Development of Objectives to Inform a National Standardized Primary Palliative Care Curriculum for Health Professions Students

Introduction

There is a great need for training of generalist clinicians in primary palliative care.^1–8 As the field has matured palliative care educational efforts have grown rapidly, most notably in undergraduate medical education, but remain underrepresented in other health professions training programs.^1–3,7,9,10 Nearly 10 years have passed since the publication of proposed essential palliative care competencies for U.S. medical students and residents, ⁵ yet standardized evidence-based curricula and assessment methods have lagged behind.^1,2,7,11 Competencies for graduate nursing students have yet to be widely disseminated ⁷ and gaps persist in undergraduate nursing education. ¹⁰

Efforts to standardize palliative care education in Europe have outpaced the United States, but the degree of institutional uptake and graduate impact is unclear.^3,11,12 A standardized developmentally appropriate national palliative care curriculum for U.S. health professions students and associated core learning objectives to guide student learning are needed.^3,6,13,14 This curriculum would support both specialist and generalist educators teaching palliative care to early learners, promote integration of palliative care concepts into already overloaded curricula, help standardize teaching and assessment methods, and address known gaps in graduate preparedness.^15–18

In 2020, Aquifer, ¹⁹ a leader in online education for health professions (physician, advanced practice nurse, and physician assistant) students, received funding from the Arthur Vining Davis Foundations to develop a course titled Principles and Practice of Excellence in Primary Palliative Care. ²⁰ The goal was to create a standardized vast-reaching national curriculum and to produce a “practice ready” health care workforce prepared to deliver high-value compassionate serious illness care. A national interprofessional strategic leadership group developed the overarching vision and principles for the course that was informed by a literature review and faculty and student needs assessments; a White Paper summarizing these findings and recommendations is forthcoming. In this study, we describe the subsequent development and validation of core learning objectives for the course and recommendations for their implementation in a variety of teaching settings.

Methods

Learning objective development

We convened a subgroup of interprofessional palliative care leaders from seven institutions around the United States to develop core learning objectives for health professions students. Group members were leaders in palliative care education at their institutions and included physicians (n = 4), advanced practice nurses (n = 2), social workers (n = 2), a chaplain (n = 1), and a medical student (n = 1). In a multistep process, we generated a comprehensive list of learning objectives based on national consensus guidelines, ²¹ previously published medical student competencies, ⁵ and existing health professions education literature.^7,10 Working in interprofessional dyads, we drafted three to six learning objectives per dyad that mapped to each of the five previously defined guiding principles and embodied our overarching vision statement for the course (Fig. 1). Through a series of e-mails and conference calls, we revised each objective and reviewed the list for completeness until agreement was reached, drafting a total of 31 objectives.

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FIG. 1.

Final list of 26 revised learning objectives mapped to overarching principles.

Results

The survey response rate was 30.8% (21/68). Demographic characteristics of respondents are shown in Table 1. The majority of respondents spent most of their clinical practice in palliative care. Both junior and senior faculty were represented, and most had taught health professions students for more than five years.

Of the 31 initially proposed learning objectives, 28 met the predetermined 75% consensus threshold to be included. The three learning objectives that failed to meet this threshold were removed. Based on written comments from respondents and our review, two other learning objectives were identified as redundant and were combined with others. Twelve learning objectives were modified in response to survey feedback. Critical feedback usually involved concerns that a learning objective was too detailed for health professions students or recommendations to change the chosen Bloom's Taxonomy verb used (i.e., changing “apply” to “describe” or “identify”). Four survey respondents suggested objectives that were missing, and we deemed these either not meaningfully different from existing objectives or out of scope for this learner level. Figure 1 includes a final list of 26 revised learning objectives.

Discussion

Based on a comprehensive needs assessment and with national interprofessional input into their development and refinement, we have created a comprehensive list of learning objectives for a national primary palliative care curriculum targeting U.S. health professions students. Our preliminary work addresses repeated calls for a standardized curriculum and core learning objectives.^{1,2,6,7,11,13,14,23} These objectives build on previously published competencies^5,11,12 with a renewed focus on communication skills, interprofessional teamwork, recognizing primary versus specialty-level skills and when to refer, cultural and self-awareness, and issues of equity and access in the context of serious illness care. These objectives are appropriate for incorporation into health professions student curricula and can be used by educators who are engaged in curriculum design and teaching at this learner level.

A standardized developmentally appropriate curricular framework has many benefits. A readily available peer-reviewed list of objectives reduces administrative burden and empowers generalists to continue the important work of teaching palliative care content—often in the preclinical years. This is particularly important in addressing the nationwide shortage of palliative care specialists available to teach this material. ²⁴ In using these objectives, institutions can demonstrate that they are promoting basic palliative care competence among their graduates and meeting credentialing requirements.

In addition to the planned nationally available online Aquifer curriculum, educators may use our principles and learning objectives across courses, clinical rotations, or teaching sites, as the objectives are broad enough to apply across specialties. For example, an obstetrics/gynecology clerkship director might integrate experiences involving delivering serious news into their clerkship requirements ²⁵ using the relevant objectives from our list. An educator in a preclinical skills course might use our objectives about responding to emotion in a class-wide communication skills workshop featuring small group practice with simulated patients and faculty feedback.

This project has several important strengths. It is one of the first U.S. efforts to nationally define a core set of primary palliative care learning objectives for health professions students. An interprofessional leadership team participating in all phases of curricular development helped reduce individual bias and ensure multiple experiences and viewpoints were represented.

This project also has several limitations. Although it nears reported mean response rates for web surveys,^26,27 the response rate was low, which limits the generalizability of findings due to potential inadequate sampling and nonresponse bias. Most respondents identified as female, so there was a degree of homogeneity in this sample, although this female predominance mirrors observed U.S. hospice and palliative care workforce demographics. ²⁸ Most respondents were physicians or social workers, so the viewpoints of nurses, advanced practice nurses, and physician assistants are underrepresented. This was not a formal Delphi ranking process and our survey instead forced choices of yes, no, unsure for efficiency.

Conclusion

Using an interprofessional approach, we have developed a comprehensive list of primary palliative care learning objectives for health professions students. We propose these be adopted by educators to ensure that graduating students demonstrate a basic level of competence in palliative care knowledge and skills as they go on to care for our nation's most vulnerable patients.