Kalisch, B.J., Xie, B. & Ronis, D.L. (2013). Train-the-trainer intervention to increase nursing teamwork and decrease missed nursing care in acute are patient units. Nursing Research, 62(6), 405-413. doi: 10.1097/NNR.0b013e3182a7a15d
The feasibility of a train-the-trainer
approach to end of life care training in care
homes: an evaluation
Andrea Mayrhofer1*, Claire Goodman1, Nigel Smeeton1, Melanie Handley1, Sarah Amador2 and Sue Davies1
Abstract
Background: The ABC End of Life Education Programme trained approximately 3000 care home staff in End of Life
(EoL) care. An evaluation that compared this programme with the Gold Standards Framework found that it
achieved equivalent outcomes at a lower cost with higher levels of staff satisfaction. To consolidate this learning, a
facilitated peer education model that used the ABC materials was piloted. The goal was to create a critical mass of
trained staff, mitigate the impact of staff turnover and embed EoL care training within the organisations. The aim of
the study was to evaluate the feasibility of using a train the trainer (TTT) model to support EoL care in care homes.
Methods: A mixed method design involved 18 care homes with and without on-site nursing across the East of England.
Data collection included a review of care home residents’ characteristics and service use (n=274), decedents’ notes
n= 150), staff interviews (n=49), focus groups (n=3), audio diaries (n= 28) and observations of workshops (n= 3).
Results: Seventeen care homes participated. At the end of the TTT programme 28 trainers and 114 learners
(56 % of the targeted number of learners) had been trained (median per home 6, range 0–13). Three care homes
achieved or exceeded the set target of training 12 learners. Trainers ranged from senior care staff to support workers and
administrative staff. Results showed a positive association between care home stability, in terms of leadership and staff
turnover, and uptake of the programme. Care home ownership, type of care home, size of care home, previous training
in EoL care and resident characteristics were not associated with programme completion. Working with facilitators was
important to trainers, but insufficient to compensate for organisational turbulence. Variability of uptake was also linked to
management support, programme fit with the trainers’ roles and responsibilities and their opportunities to work with staff
on a daily basis.
Conclusion: When there is organisational stability, peer to peer approaches to skills training in end of life care can, with
expert facilitation, cascade and sustain learning in care homes.
Keywords: End of life care, Training, Care homes, Programme implementation
Background
Residents in care homes are in the last years of life and
often present with multiple health needs, cognitive impairment,
and particular palliative care needs due to
their advanced age [1]. The implementation of education
and training targeted at end of life (EoL) care is, therefore,
particularly important for those working in long
term care [2–4]. The challenge is how to equip and
sustain the workforce to provide generalist palliative care
in settings where the staff have limited access to specialist
services, many do not have a formal qualification,
and turnover of staff is high [5, 6].
In October 2012 NHS Health Education East of England
(formerly East of England Multi-professional Deanery)
commissioned a local specialist palliative care
service to develop the Train the Trainer (TTT) End of
Life Care Education Programme for care home staff.
This built on the success of the ABC End of Life
Education Programme that had trained approximately
3000 care home staff across the East of England in
* Correspondence: [email protected]
1Centre for Research in Primary and Community Care (CRIPACC), University
of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK
Full list of author information is available at the end of the article
© 2016 Mayrhofer et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Mayrhofer et al. BMC Palliative Care (2016) 15:11
DOI 10.1186/s12904-016-0081-z
EoL care [7]. When the ABC programme was compared
with another EoL training framework (Gold
Standards Framework)[8] for care homes it achieved
equivalent outcomes in terms of impact on staff satisfaction,
confidence and competence, and in satisfaction
of next-of-kin [8]. The ABC programme was
preferred by participants, because trainees felt they
were personally supported by the visiting nurse specialists
in palliative care [9]. It was also considered to
be the more cost effective of the two schemes
reviewed [8] and reported a modest reduction in
death rates in hospital, unscheduled admissions and
bed days.
Building on the ABC programme, and working with
the same network of specialist palliative care services,
the Train the Trainer (TTT) project aimed to train two
‘trainers’ per care home, who in turn were to train six
‘learners’ each (n = 12 per care home). In order to become
a ‘trainer’ one had to have participated in the ABC
programme, which consisted of six EoL care training
modules, some input pertaining to learning and teaching
methods, and practice workshops with EoL care
educators/facilitators (EFEs). Trainers’ responsibilities
included the preparation of on-line and face-to-face
teaching sessions, the organisation and facilitation of
group discussions, and ideally offering learners bite-size
micro-teach sessions in daily practice. Full teaching
sessions were observed and evaluated by End of Life Care
Educators/Facilitators (EFEs). The EFEs were employed by
a range of organisations and held various clinical and
education roles including palliative link nurse, palliative
care nurse, practice-development nurses for care
homes, EoL care specialist and EoL educator. The
configuration that underpins the TTT model process
is depicted in Fig. 1.
The goal of the TTT pilot project was to consolidate
the success of the ABC EoL care programme, increase
the capacity of the care home workforce to provide EoL
care, and develop a model that could sustain training in
and provision of EoL care in care homes. The pilot ran
for nine months (Oct 2012–June 2013). The research
questions focused on what supported or hindered the
uptake of the programme. Number of learners trained
was used as a proxy measure by which to judge the TTT
model’s effectiveness in embedding and extending the
knowledge and practice of EoL care across care homes.
Methods
Eighteen care homes across three counties in the East of
England were recruited to the project. Thirty six care
home staff, who had completed ABC training, were selected
to be ‘trainers’ in EoL care. Recruitment of individual
care homes was based on criteria such as their
endorsement of the programme, geographical fit with
existing palliative care services, their previous engagement
with ABC EoL care training and identification of
staff who had completed ABC training and could take
on the role of trainer. As the evaluation of the TTT
training model was commissioned after the programme
had been implemented a before-after study design was
not possible.
Data collection
A mixed method design using qualitative and quantitative
data was used. Quantitative data consisted of Service
Use Logs and data collected using modified InterRAI
forms [10] from a 30 % randomly selected sample of
residents (n = 274) in participating care homes. These
data were used to establish a baseline of resident characteristics
and care requirements, and to estimate resource
use such as visits from primary care services and admission
to hospital. Resident Service Use data were collected
for three months from April to June 2013. The
study also reviewed care notes of residents who had died
(n = 150) post intervention, between October 2012 and
July 2013, to establish if previously observed findings
from the ABC evaluation of advance care planning
(ACP), documentation of palliative care, symptom management
and place of death were sustained [8, 9].
Findings from data collected via care notes have been reported
elsewhere [9].
To understand the implementation process of the
TTT model semi-structured face to face interviews
(n = 39) were conducted (Table 1), and focus groups
(n = 3) were held with trainers, EFEs, a project lead
and care home managers.
Trainers were also given audio diaries to record reflections
and experiences arising from their role, but staff
found these diaries cumbersome to use. The yield of
Fig. 1 TTT Team configuration between EFEs, trainers and learners
Mayrhofer et al. BMC Palliative Care (2016) 15:11 Page 2 of 8
data was negligible. Data collection took place from
October 2012 until the end of July 2013. Participating
care homes granted permission to collect audit
data, and written consent was obtained from all
interviewees.
Data analysis
Quantitative variables were summarised by medians,
ranges and percentages. The number of learners
trained in each care home was compared by type of
ownership (for profit organisation versus not for
profit organisation), type of care home (residential
versus on-site nursing), size of the care home (less
than 60 versus 60 or more residents), and previous
and/or additional EoL care training (yes versus no),
using the Mann–Whitney U test. Statistical analyses
were performed using SPSS [11].
Qualitative data collected in interviews were recorded,
transcribed, anonymised and analysed using QSR NVivo
Version 10 [12]. Qualitative data analysis involved crosssectional
and categorical indexing across care homes to
enable comparisons. Three researchers were involved in
the analysis of data. The study was approved by the
National Institute for Social Care and Health Research
(REC 12/WA/0384). Social Care Research Governance
Approval was obtained from Local Authorities (LAs).
Results
Three of the 18 eligible care homes left the programme
soon after it commenced. In two care homes staff were
no longer available to attend the training workshops and
in the other the reasons were unknown. Two further
care homes were recruited as replacements, which resulted
in a total of 17 participating care homes. Of 34
trainers (two per care home) 28 completed the three
skills training workshops to support their trainer role.
All trainers had completed the ABC training and held a
variety of roles, ranging in seniority from General
Manager to Support Worker, including Care Home
Trainers who held responsibilities for all mandatory
training, but were not directly involved in caring for
residents (Table 2).
Learners recruited were care home staff with similarly
varying levels of seniority. At the end of the TTT project
114 learners had been trained (median per home 6,
range 0–13). Three care homes achieved or exceeded
the set target of training 12 learners. Two care homes
had not trained any learners at the end of the pilot.
This variability was investigated in relation to care
home and resident characteristics to see if the uptake
of the programme might have been linked to factors
such as (for care homes) how a care home was
funded, on site nursing provision, size of care home,
and how many staff had already received EoL care
training, and (for residents) the presence of individuals
with more complex health care needs or shorter
life expectancies.
Care home characteristics
Table 3 reflects type of care home, type of ownership,
and additional training by county.
More learners were trained in care homes owned by for
profit organisations (median = 7.5) than in care homes
owned by non-profit organisations (median = 5), but there
was no statistical evidence for a difference (p = 0.475,
Table 1 Number of interviewees per care home
Study site Trainers Learning facilitators (EFEs) Managers Total
S1 10 4 1 15
S2 11 4 0 15
S3 6 2 1 9
Total 27 10 2 39
Table 2 Roles of trainers by site
Study site Role of trainer 1 Role of trainer 2
S1 Trainer in Care Home Carer
S1 General Manager Carer
S1 Carer Care Team/Unit Manager
S1 Nurse Carer
S1 Clinical Manager Receptionist
S1 Carer Care Team/Unit Manager
S2 Care Team/Unit Manager Only 1 trainer
S2 Deputy Manager Carer
S2 Deputy Manager Care Team/Unit Manager
S2 Care Team/Unit Manager Carer
S2 Care Team/Unit Manager Carer
S2 Care Team/Unit Manager Night Unit Manager
S3 Trainer in Care Home Only 1 trainer
S3 Carer Only 1 trainer
S3 Nurse Nurse
S3 Trainer in Care Home Only 1 trainer
S3 General Manager Deputy Manager
Table 3 Type of care home, type of ownership, and additional
training by site
Site 1
(n = 6)
Site 2
(n = 6)
Site 3
(n = 5)
Care home residential 2 5 2
Care home with on-site nursing 4 1 3
Care home ‘for profit’ 6 0 4
Care home ‘not for profit’ 0 6 1
Additional EoL Care training (Gold Standards
Framework) completed or in progress
5 1 1
Mayrhofer et al. BMC Palliative Care (2016) 15:11 Page 3 of 8
Mann–Whitney U test). The comparisons of the median
number of learners by type of care home (residential = 7.5,
nursing = 5.0: p = 0.423), size of care home (less than 60
residents = 7.5, 60 or more = 6.0: p = 0.888), and previous
or additional EoL care training in some care homes
(yes = 9.0, no = 5.5: p = 0.475) were also not statistically
significant.
Resident characteristics and resource use
Table 4 presents summary information on the residents
and their use of health care resources. The
number of learners trained in each care home could
have been influenced by differences in the resident
population of participating care homes and the services
received. For example, residents in some care
homes might have needed more support from visiting
health care professionals than residents in other care
homes or been identified as approaching the end of
life. However, the sample of 274 residents fitted the
national profile of care home residents in terms of
gender, cognitive ability, co-morbidities and function
as indicated in the literature [13, 14]. Literature does
not report any association of these factors with care
home staff engagement. Likewise, based on the qualitative
data in this study there was nothing to suggest
that residents’ characteristics or care needs influenced
whether a care home was more or less likely to engage
with the programme.
Factors influencing programme uptake
As discussed in the following section, the qualitative
data suggested that the variation in uptake was attributable
to three key contextual factors. These were the
role and responsibilities of trainers within the care
home, the uptake of EFE facilitation by the care
home, and the stability of the care home in terms of
leadership and staff.
Trainers’ professional roles and responsibilities
As indicated in Table 2, trainers’ professional roles varied
greatly, and this determined their opportunities to spend
time with learners during programme implementation.
Where teaching could be integrated with patterns of
working there was a greater likelihood of staff engagement
and discussion. For example, the teaching impact seemed
greater when a ‘trainer’ and a ‘learner’ worked on the same
unit and had opportunities to discuss the application of
theory to ‘real life’ situations. As expressed by a trainer:
“…if we know that someone is very near EoL we discuss
every aspect i.e. what we are going to do, what the care
plans say, what they [the residents] need, do they need
mouth care, what’s working for them, what pain relief
they are on… so we do a catch-up session and pre-plan
what we are going to do in relation to all the topics we
have covered” [Trainer, experienced carer, T01011].
Due to staff shifts it was often difficult to get six individuals
together for group work at the same time.
Trainers were encouraged by EFEs to adapt their support
of learners to reflect the preferences of individuals
and the working patterns of the care homes. This required
a level of flexibility and autonomy that was not
always possible because of the trainer’s role and other
commitments in the care home.
The ability to incorporate the trainer’s role into the
existing work schedule also had an impact on the uptake
of the TTT programme. When trainers held managerial
posts, this often meant that they had to create time to
carry out training within the specified timeframe, as it
was difficult to use routine encounters with staff and
residents as opportunities for learning and review. As
expressed by one of the managers who acted as trainer:
“This is extra to my job and time consuming”
[Trainer T01051SA].
This was also commented on by an EFE (training facilitator,
palliative care specialist) who concluded:
“…if I were to choose a care home [to participate in a
TTT EoL care education and training intervention] I
would be thinking very carefully about the manager
and the person who is going to be the trainer [in
relation to] what their other commitments are. It has
been very difficult to work with a trainer who is
managing a unit and has numerous other
responsibilities going on. You need to make sure you
have someone with passion [for EoL care] and
dedicated [ring-fenced] time to become involved in
training learners” [E0205].
In addition, not all learners were equally ready to receive
training at a particular level. For example, some
less experienced care staff found it difficult to watch
emotionally challenging content about death and dying
Table 4 Resident characteristics and resource use
Age at admission (years) median (range) 83 (38–99)
Female (%) 189/254 (74.4)
Diagnosis of dementia (%) 166/252 (65.9)
Condition reaching end-stage (%) 34/250 (13.6)
Advance Care Planning in place (%) 116/225 (51.6)
No admission to hospital (%) 227/238 (95.4)
Total GP visits, median (range) 1 (0–10)
Palliative care visit (%) 3/268 (1.1)
Mayrhofer et al. BMC Palliative Care (2016) 15:11 Page 4 of 8
on DVDs on their own. They preferred group work and
discussions that could offer immediate debriefing. As
stated by a trainer, the ability to be present during
learning helped to address emotional reactions to the
training:
“…some emotional issues were dealt with during
training (in relation to talking about death); this was
an opportunity to discuss how they could/would best
support each other…” [T01011].
Not only trainers in relation to learners, but also Educators/
Facilitators (EFEs) in relation to trainers were
aware of this critical part of EoL care training. As one
palliative care specialist emphasised:
“An EFE role needs to be in place for mentorship
debrief, support, and on-going training …” [E0207].
This was also a critical part of post-training support
until staff had formed their own support groups within
care homes.
Uptake of EFE facilitation by care homes
The TTT programme did not specify how EFE facilitators
should work with care homes. Care homes’
different uptake of facilitator training support is
shown in Table 5.
Significantly more learners were trained in stable care
homes (median = 10.5) than in those that were not stable
(median = 4.0) (p = 0.001, Mann–Whitney U test).
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