In collaboration with local NHS stakeholders, the University of Dundee School of Health Sciences confirmed the continuation of approved prescribing programmes. A range of mechanisms were employed to support students on the programme. This included redesigning the programme to an online format, with cognisance of the regulatory requirements. This included redesigning the programme to an online format, which required a review of governance of all programme activities, including assessment. Implications for supervision requirements in clinical practice also needed careful consideration. Many of the changes made have now been recognised as positive developments for future-proofing the programme delivery.
This paper reflects on a prescribing programme team's experience during this time and the impact it had on them and how it continues to inform and develop future delivery.
The non-medical prescribing programme is essentially a module within the post-qualifying and postgraduate programme but is defined as a programme of study by the regulatory body (Nursing and Midwifery Council (NMC), 2018; HCPC, 2019) and within this work will be described as a module. The prescribing module is delivered bi-annually and consists of approximately 50 students in each cohort. The majority of students are employed within two NHS boards, but the authors do also have students from the Scottish Ambulance Service and non-NHS clinical areas such as aesthetic practitioners.
The COVID-19 pandemic
In 2020, the COVID-19 pandemic created a major paradigm shift in the way teaching and learning occurred in addition to wider social, health and well-being implications (Douglas et al, 2020). The speed at which this shift transpired prompted staff and students to call to action a range of mechanisms that would require flexibility and self-efficacy in continuing to experience learning in unfamiliar and often uncomfortable environments (Heo et al, 2021). The necessary myriad of changes occurred at speed with hastily made decisions that potentially led to initial confusion, miscommunication and anxiety. This undoubtedly risked impacting unfavourably on both staff and students’ perception of education delivery (Ion et al, 2021). Implications relating to practice, working at home where feasible, home-schooling, access to appropriate internet and devices and e-learning overload added to the burden many felt, creating social isolation and impacting on mental wellbeing (Kulikowski et al, 2021). Within teaching, learning and assessment, changes occurred across both undergraduate and post-qualifying/post registration programmes and were compounded by the changes occurring across the NHS in terms of practice areas and roles (Scottish Government, 2022).
Historically, close relationships with the programme team and NHS partners promoted open and transparent discussions to support students being able to continue the module. In addition, practice assessment and supervision required support and alignment to maintain governance (NMC, 2018; HCPC, 2019). One of the strengths of prescribing programmes across the UK has been engagement in interprofessional practice experience that support students in their practice areas to successfully complete clinical prescribing competencies (Afseth and Paterson, 2017; Henderson and Bell, 2021). A focus for the programme team was to ensure appropriate knowledge and skills required to achieve all the learning outcomes, aligning with required governance was supported in clinical and academic work (NMC, 2018; HCPC, 2019; RPS, 2021).
As iterations of the module continued into 2021, additional consideration was required to review and act on evaluations to support a more robust, structured and future-proofed strategy moving forward for prospective cohorts. Pedagogical decisions that supported this longer-term approach were required, integrating student evaluations (formal and informal), other HEI experiences and programme staff experiences that could enhance and influence the programme design within the parameters of the PSRB (Sousa, 2021).
In addition to educational changes, student wellbeing was potentially at risk because of the clinical impact within their own roles and was recognised as a particularly challenging aspect to facilitate effectively and authentically (LaBelle and Johnson, 2018; Ion et al, 2021). The University of Dundee, alongside all higher education institutions in Scotland, followed the Scottish Government guiding principles as the pandemic began and then continued into another year with longer term implications becoming evident (Scottish Government, 2022). The School of Health Sciences adapted quickly in response to students and adhering to NHS governance. There was a clear process to assure that there was no detriment to students during this time including mitigation, additional optional submission dates and student academic online support (University of Dundee, 2020a).
Scottish wide
The Scottish prescribing programme leads network (SPPLeN) has provided national strategic direction across post qualifying prescribing programmes in Scotland for several years and this promotes a consistent approach to peer and student support, learning teaching and assessment. The network has representation on the national NHS strategic prescribing leads group and this collaborative relationship supports continuing robust professional relationships with new and existing practice partners. With the advent of the COVID-19 pandemic, there was application of these approaches across individual NHS boards to meet the specific educational practice needs including staffing and service changes (Scottish Government, 2021). This also applied UK wide where prescribing programmes adjusted to ensure they continued to meet safe effective prescribing practices that also met the needs of the NHS (NMC, 2018; HCPC, 2019).
Online delivery
Historically the prescribing programmes have delivered teaching and learning using a blended approach aligning with national and PSRB-approved programmes (NMC, 2018; HCPC, 2019; SSPLeN, 2019). This equated to classes delivered on both University of Dundee campuses and the use of virtual learning environments (VLE) with timetabled in-class and online activities (Blackboard, 2022).
As the university moved online, the teaching and learning activities were released weekly with a register continuing to be taken on the designated class day. The team were keen to describe the changes as a module delivered online rather than an online module, which supported engagement and governance of attending on a specific day and the hope was also to support protected study time for the students (NMC, 2018; HCPC, 2019). This approach was to support the mitigation of disruption to learning as much as possible and to assure quality (Douglas et al, 2020).
For the first cohort, live sessions were delivered on Blackboard Collaborate (Blackboard 2022) and using Microsoft Teams (Microsoft, 2022) and directed learning. An online wellbeing area was also introduced for all students each week that included resources relating to good posture positions, supportive activities for hands and back and additional mindfulness resources.
As the online delivery continued, and in response to feedback and suggestions from the students, all live online sessions were delivered and uploaded using Blackboard Collaborate to ensure consistency and ease of access. The university continued to use Microsoft Teams to support students individually and one cohort used this to support each other in a virtual learning and social space (Microsoft, 2022). Davis et al (2019) found students may additionally benefit from participating in discussions initiated by other students in seeking clarification of other students’ posts and cultivating a sense of virtual community.
Pharmacology teaching was quickly established as an excellent example of consistently positive feedback to online delivery due to the ability to review and return to the recorded power-points and collaborate session recordings The feedback reflected students learning a new language in pharmacology terms and this ability to repeatedly access was seen as an enhancement (Barber and Robertson, 2015; JISC, 2020). In addition, every week that pharmacology was delivered there was an associated Multiple Choice Question test in Blackboard that students completed followed by a live review session. The pharmacist team member also added a pharmacology asynchronous discussion board to answer queries and these combined approaches, as an alternative to traditional lecture-based learning, were deemed to be useful in consolidating knowledge (Kim and Jeong, 2018). The discussion boards also promoted alternative learning through reflection and validation from peers within their new virtual learning groups (Davis et al, 2019).
Additional resources and sessions delivered successfully online related to our clinical colleague's involvement, and this supported areas such as complex communications, prescribing controlled drugs and anti-microbial stewardship (JISC, 2020; RPS, 2021; NHS, Education Scotland, 2022).
Feelings relating to peer review process
The peer review process within the university is relatively new but refers to a member of teaching staff (not involved in a module) completing a peer review across the module materials online. Peer review is the process of subjecting courses to scrutiny within the context of the same field and area of expertise and initially, this risked being seen as punitive at a time when there was such urgency to develop a temporary online version of the materials. Reifsnider (2022) highlights that peer review across all professions, including nursing, is essential to catch errors, either intentional (false information) or inadvertent (not knowledgeable about the latest developments). This aligned to the academic standards across student onboarding activities, organisation and presentation of online materials, assessment information and student support and engagement. The peer review identified areas that were unclear and not presented easily for students including navigating the content folders, ability to find key resources and accessing academic level information (University of Dundee, 2020b). As the pandemic continued, the realisation that further cohorts were to be delivered online meant further peer review feedback began to be viewed as constructive, structured and accepted as invaluable. The quick fix approach that had occurred initially then was prompted to further develop and underpin the resources to address the peer review and reimagine the pedagogy and presentation of the module site (JISC, 2020; Sousa, 2020).
Online wellbeing
The concept of the ongoing delivery of online materials had to be considered by the module team in relation to student and staff well-being as this had become clear from public health messaging and students that this could put studying at risk (Scottish Government, 2020; García-Morales et al, 2021).
Within the module team, the authors also were aware of emerging themes across all curricula including poorer resilience, social isolation, ergonomic issues from home working and studying and at-risk mental well-being. These were under strain across students and teaching staff populations and in addition to NMP students working clinically during the pandemic, their wellbeing was potentially at greater risk during this additional study time (Douglas et al, 2020).
As a team, the university signposted and promoted open access to resources including short wellbeing videos, simple exercise advice and ensured breaks between all the live sessions and weeks of directed learning with optional online classes (Churchouse et al, 2021). The wider university also offered support including online staff and student support including the addition of rest days (University of Dundee, 2020). In addition to the student evaluations described below, this element was positively highlighted in peer review and student feedback:
‘Online learning wellbeing resources are a nice addition. Might be good to share these with other modules'.
‘I think the team are very mindful of distance learning and its challenges and are very accessible. I feel it could become very isolating if I was struggling and feel closer to the exam it would be nicer to have more contact with peers to discuss worries and to help each other.’
Student evaluations
As well as the formal University Module Quality Enhancement Report (MQER), there was a specific module discussion board at the beginning and midway asking students to contribute to the development of the online resources, presentation and online delivery positives and negative attributes. This meant the university could respond effectively if there were any issues raised including a small group meeting would be useful towards the end of the module to support revision. There was a myriad of broader additional comments to accompany those phrased within the more formal evaluation questionnaires including less travel, childcare, time and space to think and this was seen as a positive learning experience overall (Heo et al, 2021).
‘ I think that the effort that all of the lecturers have put into this module is tremendous. Superb online resources. The positives for me are that I can re-watch a lecture and I can watch lectures before the actual study day, so this brings in an element of flexibility’
‘This is the first time I have completed an online module. I have mixed feelings about it. Great for looking back on recordings when you feel you need to revisit, great to be able to have all my notes scattered all over the place, great for the peace and quiet to study, great for no parking fees. Not so great is not meeting people face to face.’
Despite students’ initial trepidation at the thought of learning online, there were many additional positive elements that began to emerge in feedback.
‘Working with IT is not my strongest area. However, now I am getting into the module, I am really enjoying the online learning. Having to balance work and childcare for three boys, not having to add in travel time is a bonus. Yes, would have been lovely to meet people face to face'.
There were a minority of students who would have preferred to be in class and highlighted challenges of technologies, but at this time there were no other options to deliver so the team did offer further support online sessions, drop-in support out of hours and encouraged peer support where possible. There was also sign posting to the eLearning Team and Information technologies team (Help4U) to offer additional expert online support (University of Dundee, 2020c).
‘This is the first time I have undertaken a module online, and whilst I had reservations due to my lack of IT savvy, I feel I am managing alright.’
The team met more regularly to support each other as there was a feeling of trepidation and lack of confidence in this singular way of teaching, this was in addition to a feeling of disconnection not experienced at this level before. The team addressed feedback and refreshed delivery within and then feed forwarding to the next cohort to support better structure, easier access, and variation including presentation of activities, embedded annotative power-points, and videos to attempt a flatter design and to minimise multiple clicks access within the virtual learning environment. This was also important to address areas of flexibility of delivery and to support different learning styles within these restrictions (Gibbs, 1997; University of Dundee, 2020c; Blackboard, 2021).
CPD reflective questions
- Online environments for the delivery of education and clinical assessments and consultations are now more common and likely to, in some contexts, remain permanent. In your prescribing practice, how have you adapted to these?
- How has practice assessment and supervision been developed in your area to support developing your own prescribing practice and that of future NMP students?
- With cost of living, fuel and other amenities all rising, when choosing CPD or further education, will you actively seek courses or academic programmes to be delivered fully online if appropriate?
Practice supervision and assessment
The use of appropriate professionals within practice assessment has been embedded within the prescribing programme from its initiation, whilst the addition of other roles including practice supervisors is relatively new (NMC, 2018; HCPC, 2019; RPS, 2019). The COVID-19 pandemic meant the additional requirement to promote support including programme information for practitioners new to the role (NMC, 2018; HCPC, 2019; RPS, 2019).
Along with NHS Colleagues, the module team delivered options of attending various deliveries online using Microsoft Teams and, in addition, the creation of a dedicated teams site that could be accessed by any new designated prescribing practitioner to provide an overview of the programme and the support available. The first cohort delivered during the pandemic supported over 100 practitioners. This supports collaboration and triangulation of the student's assessment, ensuring that their development and learning progress (NMC, 2018; HCPC, 2019).
Team evaluation and moving forward to a more blended approach
Moving forward as restrictions and government advice was changed, it was apparent we needed to review the delivery of the programme and realign it to more blended approach (NMC, 2018; HCPC, 2019; Scottish Government, 2022). Key to this adaptation would be reflecting and evaluating to date, the teaching delivery to ensure that the most value was appropriated by the learning environment in relation to student costs in travelling and access to technologies (JISC, 2020).
The team met (face to face for the first time in 2 years) and discussed the future teaching delivery and content, integrated with student and peer feedback. The team were unanimous in agreeing that the class time should only be reinstated for the materials that were reflected in feedback as missed most including peer support and networking, developing specific materials, and engaging with expert clinical staff and patient representatives. Pharmacology would remain online, and this iteration would be reviewed, and feedback used to develop in further cohorts as required.
Continuing to collaborate with NHS Partners and supporting a one Scotland approach from the HEI supports investment in prescribing education, is pragmatic and aligns with the required governance and regulations (NMC, 2018; HCPC, 2019). This includes continuing to develop supervision and assessment for designated prescribing practitioners using technologies to align with clinical competency prescribing needs (RPS, 2019; RPS, 2021).
Conclusion
Reimagining and transforming education delivery are key to good pedagogical teaching approaches and should include evaluation and feedback from students, module team and other key stakeholders and national networks. With the onslaught of the pandemic, education institutions were denied the time initially to support effective module redesign and this module team have worked together to transform the NMP module supported by a range of review methods including peer review, module team reflection and student evaluation and feedback. The benefits that have arisen as a result of this module transformation will hopefully continue to enhance the teaching and learning experiences of both staff and students. This evolution has been directly influenced from our reflection as a team in addition to the educational direction of the wider university.