Developing the primary palliative care workforce in Australia

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Centre for Palliative Care Research and Education, Queensland Health and Institute of Health and Biomedical Innovation, Queensland University of Technology


Abstract

Current healthcare models promote the equitable provision of palliative care to oncology patients with advancing disease, in the setting of their usual care, often in conjunction with anti-cancer therapies. This has resulted in specialist cancer services, as well as primary care across metropolitan, rural and remote communities, being called upon to integrate palliative care principles into their practice. To meet this increased demand for skilled health care professionals several national strategies have been initiated over the last five years. In this paper two projects are discussed in detail: the Palliative Care Curriculum for Undergraduates and the Program of Experience in the Professional Approach.


The person with advanced progressive cancer has some unique clinical, emotional, social and spiritual needs. Throughout their journey, people with advanced disease typically come into contact with a wide range of health professionals in specialist oncology and palliative care settings, and in primary care, who must respond effectively to their needs.

Recent policy documents from Palliative Care Australia (PCA) emphasise the important and interrelated roles of cancer professionals, specialist palliative care services and primary care providers in collaborative efforts to provide high quality care to people whose disease may not be curable.1,2 These PCA documents emphasise that while specialist palliative care services should be accessible to those patients with more complex needs, much care of patients with advanced disease is provided by specialists in areas such as cancer care. These specialist oncology staff will often have an ongoing role in the support of patients with advanced disease by adopting a palliative approach to the care they provide.1,2 In this context, specialist cancer services may be considered a primary care service, with specialist palliative care services involved on an as required basis only. These service models, which emphasise collaborative networks and interdisciplinary approaches to care, are thought to provide a more responsive, coordinated, needs based approach to care, that recognises the more diverse and complex trajectories associated with modern approaches to treatment of conditions such as cancer.

Recent health service models thus move beyond the traditional handover approach, whereby palliative needs were seen solely as the domain of specialist palliative care providers who would be referred patients only at end of life, to one which recognises the role of all health professionals in responding to palliative needs. While the substantive work of specialist cancer professionals may not be with patients with end stage disease, current policy documents emphasise that all health professionals, including specialist oncology staff, require some level of knowledge and skill in the palliative approach.

The PCA models also highlight that a range of other primary care providers may be involved in care of people with advanced cancer. Of particular importance here is the role of general practitioners (GPs). The particular needs of special populations, such as Indigenous communities, also require that a workforce with skills relevant to the cultural needs of these communities be available.

Figure 1: Conceptual model of level of need within the population of patients with a life limiting illness

The National Palliative Care Program, funded by the Commonwealth Department of Health and Ageing, aims to improve access to, and the quality of, palliative care services in Australia. The program supports a range of national initiatives, with one key area of activity being education, training and support for the health workforce. This paper provides an overview of two key initiatives which have been implemented to develop the skills of primary care providers (including cancer professionals) in Australia to provide quality care to people with life-limiting conditions such as advanced progressive cancer.

Palliative Care Curriculum for Undergraduates

The Palliative Care Curriculum for Undergraduates project (PCC4U) aims to promote the inclusion in all healthcare training of the role of palliative care and its principles and practice in the care of dying people, and to support the inclusion of palliative care education as an integral part of all medical, nursing and allied health undergraduate training. The project has been led by a consortium comprising clinicians and educators from Queensland University of Technology, Flinders University, Charles Darwin University and the University of Queensland. The focus on undergraduate education is seen as an important priority, to ensure all health professionals are equipped with fundamental skills in the palliative approach to care and in response to available evidence which suggests that undergraduate education may not adequately prepare the health workforce for end of life care.3-5

Phase 1 of the PCC4U project undertaken during 2003 to 2005 comprised three main components. The first involved a range of consultative and research activities to develop Principles for Including Palliative Care in Undergraduate Curricula. This involved: a review of literature on issues and practice in undergraduate palliative care education; scoping of existing curricula through survey and in-depth interview; a survey of healthcare professionals’ views about core principles for inclusion of palliative care in undergraduate curricula; and focus group discussions with a wide range of stakeholders to explore and refine core principles for inclusion of palliative care in undergraduate curricula. This activity resulted in publication of the Principles for Including Palliative Care in Undergraduate Curricula (available at: www.pcc4u.org). An important component of the principles publication is the description of core graduate capabilities in palliative care, that provide a framework for understanding the expectations of the capabilities of all health professionals in meeting the needs of people with life-limiting conditions.

The core principles defined in this document were used to guide the development of a suite of teaching and learning resources. This activity resulted in development, piloting and revision of learning resources including an interactive CD-ROM and web-based teaching and learning resource, with accompanying facilitator guides and a resource compendium. In addition, strategies for facilitating uptake of the core principles and learning resources more widely were developed from a review of the literature and a further series of state and territory-based workshops involving key education providers and regulatory bodies. These latter activities resulted in the identification of a range of barriers and facilitators to curriculum uptake and a set of recommendations for promoting the uptake of the core principles and learning resources.

Stage 2 of the PCC4U project was undertaken in 2005 to 2006 and involved supporting several universities to implement and promote the use of the palliative care undergraduate curriculum resources. Ten undergraduate health courses in seven universities were recruited to participate in this stage of the project. The sites represented courses in nursing, medicine, pharmacy, speech pathology and social work. The universities included four metropolitan and three regional universities. All sites incorporated the PCC4U resources in their curricula during Semester 1 2006. The pilot sites made good progress with integrating the resources during this time, with the evaluation providing important insights into strategies for optimising student learning outcomes and facilitating integration of palliative care in undergraduate courses.

Stage 3 of the PCC4U project commenced in late 2006 and will run until 2010. Building on earlier work, this stage will involve: active promotion of the uptake of PCC4U resources in all universities in Australia which offer medical, nursing and allied health undergraduate training; maintenance and nurturing of the networks that have developed between participating universities and their faculties; and developing strategies for the ongoing sustainability of the project. It will also involve seeking endorsement and support for the principles framework by key professional and regulatory bodies in this field.

While a great deal of work is yet to be done to facilitate integration of palliative care in undergraduate courses, this project has already resulted in the development of evidence-based learning resources that can be delivered flexibly, in terms of time, place and delivery mode and tailored to the needs of various disciplines. The success of this initiative will be measured by indicators such as improved learning outcomes and capabilities of graduates, evidence of integration of palliative care principles in undergraduate courses, the support of regulator and professional bodies for the initiative and ultimately improved quality of care. The curriculum scoping survey undertaken in 2004 at the commencement of the project will be used as a benchmark for assessing some of these outcomes. The project website, www.pcc4u.org, provides further information about this initiative.

A program of experience in the palliative approach

The National Program of Experience in the Palliative Approach (PEPA) is providing palliative care workplace training opportunities and workshops for a range of healthcare professionals, including nurses, allied health professionals, Aboriginal health workers, GPs and other medical practitioners. The program encourages healthcare professionals in rural and remote areas to apply. PEPA commenced in 2003 and placements were initially offered to generalist nurses and allied health staff from primary health settings in all states and territories (PEPA 1). In 2005, PEPA was expanded to include placements for GPs, rural and remote medical staff and specialist palliative care staff (PEPA 2). All jurisdictions, except the Australian Capital Territory, offered clinical placements for GPs and rural and remote medical staff, and all jurisdictions offered clinical placements for specialist palliative care staff. 

The clinical placement program is underpinned by adult learning principles, with a focus on experiential and peer-based learning. In order to reinforce learning and provide ongoing opportunities for professional support and development, the program incorporates a supervised clinical placement, activities which facilitate integration of learning into the participant’s practice and workplace and post-placement networking and learning support. Funded by the Department of Health and Ageing through the National Palliative Care Program, the program provides funding for backfill costs during the placement, as well as travel and accommodation costs for rural participants.

Demand for PEPA has been high, with the number of applications for the program being greater than the number of placements available in all states and territories. Since commencing in 2003, almost 1000 health professionals have completed a PEPA clinical placement, including nurses and allied health professionals from primary care settings, GPs and rural and remote medical practitioners, specialist palliative care staff  and specialist oncology nursing staff. Nearly 38% of participants in PEPA 1 and 22% of participants in PEPA 2 came from regions in the moderately accessible, remote and very remote categories of the Accessibility/Remoteness Index of Australia.  

PEPA has also supported a series of workshops for GPs and allied health professionals unable to take part in a clinical experience program due to difficulties with backfill or lack of access to an appropriate clinical placement site. These workshops have been held in metropolitan and rural settings and have been attended by almost 2000 health professionals since commencement of the program.

A comprehensive evaluation of PEPA was undertaken in 2006. Interviews and participant reports provided numerous examples of positive learning outcomes for participants, including examples of increased understanding of a palliative approach to care, improved knowledge about specific conditions and symptom management, improved skills in managing specific clinical problems in palliative care and improved communication skills. Employers of PEPA participants from the primary healthcare sector also provided numerous examples of ways in which participants were contributing to improvements in the delivery of a palliative approach in their settings.

A range of factors have been identified as being important to the success of the program to date. These factors have included the experiential nature of the program, the networks developed during PEPA and the interest and support provided by clinical mentors. Another key success factor associated with the program has been the partnerships developed between specialist and primary care providers, and between Commonwealth and state and territory government health departments in delivering the program. State and territory health departments have played a key role in program implementation, enabling the program to be linked with other local cancer and palliative care initiatives.

The key challenges include managing the administrative requirements associated with a large clinical placement program, pressures on host sites to provide clinical learning experiences for university students as well as PEPA participants and staff workload pressures which can impact on time that is available for mentoring. A range of strategies are being trialled to promote sustainability of learning outcomes and transfer of learning into ongoing practice improvements. This aspect of the learning program is, however, one of the most challenging and requires ongoing effort.

Funding has been provided to continue PEPA until June 2010. This next phase of PEPA will continue its emphasis on building the capacity of primary care providers. Particular attention will be given to collaborating with Indigenous communities to promote the participation of Indigenous health workers in PEPA and to develop the program so that it meets the cultural needs of Indigenous Australians. Further information about the project can be found on the project website: www.pepaeducation.org.au.  

Conclusion

An important component of our health system is the services provided for those who are dying. In 2004 in Australia there were 37,989 deaths from cancer.6 The health and support needs of these individuals are diverse and often change over time. People who are dying may have needs which are uncomplicated and which can be met by primary care providers, while others may have needs that require the resources of specialist, interdisciplinary teams.1,2 To respond effectively to these needs, all healthcare providers require as a minimum, the knowledge and skills to provide a palliative approach to care. 

A range of initiatives underway in Australia are focused on achieving improvements in the quality of palliative care. Importantly, the initiatives outlined in this paper are not solely focused on developing specialists in palliative care. Rather, they focus on enhancing the role of primary care providers, including cancer professionals, who often have ongoing contact with patients whose disease may not be curable while supported by specialist palliative care services. Some important implications arise from the initiatives outlined in this paper. In particular, the importance of embedding efforts to build the health workforce into existing service delivery networks and programs, and the benefits of using ‘authentic’ and experiential learning opportunities based on evidence-based strategies have been identified. Ongoing evaluation of these initiatives is underway, to enable assessment of the long-term impact of these initiatives on care for people with life limiting conditions including advanced cancer.

Acknowledgements

PCC4U and PEPA are initiatives of the Commonwealth Government Department of Health and Ageing, funded through the National Palliative Care Program. The author would like to acknowledge the contribution of Project team members to the development and implementation of the initiatives described in this paper, as well as those individuals and organisations who have participated in and supported the programs.   

PCC4U Project team members: Robyn Nash; Meg Hegarty; David Currow; Kim Devery; Carol Grbich; Geoff Mitchell; Bev Turnball; Deborah Prior and Debbie Canning.

PEPA management team: Linda Barrett; Shirley Connell; Dee May; and all state and territory PEPA managers.

References

1. Palliative Care Australia. A Guide to Palliative Care Service Development: A Population Based Approach. Canberra: Palliative Care Australia; 2005.

2. Palliative Care Australia. Standards for Providing Quality Palliative Care for all Australians. Canberra: Palliative Care Australia. 2005.

3. Barzansky B, Veloski J, Miller R, Jonas H. Education in end-of-life care during medical school and residency training. Acad Med. 1999; 74: S102-4.

4. Billings J, Block S. Palliative care in undergraduate medical education. Status report and future directions. JAMA. 1997; 278: 733-738.

5. Charlton R, Smith, G. Perceived skills in palliative medicine of newly qualified doctors in the U.K. J Palliat Care. 2000; 16: 27-32.

6. Australian Bureau of Statistics [homepage on the Internet]. Canberra. [updated 2006 Dec 8; cited 2007 Jan 3]. Causes of Death, Australia 2004. Available from: http://www.abs.gov.au/

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