European Journal of Cancer Care Education Education in palliative care: a qualitative evaluation of the present state and the needs of general practitioners and community nurses DAVID JEFFREY, General Practitioner, St Richard s Hospice Foundation, Evesham, Worcester, UK JEFFREY, D. (1994) European Journal of Cancer Care 3, 67 74 Education in palliative care: a qualitative evaluation of the present state and the needs of general practitioners and community nurses. A questionnaire survey was carried out of all general practitioners, community hospital nurses and community nurses working in Worcester Health District in the west of England, to assess the present state and future needs of their education in palliative care. The overall response rate of the survey was 72%. The respondents were an experienced group of doctors and nurses. They felt that their undergraduate or basic training did not prepare them to care for dying patients in the community. Educational needs were identified: control of symptoms other than pain and bereavement care were priorities for doctors. Community hospital nurses rated pain control education as a major need. Alternative medicine and caring for dying children were additional areas for further education for the general practitioner and community nurses. Ninety per cent of general practitioners, 84% of community hospital nurses and 95% of community nurses felt that multi-disciplinary teaching sessions would be helpful. Analysis of their responses revealed that these would be most likely to succeed it they were arranged in the middle of the day during lunch or in the evenings. The doctors felt that they lacked protected learning time. Nurses also felt this, but in addition, identified lack of finance as a limiting factor in their post-basic education. There was evidence that existing educational resources in the district are under-utilized. Keywords: continuing medical education, continuing nursing education, palliative care multidisciplinary education. INTRODUCTION Palliative care aims to maximize the autonomy of the dying patient (Jeffrey, 1993). This aim may be achieved by meticulous symptom control, open honest communication, family support, multidisciplinary teamwork and bereavement care. Continuing education and training is important for doctors and nurses involved in caring for patients with life-threatening diseases (Doyle, 1989). This European Journal of Cancer Care, 1994, 3, 67 74 study was carried out to determine the views of general practitioners, community hospital nurses and community nurses, about their present level of knowledge and future educational needs in palliative care. BACKGROUND Education programmes in palliative care should be based on sound information of the perceived educational requirements of potential participants. Effective programmes should have clearly defined aims and objectives. The con- 67
JEFFREY Education in palliative care tent and training methods should be appropriate to meet these identified educational needs. Calman suggested that the following topics should be part of a palliative care curriculum: concepts of death and dying, values, religion and ethics, objectives of care, quality of life teamwork, communication, education (Calman, 1988). Previous studies of the educational requirements of doctors have indicated needs in particular areas: symptom control and family support (Haines & Booroff, 1986; Rapin & Weber, 1991). CharIton calls for a radical shift in undergraduate training to allow future doctors to have an opportunity to discuss the ethical and emotional issues that they confront in their training (Charlton, 1992). Educational initiatives can improve the quality of patient care (Higginson, 1993). in a review of the factors which would enable more dying people to remain in their own homes, Thorpe suggests that special attention should be given to the educational needs of general practitioners and community nurses (Thorpe, 1993). The choice of educational methods employed is crucial if the aims of an education programme are to be achieved. Macleod & Nash (1991) found that a majority of general practitioners were uncomfortable with experiential methods and preferred didactic teaching. Their study demonstrated that participants were willing to work in small groups, but there was a reluctance to be involved in role play. Other studies, although limited by low response rates, have also shown a preference for traditional formats of medical education which emphasize acquiring information rather than improving skills (Haines, 1993). Patient s needs for open communication and emotional support are acknowledged, but this is not reflected in the doctors educational priorities. Palliative care in the community depends upon effective multi-disciplinary and inter-disciplinary teamwork. it is therefore surprising that generally, medical and nursing education programmes pursue rigidly separate paths. We need to know whether doctors and nurses feel they have sufficient protected time to utilize the considerable educational resources which exist. In Britain, there have been changes in the organization of primary health care teams. It is relevant to examine whether these changes have affected educational opportunities for doctors and nurses. Palliative care is one facet of medical and nursing care. If we are to become humane and effective carers, we need to broaden our horizons (Charlton, 1993; Macdonald, 1993; Benton, 1988). Perhaps the greatest educational challenge for doctors and nurses is to acknowledge that we need not only to work together, but also to be prepared to learn together. METHODOLOGY In July 1993, a postal questionnaire was sent to the 134 general practitioners and 137 community nurses working in Worcester Health District, serving a population of almost 250 000. The questionnaire was also sent to the 122 nursing staff of the three community hospitals within the same district. The covering letter assured respondents that their remarks would remain confidential. Four weeks later a second copy of the questionnaire was sent to the nonresponders. Responses were entered and analysed using Epi-Info s statistical software (Dean et al., 1990). The overall response rate was 285 replies to 393 questionnaires (72%); 92 (69%) of general practitioners; 102 (84%) of community hospital staff, and 91 (66%) of community nurses responded to the questionnaire. FINDINGS Years since qualification Analysis revealed that the responders were an experienced group of doctors and nurses (Table 1). Basic training The question was posed, Do you feel that your undergraduate or basic training prepared you adequately to care for Table 1 Years since qualification of respondents Years since qualification Present post 0 5 5 10 10 15 15 20 20+ Total General practitioner 7 is 30 15 20 90 (7.8) (20) (33.3) (16.7) (22.2) Community 8 13 20 20 16 102 hospital nurse (7.8) (12.7) (19.6) (15.7) (44.1) Community nurse 6 18 13 17 35 89 (6.7) (20.2) (14.6) (19.1) (39.3) Total 21 49 63 52 71 285 Percentages given in parentheses. 68
European Journal of Cancer Care dying patients in the community? The responses were graded as not at all, inadequately, adequately and well and the results are shown in Table 2. Of the 278 responders to this question, 241 (86.7%) felt that their basic or undergraduate training did not prepare them either adequately or at all for caring for dying patients in the community. Only 37 (13.3%), responders felt adequately or well prepared for this area of work. There does not seem to be any evidence that those who qualified more recently felt any better trained that their more experienced colleagues (Table 3). Post-basic training or specialist experience in palliative care The responses show that the levels of specialist experience, working in a hospice or oncology unit, seems to be similar, but community nurses tend to have more postbasic qualifications and attend more courses in palliative care than general practitioners and community hospital staff (Table 4). Does this post-basic training make professionals feel more adequately trained to care for dying patients in the community? Of the responders to this question (n = 195), 20 general practitioners, 12 community hospital nurses and 25 community nurses felt adequately trained in palliative care. CURRENT STATE OF TRAINING IN PALLIATIVE CARE Questions were asked to determine in which particular areas of palliative care the professionals felt adequately trained. The responses show that the majority of general practitioners felt adequately trained in pain control and teamwork but less confident in control of other symptoms, bereavement care and communication skills. On the other hand the majority of community nurses felt adequately trained in teamwork and communication skills, but were less happy in the other areas (Table 5). USE OF AVAILABLE EDUCATIONAL RESOURCES Ninety per cent of general practitioners stated they used the local post-graduate centre, 83% used their own practice library and 73% attended formal lectures. Only 1% used the Hospice study centre nearby and 4.5% attended a monthly multi-disciplinary Palliative Care Interest Group organized at the Hospice study centre. Sixty-two per cent of the community hospital nurses attended formal lectures and 41% used the library at the College of Nursing. Amongst this group, 6% used the Hos- Table 2 Adequacy of basic/undergraduate training in preparing doctors and nurses for caring for dying patients in the community Present post Not at all Inadequate Adequate Well Total General practitioner 34 44 9 2 89 (38.2) (49.4) (10.1) (2.2) Community 36 47 13 4 100 hospital nurse (36) (47) (13) (4) Community 31 49 8 1 89 nurse (34.8) (55.1) (9.0) (1.1) Total 101 140 30 7 278 Percentages given in parentheses. Table 3 Adequacy of basic/undergraduate training compared with years since qualification Basic training Years since qualification Not at all Inadequate Adequate Well Total 0 5 9 9 2 0 20 5 10 11 33 4 1 49 10 15 19 34 7 2 62 15 20 21 22 3 1 47 20+ 39 40 24 3 96 Total 99 138 30 7 274 69
JEFFREY Education in palliative care Table 4 Post-basic specialist training and qualifications in palliative care Qualifications in Palliative Present post Previous experience palliative care care courses Total General practitioner 18 0 21 39 Community hospital nurses 21 6 28 55 Community nurses 24 18 53 95 Total 63 24 102 189 Table 5 The areas of palliative care in which health care professions feel adequately trained pice study centre and 5% attended the Palliative Care Interest Group. Seventy-four per cent of the community nurses used the College of Nursing library and 67% attended formal lectures. Twenty per cent used the Hospice study centre and 35% attended the Palliative Care Interest Group. FUTURE DEVELOPMENT OF PALLIATIVE CARE EDUCATION In which areas of palliative care do you feel the greatest need for further education? Respondents were asked to score their need from 1 (least need) to 5 (most need) for education in pain control, control of other symptoms, bereavement care, communication skills and team working. The results are presented in Figs 1 5. Present Pain Symptom Bereavement Communication post control control care skills Teamwork General 67 36 36 48 58 practitioner (74.4) (40.4) (40.4) (53.3) (64.4) (n = 90) Community 23 19 39 53 58 hospital (23.5) (19.8) (39.8) (53.5) (59.2) nurse (n = 98) Community 38 31 39 58 68 nurse (43.2) (35.2) (44.3) (65.2) (78.2) (n = 88) Percentages given in parentheses. EDUCATIONAL NEEDS IN OTHER AREAS OF PALLIATIVE CARE Respondents were asked to indicate whether they would be interested to learn more about alternative medicine, social aspects of care, care of the dying child, spiritual aspects, HIV/AIDS and self-help groups. Amongst the general practitioners (n = 90), 74% wanted to learn more about care of the dying child, 60% about alternative medicine and AIDS. Of the community hospital nurses (n = 100), 86% indicated that they wished to learn about alternative medicine, 75% about social aspects of care and 70% about AIDS. The community nurses (n = 90), expressed a high interest in all the topics: 90% alternative medicine, 80% social aspects and AIDS, 75% care of the dying child and 71% in spiritual aspects of care. Figure 1 Educational need in pain control. 70
European Journal of Cancer Care Figure 2 Educational need in control of other symptoms. Figure 3 Educational need in bereavement counselling. Figure 4 Educational need in communication skills. FORMAT OF TRAINING Do you feel that multi-disciplinary learning sessions are helpful? Ninety per cent of general practitioners (n = 88), 84% of community hospital nurses (n = 100), and 95% of community nurses (n = 88), felt that multi-disciplinary learning sessions would be helpful. When asked to select their preferred educational formats, general practitioners, community hospital nurses and community nurses gave broadly similar responses. They favoured multidisciplinary sessions, formal lectures and small group work. The three least favoured formats were distance learning, role play and project work (Table 6). 71
JEFFREY Education in palliative care Figure 5 Educational need in team working. Preferred time Seventy-six per cent of general practitioners expressed a preference for evening sessions, with 48% also indicating that lunchtime was suitable. However, only 22% of community nurses wanted evening sessions, 52% indicated that either lunchtime or afternoon sessions were most convenient. The community hospital nurses also preferred the afternoon (61%), with 47% indicating that evenings were also convenient. Weekend and morning sessions were generally regarded as inconvenient by all groups. Forty-five per cent of both community hospital nurses and the community nurses stated that they preferred a half day session, 66% of general practitioners wanted a 1 2 hour session. No group favoured the whole day option. Preferred venue Eighty-six per cent of general practitioners preferred the post-graduate centre with 68% indicating that they would like sessions in their own health centres. Ninety-five per cent of the community hospital nurses wished to have the teaching in the community hospital. Seventy per cent of community nurses favoured the Hospice Study Centre and 63% also chose the health centres. Shared expertise A total of 4.4% of general practitioners, 3% of community hospital nurses and 14.3% of community nurses felt that they had a particular area of expertise in palliative care which they would be willing to teach others. Limits to educational activities Respondents were asked whether their educational activities were limited by either time or money or both, or whether neither of these limited their training. Their responses indicate that general practitioners are limited by time, and nurses by both lack of time and money. Only a small percentage of professionals felt no constraint from either time or money (Table 7). Table 6 Preferred form of education in palliative care Percentage of positive responses General Community Community practitioner hospital nurses nurses Format (n = 88) (n = 100) (n = 88) Multi-disciplinary 68.9 69.7 79.8 Formal lectures 71.4 71.3 68.9 Small groups 78.3 83.1 81.1 Distance learning 16.7 37.6 32.2 Private reading 64.4 40.6 48.3 Video 25.8 66.0 52.8 Role play 16.7 23.8 23.3 Clinical attachments 46.1 59.4 65.2 Projects 8.0 39.0 30.3 72
European Journal of Cancer Care Table 7 Limiting factors in palliative care education Both time Neither time Post Time Money and money nor money General practitioner 70.3 0 15.4 14.3 (n =91) Community hospital nurse 15.2 6.1 61.6 17.2 (n = 99) Community nurse 7.7 11.0 78.0 3.3 (n = 91) DISCUSSION The 72% response rate indicates that continuing professional education in palliative care is relevant to the care of dying patients in the community. It is surprising that only 13.3% of doctors felt that their basic training prepared them for palliative care in the community. Moreover, although this sample was predominantly an experienced group, there was no evidence that those qualifying within the past 10 years felt any better trained. Among the three broad groups surveyed general practitioners, community hospital nurses and community nurses-it appears that the community nurses, who included four specialist palliative care nurses, have undertaken most palliative care training since qualification. Recognition of this body of expertise by colleagues, and sharing of the knowledge and skills, could improve care of dying patients at home. More detailed analysis of current levels of knowledge indicate that doctors now feel more confident about controlling pain, but less so about other symptoms. Both doctors and community nurses are happier about their team working skills. Bereavement care and improving communication skills are priorities for all the professionals. Available resources are not being utilized. St Richard s Hospice, Worcester, has opened an Educational and Study Centre. This centre has an excellent library, lecture room, interactive computer learning, teaching videos and runs a course for nurses on Care of the Dying Patient and his Family, study days and a monthly Palliative Care Interest Group. An objective of the centre is to promote multidisciplinary education. Less than 5% of general practitioners use this resource, in contrast to the 35% of community nurses who used the centre. General practitioners feel that they do not have protected time for education and prefer to attend evening meetings. Most of the activities at the study centre occur during the day. However, the nurses also feel constrained by a lack of time, but clearly identified lack of money as another limiting factor to their post-basic training. Nurses in this study are employed by a National Health Service (NHS), self-governing Trust. It is vital that senior managers appreciate that education is an essential component of professional work and not a luxury which can be left to the individual to fund. Since the new way of working in the NHS, doctors are paid a post-graduate education allowance and so do not feel that finance limits their education. The survey highlighted areas where further education is particularly needed. It is interesting to note that in most areas the community nurses feel a greater need for further education than their general practitioner colleagues, despite the fact that their replies indicate that they have attended more post-basic courses on palliative care than the doctors. With greater experience in working in primary health care teams, it is encouraging to see that professionals feel more confident of their team-working and communication skills. Bereavement care remains a priority as does pain and symptom control for the community hospital nurses. On the other hand, doctors now feel less need for education on pain control, but have identified a need for further training on control of other symptoms. Sixty per cent of doctors expressed an interest in learning more about alternative medicine as did 90% of the community nurses. Both groups wanted more training on caring for dying children and their families. There was a clear indication from this study that both doctors and nurses would like teaching sessions to be multi-disciplinary. It is a paradox that while so much of palliative care in the community depends on teamwork, that doctors and nurses should have so few opportunities to learn together. As in the Macleod Study, formal lectures and small-group work were preferred forms for education (Macleod & Nash, 1991). There seems to be scope to develop multi-disciplinary small-group teaching, perhaps based in the health centres or community hospitals. When formal lectures are arranged, perhaps both doctors and nurses could be invited to attend. In planning sessions, this research shows that weekend or whole-day teaching is unlikely to attract a multi-disciplinary audience. Lunch-time or evening sessions would seem to be the most likely to appeal to multi-disciplinary participation. 73
JEFFREY Education in palliative care Those working in palliative care and responsible for education are aware of the enormous potential for doctors and nurses to learn from each other within the primary health care team. Only 4% of doctors, 3% of community hospital nurses and 14% of community nurses felt that they had any special expertise in palliative care that they would be willing to teach others. Perhaps if local multidisciplinary teaching sessions were arranged, then health care professionals would come to appreciate the large amount that can be learned from each other. CONCLUSION There remains a need to continue to improve the training of doctors and nurses with regard to palliative care. Doctors seem to be more confident of their ability to control pain, but need further education in control of other symptoms. Both doctors and nurses have indicated needs for further training in bereavement care. Current educational resources in palliative care in Worcester are underutilized. Doctors feel that they do not have protected time for education. Community nurses feel that their educational opportunities are limited by time and money. There is a need to develop multi-disciplinary educational initiatives. These are likely to succeed if they are locally based, less than 2 hours in length, and are arranged at lunch-time or in the evening. The local hospice educational team face the challenge of increasing the awareness of local doctors of the facilities and resources available at the Study Centre. At a time when the workload of doctors and nurses in the community is increasing there is an urgent need to provide protected time and resources for continuing education in palliative care. ACKNOWLEDGEMENTS I would like to thank medical and nursing colleagues who responded to the survey. I am grateful to the Clare Wand Fund of the British Medical Association, for a financial grant. I have had help and advice from Dr Anne Pursey and Sarah Fowles. Finally, my thanks to Wendy Rouse for her word-processing skills. References Benton T.F. (1985) Medical education and training in palliative medicine: medical under-graduates. Palliative Medicine, 2, 139 142. Calman K.C. (1988) Medical training-the early post-graduate years. Palliative Medicine, 2, 143 146. CharIton B.G. (1993) Holistic medicine or the humane doctor? British Journal of General Practice, 43, 475 477. CharIton R. (1992) The Philosophy of Palliative Medicine: A Challenge for Medical Education. Medical Education, 26, 473 477. Dean A., Dean J., Button A.H. & Dicker R.C. (1990) Epi Info, Version 5: A Word Processing, Database and Statistics Program for Epidemiology on Microcomputers. Stone Mountain, Georgia, USA. Doyle D. (1989) Education in palliative medicine and pain therapy: an overview. Royal Society of Medicine Services International Congress and Symposium, Series No. 149, 165 174. Haines A. & Booroff H. (1986) Terminal care at home: perspective from general practice. British Medical Journal, 292, 1051 1053. Haines C. (1993) Assessing needs for palliative care education of primary care physicians: results of a mail survey. Journal of Palliative Care, 9, 23 26. Higginson 1. (1993) Advanced cancer: aiming for the best in care. Quality in Health Care, 2, 112 116. Jeffrey D. (1993) There is Nothing More I Can Do. An Introduction to the Ethics of Palliative Care. Patten Press, Cornwall. MacDonald N. (1993) Priorities in education and research in palliative care. Palliative Medicine, 7 (suppl. 1), 65 76. Macleod R. & Nash A. (1991) Teaching palliative care in general practice: a survey of educational needs and preferences. Journal of Palliative Care, 7, 9 12. Rapin Ch-H. & Weber A. (1991) Palliative care: training needs, developments, difficulties and perspectives. Palliative Medicine, 5, 222 232. Thorpe G. (1991) Teaching palliative care to United Kingdom medical students. Palliative Medicine, 5, 6 11. Thorpe G. (1993) Enabling more dying people to remain at home. British Medical Journal, 307, 915 918. 74