Continuing professional development in the COVID-19 era: evolution of the Pegasus Health Small Group model

Keywords: community pharmacists, continuing education, COVID-19, general practitioners, interactive online learning, New Zealand, practice nurses, primary health care, professional development, programme evaluation.

Pegasus Health Charitable is contracted by the Canterbury District Health Board (CDHB) to provide continuing professional development for primary healthcare practitioners in the CDHB region. The programme provides continuing education for general practitioners (GPs), nurse practitioners (NPs), practice nurses (PNs) and community pharmacists (CPs). Each year, five different topics are delivered using a peer-led Small Group model, with group size being around 16 members. Groups within greater Christchurch area are mostly single discipline, with multidisciplinary groups running in rural areas across the CDHB region. A trained peer leader from the same discipline as those in their group facilitates in-group discussion informed by background reading researched and developed by the Clinical Quality and Education (CQE) team from Pegasus Health, with external clinical input from relevant experts. The evolution and expansion of the programme since its beginning in 1992 with groups of GPs has been previously described in this Journal.¹ The importance of continuing professional development (CPD) for healthcare professionals is well documented.^2–6 It maintains the knowledge and skills necessary to keep up-to-date with current best practice, thereby supporting the delivery of high-quality and safe patient care.⁷ Keeping current also contributes to job satisfaction, career progression and retention of experienced and skilled workers that the healthcare workforce can ill afford to lose.^2,4–6

When the coronavirus disease 2019 (COVID-19) pandemic arrived in New Zealand in March 2020 and restrictions on in-person meetings were imposed for an unknown period,⁸ it became urgent to find a new way of delivering the Small Group programme. At that time, there were around 1100 primary healthcare professionals enrolled in some 65 Small Groups that met in-person. Meetings for the first topic of the year were almost completed and preparation was already advanced for the following two topics to be presented in April/May and June/July. These were now paused to allow time to plan the transition from an in-person to a fully online model (eSmall Group). Providing continuity for the programme was seen as not only worthwhile in itself, but also a way of continuing the supportive community of practice engendered by the group model for primary healthcare clinicians⁹ who were working in an uncertain and stressful environment. Continuing the programme also created a focus for the CQE team members’ work. This paper outlines the developments that took place so that the Small Group meetings could continue under pandemic restrictions and so that a change to programme delivery could be quickly made to cater for any potential future restrictions on in-person gatherings.

The CQE team needed to establish who would be affected by the change to online meetings, as well as considering the guidance and training needed so that eSmall Groups provided an effective replacement for the in-person meetings for all attendees. The strategic approach was informed by a review of the international literature on online education for groups of healthcare professionals. It established three guiding principles: that group online learning must be interactive and in real time so that complex issues could be discussed, opinions shared and then applied in practice; that technical and organisational support was crucial so that attendees were not excluded or demotivated by access problems; and to be sustainable, online education needed to be convenient, create a community of practice, provide practical support and be backed up with continuing access to resources and documents that reinforce the content of the education package.^10–12

All stages of the Small Group process needed to be thought through for the new format. New procedures for recording attendance and completion were developed and cleared with the relevant professional colleges for awarding education credits. Protocols were established to ensure that the same free discussion possible during an in-person meeting could continue online without concerns that confidentiality could be compromised. Logistical issues were addressed, including the acquisition of extra Zoom licences and the management of notifications sent out to individual attendees with the correct link to join their own meeting embedded. To allow for the time this required, the usual schedule of topics for the year was reduced from five to four.

Two ‘how to’ guides were developed; one for Small Group Leaders and another for other attendees. The guides covered choosing a device, installing Zoom, camera positioning, meeting processes and etiquette, and completing the evaluation form following the meeting. A check list helped attendees ensure that Zoom had been set up correctly and tested. The guide for Group Leaders also provided tips on technical aspects and facilitation skills to encouraging participation and observe the group dynamic. Online practice sessions on Zoom were organised for Group Leaders before running their group.

Towards the end of 2020, a formal evaluation was carried out through an online questionnaire sent to all those enrolled in the Small Group programme. The questionnaire aimed to assess the experience of attendees and Group Leaders with the online format and gauge their preferences for each of three future meeting formats; all online, all in-person meetings, or a mixed option with online offered during the winter months. Group Leaders were surveyed separately to find out whether they preferred one format over the other or whether they would prefer to stay with what most of their group decided. The timing of the evaluation meant that respondents had reasonable experience of the eSmall Group and so were able to provide informed comments, but also to allow for the lead time needed for changes to be implemented in 2021. Ethics approval for the evaluation was granted by the University of Otago Ethics Committee (Reference D20/238).

The eSmall Group programme began on 28 May 2020 with the first of the Group Leaders’ briefings for the second topic of the year, followed by the remaining two briefings and then all 65 of the eSmall Group meetings, concluding in early August. All meetings were held as scheduled and largely ran smoothly. Attendees appeared to understand the necessity of moving to Zoom and that the process would not be perfect initially. The Events team from Pegasus Health started each meeting, checked the technical aspects were working, then left the meeting but remained available throughout to assist the Group Leader or attendees with any access or other technical problems. Attendees were asked to have their camera on and Zoom in gallery view so they were visible in the same way as if they were in a physical room and to have their microphone ready to be activated when called on. This emphasised the importance of being actively present and engaged in the meeting. It also underlined the real-time participative model of the eSmall Group programme and ensured it remained fully distinct from a non-participative webinar. A comparison of attendance between the first meeting of 2020 (in-person) and the second (by Zoom) showed that attendance remained stable, with only minor variations between the two topics. Moreover, attendance equalled or exceeded the average attendance for the previous year.

Although restrictions on movement eased and meetings in-person became possible again by the middle of 2020, it was decided to continue with the eSmall Group format for the rest of the year. Space constraints and the changing rules about social distancing meant that hosting an in-person meeting was only feasible when there were no restrictions on in-person meetings in place. Furthermore, continuing with the eSmall Group format allowed Group Leaders and attendees to become more comfortable and familiar with working in the online format. Accordingly, meetings for the third and fourth topics of the year all took place online, finishing in early December. Advanced features of Zoom, such as breakout rooms, were not used; groups were small and there was no tradition of sub-group discussions when meeting in-person. Moreover, it was important to consolidate experience and retain engagement of all Group Leaders and attendees who had widely differing access to, and familiarity with, the technical aspects of learning online. General feedback over the winter and spring of 2020 showed that as the Zoom format became more familiar, attendees became more comfortable with it. There were, however, some difficulties around internet connectivity from home locations and access to suitable spaces and equipment for attending online meetings.

The formal evaluation carried out in the last quarter of 2020 received 393 responses from the approximately 1100 enrolled in the programme (36% response rate). Respondents by profession were 37% GP/NPs, 30% PNs, 31% CPs and 1% multidisciplinary. Most respondents (83%) had attended an eSmall Group meeting. When respondents were asked to compare their experience of the online meetings with the in-person format, 47% overall indicated that they had found the online meetings as good as, or better than, the in-person format, with 51% noting that they found it not as good. Two percent had only attended one format so were unable to compare. Table 1 shows a breakdown of this comparison separated by discipline.

Table 1.  Comparison of online vs in-person format by discipline of respondents.

The convenience and accessibility of the online meetings was strongly supported, but there were equally those who desired the interpersonal connections that were possible with the in-person format. The stronger preference for in-person meetings among community pharmacists was attributed to many of them working with only one or no other pharmacist colleagues and therefore not having the daily collegial support other disciplines had in a group practice.

When asked what format they would prefer in future, 32% of all respondents indicated they would prefer all online, 35% opted for all in-person, 14% for the mixed option, and 19% did not mind either way. Some wished to change their group to access the format they preferred; other respondents indicated that their preference was to stay with their group whatever was decided; the interaction and positive group dynamics in some of the longstanding groups being a particular strength of the Small Group model. Again, community pharmacists showed a greater preference for an in-person format compared to other disciplinary groups.

Respondent preferences for future meeting format by discipline are shown in Table 2 below.

Table 2.  Preference for future meeting format by discipline of respondents.

The separate survey of Small Group Leaders had a 64% response rate (36 of 56 Small Group Leaders). Of these, 33% indicated that they found facilitating an eSmall Group was as good as in-person, 50% that it was not as good, and 0% responded that it was better than in-person. Preferences for the future were: 14% for continuing online, 31% for returning to in-person, 25% for the mixed option, and 22% did not mind either way. Nearly half of the Group Leaders (47%) indicated they wanted to stay with their group and would accept whatever format the majority preferred.

Based on these results, 2021 began with a newly evolved model of the Small Group programme and a return to offering five topics for the year. All attendees were able to choose their preferred format for meetings, with a one-time only change of group allowed to access their preferred option. In-person groups were conditional on there being no gathering restrictions in place. A Zoom link continued to be set up for all meetings regardless of the group format to ensure in-person meetings could change to online immediately should new gathering restrictions be imposed. Group Leaders’ briefings for each topic alternated between online and in-person to ensure that all Group Leaders were confident in both formats. Training of Small Group Leaders was expanded to cover the skills and tools needed to move comfortably between formats according to the level of restrictions in place and the format of the group that they took on as a Leader. In addition, an online Learning Management System, Pegasus Education, was set up early in 2021 for all functions related to the Small Group programme, including a permanent archive of all documents and materials from each topic that was available to all those enrolled in the programme.

The impact of COVID-19 on the delivery of the Small Group Programme resulted in a redesign of the way the programme was delivered. The results of the evaluation showed that attendees and Small Group Leaders were willing to embrace the sudden change from in-person to online education, confirming the value that they placed on the Small Group model of CPD. Even so, changing a fully in-person programme to fully online in the short space of 6 weeks was a considerable achievement. Unable themselves to meet in-person during these weeks, and with their wider organisation fully occupied with the COVID-19 pandemic response, the CQE leadership needed to engage all members of the team to draw on whatever expertise and technical ‘know how’ they could contribute to the change. They then needed to convey their confidence to the wider community of Small Group Leaders and attendees that the new format would have the same quality of professional development that they were accustomed to. Team members considered that the background mindset carried over from the post-earthquake situation in Christchurch¹³ had been a positive influence on the willingness and motivation of the CQE team to find a way forward in a context where options were limited. Additionally, the widespread use of real-time interactive modalities on social media appeared to have made the move more familiar and acceptable to those enrolled in the Small Group programme rather than being seen as an entirely new concept to them.^14–16 On reflection, it appears the time had come for offering online options and the urgency of having to respond to the COVID-19 pandemic restrictions accelerated the process. It is well established that adverse circumstances also provide opportunities for change that are ultimately beneficial. Significant advances in pre-hospital trauma care, for example, have developed from battlefield injuries far from hospital services and operating theatres.^17–19 Within the context of the COVID-19 pandemic, attention has been drawn to ‘silver linings’ that have led to positive change in cancer care, for example,²⁰ as well as innovations in policy and online learning.^21,22

A strength of the process has been the consistent adherence to the underlying principles set up at the beginning. The emphasis on the interactive aspect of professional development with all attendees together in real time whether online or in-person has been strongly maintained. Technical and access difficulties have been overcome over the time the model has been in place. Additionally, the establishment of the Pegasus Education site has provided a single point where those enrolled can go for all information related to the programme, including all resources and documents from past topics.

The decision to persist with the online meetings for the rest of 2020 even though restrictions on in-person meetings were lifted was instrumental in bedding in the new format and carrying the Small Group programme forward into a new era as a flexible model of continuing professional development. While offering a variety of options to suit individual circumstances and learning styles, it also ensured that the programme could respond quickly to further restrictions. This decision was validated when further limitations on in-person meetings were implemented during 2021 and 2022. The Small Group programme was then able to pivot immediately and revert to the online format, allowing the valued professional development that it provided to continue uninterrupted.

The data from this work are not available; respondents to the survey from which the data were obtained were assured of confidentiality.

The authors declare no conflicts of interest.

No funding was received for the work reported in this paper; all work was carried out in the usual course of employment of all authors.