Introduction ... one of the oldest and largest Integrative Medicine (IM) departments in southeastern Wisconsin, ..... aromatherapy and to non-academic, online, healthcare organizational ..... online system as a .pdf and sent via email to the tool's author. .... was different from pre- to post-course, we can infer, after reading other ...
An Online Educational Tool for Oncology Nurses On the Use of Essential Oils By Diane M. Woehlke A Capstone Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice
At The University of Wisconsin-Milwaukee May 2015
© Copyright by Diane M. Woehlke, 2015 All Rights Reserved
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Acknowledgments: This paper and its success could not be possible without acknowledging Dr. Bev Zabler’s tireless and profoundly patient efforts to make this a reality from inception onward. Dr. Zabler is the advisor every over-‐ wrought, stressed-‐out DNP student should have. I have learned volumes from her while only scratching the surface. I also wish to respectfully acknowledge Nancy Conway and Kerry Twite; two phenomenal, transformative, and impressively wonderful women! Dedication: This tome is dedicated to my unwavering, incomparable, and incredibly unselfish and loving family. All seven children have contributed to my core knowledge by being cooperative ‘patients’, substitute-mom to each other, and all-around incredible cheerleaders. Tony, your trust and belief in me is incredible; I do this for you so you can at long last, rest. I have achieved this because of you, my love. Lastly, I owe everything to my Lord, Jesus Christ, who has made all things possible.
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TABLE OF CONTENTS Abstract…………………………………………………………………………………………………………………….…..vi List of Abbreviations……………………………………………………………………………………………….…….vii Introduction…………………………………………………………………………………………………………...………1
Description of the Problem: Symptom Clusters…………………………………………………...…1
Lack of Nursing Education in CAM……………………………………………………………………...…3
Significance of the Problem………………………………………………………………………..…………6
Purpose and Objectives of the Project……………………………………………………………….…..7
Review of the Literature…………………………………………………………………………………………………8 Theoretical Framework………………………………………………………………………………………………...11 Method…………………………………………………………………………………………………………………..…….15
Design…………………………………………………………………………………………………………….....15
Setting…………………………………………………………………………………………………………….....18
Human Subjects Consideration……………………………………………………………...…………....18
Sample………………………………….………………………………………………………………………...…18
Data Collection…………………………………………………………………………………………………..19
Results…………………………………………………………………………………………………………………..……..20
Data Collected and Statistical Analysis………………………………………………………………...20
Results……………………………………………………………………………………………….………….……………..21
Figure 1: Knowledge, Comfort, Experience – pre-‐course……………….………………….…..21
Figure 2: Equipped, Recommend, Know More, Curriculum – pre-‐course………….……22
Figure 3: CAM Opinions – pre-‐course……………………………………………………………….….23
Figure 4: Confidence, Information, Needs, Recommend – post-‐course…………………..24
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Figure 5 – 6: Course Evaluation – definitions…………………………………………………..…..25
Figure 7: Course Evaluation as teaching method…………………………………………………26
Figure 8: Course Evaluation – commitment to change………………………………………….26 Cost Savings Analysis…………………………………………...……………………….……………………27
Discussion…………………………………………………………………………………………………………………....27
Summary of Outcomes………………………………………………………………………………………..27
Limitations Of the Pilot Study.…………………………………………………………………………….29
Implications: for the Organization………………………………………………………………………………..29
for Nursing Practice………………………………………………………………………………..31
for Nursing Education………………………………………………………………………….….32
for Nursing Research………………………………………………………………………………32
Conclusion………………………………………………………………………………………………………....33
References……………………………………………………………………………………………………………..……..35 Appendix A – Application for CEU……………………………………………………………………………….....42 Appendix B – Pre-‐Questionnaire……………………………………………………………………………………43 Appendix C – Post-‐Questionnaire…………………………………………………………………………………..45 Appendix D – Knowledge Check Questionnaire……………………………………………………………...48 Appendix E – Course Evaluation…………………………………………………………………………….……...52 Appendix F – IRB Approval……………………………………………………………………………………………57 Appendix G – Cost Analysis of Tool…………………………………………………………………………..……58 Appendix H – Oncology Department Needs Assessment Survey…………………….………………..59
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Abstract Every day, 87 new Wisconsinites are told they have cancer, and every hour, one cancer victim dies (Wisconsin Cancer Facts, 2013-2014). These cancer patients often suffer from ‘symptom clusters’: maladies that rob the patient of their quality of life while exacerbating their condition and contributing to poorer patient outcomes (Decker & Lee, 2010). Aromatherapy’s essential oils (EOs) are a simple and cost-effective method that can help ameliorate symptom clusters, doing so without side effects while enhancing quality of life and empowering the patient (Cho, 2013; Decker and Lee, 2010; Buckle, 2003). Information and guidance for safe nursing practice in the use of EOs is sorely lacking. An online educational tool for outpatient oncology nurses was constructed as an effective way to deliver evidence-based knowledge about EOs for the oncology patient suffering from symptom clusters. This project developed, implemented, and conducted a pilot evaluation of the tool and the nurses’ learning. Participants were self-selected to view a 45-minute PowerPoint; tool response rate was 34% within one week. In a descriptive study of the data, comfort, experience, and knowledge increased dramatically from pre-course, some at 2:1; teaching method and course evaluation scored 100% agree/highly agree as effective for learning. This tool afforded $8,750 savings per participant versus an instructor-led course.
Keywords: oncology, symptom clusters, nursing online educational tool, aromatherapy, essential oils
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LIST OF ABBREVIATIONS
ANCC……………………………………………………..American Nurses Credentialing Center CAM.…………………………………............................complementary and alternative medicine CDC……....………………………………………………………......Centers for Disease Control CEU………...…………………………………………………………....continuing education unit CNS………………………………………………………………………Clinical Nurse Specialist CON………...………………………………………………………………….College of Nursing EBP………………………………………………………………………..evidence based practice EO(s)………...………………………………………………………………………essential oil(s) HCPs………………………………………………………………………….health care providers IM…………………………………………………………………………….Integrative Medicine IOM…………………………………………………………………………..Institute of Medicine IRB…………..…………………………………………………………Institutional Review Board NIH…………….……………………………………………………..National Institutes of Health QI…………………….……………………………………………………….quality improvement RN………………...……………………………………………………………..…registered nurse
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An Online Educational Tool for Oncology Nurses On the Use of Essential Oils Introduction One of the largest health care systems in the Midwest is also the most prodigious in Wisconsin (Levine, 2013), and is the most extensive and comprehensive oncology provider in the state as well (media kit, 2014). Not unusual for this organization, it continues to hold top nationwide business and consumer slots and is listed as one of this country’s top “100 Integrated Health Systems to Know”; one of several in Wisconsin (para.9). In 2014, this organization was listed in Becker’s as being one of one hundred of the nation’s top oncology therapy providers as well (“100 hospitals”, 2014, para.8). Furthering their pioneering tradition, this institution has one of the oldest and largest Integrative Medicine (IM) departments in southeastern Wisconsin, and the staff of IM has been working to incorporate complementary alternative medicine (CAM) into its twenty-one oncology clinics. Description of the Problem: Symptom Clusters in Cancer According to the American Cancer Society’s Wisconsin Cancer Facts & Figures: 20132014, the cancer incidence in Wisconsin for 2013 revealed that 31,590 Wisconsinites were told they had cancer – 87 people every day. Out of the nearly 280,000 cancer survivors in Wisconsin in 2013, 11,220 – or one every hour – died of cancer, with cancer being the leading cause of death in the state. According to the CDC (2014), half of all adults in the U.S. had one or more chronic diseases in 2012; cancer, along with heart disease, accounted for nearly half of all deaths at that time (“Chronic disease”, 2014). Treatments for cancer, such as chemotherapy and radiation therapy, have their own ill effects. These adverse effects commonly include (“Possible side effects”, n.d.):
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• fatigue and insomnia, • oral problems, including dry mouth, nausea and vomiting, • lymphedema, • neuropathy and other pain, and, • depression and anxiety Adverse effects from cancer treatment do not necessarily end once the treatment has stopped. Researchers at Penn State Medicine (2012), for example, found that, “more than 60% of breast cancer survivors report at least one treatment-related complication even six years after their diagnosis” (Breast Cancer”, 2012, para.1). In the Handbook of Integrative Oncology Nursing: Evidence-based Practice, advanced practice oncology clinicians and authors, Decker and Lee (2010) cited the work of Esper and Heidrich (2005), both advanced oncology nurse practitioners, in realizing that cancer patients suffer many ‘symptom clusters’ – physical, emotional, and psychological maladies – from the cancer process and cancer treatment that can occur alone or in groups over various lengths of time, examples including (p.70): • anxiety, agitation, and delirium, • cough, breathlessness, and fatigue, • dyspnea, anxiety, and fatigue, • fatigue, depression, pain, menopausal symptoms, and sleep disturbances, • fatigue, nausea, weakness, appetite and weight loss, altered taste, and vomiting, • fatigue, pain, anxiety, and depression, • nausea, anorexia, and dehydration, • pain and depression, • pain and fatigue,
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• pain, constipation, and confusion, and, • pain, fatigue, and sleep disturbances Symptom clusters, if not managed appropriately, can exacerbate the cancer condition and contribute to poorer patient outcomes. Older patients, Decker and Lee (2010) continue, tend to experience greater symptomatology and require more-than-adequate management through a higher level of care. The use of some CAM methods, such as aromatherapy’s essential oils (EOs), can help decrease most symptom clusters at a lower cost and without side effects, while empowering the patient and enhancing quality of life (Cho, 2013; Decker and Lee, 2010; Buckle, 2003). The use of EOs in cancer patients may be able to obviate many of these side effects: EOs can be used for prolonged periods; are very safe and non-toxic at regular doses, and are costeffective (Schnaubelt, 2011; Price & Price, 2007; Keville & Green, 2009; Lis-Balchin, 2006; Buckle, 2003; Cho, 2013; Tisserand & Young, 2014; Tisserand & Balacs, 1999; Decker & Lee, 2010). Lack of nursing education in CAM Few oncology nurses at the Residency site have used EOs, using them on a very limited basis and for few patient complaints, according to the Director of the Integrative Medicine department (N. Conway, personal communication, December 2, 2014). These nurses have shared with her that their patients are grateful for this complementary method and appreciate the ability to have some control over their healthcare during an acutely distressful situation, thus improving and enhancing the patient experience. The use of CAM is well documented and growing. While it is unknown how much is spent specifically on EOs, the National Institutes of Health (NIH) reported that Americans spent an impressive $33.9 billion out-of-pocket on CAM in 2007; for the estimated 40% of the
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population who uses CAM, this amounts to more than 11% total out-of-pocket spending (“Americans spent”, 2009). While the following statistics are dated, they are conclusive in mirroring this trend of CAM use. In the Institute of Medicine’s (IOM) committee report on the public’s use of CAM, Complementary and Alternative Medicine in the United States (2005), the committee noted (p. 35): §
CAM use increased from 34% in 1990 to 42% in 1997;
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herbal remedy use increased by 380% in that same time;
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patient visits to CAM practitioners increased by 47%;
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out-of-pocket spending for CAM services exceeded $12 billion – that amount exceeded out-of-pocket costs for all U.S. hospitalizations; and,
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up to 72% did not tell their provider about their CAM use
Cassileth, Heitzer, and Wesa (2009) from Integrative Medicine at Sloan Kettering, noted that 56-73% of cancer patients already use vitamins, minerals, and herbs; others cite the statistic in the United States as being as high as 91% (Somani, Ali, Ali, & Lalani, 2014). Penn State pharmacology professors, Boehmer and Karpa (2011) found that, “less than two decades ago only 4,000 herbal or natural products were available in the U.S.. Today, there is more than 30,000 products with more than 1,000 new options added each year” (p.1). The fact that Integrative medicine is clearly the future of medicine and needs to be heeded especially in nursing programs, was noted by nursing professors and authors, Sohn and Loveland-Cook (2002). As large as the use of CAM is, the knowledge deficit of health care providers (HCPs) matches or outpaces it (Shorofi & Arbon, 2010; Laurenson, et al, 2006; TrailMauan, Mao, & Bawal-Brinkley, 2013). Even pharmacists decry a lack of knowledge and
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confidence in knowing CAM (Steenfeldt and Hughes, 2012). This lack of know-how can place patients at risk of complications, and has a potential to produce great harm if the use of CAM, including EOs, is not based on an evidence-based level of competence (Maddocks-Jennings & Wilkinson, 2004; Boehmer & Karpa, 2011; Sohn & Loveland-Cook, 2002); without an adequate knowledge base, poor quality of care and patient safety problems could be implied directly (Livingston, Krass, and Li, 2010; Sohn & Loveland-Cook, 2002). Nurses are rarely educated in nursing curriculum about the general use of CAM, as evidenced by studies done on nurses and nursing students’ knowledge of CAM (Sohn & Loveland-Cook, 2002; Shorofi & Arbon, 2010; Laurenson, et al, 2006; Trail-Mahan, Mao, & Bawel-Brinkley, 2013; Van Sant-Smith, 2014), despite widespread use of various CAM methods by the public (Booth-LaForce, et al, 2010). Through their own admission, most of this project’s healthcare organization’s oncology nurses are ill-prepared to use EOs or teach their patients about this complementary method (N. Conway, personal communication, December 2, 2014). Development of a continuing education (CE) course was determined to be the most costeffective and productive way of bringing this information to the nursing providers (N. Conway, personal communication, December 2, 2014). Continuing education courses are difficult for most professionals to attend; instead, they prefer self-study methods that are self-directed and flexible (Kim, 2004; Gerkin, Taylor, & Weatherby, 2009). High personal and financial costs for both learner and organization are decreased through the use of online courses (Bolan, 2003). Online CE courses:
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can be interactive while engaging and challenging the learner;
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are flexible and easily accessible;
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can be accelerated or repeated, depending on the learner’s pace;
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foster educational development of the learner;
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can be produced with varying cognitive and psychomotor capabilities in mind;
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preserve time and financial resources for the learner and the organization; and,
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are cost-effective and proven to increase professional practice (Anderson, 2008; Gerkin, Taylor, & Weatherby, 2009).
The Director of this organization’s IM Department has stated that CE tools are lacking for oncology nurses who wish to expand their educational expertise in the use of EOs for their patients’ alleviation of symptoms clusters. The Director also identified how the need for a CE tool that would be most appropriate to diffuse integrative education regarding the use of EOs in cancer care amongst the system’s 140 outpatient oncology nurses. Use of a CE tool on EOs provided uniformity of information with aromatherapy materials as part of a larger Integrative Medicine project of the clinical application of EOs. (N. Conway, personal communication, December 2, 2014) Significance of the Problem Lack of nursing education in the use of EOs for oncology patients affects both quality and cost of care. Reduction of symptom clusters for oncology patients would improve their quality of care and may lead to improved patient experience reports. In the American Journal of Managed Care, Farina (2012) highlighted the high costs of health care and cancer care: in the U.S. in 2010, we spent 18% of our gross domestic product on health care and approximately $125 billion on cancer care (“The economics of cancer care”, 2012, para.1). Fiscal costs of cancer include not only the costs of cancer diagnosis and treatment, it also includes special dietary or pharmaceutical regimens, nutritional counseling, home-care, and repeated hospitalizations required to mitigate the adverse effects suffered from chemotherapy, radiation therapy, or cancer surgery, including symptom clusters. Indeed, in one study comparing the use of various integrative medicine methods, including aromatherapy, to traditional medications used
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for some symptom clusters at Beth Israel Medical Center in New York, cost savings were noted to be halved in the IM treatment group when compared to the baseline group (Kligler, et al, 2011). Oncology nurses need evidence-based education to effectively use EOs with their cancer patients in order to help diminish symptom clusters that impact the patient’s quality of life. Nurse-educator and author, Bolan (2003), noted that when nurses study how to understand and manage patient care online in a risk-free domain, they are able to develop crucial high-level problem-solving skills that empower the learner. Development of an effective, evidence-based online educational tool to increase the oncology nurse’s knowledge about EOs use for their patients may in turn, defray health care costs, improve the patient’s care experience, decrease patient suffering, and improve the cancer patient’s quality of life by relieving symptom clusters. Purpose and Objectives of the Project The purpose of this project was to develop an online, evidence-based educational tool that informed oncology nurses about the use of EOs for cancer patients and evaluate its quality and its impact on oncology nurses’ knowledge in this area. An online tool available through this organization’s education department would improve the oncology nurse’s ability to access evidence-based guidelines for the use of EOs and aromatherapy. The project addressed a lack of an aromatherapy online educational tool for oncology nurses related to the context of patient care and strived to ameliorate the oncology nurse’s knowledge base in the use of EOs in their cancer patients. The goal of the tool was to educate oncology nurses in the safety, validity, and effectiveness of EOs for common symptom clusters of cancer and cancer’s treatment. Online education on herbal and natural products has been noted to improve the health care providers’ confidence while enhancing the quality of patient
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care (Boehmer & Karpa, 2011). This online educational tool about aromatherapy and use of EOs in oncology for patient’s symptom clusters was developed and tested online as a pilot study during the DNP Residency with this organization’s IM department. This project’s objective was to maximize the nurse’s evidence-based knowledge of EOs to expand their, and their patients’ options, for cancer patient care practices in order to improve the patient experience. Review of the Literature The review of the literature consisted of two components. First, a search related to online educational tools for oncology nurses that focused on the use of EOs for cancer patient care was performed. The second literature search explored the theoretical framework that supports the development and evaluation of such an online educational tool. Search Process for Online Educational Tools An Alt HealthWatch, BioMed Central; CINAHL; EBSCO Health Complete, EBSCO Nursing/Academic Edition, and EBSCO MedLine; PubMed; Mosby Nursing Consult, and Cochrane Collaboration database search of keywords that included: ‘essential oils’, ‘aromatherapy’, ‘oncology nursing’, ‘symptom clusters’, ‘online education’, ‘online continuing education’, and ‘online learning tools’ was performed. All words were inclusive. All searches were limited to articles in English. Date limitations were made for 2008 and later, having to be expanded to 1995 after dismal results in the initial search. When marginally related articles were found, an ancestral search was performed as well; this, too, led to disappointing results. Grey literature, such as non-medical or non-nursing books on aromatherapy in oncology was also searched. This, as well, produced no findings for online education or educational tools about aromatherapy or EOs for the medical professional.
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Exclusion criteria were: papers not written in English, papers not available through interlibrary loan at UW-Milwaukee, articles written in popular commercial or massage magazines, newsletters, letters to the Editor, or non-peer reviewed aromatherapy magazines. Inclusion criteria were articles that were directly applicable to the use of aromatherapy or EOs in nursing, oncology nursing or medicine, and those written for scientific research. Inclusion criteria for educational online tools were articles that were applicable to higher education, nursing or medicine, and articles that were written post-2008. Database searches with the keywords ‘online educational tool’, ‘essential oils’, ‘oncology’ in combination yielded zero results; the same results applied to similarly applied keywords specific for this project. The necessity to search using combined terms was to reduce the exorbitant number of results gleaned when only generic terms as ‘essential oils’ or ‘cancer’ was used. The goal was to narrow the search to the general topic of aromatherapy in oncology and aromatherapy online education so as to provide as much noteworthy evidence as possible. As the database search produced no results with the necessity of combining keywords, online websites connected with academic and medical centers were explored. Inclusion criteria for educational online tools were sites that were applicable to higher education, nursing or medicine, and sites that had information that was written post-2008. This search revealed a core group of academic integrative physicians as part of the Consortium of Academic Health Centers for Integrative Medicine, a group of approximately 59 members from across the U.S. since 2004 (Consortium, 2014). The majority of the academic centers do not offer online information even for the lay public on aromatherapy, essential oils, or herbal medicine. The exception was the University of Minnesota’s Center for Spirituality & Healing, which is also partners with the Mayo Clinic; this center offers an online module on
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aromatherapy for clinicians – but not for oncology nursing (Halcon & Bashara, 2013). A secondary online database search used various keywords related to oncology nursing or aromatherapy and to non-academic, online, healthcare organizational education, found skimpy results for abstracts or citations and neglected to lead to other works that might have answered this project’s research questions. Nursing educators and authors, Ryan, Campbell, and Brigham (1999), wrote of variables that may have an influence on a continuing education participant’s change in practice while suggesting ways in which to measure those changes. The authors’ findings seemingly noted the conundrum of the research involved with this project: continuing education is a must in healthcare yet the education a HCP receives is only as good as its implementation; some continuing education is effective and yet, some have not been realized. Through it all, research into behavioral changes in nurses who take continuing education has not been consistent. While the article is not current, others have cited it as well and were included as a citation in an article by Atack and Luke (2008). Nursing professor Atack and Research Director, Luke (2008), realized the richness and cost-savings of an online program to educate nurses; however, they regarded the foundation as everything, and indicated that it is incumbent upon the health care organization providing the online education to measure its significance or outcomes longitudinally. Both Atack and Luke (2008), and Ryan, et al (1999), noted the lack of measuring outcomes along future lines. These inconsistent measures of behavior change brought about by an educational tool is very important for future CE planners to devise superior tools that will bring about specific and long-lasting healthcare changes. In summary, there is a dearth of information, much less evidence-based information, on
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online educational tools for aromatherapy use by oncology nurses for their cancer patient’s symptom clusters. While the literature abounds with information as to how to educate adult learners, education on aromatherapy for patients’ use or for cancer patients, specifically, coupled with the relatively adolescent age of online education, I found that there is nothing specific for nurses within an organization to learn evidence-based aromatherapy aspects for cancer patient care. While individual organizations may have their own learning connections that may house information for their employees, those learning modules usually have a connection to the organization and the services the organization offers to patients; this, as well, has been sparse. One way to view these limitations is that CAM is not a readily acceptable part of patient care, nationwide. While some healthcare organizations have been pioneers in this venue, they are few and far between, and very, very few offering aromatherapy for cancer patients. Likewise, medical and nursing schools are remiss in their offerings of educational offerings in the realm of CAM; rather, classes in CAM methods are relegated to sparse, optional offerings. Theoretical Framework Two theories were helpful in the development and construction of this educational tool: Kolb’s Experiential Learning Theory and Cervero’s Model of Continuing Education Factors. Both models can provide a foundation to guide and establish boundaries for the two major facets of this project. Both theories complemented each other in helping to make the tool specific to professional, adult-learners. The Experiential Learning Theory, developed by Kolb in 1984 and cited by Anderson in his 2nd edition of The Theory and Practice of Online Learning (2008) and Bolan (2003), was used to address certain aspects in the development of this online educational tool. Kolb’s theory, according to Anderson (2008) and Bolan (2003), highlights life-long learning, addresses all
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learning styles, and helps the learner to build abstract skills. These attributes make this theory the most applicable to online learners, and nurses in particular, as Bolan (2003) noted that nurses tend to be life-long learners who are self-directed. An online tool will provide the flexibility and self-directed study that is most attractive to nurse-learners (Grant, et al, 2011; Gerkin, Taylor, & Weatherby, 2009). Kolb, as cited in Bolan (2003), emphasizes four stages of the Experiential Learning Cycle: §
concrete experience,
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reflective observation,
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abstract conceptualization, and,
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active experimentation.
The online educational tool about EOs in oncology for symptom clusters was developed to model initial learning from previous concrete experiences of oncology nurse-learners, such as adverse effects from cancer therapies. According to this theory, it is thought that as the learner reflects on her/his experiences in this area, her/his thoughts and ideas (observations) are noted. Abstract conceptualization occurs as the nurse ponders the applicability of this integrative method used when compared to conventional medical methods for her/his patient’s common complaints and the effectiveness of each. Building on past knowledge combined with new learning, the nurse-learner is able to formulate a concept of improving patient care and alleviating patient discomfort. Active experimentation will take place as the nurse-learner is able to apply this knowledge to her/his own life or in the life of the cancer patient, further advancing the new expertise s/he has learned. S/he has tested a new theory and can now apply it to similar situations. (Bolan, 2003)
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This theory suggests that a good online tool provides simulations and case-based scenarios that will allow the nurse-learner to learn while making a determination in care in a ‘risk-free’ environment. The tool is user-friendly, and provides immediate feedback to maximize the learning experience. Bolan (2003), through Kolb’s theory, had suggested the following template for the online learning tool: §
a plan that identifies the process and the content,
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learning objectives,
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key concepts,
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pretests that help to identify any deficiencies in the learner’s present knowledge,
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case scenarios,
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suggested readings,
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post-tests and links.
Anderson (2008) acknowledges that an online learning tool should allow the learner to be autonomous, to unlearn old information while learning new, to understand that the information is not specific to one area; rather, the tool gleans information from multiple sources, and the tool will have instructions that are able to be updated as needed. While Kolb’s theory was helpful in depicting learning styles of the adult learner and a template for the flow of the tool, Cervero’s Model (1995) for CE planning was instructive in understanding organizational and participant underpinnings while devising and constructing the online tool. Cervero and Wilson (1995), professors of adult education, defined the construction of a CE program as a collective action that encompasses four concepts: “power, interests, responsibility, and negotiation”(p. 196). Constructing the tool requires negotiating between several groups. It centers on what the organization wants versus, or in conjunction with, what participants want. Cervero and Wilson (1995) state that most educational planners construct learning activities
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along the same four lines of medical care: diagnose, treat, implement, and follow-up, and that those who think in other ‘noisy’ terms obstruct the task. But CE development is not just a task, or a ‘neutral activity’, as the authors noted; it is a way to fashion and change outcomes for the way things ought to be. The CE tool, then, is a representative ‘contract’ between the organization and the learner (Cervero & Wilson, 1995). A closer look, then, at the four concepts of Cervero and Wilson (1995) that are helpful in explaining how to construct an online tool include: §
power, or hierarchy of the organization, departments, and those that will be utilizing the CE tool;
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interests of those targeted to take the course that are usually related to the underpinnings of the tool, and is a complex intersection of standards, principles, expectations, and desires that ultimately prompt people to act in one way or another;
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the responsibility of the planner to work between and within the groups that are represented by and within the tool; and,
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negotiation that is carried out within the organizational groups, to bring about the development and implementation of the tool.
In developing the CE tool, it is noteworthy that Cervero and Wilson (1995) wrote that it is not the planner’s desires in negotiating the construction of the CE tool that is important, it is the group or people to whom the tool’s planner is ultimately and administratively answerable to. Furthering the studies into effective CE development and implementation, Ryan, Campbell, and Brigham (1999) and Atack and Luke (2008) cited an earlier tool of Cervero (1985) in ascertaining whether or not changes in practice will actually take place after CE is taken:
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the professional’s reason and inducement to change, including such things as that person’s learning characteristics and styles, and demographics;
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the social system, or peers of the participant within the organization;
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the professional’s self-realization that s/he can or cannot make the proposed change that is proposed within the CE tool; and,
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the professional’s judgment and evaluation of the value of the CE tool.
Cervero’s theories and concepts drawn from Ryan, et al (1999) and Cervero and Wilson (1995) were helpful in understanding how to devise, construct, and implement the CE tool within a healthcare organization. Cervero’s concepts provided guidance through his description of the tool as not being just a piece of information that is educative, but a skills-set work of organizational and diplomatic deftness that encompasses understanding the ability to negotiate interests. Both Kolb (1984) and Cervero (1995) were instrumental in understanding the overarching aspects of the construction of this online educational project: understanding how to work within a large healthcare system to accomplish things in an expedient and socially acceptable manner, and, how to create and formulate an educational tool that can be utilized by adult learners with different styles. Method Design Overall, this online educational tool on the use of EOs in oncology for patient’s symptom clusters was part of a quality improvement project, envisioned by the IM department Director of the organization. Quality improvement (QI), Marquis and Huston (2009) noted is a continual
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process of innovation; one that projects repeated aims at improving quality. Innovation should be an integral part of the organization’s structure and philosophy, and helps to generate flexible ideas to improve care at lower cost, a balance between innovative ideas and the values of the organization (Mitchell, 2008). The project design included program development implementation, and evaluation of an evidence- based online learning tool within a major healthcare system’s IM program to expand oncology nurses’ use of EOs for cancer patients’ symptom clusters. The tool’s content was developed in the first eight weeks of the Residency with direct input from leaders and practitioners of oncology nursing and the IM director based on the principles of both Kolb and Cervero described, above, in the Theoretical Framework section. The specific learning goals of the tool included: •
how eight organizationally-approved EOs can be used in conjunction with allopathic medicine for common cancer symptom clusters;
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possible interactions with comorbidities or prescribed therapies;
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various methods of EO application, use and contraindications;
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cost-effectiveness of EO therapies;
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how to educate the patient and patient’s significant others in the use of EOs; and,
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how to assess the patient for use of other complimentary methods.
During the tool’s development, content validity was established through surveys and interviews of five experts on aromatherapy in cancer care through this organization’s IM and oncology departments: a Nurse Practitioner specializing in the use of EOs; a Clinical Nurse Specialist (CNS) in oncology; two directors of oncology clinics, and the Director of the healthcare organization’s IM Department. The quality of the online educational tool design was
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assessed by the Director of IM at the organization, the CNS for oncology, and the online educational development expert at the healthcare organization along with input from one online course development expert at UW-Milwaukee’s College of Nursing (CON) and this project’s lead advisor from the CON. The CNS for oncology then independently assessed the time needed to complete the online tool. Based on her assessment, an application for 0.75 contact units of continuing education credits was completed. A final quality check was performed by the Oncology CNS and this tool’s author. The final online tool consisted of a PowerPoint presentation with 66 slides that took participants approximately 45 minutes to complete, not including surveys and knowledge check. Once the tool was developed by the author in collaboration with the IM Director and oncology nursing departments, and before online implementation, the tool was quality checked and reevaluated by the organization’s senior e-learning coordinator, the oncology CNS, and the tool’s author. This quality check included time and flow of information within the tool and determination of CEU applicability; the tool awarded .75 CEU in accordance with the American Nurses Credentialing Center (ANCC) educational criteria (Appendix A). The tool then went ‘live’ online on the organization’s website through their Learning Connection on April 3, 2015. It was assumed that participants have internet access, organizational email accounts, and a minimum of computer literacy to log onto the organization’s Learning Connection, which is the venue for this organization’s nursing CE offerings. It was also assumed that participants were RNs, had minimal experience with oncology patients and some ability to recognize symptom clusters. It was assumed that participants knew little to nothing of EOs or aromatherapy. Finally, four evaluation surveys (Appendices B-E) were developed in collaboration with the organization’s continuing education experts using Likert-scale, yes/no and multiple choice
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questions. Both the pre-course and post-course design utilized Likert-scale questionnaires which were intended to measure the learners’ comfort, knowledge and experience with the use of EOs and CAM for self and for patient care. One of the post-course surveys evaluated the knowledge of the online tool’s content. The last survey looked at the quality of the course content and the online education tool, along with how the course participant would carry the information forward. There was an available comment section in the post-course course survey. These surveys were titled: the Pre-Questionnaire – Using Aromatherapy (Appendix B), the PostQuestionnaire – Using Aromatherapy (Appendix C), the Knowledge Check – Aromatherapy (Appendix D) and the Course Evaluation – Aromatherapy (Appendix E). Setting The online educational tool was implemented within the organization’s Learning Connection education department and will be there for one year from its inception. Human Subjects Consideration This project proposal was submitted to both the healthcare organization’s review board (IRB) and the University of Wisconsin-Milwaukee’s IRB. As this project posed no more than minimal risk to the subjects in review, the project was qualified by both organizations with an exempt status (Appendix F). No private information or nurse identifiers were included in any of the evaluation surveys or the data report. Sample Following approval by the human subjects committee at the organization and at UW Milwaukee, a pool of 140 potential participants within the organization were recruited from the staff and management of oncology nursing. Recruitment was done through an email announcement a week before the tool went live. The email was constructed and sent via the
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organization’s email address system by the oncology CNS involved with quality and CEU determination of the tool. Oncology nurses who are RNs, and managerial nurses were recruited by a non-randomized, convenience sampling through invitational email of the organization’s employee email system. Requirements for the participants were to have online access, a computer, and the commitment to take both pre- and post-course surveys. By April 9, 2015, there were 35 nurses who registered to take the course, and who completed the Pre-Questionnaire – Using Aromatherapy survey (Appendix B). Thirteen of these participants actually completed the 45-minute power-point course, which introduced them to aromatherapy and the use of organizationally approved EOs, and the three final evaluation surveys by the closing date of data collection for this pilot project. No demographics or identifying information were collected on the surveys. Completion of the surveys implied consent. Because of strict time constraints of this project, pilot data was collected within one week of the course’s initiation. This resulted in a small sample size, deemed to be adequate size for a pilot study. This introductory limitation, a constraint imposed by the concern of length of time for the training and the initial decision to opt for fewer surveys with a shorter number of questions in the preliminary evaluation, could be changed to a true pre/post design after the pilot is done. The IM department will continue to collect data and complete the longitudinal study over the year the online educational tool remains on the organization’s Learning Connection. Data Collection Data was collected electronically through the organization’s secured Learning Connection. The CNS for oncology was instrumental in guiding the CE tool online and helping to perform quality checks on the tool. The final results of the surveys were downloaded through a secure
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online system as a .pdf and sent via email to the tool’s author. Through this system, there was no way to add, delete, or alter data. Results Data Collected and Statistical Analysis Data was collected included the responses to the four evaluation surveys (Appendices B-E) described above. A quasi-experimental pre- and post-test group design (Polit & Beck, 2012) was anticipated to evaluate the nurses’ learning from the online educational tool through the Pre/Post – Using Aromatherapy survey (Appendices B & C). Unfortunately, the nurses in this pilot could not serve as a nonequivalent control group (Polit & Beck, 2012; Fink, 2008), since it could not be determined which of the initial 35 Pre-Questionnaires completed were in the post-completion pool. Possible threats to internal validity included testing threat, instrumentation threat, and regression threat (Polit & Beck, 2012). A control group would have ruled out the single-group threat to internal validity, however, because of the time factor, results of pre-and posttests had to be quantified (Polit & Beck, 2012) and remain descriptive. Many of the same survey questions that were used for pre-Using Aromatherapy were used for post- Using Aromatherapy test (Appendices B & C) to assess the oncology nurses’ change in knowledge in regards to the use of EOs and their comfort, confidence, and competence in applying this new knowledge. A meeting with the UWM CON Harriet Werley Center for Nursing Research and Evaluation statistician was helpful in labeling this as a pilot study due to the low response rate. We noted wording differences in the Likert scale choices between the Pre- and Post-Using Aromatherapy surveys (Appendices B & C) that were shared with the result reports. The statistician relayed that the effect of these minor word differences was negligible and the data analysis was completed. The statistician requested an Excel spread-sheet with data from the
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surveys to better quantify it; however, the organization did not have the capability to provide this. Therefore, we perused descriptive analysis of the data by hand to determine quantitative outcomes. Data that was collected included responses to the four evaluation surveys described above. In the initial data, there were very few comments collected on any of the surveys by the time of the data analysis. Too few for a qualitative analysis. This could feasibly be done in the future as more data is collected. Online Education Tool Evaluation - Survey Results The results from the evaluative surveys (Appendices B-E) are shared in this section. Each of the survey’s results are summarized in a table or figure and briefly described below. Figure 1. Pre-Post Using Aromatherapy Survey – Questions on Knowledge, Comfort and Experience (n=35 pre-course and n=13 post-course) 90% 80% 70% 60% 50%
Pre-‐Course None to Minimum
40%
Post-‐Course None to Minimum
30% 20% 10% 0% Knowledge of CAM
Comfort
Experience
In Figure 1, when comparing data from participants describing their knowledge, comfort, and experience with CAM, pre-course participants had a higher rate of none-to-minimal knowledge
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of CAM at 61% compared to 25% post-course; self-reported knowledge of CAM improving by 36%. In rating comfort, 80% of pre-course participants had no-to-minimal comfort with CAM, falling by 63% after taking the course to only 17% of post-course participants claiming perceived discomfort with use of CAM. Finally, 85% of pre-course participants had no-to-minimal experience with CAM before taking the course, falling to 58% post-course. While this last figure appears to show that a 27% improvement in those who felt they had more experience, perhaps these respondents are answering on the basis of learning versus actual experience in the clinical setting. Figure 2. Pre-course survey (Appendix B): Using Aromatherapy: Questions on Equipped, Recommend, Know More, and Part of Curriculum (N=35)
In the pre-course survey (Figure 2), questions were asked of participants regarding their selfreported feelings of being equipped to educate patients about CAM; if they would recommend CAM to others; did they think that CAM should be a part of the mandatory curriculum in nursing
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and medical schools, and, would they like to know more about other CAM methods? Those that felt equipped, pre-course, to educate their patients were a dismal 25% of respondents; however, 70% said that they would recommend CAM to their patients. Though nearly 90% of respondents indicated that they wanted to know about other CAM methods, only 64% felt that educating those in nursing and medical schools about CAM methods should be a mandatory part of the curriculum. Figure 3. Pre-Questionnaire Using Aromatherapy (Appendix B): CAM Opinions (N= 35)
Continuing in the pre-course survey were questions regarding beliefs in how or when CAM methods should or should not be used (Figure 3). When queried if CAM should only be used as a last resort when nothing is left to try, 97% of respondents disagreed, indicating that it should be an available choice at any point; similarly, 97% also responded that CAM should be acceptable in a medical setting. Nearly 100% of the pre-course survey respondents felt that CAM was a ‘natural’ method that works with the body to bring health; however, there was a near 50-50 split amongst respondents in their belief that this method should not be used unless there is evidencebased data to back it. Slightly more than one-third of pre-course respondents felt that CAM
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should be regulated and delegated to licensed practitioners only. Figure 4. Post-Questionnaire (Appendix C): Confidence, Apply Information, Met Needs, Recommend (n=13)
After taking the online educational tool, respondents completed a post-course survey (Appendix C). These post-course participants (Figure 4) were 64% more confident in their capacity to use EOs for their patient’s symptom clusters and 75% felt that they could now apply their new knowledge in their clinical settings. Over 90% of the post-course respondents would recommend the educational tool to others, with 84% stating that it met their professional needs.
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Figure 5. Post-course evaluation (Appendix E) (n=12)
In the Course Evaluation, Figure 5, (Appendix E), participants (n=12) were asked if they could now define aromatherapy and its practice in the context of patient care; nearly 100% believed they now could after taking the course. Contrast these findings with the precourse survey (Figure 2) where only 25% of participants felt equipped to educate patients about CAM and only 20% felt comfortable with CAM. Discrepancies with the difference in the two populations, pre-course survey and post-course survey, was due to several technical problems with the organization’s online learning center and the voiced difficulties some participants had in following instructions embedded within the organization’s online program. Figure 6. Course evaluation (Appendix E) (n=12)
In the Course Evaluation, Figure 6, participants (n=12) were asked if they could now describe EOs to ameliorate cancer symptom clusters; 73% were strongly confident they could. Comparing, again, to 80% who were uncomfortable pre-‐course (Figure 1).
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Figure 7. Course Evaluation (Appendix F) (n=12)
In the Course Evaluation (Figure 7), participants (n=12), were asked if they felt that the teaching method, an online educational tool, was effective; 64% agreed that it was an effective tool. This same data held true for another post-course question regarding relevancy of this educational tool to their work; 64% agreeing that it held relevance and 36% strongly believing it did. Figure 8. Course Evaluation (Appendix F) (n=12)
In the Course Evaluation (Figure 8), participants (n=12) were asked about their commitment to implementing one learned practice into their clinical area. 36% were very committed after taking the online course; 9% were not committed at all.
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Cost Savings Analysis In addition, a cost savings analysis (Appendix G) was done and shared by the e-learning coordinator using the organization’s own cost calculator based on the organization’s research of cost-savings. Through the use of this calculator, it was estimated that there would be a costsavings of $8,750 per participant for using the online educational tool versus an instructor-led type course. Discussion Summary of Outcomes In summarizing the outcomes of this tool’s implementation, findings were not surprising with the realization that this organization’s oncology nurses are pressing to be educated about CAM methods (Appendix H). Last year, this organization’s Oncology Department conducted a continuing education needs assessment amongst 55 oncology nurses (Appendix H). The nurses (n=55) were given eleven choices of miscellaneous topics they would be interested in. Of eleven topics to choose from, 56% of the respondents picked CAM. This is similar to the findings that 88% of precourse respondents desiring to know more about CAM methods (Figure 2). Interestingly, even though 80% nurses surveyed in this pilot thought there was a gap in their knowledge of CAM, only 64% thought it should be a mandatory part of nursing or medical curriculum. This refutes the recommendations in the literature that CAM be included in nursing education (Sohn & Loveland-Cook, 2002; Shorofi & Arbon, 2010; Laurenson, et al, 2006; Trail-Mahan, Mao, & Bawel-Brinkley, 2013; Van Sant-Smith, 2014). Implementing the tool decreased the number of participants who had minimal to no knowledge of CAM from 61% to 25%. While the number of respondents answering this question
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was different from pre- to post-course, we can infer, after reading other results, that this increase in the number of those who felt they held more knowledge post-course is meaningful, because the post-course data showed a significant trend when compared to pre-course. The findings of the data from this pilot evaluation of an online educational tool support the findings of previous studies in the knowledge deficit of HCPs in the use of CAM (Shorofi & Arbon, 2010; Laurenson, et al, 2006; Trail-Mauan, Mao, & Bawal-Brinkley, 2013). This lack of know-how can place patients at risk of complications, and has a potential to produce great harm if the use of CAM, including EOs, is not based on an evidence-based level of competence (Maddocks-Jennings & Wilkinson, 2004; Boehmer & Karpa, 2011; Sohn & Loveland-Cook, 2002); without an adequate knowledge base, poor quality of care and patient safety problems could be implied directly (Livingston, Krass, and Li, 2010; Sohn & Loveland-Cook, 2002). While nursing is often as behind as medicine in their knowledge of CAM despite the public’s widespread use of CAM (Booth-LaForce, et al, 2010), nurses still seem reticent to agree that education of CAM methods should be a requirement in schools (Figure 2; Sohn & LovelandCook, 2002; Shorofi & Arbon, 2010; Laurenson, et al, 2006; Trail-Mahan, Mao, & BawelBrinkley, 2013; Van Sant-Smith, 2014), despite widespread use of various CAM methods by the public (Booth-LaForce, et al, 2010). In conjunction with the realization that a tool such as the online educational tool used in this project can help increase CAM knowledge in nurses (Figure 7), there is a need to appreciate and delineate its positive or negative impact. As research has indicated, there is a sparseness of longitudinal studies to realize such a tool’s impact on nursing knowledge retention or patient care. Data furnished over a longer period of time may or may not support the use of this tool in generalized nursing practice for patients who suffer from like-symptoms that are not cancer-
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related. The total number of participants that can be anticipated as this study continues will serve to provide much to the field of CAM, aromatherapy, and oncology research. Limitations of the Pilot Study There are several limitations that can be applied to interpretation of the data from this pilot study as implied by Sohn & Loveland Cook (2002): •
the participant’s estimation of knowledge may be appreciatively different than what actually exists;
•
participants actual use and experience with CAM cannot be objectively measured; and,
•
demographic variables of each participant was not measured, resulting in nongeneralized data.
If the tool is found to improve existing organizational nursing guidelines, the framework can easily be transferred to similar tools in nursing practice. If another tool is constructed, it would be helpful in data analysis, to meet with a statistician beforehand. Doing so will aid the tool’s author in devising fewer surveys/survey questions with questions that have more statistical power. Variables such as age, sex, years in practice, and level of education were not obtained so it was not possible to correlate pre- and post-course findings to any of these variables, nor to delineate any correlation between them. Implications for the Organization Findings will be relayed to the organization through submission of this paper to the organization’s Director of IM. It would be advisable to share findings in-person with those in management and on staff who provided input during the genesis of this project. The excitement for this ‘innovative’ project has been infectious. Innovations typically take one of three
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contradictory propositions, notes health science authors, Dixon-Woods, Amalberti, Goodman, Bergman, and Glasziou (2011): §
Some innovative projects jump out at the gate even though they have no proven benefits, may harm, or have minimal worth, while some that have proven benefit never get off the ground, running at a snail’s pace and not attracting the attention it should;
§
Some go about in a democratic manner, pleasing everyone, yet it is just that autonomous role that may do the innovation in; and,
§
Quality improvement through innovation requires change. People dislike change.
The nurse is often seen as a change agent; the study and use of aromatherapy in patient care is no exception. Participant adoption of aromatherapy into patient care can only be measured longitudinally as a change in performance. Statistical measurements over time can be used to uphold and provide a new practice guideline, or it can debunk it. Either way, nursing within this organization is in a unique position to change the status quo. Oncology nurses are on the frontline for their patients and patients’ families. These nurses are the providers that vulnerable patients turn to and rely on for sound guidance. It is crucial that the organization support these nurses in their educational endeavors; nurses who are proficient in their knowledge of aromatherapy and other CAM modalities will only insure the safety of the patient, improve the patient experience, and elevate the opinion of the organization in the public’s eye who will seek them out for care. Integrative therapies such as aromatherapy provide the cancer patient with a ‘tool box’ that will give the patient a sense of control and increase his quality of life (Marchand, 2014). Using
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aromatherapy and other CAM methods have been shown to help reduce health care costs overall and improve the patient experience (Marchand, 2014), something health care organizations are very sensitive to. Implications for Nursing Practice Nursing, since the day of Florence Nightingale, has had holism as its foundation. It’s a fundamental aspect of nursing and why some choose nursing over medicine: the approach to treating and considering the person as a whole, made up of different elements that include emotion, lifestyle, physical being, living environment, and spiritual self. It is holism that is part of CAM in ways that allopathic medicine is not. (O’Regan, 2010; Hayes & Alexander, 2000) Two out of three cancer patients integrate CAM into their allopathic therapies. CAM is no longer something ‘nice to know’; instead, it is a duty of nursing to be informed, to sort through the evidence to be able to discuss both safety and effectiveness along with limitations of CAM modalities (Bauer-Wu & Decker, 2012). The nurse cannot champion for patient choice or educate the patient to the contrary if s/he is not familiar with the benefits and risks of a CAM method (Trail-Mahan, Mao, & Bawel-Brinkley, 2013). While our holistic foundation is important, more significant is nursing’s concern for patient safety. Nurses who practice CAM out of hearsay or personal experience run the risk of creating a communication gap with patients that may cause harm. It is imperative that nursing be knowledgeable of CAM so that the nurse can educate the patient, helping the patient avoid the possibility of delaying diagnosis or necessary treatment. Sharing our analysis of the effectiveness of CAM therapies helps the cancer patient when he is most vulnerable. (Somani, Ali, Ali, & Lalani, 2014)
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Implications for Nursing Education The realization from the evaluation survey information from this project that some nurses are recommending aromatherapy or other CAM methods despite not having formal or evidencebased training raises concern as noted, above. Recommending a CAM method based on one’s personal experience may provoke legal squirming. Not only is this a dangerous precedent, it may cause a nurse to lose believability at precious cost. Having CAM as a mandatory part of medical and nursing curriculum, and not just a brief mention, will help nurses stay safely within the scope of their license to practice. (Sohn & Loveland Cook, 2002) It has been said that nursing academia must move into the 21st century and provide students with a sound foundation and proficiency in understanding about utilizing CAM methods; a time to be empirical, yet inventive while equipping the nursing student with the ability to inform her patient in the best way possible (Van Sant Smith, 2014). Professors of nursing and authors, Wyatt and Post-White (2005) noted in their critique of CAM in education and research that CAM therapies are largely unregulated with a lack of standard guidelines; there is a scarcity of expertise in knowing what CAM modalities are safe or unsafe to use with allopathic treatments, and a paucity of understanding the cultural roots of some practices and the philosophical basis for others. Despite these limitations, these authors recommend making this a mandatory part of the curriculum to encourage nurses to be critical thinkers, guiding them to research anew and develop new guidelines. Implications for Nursing Research Further research into any method of CAM and its implications for nursing and patient care is urgently needed. To date, very little is known about the level and source of knowledge of CAM that each nurse holds. By advancing knowledge in the CAM realm, it will only serve to
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strengthen and augment nursing practice. Academia that supports scholastic inquiry will only help further much-needed research into this burgeoning healthcare modality. (Sohn & Loveland Cook, 2002) Conclusion The most recent IOM report on CAM use by the American public states, “…all scientific conclusions are tentative” (2005, pg. viii). An interesting way to say: keep an open mind. In our rush to make everything we do in health care be nothing less than evidence-based, are we in danger of throwing out the baby with the bath water? Any therapy – efficacious or not – can be dangerous to anyone. Is the patient to be intimidated because he chooses a method of CAM that may not necessarily have EBP behind it, or do we collaboratively encourage the patient to seek out the safest, most effective, and interdisciplinary path for him to follow (IOM, 2005). Aromatherapy is one such path. The results of this quality improvement project indicate that the oncology nurses were eager for aromatherapy and CAM knowledge to incorporate into their practices. It is an exhilarating time in health care; we have the unprecedented opportunity to meld the best from all venues of care from CAM and allopathic medicine. Educating ourselves and our patients can only serve to enrich the neglected soil of inquiry into aromatherapy’s effectiveness – or ineffectiveness. We will not know until we regard this modality with the same degree of possibility or skepticism that we do other therapies, be they allopathic or not (IOM, 2005). There are huge gaps in our research of the efficacy of aromatherapy and other CAM methods. Some are flawed, some are too small to make statistical proof, some are compared toeto-toe with conventional therapies when they should not be. When the evidence is seemingly lacking, and the patient chooses aromatherapy or other CAM method, we must:
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§ weigh the severity and acuteness of the patient’s illness; § consider how invasive the disease is; § review the toxicities that may be associated with either method; § ascertain the “availability…quality of evidence…[and] safety of CAM”; § contemplate the patient’s ability to understand and weigh benefits versus risks; § decide whether the patient is capable of accepting risks – no matter the method; and, § realize that some patient’s will be insistent on using CAM (IOM, 2005, p.181). This project’s online educational tool has seemingly made a measurable impact on this organization’s oncology nurses. There is a palpable hunger in the oncology nurse to appreciate the possibilities of alternative methods. Aromatherapy has distinct possibilities in ameliorating cancer’s symptom clusters. This influential online educational tool is a cost- and time-effective way that was found favorable by the organization’s oncology nurses while educating them to be able to deliver quality, evidence-based care. The tool provided a well-accepted way to learn that can be tailored to different provider populations, different learning and literacy levels, and various time constraints. Online educational tools have the frugal ability to be interactive while imparting up-todate information on best practices. A tool that is asynchronous adds the convenience of being able to be done at the participant’s leisure. A healthcare organization that is resolute in providing resources, incentives, and encouragement to be innovative is of prime importance to helping nurses transfer what they have learned into practice. The online educational tool for outpatient oncology nurses tested in this pilot study shows promise of being an effective means to increase oncology nurses’ expertise in use of EOs.
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Appendix A – Application for CEU
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Appendix B – Pre-Course Questionnaire Please fill out a brief questionnaire on your knowledge, comfort and experience in using aromatherapy or essential oils for personal use and in your care of the oncology patient. This survey will help to determine the effectiveness of this training tool and will be filled out at the beginning of the course.
1. How do you rate your knowledge of Complementary and Alternative, or Integrative Medicine (CAM)? 1 = no knowledge 2 = minimal knowledge 3 = average knowledge 4 = above average knowledge 5 = very knowledgeable 2. How do you rate your comfort in use of aromatherapy or essential oils for self-‐ care? 1 = not comfortable at all 2 = minimally comfortable 3 = moderately comfortable 4 = above average in comfort 5 = very comfortable 3. How do you rate your experience in the use of aromatherapy or essential oils for self-‐care? 1 = no experience at all 2 = very little experience 3 = moderately experienced 4 = above average in experience 5 = very experienced 4. How do you rate your comfort in use of aromatherapy or essential oils for patient care? 1 = not comfortable at all 2 = minimally comfortable
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3 = moderately comfortable 4 = adequately comfortable 5 = very comfortable 5. How do you rate your experience in use of aromatherapy or essential oils for patient care? 1 = no experience at all 2 = very little experience 3 = moderately experienced 4 = above average with experience 5 = very experienced
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Appendix C – Post-‐Course Questionnaire Please fill out a brief questionnaire on your comfort, experience and knowledge in using aromatherapy or essential oils in your care of the oncology patient now that you have viewed this course. This survey will be filled out at the end of the course. 1. How do you rate your knowledge of Complementary and Alternative, or Integrative Medicine (CAM)? 1 = no knowledge 2 = minimal knowledge 3 = average knowledge 4 = above average knowledge 5 = very knowledgeable 2. How do you rate your comfort in use of aromatherapy or essential oils for self-‐ care? 1 = not comfortable at all 2 = minimally comfortable 3 = moderately comfortable 4 = above average in comfort 5 = very comfortable 3. How do you rate your experience in the use of aromatherapy or essential oils for self-‐care? 1 = no experience at all 2 = very little experience 3 = moderately experienced 4 = above average in experience 5 = very experienced 4. How do you rate your comfort in use of aromatherapy or essential oils for patient care? 1 = not comfortable at all 2 = minimally comfortable 3 = moderately comfortable 4 = adequately comfortable
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5 = very comfortable 5. How do you rate your experience in use of aromatherapy or essential oils for patient care? 1 = no experience at all 2 = very little experience 3 = moderately experienced 4 = above average with experience 5 = very experienced Please rate the following: 1. The difficulty of this training module was about right. 1 = strongly disagree 2 = slightly disagree 3 = it was about average 4 = moderately agree 5 = strongly agree 2. The course length was appropriate for the topic 1 = strongly disagree 2 = slightly disagree 3 = it was about average 4 = moderately agree 5 = strongly agree 3. I can apply the information in my clinical practice setting. 1 = strongly disagree 2 = slightly disagree 3 = it was about average 4 = moderately agree 5 = strongly agree 4. The presentation met my professional educational needs. 1 = strongly disagree 2 = slightly disagree
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3 = it was about average 4 = moderately agree 5 = strongly agree 5. I would recommend the course to others. 1 = strongly disagree 2 = slightly disagree 3 = it was about average 4 = moderately agree 5 = strongly agree 6. As a result of this training, I feel more confident in my capacity to use essential oils for symptom clusters in my oncology patients. 1 = strongly disagree 2 = slightly disagree 3 = it was about average 4 = moderately agree 5 = strongly agree
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Appendix D – Knowledge Check
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Appendix E – Course Evaluation
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Appendix F – IRB Submission and Approval
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Appendix G – Cost Savings Analysis
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Appendix H: Oncology Nurse Educational Program Offerings Survey Results from Residency organization (2014)
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