Scientific Papers

Training nurses to facilitate and implement CURA in palliative care institutions: development and evaluation of a blended learning program | BMC Palliative Care

In this section, we will describe the content and evaluation of the training.


  1. a.

    Learning objectives

On the basis of co-creation with our CoP, we formulated five main learning goals of the training (Fig. 4), focusing on development of competencies that are needed to initiate, facilitate, and participate in implementing ethical reflection with CURA within an organization.

Fig. 4
figure 4

Main learning goals of the training

  1. b. 


We chose a blended learning approach to our the training. Blended learning, i.e., the combination of training sessions or instructions and technology-mediated instructions or programs [14,15,16] holds several advantages. First, it gave us the opportunity to optimally utilize the training sessions to practice the facilitation of CURA and to discuss implementation, while transferring knowledge via the e-module. Second, participants could have more control over their learning trajectory and follow the technology-mediated part of the training at their own pace [17]. This is convenient for healthcare professionals that work at different locations and have varying work schedules. Third, the e-module platform enabled the participants to interact with each other. Finally, the platform enabled them to upload materials that helped the trainers to track and evaluate their progress.

The training consists of three elements: (1) an e-module, (2) three training sessions (one-kick-off meeting and two meetings to practice the facilitation of CURA and to discuss implementation), and (3) practicing with organizing and facilitating CURA sessions within their own organization (see Fig. 5). Four to five weeks are given in between training sessions, giving participants time to complete the e-module and to practice organizing and facilitating CURA in their own work environment. The entire training program takes approximately 23 h to complete. The content of the training is as follows:

Fig. 5
figure 5

Structure of the training program

Kick-off: An introductory kick-off meeting of 75 min, focusing on becoming acquainted with each other, CURA, and the set-up of the training. In order to introduce CURA, the trainer facilitates a CURA session using a case of one of the participants. Furthermore, couples are set up using the ‘buddy system’. Buddies will give each other feedback on the assignments of the e-module and serve as sparring partners throughout the training.

E-module part 1: Participants can individually go through the e-module at their own pace, either at work or at home. The content consists of reading material (such as the CURA manual for facilitators and an e-book with more background information on the instrument); two videos with clarification of CURA and background information on moral distress and moral resilience [1, 6]; and several assignments such as an interactive demo of using CURA with a pre-given case.

Training session 2 and 3: each of these meetings lasts three hours. All participants facilitate at least one CURA-session based on a case presented by one of the group members, under supervision of a trainer during the meeting. The participants receive feedback from the trainers and other participants on their performance as facilitators. Furthermore, there is time for sharing experiences and questions regarding the e-module. One or two trainers are present, depending on the group size.

E-module part 2: The second part of the e-module is done in between the second and the third training sessions. This e-module focuses primarily on the dissemination and implementation of CURA. Participants are instructed to prepare and deliver a pitch for their colleagues in order to raise publicity for CURA. This could either be a presentation, a video or a newsletter. Furthermore, they get a short introduction on how to write an implementation plan and then are tasked with writing their own 2-page plan. In this plan, they envision what successful implementation of CURA entails and what they need to achieve this. They distinguish promoting factors from barriers for implementation and what their own role in the implementation of CURA could look like. Next, the buddy-couples read each other’s implementation plan and discuss them. They document what they learned from each other’s plans. If necessary, they can adjust their implementation plan. The implementation plans are discussed during the second training day. Furthermore, the plans are used as an inspiration to write a more elaborate implementation plan after the training is completed (described in another paper).

Practicing with colleagues: in between the second and the third training sessions, participants practice their role as a facilitator at least twice using CURA in a small group setting with colleagues. Depending on their working environment and preference, they are able to choose with whom, when, and where they organize and facilitate a CURA session. Their buddy is present to observe and give feedback afterwards using a standardized handout. Participants also fill out self-assessment forms to stimulate reflection on their skills and development.

At the end of the training program, participants receive a certificate if they have successfully completed the entire program. They also receive an evaluation with personal feedback from one of the trainers.

The overall structure and content of the training is presented in Table 1.

Table 1 Content and structure of the training program


In this section, we present the findings of the evaluation of the training program of both cycle 1 and 2. We will first present the characteristics of the participants in the training, and the setting.

  1. a.

    Characteristics and setting

Participants in the CURA-ambassador training were recruited by the participating healthcare organizations. Characteristics of participants are presented in Table 2.

Table 2 Characteristics of ‘CURA-ambassadors’

Forty-one participants filled out the questionnaire (first cycle: n = 28 / response rate: 61%), second cycle: n = 13/ 52%). The overall response rate was 57%. Most participants were registered nurses (14/ 34%); followed by licensed nurse practitioners / health care assistants (9 / 22%) and spiritual counselors (7/ 17%). 2 (5%) were physicians; 2 (5%) were physician assistants and 7 (17%) had a different profession. Furthermore, six interviews were held after all organizations were trained in order to deepen our insights into the quantitative data from the questionnaires. These participants worked in nursing homes (n = 2), hospitals (n = 1), hospices (n = 1), and in home care (n = 2). Participants were nurses (n = 2), nurses with a specialization in palliative care (n = 2), physicians (n = 1) or spiritual counselors (n = 1).

Due to COVID-19 restrictions, not all training sessions were in-person; most were online. We followed the organization’s guidelines and national restrictions that were effective at the time. Most participants followed the training sessions online (24 / 59%). 11 (27%) followed the meetings in-person, and 6 (15%) had a mix of in-person and online meetings. The mean time spent on the entire training program was 23 h (SD: 9.7).

  1. b.


Overall, most participants evaluated the training program positively. The training as a whole received a mean score of 8 on a 10-point scale (range: 7 – 9). Results of the items measured with a 5-point Likert scale are presented in Table 3.

Table 3 Results of questionnaire items (n = 41)

Our qualitative data, both from the questionnaire and the interviews, can be subsumed in four topics: content of the training, training sessions (virtual or in-person), e-module, and acquired competencies relevant to being a CURA-ambassador.

Content of the training

In general, the training was positively evaluated, and the content was experienced as relevant and instructive. Participants were especially positive about the competences of the trainers (73% strongly agreed). On the open-ended question ‘what did you appreciate about the training?’, some participants responded that they especially appreciated the fact that they had learned new skills, such as being able to better recognize and deal with moral challenges. Furthermore, they mentioned that the theoretical foundations were clearly explained and well connected to examples from daily practice. Other participants responded that they appreciated the variety in the training program: “the training is well put together. It focuses on the content of CURA; the use of CURA in practice (implementation and how to deal with obstacles) and on facilitation techniques.” [Questionnaire].

While participants were positive of the content, the open-ended questions and the interviews showed that participants were still in need of more knowledge about specific elements of CURA and implementation. One participant wrote: “How to cope with resistance from colleagues? And I would like to learn how to deepen insight in the step Unrush during the CURA-process.” [Questionnaire].

Training sessions

Participants appreciated the open and safe environment and the personal feedback they received from the trainers. One of the participants of the interviews mentioned: “it is a bit uncomfortable at first [to facilitate]. But the trainers knew how to ensure a safe space. They gave very good feedback, but also a lot of compliments, which made it a very nice experience for me.” [Interview R1, Physician].

Participants appreciated learning from and with each other during the training sessions: “The sessions were meaningful. I learned the most from practicing together” [Questionnaire]. Due to COVID-19 restrictions, most training sessions were online. This was mentioned as a potential improvement for the training. As one of the participants mentioned in the open-ended questions of the questionnaire: “It was due to the circumstances [COVID-19], but I prefer in-person meetings.” [Questionnaire].


The e-module was appreciated in general. One participant wrote: “E-module: Short and to-the-point. (…) The variety of videos, podcast, and text was nice.” [Questionnaire]. During the interviews, one participant mentioned that she noticed some overlap in the online material, for instance in the videos and the manual. She appreciated the overlap—because it can be useful to repeat important elements – and she also liked that she could go through certain elements more quickly: “That’s the benefit of online: you can just scroll through it. You put your own twist on it.” [Interview R3, nurse].

However, a third (35%) experienced technical difficulties with the e-module. For instance, they experienced difficulties in uploading assignments: “For me the e-module was an obstacle. It might have helped if there was more instruction available.” [Questionnaire]. Based on these findings, we resolved the technical problems by improving the structure of the e-module: we changed instructions that were perceived as confusing, improved the lay-out, and added extra instructions to create more lucidity. For instance, we wrote instructions on how to use the online environment. These instructions appeared upon the first entrance of the e-module, ensuring that all participants were informed. Participants were positive about the length and the content of the e-module; therefore we did not make adjustments in those respects.

Competence in using CURA

The training is aimed at learning CURA-ambassadors to initiate and facilitate CURA sessions with colleagues in a small group setting. Hence, we asked participants whether they felt confident to do so. Most participants (95%) on the questionnaire (strongly) agreed with the item “I am sufficiently prepared to use CURA independently with colleagues”. However, during the interviews, one participant mentioned that she did not feel fully equipped to implement CURA by herself: “It would’ve been nice if [the trainer] would reach out to us more [after completion of the training]. So, we can say ‘we struggle with this or that’, and perhaps we could get some advice” [Interview R6, registered nurse].

Furthermore, support from others in the organization, specifically from managers, was considered essential for successful implementation: “[Another CURA-ambassador] wanted to implement it in her team but her manager thought it would cost too much time and money. She really had to give good arguments and needed support from the CURA-project leader before she could start.” [Interview R4, nurse].

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