Instructional Design in Healthcare

Table of Contents

Introduction
Christine Thornam
Stephen Brewer
Conclusion

Introduction

As a registered dietitian, I spent the first 7 years of my career working in hospitals in different capacities educating patients and employees. There seemed to always be a need to teach somebody something. I would educate patients about their diets. I educated food service workers about food safety. I educated physicians about improving a patient’s nutritional care plan. And when I branched into soft skills training; I even taught housekeeping and hospital engineers how to work together as a team. When we moved to Colorado, my career path moved into computer applications training but I have always felt that my roots are in healthcare.

As graduation from the University of Colorado’s M.A. in eLearning Design is getting closer, I find myself hoping to return to my roots as an instructional designer for a healthcare organization. So when asked to interview practicing instructional designers, I immediately sought out those working in the healthcare field and was fortunate enough to meet two amazing practitioners.

Christine Thornam is Manager of Clinical Education and Support at Exempla Lutheran Medical Center. Christine has known that education was a passion of hers since her undergraduate nursing days. She has strived to improve nurse education most of her career. She gives some excellent advice for new instructional designers.

Stephen Brewer is the Manager of Learning Technologies for Texas Health Resource. If there is an issue at THR that will require any level of the more than 18,500 employees to receive training in anyway, Stephen is more than likely involved. His decision making process for determining training platforms is an excellent guide for those new to the field.

I hope you enjoy these interviews as much as I did.

Back to top

Christine Thornam, R.N., M.N., Ph.D.

Christine is the Manager of Clinical Education and Support at Exempla Lutheran Medical Center. She received her Ph.D. from the University of Colorado completing her dissertation on the topic of “Teaching Presence in Face-to-face and Online Learning Environments”. Prior to Exempla, Christine was the Director of Educational and Communication Technologies at Nurse-Family Partnership, a non-profit nurse home visiting program serving low-income, first-time parents in 22 states. While working with the Nurse Family Partnership, her accomplishments were numerous. These included:
• Brought web-based community of practice from concept to reality for over 300 nurses.
• Led the design and development of online modules
• Produced video segments to complement face-to-face and online instruction
• Advanced the use of room-size video conferencing
• Introduced live, web-cast meetings to the NFP National Office, its partners (Public/Private Ventures and Invest in Kids), and local site supervisors and home visitors
• Developed home visitor and supervisor competency standards

Tell me about your role at Exempla.

I am new to the job as of August 30th. My first priorities for the next 4-6 months will be to work on an existing program called “R.N. Transition to Practice”. The focus of this extended orientation program for new nurse graduates is to build R.N. confidence, improve retention and familiarize the new nurses with working in a team setting. Much of the training takes place in a classroom setting. It is possible that when I am more familiar with the program, I may try to introduce learning technologies such as simulations. I am still in the planning stages for moving more training and education to an eLearning platform for all employees; however, it is still too early to tell you the topics for those first programs.

I read the paper “Bounded Community: Designing and Facilitating Learning Communities in Formal Courses“. How has your research and background influenced your practice in your current role?

If you would have asked me this question 6 months ago, I would have said very little. However, I am finding that Exempla uses the term “healing presence” often when discussing issues. This is very similar to the focus of my research “teacher presence”. (In the paper referenced above, Christine defined teacher presence as: an intersubjective experience during which a teacher and a student willingly move together toward valued learning. By being there with the student, the teacher reduces the student’s educational vulnerability and by knowing the student, feelings of helplessness or abandonment are allayed. Both submit to the power of the other to influence, penetrate and engage, and are equally willing to be changed by the experience). The similarity of these statements may mean that we are on the same page and may allow me to continue my research in this area.

What obstacles exist for instructional designers in the healthcare arena?

I don’t see obstacles for instructional designers in healthcare alone but a more universal set of obstacles. The biggest obstacle I have encountered has been the lack of understanding in what an instructional designer does and how much they can benefit learning. Many educators have this idea that explaining and teaching are the same thing and that an instructional designer is simply not necessary. Also, many educators are satisfied with teaching “the same way they learned” or “the way it has always been done”. There is a reluctance to change. They don’t take a step back and use metacognition to decipher “how did I really learn”. I was able to convince my last company to hire an Instructional Designer after some initial resistance.

Tell me how you were able to do this.

In my last position as the Director of Education and Communication Technology with the Nurse Family Partnership, we were experiencing substantial growth. In my proposal for an instructional designer, I stated that we could not afford to physically fly thousands of nurses in for training every few months and therefore we would need to utilize distance education. Distance education design would require the use of an instructional designer familiar with implementing learning strategies in a distance learning format.

My background as a dietitian includes working with and the need to train service employees such as food service workers. Perhaps this is present in many organizations but I have always thought that healthcare has an especially diverse employee base. What is the role of the instructional designer when trying to meet the educational needs of all the employees in such a diverse organization?

Exempla uses an eLearning product which covers the Joint Commission of the Accreditation of Hospital (JCAHO) requirements for staff training and education. This product is used with all employees.

Has it been successful?

It is successful at meeting the requirements for delivering the education. I am not sure there are any assessments to determine how much learning is occurring.

Can you share your insights regarding any dominate trends you see for training and development in the healthcare arena?

In the clinical setting, it seems that the ball is really rolling with high level simulations such as what you find at the WELLS Center (http://www.coloradonursingcenter.org/CurrentProjects/WellsCenter.html). These simulations are very high quality and therefore very expensive. They must be updated regularly. My thought as an instructional designer is “Can I design instruction that simulates reality without the expense?” Perhaps this will be another area of research for me.

Final thoughts for breaking into instructional design in a healthcare setting?

Find a niche, find your spot. Your impact to the organization from a learning standpoint can be huge.

 

Some selected publications by Christine Thornam

Thornam, C. & Clark, L. (2005). Culture in health and health care case study. In P.A. Ertmer and J. Quinn (Eds.), The ID CaseBook: Case Studies in Instructional Design (3nd ed.). Columbus, OH: Prentice Hall.

Wilson, B., Ludwig-Hardman, S.,Thornam, C., Dunlap, J. (2004). Bounded community: Designing and facilitating learning communities in formal courses. International Review of Research in Open and Distance Learning.

Clark, L. & Thornam, C. (2001). Using educational technology to teach cultural assessment. Journal of Nursing Education, 41(3), 117-120.
Lowry, M., Thornam, C. & White, C. (2000). Preparing learners for the web-based environment. In R.A. Cole (Ed.), Issues in web-based pedagogy: A critical primer. (pp. 297-316) Westport, CT: Greenwood Publishing Group.

Thornam, C.L. & Phillips, S. (2000). Interactivity in online and face-to-face sections of a graduate nursing course. TechTrends, 45(1), 34.

Back to top

Stephen Brewer, M.S.

Can you give me more information about your background?

The dreaded background question… Here goes. My undergraduate and graduate degrees are both in psychology. My Bachelor of Science with Honors in Applied Psychology dates back to 1979. I received my Masters in 1981. Both were awarded from Western Michigan University (http://www.wmich.edu/) in Kalamazoo, Michigan. At the time, it was a coin toss over whether WMU or the University of Kansas had the nation’s top program in behavioral psychology. And yes, that means that I spent six happy years exploring and applying principles of operant psychology on rats, pigeons and the occasional undergraduate. In subsequent years, I rounded out my education by picking up a few business and graduate level psychology courses at the University of Texas at Arlington (http://www.uta.edu).

Although this suggests I will soon be receiving my AARP card, I’ve worked in industry for 25 years. I’ve somehow managed to keep my focus in three primary sectors: Software, government and health care. Across my career, my overall responsibilities were to design, produce and occasionally deliver training content across multiple modalities (stand-up, video/television, computer/web, text). Prior to joining Texas Health Resources (THR), I ran my own consulting business. I’ve been THR (www.texashealth.org) since 1998.

Tell me about your role as Manager of Learning Technologies for Texas Health Resources.

The job has three core functional areas:

1. Learning Technology. THR originates and relays videocasts of academic content from local universities internally (13 hospitals across North Central Texas) and externally (two health care systems) through its’ Distance Learning Network. I am responsible for the network’s daily operation and future direction (both in terms of growth and adapting/adopting new technology). I also have oversight of our Learning Management System (LMS). The LMS serves as both a delivery platform for web-based training and as the education record repository for THR’s employees, physicians, volunteers and contractors.

2. Core Cultural Training. Corporate training initiatives that touch the majority of our 18,500+ employees have an annoying habit of landing on my desk. Depending on the project, I may serve on a cross-disciplinary work team, author and produce the materials or oversee outside contractors tasked with creating content.

3. Communication. At its heart, instructional design is a systematic approach to relaying content that ultimately changes behavior. It’s a skill set that extends beyond the training and development function. I am frequently brought in to analyze dispirit chunks of data and repackage/reframe content. Projects range from white papers and proposals to executive presentations.

A little about the future of learning technologies at THR…

In 5 or 6 years, it is hoped that more of the education that takes place at THR will become centralized. This includes clinical education. For example, we now offer to provide associate nurse education for our patient care technicians via a classroom and video conferencing. We hope to continue to grow this program to include more advanced degrees for nurses. Next year, our goal is to look into improving nurse retention.

There are about 17 (i’m guessing a little here but that is probably close) different languages spoke by patients throughout the entire system. We are looking into expanding the videoconference translation capabilities in each facility. This has many obvious benefits. It means we are able to understand our patients more quickly and it means that there is an objective translator available to answer sensitive health questions versus a family member.

From you job title, it sounds like you determine much about how learning is delivered at THR. What has or does influence your decision making process for your organization?

“Determine” may be a bit harsh. It is safer to say I can influence. An organization the size of THR has multiple, shifting power centers and even more projects running at any given time. Let’s just say that there are still paths to walk on the journey to systematize.

As for what influences my decision making, I haven’t had a chance to be quite that introspective in a while. Here goes…

1. If I am brought in early enough in the process, it is always good to ask Gilbert’s fundamental question: Is it a training problem? That is, if you put a gun to their head, could they do the task? If the answer is yes, it is either an environmental problem (they don’t have the right tools/resources) or an incentive problem. Rolling out training won’t result in the desired behavior. It will, however, allow people to proudly announce that they did try something.
   This step is very important. You must make sure there is a training need.
2. The second test is the proverbial gut check. Does your gut tell you there’s a chance for success? Some topics simply do not translate well to certain modalities. Instructor-based software training without a hands-on component is one of Dante’s Nine Circles of Hell. A static, web-based training on interviewing skills won’t give you a chance to apply and receive feedback on the techniques. Both cry out to be presented using a different modality.
3. The third test is to explore cost effectiveness. Will the number of people touched by the training or the cost of not demonstrating the behavior merit the cost of the solution? A web-based training impacting 20 employees is a costly endeavor (in terms of hard dollars and resources used). It could very well be the case that a combination of mentoring and shadowing could meet the need.
4. The last test is time. If the product is needed in a week, it suggests certain delivery platforms may be unrealistic.

There’s probably more, but that’s what comes to mind at the moment.

My background as a dietitian includes working with and the need to train service employees such as food service workers. Perhaps this is present in many organizations but I have always thought that healthcare has an especially diverse employee base. What is the role of the instructional designer when trying to meet the educational needs of all the employees in such a diverse organization?

An instructional designer is like a therapist. A client comes in filled with questions, doubts and overwhelmed by the enormity of the task. A therapist listens. And then, listens some more. After a few guided questions, the therapist works to build approval/consensus around a solution. A therapist simplifies. So does an instructional designer.

What obstacles exist for instructional designers in the healthcare arena?

Health care is a highly regulated industry that requires an amazing amount of resources (people, time and technology) and survives on razor-thin margins. Education is a constant balance between the need to document compliance (for regulatory requirements) and changing behavior.

Perhaps more than most industries, health care is a land of specialists. It’s the nature of us all to assume that the world will come crashing down without members of your profession/practice. The statement takes on increased validity in direct proportion to the number of letters following your name. Without a degree or two in a medical field, it takes extra effort to ensure that your voice is heard.

You have made the statement “changing behavior” a great deal. Why?

Behavior change is generally measurable and therefore what is looked at to determine effectiveness of a training initiative. We are having to justify more and more of our training. The ADDIE model should be thought of as a cycle. Once evaluation is done, repeat the steps based on the evaluation. Follow-up is also as important as making sure your training program is effective. Follow-up can be as simple as sending an email to former class participants to remind them of the training content and desired behaviors.

Can you share your insights regarding any dominate trends you see for training and development in the healthcare arena? Are you using or do you foresee the use of social learning tools such as wikis or blogs?

Sure. Here are three:

- Online Delivery. Online delivery hits two requirements for training in health care: Information can be standardized and can be accessed 24×7.
- Just in Time/Modular Training. In an era of tighter margins driven by reduced reimbursements, carving out time for training can be an issue. Short, 10-12 minute modules on targeted topics are highly valued.
- Information Sharing. Every health care organization has expertise that is going underutilized. Successful organizations will set up natural, organic systems that leverage existing talent by promoting sharing best practices. Reinventing the wheel can be costly.
-Podcasts. We are currently working on funding an initiative to implement podcasts for some of our training programs. One of our hospitals has very few new hires in a year but even with those small numbers, all new hires need benefits training. This is a perfect target audience for our podcasts whether via computer or an actual ipod.

Regarding wikis and blogs: Both are problematic in health care unless highly moderated. Issues surrounding the privacy of patient information and data accuracy could put the institution at risk.

Back to top

Conclusion

The information I found most valuable from these interviews is the information that I would not otherwise get from a class. For example, Christine’s comment that many do not know what function an instructional designer serves or how it could benefit a learning organization. I would never have thought I may someday have to justify my job. I also found Stephen’s comment comparing an instructional designer to a counselor insightful. An instructional designer evaluates problems, gathers more information with guided questions and listening and builds consensus for a solution. I found that analogy very accurate. Perhaps the most important message from each of my interviews was the ability an instructional designer has to influence and impact an organization. Although this is somewhat daunting, I’m willing to give it a try! I can’t wait to “influence“.

Making Sense of Mayer – Chapter 1

I just tackled the first 3 chapters of Mayer. Whew! That is a cognitive load! I will try to sum it up here.

Multimedia: In its simplest form, it is the presentation of material in words and pictures.

Multimedia messages can be viewed in 3 different ways:

1. The Delivery Media View: This view is focused on the technology used to deliver the information such as computer, television, blackboards etc. The emphasis here is on the devices and not the student or learner.
2. The Presentation Modes View: The manner or mode in which the material is represented is the focus here. So in an eLearning presentation, words can be represented on screen and pictures would be represented as graphics. This view is considered to be learner centered because the learner can choose to interpret the information using either the text representation or the image.
3. The Sensory Modalities: This view focuses on the sensory system used to interpret the message. For example the ears are used for auditory information and the eyes for visual information. It is also learner centered since the learners “information processing activity” is taken into account.

Multimedia design has 2 views:

1. Technology Centered: This view states that the technology is the focus for delivering multimedia presentations. The issue with this view is the history has proven that technology has a poor success rate for improving learning. From motion pictures, radio, television and even the computer, learning has not improved just because it can be delivered via new technologies.
2. Learner Centered: This view begins with the human mind and how we learn. It asks “How can we adapt multimedia to enhance human learning” and uses cognitive science in the development of educational mulitmedia presentations.

Multimedia learning has 2 views:

1. As Learning Acquisition: This simply states that learning is adding information into the mind.
   1. Learning is simply information moving from material to the mind.
   2. The learners job is passive in that they simply receive the information.
   3. The teacher presents the information.
   4. The goal is efficiency of information delivery.
2. As Knowledge Construction:
   1. The information is constructed by the learner.
   2. The learner must make sense of the information.
   3. The teacher must assist the learner in making sense of the information.
   4. Information presents information as well as provides guidance for how to make sense of the information.

There are 3 outcomes of multimedia learning

1. No learning
2. Rote learning: good retention but poor transfer
3. Meaningful learning: good retention and good

2 kinds of active learning. Active learning is the “best way to promote meaningful learning”:

1. Cognitively active: the learner must construct and make sense of the information
2. Behaviorally active: the learner is physically active such as typing or clicking the mouse but there is no real learning occurring.

The Learning Organization Meets the Long Tail

I attended my first webinar (live web seminar) last Thursday, Sept. 6th. The topic of the webinar: “In this complimentary Chief Learning Officer e-Seminar, you will learn how learning management professionals can best harness the nearly limitless amount of information available to provide employees with the best resources to maintain the organization’s competitive edge.” The presenter was Dennis Kilian, Vice President of Sales for Safari Books Online. Here were the highlights for me:

• Fads in training and development
• Defining “The Learning Organization”
• Defining “The Long Tail” and the limitless choices of learning content
• Search engines and filters
• The new rules that must be defined (by organizations and Learning and Knowledge Management professionals) when using new learning tools such as blogs.

Fads
The presenter stated that TQM (total quality management) and Reengineering were fads but that learning organizations were here to stay. He stated the every organization must have some type of quality management program to stay competitive but these programs would not separate you from your competitors. Reengineering in an organization generally starts from the top of the organization and filters down to the front line employee which limits buy-in and motivation.

The Learning Organization
The learning organization is one that fosters a constantly improving/learning organization at the employee level.

The Long Tail
I liked the definition given by the presenter. He stated that in the “old”(this term is relative based on the reader) days, when someone wanted to hear a song or a band, they had to buy the album. Therefore, record stores sold a great deal of albums because the options to the customer were limited. But now, the consumer has many more options (hence the “long tail”) for music including legitimate downloading, peer-to-peer sharing, illegal downloads etc. Wikipedia defines it as: The phrase The Long Tail (as a proper noun with capitalized letters) was first coined by Chris Anderson in an October 2004 Wired magazine article^[1] to describe certain business and economic models such as Amazon.com or Netflix. Businesses with distribution power can sell a greater volume of otherwise hard to find items at small volumes than of popular items at large volumes.

For the learning organization, employees also have more options for information and learning than they ever have. How does an organization control where and what information/learning the employee receives?

Filters
Search engines were mentioned as one method for limiting choices. However, search engines are partly based on popularity, may be biased and do not benefit the organization as much as the individual. “Enterprises relying solely on search engine filters risk obsolescence at the same time the pace of technological change continues to accelerate”.

New Rules
The presenter stated that the organization must create new processes to “filter” the information before it is disseminated throughout the organization. For example, if a team learned a new procedure from a source on the internet, a process for passing the new procedure by a SME before distributing throughout the organization.

New Metrics
The questions at the end were some of the most interesting content of the webinar and I wish more time could have been spent answering them. Many of the questions involved the use of blogs or wikis in a learning organization. Many in the audience (Chief Learning Officer subscribers), were a bit worried that the information being learned or being published may not align with business objectives. His answer was that new metrics must be created before these social learning tools are implemented (this is very paraphrased). For example, perhaps a team creates a wiki to create a new procedure that improves productivity by ?%. The new wiki collaboration results in this new procedure. The procedure is reviewed by committee or SME(s) before implementation. The new procedure’s effect on productivity is then measured.

In closure, Dennis stated that:

• The learning management professional is a change agent.
• Need to assess current tools, identify any gaps in knowledge and then effect behavior change.
• Change should occur at all levels of the organization.

Visual Interpretation of Web Trends

In searching the web, I came across this very interesting graphic. It is a visual interpretation of web trends as of 2007 and it is a map of the “200 most successful websites on the web” according to the creators, Information Architects Japan. (Here is a link to the large version of the image). I found it interesting that there were no eLearning sites on the map. Isn’t eLearning a web trend? If this were a map of my personal web trend/usage, eCollege would be surrounding “me” in the center of the graphic. So I went to http://www.quantcast.com to see if I could determine how much of a trend eLearning was to the general population. I definitely did not see a website explicitly devoted to the delivery of educational information in the top 200 sites. So for grins, I looked up eCollege on quantcast.com and it had an impressive ranking of 5,875. Another interesting statistic from quantcast.com is that eCollege “caters to a heavily female, more educated, younger, more African American audience”. I wonder if this statistics carries over to all eLearning? I may have to explore this in future blogs!

Welcome to my eLearning Lounge Blog!

Welcome to my blog. I am a student at the University of Colorado’s eLearning Design and Implementation MA program. This blog will discuss issues, trends and topics in Instructional Design Technologies. I am looking forward to writing and learning more about this topic.