The growing demand for palliative care means that health professionals are expected to provide palliative care as a core part of their practice.
Training in the practice of palliative care is a recent addition to undergraduate and postgraduate medical and other healthcare curricula, and several initiatives are under way to promote palliative care principles and practice in healthcare training.
The challenge that we all face is how to develop these skills in the face of multiple demands on our time.
Strategies for improving palliative care education include a national undergraduate curriculum for palliative care, expanded training opportunities for generalist practitioners, and further recognition for the role of practitioners of specialist palliative care and associated curriculum development.
In the 21st century, providing palliative care is an obligatory component of health services. As a community, we expect that, when prolongation of life is neither possible nor appropriate, effective care and support will still be available as palliative care. Virtually all health workers who come into contact with patients require some knowledge of both the unique needs of people facing death, and their own responses to these needs. The extent of this knowledge ranges from simple awareness of the availability of palliative care through to the highly specialised skills required for referral practice. Here we discuss the educational and training needs of medical, nursing or allied health professionals who provide primary care with a palliative approach, or specialist palliative care services.
Despite considerable resources being devoted to treating people with progressive and fatal disease in the 20th century, only in the last 25 years were efforts made to prepare health professionals to meet the needs of dying patients. The principles and practice of palliative care are now incorporated into undergraduate curricula.1,2 In Australia, there is limited information about its place in these curricula, and what there is indicates that there may be deficits. Glare and Virik3 have reported that Australasian medical schools place greater emphasis on disease pathophysiology and treatment, and little on interdisciplinary management or exposure to the team approach in palliative care. Similarly, a 1994 report on undergraduate nursing education in Australia noted that the total time spent on education about death and dying in nursing programs ranged between 5 and 192 hours, with little consistency in the content or teaching strategies used.4 There is also little information about the palliative care content of allied health curricula in Australia.
The usual excuse given for limiting the palliative care component is overcrowding of undergraduate curricula. Universities try to foster a broad range of attributes in their graduates — information literacy, capacity for life-long learning, and adaptability and ability to work in multidisciplinary contexts.5 There are also pressures to include a diverse and expanding body of discipline-specific and specialised professional knowledge and skills, thus presenting enormous course design challenges. However, if the care of people with degenerative and progressive diseases is an essential facet of practice, rather than just a skill to be learned, then palliative care must be integrated throughout the curriculum. Unfortunately, there is limited evidence to guide the selection of teaching and learning methods that most effectively achieve this outcome.
Efforts are under way in Australia to close the gaps in providing health professionals with fundamental palliative care skills. The Australian and New Zealand Society of Palliative Medicine has developed an undergraduate curriculum in palliative medicine that identifies core concepts to guide medical student training.6 Furthermore, the Australian Department of Health and Ageing recently awarded a tender to undertake the National Multidisciplinary Undergraduate Palliative Care Curriculum Project to promote inclusion of palliative care and its principles and practice into all healthcare training. It will develop a set of educational resources for undergraduate courses, and identify strategies to encourage the uptake of palliative care principles and associated resources within tertiary education. The project will be completed in late 2004.
Training in the practice of palliative care is included in the curricula of many postgraduate training programs for generalist and primary care health professionals dealing with patients with terminal illnesses. A recent Australian study identified 57 different organisations providing palliative care education for general practitioners in Australia. Most occur as a collaboration between specialist palliative care services and Divisions of General Practice.7 Many of the specialised areas of medical and nursing practice, particularly general practice, the oncological specialties and pain medicine, encourage their trainees to spend time working in palliative care services and/or include examinable requirements for an understanding of palliative care and palliative medicine. In addition, they encourage the development of the communication skills fundamental to palliative care.8-10
Other recent initiatives in training of non-specialist health professionals in palliative care include the Australian Palliative Aged Care Project. This project, due for completion at the end of 2003, aims to develop palliative care guidelines for aged-care facilities, and educational and training resources for staff involved in palliative care.
While specialist palliative medicine was formally recognised in the United Kingdom in 1987 and a training pathway created, most palliative medicine practitioners in Australia have gained their expertise through experience rather than formal training. One of the earliest training programs in palliative medicine in Australia was introduced in the late 1980s by the Sydney Institute of Palliative Medicine, subsequently recognised as a centre of excellence for palliative medicine training.11 In the early 1990s, the Royal Australasian College of Physicians (RACP) developed a training program for palliative medicine as a subspecialty of internal medicine, and in 1999 created the Australasian Chapter of Palliative Medicine to allow an alternative training pathway for doctors moving into the field from other specialty areas, including general practice. These 3-year supervised advanced training programs provide doctors with the skills to undertake specialist practice as members of interdisciplinary palliative care teams. The RACP has applied to the Australian Medical Council for recognition of palliative medicine as a full specialty, and a curriculum for specialist training in palliative medicine is currently being written.
There is currently no credentialing or accreditation system for specialty practice in any field of nursing, except for specific skill areas such as midwifery or immunisation. There is also no agreement on a national approach to regulation and education of nurse practitioners. As palliative care is a relatively new specialty, education for nurses is underdeveloped in comparison with other more established fields. Nursing labour force data collected by the federal government do not provide any information on nurses with postgraduate qualifications in palliative care. In fact, recent data suggest a decline in postgraduate course enrolments in nursing generally in the past few years12 and identify palliative care nursing as an area of skill shortage in every state of Australia. Strategies, such as increasing collaboration between the higher education and health sector, have been offered in the recent National Review of Nursing Education.13 To date, there has been no major commitment from the federal government to implement these recommendations.
A search of websites of the 38 publicly funded Australian higher education institutions identified 12 universities offering discipline-specific and interdisciplinary degree courses related to palliative care. Most are offered as specialist training for clinical palliative care. Other recent developments include postgraduate courses in “health promoting palliative care” at La Trobe University. Around half of the available university courses are open to a range of qualified health professionals, while the remaining courses are offered for a specific discipline such as nursing. More than half the courses are listed as available as off-campus or online study. Despite this diversity in course offerings, uptake by health professionals has been low.7
Continuing professional development (CPD) for doctors is evolving very rapidly in Australia. GPs are required to participate in these programs to maintain their vocational registration, and state medical boards are increasingly requiring doctors to show evidence of participation for ongoing registration. At the same time, the accreditation processes of the Australian Medical Council require that the medical colleges develop effective evidence-based CPD programs. The Australasian Chapter of Palliative Medicine has established its CPD program to ensure the maintenance of professional standards with these developments in mind. Doctors from many fields of practice, but particularly GPs, have obtained CPD credit for study in a wide variety of aspects of palliative care.
CPD for nurses and other health professionals is based on self-regulation, with annual reporting to regulatory bodies. It is difficult to determine the extent of participation by these groups.
The explosion of knowledge and information means that health professionals are unable to participate in ongoing training across the full range of their field of practice. GPs and generalist health professionals, in particular, must choose CPD courses from a huge range of options, and areas other than palliative care may seem more attractive or important in day-to-day practice. Even enthusiastic GPs who see only two to four palliative care patients per year may have difficulty maintaining their practical skills. Current workforce shortages make it difficult to release health professionals to participate in ongoing education. These problems will require more flexible approaches to the delivery of CPD, and models of care providing support for palliative care in generalist practice, such as mentoring. Strategies that develop capabilities in self-directed learning are integral to the delivery of quality palliative care services.
A variety of education providers have emerged in palliative care, with many palliative care services continuing to maintain a strong commitment to the traditional hospice philosophy of professional and community education. The Palliative Care Australia planning guide states that it is essential that palliative care service providers be involved in undergraduate, postgraduate and inservice education of all health professions to support the ongoing provision of palliative care.14 The range of education providers and course offerings reflects the diversity of palliative care. However, while the development of guidelines for palliative care education in aged care facilities is a welcome initiative, such standards are not generally available in the education of non-specialist providers of palliative care. An exception is the very detailed curriculum of the Australian College of Rural and Remote Medicine.10 Moreover, substantial resources are required for services to maintain high quality and flexible education.
The number of palliative care education opportunities offered as interdisciplinary programs has increased in recent years. This trend reflects a shift away from valuing the specific combination of skills and knowledge of one professional group, to greater recognition of the complementary and overlapping nature of professional practice and the importance of teamwork.15 This trend resonates well with palliative care’s emphasis on a team approach. However, there is as yet limited evidence that interdisciplinary education does in fact achieve these desired outcomes. Moreover, while the experience of interdisciplinary education is reported by many to be satisfying, some concerns have been raised that such approaches present difficulties for maintaining professional identity, standards and value systems, and that the depth of knowledge required for specific disciplines is compromised by the need to target education for the average participant.15
There is evidence that experiential learning, along with strategies that facilitate reflection on these experiences, can improve health professionals’ confidence in providing palliative care, and their capacity to support and communicate with patients and their families.16 However, the diverse and holistic nature of palliative care suggests that a wide range of teaching and learning strategies, when tailored to individual needs, can be very effective. Modern technologies provide enormous scope for further improvements in the delivery of palliative care education.
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