
phase allows for reflection on the class. Feedback and comments are solicited from learners to
improve the class for next time (Shelton & Saltsman, 2007).
Medical Error and Patient Safety
As it pertains to the subject matter of the class, the Institutes of Medicine estimated that
between 44,000 and 98,000 Americans die each year because of medical errors (Kohn, Corrigan,
& Donaldson, 2000). That number was raised to an average of 195,000 people in the United
States who died in each year between 2000 and 2002 of potentially preventable, in-hospital
medical errors. This was determined by the study of 37 million patient records by Healthgrades
in 2004 (“In Hospital Deaths from Medical Errors”, 2004). Medical errors are cited as the eighth
leading cause of wrongful death in the nation (“Guide to Medical Errors Prevention”, 2009).
Additionally, the Institute for Healthcare Improvement estimate that nearly 15 million
instances of medical harm occur in the country each year (“Protecting 5 Million Lives”, n.d.).
Weingart, Wilson, Gibberd, and Harrison (2000) concluded that other studies found injuries
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caused by medical management occurred in 3.7% of admissions. These authors claim another
study stated preventable adverse drug events cost a 700-bed hospital $5.6 million per year.
Weingart et al. went on to report the likelihood of an adverse event increases by 6% for each day
spent in the hospital. The authors added that medication errors were seven times more likely to
occur in the intensive care unit and preventable mistakes are prevalent in the emergency
department.
These authors concluded that most medical errors are systems-related and due to the
increasing complexity of health care. Errors may be the result of poor communication, drug
name confusion, misinterpretation of handwriting, or sleep deprivation of health care providers
(Fahrenkopt et al., 2008; Weingart et al., 2000). Weingart et al., (2000) point out that safe
practices have been identified to improve patient safety and recommended for universal
implementation. Various health care disciplines in Florida are required to learn more about
medical error and attend at least two hours CE pertaining to the prevention of medical errors
(“Florida’s Health,” n.d.).
Within the Online Learning Environment
Davis (2010) recommends presenting materials in a cohesive and consistent manner. In
addition, providing lessons in an easily manageable length increases completion rates (Johnson-
Curiskis, 2006; Smith, 2008). Smith (2008), Cercone (2008), and Draves (2002) all recommend
chunking the information into meaningful segments. Chunking content helps to keep learners
from feeling overwhelmed while providing essential information for completing exercises and
comprehending concepts (Smith, 2008). While online learners are able to control how long each
learning event is, Smith recommends portioning material into that which can be accomplished in
20 minutes or less. Because the online lesson completion rate has more to do with the length of
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the lesson than the format in which it is delivered, online lessons should also be roughly
equivalent in terms of the length of time it takes to complete each (Draves, 2002; Smith, 2008).
With shorter lessons, Smith contends learners are more likely to log in and less likely to
postpone entering the online class until they have a larger amount of time. Learners, Smith
(2008) claims, who log into the course frequently are more likely to keep up.
New knowledge is retained only briefly unless a memory aid is provided (Smith, 2008).
To accommodate memory processing, Smith (2008) recommends presenting five to nine minutes
of passive learning followed by an opportunity to reinforce the concept with a participatory
learning activity or reflection. Additionally, this author recommends utilizing a bridge to
maintain interest when transitioning from one lesson to the next. This may consist of a summary
statement of the current lesson or a transition statement connecting previous content to the next
lesson (Smith, 2008).
Online classes can address design multiple learning styles (Bristol & Zerwekh, 2011). To
appeal to visual learners, Draves (2002) recommends the use photographs, video, clip art, charts,
graphs, PowerPoint, animations, and maps within the lesson. The author adds that auditory
learners appreciate audio lectures, chats, sound tracks, and music. Finally, Draves states
kinesthetic learners might enjoy simulations, scavenger hunts, Web field trips, and exploded
diagrams of parts and processes.
Gaumer Erickson and Noonan (2010) also recommend allowing learners access to the
online classroom one week before the start date, to permit leisurely familiarization and
exploration of the site. Additionally, Draves (2002) suggests sending an e-mail that provides
initial instructions how to log into the class before the class starting date. Johnson-Curiskis
(2006) warns to be mindful of holidays when determining the schedule. Draves suggests there
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be a listing of pertinent dates such as when the completions of all activities are due, chat dates,
start and end of class dates. The author states this may be in a calendar form or on a list.
Special Challenges
Internet access may continue to be problematic for learners with a variety of physical
handicaps; however in comparison with books or video media, the Web provides a much greater
quality and quantity of access to nearly all learners including those with disabilities (Anderson,
2004). Making the class content accessible to learners with disabilities and special challenges,
Anderson adds is an important consideration in online learning.
For example, Draves (2002) recommends a transcript of audio messages be provided for
learners with hearing disabilities. This author also states screen readers are available for learners
with visual disability to convert the written word into verbal information. Hislop (2000) finds
that for learners whom English is a second language, online classes may present new challenges.
According to this author, some non-native speaking learners have indicated writing in an
asynchronous discussion is actually easier, provides more time to think, and eliminates
pronunciation difficulties. However, Hislop notes other non-native speakers find it difficult and
time-consuming to read and comprehend items posted by fellow learners and the instructor. The
author concludes this may be due the conversational nature, idioms, and cultural specific
references or humor used in online discussions.
Cercone (2008) reports that adults might have limitations to consider when creating the
online environment. The author recommends easy to read fonts and bold colors make the screen
easier to read. Graphics, images, tables, maps, flow charts, and Venn diagrams, Cercone notes
help learners to readily comprehend concepts, process, and locations. This researcher also
24
comments that a clear menu structure, search help functions, and well-labeled entry and exit
points aids in online classroom navigation.
Academic Integrity
According to Olt (2002), academic dishonesty takes on some new methods in online
learning. Since the learners are no longer in close proximity, the author points out, looking at
each other’s papers now requires technology to accomplish. Distance, however Olt surmises
does not diminish unethical practice. Likewise, the author adds, technology eliminates the
ability of instructors to identify different handwriting, ink color, or erasure marks as evidence
that a learner has changed answers.
Creating a high level of instructor to learner interaction Olt (2002) concludes makes it
difficult for the learner to find consistent help to complete tasks. Furthermore, the author
recommends rotating the curriculum frequently by changing reading assignments and activities
to reduce academic dishonesty between classes. Additionally, Draves (2002) contributes that
within the online environment, it is simple monitor learner activity as many virtual environments
measure the participation by individual learners.
The simplest way according to Olt (2002) to combat cheating during exams or quizzes is
to encourage learners to access the learning materials during the assessment. The author adds
many online platforms have the capability of creating large pools of test items that ensure no two
learners take exactly the same assessment. Olt also mentions it is also important to word
multiple-choice items to discourage guessing the correct answer.
Finally, the author emphasizes all learners at the onset of the class should acknowledge
an academic integrity policy. The intent is to affirm the importance of integrity, promote an
25
environment of trust, encourage learners to take responsibility for academic integrity, clarify
expectations for learners, and reduce opportunities that promote academic dishonesty (Olt,
2002).
The Evaluation Process
Feedback
Feedback, according to Archer (2009) is defined as information about previous
performance used to promote positive and desirable development. It is a method of supporting
recipients to become more learning-oriented and is positively associated with learner
achievement (Archer, 2009; Ruey, 2010). Archer adds it is also essential to supporting the
cognitive, technical, and professional development of the learner.
When giving feedback, Archer (2009) states it is important instructors acknowledge the
psychosocial needs of the learner while ensuring the feedback is both positive and accurate. The
author comments that feedback should be specific and focuses on the task, not the individual.
Likewise, Archer recommends feedback be timely as evidence suggests the timing of feedback
may influence its effectiveness. The author adds inconsistent feedback may have a negative
effect by making it appear inaccurate to the recipient. Finally, the author concludes that
feedback can change clinical performance when it is systematically delivered from credible
sources.
Evaluation
The article by Gaytan (2007) finds many individuals measure the quality of online
instruction against the standards established for the traditional face-to-face classroom instruction.
The author states researchers have attempted comparisons of online and face-to-face classes in
26
terms of learning effectiveness. According to Gaytan, results indicate that online instruction is at
least as effective as face-to-face teaching.
Learning evaluation methods are a widely researched concern (“Kirkpatrick Model of
Training Evaluation,” n.d.). One example is Kirkpatrick’s four levels of evaluation model. It
includes: (a) the reaction of the learner, (b) the learning itself, (c) behavior, and (d) results.
Kirkpatrick’s model attempts to measure (a) what the learner thought or felt about the learning,
(b) the resulting increase in knowledge or capability, (c) the extent of behavior or capability
improvement, implementation, or application, and (d) the effects on the environment resulting
from the learner’s performance (“Kirkpatrick Model of Training Evaluation,” n.d.).
Bedi and Singh (2008) state online classes may also be evaluated via various other
means. For example, the authors recommend the college or institution may be interested in
determining: (a) how many learners are enrolled in the class, (b) how many learners completed
the class, (c) evaluating whether online classes generated learners who would not have taken
traditional campus placed classes, (d) how easily learners can register, and (e) how much tuition
was generated. They also suggest evaluating the class itself by: (a) measuring how many
learners enrolled in subsequent online classes, (b) comparing learner performance in online
classes versus traditional classroom classes, (c) measuring learner assessment results, and (d)
determining how easily learners access materials and receive feedback.
27
Chapter 3
METHODOLOGY AND PROCEDURES
Methodology
A developmental research methodology was used in this practicum. A review of
literature was conducted through online searches of databases, journals, professional
organizations, and relevant Web sites. Resources included ERIC, CINAHL, Google Scholar,
PubMed, the Journal of Online Learning and Teaching, and ProQuest. Key phrases such as adult
learners, instructional design methods, online curriculum design, academic integrity online,
learning styles, online instruction, and more were utilized in the search. The majority of the
material utilized was no more than 5 years old. Research was also performed on references cited
in scholarly articles.
Procedures
Several procedures guided this practicum. Daytona State College established a date for
this class, arranged registration of learners, provided an online classroom shell for its creation,
and technology personnel to assist as needed. The class offering was included into marketing
materials for the college and on the IHS Web site. Content from the campus-placed class
pertaining to the Prevention of Medical Errors was modified, added to, and adapted to the online
format. Content presentation methods were employed to accommodate various adult learning
styles. Extensive interaction was conducted with IHS and technology personnel at DSC to
create, coordinate, and implement this online CE class. Additionally, a two-hour campus-placed
class was taught for health care professionals interested in learning how to take an online CE
class. Learner needs were observed and noted during that class.
28
A comprehensive review of literature was completed. While information specific to
creating an online CE was sparse, various applicable aspects of creating and conducting online
classes in general were utilized. Topics included (a) pitfalls of online learning, (b) teaching
adults, (c) curriculum design, and (d) enhancing interactive communication to improve critical
thinking skills. Information that pertained to exclusively online college-credit classes without
application to online CE classes was excluded from this study.
A formative committee was assembled and guided the work, reviewed the progress, and
made beneficial suggestions for the project. The summative committee actively provided
feedback, and advice. The summative committee also evaluated the project as it neared
completion. The practicum experience was also evaluated by learner feedback upon completion
of the online CE class. Additionally, feedback was generated from DSC personnel and
adjustments were made to the registration process, classroom presentation, and marketing.
Assumptions
The successful completion of the practicum was based on four assumptions. It was
assumed staff at DSC would be available should assistance be needed during this endeavor.
Multiple contacts with technology and IHS personnel were made without difficulty and
marketing sent notices to inform potential students of the first online CE class. It was assumed
the formative committee members were wise and participative choices (See Appendix N). It was
likewise assumed the summative committee members would serve this practicum well (See
Appendix O). Finally, it was assumed there would be ample current literature pertaining to each
aspect of this practicum. A thorough review of literature resulted in identifying teaching
strategies effective within the online environment that were applicable to CE classes.
29
Limitations
There were three limitations associated with this practicum. As this was the first online
CE class for health care professionals at DSC, there was no history at IHS pertaining to routine
online CE operations. Some processes were adjusted to accommodate unforeseen challenges
such as differing certificate requirements for various health care specialties and improved
registration methods. Secondly, the online environment was updated at the onset of this
practicum, which required further training of the author. This significantly increased the time
required to create the online class within the revised environment. Finally, DSC continues to
have limitations pertaining to placing information regarding this class on their main Web site.
Methods to compensate for this are ongoing and include consideration of an event vendor to
provide notifications of upcoming classes to potential learners online.
30
Chapter 4
RESULTS
The purpose of this practicum was to create and implement an effective online class to
meet the CE needs of health care professionals. The challenge was to adapt existing content and
select educational activities and methods to maximize the interactive advantages of online
learning. Furthermore, the online activities and instructing methods were directed to meet the
various learning styles of adult learners. The literature search, online environment, and
evaluation methods provided the information, format, and results that addressed the research
question of “How should class content be provided to influence learning in an asynchronous,
instructor-led online CE class for health care professionals pertaining to the prevention of
medical errors?”
The first asynchronous, instructor-led online CE class for IHS and DSC opened February
28, 2011 to seven health care learners. Three more learners enrolled in the class after the start
date. All ten learners started and successfully completed the class. Three learners admitted to
being novices to online learning. The online classroom stayed open for a week and the class
introduction screen encouraged learners to complete the class over a few days to best take
advantage of learner and instructor interactions. The class introduction page provided
information pertaining to (a) the class format, (b) learner expectations, (c) requirements to pass
the class, (d) completion date and time, (e) instructions to obtain help, (f) and where and how to
start within the class (See Appendix D).
Within the Table of Contents screen was learner introductions, a link to answer
frequently asked questions and six lessons pertaining to differing aspects of medical error (See
Appendix E). The first four lessons provided brief articles and items to read (See Appendix F).
31
The remaining two lessons provided a five-minute audio-visual presentation (See Appendix G).
These presentations were narrated and animated slides created in Captivate software. Upon
completion of each lesson, the learner was required to respond to a discussion question and to
comments from at least one other learner.
The discussion questions were intentionally thought provoking, provided an authentic
situation relevant to health care professionals, and was associated with patient safety. Learners
applied new learning to current knowledge, participated in reflection, and shared experiences as
they produced in excess of 150 responses and interactions to discussion items in this class.
Furthermore, through responses to the discussion questions, the instructor guided learners with
more information and insights. Critical thinking skills and constructivist theory were utilized
(See Appendix H and Appendix I).
The online CE class content was designed to encourage interactivity and critical thinking,
be learner-centered, and establish a sense of community. It provided a logical flow of
information, opportunity to apply and reflect upon learning, and integrated activity with
objectives. Instructions were written in a conversational style and information was chunked into
individual lessons that could be completed within 20 minutes (See Appendix J). To
accommodate learners new to the online environment, navigation within the virtual classroom
was simplified and the verbiage was consistent. The resulting online classroom was reviewed
with others to assess for comprehension and clarity before the start date of class.
Recommendations were taken into consideration and adjustments were made.
All learners within this online CE class completed the discussion questions, viewed the
content of each lesson, and passed the final quiz. The quiz was 10 questions and the average
score on the quiz was 99%. Finally, feedback indicated the learners were very satisfied with the
32
class and felt they learned something new and applicable to their work environment. Personal
conversations with three of the learners also demonstrated their satisfaction with the class and
mode of delivery. All three questioned when more such classes would be offered. Most learners
also provided narrative comments on the feedback survey (See Appendix K and Appendix L).
33
Chapter 5
DISCUSSION, CONCLUSIONS, IMPLICATIONS, AND RECCOMMENDATIONS
Discussion
It was thought the very short nature of a CE class would limit the opportunity for
interactivity and establishing a sense of community among the learners. For example, the first
learner to enter the online CE class did complete all the required activity in one sitting. This
learner did not interact with other learners since there were no other responses posted yet. As
this was only a two-hour class and interaction was requested within the instructions, means were
not employed to require it to complete the class. However all learners, with the exception of the
first entrant responded to other classmates. Likewise, because of the limited duration of the
class, it was felt important to provide instant access to the certificate of completion to the learner
upon successful class completion. Waiting for a certificate to be mailed to the learner was seen
as an unnecessary distraction and potential dissatisfier.
For learners new to the online environment, frequently asked questions were provided on
the classroom site, along with help contact phone numbers and email addresses (See Appendix
M). To meet the state requirements for CE credit, a short quiz and a feedback survey were
required upon completion of the lessons. Larger, Arial font was used where possible to aid in
reading text. Links were also provided to learn more about medical errors.
Because this was the first class and the previous online learning experience of the
learners was unknown, a two-hour live session was scheduled to allow learners to email or call
the instructor in real-time during the class week. While this did not quite qualify as a chat, nor
was it required for learners to attend, it was provided to support learners in an immediate fashion
34
if needed. One learner did call in during that time and asked a question about the process to
respond to other learners.
Finally, unique characteristics of online CE classes were identified during this practicum
and include the following:
1. Online CE classes for health care professionals are considerably shorter than semester
length online college-credit classes. CE classes may be one to eight hours in length.
Classes of longer duration are rare. Therefore, a sense of community must be
established quickly. The classroom presentation and navigation must be especially
user-friendly, as learners do not have much time to become acquainted with the
environment.
2. Online CE classes generally have no need for grade books, major exams, drop boxes,
or significant assignments to submit. Links to these areas within the online classroom
can be eliminated. This simplifies navigation within the class. The ability to conduct
learner interaction within the content area of the online class also eliminates the need
for navigation to a separate discussion link.
3. Learner expectations of online CE classes differ from than college level classes. CE
classes tend to provide more of a training focus with immediate application of the
learning to the working environment. Online college-credit classes generally have
more of a conceptual focus.
4. There is no college-credit or grade (other than pass or fail) provided for online CE
classes. Some college classes however may apply toward CE credit provided the
learner successfully completes and passes the class.
35
5. Information pertaining to the class overview along with objectives and pertinent
announcements placed on the class introduction screen replaces the syllabus.
6. While restrictions can be placed on quizzes and certifications of completion in most
online environments, because the stakes are lower and the class is shorter, cheating is
likely less prevalent (but possible) in online CE classes.
7. Textbooks are not required for online CE classes. The learner or the instructor finds
most information on the Internet, or files and links provided within the class.
8. Historically, learners were required to do little more than show up to a CE class and
listen to information. However, similar to online college-credit classes, online CE
classes require more active learning and higher thinking skills.
9. Online CE classes pertain to narrowly focused topics specific to a well-defined
occupational or professional field. The learners may represent diverse disciplines,
work settings, and circumstances within that field and topic.
Conclusions
Previous asynchronous, instructor-led online college-credit classes have paved the way to
apply many of the methods to online CE classes. Additionally, not only are recent college
graduates expecting online classes, experienced adults are also making the transition from
traditional classroom learning. Perhaps in addition to the convenience, learners appreciate the
adult learning principles and active learning methods in online learning. Whatever is the root of
their satisfaction with online CE learning, this first online CE class for health care professionals
at IHS appears to have stimulated interest in the learners and at least one more instructor. This
class will be offered again next month and another class is currently being redesigned for the
online CE environment.
36
Implications
Benefits to Daytona State College
This online CE class provides the potential for increased enrollment because learners are
being offered more options to obtain CE credit. As health care workers frequently work odd
hours and days, traveling to the campus to attend a short class is often inconvenient and conflicts
with work schedules. Offering more flexible scheduling has the potential to increase revenue
and capture current students enrolled in health care programs at DSC for their future continuing
education needs.
Benefits to Learners
Most students graduating from colleges today are at least somewhat familiar with online
learning. As online college-credit classes become more prevalent, the demand for online CE
classes will grow. When properly created, online classes can be at least as effective as those
presented in traditional classrooms
Benefits to the Health Care Profession
Online CE classes have the potential to provide a widely diverse health care market with
current information pertinent to professional educational needs in an easily accessible format.
Keeping health care professionals current with the latest information pertaining to advances,
procedures, and medications can result in more effective, safe, and quality health care for
patients. Furthermore, learning online can accommodate the varied schedules of working
professionals and provide an opportunity to share experiences among learners.
Recommendations
Preventing medical errors is an important topic to protect patient safety. However, online
learning can easily be expanded to include fall prevention, domestic violence, new surgical
37
techniques, advances in diabetes care, care of the elderly, etc. While this two-hour CE class was
successful, asynchronous, instructor-led online CE classes may be best suited to those classes of
four more hours or open for at least two weeks. This provides many opportunities for the
learners to interact and share experiences, participate in problem-based learning to a greater
degree, and establish a better sense of community.
As an example, a future application for this instructional method might be applied to a
series of career development classes. A Registered Nurse considering further insight into Risk
Management might take a four-hour online CE class pertaining to Introduction to Health Care
Risk Management. Another four-hour online class pertaining to the Protection of Assets in
Hospital Settings may follow this. In addition, a hybrid class could be created where concepts of
intravenous therapy are learned online and followed by traditional classroom practice of
intravenous insertions.
Perhaps the largest barrier to providing more online CE classes is the amount of time
required to create the class. Creating an online classroom is labor intensive and requires focused
attention to detail. The concept of teaching online also requires a large paradigm shift for the
instructor. This might explain the shortage of instructors willing to dedicate uncompensated time
to create online CE classes. However, because of this practicum, DSC has approved a tutoring
class specific for potential online CE instructors be created.
Furthermore, marketing methods could be employed to attract learners outside of the
local area. Additionally, the development of a community advisory board could determine
upcoming educational needs of health care professionals. This would also support a goal of IHS
to provide career development and community education in an asynchronous, instructor-led
38
online environment that meets the needs of the health care community through collaboration,
cooperation, communication, and application of knowledge.
39
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APPENDIXES
44
Appendix A
Types of Online Classes
There are many confusing and overlapping definitions for various methods of learning with technology. In an effort to be consistent with terminology, the following defines the terms used or referred to in this paper (Bristol & Zerwekh, 2011)
Asynchronous activities do not require all participants to be online at the same time or at the same location. Examples include e-mail and discussion board items. Blended or hybrid learning environments utilize both face-to-face and online learning methods within one course. Sometimes this is done to reduce the amount of time required in the face-to-face or traditional classroom setting. Computer Assisted Instruction utilizes technology to provide learning activity. CAI can occur with or without being online. Continuing Education is a process whereby pertinent information is provided that is usually associated with an occupation or work-related position. These classes are generally conducted from one hour to a few days and maybe presented by a variety of methods including a traditional classroom, viewing a PowerPoint presentation online or via computer file, by reading material and answering questions, or online. Instructor-led implies an instructor will guide and act as a resource for the learning of the student in the online class. Non instructor-led online classes do not have this interaction. Online learning uses Internet technologies to provide course activities. Synchronous activities are completed at real-time and all participants are online and performing same activity at the same time but perhaps from different locations. Examples include online chats. Traditional classroom is place-based learning where all students attend class in one location at the same time. Technology may or may not be used in the class.
45
Appendix B
Instructor Attributes
According to Bristol and Zerwekh (2011), the following lists effective pedagogy for online teaching:
1. Foster relationships by being personable. 2. Encourage engagement by helping students contribute and respect the contribution of
others. 3. Respond to students in a timely fashion. 4. Connect with student through good communication. 5. Provide a well-developed learning environment through organization. 6. Be current and fluent with the technology. 7. Be patient and flexible. 8. Exhibit high expectations and clearly identify what is expected of the students.
Published in 1987, a work by Chickering and Gamson listing seven principles of good teaching is still widely referenced today.
1. Encourage contact between students and faculty. 2. Develop reciprocity and cooperation among students. 3. Encourage active learning. 4. Provide prompt feedback. 5. Emphasize time on task. 6. Communicate high expectations. 7. Respect diverse talents and ways of learning.
Chickering and Gamson (1987) also list six powerful forces of education: 1. Activity, 2. Expectations, 3. Cooperation, 4. Interaction, 5. Diversity, and 6. Responsibility.
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Appendix C
Shifting to an Online Learner-Centered Approach Communication Write clear agendas and objectives (Liu, Bonk, Magjuka, Lee, & Su, n.d.). Provide attention to detail and communication (Wagner, Vanevenhoven, & Bronson, 2010). Respond to e-mails quickly (Wagner et at., 2010). Simulate the face-to-face interaction of a traditional classroom setting (Gaytan, 2007). Meet or beat the expectations the learners have of the instructor (Wagner et al., 2010). Present content in a cohesive and consistent manner (Davis, 2010). Critical Thinking Skills Integrate real world problems into active learning (Nelson, 2010). Guide learners through discovery, inquiry, and analysis (Nelson, 2010; Hislop, 2000). Move discussion to higher thinking in an unobtrusive manner (DeLoach & Greenlaw, 2007). Post probing questions directed at the entire group (DeLoach & Greenlaw, 2007). Lesson Development Create lessons that can be completed in 20 minutes or less (Smith, 2008). Present five to nine minutes of passive learning followed by activity or reflection (Smith, 2008). Chunk content into manageable lessons to aid comprehension (Johnson-Curiskis, 2006). Establish a direct connection between activities and the outcomes or goals (Davis, 2010). Align content to learners accomplishing the objectives (Davis, 2010). Interactivity The most important element is interaction among participants (Johnson-Curiskis, 2006). High levels of interactivity increase learner satisfaction (Wagner, Khaled, & Head, 2008). Create interaction between the learner and content, instructor, and other learners (Davis, 2010). Discuss both sides of an issue. Provide evidence and counterexamples (Liu et al., n.d.). Sense of Community Design activities to stimulate a sense of community and social presence. Encourage participation. Provide ample feedback. Use friendly, personal tone (Liu et al., n.d.). Developing the Environment Use easy to read fonts and clear, bold colors. Use clear menu structure, search functions, and well-labeled entry and exit points to aid navigation (Cercone, 2008). Consider learners with disabilities and special challenges. Feedback Feedback should be positive, accurate, and timely (Archer, 2009). Feedback should be specific. Focus on the task, not the individual (Archer, 2009). Feedback can change performance when systematically delivered from credible sources (Archer, 2009).
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Appendix D
Class Introduction Screen
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Appendix E
Table of Contents Screen
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Appendix F
Example of Articles to Read
Friday, October 29, 2010
Doctors Confess Their Fatal Mistakes By Joe Kita "It was more than 20 years ago, but it still haunts me," says Bryan E. Bledsoe, a clinical professor of emergency medicine at the University of Nevada School of Medicine. "I made a mistake that may have cost a woman her life." Bledsoe's oversight, which you'll read about later, has driven him throughout his career. To this day, he is an outspoken advocate for health care safety, teaching physicians-in-training to treat patients as individuals, not as numbers at a deli counter. It sounds like an obvious message, but an overemphasis on speed is just one of the reasons that, every day, Americans in hospitals around the country are injured or die because of a medical error. "Any physician who says he or she never made a mistake is a liar," Bledsoe says. The problem of avoidable medical error burst into the news in 1999 when the Institute of Medicine published To Err Is Human: Building a Safer Health System. Highlighting an estimated 98,000 unnecessary deaths every year, the report inspired a patient-safety movement—but over a decade later, not nearly enough progress has been made, say many experts. What's still needed: more thorough approaches to investigating errors, support systems that help doctors admit to and learn from their failings, and better methods of adopting proven solutions. In the meantime, people are still dying needlessly. "If we don't talk about the problem of hospital error, there's no way to fight it," says Peter Pronovost, MD, PhD, a professor at Johns Hopkins University School of Medicine, whose own father died because of medical errors at age 50. "Whenever I've worked up the courage to share a personal mistake, my colleagues listen raptly. But most don't say anything, even though I know they're just as guilty. The culture of medicine still won't allow it." But that's changing. When Reader's Digest first considered approaching health care professionals to ask them to confess their biggest mistake, we worried that few would speak up. We were wrong. Doctors, nurses, and pharmacists all stepped forward. Each of these professionals welcomed the chance to say "I'm sorry"—and, more important, to address the weaknesses in the health care system that continue to make errors like theirs possible. Read their stories and see if you, too, don't entertain some hope that a better, safer health care system is on the way. "After six hours, he still wasn't waking up. What had I done?" -- Peter Pronovost, MD, PhD I was a young doctor doing specialty training in critical care, and I was exhausted. Partway through a 36-hour shift at Johns Hopkins Hospital, I was hungry and hadn't slept for 24 hours, but I was facing an overflowing intensive care unit and somehow needed to discharge five patients to make room for more. Mr. Smith,* who'd had esophageal surgery, was a borderline call. But because of the pressure I was under, I decided to remove his breathing tube and transfer him to another unit. That turned out to be a very bad decision. Before long, his breathing sped up as his oxygen levels dropped dangerously. I needed to reinsert his breathing tube. But what I didn't know was that he had severe swelling in his throat—in fact, the anesthesiologists in the operating room had had difficulty placing the tube in the first place. When I
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Appendix F (Cont.)
Example of Articles to Read looked into his mouth and tried to identify his vocal cords in order to insert the tube, all I saw was a swollen mass of dark pink tissue, like raw hamburger meat. I took the instruments out and started to bag him, breathing for him, but he vomited, making that almost impossible. I finally got the tube in—but quickly realized it was in his esophagus, not his airway where it belonged. Understand that when you insert a breathing tube, you give the patient medication to stop his breathing. You have about four minutes before he suffers brain damage. It took me between three and five minutes to get the tube properly placed. I waited anxiously for the medication to wear off, which usually takes about 15 minutes. But after an hour, Mr. Smith was still asleep. After six hours, I was panicked. I explained the situation to the patient's wife—well, I sort of explained it. Fighting back tears of shame and guilt, I told her I'd had difficulty reinserting the tube, but I didn't mention that it was the wrong decision to remove it in the first place. Doctors, especially Johns Hopkins doctors, didn't make mistakes. If you did, you suffered your shame silently. Luckily, Mr. Smith regained consciousness shortly thereafter and recovered with no ill effects. I still remember my overwhelming feeling of relief. Many medical errors occur because hospitals lack standardized checklists for common procedures designed to minimize the chance of bad judgment. Airline pilots and NASCAR teams have them—why don't doctors? I think it's partly because it's so important to us to believe in the myth that doctors are perfect. Before I pulled that tube, I should have had to complete a checklist that included input from the patient's senior physician and nurse. If anyone had disagreed, I wouldn't have been able to act. A simple system like this not only protects patients but also promotes honesty, respect, and teamwork among hospital staff. A few years ago, I helped develop just such a list for doctors and nurses in more than a hundred ICUs in Michigan. It focused on a common intensive care procedure: inserting a catheter into a vein just outside the heart for delivery of intravenous liquids. It ticked off five steps everyone had to follow, and in 18 months, it lowered the rate of catheter infection by 66 percent and saved 1,500 lives. Mr. Smith taught me a lesson I never forgot. It's time we let him teach us all. —Peter Pronovost, MD, PhD, is a professor at Johns Hopkins University School of Medicine and the coauthor of Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. "Her name was Emily, and she was two years old." --By Eric Cropp It was a busy Sunday in the pharmacy at Rainbow Babies & Children's Hospital in Cleveland. The hospital's computer system had been down for about ten hours before I started my shift, and because I was teamed with a pharmacist who was fairly new to the department, I had additional responsibility. But I'd been in busy situations many times before. In fact, I had 14 years of experience and had been president of the Northern Ohio Academy of Pharmacy. But on this day, I made the mistake of not thoroughly checking a saline-solution base that a technician had prepared for a child's chemotherapy treatment. She mixed it more than 20 times stronger than ordered, and I didn't catch it. When a nurse administered it, the high concentration of sodium chloride flowing through the child's veins made her brain swell and put her in a coma. Three days later, she died. Her name was Emily, and she was two years old. I was eventually convicted of involuntary manslaughter, for which I received six months of jail time, six months of house arrest, three years of probation, a $5,000 fine, and 400 hours of community service. I also lost my license, career, reputation, and confidence. But most devastating of all is that I have to live every day with the memory of that little girl.
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Appendix F (Cont.)
Example of Articles to Read
I accept full responsibility for what happened. I should have checked that solution more carefully. But there are some facets of hospital and retail pharmaceutical work that desperately need fixing if similar tragedies are to be avoided. Pharmacy technicians need better training. Most people don't realize that techs have something to do with approximately 96 percent of prescriptions dispensed in pharmacies, according to the National Pharmacy Technician Association (NPTA). Yet 92 percent of us live in states that do not require them to have any formal training. (The tech in my case had a high school diploma.) Ohio recently adopted Emily's Law, which requires that all techs undergo training and pass a competency exam. The NPTA is currently working on a bill that would institute Emily's Law nationwide. We should also take advantage of technology. There are lots of look-alike, sound-alike medications that come in small vials with tiny labels. A bar-code scanning system, like the ones in supermarkets, would supply an extra layer of safety. But technology isn't enough; pharmacists and techs need better working conditions. Pharmacies can be cramped and the workload is often heavy. But studies suggest that crowding and dim lighting make mistakes more likely. So do interruptions, and the need to fill too many prescriptions. Believe me, a lot of pharmacists say a little prayer on their way home that an error didn't slip through. Finally, I wonder what would have happened if I had talked to Emily's family right away and said I was sorry. I was advised against doing that. That's the way it is in the medical world when a mistake occurs: Hospital management may meet with the family, but the health care worker is often advised not to make a personal apology. Too much of a culture of silence still exists and must change. Doctors, nurses, pharmacists, and others need to be able to come together to confess their mistakes, clear their consciences, be supported, and, most important, work together to make the system safer. —Eric Cropp, 42, is currently unemployed. *Names changed to protect privacy. Read more doctor confessions. http://shine.yahoo.com/channel/health/doctors-‐confess-‐their-‐fatal-‐mistakes-‐2392
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Appendix G
Audio–Visual Presentation – Prevention of Medical Errors
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Appendix G (Cont.)
Audio–Visual Presentation – Prevention of Medical Errors
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Appendix G (Cont.)
Audio–Visual Presentation – Prevention of Medical Errors
55
Appendix G (Cont.)
Audio–Visual Presentation – Prevention of Medical Errors
56
Appendix G (Cont.)
Audio–Visual Presentation – Prevention of Medical Errors
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Appendix H
Examples of Discussion Questions
Examples of the discussion questions include the following:
1. What have you seen in regards to medical error? What error prevention tips would you tell a family member who is about to be hospitalized for abdominal surgery?
2. What do you feel contributes to or are the reasons for medical error in health care? Do you feel these numbers are accurate? In your experience, do you feel health care is getting safer?
3. Humans make mistakes - but would we really want robots taking care of us? What are some ways to lessen the chance of a mistake - and what are some of the pressures
to cut corners on safety? 4. What are some ways medication errors could or have occurred in your experience? What are some measures to ensure the correct medication is administered to the correct patient with the correct dose, and form at the correct time?
5. What are some factors you think have contributed to the emergence of "Multi-drug resistant organisms" - for example MRSA? In addition, there are new reports of increasing amounts of TB, Whooping Cough, and even Bed Bugs. What do you think is causing this and how can we protect our patients? 6. Respond with at least one thing you learned or will do differently. 7. Legislators and The Joint Commission are pushing to mandate flu shots for those who work with patients. How do you feel about that?
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Appendix I
Example of Learner Interaction Responses
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Appendix J
Average Time per Lesson
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Appendix K
Feedback Survey
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Appendix L
Learner Narrative Comments
Enjoyed and learned from interactional aspects of course. I found the class to be helpful when reading the comments of others. I really enjoyed the interaction with fellow students. I really enjoyed the class especially being able to interact with the students. Thank you for the class. It was enjoyable. I liked the questions and being able to respond because I learned more from writing down thoughts and reading others input. The interactive style was interesting to me because I don't work in clinical so I enjoyed a window into other professionals challenges I thought it was excellent. Congratulations on your first online class. I enjoyed the brief presentations and review with others through the reply process. The reviews at the end were helpful as well. I liked the presentations with visual and concise information.
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Appendix M
Frequently Asked Questions
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Appendix N
Formative Committee Members
Jerry Hood, MS, RPh ICU Pharmacist Providence Medford Medical Center Medford, Oregon Linda Misko, RN, MSN Manager of Staff Education Florida Hospital Memorial Medical Center Ormond Beach, Florida Charles Russo, PhD Professor American Military University Charles Town, West Virginia
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Appendix O
Summative Committee Members
Sue Cole, RN, CPHQ Director of Clinical Effectiveness and Education Florida Hospital Fish Memorial Orange City, Florida Paula Morton, RN, MSW Coordinator, Institute for Health Services Daytona State College Daytona Beach, Florida Christal Paetz, BS, MCSM Clinical Informatics Liaison Performance Improvement Asante Health System Medford, Oregon
