ORIGINAL ARTICLE /ARTICLE ORIGINAL DOSSIER
Interprofessional Psychosocial Oncology Education:
Nurse Outcomes of the IPODE Project
L’éducation à distance en oncologie psychosociale interprofessionnelle : résultats du projet ÉDOPI chez le personnel infirmier
D.L. McLeod · J. Curran · M. White
Received: 16 February 2011, Accepted: 25 April 2011
© Springer-Verlag France 2011
Abstract Aims: Standards of Care in Psychosocial Oncol- ogy (CAPO, 2010) identify that patients and families should expect to receive evidence-based psychosocial oncology health services in addition to their medical care. In Canada however, and in many other countries, the reality often falls short of these standards. While nurses often recognize the psychosocial needs of their patients, they identify that they do not feel confident about meeting them. Opportunities to collaborate with other health professionals who may be able to support the nurse in her or his practice as well as the patient/family are often limited. To address these gaps, the Canadian Association of Psychosocial Oncology (CAPO) launched a pan-Canadian education initiative, the Interpro- fessional Psychosocial Oncology Distance Education (IPODE) project. The aim of the project was to create web- based, interprofessional learning opportunities for practicing health professionals and graduate students in five core disciplines: nursing, social work, psychology, spiritual care and medicine. We report the nurse-related outcomes in this article.
Procedure: A web-based course titled “Interprofessional Psychosocial Oncology: Introduction to Theory and Practice” was developed and received approval from 11 Canadian universities. The course objectives related to
psychosocial oncology content as well as interprofessional collaboration. Pre- (T1) and post-course surveys (T2— immediately after the course) were administered. A non- parametric Wilcoxon signed-rank test was used to compare changes in pre- and post-course knowledge and attitudes.
Narrative data were thematically analysed.
Results: Analyses of the 53 pre-post surveys completed (49%) revealed the course was effective and significantly improved knowledge of other disciplines’roles, confidence, and satisfaction with interprofessional collaboration and with psychosocial oncology practice. Implications for oncol- ogy nurses with regard to retention and compassion fatigue were identified.
Conclusions: Web-based learning is a viable alternative for interprofessional psychosocial oncology education and offers certain advantages over face-to-face education in speciality health professional education. Online interprofes- sional learning can benefit post-licensure as well as under- graduate students. To cite this journal: Psycho-Oncol. 5 (2011).
Keywords Interprofessional web-based learning · Oncology nurses · Psychosocial oncology
RésuméObjectifs: Les standards de soins en oncologie psy- chosociale (CAPO, 2010) identifient que les patients et les familles devraient s’attendre à bénéficier de services d’onco- logie psychosociale factuels outre leurs soins médicaux. En réalité, au Canada comme dans de nombreux autres pays, ces services font souvent défaut. Bien que le personnel infirmier reconnaisse les besoins psychosociaux de ses patients, il admet manquer de confiance pour y répondre. Les occasions de collaborer avec d’autres professionnels de santé suscep- tibles d’épauler le corps infirmier dans sa pratique ainsi que le patient et/ou sa famille sont souvent limitées. Pour pallier ces manquements, la Canadian Association of Psychosocial Oncology (CAPO) a lancé une initiative éducative pancana- dienne, à savoir le projet d’éducation à distance en oncologie
D.L. McLeod (*)
Clinician Scientist, Psychosocial Oncology Team (NSCC), QEII Health Sciences Centre, Assistant Professor, School of Nursing, Dalhousie University, Victoria 11-006, 1278 Tower Rd., Halifax, Nova Scotia., Canada, B3H 2Y9 e-mail : [email protected]
J. Curran (*)
Postdoctoral Fellow, Ottawa Hospital Research Institute e-mail : [email protected]
M. White (*)
Lecturer, School of Nursing, Dalhousie University, University Ave., Halifax, Nova Scotia, Canada, B3H 4R2 e-mail : [email protected]
DOI 10.1007/s11839-011-0318-2
psychosociale interprofessionnelle (ÉDOPI). Le but de ce projet a été de créer des possibilités d’apprentissage interpro- fessionnel sur le Web destinées aux professionnels de la santé en exercice ainsi qu’aux étudiants de troisième cycle.
Cette formation porte sur cinq disciplines phares : les soins infirmiers, le travail social, la psychologie, les soins spirituels et la médecine. Nous indiquons dans cet article les résultats concernant le corps infirmier.
Procédure : Un cours sur le Web intitulé « Oncologie psychosociale interprofessionnelle : introduction à la théorie et pratique » a été développé et a reçu le feu vert de 11 uni- versités canadiennes. Les objectifs du cours concernaient l’oncologie psychosociale ainsi que la collaboration inter- professionnelle. Des études précours (T1) et postcours (T2-immédiatement après le cours) ont été menées. On a eu recours au test non paramétrique des rangs signés de Wilcoxon afin de comparer les changements intervenus dans les connaissances et les comportements avant et après le cours. Les données narratives ont été analysées de façon thématique.
Résultats: Les analyses des 53 études pré- et postcours ache- vées (49 %) ont révélé que le cours était efficace et avait considérablement amélioré les connaissances en termes de rôles d’autres disciplines, de confiance et de satisfaction apportée par la collaboration interprofessionnelle et la pratique de l’oncologie psychosociale. On a identifié les implications du personnel infirmier en oncologie en matière de fidélisation et de fatigue compassionnelle.
Conclusions: L’apprentissage sur le Web est une alternative viable pour l’éducation en oncologie psychosociale interpro- fessionnelle et, comparé à un enseignement direct, il offre certains avantages en termes de formation des professionnels de la santé spécialisés. L’apprentissage interprofessionnel en ligne peut convenir aussi bien aux étudiants postlicence qu’aux étudiants de premier cycle. Pour citer cette revue : Psycho-Oncol. 5 (2011).
Mots clésApprentissage interprofessionnel sur le Web · Infirmiers en oncologie · Oncologie psychosociale
Cancer care systems in North America generally do a good job of addressing the medical needs of cancer patients. We have been less successful in providing adequate psycho- social health services [1,5,6]. Front-line health professionals, such as oncologists and nurses, often recognize the needs but identify that they do not have the knowledge, skills or confi- dence in addressing them [11,13,20]. When psychosocial needs are identified, but not addressed, this can increase pro- vider stress and compassion fatigue. It can also decrease job satisfaction, leading to problems with retention [14,17].
Opportunities for front-line staff to collaborate with those who are specialists in the area are sometimes limited [18].
In Canada, a number of initiatives designed to address the gaps in psychosocial oncology services have been imple- mented in recent years. The Canadian Association of Psy- chosocial Oncology (CAPO) recently published“Standards of Psychosocial Health Services for Persons with Cancer and their Families” [3]. These identify that all health profes- sionals have responsibility for psychosocial care; with some professionals providing more “generalist”level care and others specialized care. Nationally, we are also imple- menting screening for distress as the 6thvital sign [4,7], with several jurisdictions already engaged in large-scale screen- ing projects. These and other initiatives underscore the need for psychosocial oncology education and support for nurses and other front-line health professionals.
One CAPO initiative to address education needs is the Interprofessional Psychosocial Oncology Distance Educa- tion (IPODE) project. The IPODE project launched its first web-based course in 2008 and to date has had more than 320 practicing health professionals and graduate students take one or more of the IPODE courses. While the target groups for these courses include social work, psychology, nursing, spiritual care and medicine, approximately 54% of the course participants are nurses. In this article, we describe the IPODE project and outcomes for one course, with a particular focus on nurses.
Project Description
The IPODE project was initiated in 2006 with funding from Health Canada. The grant was one of 21 awarded to explore and enhance interprofessional education for collaborative patient-centred practice. Our first course “Interprofessional Psychosocial Oncology: Introduction to Theory and Prac- tice” was approved in 11 universities and cancer agencies in 8 provinces across Canada. Graduate-level health profes- sional students (Masters or PhD level) take the academic version; a continuing education (CE) version is offered to practicing (post-licensure) health professionals. Course par- ticipants learn about psychosocial oncology with, from and in relation to each other [2]. Course participants join a national cohort of learners, forming small interprofessional learner groups that meet in real-time, web-based seminars each week. Course objectives are divided between psycho- social oncology and interprofessional collaboration.
This and other courses in the series are informed by an interpretative pedagogy with an emphasis on the social con- struction of knowledge in relation to the illness experience, diversity, assessment of psychosocial oncology needs and evidence-based interventions to meet those needs. To date, 293 health professionals and students have completed the first course, which is offered in English and French. The project is described more fully in a forthcoming paper [12].
Evaluation
Students outcomes were evaluated using a pre-post course survey. The post-course survey included narrative questions about learning, planned changes in practice and suggestions to improve the course.
To assess interprofessional learning, we adapted Stone’s [19] self-assessment questionnaire. This tool captures parti- cipants’perceptions of their interprofessional strengths and challenges. Descriptive statistics (frequencies, means and modes) was used to analyse the survey data. A non- parametric Wilcoxon signed-rank test was used to compare changes in pre- and post-course knowledge and attitudes.
Narrative data were thematically analysed.
Results
A total of 293 health professionals and students completed the course between 2008 and 2010. Of these 54% (158) were nurses. Sixty-five percent (n = 103) completed pre-course surveys in the academic (n = 19; 18%) and CE (n = 84;
82%) sections of the course between January 2008 and December 2010. Thirty-eight percent reported previous experience with web-based learning. Slightly less than one- third (31.6%; n = 6) of the AC group and 27.4% (n = 23) of the CE group reported previous experience with interprofes- sional graduate level courses. The CE group was slightly older (mean = 42.18 years) than the AC group (mean = 34.16 years) (Table 1).
A total of 53 students (49%) completed both the pre- and post-course follow-up surveys. Table 2 reflects students’
post-course feedback regarding course design and web- based learning tools. Students generally reflected a positive response to course elements with the in-depth cases and videos making up the most favourable attributes.
Nurses realized a number of significant changes in their knowledge and attitudes after completing the course (Table 3), including a stronger appreciation for the impact of interprofessional practice on the health outcomes of patients. They also had a better understanding of the roles of other health professionals and their confidence in interact- ing with other disciplines had improved (Table 3). These findings are highlighted further in the qualitative data.
Table 1 Demographics
AC N = 19 N (%)
CE N = 84 N (%) Age
20–29 29 (40.8) 11 (13.1)
30–39 21 (29.6) 21 (25)
40–49 14 (19.7) 30 (35.7)
50–59 7 (9.9) 20 (23.8)
> 60 0 2 (2.4)
Gender
Male 2 (2.4)
Female 19 (100) 82 (97.6)
Years of Experience
Less than 1 year 1 (5.3) 2 (2.4)
1–3 years 5 (15.8) 12 (14.3)
4–6 years 5 (26.3) 4 (4.8)
> than 6 years 8 (36.8) 66 (78.6)
Table 2 Course Evaluation (N = 53)
Item Mean Mode Range
Course objectives were clearly stated 1.58 2 1–3
The assignment requirements were clearly stated 1.87 2 1–4
I received feedback in a timely manner 1.75 2 1–5
Small group work contributed to my learning 1.72 1 1–4
The interdisciplinary makeup of the small group contributed to my learning 1.79 2 1–5 Exploring in-depth cases during the semester contributed to my learning 1.62 2 1–3
The videos contributed to my learning 1.34 1 1–3
The reading assignments contributed to my learning 1.55 1 1–4
The content on the discussion board contributed to my learning 1.81 2 1–4
The website was easy to navigate 1.79 2 1–5
The layout of the course content on the website was intuitive 1.98 2 1–4
I had trouble managing my time in this course 3.30 4 1–5
I learned a lot from students from health disciplines other than my own during this course 2.00 2 1–5 I would recommend this course to other students from my health discipline 1.38 1 1–5 Note: 1 = strongly agree, 2 = agree, 3 = uncertain, 4 = disagree, 5 = strongly disagree.
Qualitative findings
The post-course survey included a number of qualitative questions about interprofessional collaboration and intended changes in practice. A thematic analysis of qualitative responses was completed and 3 themes were identified.
These included: 1) psychosocial oncology as a practice, 2) shifting practice to the relational and 3) interprofessional collaboration. A fourth theme, personal wellbeing in oncology nursing, cut across the other three.
Psychosocial oncology as a practice
Nurses developed knowledge in specific content areas related to psychosocial oncology. Some expressed surprise about the“breadth”and“depth”of the field. Particular areas highlighted were distress screening and assessment, depres- sion, anxiety, sexuality and hope:
I have developed increased knowledge in assessing for and intervening with anxiety & depression, in sexual- ity concerns and in the area of hope. I feel better equipped to deal with hopelessness and the search for meaning.
Other areas highlighted were cultural safety and the impact of cancer on the family as a whole:
I learned how to more fully care for my First Nations clients. These cultures have endured much oppression under Colonial rule . . . I am more adequately prepared to meet their health care needs as I now understand some of the issues they face.
The family and couples with cancer units were important areas of learning for me, particularly the impact of cancer on stages of development and family functioning.
Shifting practice to the relational
Many nurses found their confidence about how to help patients and families with the difficult aspects of living with cancer was enhanced through the course, particularly with regard to therapeutic relationships. Opening space in their relationships with patients and families to explore
“tough” topics became more possible. They learned to value “silence”, “listening” and “being with”as powerful therapeutic interventions to ease distress and suffering
“without always having to give solutions”. The therapeutic relationship was seen as important in supporting adjustment and meaning-making:
I learned that just being present and sitting and listen- ing, often without the need for an answer, is therapeu- tic in itself. Patients sometimes need to have their story acknowledged.
Others noted they“listened differently”:
I listen differently to my clients. I listen for more cues and clues for deeper issues, which may be impacting their journey. As a result, I am able to provide more appropriate support to them.
Shifting practice to include the psychosocial was seen as offering“better”and more“comprehensive”care to ease dis- tress and help families manage the illness experience. Will- ingness to take responsibility for holistic care increased and many reported that they had developed a greater tolerance for ambiguity and uncertainty. Comfort in discussing diffi- cult topics also increased: “I am more relaxed in talking about disease progression”. One nurse described the changes in her practice as follows:
I think the course is already having an impact on my practice. Yesterday, I had a conversation with a patient that I had just met, about his hopes and wishes as he Table 3 Comparison of Pre/Post knowledge and attitudes (N = 53)
Items Pre-survey
Mean (range)
Post-survey Mean (range)
Z score
I would like to work in oncology/Psychosocial oncology 2.58 (1–5) 2.09 (1–5) –2.335**
Improving interprofessional practice is likely to improve health outcomes 1.72 (1–5) 1.15 (1–2) –2.869***
The culture of my profession is very different to the culture of other professions 2.75 (1–5) 2.91 (2–4) –.817 I have a comprehensive understanding of the roles of other health professions 2.62 (1–5) 2.06 (1–4) –3.33 ***
I feel confident interacting with practitioners from other disciplines 2.36 (1–4) 1.75 (1–2) –3.566 ***
I usually gain high levels of satisfaction from my interprofessional interactions 2.32 (1–5) 1.89 (1–4) –2.50**
I believe I am highly effective at interprofessional collaboration 2.51 (1–5) 2.04 (1–5) –2.778***
I need to improve my interprofessional effectiveness 1.94 (1–4) 2.34 (1–5) –2 711 ***
Note: 1 = strongly agree, 2 = agree, 3 = uncertain, 4 = disagree, 5 = strongly disagree ** P < .05, *** P < .01.
faces end of life care issues and decisions. I think he appreciated me bringing up the topic and he was very forthright with his answers. As the patient was unable to speak due to his cancer he wrote everything out to communicate. As he is very isolated at home, he stated how appreciative he was of our conversation. To me, this course has taught me to’be present’, wherever the patient is at and REALLY LISTEN to what the person is saying, as their story unfolds.
The interprofessional aspects of the course were key to the nurses’learning in this area.
Interprofessional learning and collaboration
Faculty played a key role in modelling and fostering inter- professional trust and respect. Nurses noted this made it safe for them to engage in the learning process. They felt the facilitator “acknowledged everyone’s role in psychosocial oncology” and “found commonalities so that all students were comfortable to contribute—even if they had limited experience in that particular area.”Another noted:
There was a lot of trust among the members of our group and this promoted sharing of personal experi- ence and knowledge. I learned a lot from them. Each member brought a unique perspective to the discus- sions - both in the live-classroom setting and on the discussion board posts. This has improved my confidence in dealing with other members of our inter- professional health care team.
The dialogue among disciplines in the real-time seminar, as well as on the discussion boards, helped nurses to look at case situations and care processes from different perspec- tives, informed by reading and discussions of literature and theory drawn from a broad range of disciplines. Case discus- sions also enriched the nurses’learning as they drew ideas from others about how to approach particular situations. One nurse noted,“my learning was enhanced due to the diversity and expertise from other disciplines.”
While nurses developed a much deeper appreciation of, and respect for, the contributions and roles of other disci- plines; they also learned more about their own role and seemed more willing to take responsibility for the psychoso- cial aspects of the illness experience. The following com- ment was common:
I now have a renewed awareness of my role as a valu- able member of an interprofessional team and will con- tinue to collaborate with members of psychosocial oncology. I am also willing to address issues myself rather than immediately referring. Through this course I have been able to discuss my own practice with others and receive valuable feedback.
Nurses also came to see themselves as more similar to other disciplines than they did prior to the course.
I developed greater confidence sharing my profes- sional perspective within the interprofessional team.
Although we are from different disciplines or profes- sions, we likely have more similarities than differences in our approach to our patient’s psychosocial needs/
concerns.
Some nurses had not had good experiences with teams in the past and were surprised to learn interprofessional teams could work well. One nurse said,“I learned that interprofes- sional psychosocial oncology teams do exist and can be functional.” Many expressed strongly facilitative beliefs with regards to interprofessional collaboration: “you can’t meet all the psychosocial issues in isolation. Collaborative efforts by distinct health professionals are the only way to effectively respond to the complexity and interrelated nature of psychosocial issues.”
Personal well-being in oncology nursing
“Personal wellbeing” was seen as an overarching theme.
Nurses commented they felt more confident about drawing on the team. This gave them a sense of being supported in their work and possibly a reduced sense of isolation:“I have a national network of oncology colleagues as a result of this course.” Repeatedly nurses commented they had learned
“you don’t always have to have the answer,” noting they can draw on others but also, sometimes, “no one has an answer”. One nurse said, “oncology is a demanding and exhausting career, which requires the collaborative support of one’s colleagues”; while another had learned to“look for support from a team member if you feel you need it.”The comment, “It’s OK to be feeling the way you feel, likely others are too”perhaps reflects a reduced sense of isolation and burden.
Nurses also developed a greater sense of personal power and confidence about meeting the needs of their patients:“It was an inspiration to see power in myself.”Another nurse learned to value her clinical knowledge:“I am more knowl- edgeable than I thought. I learned to take a step back with my reflection papers and put a value to my experiences, so I can move forward.”There was a sense of greater authenticity reflected in comments also:“I can be myself, a human being with feelings when talking with clients about disease pro- gression.”
Some nurses wrote explicitly about inspiration, hope and the way in which the course, and other educational experi- ences like it, might reduce“burnout”for them:
This course has provided me with increased knowl- edge, increased confidence, and given me a greater
respect for other professionals that are working with our patients. I cannot really explain how this course has helped me. After being an oncology nurse for more than 20 years, I was feeling a bit burned out.
I am feeling inspired through the course material, live classroom sessions and the blackboard posts. It has made me realize that I want to continue to do this, and that maybe by doing more courses rather than burning out I will feel energized.
Discussion
The IPODE project was designed as a web-based conduit to enhance the interprofessional community of practice for psy- chosocial oncology. Our goal was to facilitate the develop- ment of shared understandings across professions to build capacity for collaborative person-centred cancer care.
Experiences with learning communities in cyberspace [16]
support the belief that meaningful interaction, collaborative learning and reflective practice are the key elements of learn- ing valued by faculty and students. Our findings confirmed the“magic”of these elements. While some authors [8] rec- ommend blending face-to-face learning with e-learning in order to address the need for interactivity, we found that skillfully facilitated virtual seminars with small groups of learners provided a viable alterative to face-face education.
Nurses were highly satisfied with the overall course structure and process, with the interprofessional, interactive and audio-visual elements of the course being most highly valued.
The course enhanced nurses’ability to envision collabo- rative teams, deepened knowledge of other professionals’ roles, and increased trust, skill and confidence in collabora- tion. The commitment to working in oncology in the future also significantly increased in the post-survey, suggesting that courses such as this may contribute to retention.
A somewhat surprising finding was the strength of the nurses’ feedback with regard to their personal well-being.
There was a strong sense that after taking the course they felt less isolated and burdened by the difficult emotions and other challenges that arise for people affected by cancer.
This seemed related to better understanding of the role of other disciplines and thus recognizing they could draw on others’expertise, as well as the increased feelings of trust and respect that came from being part of an interprofessional learner group. Not only did the nurses seem more willing to consult with or refer issues to other professionals, they also seemed more confident about intervening themselves. Areas such as depression or hopelessness that had seemed more difficult previously, seemed more approachable after taking the course. The recognition that they did not need to“have
the answers”in difficult situations was a revelation and a relief for some nurses.
The literature on compassion fatigue and vicarious trauma reflect numerous protective and exacerbating variables [9,14,17]. Certainly, experiencing oneself as an integral part of a supportive team where trust and respect is mutual and strong is one element. Another is feeling comfortable with oneself [14,15]. Education, particularly with a focus on reflection and meaning-making, is also helpful [10].
Conclusion
We found that web-based learning is a viable alternative to face-to-face education and has the potential to overcome pre- viously identified limitations, particularly those related to interaction among learners. Web-based learning may have additional benefits however. The IPODE project was suc- cessful in creating pan-Canadian learning opportunities across disciplines and universities in a specialized area of practice, psychosocial oncology. Where previously extremely few graduate level courses were available, stu- dents in 11 universities now have access to elective courses in the field. Practicing health professionals across the coun- try, in urban and in rural or isolated communities also, have education options available. Clearly, the IPODE model is effective for enhancing capacity for collaborative, person- centred cancer care.
Conflict of interest statement:the authors don’t have any conflict of interest to declare.
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