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Palliative care training in undergraduate medical, nursing and allied health: a survey
  1. Nicola White1,
  2. Linda JM Oostendorp1,
  3. Ollie Minton2,
  4. Sarah Yardley1,3 and
  5. Patrick Stone1
  1. 1Marie Curie Palliative Care Research Department, University College London, London, UK
  2. 2Palliative Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
  3. 3Palliative Medicine, Central and North West London NHS Foundation Trust, London, UK
  1. Correspondence to Dr Nicola White, Marie Curie Palliative Care Research Department, University College London, London W1T 7NF, UK; n.g.white{at}ucl.ac.uk

Abstract

Objectives Impending death is poorly recognised. Many undergraduate healthcare professionals will not have experience of meeting or caring for someone who is dying. As death can occur in any setting, at any time, it is vital that all healthcare students, regardless of the setting they go on to work in, have end-of-life care (EOLC) training. The aim was to determine current palliative care training at the undergraduate level, in multiple professions, in recognising and communicating dying.

Methods Current UK undergraduate courses in medicine, adult nursing, occupational therapy, social work and physiotherapy were included. All courses received an email asking what training is currently offered in the recognition and communication of dying, and what time was dedicated to this.

Results A total of 73/198 (37%) courses responded to the request for information. 18/20 medical courses provided training in recognising when patients were dying (median 2 hours), and 17/20 provided training in the communication of dying (median 3 hours). 80% (43/54) of nursing and allied health professional courses provided some training in EOLC. Many of the course organisers expressed frustration at the lack of resources, funding and time to include more training. Those courses with more palliative care provision often had a ‘champion’ to advocate for it.

Conclusions Training in EOLC was inconsistent across courses and professions. Further research is needed to understand how to remove the barriers identified and to improve the consistency of current training.

  • palliative care
  • education
  • death

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Introduction

Due to improvements in technology and medicine, people are living longer with more complex health conditions.1 Many undergraduate students have had little experience of meeting or caring for someone who is dying. Yet, caring for dying people is something they will potentially need to do from the first day of their professional careers,2 and impending death has been shown to be poorly recognised.3 4 While it is primarily doctors who are responsible for making treatment decisions, it is often non-medical staff who spend more time with patients.5 It is, therefore, important to provide relevant training, at the undergraduate level, to all healthcare professional students. Such training should include the recognition of imminent death and training in how to communicate to patients and relatives about death and dying. These are areas that have been highlighted in the End of Life Care Strategy.6

Previous evidence has described the provision of general palliative care training for medical students7–9 and nurses,10 11 suggesting that the provision of palliative care training is inconsistent. To the authors’ knowledge, there has been no previous evidence regarding training provision for other professional students who might be involved in the care of dying people.

The aim of this survey was to determine what is currently being taught about (a) recognition and (b) communication of dying in undergraduate courses for students who are training for those professions that form the core specialist palliative care team.

Methods

Study setting

The following undergraduate courses (professions that are defined as those that constitute the core specialist palliative care team)12 were contacted by email (between November 2018 and April 2019): (1) medicine, (2) adult nursing, (3) occupational therapy, (4) physiotherapy and (5) social work. All were identified either through the Universities and Colleges Admissions Service website or a medical school website13 14 and received one reminder email.

Outcomes

All adult nursing and allied health course leaders were asked if they provide training for working with a dying person. Medical schools were not asked this question as it is a core outcome of the curriculum (see online supplementary file 1).

All course leaders were asked:

  1. Do you provide any specific training on the recognition of dying in patients who are terminally ill? (Y/N)

  2. Do you provide any specific training on how to talk about prognoses with patients who are dying and/or their relatives? (Y/N)

For each question, course leaders were asked to provide further details on content, when the topic was covered in the curriculum, time dedicated and whether or not the training was mandatory. Responses were collected either by email or telephone.

Analysis

Data are presented by frequencies and described narratively. One author (NW) identified themes from the free-text responses and selected illustrative quotes, this was reviewed by the research group.

Results

A total of 73/198 (37%) courses responded to the email. The majority (43/54, 80%) of the nursing and allied health courses provided training in the end-of-life care (EOLC).

Responses

Respondents did not always provide specific answers to the questions posed but often elaborated on their responses using free text. Thus, it was difficult to capture the precise amount of time dedicated solely to the recognition and communication of dying. The teaching hours presented here are the maximum estimates derived from the respondents’ free-text replies. Several respondents provided additional feedback about their course, either in direct response to the questions or separately in their email.

Current training

Table 1 details the responses from course leaders regarding current teaching (up to the end of the academic year 2018–2019).

Teaching methods for both recognition and communication of dying varied from (1) lectures; (2) online learning; (3) group work or workshops; (4) placements; (5) simulated environment and (6) external speakers. One nursing course described a ‘worries in a hat’ session for anonymous concerns of working with dying people.

Table 1

Responses regarding current training in the UK

Many courses identified that the teaching they provided was not specific to death and dying but part of general palliative care or general skills training, within the realm of their profession.

We teach them about what dying looks like, what to look out for and how to respond to it—which will often be to share their observations with the MDT… We do not normally give prognostic information. (Occupational therapy courses)

….covered in the lecture (about recognising dying) and also covered in the breaking bad news training, although not specifically about prognosis, some of the cases cover topics such as discussing uncertainty re: outcomes (Medical course)

The reliance on experience through placement or attending optional sessions run by external agencies was highlighted by several allied health courses.

We don’t routinely cover this area (…)—some students may come across such situations while on placement (…) (but not many). (Social Work course)

We encourage students to attend sessions run at the local trust, one of which is about this subject ‘how to have conversations with someone who is dying’? (Occupational therapy course)

Additional feedback

Three additional topics were mentioned by respondents.

A champion. Many of the courses in which there was training had a leader who was passionate about increasing palliative care knowledge. One example was a nurse who described it as a challenge to get 2 days a year designated specifically to working with dying people.

Barriers. All respondents acknowledged the need and importance of teaching students to work with dying people, but many identified logistical and practical issues.

(There are) so few palliative care placements available and few social work specialists. (Social Work course)

(They were) originally provided a taught session on the recognition of the dying patient. However, due to constraints with time, this was changed to a guided study with identified reading. (Nursing course)

Engagement. Several nursing and allied health courses reported that they were in the process of updating their training content to include EOLC. Many courses were keen to know how other courses were providing training in this area so that they could learn from them.

(I) found your email to really prompt some questions about how and where this subject should be integrated into the degree. I would be interested in discussing/exploring this further (Social Work course)

Discussion

Teaching about EOLC was variable across the courses and professions, which echoes previous evidence looking at medical and nursing schools,7 10 11 but is a novel finding across multiprofessional courses. The nursing and allied health courses that contained more palliative care content were those that appeared to have a ‘champion’. That is, someone with experience in palliative care and an interest in bringing that into the curriculum in novel and creative ways. Issues, such as limited funding for the courses, shortage of expert staff, shortage of placement opportunities and limited time during the course, were all key concerns, which limited the inclusion of EOLC.

The course leaders who responded to this survey were acutely aware of the need to prepare students to work with dying people. There was recognition across the board that the demographics of the population are changing and this will affect the nature of the people that the students will support once they graduate: they will be older and with more complex comorbidities.15 Course leaders were keen to learn from their peers at other institutions about how they had successfully implemented additional training.

To the authors’ knowledge, this is the first paper to summarise EOLC training in multiprofessional courses in the UK. The estimates of the time spent on each topic that we obtained for the allied health courses are likely to be overestimates. Some of the courses found it difficult to disentangle how much time was spent on these topics as opposed to palliative care in general. For this reason, we opted to present the figure that used the most generous interpretation of their responses. The overall response rate of the survey was 37%, which means that it is not possible to be sure how representative the sample is, and this thereby limits the generalisability of our findings.

This survey identified how courses are preparing students to work with dying people at the undergraduate level. Further research could be to include students in the survey to understand what is being learnt, in addition to what course providers report. Given the myriad of teaching methods identified in the responses, further research could also seek to measure the impact of training on developing appropriate professional behaviours. This could help to establish the best combinations of these methods, not only at the undergraduate level, but also at the postgraduate training level.

Conclusion

The population of the UK is ageing and living longer with more complex health conditions. It is vital that all healthcare professionals receive training as part of their undergraduate courses to recognise when someone might be approaching the final days of life and to communicate with the person and those around them during this time. This survey identified inconsistencies in the available training, which could affect the ability of healthcare professionals when working with dying persons.

Acknowledgments

We would like to thank the course leaders for responding to the email request.

References

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Footnotes

  • Twitter @@n_g_white, @@LindaOostendorp, @@drol007, @@MCPCRD

  • Correction notice This article has been corrected since it was first published online. The citations in text have been amended to follow the original submitted manuscript.

  • Contributors All the authors contributed to this manuscript and have consented to the submission of this paper. NW, LJMO, SY and PS refined the aims, methodology and interpretation of the responses. OM helped in the interpretation of the responses.

  • Funding This work was supported by the Marie Curie Care (MCCC-FPO-16-U) and the UCLH NIHR Biomedical Research Centre.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The UCL ethics committee determined that no ethical approval was required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data set supporting the conclusions of this article is included within the article.

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