Workshop II: Understanding Whom, What and How Exactly to train.

Our first workshop was titled ‘Diagnosing and Treating Problems in Palliative Care.’ It focused on corporate training and professional development programmes. We discussed how to assess whether training is necessary—and if so, to what degree.

Before developing a training programme, it’s essential to understand the goal clearly. The first question to ask yourself is: What work-related problem or task are we trying to solve? What else, besides training, is needed to address this issue? It’s possible that training is not the primary tool, but rather a subsequent step, one to be taken only after other root causes have been addressed.

In the previous workshop, I introduced three steps for diagnosing and addressing workplace problems:

Here is an example based on a homework assignment from one of the participants in the previous workshop. The problem was described as follows:
‘Pharmacies are not stocking opioid medications due to low demand, which stems from doctors not prescribing them.’

We analysed the root causes:

• lack of knowledge among doctors;
• complex paperwork and restricted access to prescription forms;
• patients fear these medications;
• lack of communication between doctors and pharmacists.

As you can see, a lack of knowledge is only one of the causes, and training doctors is merely one of the measures required to tackle the issue. If the other causes are not addressed, training alone will not yield results; it will simply be a wasted effort.

So, we’ve established that training is essential. But how can we ensure it is genuinely practical and concise?

We must remember that we are discussing continuing education for professionals who are already working under pressure. The aim is to provide the maximum amount of useful information within a limited time frame.

Each of these topics is profound and complex. We won’t be diving in with scuba gear; instead, we’ll conduct some methodological ‘snorkelling’ to observe what often remains unseen ‘beneath the surface.’

Let’s say we have a topic. To understand precisely what to teach within that topic, we must first conduct some preliminary research.

• Clients and stakeholders are those who are interested in the outcomes of the training. This may include managers, policymakers, patients, and their families. Researching the latter group can be more complex as it requires ethically sound approaches. However, speaking with individuals such as the head physician or department supervisor is generally quite feasible. We speak with them to understand:

1. What issue are we aiming to resolve?
2. What do they believe the causes of the problem are?
3. What else, apart from training, is required to address it?

This is exactly what we discussed in detail during the previous webinar.

The target audience consists of the individuals we intend to train, including doctors, nurses, social workers, or volunteers. It is important to explore with them:

1. How are they currently approaching the identified task or problem?
2. Why do they behave in certain ways?
3. What challenges do they face?
4. Where and how do they presently obtain relevant information?
5. How much time do they realistically have for training?
6. What motivates them to learn? And more.

Researching the target audience enables us to:

1. define the training goals more accurately;
2. ground the programme in real workplace experience;
3. assess both motivation and barriers to applying new knowledge in practice.

It is also essential to investigate the context or environment in which people work. Do they have the conditions and resources to apply what they have learned? Otherwise, we risk situations such as training nurses to move patients using functional hospital beds, while in reality, the patients lie on basic beds.

All of this is essential to minimising the risk of training being ineffective or irrelevant.

Of course, traditional ‘desk research’ hasn’t gone anywhere—it’s always useful to review relevant literature, regulations, local policies, and similar sources. However, today I’m primarily focusing on the tools that are often overlooked when individuals rely solely on the perspective of an expert lecturer or a manager-client, or base their approach exclusively on official standards and professional guidelines. This is a mistake—without preliminary research, there’s a significant risk of misalignment with the training objectives, content, or format. The result may well be superficial training. Let me illustrate this with real examples from our practice.

The tools highlighted in yellow on the slide are those that are seldom used in medical education, yet they can offer the most valuable insights.

Today, I shall focus on two aspects: in-depth interviews and large-scale surveys. Regarding testing and knowledge assessments, we will only briefly touch on these topics — they are complex and often the subject of debate, not only in medicine.

This is a tool widely used in marketing and advertising, with a wealth of professional literature available. In fact, conducting in-depth interviews is a distinct skill set that can be taught in an entire training course. I will provide you with a brief overview here.

The essence of the method is this: you conduct a one-on-one conversation with a person, asking open-ended questions to explore their opinions, needs, experiences, and doubts.

For example, let’s say we have a hypothesis that doctors do not prescribe opioid medications because they lack the necessary knowledge. We conduct interviews and ask how they currently manage pain, what therapies they recommend and why, and where they received training in pain management, among other things. Our hypothesis may be confirmed — we might find that the root cause truly is a lack of knowledge. However, it is also possible that we will discover it is not about knowledge at all, but rather that the main barrier is religious stigma or fear of legal consequences.

Ideally, one should speak with more than just one person, at least three representatives from each homogeneous group (for example, three doctors, three nurses, three department heads).

It is advisable to reach out through ‘warm’ contacts — this enhances trust and the likelihood that respondents will answer honestly rather than giving the ‘correct’ response. Also, always use open-ended rather than multiple-choice questions.

After conducting interviews with a small group, we can confirm our hypothesis regarding what to teach, formulate new assumptions, or identify knowledge gaps. Next, we need to ascertain whether our conclusions apply to a broader group of professionals or the entire team. This is where another research tool comes into play — a large-scale anonymous survey or questionnaire.

The number of respondents depends on your objectives and the size of your team. If you have 10 people, you can survey everyone. If there are 100, a survey covering 40–50% of staff is already significant. If the audience is external (not part of your organisation) and large, it’s advisable to survey at least a hundred people.

It’s not always necessary to conduct both types of research—qualitative (such as interviews) and quantitative (such as surveys). It depends on the complexity and scale of the problem, how well you understand it, and how familiar you are with the target audience. We ALWAYS conduct in-depth interviews when developing a new programme or a new version of an existing one.

The QR code provides links to examples of in-depth interview guides, survey questionnaires, and templates that we utilised in the case we’ve just discussed. To conclude this section, I’d like to highlight the following:

Our experience demonstrates that each research effort has given us critical insights that have made our programmes significantly more beneficial.

We have identified the workplace problem we wish to address and clarified exactly what we need to teach. Now it’s time to plan the training—but we should develop the programme not ‘from the topic,’ as is often done, but from the learning outcomes. A ‘topic’ is always broad, and there’s a risk of filling it with content that doesn’t meet the actual needs of the target audience. Formulating learning outcomes at the start helps to avoid this.

When formulating a learning outcome, it is beneficial to employ the ABCD formula (also known as Mager’s formula):

Training is a journey. To avoid wandering or going in circles, it is essential first to determine the direction of movement and then to set precise ‘coordinates’—these are the learning outcomes. Only by understanding where the learner needs to arrive can we map the ‘route’ and select the appropriate formats and teaching methods. This approach is known as backward design.

Let me illustrate with examples how this approach differs from planning ‘from the topic’ and why it is more effective.

In 2021, we conducted a needs assessment prior to developing a course on respiratory failure. We discovered that many doctors were unaware of certain contraindications for prescribing oxygen therapy, particularly in cases of muscular diseases. Additionally, we found that doctors were hesitant to use morphine to treat distressing dyspnoea due to its side effects, which included ‘respiratory depression,’ and prescribing morphine for dyspnoea was deemed off-label.

The topic of pharmacotherapy is extensive. If we had designed the course based solely on this topic, important insights could have been overlooked or minimised. A clearly defined learning outcome sharpens focus and ensures that essential content is incorporated into the training.

In 2024, we decided to redesign the course thoroughly and once again began with research. This time, the findings revealed that some emphases within the topic of ‘Pharmacological Management’ had shifted dramatically. Physicians were no longer afraid to prescribe morphine; on the contrary, they sometimes prescribed it in cases where etiological treatment would have been more appropriate. Consequently, the intended learning outcome had to be revised.

The task becomes more complex when we aim to teach soft skills, such as communication and collaboration, or, more ambitiously, to instil values or shift learners’ attitudes. It is challenging to formulate measurable outcomes for such goals; instead, we define a direction. Herein lies an important nuance.

Many of us are familiar with the NURSE protocol for empathetic communication: Name the patient’s emotion, Understand it, Respect, Support, and Explore. Memorising the steps is easy. However, whether a doctor applies the protocol in practice largely depends on their recognition of the importance of empathy. This awareness and internal acknowledgement of empathy’s value should be the desired learning outcome — the direction we strive to lead the learner towards.

To summarise the value of research and the formulation of learning outcomes:

Previously, I shared examples of how a well-formulated learning outcome can assist us in selecting the appropriate training format. Let’s now examine this topic more closely.

In education, it is essential to adhere to the principle of constructive alignment—that is, the learning objectives, training methods and strategies, and assessment approaches must be aligned.

For instance, if we want experienced physicians to learn about new prescription regulations (due to a new ministerial order), a lecture followed by a knowledge test will suffice to achieve the intended outcome. However, if the goal is for new physicians to complete prescriptions accurately, theory alone is insufficient. They will need practical tasks, and the assessment will appear different, resembling the completion of sample forms rather than a traditional test.

Let’s return to the example of the NURSE protocol. If our learning outcome is something like: ‘the physician recognises the importance of empathy in communication’ or ‘the physician has practised using the NURSE protocol,’ then simulations are necessary. The learner needs to experience both roles—those of doctor and patient. We also require instructor feedback, group reflection, and discussion—these activities are integral to the learning format. The most suitable assessment method in this case would involve simulations or observing real-life patient communication. Let’s explore this further.

The term ‘training format’ is broad. It can encompass group or individual learning, synchronous or asynchronous learning, as well as face-to-face or online delivery.

• Synchronous learning occurs when the instructor and learners participate in real-time, whether offline (in person) or online (via video conference).
• Asynchronous learning involves learners working through pre-prepared materials independently and at their own pace.

The choice of learning format and type of activity depends on the intended learning outcome. Here’s an example from our course on the diagnosis and management of chronic pain syndrome.

Training formats and learning activities are selected based on the intended learning outcomes. Lectures or video lessons provide the necessary theory—enabling learners to understand how to diagnose and choose the right therapy. Skills, however, are developed through in-person discussions of clinical cases and problem-solving on an online platform.

To assist doctors in explaining prescribed therapy to patients in simple terms and addressing difficult questions about opioids, we provided prepared response scripts and recorded video examples of effective communication, demonstrating how to structure the conversation, how to sit, where to look, and how to maintain rapport.

Of course, developing such a skill through training can be challenging; it takes time to master. Typically, the learning process only permits participants to ‘try it out’—that is, to practise the skill within a training context.

You can find more information about selecting suitable training formats in the lecture excerpt on planning education for the chronic pain management course.

Here’s another example from nurse training—also focused on shifting mindsets. In the workplace, we observed that nurses often moved and fed patients without saying anything, failing to inform them of their actions. Consequently, patients experienced fear, helplessness, and confusion. At first glance, it might seem sufficient merely to remind nurses to verbalise their actions. However, the root of the problem lay in their mindset. Nurses didn’t engage with patients because they didn’t perceive it as important.

We formulated the learning outcome as: ‘The nurse understands the importance of verbalising their actions during patient movement and feeding.’

To achieve this outcome and change attitudes, we employed various approaches; for example, ‘lying-down’ training sessions. One nurse assumed the role of a helpless patient, while another moved or fed them without verbalising their actions. The emotions and feedback shared by the ‘patient’ afterwards proved to be more effective than any lecture. The training succeeded because it provided personal experience and emotional insight.

In another training session, participants wore an ageing simulation suit that restricted their hearing, vision, and mobility. While wearing the suit, they had to walk to a nurse’s station and interact with the medical staff.

Another method to influence attitudes is through VR simulators; by wearing virtual reality goggles, healthcare professionals can perceive the world from the perspective of a patient with dementia.

When choosing a training format, it’s also important to assess the available resources and constraints from the beginning, as these can significantly influence how the training is ultimately designed.

Recently, we held a training session for senior nurses on quality control in medical care.

We defined the following learning outcome:
A senior nurse understands the key quality control points in caring for patients with severe symptoms and conditions and is able to apply this knowledge in practice.

After conducting a needs assessment and evaluating available resources and constraints, we realised that our initial training formats were not feasible. Consequently, we redesigned the programme completely differently from our original plan.

Lastly, a brief note regarding the assessment of training.
When should assessments be conducted?

• For lengthy courses, it is advisable to carry out interim evaluations after each module.
• In the case of shorter training sessions, a final evaluation at the end will suffice.

What should be assessed?

• Immediately after training, assess how effectively the knowledge and skills were acquired.
• Over time, assess whether the learning has been applied in practice. However, remember that it depends not only on the training itself but also on the working conditions—specifically, whether there is support, oversight, and incentives to utilise the new skills.

To create genuinely applicable training, it is essential to follow all the steps without omitting any:

1. Identify the work task you wish to address through training.
2. Ensure that training is the most suitable tool for addressing this issue.
3. Conduct initial research to thoroughly understand what to teach and to identify the opportunities and constraints that exist.
4. Formulate precise learning outcomes or learning paths.
5. Design the training to ensure that the formats and assessment methods are aligned with the desired learning outcomes.
6. After planning the training, return to step 1 and re-evaluate whether the designed programme genuinely addresses the identified work task.