UBC Nursing Student Journal (UBC-NSJ), 2012

University of British Columbia nursing student journal NSJ Editorial Committee 2012

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University of British Columbia Nursing Student Journal Volume 1  Number 1  May 2012 Letter from the Director  ..................................................................................................................................... 3 Letter from the Editor  .......................................................................................................................................... 4 Faculty Interview  ................................................................................................................................................... 5 Student's Current Perspective  ........................................................................................................................... 6 Nursing Research Synthesis Projects  .......................................................................................................................................... 7 Post-Cardiac Surgery Delirium Management ( Cherry Xue Hong Chen & Mark Bell ) ................................................................................. 8 Education Tool Development to Support Cardiac Electronic Implantable Device Practice ( Meghan Barnhart ) ...................................................................................................................... 9 Impact of Losing a Tobacco Cessation Counselor for Inpatient Cardiac Units ( Jae-Young Kwon, Clarissa Mak, & Stephanie Yoon ) .................................................. 10 Knowledge to Action Translation Framework: Screening for Delirium in Inpatient Psychiatry Populations ( Aruba Nurullah & Julia Ott ) ................................................................................................. 11 Patient and Family Education Pathways for the Inpatient Eating Disoders Program at BC Children's Hospital ( Anne Marie Hansen, Jessica Jobin, Eilleen Li, & Caroline Philippson ) ................ 12 LEAN Education Modules: Teaching LEAN to Frontline Nurses ( Jay Estoque ) ................................................................................................................................ 13 Surveying Client Experiences: Burnaby Healthy Heart Program ( Melissa Lee & Nicola Fichett ) ............................................................................................... 14 Mass Casualty Incidents Over Three Decades ( Kate Maki, Melissa Erasmus, Alana Miles, & Chris Dearing ) ................................. 15 Pain Assessment for Palliative Care Patients ( Tenny Bache, Aja Egglestone, Neda Khoshnood, & Kelly Soros ) ............................ 17 Immunization Resources for BC Midwives ( Dawn Waters, Jennifer Funo, & Adrienne Johnson )   ................................................ 25 UBC Nursing Student Journal, Vol.1, Issue 1. 2 Contents I am honoured to have the opportunity to be included in the first ever issue of the University of British Columbia’s Nursing Student Journal – UBC-NSJ! First, I would like to congratulate our student leaders who have initiated and developed this important innovation. When I ask nurse leaders in our community what the UBC School of Nursing is “about”, they always reply that it is research and scholarship that define our school. When I ask what we could do better, they always want more engagement. The UBC-NSJ exemplifies both: our extant research and scholarship and our increasing engagement in practice. The NSJ originated from the Synthesis Project – a final project in which groups of students are paired with leading nurses in practice and a faculty member to engage in a project of importance to practice that requires scholarly focus. Students conduct the project, which often includes literature synthesis, learning about the particular setting, and meeting with key stakeholders. The students generally create a report or plan or some other product meaningful to the practice setting, and present in a final poster presentation to the practice and academic community. In taking this extra step of turning these projects into papers published in this new NSJ, the students exemplify all that UBC Nursing graduates should be – scholarly, collaborative and innovative! -Colleen Varcoe, RN, PhD Professor and Director, Pro tem University of British Columbia School of Nursing UBC Nursing Student Journal, Vol.1, Issue 1. 3 Letter from the Director We are proud and excited to present the inaugural edition of the UBC Nursing Student Journal (UBC-NSJ). This idea started because we wanted to encourage and acknowledge the work of our nursing students in a non-intimidating way and to share with our community what kinds of nursing research we do. The highlight of our journal is the synthesis projects in the N344 course where nursing students were involved in practice-based projects in diverse healthcare settings guided by practice partners and faculty facilitators. We sincerely believe that this journal will serve as a medium to explore and analyze our nursing practice in order to address diverse challenges of our healthcare system. This journal could not have started without the support from the faculty, nursing students, and staff. Finally, we would like to acknowledge nursing students and practice leaders who participated in research projects in collaboration with the UBC School of Nursing. We welcome your feedback on Volume 1 of UBC-NSJ and encourage you to consider publishing with us in our next edition. Sincerely, - Jae-Young Kwon, UBC-NSJ Coordinator UBC Nursing Student Journal, Vol.1, Issue 1. 4 UBC-NSJ Editorial Board Faculty Advisors: Colleen Varcoe, Vicki Smye, John Oliffe, Bernie Garrett, Pam Ratner, Maura MacPhee, Jennifer Baumbusch Editorial Board: Jae-Young Kwon, Samantha Thompson, Stella Yeung, Melissa Godinho, Emily Hsiung, Darlene Tam, Natalie Tabakman Special Thanks to Merrilee Hughes, Paul Zimeras, Lee Ann Bryant, Julia Thompson, and Hilde Colenbrander for their support and encouragement Letter from the Editor         What is your nursing background? I spent just on 20 years in acute care nursing the vast majority as a clinical  nurse  specialist  in  the  emergency  room.  I  began  teaching clinically and decided to do an MEd to better understand how people learn. I later became interested in research – so I did a PhD  to develop a skill set for doing that independently. How did you become interested in nursing research? I  always  liked  people,  and  thought  nursing  would  afford  me  an opportunity to help people who were genuinely in need. My research is similarly driven by the lofty goal of wanting to make a difference to people’s well-being and leaving a legacy that others can continue. What is your current research project? I am involved in 6 projects as the principal investigator. These include men’s depression, extending the role of prostate cancer support groups in  health  promotion  and  the  development  of  an  on-line  smoking cessation resource for dads who smoke. While my research program is in men’s health I have focused on including the men’s partners, family and  friends  to  better  understand  men’s  health  issues  and  how  we might effectively intervene to advance their well-being. Any  advice  for  undergraduate  nursing  students  interested  in research? You are in a very successful school in terms of our research success and capacity to mentor. There is a wide array of topics researched by the faculty (http://www.nursing.ubc.ca/  researchindex.aspx  ) and we are always looking for help with our projects. Indeed there are lots of job opportunities  and  internships  available  –  and  I  strongly  encourage students  to  connect  with  faculty  to  explore  the  possibilities  round developing research skills  with  the guidance  of  our  highly  talented researchers. UBC Nursing Student Journal, Vol.1, Issue 1. 5 Faculty Interview John Oliffe - Associate Director of Research The College of Registered Nurses of B.C. and nine other Canadian nursing regulators have advised that there will be a new entry-to-practice examination coming into effect in January 2015. Although the new exam format will not affect our class, I was quite intrigued to hear about a computer-adaptive test replacing the Canadian Registered Nurse Exam (CRNE) currently available from the Canadian Nurses Association (CNA). The new exam will be developed by the National Council of State Boards of Nursing, which develops and administers the NCLEX or entry-to-practice examination for nurses in the United States. There has been a lot of outcry from the CNA as well as the Canadian Nursing Students’ Association (CNSA) around the decision to go with a US-based exam developer, but what I did not realize is that the CNA profits to the tune of around eight million dollars a year from the CRNE. Every student that wants to become a registered nurse in Canada must write the exam at a cost of about $600 whereas the new exam will cost at least 50% less than that. I would love to see the cost go down – did you know the US developer is a not-for-profit organization? Did you know that the new exam is designed to adapt to a specific exam candidate’s knowledge-base so that if you are doing well, the computer will ask harder questions and end the exam earlier? This will result in a more precise estimate of a candidate’s knowledge and should reduce false positive and false negative classification errors associated with the determination of pass/fail. Currently, the CRNE is only offered three times a year on a single day, so if you fail the exam you must wait until the next sitting or if an illness or situational problem occurred, again, you would have to wait until the next available exam writing date. Because the new exam is a computer- adaptive test, there will be many more opportunities to take the exam. There is one aspect that troubles me, and that is that it is too bad that a Canadian company was not able to meet the requirements of the nursing regulatory bodies. But that one disappointment will not cause me to be against the change. The ability for nurses in other countries to take the exam and come to Canada to work may also help reduce nursing shortages. As well, the option to practice in the US will be increased because instead of having to study and write two separate exams, they will be the same. I look forward to this historical change and the positive effects it will bring to the nursing profession in Canada. -Jodi Meacher, nursing student UBC Nursing Student Journal, Vol.1, Issue 1. 6 Student's Current Perspective What do you think about a US company being responsible for making a Canadian RN exam? During the final semester of the undergraduate nursing program, students participate in project work with practice-based nurse leaders. Nurse faculty are available for project support as needed. Every summer, UBC SON sends out invitations to the practice community to sponsor an 18-week (Sept-Feb) student project. Students' interests are matched to available projects, and whenever possible, students work in teams of 3-6 on diverse projects that include everything from the development of teaching materials, website resources and new policies and protocols to participation in funded clinical research programs and systems-wide quality assurance initiatives. The model of the synthesis project course (N344) is practice-academic collaboratives (PAC). The PAC philosophy is: By working together on practice-based projects, students, faculty and practice partners will build stronger, more meaningful relationships. Through project work and enhanced relationships, capacity will grow to mobilize knowledge and ensure better, evidence- informed practice. Synthesis projects have been an eye-opening experience for students--showing them what nurses are capable of doing--how nurses can make significant differences with respect to safer, quality healthcare delivery. Students have learned the importance of effective leadership and teamwork; the necessity of building and maintaining respectful relationships; and the promise of critical inquiry--translating evidence into practice that matters. Practice partners and SON faculty have been impressed and proud of students' synthesis of knowledge gained--recognizing that these students are our future nursing generation. -Maura MacPhee, RN, PhD Associate Professor & N344 Course Leader UBC Nursing Student Journal, Vol.1, Issue 1. 7 Nursing Research – Synthesis Projects UBC Nursing Student Journal, Vol.1, Issue 1. 8 UBC Nursing Student Journal, Vol.1, Issue 1. 9 UBC Nursing Student Journal, Vol.1, Issue 1. 10 UBC Nursing Student Journal, Vol.1, Issue 1. 11 UBC Nursing Student Journal, Vol.1, Issue 1. 12 UBC Nursing Student Journal, Vol.1, Issue 1. 13 Surveying Client Experiences in Burnaby Healthy Heart Program Review Melissa Leeª & Nicola Fichettª ª UBC School of Nursing Program 2012, Vancouver, BC Fraser Health, Burnaby Hospital Healthy Heart Program: Margaret Meloche Summary Nicola and Melissa conducted a survey at the Burnaby Hospital Healthy Heart Program to measure client satisfaction and to determine strategies for program improvement. We began by speaking with the program’s multidisciplinary team to learn about the services offered by the program and its capacity to meet its clients’ health needs. Once we gained a basic understanding of our client population, we sought advice from the multidisciplinary team regarding how the program’s services could be improved to enhance client satisfaction. We then drafted survey questions, which were reviewed by our manager and the Healthy Heart team. With their assistance and feedback, we developed a three-page comprehensive survey consisting of questions covering topics such as program availability, heart healthy education, and overall client satisfaction.  We also developed open-ended questions to allow participants to expand on topics such as managing their own health, benefits they received from the program, and areas for program improvement. We distributed the surveys at six Healthy Heart classes.  Thirty-seven surveys were returned to us; the results were compiled and analyzed; and a summary of our findings were submitted to the Team. Overall, clients were very satisfied by the program. However, participants indicated they were “somewhat satisfied” or “not satisfied” with certain aspects of the education component of the program, such as Stress Management, Medication Management, and Emergency Management. Although they were given space to provide comments or feedback about the reasons they were dissatisfied or how the program could be improved, most left this space blank. However, the majority of comments focused on the positive aspects of the Healthy Heart Program, such as “I have better knowledge of exercise and diet, plus my confidence has returned” and “I lost weight and kept it off, and enjoyed the company of fellow suffering souls.” The staff at the Healthy Heart could further their knowledge of client satisfaction by verbally engaging with them about specific areas for improvement, which were indicated on the written surveys. UBC Nursing Student Journal, Vol.1, Issue 1. 14 Mass Casualty Incidents Over Three Decades Kate Maki,ª Melissa Erasmus,ª Alana Miles,ª & Chris Dearingª ªUBC School of Nursing Program 2012, Vancouver, BC Vancouver Coastal Health: Sheila Turris, Adam Lund, Kerrie Lewis UBC faculty partner: Colleen Varcoe Abstract Background: Annually, millions of people around the world attend events such as music festivals, rock concerts, marathons, and parades. These events can be referred to as “mass gatherings” as they have the potential to draw thousands of people into attendance or participation. Large numbers of people – gathered together in small geographical spaces, on unfamiliar terrain, often in the presence of drugs and alcohol – are at a higher risk of injury and illness than the surrounding population. Despite the best intentions of event planners and medical teams, unexpected incidents do occur and can result in injury and death for event attendees and participants. These are termed “mass casualty incidents (MCI).” Currently, it is difficult to plan a medical response and to provide medical support for mass gathering events in relation to MCIs because systematic reviews of existing literature have occurred infrequently. Purpose: The purpose of this research is to gain an understanding of the types of MCIs occurring at mass gathering events and to identify whether or not trends exist between the type of MCI and the type of mass gathering. Methodology: We executed a systematic review of mainstream media, grey literature, and the mass gathering medicine literature to identify MCIs at mass gathering events from 1980 to 2011 on an international scale. Results: One hundred and forty-six MCIs were documented and reviewed for frequency at event type, mechanism(s) of casualty, and precipitating factors. Of the events reviewed, MCIs were most common during sporting events (36.3%), followed by, religious events (15.0%), music concerts/festivals (13.0%), cultural festivals and events (9.6%), nightclubs/dance (9.6%) miscellaneous (6.2%); air shows (5.5%); and non-sporting stadium events (4.8%). Conclusion: On an international scale, MCIs have occurred most frequently at sporting events between the years 1980 to 2011. The most common cause of injury at these events has been the result of stampedes followed by riots and violence. Although the precipitating factors for MCIs were reviewed, the relationship is complex and requires further research to better inform event planners and medical teams in their management of mass gathering events. Addressing this gap in current health-care literature may assist medical teams, on site and locally, to better prepare for mass gatherings and in planning a response to mass casualty incidents. UBC Nursing Student Journal, Vol.1, Issue 1. 15 UBC Nursing Student Journal, Vol.1, Issue 1. 16 Report on Pain Assessment for Palliative Care Patients Tenny Bache,ª Aja Egglestone,ª Neda Khoshnood,ª & Kelly Sorosª ªUBC School of Nursing Program 2012, Vancouver, BC Vancouver General Hospital: Nicole Wikjord UBC faculty partner: Helga Marshall Purpose: The purpose of this project is to provide evidence-based recommendations on specific pain measurement tools and flow sheets that would be appropriate for use in the Acute Palliative Care Unit at Vancouver General Hospital (VGH APCU). Through research and analysis of various pain assessment tools, consideration of peer-reviewed articles, performing a needs assessment of the unit and benchmarking with various health care facilities across BC and Canada, we have identified the effectiveness and usefulness of various pain assessment tools in the acute palliative care setting. Overview: We have identified and compiled a table of 22 pain measurement and assessment tools. A brief description of each tool is provided as well as the strengths, weaknesses, ease of administration, validity, and validity specific to palliative. Additionally, a needs assessment was conducted in order to address the gaps in the current pain assessment tool used at VGH APCU. This was achieved by performing chart reviews, interviews and questionnaires. Collaborative benchmarking of current palliative pain assessment tools from various health authorities (Fraser Health Authority, Providence Health, Calgary Health Region, Nova Scotia Health and the United Kingdom) is also provided. A table has been included that lists the tools utilized in each health authority along with their respective features, benefits, limitations and remarks. It is our hope that this project will facilitate the discussion around the implementation of new standardized pain measurement tools and documentation at VGH APCU. Background: Research shows that pain assessment in a clinical setting requires a systematic approach (Weissman, Griffie, Muchka, & Matson, 2000). This will avoid unnecessary complex assessment methods, ensure efficient use of resources, minimize the number of instruments used, create standardization of the tools, improve patient assessment and care, and improve documentation and communication between health care providers (Weissman et al., 2000). However, any systematic assessment tool must be considered in the context of the clients’ current situation, and variances in sources and perceptions of pain need to be addressed. Components of assessment tools which are most relevant for the clinician and the patient may vary along the disease trajectory and between patients (Kaasa et al., 2008). Therefore, selecting a flexible tool (eg. a tool that can be administered via a combination of self-reports, caregiver reports, and/or behavioural indications) may be the most efficient option particularly for those unable to verbally express pain. Literature Analysis: Health care professionals, patients, and families can use pain assessment tools to UBC Nursing Student Journal, Vol.1, Issue 1. 17 gather data through patient self-reporting and behavioural observation. If possible, self-reporting should be the primary source of information when completing a pain assessment as it “is still the most reliable indicator of pain” (Jaggar & Holdcraft, 2005, p. 81). The exception to self-reporting is with non-verbal, non-cognisant persons. For these populations, behavioural observations validated by family and caregivers should be the primary source of information for a pain assessment. Observational assessments can also be used routinely in order to reduce the patient burden of routine hourly pain checks. The pain assessment tools listed are either unidimensional or multidimensional. Unidimensional tools such as the Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), and Verbal Analog Scale (VAS) are highly sensitive in assessing specific features (ie. pain intensity), but rarely address the other components of pain (Katz & Melzack, 1999). Unidimensional tools are quick to administer, easy to understand, and have been widely used and validated. A major criticism of these rating scales is that they “do not actually provide ration-level scaling of pain. Therefore, if a patient’s pain is reduced from 8 to 4 after treatment, it cannot be inferred that she or he has experienced a 50% reduction in pain” (Fillingham, 2005, p. 72). Multidimensional tools such as the McGill Pain Questionnaire (MPQ), Brief Pain Inventory (BPI), and Memorial Symptom Assessment Scale (MSAS) can be highly sensitive at assessing all of the common components of the pain experience (physical, psychological, social, cultural and spiritual). Many multidimensional tools have also been validated across cultures and languages and demonstrate a high level of consistency (Jagger & Holdcroft, 2005). Furthermore, because pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (IASP, 2011), a full assessment of pain therefore requires a multidimensional approach for pain evaluation (Jaggar & Holdcroft, 2005). However, multidimensional assessment tools require more time (from the patient and the person performing the assessment) than unidimensional scales and tend be harder to learn to administer and score, limiting their routine use in clinical settings. Multidimensional Palliative Pain Assessment Tool: The Edmonton Symptom Assessment System (ESAS) is a valid and reliable assessment tool to assist in the assessment of nine common symptoms experienced by cancer patients (Watanabe et al., 2011).  The original tool was developed by the Regional Palliative Care Program, Capital Health in Edmonton, Alberta, and is one of the key assessment tools used in the Palliative Care Integration Project initiated by Queen's University (2012).  The ESAS is designed to assist in the assessment of: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well being, and shortness of breath. One blank scale is available for patients to use to assess an “other problem” as needed.  The severity at the time of assessment of each symptom is rated from 0 to 10 on a numerical scale; with 0 meaning that the symptom is absent and 10 that it is the worst possible severity. The ESAS was designed so that the patient, or his/her family caregiver, could self-administer UBC Nursing Student Journal, Vol.1, Issue 1. 18 the tool, and ideally, the patient and family should be taught how to complete the scale. It is the patient’s opinion of the severity of the symptoms that is the gold standard for symptom assessment, and the ESAS provides a clinical profile of symptom severity over time. It provides a context within which symptoms can be understood. However, it is not a complete assessment in itself and must be used as one part of a holistic clinical assessment. A Needs Assessment: A needs assessment is a critical component in understanding and addressing concerns expressed by the staff, clinicians, and management surrounding pain assessment at VGH APCU. To analyse the current pain assessment tool in use (a  flowsheet used VGH-wide which was developed originally for use in acute medicine); chart reviews, questionnaires, and clinician interviews were conducted to identify possible gaps, effectiveness, accuracy and adherence to using the tool. After careful review of charts and documentation records on the APCU, it was evident the major use for the pain assessment flow sheet was as a medication administration record.  Specifically, the scheduled and breakthrough pain medications and doses were recorded on the flow sheet, while subjective pain data was rarely recorded. This type of documentation does not provide a  full clinical picture of client circumstances prior to medication administration, raising a number of issues related to documentation practice standards as put forth by the College of Registered Nurses of British Columbia (CRNBC, 2012) such as communication, safe and appropriate nursing care, and professional and legal practice standards After a chart review, seventeen questionnaires were administered to staff including registered nurses, licensed practical nurses, medical residents, and physicians. The questions investigated the perspectives of the staff surrounding: (1)  the usefulness of the flow sheet in use,  (2) information that should be be added or removed, and (3) concerns addressing gaps in the current pain tool and documentation method. The data collected from the interviews and questionnaires were congruent with the information collected from the chart and documentation review. Several reasons suggested by staff members provide a rationale for the method of documentation evident in the  chart review. First and foremost, staff nurses and physicians appreciated that the current tool allowed a clear visualization of the trends in medication administration over a period of time. Second, respondents reported that staff were reluctant to use the tool regularly because they felt that due to the patient burden incurred during assessment, clients could possibly be annoyed or disturbed by self-report pain on a frequent basis (eg. every one hour). Recognizing and understanding the patients’ perspective is an important issue to address, because in order to achieve optimal health outcomes, patients need to be active partners in their care. We suggest that further research be carried out to determine patient satisfaction with participating in frequent pain assessments at VGH APCU. Thirdly, all staff members indicated that including a section for respiratory distress medications would be helpful because currently there is no space to write it on the flow sheet, so they were recording these medications on the flow sheet in a section designated for pain intensity, respiration rate, sedation UBC Nursing Student Journal, Vol.1, Issue 1. 19 score, and side effects. Forthly, respondents felt that the addition of a section indicating the 24 hour medication totals would be beneficial. Overall, the staff members were pleased with the current pain assessment flow sheet and found it useful in monitoring pain control, titrated medications, and medication trends over time. These interviews and questionnaires were crucial to understanding the perspective of the staff, which will help select a relevant and appropriate pain assessment tool and documentation flow sheet, and improve clinician adherence to utilizing the tool and improving pain- related documentation in the future. Benchmarking: Part of this project involved contacting a number of local and national health authorities to determine what kinds of documentation and pain assessment tools are used in other jurisdictions. The following health authorities were contacted: Providence Health Care, Fraser Health Authority, Calgary Health Region, Capital Health (Nova Scotia), and NHS in the United Kingdom. Victoria Hospice was contacted regarding this project however we received no reply.  All health authorities’ documentation was reviewed and analysed for features, benefits, limitations and remarks (see the benchmarking table for details).  The remark section includes information given from the various health authority contacts regarding the subjective usefulness and features of the documentation. The conclusion from the collaborative benchmarking indicates that while no health authority uses the same pain assessment tool, there are several contributing factors which determine an effective and efficient tool.  Such factors include simplicity and efficiency for both health care provider and patient.  Additionally, in order to achieve optimal outcomes, a visualization of the trends over time and the various interventions used should be illustrated. Recommendations: Based on our literature analysis, needs assessment and benchmarking, we recommend that (1) a comprehensive, multidimensional tool be administered upon admission to VGH APCU, while (2) continuing to use a unidimensional tool (eg. NRS) for assessing patients’ pain prior to any intervention. 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UBC Nursing Student Journal, Vol.1, Issue 1. 23 UBC Nursing Student Journal, Vol.1, Issue 1. 24 Midwifery Immunization Practice Survey Dawn Watersª, Jennifer Funoª, & Adrienne Johnsonª ªUBC School of Nursing Program 2012, Vancouver, BC BC Centre for Disease Control (CDC): Brittany Deeter Introduction: Recent discussions between the British Columbia Center for Disease Control (BCCDC), the Midwifery Association of British Columbia (MABC) and the Midwifery Department of the University of British Columbia (MDUBC) have identified a need for immunization resources designed to meet the specific needs of midwifery clients. A 2010 survey of 39 British Columbia midwives identified that approximately 63% of midwives would be interested in taking a BCCDC online course on immunization to increase their knowledge base and comfort around immunizations (BCCDC, 2011). Research has shown a number of advantages exist for internet based learning: an increase in knowledge (Casebeer, Kristofco, Strasser, Reilly, Krishnamoorthy, Rabin, Zheng, Karp, et al.,  2004;, Boren, & Balas, 2004; Langkamp, Darden, Kittredge, Gilbertson, Lancaster & Mauldin, 2004; Sullivan, Gitelman, Shapiro, & Rushakoff, 2010; Stamatikos, Alexis, Ratnapradifa, & Dhitinut, 2001; Carroll, Booth,  Papaioannou,  Sutton,  &  Wong,  2009;  Cook  et  al.,  2007),  flexibility  in  time  and  location (Huckstadt & Hayes, 2005; Stamatikos et al.,  2011; Cook, 2007; Cook et al.,  2007; Harden, 2005; McKimm,  Jolie  &  Cantillon,  2003),  easier  to  maintain  and  disseminate  than  paper  resources (Langkamp et al.,  2004), provides a safe environment that allows participants to learn from their mistakes  without  risk to patients  (Zary et  al.,  2006),  and it  is  adaptable to a  variety  of  learning approaches  (Cook,  2007;  Cook,  Gelula,  Lee,  Bauer,  Dupras,  &  Schwartz,  2007;  Harden,  2005; McKimm, Jolie,  & Cantillon,  2003).   Studies by Atack and Rankin (2002) and Francis,  Mauriello, Phillips, Englebardt & Grayden (2000) found that learners were satisfied with web learning,  and would recommend on-line learning to professional colleagues. As  on-line  learning  has  been  shown  to  be  an  effective  learning  tool,  the  BCCDC,  in collaboration with nursing students from the University of British Columbia (UBC), plans to create an online  course  on immunization for  BC midwives.   In  creating  this  course,  it  is  important  to  be cognizant of the attributes of a good on-line learning program.  Over 60 articles were approached using  the  same  question  for  analysis:  “What  are  the  attributes  of  an  effective  on-line  learning program according to learner feedback and program performance outcomes.”  Of the 60 articles examined, 20 were included in this review.  As the BCCDC learning tool will be module based, of brief duration, and lacking an instructor/facilitator, articles that referred to on-line learning in the context of distance based university education were excluded. Findings: Results were categorized into the following sections:  use of active learning techniques, with UBC Nursing Student Journal, Vol.1, Issue 1. 25 a  focus  on  the  effectiveness  of  case-based  learning;  learner  motivation;  flexibility  and individualization;  ease  of  use  and  navigation;  feedback;  relevance  to  practice;  and  peer-to-peer learning. Use of Active Learning Techniques: According to Bonwell & Eison (1991), active learning is “anything that involves students in doing things and thinking about the things they are doing” (p.91). It aims to have  students  control  their  learning (Bransford,  Brown,  & Cocking,  2000).   Techniques  include: leading questions,  puzzles  and games,  brainstorming,  concept mapping,  case studies,  simulations, role-playing, and debates (Office of Instructional Consulting, n.d.) User feedback.:  The use of active learning techniques was well received by on-line module users (Kenny,  2002;  Cook  et  al.,  2007;  Bryce,  Choi,  Landstrom,  &  LoChang,  2008).   The  use  of  self- assessment questions, review activities, and the inclusion of photographs, images and hyperlinks to additional  online  resources  was  well  received  by  learners  of  an  on-line  introductory  course  on complementary and alternative medicine (Cook et al., 2007). Face-to-face interviews with users of the Department for Work and Pensions’ online learning module, “Sickness Certification Made Easy,” revealed that participants felt such modules need to be interactive (Larsen & Jenkins, 2005). Several studies specifically addressed the effectiveness of case based learning (Jenkins, Cook, Edwards, Draycott, & Cahill, 2001; Cook, Thompson, Thomas, & Pankratz, 2006; Cook et al., 2007; Huckstadt & Hayes, 2005; Larsen & Jenkins, 2005).  Case based learning activates prior knowledge and provides a context in which to situate the learning (Bransford, Brown & Cocking, 2000; Brown, Collins & Duguid, 1989), allowing for improved learner performance and knowledge retention.  A pilot training program in reproductive medicine created by the Center for Reproductive Medicine in Bristol delivered one case study per month to participants.  Overall satisfaction with the program was high (Jenkins et al., 2001).  A study exploring the effectiveness of two interactive case-based online modules designed for Nurse Practitioner (NP) students as part of a grant-funded NP learning project found that the evaluation of the online modules and the enthusiasm of the participants support case- based online learning as a successful method of education (Huckstadt & Hayes, 2005).  The use of real-life case studies and scenarios in the aforementioned “Sickness Certification Made Easy” module was well received by participants (Larsen & Jenkins, 2005). Results  of  Performance  Outcomes.:  Active  learning  techniques  were  not  only  well  received  by participants, but have been found to improve user performance outcomes (Cook et al., 2006; Allison et  al.,  2005).  A recent  study by Cook et  al.  (2006) found that  case-based questions significantly improved test scores. A randomized controlled trial testing  a multi-component internet continuing medical education (CME) intervention for increasing Chlamydia screening of at-risk women aged 16 to 26 years found that courses based on active learning techniques (participant interaction, decision making,  problem-solving)  resulted  in  positive  changes  in  practice  patterns  as  an  outcome,  as measured by an increase in Chlamydia screening rates of 60% (Allison et al., 2005). UBC Nursing Student Journal, Vol.1, Issue 1. 26 Learner Motivation:  Many studies found that learners require motivation to learn (Newton, Hase, & Ellis, 2002; Stamatikos & Ratnapradifa, 2011;  Langkamp et al., 2004; Jenkins et al., 2001).  A case study exploring the effective implementation of online learning in the Queensland mining industry found that factors important for effective online learning implementation included incentives for the learner’s participation, and explicit motivations to learn (Newton, Hase, & Ellis, 2002). People are most likely to complete online training because it is a requirement (Stamatikos & Ratnapradifa,  2011).   Motivation  is  often  provided  in  the  form of  continuing  education  credits (Langkamp  et  al.,  2004)  and  a  certificate  of  completion  (Jenkins  et  al.,  2001).   Certificates  of completion have been found to increase motivation, and increase module completion rates (Jenkins et al., 2001). Flexibility: Module flexibility was a theme addressed by numerous sources (Billings & Rowles, 2001; Bryce et al., 2008; Larsen & Jenkins, 2005; Kenny 2002; Harden, 2005; Zary, Johnson, Boberg, & Fors, 2006; Canchihuaman, Garcia, Gloyd, & Holmes, 2011).  It was felt that module formats should allow learners to enter and exit at any point in the course, and repeat sections as desired (Billings & Rowles, 2001; Bryce et al., 2008; Larsen & Jenkins, 2005). Harden  (2005)  found  that  modules  should  incorporate  “just  in  time  learning,”  wherein learning resources are available to participants when they are required.  This means having module content available at all hours of the day from a variety of locations.  Home is the more frequent and preferred  site  for  internet  use  (Cobb,  2004),  and  so  the  module  needs  to  be  available  on home internet,  not just on clinical intranet.   Learners would also like to have the site available at their practice  locations  for  reference (Huckstadt  & Hayes,  2005).   In  light  of  this,  modules  should be designed for the lowest technological denominator so that they are compatible with all systems in all locations (Casebeer et al., 2003). Individualization: Individualization, or “just for you learning” (Harden, 2005), allows learners to have some influence over what is learned and how it is learned, and adapt the program to their needs (Harden & Laidlaw, 1992).  A qualitative study exploring physicians’ perceptions of and experiences in participating in interactive on-line CME found that participants liked to be able to skip parts they felt  versed in and go to  parts  they needed more education in (Sargeant,  Curran,  Jarvis-Selinger, Ferrier, Allen, Kirby, & Ho, 2004). Part of individualization is having the ability to self-pace one’s learning.  Self-pacing allows learners to progress at their own rate, select content on a needs basis, and allows more experienced learners to skip content to finish the module more rapidly, and was seen to be a positive attribute of a learning module (Sargeant et al., 2004; Newton, Hase, & Ellis, 2002). Ease of Use and Navigation: Modules should be easy to navigate (Phillips, 2005; Casebeer et al., 2003) and easy to use (Casebeer et al., 2003, Newton, Hase, & Ellis, 2002).  Lessons need to be in a logical sequence (Billings & Rowles, 2001), and each module should have a clear purpose and objective and UBC Nursing Student Journal, Vol.1, Issue 1. 27 defined beginning and end (Phillips,  2005).   Instructions  should be  understandable,  and easy to follow (Phillips,  2005).   Vancouver  Coastal  Health  created  an online  module  consisting  of  basic infection  control  content,  video  clips,  and  information  on  antibiotic  resistant  organisms.   280 participants completed the module, and found it easy to begin, exit, re-enter, and move through the course, and felt that the content was clearly and logically presented (Bryce et al., 2008).  Structured learning was highlighted as an attribute in several studies (Sargeant et al., 2004; Huckstadt & Hayes, 2005). As a lack of technical skill was noted as a barrier to effective online learning in studies by Sargeant et al. (2004) and Cobb (2004), modules should be simple and appeal to those with limited computer competency. Feedback: Another attribute of an effective on-line learning program is the provision of feedback on knowledge,  comprehension,  and  performance  (Sargeant  et  al.,  2004;  Billings  &  Rowles,  2001; Canchihuaman et al., 2011; Harden, 2005; Zary et al., 2006; Bryce et al., 2008; Larsen & Jenkins, 2005).  Feedback on performance can support metacognition, as students evaluate their performance against an expert, a case author, or through analyzing expert reasoning on differential diagnoses or tests performed (Zary et al., 2006). According to Billings & Rowles (2001),  each module should have its  own assessment and evaluation segment.  Participants in the “Sickness Certification Made Easy” module enjoyed being tested on what they had learned, and found quizzes to be an effective teaching method (Larsen & Jenkins, 2005).  In addition to being tested, participants want to be provided with answers to case scenarios, regardless of whether answers were right or wrong (Canchihuaman et al., 2011).  A lack of feedback when questions were answered incorrectly in the post-test was seen as a negative attribute of the Vancouver Coastal Health online immunization module (Bryce et al., 2008). Relevance to Practice:  In order to be effective, the module should contain content that is directly relevant to practice (Harden & Laidlaw, 1992; Newton, Hase, & Ellis, 2002; Larsen & Jenkins, 2005). In  the  online  learning  module  “Sickness  Certification Made  Easy,”  information  applicable  to  the health professionals’ jobs was well received.  Information should also be quickly and continuously updated as content or standards change (Newton, Hase, & Ellis, 2002). Peer-to-Peer Learning: One of the main barriers to effective online learning is the lack of an online community  (Sargeant  et  al.,  2004).   An  effective  online  module  would  create  a  community  of learners, and allow for interaction with peers and facilitators (Harden, 2005; Newton, Hase, & Ellis, 2002; Stamatikos & Ratnapradifa, 2011).  Learners would like to be able to share experiences with other learners (Sargeant et al., 2004), and feel a sense of belonging when engaged in discussions or other forms of peer-group interactions (Carroll et al., 2009). Limitations of Findings:  While it is clear that there is a growing body of literature to support the effectiveness  of  online  learning  and  the  attributes  of  effective  online  learning  modules,  further UBC Nursing Student Journal, Vol.1, Issue 1. 28 research is required.  Many of the studies have small sample sizes, and only a few were controlled trials. Only one study (Canchihuaman et al., 2011) addressed continuing education courses that were specifically  aimed  at  midwives.   The  remainder  of  the  studies  focused  either  on  other  health professions  (physicians,  nurses,  pharmacists,  dentists)  or  other  professions outside of  health care. Specific  research  is  needed  to  address  the  learning  needs  particular  to  midwives  as  a  unique professional group.  However, these studies do provide information and learner feedback on effective attributes of online learning that will prove useful in the development of an online learning module for midwives. Conclusions  and Recommendations:  A review of  the literature  highlights  that  an effective online module should incorporate a number of attributes.  It should make use of active learning techniques, with an emphasis on the use of case studies.  The BCCDC module should use case studies specific to midwives’  professional  learning  needs.  An  effective  module  should  also  motivate  learners  to participate,  either  by  awarding  continuing  education  credit  or  by  providing  a  certificate  upon completion.   As midwives in British Columbia are not awarded continuing education credits (MABC, 2011), incentives for the BCCDC module would most likely be in the form of a certificate. The module should be flexible, have exit-and entry points, and allow users to return to and repeat sections as desired.  It should be available at any time of day and at any location, and should be created  at  a  low  technological  denominator  to  ensure  compatibility  with  all  user  systems. Individualization of content should be optimized by allowing users to self-pace their learning, and move past sections containing content in which they feel well-versed.  Placing the module on the MABC website would allow participants to access the module from both work and home. In  addition,  modules  should be  easy to  use  and navigate.   Lessons  should be  in a  logical sequence, and each module should have a clear purpose.  Instructions should be understandable and easy to follow.  The module should be simple, and appeal to those with limited computer competency. Learners want feedback on their progress, knowledge, and competence.  This can be provided in  the  form of  quizzes  and evaluations  at  the  end of  each module  or  section of  a  module.   All evaluations should provide the correct answers upon test completion so that learners can  compare their performance to that of the expert. All module content should be directly relevant and applicable to professional practice, and content should be continuously updated to remain current with changes in knowledge and practice standards.  The BCCDC and the MABC would be responsible for ensuring that content is constantly updated,  and that,  not only is the data up to date,  but the technology is current and the format remains  appealing  to  the  audience.  Lastly,  modules  should  facilitate  the  creation  of  learner communities and peer-to-peer learning.  As the BCCDC module will not have a facilitator or on-line moderator, the most likely form of learner interaction would be an online discussion forum attached to the module.  The effectiveness of online discussion forums as they relate to module learning was UBC Nursing Student Journal, Vol.1, Issue 1. 29 not addressed in the reviewed literature, and this is another area that needs to be further researched. Just  as  the  modules  in  the  literature  reviewed  were  assessed  for  user  satisfaction  and performance outcomes, the same needs to be done with the BCCDC module upon completion.  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Association for Medical Education in Europe (AMEE) Medical Education Booklet No. 4: Effective continuing education: The CRISIS criteria, Medical Education, 26: 408–422. UBC Nursing Student Journal, Vol.1, Issue 1. 30 19. Huckstadt, A.H., & Hayes, K.  (2005).  Evaluation of interactive online courses for advanced practice nurses.  The Journal of the American Academy of Nurse Practitioners, 17(3), 85-89. DOI: 10.1111/j.1041-2972.2005.0015.x (10) 20. Jenkins, J., Cook, J., Edwards, J., Draycott, T., Cahill, D.  (2001).   A pilot internet training programme in reproductive medicine. British Journal of Obstetrics and Gynaecology, 108:114 –116. 21. Kenny, A. (2002). Online learning: Enhancing nurse education.  Journal of Advanced Nursing, 38, 127–135. 22. Langkamp, D., Darden, P.M., Kittredge, D., Gilbertson, B.O., Lancaster, C.,  & Mauldin, M.P. (2004) Effectiveness of an internet-based curriculum to increase knowledge of immunization delivery.  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Strategies for active learning in online continuing education. The Journal of Continuing Education in Nursing, 36(2): 77-83. 28. Sargeant, J., Curran, V., Jarvis-Selinger, S., Ferrier, S., Allen, M., Kirby, F., & Ho, K. (2004). Interactive on-line continuing medical education: Physician’s perceptions and experiences. The Journal of Continuing Education in Health Professions, 24(4), 227-236.  (5) 29. Stamatikos, A., & Ratnapradifa, D.  (2011).  Online learning in public health education. Techniques: Connecting Education and Careers, 86(2): 48-51. 30. Sullivan, M.M., O’Brien, C.R., Gitelman, S.E., Shapiro, S.E., & Rushakoff, R.J.  (2010). Impact of an interactive online nursing educational module on insulin errors in hospitalized pediatric patients.  Diabetes Care, 33(8), 1744-1746. DOI: 10.2337/dc10-0031. (18) 31. Wutoh, R., Boren, S.A., Balas, E.A.  (2004).  eLearning: A review of internet-based continuing medical education. Journal of Continuing Education in the Health Professions, 24(l): 20-30. (4) 32. Zary, N., Johnson, G., Boberg, J., & Fors, U.G.  (2006).   Development, implementation and pilot evaluation of a web-based virtual patient case simulation environment–Web-SP. BMC Medical Education, 6: 10. UBC Nursing Student Journal, Vol.1, Issue 1. 31 Midwifery Immunization Practice Survey Summary of Findings Dawn Watersª, Jennifer Funoª, & Adrienne Johnsonª ªUBC School of Nursing Program 2012, Vancouver, BC BC Centre for Disease Control (CDC): Brittany Deeter Background: The British Columbia Center for Disease Control (BCCDC), in collaboration with the Midwifery Association of BC (MABC), recently surveyed 39 BC midwives about their immunization practices.  Since many midwives only follow their clients for 6 weeks postpartum, they are not involved in the administration of infant immunizations; though they do administer vaccines to ante- and post-partum women and Hepatitis B vaccines to infants when required.  Many midwives report that they are often asked in depth questions about immunization and what their professional perspective is on the immunization program, and that they would like additional information on both the vaccines that they are administering, and those involved in the infant immunization series. The survey has identified a need for immunization resources designed to meet the needs of midwives. Participant Profile: Of the 39 midwives who participated in this survey, 67% graduated within the last 10 years.  According to the survey, 64% of midwives graduated from programs outside of BC, and of those programs, 50% were completed overseas.  Midwifery is not standardized internationally, and within Canada, each province determines laws and standards.  The range in year of graduation and the variety of program locations may contribute to the lack of consistency in knowledge and practice surrounding maternal and infant immunizations. The results of the survey show that 71.8% of midwives have a group practice, 23.1% practice solo, and only 5% are involved in inter-professional practice with other health care professionals.  The midwives surveyed practice in both rural and urban areas. Providing Information and Resources to Clients: Midwives reported that they have, on average, 100 contacts a month with their clients.  These contacts include speaking to their clients about immunizations; although, the degree, timing, and regularity to which these discussions occur varies amongst midwives.  Nearly 90% of midwives reported that they provide information about the infant immunization series and about 70% provide immunization information about the pregnant/post- partum women.  Of the midwives surveyed, 53% reported discussing immunizations at least once in their relationship with the client, with 31% having this discussion during the final post-partum visit with the client.  Others will only discuss immunizations at the request of the client.  None of the midwives surveyed refused to discuss the topic of immunizations with their clients, nor did any discuss immunizations at every visit. When answering immunization questions, midwives are obtaining information from many different sources, including BC Health Files, Public Health Nurses (PHNs), the BCCDC immunization UBC Nursing Student Journal, Vol.1, Issue 1. 32 manual, and other midwifery colleagues.  Half of the midwives reported using the College of Midwifery of BC’s position statement on vaccination as a resource when answering questions. When midwives guide their clients to additional resources regarding immunizations, 83% refer them to the local public health nurse.  Other referral resources include family doctors, BC Health Files, and on-line and print material from various sources. The 5 most common questions midwives are asked by clients are ranked as follows: 1. Adverse events after immunization 2. Benefits of immunization 3. Timing of immunizations 4. Common side effects 5. Effects of immunization on the fetus Midwives reported the following questions to be some of the most difficult to answer: 1. Vaccine components 2. Adverse events after immunization 3. Effects of immunization on the fetus 4. Immunization while breastfeeding 5. Risks of not immunizing 6. Multiple Injections Administration of Immunizations: Providing immunizations to both mothers and infants is part of the midwifery scope of practice; however, only 23% of midwives provide immunizations to women, and 11% to infants. 69% of midwives do not provide immunizations and refer their clients to the PHNs at the local health unit.  Over 80% of midwives did not administer the H1N1 vaccine to pregnant women in the 2009-2010 influenza season. In a home birth situation, some midwives provide the HBig and Hepatitis B vaccine following the delivery of an infant from a mother who is a Hepatitis B carrier.  However, some midwives refer the vaccination to the Public Health Nurse, while others indicate that this situation never or rarely occurs. Barriers to Providing Immunizations: Midwives reported many barriers to providing immunizations. Two predominant reasons were that infants are no longer under the care of the midwife at the appropriate time for the immunizations and that the service is already well administered by PHNs. Other barriers include: a lack of access to vaccines in their practice; a lack of facilities to store vaccines; and a lack of time in their practice to give vaccinations.  Overall, midwives seemed most UBC Nursing Student Journal, Vol.1, Issue 1. 33 interested in providing required ante- and post-partum immunizations for women and Hepatitis B/HBig immunizations for infants, as they felt other immunization services were adequately provided elsewhere. Interest in Immunization Information and Resources: Over 82% of midwives would like to receive more information on immunization guidelines.  In particular, nearly 80% of midwives would like teaching resources for clients and 76% would like information on immunization guidelines, such as schedules and how to give vaccines. Over 37% would like to receive immunization information from one central website, and 35% would like to receive the information through their professional association. Approximately 63% of midwives would be interested in taking a BCCDC online course on immunization.  Some particular topics of interest raised included: how to handle client prejudice against immunization and distrust of official information; the need for high-quality evidence based information; access to and administration of Hepatitis B vaccinations; and information regarding delaying and spacing immunizations. Recommendations: As evidenced by the survey, midwives act as an important resource for clients regarding immunizations.  It is therefore imperative that immunization resources be designed to meet the practice needs of BC midwives. Midwives indicated that they would like a central location for immunization information, such as on-line resources, or resources within their professional association.  Due to the varying backgrounds and needs of midwives, it will be important to provide standardized information that is regularly updated and accessible to midwives across the province. We recommend that educational resources be added to the MABC website.  These resources would not only address topics of interest in the midwifery community, but also the most commonly asked questions and the most difficult questions asked by clients.  Midwives desire information about the immunizations that they are providing to women (influenza, H1N1, HPV) and to infants (Hepatitis B and HBig), in addition to information about the infant immunization series that will be provided after the clients are discharged from their care.  Midwives did not explicitly express a desire to provide additional infant immunizations, and several mentioned that this service is already well established within the scope of the PHNs. Given the interest in on-line learning, resources could be delivered in modules that would cover single topics in a short period of time.  Educational tools may include videos, webinars, and interactive quizzes.  Further investigation will be required to determine which will be the most appropriate tools for on-line learning.  It is our hope that providing accessible information on topics of interest to this community would drive higher uptake in all of the resources provided; therefore, increasing the general knowledge and ability to inform clients about immunizations. Midwives also expressed a need for current, evidence based information on maternal and UBC Nursing Student Journal, Vol.1, Issue 1. 34 infant immunizations.  As clients may have a distrust of official information, sources must be reputable and unbiased.  Midwives therefore need access to this information, as well as resources on how to find high quality evidence, and how to recognize false or misleading information. UBC Synthesis Project: The UBC Synthesis project deadline is Feb 2012.  It is not within the scope of our project to address all of the information needs highlighted in this survey. It is our intention to focus specifically on the creation of an on-line, centralized resource to be made available on the MABC website.  As a test pilot, we will develop a learning tool that consists of current evidence-based information on aspects of the infant immunization series that were of most interest to midwives.  We then plan to survey or meet with a focus group of midwives to evaluate the on-line learning tool. Future resources will need to be created to address the issue of immunizations and the ante and post-partum woman, in addition to administration of Hepatitis B and HBig vaccines and issues surrounding the storage, transportation, and acquisition of vaccines for midwifery practice. 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