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รูปแบบ e-learning ในประเทศแคนนาดา
Online Training for Healthcare Workers
Improving the quality of life for dementia patients in long-term care facilities

By Dr. Colla J. MacDonald, Dr. Emma J. Stodel, and Lynn Casimiro (Ph.D. candidate), University of Ottawa

Canada's population is rapidly aging. Associated with an aging population is a prevalence of syndromes such as Alzheimer's disease and other dementias (Romanow, 2002). Governments, healthcare consumers, and the healthcare community are concerned about the inadequate supply of trained professionals to provide quality care for Canada's seniors, many of whom require some level of nursing assistance with activities of daily living (Romanow). Long-term care (LTC) facilities have been impacted by a high volume of patients with dementia disorders. The rise in cognitive and behavioral disturbances among the LTC client population requires a workforce knowledgeable and skilled in dementia care. There is an urgent need to provide training and support for healthcare workers in LTC facilities to ensure they are qualified to provide quality care to their residents.

The purpose of this study was to design, develop, deliver, and evaluate an e-learning dementia care program aimed at enabling healthcare teams to deliver better service to residents with dementia in LTC facilities. The study used the Demand-Driven Learning Model (DDLM, MacDonald, Stodel, Farres, Breithaupt, & Gabriel, 2001) and the DDLM companion evaluation tool (MacDonald, Breithaupt, Stodel, Farres, & Gabriel, 2002) as a quality standard to evaluate the process and outcomes of the program on learners' attitudes and practices towards persons with dementia, gain an understanding of stakeholders' experiences with and perspectives on the process, and identify the lessons learned in order to provide recommendations for future e-learning initiatives. A Community-Based Participatory Research (CBPR) orientation (Minkler & Wallerstein, 2003) aimed at understanding the socio-cultural factors that impact learning and community building was implemented to involve stakeholders as agents of change in this research endeavor.

The project, involving multiple partners, developed a bilingual dementia care program that comprised four modules and was offered at six sites in three provinces across Canada. Ninety-five learners started the program. Forty-nine (52%) enrolled in the French language program and 46 (48%) enrolled in the English language program. The attrition rate was 24.2% and the level of involvement of those that finished varied greatly. The learners varied in the number of pages they visited, amount of postings they made and read, and number of exercises they completed.

Overall, the dementia care program was a success. The learners reported that participating in the program was both a challenging and rewarding experience. It is apparent there is a great need for such training. Learners in the program commented on the ineffective ways their co-workers' sometimes approached the residents. This is an important observation in light of recent reports in the popular press on the abuse many residents are suffering at the hands of healthcare workers in some LTC facilities. However, despite the positive outcomes of this program, based on the findings from the comprehensive evaluation there are a number of suggestions and recommendations for how the program can be further improved for future delivery. The findings and discussion should be considered in the context of both the constraints imposed by the project timelines and the complexities resulting from the heterogeneity of the learner cohort participating in the program (diverse educational levels and professions, different levels of computer skills, range in age, cultural issues, and language abilities of the participants). The recommendations proposed in this report are presented as next steps for improving and refining this pilot program as well as opportunities for follow-up initiatives. In this report, the DDLM constructs (i.e., content, delivery, service, structure, and outcomes) are used as a framework to discuss the participants' experiences with the program.

Content
The vast majority of the learners who participated in this dementia care program reported that they liked and enjoyed the content and found it relevant. Having relevant content appeared to have a positive impact on the success of this program. MacKeracher (1996) emphasised that "if the content is directly relevant to some aspects of what they currently do, then learners are more likely to be motivated to look for connections and develop new meanings" (p. 256). A central principle of adult education is that adults bring much experience to the learning situation and this experience must be respected (MacKeracher; Maehl, 1999). Adults need to be able to connect new learning to their current knowledge base. In this program, the more successful participants were able to select the information and techniques that were applicable to them and integrate them into their current practices. Learners said the exercises and discussions facilitated their learning, as did the printed version of the content.

However, not all the participants' experiences with the content were positive. It was clear that the expectations the pedagogy team had for the learners in this program were too high for the time allotted, particularly in terms of the amount of material and the number of exercises the learners were originally expected to complete. These unrealistic expectations caused a number of learners to become discouraged with the program, and some even dropped out for this reason. This finding underscores the importance of pacing in teaching, not introducing too much information too soon, and communicating realistic timeframes for completing activities. Furthermore, it should be recognized that individuals will have different levels of previous knowledge and engagement and therefore a variety of levels of information should be included that will satisfy individual needs (Stodel, 2004). In this program, once the number of exercises was reduced, learners felt less pressure and indicated that these more realistic expectations facilitated their learning.

One of the biggest challenges these learners faced was getting together as a team to complete the team exercises; high workloads and shift work were the main barriers to this. Again, this was a source of frustration and often served to dishearten the learners. However, the team-learning approach this project took was part of what made it unique. Moreover, one objective of this program was to enhance teamwork among healthcare teams. As such, eliminating team exercises would defeat part of the purpose of the program. One solution to the problem, as suggested by a number of the participants, would be to pay or replace the learners so they can participate more fully in the program and get together with their team members.

Another demand on the learners' time was reading and participating in the discussion forums. Learners reported that the forums became unmanageable due to the amount of postings. Online facilitators should ensure that participants have the skills necessary to work effectively in discussion forums. Moreover, as with face-to-face discussions, facilitators need to create a climate of mutual respect and be able to encourage non-participants to become more active in discussions while reducing the time the "discussion monopolizer" speaks (McKeachie, 1999; Poonwassie, 2001). Lastly, as highlighted by Brookfield (1986) in a face-to-face context, it is as important for the online facilitator to properly plan and facilitate group discussion to ensure that learning outcomes are met.

Lastly, it was apparent that the language level in this program was too high for many of the learners. It is critical that program designers are aware of who their audience is and tailor the content to their level.

Delivery
In general, the learners had very limited computer knowledge and many of them struggled with using the program. It was blatantly apparent that the one-hour of face-to-face computer training offered to learners was not sufficient preparation to make this a positive learning experience for some of the learners. When told the learners would have minimal computer experience, the instructional designer suggested, "There should be a short computer training before starting the program and there should be an introductory forum exercise." However, he noted that this never occurred. He further relayed, "Although the computer competencies required to do this program are minimal, there is a minimum: using a keyboard and mouse; using the Windows interface; using the Explorer or Netscape interface; knowing the basic vocabulary of a computer and online environment (file, link, folder, window, email, forum, print, etc.); reading the student guide and the instructions; and sending a message via email and forum.

Similarly, the online facilitator noted, "The learners need a basic computer course in order to navigate the course more efficiently and effectively—how to operate the computer, how to access different programs, how to use a mouse, how to write an e-mail, how to post an answer on the forum, how to move to and from one part of the course content to another without getting lost, how to navigate the system, [and] how to import text for another program." It is quite clear that learners should not be expected to engage in e-learning before they have developed the necessary computer skills. However, this does not mean that individuals with no computer experience should be prevented from participating in e-learning; this would only serve to increase the "digital divide." What it does mean is that learners need to be provided with the necessary computer training and support before and during their participation in the program.

Navigation issues were a recurring theme and many participants felt they had wasted a lot of time due to barriers they faced navigating through the program. Many of these problems were due to oversights during program development and were quickly fixed when they were identified by the learners. Others were the result of poor design due to the pressure of timelines and the need to have the program online by a specific date. It is widely agreed that program design is the cornerstone of e-learning (Jung, 2000; McLoughlin, 1999; Pahl, 2003; Willis, 2000) and well known that good design requires a considerable amount of time and work (Smith, Ferguson, & Caris, 2002). In this project, it appears that the pressure of imposing timelines affected the quality of the program.

The learners found this program more interactive than the face-to-face in-service training they had previously done. The exercises required the learners to engage in active learning and apply their knowledge rather than be passive recipients of information. The students reported that this approach facilitated their learning.

Service
The service in this program comprised the provision of support by the site coordinators, learners, higher management, and the online facilitator. The learners greatly valued the support they were provided and felt it played an important role in their learning; both in terms of getting through the program and facilitating their learning. This finding supports the notion that adult learning should be viewed as a collaborative activity (Brookfield, 1986, Silverman & Casazza, 1999; Stodel, 2004). Moreover, some of the learners enjoyed learning from each other. This is a finding mirrored in other studies in other contexts (e.g., MacDonald, Gabriel, & Cousins, 2000; Stodel, 2004). In the future, better use could be made of the participants' experiences by providing them with more occasions for sharing their personal experiences (MacDonald et al., 2000). Moreover, the social facet of learning has been found to be a source of support and encouragement during learning (Stodel, 2004).

Structure
Most learners liked the convenience that the online learning delivery format provided. They appreciated being able to learn where and when they wanted to and at their own pace. Moreover, the flexibility of online learning allowed learners to schedule their learning around their duties. Indeed, it is these features of e-learning that make it such an attractive medium through which to learn (MacDonald et al., 2001; Stodel & Farres, 2002) and no doubt the reason why e-learning is becoming so popular in the healthcare field.

A number of factors impacted the learners' motivation to engage in the program. As with the majority of adult education, participation in this learning experience was voluntary. Yet the participants' level of involvement with the program varied. In adult education, effective practice is often linked to humanist philosophy, an important aspect of which is that adults take responsibility for their learning (MacKeracher, 1996; Merriam & Caffarella, 1999; Poonwassie, 2001). However, it appeared that not all the learners were ready to do so. Once again, this finding attests to the importance of relevant content that has personal meaning to the learner.

The learners who completed the program received a certificate of completion and those who completed only a portion of the program received a certificate of participation. A number of the participants would have liked to have received more recognition, especially in terms of recognition by higher management. It would be of great benefit to the program and learners if the program was accredited and learners received professional development credit for completing it.

The biggest weakness of this program was the amount of work the learners were requested to do in such a limited time. In future, this program should be delivered over an extended length of time. The online facilitator attested, "The amount of content was extensive and could easily be spread over a longer period of time for the learner to integrate it.".

Outcomes
The learners enjoyed the program and acquired and applied new knowledge and skills, which led to greater value for their employer and a better level of care for the residents they work with. Not only did the learners develop a better understanding of dementia and learn how to interact with the residents, but they also learned how to use a computer. Positive outcomes of this program included many instances of residents being better understood and treated with more respect by members of the healthcare team. The program also provided learners with the opportunity to use computers and develop computer skills, thereby reducing the digital divide. For many of the learners this was the first time they had ever used a computer. Team functioning also improved, specifically in terms of communication between and across shifts. Moreover, the program increased learner confidence, organizational learning, and community building among stakeholders. These findings are consistent with the literature about the benefits of e-learning. Higher management at the LTC facilities involved in this project supported the program and indicated they would offer it again if they were given the opportunity.

What were the lessons learned that can be used to improve future e-learning initiatives? Effective e-learning requires a commitment to a planned learning experience (Carr & Carr, 2000). The design and development of a well-designed course requires a considerable amount of time and work, both in up-front preparation and the actual delivery (Smith et al., 2002). Palloff and Pratt (2001) asserted that pedagogy and a purposeful design, more so than the technology, are critical to the success of an online course. Based on the lessons learned in this project, several recommendations were made for future offerings of this program.

Conclusion
This project revealed that there is a desperate need for more accessible training programs on dementia care, with differing levels of difficulty, to ensure the residents in LTC facilities are treated with dignity and respect and receive high-quality care. Some learners in this program suggested that everyone who works in a LTC facility should take this program.

The diversity of the LTC workforce provides challenges for educating this sector. It appears that an effective learning approach for these adult healthcare workers is one that provides relevant, practical information that is easily accessible in terms of understanding and convenience, and is simple and easy to use. Moreover, the program must address differences in individual learning styles, while integrating team learning. From an employer's perspective, programs that do not pull learners away from their work for long periods of time are also necessary. E-learning is a viable means for achieving all these objectives. Furthermore, the economy of scale is significant. The number of healthcare workers who could benefit from the dementia care program makes its delivery through e-learning extremely attractive. In Ontario alone it is estimated that, on a daily basis, approximately 100,000 people work and interact with residents with cognitive disorders in LTC facilities (Ontario Ministry of Health and Long-term Care Communications Office, 2003). When one considers that, through e-learning, the same program can be delivered to healthcare workers across Canada simultaneously, the benefits are magnified.

It is clear that the e-learning dementia care program developed in this project met many of the demands of the learners and organisations. Learners learned and applied new skills and their organisations benefited. Higher management were interested in offering this program in their facilities again. Although the demands of the program were too high for the time available, the learners found it to be a convenient and flexible way to learn and benefited from being able to engage in the program at any time and any place. This project demonstrated that online dementia care training is both a feasible and cost effective strategy for delivering consistent, high quality training in the healthcare field. A number of recommendations for improving this program for future e-learning initiatives have been presented. It should be noted that all of these recommendations can be implemented with relative ease and should be before the program is offered again.

In the future, this program has the potential to allow healthcare professionals from across Canada to access dementia care training at any time and any place, including those who live in rural and remote areas. Moreover, this project makes steps in assisting Canada become a world leader in healthcare e-learning.

สรุป  ประเทศแคนนาดาได้จัดทำระบบการเรียนการสอนผ่านระบบเครือข่าย e-learning ในเรื่องการดูแลรักษาสุขภาพของประชาชน ทำให้เกิดประโยชน์ในการเรียนรู้เรื่องสุขภาพอย่างไม่มีขีดจำกัด สามารถใช้เป็นแนวพัฒนาการเรียนรู้การดูแลรักษาพยาบาล ควบคู่ไปกับการพัฒนาการใช้อินเตอร์เน็ตได้เป็นอย่างดีอย่างเหมาะสม อันเป็นสิ่งที่น่าจะเกิดกับประเทศไทยอย่างกว้างขวางต่อไปได้

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