Review of the effectiveness of educational tools for teaching Telehealth care
In this project researchers from the health and education disciplines sought to address the lack of a pedagogical and professional development model for teaching Telehealth to healthcare workers.
Dr Arindam Basu
Telehealth is broadly defined as the delivery of health-related services at a distance. Recent advancements in Telehealth applications are challenging the assumption that physical presence is necessary in some healthcare circumstances. Telehealth applications are rapidly expanding and are already widely deployed in New Zealand. An early review identified that between 2000-2003, the number of telemedicine projects across New Zealand nearly doubled from 12 in 2000 to 22 in 2003 (Kerr & Norris, 2004). These developments have given rise to a need to prepare health professionals for the delivery of Telehealth care.
While well established models of face-to-face and hands-on learning exist for healthcare professionals, their applicability in professional preparation for using Telehealth is unclear. In this project researchers from the health and education disciplines sought to address the lack of a pedagogical and professional development model for healthcare workers related to Telehealth applications.
A systematic review of research related to teaching Telehealth care was undertaken. The purpose of this was to identify studies that describe the design and conduct of programmes teaching Telehealth to health care professionals and provide an evaluation of the programme, to identify whether the teaching programme was successful in achieving the teaching or learning objectives. Based on the review of literature, the key components of possible ’best practices guidelines’ were developed to support teaching Telehealth to current and future health care professionals.
Literature on the existing teaching practices of Telehealth aimed at health care practitioners was reviewed using a standard approach of framed research questions, identification of relevant studies based on specific conditions of inclusion and exclusion, appraisal of the literature, and summarization of results.
The research questions considered in the review were:
- What specific teaching programmes are reported in peer reviewed literature aimed at physicians, nurses, and other healthcare workers or professionals to teach or learn Telehealth?
- Where available, what is the relative effectiveness of one training method over another?
The inclusion criteria for the review were:
- English language peer-reviewed articles published in the period between 1999-2009,
- description of training programmes aimed at teaching Telehealth to health care professionals in practice,
- a process of evaluation of the training programme. All other studies, including those for which full text abstracts were not available, were excluded from this review.
Studies that met the criteria were critically appraised and coded according to a modified version of the PICO (Participants, Intervention, Comparator, and Outcomes) framework, which is commonly used in evidence based appraisal of health care literature (Richardson, Wilson, & Nishikawa, 1995).
Qualitative interpretive data analysis and synthesis techniques facilitated by the use of NVIVO were used to identify common themes occurring in the literature that would be useful in guiding Telehealthcare education.
Ten studies met the inclusion criteria and are reported in this review; no study from New Zealand was identified. The studies available in the published literature were predominantly case studies of specific courses or programmes, some of which included course evaluations from participants or stakeholders.
Qualitative review of the content of the studies revealed four themes that are important for designing any Telehealth educational initiative:
Role of context
The availability of resources and the professional or occupational context within which Telehealth is to be practiced are significant factors. The problems of geographical distance, population sparseness, poor communication infrastructure, and connectivity issues that often drive the implementation of Telehealth projects may also make teaching and learning Telehealth difficult (Amarsaikhan, Lkhagvasuren, Oyun, & Batchulun, 2007; Atack, Luke & Sanderson, 2004). It is important that courses/programmes for learning Telehealth are designed to acknowledge these contextual realities (for example: slow internet connections) as well as exploring the higher specification, or more advanced state of the science technologies (Amarsaikhan et al., 2007).
Learning transfer from the educational environment to the practice environment has been found to depend more on the work context and work climate than on other factors (Atack et al., 2004; Glinkowski & Ciszek, 2007; Kobb, Lane & Stallings, 2008). Kobb et al. (2008) identified four factors that enable the learner to apply the skills to their job: relevant content (33%), supportive co workers (26%), work environment (25%), and work schedules (18%). Blignault & Kennedy (1999) note the impact of staff turnover on Telehealth education which presents issues related to retaining a skilled Telehealth workforce.
Role of learner characteristics and preparedness
Learning for Telehealthcare needs to relate to the user’s situation, their characteristics, and readiness for learning in this field. Learner’s individual characteristics, as well as their interaction with the context of learning and the practice in which they will use Telehealth knowledge and skills, have a significant impact on their learning (Atack et al., 2004; Blignault & Kennedy, 1999). Underpinning learners’ capacity for Telehealthcare training is their computer literacy. Training may be required for users to attain the appropriate level of technical competence before embarking on learning technology and practice specific to Telehealthcare.
Relevance of content
Although the literature identified courses for learners from differing health professional groups, there was some consistency in the content they recommend as being relevant. Relevant general content areas, applicable to all health professional groups (to be used with discipline specific knowledge and skill requirements) include:
- the technology, tools, and applications (including troubleshooting)
- client related topics (such as privacy, ethics, legal issues)
- practitioner related knowledge and skills (for example diagnostics and patient outcomes, documentation, communication skills in the Telehealth environment)
- in some instances, information about starting up projects and project implementation may be useful depending on the purpose of the course
Course design and teaching and learning methods
Most of the studies included in this review imply, rather than provide specific recommendations for, course design. Atack et al. (2004) noted that learners need easy access, an online orientation, rapid access to technical support during the course, clear ‘help’ features, and use of non-technical language to help them understand the technology. They suggest keeping online course design and navigation simple.
Accepted principles of effective teaching and learning that apply in any course for developing knowledge and skills for application in a practice context are also required for Telehealth courses. Of specific interest to health professionals are preparation for practice, not just knowledge acquisition. Building on John Dewey’s theory of experiential education (1938), this suggests that the learner’s ability to apply knowledge requires an integration of practice and knowledge, or life and education.
A range of teaching and learning methods were utilised in the studies reviewed. Evidence from the studies showed a clear learner preference for methods that focused on experiential learning and the practical acquisition of knowledge and skills, such as simulation, demonstration, and practice experience, aligned with methods that supported learning (for example, discussion with providers and users, and support from other learners).
Telehealth education as learning for workplace practice
The findings of this review reinforce that Telehealth related training is essentially learning a workplace practice skill. These findings highlight that learning Telehealthcare is not solely about learning a new technology; it is also about adapting practice within a new technology and engaging with that technology. Therefore, it is useful to discuss teaching and learning Telehealth in the context of workplace learning. Studies outside health professional education have shown that the workplace offers learning outcomes that cannot be obtained in formal courses (Billet, 1994; Boud & Garrick, 1999; Candy & Mathews, 1999). Billett’s (2001, 2002) work notes the significance of participation in workplace learning and suggests the process of the construction of vocational knowledge depends on interaction with the work environment. Apprenticeship learning practices including coaching, modelling, observation, scaffolding, and fading assist the learner towards increasingly independent practice and expertise. These concepts appear useful and applicable in the teaching of Telehealthcare. In addition, the principles of cognitive apprenticeship are likely to be important for the consultation and case management aspects of learning teleconferencing for Telehealth; skills that are vital in health professionals’ practice.
Identified gaps in Telehealth education research
Several significant gaps in the research and current knowledge emerged from this review of educational programmes for Telehealth practice. These related to a focus on the technology, a lack of an underpinning education framework guiding the programme, and the importance of practical hands-on training facilities and opportunities to enhance learning transfer.
The findings of this study and its recommendations need to be interpreted in the light of several limitations. Firstly, filters and criteria for selection of literature were based on best practices in integrating research evidence translated from traditional systematic reviews in healthcare. Application of such filters may miss some studies. Secondly, with education for Telehealth being an emergent field, few materials were available for review despite extensive searching. Thirdly, because technologies mature and change rapidly, we limited our searches to only the past ten years. Finally, the recommendations for guidelines that we propose are based on the little empirical evidence available as well as contemporary thinking on educational research.
This review of literature shows there is little information available in terms of formal preparation of health care professionals whose main roles are to provide healthcare services over distance based networks or asynchronously delivered services. Evaluations of curricula reported in the literature have been based on student satisfaction or self-reported competence surveys, rather than measuring changes in competency or knowledge, attitudes or skills between pre implementation and post implementation of the programmes. As a result, there is little formal empirical evidence (or sufficient level or quality of evidence) to help in the formulation of a model of most effective Telehealth training practices.
However, within the limitations of quantity and quality of data available in this review, the following recommendations are made as a basis for guidelines for teaching Telehealth care:
Learning in practice
- Incorporate existing communities of practice of Telehealth professionals to scaffold and mentor learners as they move to independent Telehealth practice.
- Provide workplace learning and on-the-job training to maximise the application of skills in a relevant context.
- Provide ongoing practice opportunities so practitioners can develop and maintain competence.
- Focus teaching and support on optimising the practitioner’s transfer of professional skills to the new medium.
- Incorporate apprenticeship models of learning whenever possible.
- Emphasise hands-on learning and practical experiences.
- Utilise multiple teaching methods to ensure learner needs are met.
- Develop Telehealth-based training in undergraduate training of health care professionals.
- Design Telehealth training that reflects and utilises the modalities used by the healthcare professional in their practice.
- Undertake needs assessment to assess the level of technical support the practitioner will require.
- Provide training to increase computer literacy when necessary.
- Deliver training that is appropriate for the technological constraints of the work context.
This review points out that (a) there are significant gaps in research around the evidence based good practices in Telehealth teaching programmes worldwide that may have important implications for New Zealand; (b) experience from the review of limited studies and training description show that a programme on Telehealth teaching and training can work only when teaching and learning modalities and training sessions are contextualized with practice; (c) training for Telehealth should be tightly coupled with students’ everyday practice and must be associated with ongoing practice opportunities to retain competence.
An additional benefit of this project is the presentation of an applied example of a systematic review that may be relevant to other professions in the tertiary education sector. Systematic reviews are extensively used in healthcare to underpin evidence-based practice and provide guidelines for best practices. This project provides an example of using the systematic review method in the educational context that gives a model for educators, and potentially other disciplines, to use in their own fields.
Finally, educational practice spans many fields and disciplines. Many of the findings of this review may also be of interest, and use, to professionals beyond the health professions, particularly those in applied fields (such as teaching) or fields in which new information and communications technologies are increasingly impacting on practice.
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