Article Text
PDF
Statistics from Altmetric.com
Dear Editor,
We have read with interest recent articles describing modifications made to specialist palliative care services during the COVID-19 pandemic.1 2 Care providers have been flexible and innovative, in providing support to patients, families and non-specialists. They have used new ways of working to improve care and facilitate advance care planning to enable patient’s wishes to be fulfilled and hospital admissions to be avoided.3 4 Feedback from patients and families has been encouraging. We note that while the views of several stakeholder groups have been explored, evaluations to date have not focused on the experience of palliative medicine trainees who have faced specific pandemic challenges.
To capture trainees’ views, we surveyed all UK palliative medicine trainees regarding the effect of the pandemic on their work. We received 38 responses from all UK training regions. We collected quantitative and qualitative data on changes to the workplace and training. The latter was interpreted using thematic analysis.5
During the pandemic, changes to models of care affected the delivery and experience of palliative care training. New ways of working and redeployment changed how competencies were achieved. Although trainees faced challenges with the rapidity of changes to working practices, additional opportunities arose that allowed trainees to develop new skills. Redeployment was seen for nearly a quarter of the trainee workforce. The majority were redeployed to other palliative medicine services, 23.7% of trainees were redeployed to areas out with the specialty. Four main themes arose from the survey: communication, work opportunities, education and well-being.
Communication
All survey respondents recognised a change to consultations. Inpatient liaison services reported an increase in face-to-face consultations and increased requests for telephone advice and telephone consultations. Community and outpatient settings reported reduced face-to-face consulting and increased telephone and video consultations. Hospice settings continued to require face-to-face consultations, with increased telephone interactions due to visiting restrictions. Personal protective equipment and physical barriers added further complexity to all interactions.4
Despite discomfort in using video consultations, trainees commented on the innovation of this method and its added benefits. Challenging virtual consultations included those with cognitively impaired patients, performing initial assessments and supporting family members. Respondents felt the experience improved communication skills and allowed exploration of new ways to consult, but reduced the opportunities for directly observed assessments which are required to demonstrate competencies and progression in training.
Work opportunities
The pandemic presented several positive work opportunities. Trainees were actively involved in policy, guideline and educational resource development. Trainees reported increased opportunities to lead on acute complex symptom management and situations, such as the withdrawal of non-invasive ventilation.
Due to pressures from the pandemic, several trainees highlighted reduced support from seniors. For some trainees, this created opportunities to develop supervisory and leadership skills; for others, this meant less support and fewer opportunities to complete workplace-based assessments. Notably, some trainees experienced an increase in consultant presence. Trainees highlighted opportunities to witness good leadership skills in seniors. Varied workloads were noted with some teams reporting a significant influx of work, while others had reduced caseloads with a reduction in learning opportunities.
Education
Face-to-face education halted for most training sites. This was largely followed by introduction of virtual teaching. The survey results spoke highly of this shift, with 35.3% of all the trainees feeling this allowed for greater flexibility, particularly if the sessions were recorded. Travel time between teaching sites was also eliminated. Increased access to regional and national teaching, along with access to a wider cohort of speakers, was noted. The opportunities for trainees to deliver teaching were, at times, reduced, which limited opportunities to complete teaching assessments.
Nearly 60% of respondents found acquiring direct observation of procedural skills assessments challenging, with increased workload and reduced movement to other clinical areas. Mini-Clinical Examination assessments were also affected by increased clinical pressures and a reduction in joint reviews. Ninety-five per cent of trainees surveyed felt essential training components were impacted.
60.9% of trainees reported research meetings or projects being postponed. 45.9% of trainees felt it was more difficult to gain research opportunities. Conversely a similar number (43.5%) reported being engaged in new research.
Well-being
The words ‘emotional intensity’ and ‘fatigue’ featured several times in the responses. Trainees acknowledged that there was increased anxiety and stress for staff and patients. At times, trainees found it difficult to look after their own well-being. Several trainees identified increased focus on staff well-being and support within palliative care teams. Peer support for trainees, arising from face-to-face teaching and social events, was lost. Although virtual attempts were made to counterbalance these changes, they were not without challenge.
Shielding and self-isolating trainees were faced with navigating different approaches to work. Some expressed having lost a sense of team working. Many trainees were provided with remote access to hospital systems in order to facilitate their altered role. Trainees reported opportunities to engage virtually in audit work, guideline development and teaching. Despite these interventions, only 30% of this group felt fully able to work from home.
Reflections
We have captured the impact of the COVID-19 pandemic on palliative care specialist training, identifying a range of trainee experiences. Despite a small sample size, the responses have raised questions about how training may evolve in future. Helpfully, pandemic-related training challenges were acknowledged and accounted for during annual competency assessments in the UK.
Education delivery has been challenging, but the predominant virtual delivery of education has increased opportunities for attendance as well as the breadth of speakers. The survey highlights new opportunities in teaching delivery that could increase and facilitate interdeanery, even national teaching.
A noticeable change was greater emphasis on the use of virtual and telephone consultations to review patients. As a result, training programmes should consider incorporating formal virtual and telephone communication skills training into curriculums to support trainees in these newer ways of working that will allow the possibility for increased patient contacts, while continuing high-quality individualised care.
Given the relevance of these findings, we hope that future evaluations of palliative care will incorporate the perspective of the trainee workforce.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Newcastle University Ethics Committee Ref: 6419/2020 Participants gave informed consent to participate in the study before taking part.
Acknowledgments
Our thanks go to the following consultants for their guidance and support. Dr Polly Edmonds, Consultant in Palliative Medicine, Kings College Hospitals, Chair of Palliative Medicine SAC, UKDr Jen Vidrine, Consultant in Palliative Medicine, Newcastle Hospitals, Training Programme Director North East, UK.
Footnotes
Twitter @cgouldt
Contributors The project was led by the North East Palliative Registrars Research & Education Alliance (NEPPRA) who include GR, HB, FD, CG, MC, KH, EW, AH, EK, RK, AL, FM, LS. It was also supported by the Association of Palliative Medicine Trainees Committee (SE, HR, JL) who assisted in distributing the survey nationally. GR, HB, FD, SE, HR and JL: survey design and distribution. HB, GR, CG: review of results. MC, GR, FD: reporting of the work described in the letter. CG, KH, EW, SE, FD: review of the letter. AH, EK, RK, AL, FM, LS: research group involved in review of initial survey.FD: guidance on the research process, application for ethical approval.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.