Palliative medicine Master Classes for primary care: an evaluation

Keywords: co‐design, competencies, education, educational evaluation, Kirkpatrick levels of learning, Master Classes, palliative care, primary care.

Palliative care is an approach that focuses on quality of life for people with life-limiting illness and their families through the assessment of physical, psychological, social, financial, and emotional needs.¹ In 2017, a Lancet Commission stated that the alleviation of the burden of pain, suffering and severe distress associated with life-limiting health conditions and with end-of-life is a global health and equity imperative.² In Aotearoa New Zealand (NZ), palliative care is generally provided by primary care. In 2015, a NZ Ministry of Health report defined primary palliative care as integral in the national model of care.³ In this report, the number of people requiring palliative care is projected to rise by 51% by 2038.³ This report also states that 81% of all deaths will require a palliative approach at the end-of-life. Of these, 60% will die under the care of a GP at home or in residential care.

The current model of palliative care in NZ has regional differences, but generally consists of a core team of district nurses, community pharmacies, practice nurses and the GP.⁴ A recent review showed the continuity of care and long-term relationships with patient and families that GPs provide as key factors in quality provision of end-of-life care services.⁵ General practitioners also report that palliative care is an essential part of their job.⁶ In a UK-wide GP survey, 97% felt that primary care played a pivotal role in the delivery of this care to their communities.⁶ Patients with palliative care needs appreciate the ability of GPs to co-ordinate health care, and their knowledge of a wide variety of health issues.^5–7 In NZ, the primary care team is supported where necessary, by secondary care and specialist palliative care services.⁴

The provision of primary palliative care does pose some specific challenges. End-of-life care requires an individualised approach for each patient, a broad knowledge of different diseases, and complex symptom management. Furthermore, palliative care sometimes requires the knowledge of specific medications, or medical procedures that a GP does not encounter often, which include prescribing methadone, palliative care emergencies, or opioid rotation. Jors et al. surveyed experienced clinicians about their recommendations for the improvement of palliative care education.⁸ Suggestions included communication training, knowledge of how to care for family caregivers and basic information on palliative care. Although uncommon presentations of illness might present General Practice with a fresh challenge, the time-constrained environment can lead to palliative care delivery becoming burdensome.⁹ These challenges result in a GP feeling they need further training and the importance of continuing education in palliative medicine.⁸

It is unknown to what extent NZ GPs report they lack specific knowledge about palliative care. An University of Otago review of the undergraduate palliative and end-of-life curriculum in NZ highlighted that this area of medicine has only recently been added.¹⁰ General practitioners acquire relevant skills on the job, or through continuing medical education. It is unclear to what extent GPs have been able to acquire these skills, as no systematic assessment of potential gaps with specifically designed educational tools, has been published.

In NZ there is a need to provide palliative care to a diverse range of ethnic groups, particularly the indigenous Māori population, paying close attention to Te Tiriti (Treaty of Waitangi) obligations.¹¹ Māori, along with Pacific people, experience inequities in the delivery and uptake of palliative care services and have worse health outcomes.¹² Therefore, it is important the care is delivered in a culturally appropriate manner.¹³ Palliative care educational interventions may help address any inadequacies in cultural competence for the learner who is potentially involved in the delivery of end-of-life care in Aotearoa New Zealand.

This study aims to assess improvements in confidence levels of GPs and other health-care professionals before and after delivery of a Master Class series by a specialist palliative care service. The retention of the palliative care knowledge was also evaluated 3 years after the educational intervention. Finally, we plan to use the outcomes of this study to develop a palliative care online module for primary care addressing any knowledge gaps highlighted.

The study took place in the Canterbury region of NZ in 2017 and 2018. Ethical approval was obtained from the Nurse Maude Hospice Palliative Care Ethics Committee. The Master Classes were advertised to primary care providers throughout the region. Participants who had attended a previous session were emailed directly and offered a place in the workshop. The participants were predominantly health-care professionals able to prescribe medication. Convenience sampling was utilised by asking the clinicians attending the sessions to participate in the evaluation. Consent to participate in the study was obtained immediately prior to the Master Class commencement.

In response to a perceived gap in palliative care education for primary care, the lead investigator (AL) assessed current literature and overseas educational programmes for relevant palliative care topics and learning outcomes for primary care. Two of the authors (AL, RJ) worked in a large urban community palliative care service with a strong primary care interface. The original topics were chosen in response to many conversations with local GPs. The Master Classes commenced in 2011 and received strong support from primary care. Each session was evaluated, which was utilised to obtain more specific knowledge of educational needs.

The Master Class series consisted of four workshops delivered over 2 years and included education on opioids, symptom management, non-malignant palliative care, food, and fluids at the end-of-life and ethical dilemmas. The overall learning objectives were to improve knowledge and understanding of several aspects of palliative care and be able to apply this knowledge to end-of-life care. The classes also provided a valuable opportunity to meet members of the specialist palliative care team in person who may be consulting on their patients. The Master Classes were held in the evening, lasted 3 h and each class was facilitated by three local palliative care physicians. Numbers were kept to a maximum of 20 to encourage interaction. All the Master Classes included case-based learning and the opportunity for the health-care professional to bring along their own cases to discuss. The Master Classes were endorsed by The Royal New Zealand College of General Practitioners (RNZCGP) for continuous professional development.

Our study was designed based on the Kirkpatrick model as a way of evaluating the effectiveness of training programmes. The Kirkpatrick four levels of evaluation provide a framework for measuring educational interventions.¹⁴ The first level is a simple evaluation of a course or training session, whereas the second level enquires about changes in confidence. The third level of evaluation focuses on application of the educational intervention learning outcomes and the last step measures changes in practice from the perspective of patients and colleagues. Our study design utilised the first three levels.

For each Master Class, the key learning outcomes were identified as 15–18 first-person statements and formed the basis of the questionnaire (Supplementary materials S1–S4). Participants were given paper copies of the questionnaire before and after the Master Class. The questionnaire included demographics such as gender, age, and years of practice. There was also a question on their role in the provision of palliative care and the approximate number of palliative patients they manage per year. The participants were asked to rate their confidence against the statements on a 100-point scale (0 being not very confident, 100 being very confident) before each Master Class. They were subsequently asked to complete the same questionnaire immediately post each Master Class. The survey ended with a question asking if anything could have been done better.

In 2021, the participants were asked to complete a survey rating their current level of application of knowledge and confidence against 31 listed palliative care competencies (or behaviours) (Supplementary materials S5). A five-point scale was used (1 being little or no application and 5 being a strong degree of application). Participants were also asked to list any palliative care topics that had not been included in the Master Classes and if they would be interested in an online Palliative Care module in the future.

The survey results were analysed using descriptive statistical methods in Microsoft Excel (2016; Microsoft Corporation) to obtain averages, ranges, and standard deviations. Data for the pre and post outcomes were compared using paired t-tests. A P-value <0.05 was the threshold for statistical significance. Effect sizes of each Master Class were determined in the conventional way by measuring differences in means as a proportion of the standard deviation. Evaluation of the free-text questions involved simple content analysis by authors AL and RJ, which identified recurrent themes.

Fifty-six pairs of surveys were completed by the workshop participants. It is unknown how many unique participants there were as the information was collected anonymously and it is possible the same person filled out questionnaires at multiple Master Classes. Most participants who attended the workshops were experienced female GPs (Table 1). There was a small group of Nurse Practitioners and Medical Registrars. The number of palliative care patients they had varied from one to >10 per year. The demographics were similar for the 3-year follow-up group.

Table 1.  Characteristics of participants who attended all four Master Class workshops and the 3-year follow-up group.

Almost all the learning objectives measured in the questionnaires improved significantly. The top five objectives ranked by mean change are displayed in Table 2. The learning objectives that did not significantly improve included: confidence with subcutaneous infusions, ethical dilemmas, and advance care planning (see Supplementary materials S6 for full results). These topics already showed a high degree of confidence and did not show much improvement. The overall effect size of each workshop (range 0.98–1.82) showed a high degree of change.

Table 2.  Five most improved learning objectives from each workshop as per the mean change.

In the 3-year follow-up questionnaire, there was a very strong, or strong degree of application of the Master Class content for most of the learning objectives (Fig. 1). The most strongly applied information to practice included: prescribing breakthrough pain options, using the correct opioids in a palliative patient, and managing constipation. The palliative care emergency topics were least applied.

Fig. 1.  Degree of application to practice of the Master Class learning objectives the participants reported 3 years after the educational sessions.

Analysis of the qualitative comments from the participants showed some common themes. The respondents reported that the educational material was relevant and practical to their clinical practice. Clarity of the teaching and quality of the resources was mentioned. Several participants reported that the format was engaging, and they particularly enjoyed the multiple speakers.

General practitioners are crucial to the provision of palliative care in the community. Education, training, and support from specialist services helps primary care to improve their skills and confidence in the complexities of symptom management, the use of certain medications and goal setting at the end-of-life. This study shows that evidence-based Master Classes designed with local input appears to be effective as an educational model. The improvements from the Master Classes were sustained after three years, except for those situations rarely seen by General Practice such as palliative care emergencies. The participants indicated there was interest in an online palliative care module for further advancement.

The content of the Master Classes was developed in collaboration between the specialist palliative care service and local GPs. Previous studies have shown that GPs report the need for ongoing palliative care training.^15,16 Often, these courses are designed by specialist services; however, unless the content has practical application to the GP, they will be less effective.¹⁷ Co-designing our educational intervention allowed us to resolve any discordance between the priorities of the expert and the participants, as well as deliver the material in an engaging format.¹⁵

Evaluations of continuing education are important in ensuring the delivery of high-quality content.¹⁸ Assessments of the content of palliative care educational interventions and how they impact physician practice and patient outcomes are scarce in the literature.^19,20 We used the Kirkpatrick model to guide our evaluation at the time of the intervention and assess behaviour changes three years later.¹⁴ The Kirkpatrick model has been used in education evaluation since the 1950s and has been found to offer curriculum developers a simple framework to assess interventions.²¹ The model can be adapted to different settings and topics. Artioli et al. assessed a palliative care training programme designed by palliative care specialists for hospital health-care professionals.²² The research team utilised the Kirkpatrick model to evaluate the programme content of the course and tested knowledge that increased significantly. Their positive outcomes were similar to our findings.

Various educational formats for training in palliative care have been studied, including online options.^23–25 Online training formats have the added advantage of reaching rural and remote practitioners more easily, particularly as 16% of the NZ population lives rurally.²⁶ Dy et al. developed an online palliative care module for hospital specialists to manage pain in ambulatory patients.²³ Similar to our study, they found pre-test knowledge of pain management was low across many domains and scores improved immensely after the educational intervention. A randomised-controlled trial utilising an online palliative care education programme showed improvements in symptom management for patients and decreased family anxiety.²⁴ The participants in this study also reported increased confidence in communication and knowledge. Although our participants highly rated the face-to-face element, the emergence of coronavirus disease 2019 (COVID-19) has made the online environment for medical education more convenient. It is reassuring to see that in the literature, results were similar for online formats.

The main strength of our study was the formal evaluation of a palliative care educational intervention using the Kirkpatrick model, both immediate and long-term. The three-year follow-up survey identified the lasting effects of the education and the strong degree of relevance of the course content. Other strengths of the study were the diverse nature of the participants and the co-design of the course material.

The limitations included a relatively low number of participants who were all from the same region; therefore, outcomes may not be representative of all GPs across New Zealand. Data were not collected about the ethnicities of the participants, which would be important for future evaluations. Education in the delivery of culturally appropriate palliative care was not included in the content as the information mainly focused on symptom management. Those who attended the Master Classes were likely to be a highly motivated group, willing to learn about palliative care topics and engage with the content. Although the study aimed to evaluate the enduring impacts of the learning, this was all self-reported.

Continuing medical education is vital for updating and upskilling practitioners in health. The interface between specialist palliative care and General Practice is strong, particularly in community settings. A co-designed palliative care course with content relevant to GPs and other health-care professionals can make a significant positive and lasting impact; however, the evaluation highlighted that not all the content was necessary, and further refinements can now be made to the curriculum. The Master Classes were all in person, with the training delivered in a hospice by several palliative care specialists. A change in educational format may be necessary as the world faces pandemics, isolation, physician time pressures and the growing complexity of patients. In the future, palliative care education may need a hybrid, blended format of in-person and online options. In-person training helps with collegiality and engagement, whereas online content is accessible to more health-care professionals. This change in educational delivery will need evaluation and further refinement to find the best balance for positive learning outcomes. Future research should focus on the potential of online modules and more personalised education based on individual knowledge gaps. Consultation with Māori and Pacific clinicians to ensure the content is culturally appropriate and provides information to improve palliative care provision to these communities is vital.

These Palliative Care Master Classes for primary care led to a lasting improvement in many learning outcomes. Educational programmes such as Master Classes may help meet the global demand for ongoing medical education on palliative care.

The data used in this research are available on request.

The authors declare no conflicts of interest.

This study received no specific funding.

Initial research design and interview questionnaire were done by AL and RJ. AL, RJ and PH were involved in the data analysis and writing of the article. All the authors have read and approved the final version of the paper.

Supplementary material is available online.