Building bridges in palliative care: evaluating a GP Facilitator programme

End-of-Life Care Education as Blended Learning Approach for General Practitioners: a Scoping Review

General practitioners (GPs) are critical in providing primary palliative care in the community. Apprehensions about managing a dying person at home, difficulties in goals of care discussion, limited resources and lack of palliative care education often hinder end-of-life care provision in the community. This review focused on the end-of-life care training programs accessed by GPs and sought to understand if the training programs' content and mode of delivery aligned with their preferred needs. MEDLINE, EMBASE, CINAHL, and PsycINFO were searched to identify articles published in English between 01 January 1990 and 30 September 2022. Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts. The reviewers screened the titles, abstracts, and full text to identify eligible studies and extracted textual data to analyse and generate themes. Out of 5532 citations initially accessed, 17 studies were included in the review. Six themes were generated: knowledge translation, skill development, a change in attitude, self-efficacy, satisfaction, and patient outcomes. The GPs' end-of-life care knowledge, skills, attitude, self-efficacy, and patient outcomes were better when their training had a combination of small-group interactive workshops, trigger case-based reflective learning, mentor-facilitated experiential learning, web-based modules, and peer learning. The synthesis of review findings supports blended learning as a training approach for general the practitioners' end-of-life care education as it facilitates learning and patient outcomes.

From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation

INTRODUCTION

The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes.

METHODS

Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management.

RESULTS

Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent.

DISCUSSION

Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.

Public Health Perspective of Primary Palliative Care: A Review through the Lenses of General Practitioners

The rising trend of chronic life-threatening illnesses is accompanied by an exponential increase in serious health-related suffering. Palliative care is known to ameliorate physical and psychosocial suffering and restore quality of life. However, the contemporary challenges of palliative care delivery, such as changing demographics, social isolation, inequity in service delivery, and professionalisation of dying, have prompted many to adopt a public health approach to palliative care delivery. A more decentralised approach in which palliative care is integrated into primary care will ensure that the care is available locally to those who need it and at a cost that they can afford. General practitioners (GPs) play a pivotal role in providing primary palliative care in the community. They ensure that care is provided in alignment with patients’ and their families’ wishes along the trajectory of the life-threatening illness and at the patient’s preferred place. GPs use an interdisciplinary approach by collaborating with specialist palliative care teams and other healthcare professionals. However, they face challenges in providing end-of-life care in the community, which include identification of patients in need of palliative care, interpersonal communication, addressing patients’ and caregivers’ needs, clarity in roles and responsibilities between GPs and specialist palliative care teams, coordination of service with specialists and lack of confidence in providing palliative care in view of deficiencies in knowledge and skills in palliative care. Multiple training formats and learning styles for GPs in end-of-life care have been explored across studies. The research has yielded mixed results in terms of physician performance and patient outcomes. This calls for more research on GPs’ views on end-of-life care learning preferences, as this might inform policy and practice and facilitate future training programs in end-of-life care.

Instrument development of health providers' Knowledge, Attitude and Practice of Hospice Care Scale in China

OBJECTIVE

To match the reform of hospice development in China, this study aimed to construct an indigenized health providers' Knowledge, Attitude and Practice of Hospice Care (KAPHC) Scale in China with good validity and reliability.

METHODS

We used three steps to develop the scale, establishing items-pool firstly based on literature review and expert consultation, followed by forming a draft-scale design through synthetically consideration, and finally modifying the draft by conducting a self-administrative survey in sampled institution and testing the reliability and validity by statistical analysis.

RESULTS

The KAPHC Scale was comprised of 15 knowledge items, 24 attitude items and 22 practice items. In the part of knowledge, the Cronbach's α coefficient was 0.686, the average difficulty was 0.62 and average discrimination was 0.46. The attitude items were divided into four domains (KMO = 0.770), with Cronbach's α coefficient of 0.868. The practice items included confidence of practices and self-reported behaviors (KMO = 0.732), with Cronbach's α coefficient of 0.958.

CONCLUSION

The KAPHC Scale demonstrated good validity and reliability. As an effective tool, the scale may contribute to assessing health providers' KAP status of hospice care and exploring their future education needs in mainland China.

General practice nurses and physicians and end of life: a systematic review of models of care

BACKGROUND

General practitioners (GPs) and general practice nurses (GPNs) face increasing demands to provide palliative care (PC) or end-of-life care (EoLC) as the population ages. In order to maximise the impact of GPs and GPNs, the impact of different models of care that have been developed to support their practice of EoLC needs to be understood.

OBJECTIVE

To examine published models of EoLC that incorporate or support GP and GPN practice, and their impact on patients, families and the health system.

METHOD

Systematic literature review. Data included papers (2000 to 2017) sought from Medline, Psychinfo, Embase, Joanna Briggs Institute and Cochrane databases.

RESULTS

From 6209 journal articles, 13 papers reported models of care supporting the GP and GPN's role in EoLC or PC practice. Services and guidelines for clinical issues have mixed impact on improving symptoms, but improved adherence to clinical guidelines. National Frameworks facilitated patients being able to die in their preferred place. A single specialist PC-GP case conference reduced hospitalisations, better maintained functional capacity and improved quality of life parameters in both patients with cancer and without cancer. No studies examined models of care aimed at supporting GPNs.

CONCLUSIONS

Primary care practitioners have a natural role to play in EoLC, and most patient and health system outcomes are substantially improved with their involvement. Successful integrative models need to be tested, particularly in non-malignant diseases. Such models need to be explored further. More work is required on the role of GPNs and how to support them in this role.

Continuing Professional Development for Primary Care Providers in Palliative and End-of-Life Care: A Systematic Review

Background and Objective: This review updates and expands on previous reviews of educational interventions for primary care providers (PCPs) involved in palliative and end-of-life care (PEoLC) and is the first to include early studies related to medical assistance in dying (MAiD). Methods: A comprehensive search strategy was conducted across five electronic databases to locate published interventional studies related to ongoing PEoLC and/or MAiD education for primary care professionals. A descriptive summary of results and a narrative discussion of common themes and comparisons are provided. Results: Thirty-seven studies met the inclusion criteria. The researchers found a myriad of interventions, including courses based, practical experience, mentoring, and workshops. The researchers categorized results by four domains: attitude, confidence, knowledge, and skills. Across domains, seven educational topics emerged: general care, interprofessional collaboration, nutrition, pain and symptom management, patient communication, and professional coping. Overall, studies employed various methodologies, but often relied on cross-sectionally measured self-assessment. Two articles were found that measured the impact of MAiD education. Conclusion: These findings suggest that PEoLC education can improve PCPs' perceived attitudes, confidence, knowledge, and skills across multiple areas of palliative care practice. While PCPs across studies valued educational interventions, the findings relating to the impact of PEoLC education on PCP's provision of effective PEoLC were unclear. However, most interventions resulted in enhanced confidence and knowledge. To date, there are only two studies that have examined MAiD educational programs. There is a need for studies of higher rigor with more emphasis on follow-up to clarify the impact training has on those involved in PEoLC and MAiD.

Facilitation roles and characteristics associated with research use by healthcare professionals: a scoping review

BACKGROUND

Implementing research findings into practice is a complex process that is not well understood. Facilitation has been described as a key component of getting research findings into practice. The literature on facilitation as a practice innovation is growing. This review aimed to identify facilitator roles and to describe characteristics of facilitation that may be associated with successful research use by healthcare professionals.

METHODS

We searched 10 electronic databases up to December 2016 and used predefined criteria to select articles. We included conceptual papers and empirical studies that described facilitator roles, facilitation processes or interventions, and that focused on healthcare professionals and research use. We used content and thematic analysis to summarise data. Rogers' five main attributes of an innovation guided our synthesis of facilitation characteristics.

RESULTS

Of the 38 488 articles identified from our online and manual search, we included 195 predominantly research studies. We identified nine facilitator roles: opinion leaders, coaches, champions, research facilitators, clinical/practice facilitators, outreach facilitators, linking agents, knowledge brokers and external-internal facilitators. Fifteen facilitation characteristics were associated with research use, which we grouped into five categories using Rogers' innovation attributes: relative advantage, compatibility, complexity, trialability and observability.

CONCLUSIONS

We found a diverse and broad literature on the concept of facilitation that can expand our current thinking about facilitation as an innovation and its potential to support an integrated, collaborative approach to improving healthcare delivery.

Factors supporting good partnership working between generalist and specialist palliative care services: a systematic review

BACKGROUND

The care that most people receive at the end of their lives is provided not by specialist palliative care professionals but by generalists such as GPs, district nurses and others who have not undertaken specialist training in palliative care. A key focus of recent UK policy is improving partnership working across the spectrum of palliative care provision. However there is little evidence to suggest factors which support collaborative working between specialist and generalist palliative care providers.

AIM

To explore factors that support partnership working between specialist and generalist palliative care providers.

DESIGN

Systematic review.

METHOD

A systematic review of studies relating to partnership working between specialist and generalist palliative care providers was undertaken. Six electronic databases were searched for papers published up until January 2011.

RESULTS

Of the 159 articles initially identified, 22 papers met the criteria for inclusion. Factors supporting good partnership working included: good communication between providers; clear definition of roles and responsibilities; opportunities for shared learning and education; appropriate and timely access to specialist palliative care services; and coordinated care.

CONCLUSION

Multiple examples exist of good partnership working between specialist and generalist providers; however, there is little consistency regarding how models of collaborative working are developed, and which models are most effective. Little is known about the direct impact of collaborative working on patient outcomes. Further research is required to gain the direct perspectives of health professionals and patients regarding collaborative working in palliative care, and to develop appropriate and cost-effective models for partnership working.

The role and impact of facilitators in primary care: findings from the implementation of the Gold Standards Framework for palliative care

BACKGROUND

Facilitation is the process of providing support to individuals or groups to achieve beneficial change. It is intrinsic to the Gold Standards Framework (GSF) for palliative care, a programme introduced widely in UK general practices.

OBJECTIVES

To explore how GSF facilitators fulfil their role and the impact of the facilitators' backgrounds and approach on practices' uptake of the programme.

SETTING

Primary care organizations and general practices in England and Northern Ireland.

METHODS

Self-completed questionnaire and semi-structured interviews with facilitators. Practice audit questionnaire. Descriptive statistics. Thematic analysis. Linear and random effects models.

RESULTS

A total of 102 (59.6%) facilitators completed a questionnaire; interviews were performed with nine facilitators. A large variability was found in the facilitators' professional backgrounds, role setup and activities. The impact of several facilitation characteristics on practice change was modelled for 63 (36.8%) facilitators and 266 practices (20.4%). No evidence was found of an association between practice change and facilitators' specialist knowledge of palliative care, mean facilitation time per practice, mean number of visits, facilitator budget and incentives offered to practices. Facilitators with a GP background were associated with higher levels of GSF change than those with a clinical nurse specialist background (P = 0.0078 with Bonferroni correction, significance threshold for corrected P = 0.008). The interviews indicated that the differential implementation of the framework might have been strongly affected by internal and external practice-related factors that were not readily amenable to facilitation.

CONCLUSION

This study goes some way towards untangling aspects of facilitation associated with successful implementation of the GSF. Further prospective research and evaluation is needed to identify ways of improving its sustainability, effect on patient outcomes and cost-effectiveness.

Community palliative care development: evaluating the role and impact of a general practitioner with a special interest in palliative medicine

In the context of an increased national policy focus on the development of palliative and end of life care services the post of a GP with a special interest in palliative medicine (GPSI) was introduced in one region of the UK to fortify its current palliative care provision. This paper presents findings from an evaluation of the first 2 years of the GPSI post. A mixed method evaluation design was adopted incorporating qualitative interviews, a satisfaction survey and an activity log. As a concept, the GPSI was welcomed as a suitable and imaginative way to provide much needed medical input. At baseline interviews stakeholders saw the role as an added resource both clinically and educationally, placing highest value on the clinical element of the role. There were concerns related to referral practices (referral was via a GP only) as well as the low profile of the new role. At the final stage of the evaluation, almost 2 years since the role began, stakeholders noted that the use of the GPSI for informal advice and support was highly valued, but also noted that more had been expected, particularly in relation to increased clinical input. The evaluation contained important lessons both for the continuation of this GPSI post and for other regions considering appointing a GPSI in this speciality.

Gaps between knowing and doing: understanding and assessing the barriers to optimal health care

INTRODUCTION

A significant gap exists between science and clinical practice guidelines, on the one hand, and actual clinical practice, on the other. An in-depth understanding of the barriers and incentives contributing to the gap can lead to interventions that effect change toward optimal practice and thus to better care.

METHODS

A systematic review of English language studies involving human subjects and published from January 1998 to March 2007 yielded 256 articles that fulfilled established criteria. The analysis was guided by two research questions: How are barriers are assessed? and What types of barriers are identified? The studies abstracted were coded according to 33 emerging themes; placed into seven categories that typified the barriers; grouped as to whether they involved the health care professional, the guideline, the scientific evidence, the patient, or the health system; and organized according to relationship pattern between barriers.

RESULTS

The results expand our understanding of how multiple factors pose barriers to optimal clinical practice. The review reveals increasing numbers of behavioral and system barriers. Quantitative survey type assessments continue to dominate barrier research; however, an increasing number of qualitative and mixed-method study designs have emerged recently.

DISCUSSION

The findings establish the evolution of research methodologies and emerging barriers to the translation of knowing to doing. While many studies are methodologically weak, there are indications that designs are becoming more aligned with the complexity of the health care environment. The review provides support for the need to examine multiple factors within the knowledge-to-action process.

Systematic review of educational interventions in palliative care for primary care physicians

BACKGROUND

A literature review of educational interventions in palliative care (PC) for primary care physicians (PCP) was performed, to evaluate its impact in changing professional practice.

METHODS

Studies undertaking any educational intervention in PC by PCP, published between 1966 and February 2005, identified through Medline, EMBASE, Cochrane Database of Systematic Reviews and Clinical Trials, Educational Resources Information Centre, Research and Development Resource Base in Continuing Medical Education, Spanish Medical Index, using a combined text word and MESH heading search strategy.

RESULTS

Eighteen articles were included with 1653 physicians. Educative methods were: role model training, small group discussions, and distribution of guidelines. Quality of the studies was low. Opioids prescription improved in two studies. Discrepancies were shown between the perception of PCP in symptom management, determined through questionnaires, and the data concerning opioids prescription. Knowledge improved in all studies. Some benefit of multifaceted approach was stated. Carers were satisfied, in general, with the PCP care, but dissatisfied with patients' pain control.

CONCLUSION

PC education for PCP is poorly studied. Adequate research designs are necessary in future studies with objective outcomes and patient opinion.

Roles, service knowledge and priorities in the provision of palliative care: a postal survey of London GPs

OBJECTIVES

To explore general practitioners' (GPs) current involvement in and attitudes towards the provision of palliative care in primary care.

METHODS

Postal survey of 356 London-based GPs, assessing attitudes towards palliative care provision, district nursing and specialist palliative care services, and priorities for future service development.

RESULTS

Currently, 65% of GPs were providing palliative care to patients on their list; 72% agreed or strongly agreed palliative care was a central part of their role; and 27% wanted to hand care over to specialists. Most GPs (66%) disagreed with the statement that 'palliative care is mainly district nursing (DN) work'. Many were unaware of out-of-hours DN and specialist palliative care services. Multi-variable analysis found four GP characteristics--larger practice size, more years experience as a GP, receipt of palliative care education, and current provision of palliative care--were associated with agreement that palliative care was central to a GP's role.

CONCLUSION

A minority of NHS GPs in London would rather have no involvement in palliative care in primary care. Knowledge of current services for palliative care is generally poor among GPs. These findings highlight potential gaps in services, particularly in small practices. Specialists will need to consider these factors in working with GPs to develop primary palliative care and to enable greater access to specialist palliative care.

Impact of the Powys Macmillan GP clinical facilitator project: views of health-care professionals

The UK charity, Macmillan Cancer Relief, commissioned a 3-year pilot project employing 12 GP clinical facilitators (GPCFs). The aim was to raise the standard of generalist palliative care, provide extended clinical palliative care and provide a coordinated framework for commissioning specialist palliative and cancer care in Powys, rural Wales. As part of the comprehensive evaluation, surveys of GPCFs, GPs, district nurses and community hospital nurses were undertaken in order to record changes in palliative care activity, specialist palliative care services and training needs. Services providing 24-hour nursing and social services were perceived as in need of development. Referrals to Macmillan nurses increased by 40% and GPs reported that time spent on palliative care increased, on average, from a quarter of a day to half a day per week, although district nurses reported a reduction in palliative care activity. The majority of nurses thought that the GPCF's contribution was important. The use of local palliative care guidelines increased significantly among district nurses by the end of the project.