Towards quality indicators in palliative care education: An umbrella review

Timing and duration of palliative care exposure

The reviews reported high variability in the timing and duration of education across settings and learner levels. Educational exposure ranged from brief, single-session interventions to longitudinal, extended over months.^17,26,32,36

Short, structured interventions, such as a 2-h seminar, demonstrate statistically significant improvements in knowledge, self-efficacy, and attitudes.^24,30,33 Similarly, brief but immersive experiences, such as a 48-h hospice-home stay, enhance learners’ emotional readiness and reflective capacity. ³⁸

Several reviews reported that longer interventions^22,26 were more effective in supporting attitudinal change, particularly in sensitive domains such as attitudes towards death, an outcome known to be resistant to short-term educational efforts. ²² Iida et al. ²⁶ further noted that programs spanning 12–18 months allowed for deeper integration of learning into clinical practice. Similarly, Kirkpatrick et al. ³⁶ highlighted the value of longitudinal interprofessional courses, supporting progressive knowledge, self-efficacy, and collaborative competence development. Courses delivered across multiple, structured sessions, rather than single workshops, reported stronger impacts for clinical outcomes and learner competence, especially in areas such as symptom management and family caregiver support.

Overall, the evidence does not support the superiority of any specific programme duration.^20,33 Instead, content quality, instructional design, and delivery method appear to influence outcomes more strongly than the length of the programme itself.^20,33

Instructional format/delivery

The reviews reported a broad spectrum of educational delivery methods in palliative care training. Several structural characteristics are associated with enhanced learning outcomes, learner satisfaction, and greater programme scalability.

Studies emphasised the value of voluntary, interest-driven participation. Students who enrolled in elective palliative care courses consistently demonstrated greater gains in knowledge, reduced fear of death, and a stronger commitment to patient-centred care. ²⁵

Face-to-face teaching remains the most common and consistently favoured method, especially when using small-group formats. It is linked to greater satisfaction, deeper engagement, and improved communication skills compared to web-only programmes.^25,39

Several studies identified eLearning and blended learning approaches as effective in improving knowledge and self-efficacy, particularly when grounded in educational theory and delivered over time. These formats also offer logistical advantages, including scalability and asynchronous access/delivery,^29,31,33 making them particularly suitable for individual learner needs. Although not always compared directly with in-person training, eLearning and blended learning are viable and scalable options. ³³ Remote learning, including virtual role-play, receives positive learner evaluations in some situations. For example, Novaes et al. ²⁸ described a remote role-play strategy that students perceived as more effective than in-person delivery. Remote and flexible formats increase accessibility to learning in some situations (for distributed learners or where social restrictions were imposed) and reduce learner anxiety, particularly for emotionally demanding topics.

Format, and delivery or learning method superiority was not identified across reviews. These rather depend on the competencies to be acquired and the context. The design quality, contextual adaptations, and learner engagement appear more influential than delivery mode alone.^32,33

Contents

PC-education includes more than clinical instruction, encompassing holistic content that integrates communication, ethics, interprofessional collaboration, and cultural safety. Educational content that includes spirituality and/or grief management is suggested to have a stronger emotional impact, especially for shifting attitudes towards death, including spiritual themes in care, and supporting attitudinal transformation. ²²

Content reflecting cultural values, beliefs, and languages improves equity and learner receptivity. For example, some programmes tailored their curriculum to include indigenous language or culturally relevant practices, strengthening accessibility and inclusivity. These adaptations reflect respect for diverse communities and prepare students to provide culturally safe care. ²⁷

Programmes co-designed with patients or caregivers, such as ABC4Nurses, brought emotional depth and real-world relevance. ²⁹ Teaching informed by interdisciplinary scenarios and team-based care promote interprofessional skills and ethical decision-making. ²⁵

This broader approach enhances the depth and quality of learner preparation for palliative and end-of-life care.

Structured course development

Effective education programmes often demonstrate clear theoretical grounding, intentional design aligning learning objectives, pedagogical approaches, and assessment strategies, as well as incorporation of evidence-based models. These elements contribute to both educational rigour and clinical relevance. Contextually tailored teaching and learning materials enhance relevance and learner engagement. ²⁷

Courses that reference existing literature, prior learning, and, especially in the context of communication training, strategies such as SPIKES (Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary) or PREPARED (Prepare, Relate, Elicit, Provide, Acknowledge, Encourage, Document), and that are grounded in learning theories and frameworks, are highlighted. ²⁰

Involvement of local staff or experts

The inclusion of local staff or trained experts in the design and delivery of education enhances the perceived relevance and contextual applicability of the programme content. Involvement of local staff or expert input improved perceived relevance.^20,35

Learners consistently perceive courses that incorporate local clinicians, cultural advisors, and community stakeholders as enhancing relevance. This contextual grounding improved both engagement and applicability to real-world clinical practice. ²⁰

While local involvement was valued, the presence of formally trained facilitators (whether internal or external) was critical to ensure instructional quality, structured support, and continuity throughout the course. ³⁵ Despite this, a systematic review by Collingridge Moore et al. ³⁵ noted that only 20% of included studies reported facilitators with specific training, suggesting a significant area for development in faculty preparation.

Skilled facilitators are essential to optimise learning, no matter the learning approach or delivery medium. In simulation-based learning environments, the role of the facilitator is even more pivotal. Skilled facilitators are essential to guide debriefings, ensure emotional safety, and reinforce learning objectives. Their presence enhances the authenticity and impact of the simulation experience. ²⁸

Multidisciplinary and context-specific learning

Palliative care is inherently team-based, requiring collaboration across medical, nursing, social, and allied health professions. Educational programmes that reflect this interdisciplinary reality by involving diverse professional groups (e.g. doctors, nurses, and students) and engaging with realistic clinical scenarios tend to yield stronger learning outcomes and promote both individual competence and broader organisational change. Reviews have identified a strong interprofessional focus, in both faculty and learner composition, as a key marker of excellence in education. ³⁶ Combined sessions, such as those involving medical students and practicing nurses, can leverage varied perspectives, bridge theory-practice gaps, and improve students’ readiness for collaborative, ethically grounded decision-making in palliative care.^22,25 Despite these advantages, only 22% of communication courses in one review were truly inter- or multiprofessional. By contrast, 75% of courses were single-profession offerings, most commonly attended only by physicians. The remaining 3% also trained a single profession, but included participants with different levels of experience in the field. ²⁰

Programmes that adopted an inclusive approach, involving even non-clinical staff, improved overall understanding of palliative care and fostered greater staff cohesion and cultural awareness. ³⁵ Some studies included professionals beyond healthcare. ²⁸

Organisational support

Organisational support plays a crucial role in the implementation, sustainability, and perceived legitimacy of PC-education. Successful programmes often go beyond well-designed curricula by aligning educational efforts with institutional structures, leadership priorities, and active engagement and support from senior and managerial-level staff. ²⁶ Visible commitment from leadership – through the allocation of time, personnel, and financial resources – is a critical enabler of sustained engagement. ³⁵ Similarly, in the context of advance care planning, organisational infrastructure was essential to effective facilitator training and delivery. ²¹

Palliative care content is delivered either as a standalone course or integrated into broader medical and nursing curricula. While earlier studies ³² found no significant differences in outcomes between these two models, more recent work emphasises that formal intentional curriculum integration, leveraging opportunities for both standalone palliative care curricula and opportunities to integrate palliative care elsewhere, enhances effectiveness and consistency. Programmes that formally embed palliative care into undergraduate medical or nursing curricula rather than treat it as optional courseware or scattered in other subjects, are viewed as more effective. ³⁴ Better alignment with academic structures improved reach and legitimacy. ³⁴

Organisational commitment must also extend to continuing professional development through mentorship, equity, and the long-term integration of training into practice. Educational interventions are more effective when complemented by institutional systems and processes that support implementation: “Training is not enough. . .it is necessary to mentor ethnically diverse staff and integrate learning into practice.” ³⁹

Experiential learning

Real-world exposure provided opportunities to observe and practice care, thereby deepening clinical understanding and nurturing humanistic, person-centred care. Direct clinical exposure, such as hospice visits and interactions with patients at end-of-life, strengthened learners’ understanding of suffering, humanistic care, professional identity, and the work-related meaning ³⁴ and the practical applications of knowledge in real-life contexts. ³¹

Rotations in palliative care settings improve knowledge on symptom management and practical skills, although the optimal duration of such training remains uncertain. ³¹

Additional experiential learning methods – such as simulation, role-play, case-based learning, and guided bedside learning – consistently improve learners’ practical competencies and emotional readiness.^{19,23,25,27,28,38} Experiential methods help develop emotional readiness, communication skills, and self-awareness. ²⁹

Skill-specific simulations, particularly for communication and symptom management, have proven to be highly effective in education.^25,40 Realistic, immersive environments support learner engagement and scenario authenticity. ⁴⁰ These simulations bridge the gap between theoretical knowledge and practical application, enhancing learners’ understanding of clinical documentation and care scenarios. Participants in simulation-based training report increased confidence, reduced anxiety, and better preparedness for real-world clinical situations, indicating that such simulations foster both emotional resilience and practical competence. ²⁴

Role-play is especially effective for teaching communication in emotionally charged situations, including delivering bad news and end-of-life discussions.^24,28 Role-play is effective in all experimental or quasi-experimental studies as reported by Novae et al. ²⁸

Programmes combining simulation, role-play, group discussions, and structured reflection promote empathy, self-awareness, and applied skill development.^20,27,34 Simulation studies excel in pre-briefing, simulation design, and evaluation of learning. These strategies align with educational best practices and are tied to improved attitudes, role understanding, and confidence. ³⁶

Multi-modal approaches

Multi-modal learning methods support different learning styles and improve retention, engagement, and confidence.^21,25 Technology-enhanced formats such as eLearning and audio-visual tools are associated with higher educational quality, as measured by increased competence, confidence, and engagement, at least in the area of advanced care planning. ²¹

Programmes that combine didactic sessions with interactive formats, such as small groups, real patient exposure, and audio-visual tools, outperform lecture-only models.^21,23

Web-based and game-based interventions are effective in reducing fear of death and increasing self-efficacy. ²⁵ Similarly, online interventions (e.g. asynchronous modules and discussions) are effective and feasible, especially for working professionals with demanding schedules. ²²

Humanities-based (including the use of art, literature, and theatre) methods added ethical depth, emotional resonance, and insight into topics such as grief, empathy, compassion, and person-centred care. ³⁸ Programmes that combine lectures, films, group discussions, patient exposure, and case-based learning lead to enhanced empathy, self-awareness, and competence in communication and decision-making. ²⁵

Reflective practice and emotional processing

Reflective practice was implemented in multiple ways across the included studies, most commonly as post-course written narrative reflections and reflective case discussions. Written reflections were predominantly evaluated using qualitative designs, with narrative texts analysed for aspects of emotional processing. In contrast, reflective case discussions and group debriefings were mostly included within multi-component evaluations and were not evaluated as a standalone component.

Structured reflection on personal values, death, and clinical experiences deepened emotional learning and attitudinal change.^34,40 Relevant, emotionally grounded content encourages reflection and deeper learning. ³⁰

Opportunities for ongoing reflection during workshops or on-the-job learning helped translate education into practice and behavioural change. ³⁵

Ratislavová et al. ³⁸ reported awareness of the need for a safe environment conducive to the sharing of emotions in lessons. Emotionally safe learning environments encourage reflection, deeper emotional engagement, and openness. ³⁸

Meaning-centred teaching and reflective case discussions support deeper internalisation of palliative values. ³⁰

Group-based, peer learning

Learning in small groups supports collaboration, mutual learning, and the exploration of ethical and emotional topics. Small-group discussions in or outside the context of problem-based or case-based learning encourage collaboration, practical applications of theory, ethical reflection, emotional processing, and critical thinking.^22,23

Students value dialogue, which is inherent in small-group discussions. They help nurture an atmosphere of trust and security. Exposure to interdisciplinary teams and problem- or case-based scenarios further enhances teamwork skills, knowledge, and communication. ²⁵

Group settings are reported to foster trust, dialogue, and peer-supported learning. ³⁸ Face-to-face or asynchronous group-based modules increase emotional engagement and peer learning. ²² Discussion-based methods help process emotional content and build confidence in difficult conversations. ³⁸

Embedded learning

Closely linked to experiential learning, embedded learning clarified how and when learning was applied in practice. The integration of learning tools into clinical workflows improved access and encouraged repeated, just-in-time use. These tools enabled immediate evaluation of learning experiences, including where and what learning occurred, as well as teaching methods and attitudes towards learning. ³¹ Embedding experiential learning and reflection into current practices supports emotional preparedness and behaviour change. In most cases, learning activities were conducted within the facility; however, in some instances, the intervention required involvement from healthcare professionals outside the facility. Adaptations are necessary to incorporate existing patterns of work into the learning process. ³⁵

Flexibility

Flexible formats (in timing, location, and method) help overcome logistical barriers such as workforce challenges and support continual professional education. ³⁵

Feedback

Personalised feedback (audio/video) adds educational value. ²⁰ Active skill rehearsal and feedback promote real-world communication competence. ²³

Enhancement of competencies

PC-education consistently demonstrates improvements in learners’ knowledge, self-efficacy, and clinical competence. Across multiple studies, interventions lead to statistically significant gains in knowledge, especially regarding communication frameworks and symptom management.^{21,23,24,27,31,38,39} A meta-analysis by Donne et al. ²⁴ reveals a large effect size for knowledge acquisition and moderate gains in attitudes. Confidence, particularly in conducting End-of-life discussions and managing complex symptoms such as pain, nausea, or delirium, is the most frequently reported outcome. ²⁴ Although confidence increases are widely reported, ²⁹ they are often self-assessed rather than observed in practice. ³⁰

Many interventions contribute to positive shifts in attitudes towards caring for dying patients. Studies emphasise that changes in these specific care-related attitudes are more pronounced than shifts in abstract concepts, such as attitudes towards death. ²² Training also improves affective skills such as empathy, family-centred communication, and comfort in discussing emotional or sensitive topics. ²⁹ However, evidence on whether these attitudinal gains consistently translate into behavioural changes in clinical practice remains mixed. For example, Tropea et al. ⁴⁰ reported limited transfer of communication skills into real patient interactions, underscoring a potential gap between training and practice.

Sustainability and long-term impact

Short-term outcomes, such as pre-training versus immediate post-training, are most commonly studied and reported. Long-term impact, including knowledge retention and sustained application of what was learned, is less frequently evaluated. Short time intervals between pre-testing and post-testing^31,33 and inadequate post-training intervals restrict the ability to detect long-term behavioural or system-level impact.^{18,19,26,28,30,32,33} In addition, it could limit meaningful measurement and the comprehensive assessment of impact, durability of learning, and clinical integration.^20,28,30,31

In one study reported in Centeno and Rodríguez-Núñez’s review, learners retained and applied palliative care values and skills up to 3.5 years post-graduation, an exception that highlights the importance of longitudinal assessment. ³⁴ Another review, however, reported a lack of sustained clinical impact, with one study assessing clinical behaviour 10 months later and found no difference in quality of care or communication, suggesting that skills were not retained or applied over time, showing a gap between training and sustained practice change. ⁴⁰

Methodological design, as well as lack of resources, often limit the ability to evaluate sustained learning. ³¹ These types of studies often require additional resources and funding. Poor reporting, lack of control groups, and reliance on self-reported data, with limited confidence in many studies was reported in a systematic review of communication skills training for generalist palliative care providers. ²⁰

A systematic review and meta-analysis of RCTs of palliative care teaching to health professional students concluded that there was an overall lack of impact and stressed a need for improved skill-building strategies. ²⁴

Validated tools for evaluation

The quality of outcome measurement varies substantially across studies. Programmes using validated instruments offer more robust evidence of effectiveness.^26,36,38 Studies that used validated outcome measures for knowledge, attitude, or behaviour change help measure impact bettert ²⁰ and allow comparability across studies. ¹⁸

The lack of objective measures, such as observed communication performance or clinical outcomes, is a recurrent limitation.^30,31 Incorporating validated, multi-source assessment tools is essential for improving evaluation rigour. Repeated measures would also provide a more reliable outcome assessment. ³⁶

Self-assessment of competencies, while useful, may by themselves be insufficient to explore the full impact of education interventions.^30,31 In a review of postgraduate pain and symptom management training, assessment tools often lacked reporting of psychometric properties and sometimes failed to measure application of knowledge. ³¹

Participant satisfaction

Learner satisfaction is a useful starting point to assess a programme, as a positive learning experience is often a pre-requisite for an impactful intervention. Learner satisfaction is generally high, particularly in programmes that use interactive, reflective, or postgraduate formats.^27,29 Participants frequently report that the training is relevant, practical, and emotionally engaging. However, satisfaction, being subjective, may not necessarily correlate with improved competencies or clinical outcomes. For instance, Nevis ³⁷ found no significant difference in satisfaction between intervention and control groups, even when other care QIs improved. Satisfaction alone may not reflect deeper educational impact. ³⁷

Integration into routine practice

Effective integration of training into existing care structures was identified as a key facilitator of sustained impact. Embedding educational practices into routine workflows enhances sustainability and avoids duplication. ³⁵ However, evidence of broader system-level impact remains limited. Nevis ³⁷ and Seow et al. ¹⁸ found no consistent reduction in hospital admissions, ICU stays, or emergency visits following training. Similarly, patient and family-reported outcomes – such as communication quality or psychological wellbeing – did not consistently improve post-intervention.^31,40 These findings point to a need for better alignment between educational interventions and measurable improvements in patient care and healthcare utilisation.

Impact on patients and families

Few studies assessed the impact of staff training on patient or family outcomes, although some do exist. ²⁰ Structural and methodological design, lack of research funding, and great complexity, limit the ability to evaluate the impact on patient care. ³¹

Objective measurements of actual or simulated encounters (e.g. time spent, topics covered) were used, and qualitative data from patients/families were also collected to assess the real-world application of the training. ²¹

The quality of patient and family-reported communication did not improve; some patients had higher depression scores. Simulated training does not translate into measurable improvements in patient/family experience.^21,40