Analyzing the Unique Needs of International Palliative Care Learners Attending a United States-Based Palliative Care Education and Practice Course

Abstract

Background:

Many seriously ill patients in need of palliative care (PC) globally never receive it, partly due to a lack of well-trained providers.

Objectives:

We analyzed feedback from international participants in a U.S.-based PC training course: “Palliative Care Education and Practice” to identify elements of the course that would meet the needs of international learners.

Design:

This was a qualitative analysis of international course participants' written survey responses. Survey questions were related to anticipated PC practice change, barriers to PC practice change, and course strengths/weaknesses.

Results:

Key barriers to PC practice change included lack of awareness of PC among local providers, challenges navigating institutional leaders, and a lack of trained providers. Participants requested an increased focus on topics such as resiliency, leadership, and pediatric PC.

Conclusions:

To address the needs of international learners, PC courses should consider offering a specific track for international participants, as well as an increased focus on topics such as resiliency, leadership development, and pediatric PC.

Introduction

Of the 52 million adults in need of palliative care (PC) globally, more than 76% live in countries where there is a profound lack of PC education and resources.¹ In 2011, it was estimated that 42% of countries around the world have no PC services and another 32% have only isolated PC services.² Provider training has been identified as a key component of increasing access to PC services around the world.^3–5

Palliative Care Education and Practice (PCEP), a Continuing Medical Education course offered through the Harvard Medical School Center for PC, started in 2000. It has since grown into an internationally recognized course for clinicians from around the world to enhance their PC communication, teaching, clinical, and program development skills. The course structure is one week of in-person sessions in winter and one week in spring interspersed with teleconferences/online discussions within small project groups for learners to design and implement a PC initiative at their home institution.

Given the ongoing need for increased provider education and training in countries where access to PC remains severely limited, PCEP has welcomed international participants since 2003 and provided a limited number of tuition scholarships. As the number of international participants has grown, we sought to analyze course feedback from international participants to identify curricular areas relevant to an international audience that may not have been sufficiently covered, identify key barriers to implementing/improving PC that international participants face, and develop an international curricular track informed by the gaps identified.

Methods

The PCEP participants received evaluation surveys after each course week. These online surveys included questions regarding participants' demographic information (country and degree) and open-ended questions about anticipated practice changes, barriers to change, and course strengths and weaknesses. Due to ongoing changes to the PCEP course (and resultingly changes to the evaluation surveys) since its inception, we analyzed data from the six contiguous years (2010–2016) where survey questions remained constant. Participant open-ended feedback was summarized and reported via representative comments for participants' plans for practice change and barriers to change. These qualitative data were analyzed for common themes utilizing standard approaches to qualitative data analysis.^6,7 Two authors (B.R.D., M.S.) independently reviewed participants' comments to identify common themes. Disagreement was resolved through consensus with input from a third author (K.K.). This project was undertaken as a Quality Improvement Initiative through Massachusetts General Hospital, and as such was not formally supervised by the Institutional Review Board per their policies.

Results

Participant demographics

During the study period, 51 international participants completed PCEP, representing 31 individual countries. Forty one percent of international participants were from low- and middle-income countries (LMICs), and 59% of participants were from high-income countries (note: classification of low, middle, and high income based on the World Bank standards).⁸ All continents except Antarctica were represented. Eighty percent of international participants were physicians, 8% were nurses, and 12% held other clinical roles.

Plans for practice change

When asked to identify their plans for practice change, the most common theme identified by international participants was educational program development (42%). The second most common theme was clinical practice change (25%), followed by strategic/programmatic changes (21%) and communication program developments (9%). See Table 1 for representative comments on each theme.

Table 1.

Common Themes Identified by International Palliative Care Education and Practice Participants as Plans for Practice Change

Theme	Representative comments regarding plans for practice change
Educational program development	- “preparation and delivery of palliative care education and training content.” - “I will also be more confident in setting up a teaching program for GPs (general practitioners).”
Clinical practice change	- “to start to use opioids in my hospital.” - “deep learning in the use of [specific medications].”
Strategic/program change	- “Create a Neonatal Palliative Care Unit and work on improving the standard of care that pediatric palliative patients are currently offered.” - “Already started to contact some stakeholders and initiate a taskforce group.”
Communication program developments	- “Implement different communications skills learned during the course.” - “Intensive communication skills debriefing.”

Barriers to implementing change

International participants described various barriers they anticipated facing in returning to their home country and practicing PC, as seen in Table 2. The majority of respondents (52%) identified institutional barriers, including lack of time, funding, and/or administrative support. The next most common theme identified was cultural barriers, particularly the culture within the participants' home countries and culture of their health systems (27%). Additional barriers included lack of trained providers/educators (11%), and systems barriers, particularly within the ministries of health and the referral system (9%).

Table 2.

Common Themes Identified by International Palliative Care Education and Practice Participants as Barriers to Change

Theme	Representative comments regarding barriers to change
Institutional barriers	- “lack of materials and tools, lack of staff resources.” - “lack of time, low institutional support.”
Cultural barriers	- “In some places of [my country], the cultural aspect, (multiethnic), the language (multilingual), and the illiteracy.” - “There's no palliative care culture where I live.”
Lack of trained providers/educators	- “Lack of knowledge on the topic in the other specialties, like how to address end of life issues.” - “Skilled professionals are lacking in this field.”
Systems barriers	- “Ministry of health approvals which takes time.” - “Geography, i.e., rural areas, small populations, late referrals”

Course strengths/weaknesses

The most common theme identified regarding course strengths was the teaching faculty (37%) followed by small-group sessions (31%) and the personal growth and reflection the course engendered (18%). The main weakness identified was structural: the timing and length of the course (40%), particularly traveling internationally twice in one year. Participants also identified weaknesses with the small-group learning environment (27%), expressing a desire for increased time within the group to develop their project and receive feedback from other participants.

Other content themes highlighted were a desire for more time spent on the issue of burnout and increased leadership skill building. One participant requested more training on “leadership, more about team dynamics, more about implementing a PC program.” International participants also expressed a desire for more pediatric content. Lastly, they requested increased access to course materials, suggesting that they would have wanted concrete materials such as “handouts or online activities with case studies and answers” to take back to their home institutions.

Discussion

In this article, we analyzed six years of qualitative data from PCEP's international participants for themes that could inform future education programs targeted at increasing PC education and training in countries with limited access. Responses were from participants whose home countries represented a wide range of geographic areas and income-levels. Although we appreciated this broad range of perspectives, future work may focus solely on participants from LMICs where the need for PC is most urgent.

International participant perspectives on course strengths and weaknesses

Given that many international participants may be the only PC provider in their home institution (and sometimes even their entire country), it was not surprising that course strengths identified included the emphasis on small-group work and the chance to reflect on their own practice. This was further highlighted by their specific interest in including more content on burnout and leadership. Although these issues are critical for anyone tasked with bringing PC skills to their home institution (indeed, a recent study showed a burnout rate of 39% among hospice and PC clinicians in the United States⁹), international participants who may be one of a few PC clinicians in their country may not experience protective factors against burnout such as on-site colleagues and support from leadership.^10–12 They may be at higher risk of burnout and benefit from additional training in professional resilience and from a small-group cohort of international colleagues facing similar difficulties.

Another important theme identified was the desire for increased access to course materials. This again highlights that many international participants are uniquely focused on bringing back concrete aspects of their learning to their home countries with a goal of transferring their newfound skills to others.

International participants' reported barriers to change

Given that the dissemination of high-quality PC practice requires not only the transferring of knowledge and changing attitudes to colleagues, but also broader institutional change—it was not surprising that the most common barriers identified were institutional and cultural. This also aligned with participants' desire for more leadership skill-building, as international participants may be more likely to be starting or leading PC teams and negotiating with their institutions and ministries of health, and may benefit from additional training in these skill sets. The request to include more pediatric content was likely suggestive of the wider scope of PC that many international providers must provide within their home institutions, which should be considered for future courses.

Creating curricula responsive to international learners

In response to these identified themes, several adaptations could be considered to better meet the learning needs of international participants for courses such as PCEP. One such innovation is offering a separate small group for international participants to better match their unique learning needs while also increasing opportunities for bi-directional learning across the group. This could be especially helpful for the project groups as participants consider how to design and implement novel PC initiatives at their home institutions.

Another potential adaptation could be to offer similar advanced PC courses in partnership with regional PC leaders that could be delivered within their home countries. Not only would this substantially decrease the costs and burdens of travel to the United States, but it could also provide an opportunity to better adapt course content to fit the local needs of PC leaders within a particular region.

In addition, as COVID has forced educators to consider virtual learning platforms, it is crucial to consider how this may impact international learners. For example, a virtual PCEP course would have decreased travel and cost barriers for international learners and could more easily have online repositories of materials that learners could adapt for their home settings, yet it may create logistical barriers for settings without stable Internet access and may decrease the sense of community and connection that international learners rated as a crucial course component. For future iterations of the course, it will be important to consider whether a hybrid in-person/virtual model may allow for further learning and collaboration to better meet the needs of international participants.

Though robust programs such as the International Palliative Care Leadership Development Initiative^13,14 have provided leadership training for international PC providers, given the immense global shortage of PC practitioners, it is important for programs in high-income countries such as the United States that are not exclusively internationally focused to provide content that is relevant and applicable to international learners. Though this study began as a quality improvement initiative for our own program, the data gleaned may have relevance for other PC educational programs to consider how course content and structure can be adapted to a broad range of national and international learners.

Conclusion

With growing recognition within the international literature that one of the ongoing barriers to expanding PC services globally is the lack of well-trained providers, PCEP, one of the oldest and largest PC training opportunities in the United States, seeks to understand and meet the learning needs of international participants. Our experience shows that gaps remain in the education provided to these participants, and future courses should consider cohort opportunities for international participants to be able to connect with one another from within the larger group of participants, increased focus on topics such as burnout, professional development, and pediatric PC, and improved access to concrete materials to bring back to international participants' home institutions.

Footnotes

Authors' Contributions

All authors contributed equally to article conception and design. L.G. contributed to acquisition of data. B.R.D., M.S., and K.K. contributed to data analysis and interpretation. All authors contributed to article writing, editing, revision, and approval for submission.

Funding Information

There is no funding support to disclose.

Author Disclosure Statement

The authors have nothing to disclose.

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