The Organ Donation (Deemed Consent) Act 2019 was enacted on 20 May 2020. Before this, on 18 May, Lord Bethel acknowledged, in a House of Lords debate, that deemed consent may not come into practice immediately because of the impact of COVID-19 and the need to ensure that transplants went ahead when it was safe and legislation training for specialist nurses for organ and tissue donation (SNs) had been completed.
Redeployment of SNs to frontline NHS services, and restrictions placed on travel and social distancing, meant the final education and training sessions for the legislation change (module 3: consolidation), were adapted from a face-to-face content in order to be delivered via a virtual platform. Legislation (module 1) and conversation (module 2) have been evaluated previously (Miller et al, (2020).
The purpose of this article is to evaluate module 3 and discuss how the legislation change has been applied in the clinical context.
Summary of legislation training for modules 1 and 2
The tri-modular approach was designed based on adult learning theory and building on the knowledge and skills that the SNs had already acquired during the previous two modules. The education and training was originally developed over a period of 6 months based on Bloom's Taxonomy (Figure 1). The framework elaborated by Bloom and his collaborators consists of six major categories: remember/understand/apply/analyse/evaluate/create. The categories after knowledge are presented as ‘skills and abilities’, with the understanding that knowledge is the necessary precondition for putting these skills and abilities into practice.
The Legislative Change Team (LCT) were seconded into specific professional development roles for this fundamental and historically groundbreaking project and developed the training, starting at the recalling, remembering stage in module 1.
Module 1 was focused on ensuring that the SNs were able to recite how deemed consent applies to everyone in England, except for those who are part of an excluded group (Box 1) and progressing to understanding the legislation and its application in the clinical context, when conducting sensitive donation conversations with potential donor families.
Feedback from module 1 showed that the blended approach to education and training using innovative technology was well received. Video diaries were filmed by the LCT while undertaking clinical practice. These visual aids brought together the theoretical aspects of the legislation change. The video diaries applied hypothetical legislation scenarios to real organ donation scenarios in a live environment to create learning opportunities. The video diaries were helpful in exploring the nuances of the legislation and the groupwork enabled people to discuss the considerations for deeming consent. The LCT then built on this education and training to focus on the conversational aspects in module 2, to help prepare the SNs for applying the legislation in the clinical context when sensitively supporting potential donor family members through donation discussions, as part of end-of-life care.
Feedback from module 2 showed how beneficial the SNs found the use of practising deemed consent conversations with professional actors playing the role of family members, using a forum theatre approach. Forum theatre allowed real-time audience participation, feedback and the opportunity to stop, start, rewind and pause the scenario in which the SNs were participating. Practising diverse scenarios inspired by real cases with the actors, helped to increase confidence and build upon skills already developed as part of the donation conversation in module 1. It also enabled practice sharing from other parts of the country in a non-pressured and safe environment.
Module 3
Module 3 was designed as a consolidation module to build on modules 1 and 2, so the SNs were able to critically analyse the legislation and make judgement calls and even start to create new language options for introducing or softening the way in which the legislation was explained to potential donor families. Module 3 was developed to instil confidence in the SNs, clarify questions relating to the Human Tissue Authority's (HTA) Codes of Practice, which is the guidance issued by the regulators, which underpins the Organ Donation (Deemed Consent) Act (2019), and to ensure consistency in operational application.
There was planned time to discuss and scrutinise the practical applications such as consent form completion. There were also opportunities for sharing practice within many organ and tissue donation teams from across England, Wales and Northern Ireland, practising using language that could be used in a deemed consent conversation in a safe learning environment. The scenarios were designed to cover the diverse population we serve in England, complementing the extensive work that had been undertaken with stakeholders from a number of differing faith and culture groups.
In light of the travel and social distancing restrictions placed on us by COVID-19, the intended face-to-face delivery of module 3 required a redesign for virtual delivery. Development, testing and delivery of the education and training for module 3 was expedited and completed in just 4–8 weeks to the entire SN workforce by a regional cluster approach across England.
In total, 333 SNs required training in module 3 consolidation, in order to be signed off as competent and confident in applying the legislation change in practice. Just 7% of SNs were unable to train (n=22) due to absence, including sickness, maternity leave and sabbaticals. Given this was during a global pandemic, the LCT felt fortunate to have such support, engagement and enthusiasm from the SN workforce.
As such, the team were able to provide education and training for 100% (n=311) of SNs facilitating the organ donation process at that time, enabling us to meet our commitment to the Department of Health and Social Care (DHSC).
Of the SNs attending the education and training, 69% (n=215) completed the evaluation questionnaire for module 3. Worthy of note is that there was greater participation in the evaluation process for module 3 than modules 1 and 2, due to the ease of electronic evaluation using a QR code or link to a questionnaire.
In total, 17 education and training sessions were delivered virtually, averaging 18 SNs per session, 4 being the lowest number attending and 29 the highest. The number of people attending the training did not appear to affect the evaluation.
Responses to module 3
In response to the statement ‘There were different opportunities for questions/interaction/videos on Zoom to meet my learning needs’, 84% (n=180) felt this was ‘extremely true’ and 15% (n=32) agreed this was ‘somewhat true’, while 1% (n=3) suggested this was ‘slightly true’. Nobody felt there were no such opportunities (Figure 2).
In response to the statement ‘The course has built on my knowledge, increasing my understanding of the legislation change and what this means to me in practice’, 70% (n=150) of participants agreed that the course built on their knowledge and increased their understanding of the legislation change and what this means in practice, along with 26% (n=56) who also felt this was ‘somewhat true’; 4% (n=9) felt the statement was ‘slightly true’, and no one disagreed (Figure 3).
On average, participants scored 8.53 on a scale of 1 to 10 depicting confidence levels (where 1=no confidence at all; 10=extremely confident) in understanding the inclusion/exclusion criteria for applying the deemed consent legislation in England. When asked about confidence levels for conducting a ‘planning’ conversation with a clinician where deemed consent could be a possibility, the average score was 8.2. This score dropped slightly to 8.04 in response to the question on confidence in conducting a potential deemed approach and consent conversation.
When asked if they would recommend the training to colleagues, 92% (n=198) responded ‘yes’, 6% (n=13) said ‘maybe’ and 2% (n=4) said they would not recommend the training to colleagues (Figure 4).
The participants' narrative responses to the questions are quoted below.
What went well?
‘It was fantastic—so well facilitated, great having different members of the professional development specialist team presenting, really liked the case studies, which helped me understand how to apply the legislation. It was effective attending via Zoom—felt like I was in the same room, but without the challenge of commuting. I felt much more engaged and hope Zoom is used for future training as it is so interactive.’
‘It's just been brilliant, and as someone who has to shield, I feel up to date and very well informed.’
‘Good summary, with examples and opportunities to ask questions. Good to see an example of speaking to a family whose loved one opted out and this conversation can be normalised to be part of a usual end-of-life conversation.’
‘Good visuals and a lot of opportunities to ask questions as we went along, which is much better than all at the end.’
‘Really well delivered, clear content explained really well—I feel so much more prepared and confident.’
‘It was good practie, to test which section of the consent form to complete as there have been many occasions in Wales where this has been completed incorrectly due to confusion between section B and C.’
What could be better?
‘Longer time spent on approach and phrases.’
‘Maybe use break-out rooms for discussion points to encourage more people to get involved. Delivery was good, but I prefer face to face for asking questions, acting out scenarios.’
‘It was extremely repetitive and probably didn't need to be so long. Maybe should send a quiz out beforehand to see what people already know and then answer questions and queries.’
‘So much better doing it as Zoom than travelling to meetings.’
The overall evaluation rating for module 2 face-to-face education and training was 9.1 out of 10. In comparison, the virtual format of module 3 was evaluated at 8.6 out of 10 (Table 1), an improvement on the evaluation of the online digital platform training in module 2, which was 8.3. This led the team to conclude that there was improved understanding of the technology by the facilitators and greater familiarity by the attendees with the virtual learning environment. This was demonstrated by the participants' ability to use the annotate and chat functions on Zoom, for example.
| Module | Mode of delivery | Star rating |
|---|---|---|
| 1. Legislation | Face to face | 8.7/10 |
| 2. Conversation | Face to face | 9.1/10 |
| Virtual | 8.3/10 | |
| 3. Consolidation | Virtual | 8.6/10 |
By design, module 1 was more theory laden, detailing the inclusions and exclusions of the deemed legislation. The fact that module 2 scored high at 9.1 would indicate the preference of the SNs in practising the conversational aspect of the deemed legislation in a safe environment.
The evaluation also indicated an increase in the overall rating from module 1 to module 2 and possibly reflects an improvement in the facilitators' understanding of the legislation change, as the evolving HTA Codes of Practice were developed. It must be acknowledged that the training was designed using draft HTA Codes of Practice, which were evolving at the same time as training was being delivered.
Although this was challenging at times, because there were questions under legal review awaiting an answer, the positive benefits were outweighed by the ability to collaborate and shape the HTA Codes of Practice in conjunction with the HTA. We were able to gather intelligence from the SNs to shape and influence the Codes of Practice to ensure the guidance was relevant in the clinical context. An example was the use of a ‘car park’ in module 1, where questions raised were documented on a flipchart and photographed for discussion as a training team and to enable us to seek clarity from the HTA.
It was always our intention as facilitators that any questions that could not be fully answered in modules 1 or 2 would be clarified and discussed in consolidation module 3. The team considers that this was reflected in the change in evaluation scores between modules 2 and 3 (Table 1).
Summary
The flexibility and adaptability of the LCT and the support of the SNs during the global coronavirus pandemic greatly assisted in the redesign, re-testing and delivery of module 3—a consolidation module. The team was able to implement the legislation into the clinical context, as the Government had planned, sooner than expected.
The team is committed to embedding the legislation change and will seek ways to explore and support colleagues who are meeting with potential donors and their families in the coming weeks, months and years. The LCT aims to do this by practice sharing and undertaking debriefs for a 3-month period with SNs who have been involved in conversations where deemed consent was a possibility and create an easily accessible resource repository that is accessible online.
The team is hopeful that the education and training has been understood and allows for practical application and, where feedback has highlighted gaps, the team will endeavour to provide further resources and education to provide the answers and ensure that SNs are working within the legal framework of deemed consent.
The team will continue to work closely and collaboratively with our colleagues in the professional development team to ensure the transfer of knowledge, so that the legislation is threaded through all NHS Blood and Transplant education courses for SNs on organ and tissue donation.