Abstract
Abstract
Purpose:
To describe development of the Standard Hospice & Palliative Care Education Program in Korea, a basic training program for hospice & palliative care professionals, and to report preliminary results from the 2008-2009 demonstration project at 2 sites that support its effectiveness.
Method:
We developed the Standard Hospice & Palliative Care Education Program, consisting of 19 modules, under the initiative and financial support of the Ministry of Health, Welfare, and Family Affairs. We adapted the train-the-trainer model and benchmarked the EPEC (Education in Palliative and End-of-life Care) course. In order to evaluate the effectiveness of the program, session evaluation, pre-post test of knowledge, and overall course evaluation were assessed by participants.
Results:
The demonstration program included a total of 105 participants. Overall rating by participants was 4.1 for relevance and usefulness of program contents (range, 4.1–4.2; 1 = strongly disagree, 5 = strongly agree) and 4.1 for the trainer's teaching skills (range, 4.0–4.2). Participants demonstrated significant improvement in their knowledge on the pre-post test for 6 of the 17 modules, and reported that they had gained confidence in their ability to perform palliative care practices (overall mean ratings, 4.0, range; 3.6–4.3; 1 = very low, 5 = very high). Overall evaluation of the program was very high (very satisfied or satisfied; 86%).
Conclusion:
Development of the Standard Hospice & Palliative Care Education Program was successful, and its preliminary effectiveness was shown by the demonstration program. Comments on our experience in Korea would be helpful to efforts in other countries, particularly those with limited resources for hospice and palliative care.
Introduction
The first formal training for Hospice professionals began in 1985 as a continuing medical education (CME) course administered by the Korean Nurses Association.4‐5 This was followed by short courses developed at the postgraduate level by several Nursing Colleges, and several institutions have provided educational courses in palliative care that vary in duration and content. However, training courses were not systematically developed, and some were religiously oriented; some were even developed primarily for hospice volunteers and were not adequate to meet the training needs of hospice and palliative care professionals.
Faced with an increasing need for hospice & palliative care, the Ministry of Health, Welfare, and Family Affairs included 'promotion of hospice & palliative care' in its second-term 10-Year National Cancer Control Plan, which started in 2006, based on successful results from the 2003-2004 Hospice & Palliative care demonstration program. 6 The plan included support for growth of hospice and palliative care services by government subsidy and training of professionals to meet the growing need for manpower. It was suggested that a basic training program should be developed and should provide for all professionals until 2015 (Table 1). Although the ‘End-of-life Care Task Force Team’ of the Ministry of Health and Welfare established a basic requirement of ‘60 hours of hospice education’ for hospice professionals in 2005, 7 a recent survey showed that less than half of professionals have met this 60 hour criteria; and significant regional variations exist, particularly for hospice professionals in small cities or rural areas who have received less education than those in metropolitan areas. 8
Those who completed Train-the-trainer workshop.
Under the initiative and financial support of the Ministry of Health, Welfare, and Family Affairs, the National Cancer Center started the ‘End-of-Life Care Professional Training Project’, and developed the 60-hour basic standard hospice and palliative care education program during the 2006-2008 period. In this article, we describe the strategies and process of program development and preliminary results from the demonstration program.
Methods
Standard hospice and palliative care education program development process
Table 2 shows an outline of the development process.
NCC, National Cancer Center; RCC, Regional Cancer Center.
Setting goals and program targets and establishing strategies
As palliative care in Korea was in its initial stage, our goal was to develop a program for all types of professionals involved in hospice & palliative care, and to plan for its rapid and effective dissemination to those who need to acquire the basic knowledge, attitudes, and skills, for the practice of hospice and palliative care. In order to achieve this goal, the National Cancer Center organized ‘the Hospice & Palliative Care Education & Training Task Force Team (the TFT)’ with experts in hospice and palliative care from multiple disciplines.
To achieve its goals, the TFT has established three basic strategies. The first strategy was to standardize the education program for control of program quality, so that every professional will be equipped with the necessary basic knowledge, skills, and attitudes, regardless of where or from whom they receive their education and training. The second strategy involved rapid dissemination of the program across all regions in Korea, so that every professional can have equal access to the program, regardless of their place of residence; 9 regional cancer centers designated by the Ministry of Health, Welfare, and Family Affairs for the purpose of reducing geographic inequality of cancer care were considered suitable platforms for program dissemination. The third strategy involved development of dedicated trainers who can teach the end-learner at the regional level, and have adequate teaching skills to increase the effectiveness of education.
The TFT has chosen the EPEC (Education in Palliative and End-of-life Care) course as a suitable benchmark, 9 and attended the ‘Become an EPEC Trainer’ conference for three consecutive years from 2006 to 2008. The EPEC project was chosen for the following reasons: 1) it is a comprehensive, modular, and multiformat approach inclusive of all domains for end-of-life care,10–11 2) it stresses a rapid dissemination model adapting the train-the-trainer model, and 3) it also adapts learner-centered methods, such as the use of trigger videos and interactive participant discussions. 10
Program design
The TFT selected the core areas and modules based on WHO guidelines for palliative care services skill area, EPEC curriculum, and results of the educational needs survey from the 2004-2005 Hospice & Palliative care demonstration program. 7 Two modules- spiritual care and social care-, which were not included in the EPEC curriculum, were added. The final program consisted of 19 modules covering two areas, philosophy and principles of palliative care and end-of-life care skills (Table 3). Interactive lecture, small group discussion, and role play were selected as specific teaching methods for use in these courses. Appropriate teaching methods for each module were also discussed, and were intended for inclusion in material development.
Material development
For each module, content was developed based on EPEC materials. However, it was modified considerably for adaptation to our social and cultural contexts. For example, ‘Gaps in end-of-life care’, ‘Legal issues’, ‘Advance care planning’, ‘Physician-assisted Suicide’ modules were modified to reflect legal and cultural context in Korea, which is quite different from Western country where patient autonomy is highly valued.12–14 Materials developed included 1) Participant's Handbook, 2) Trainer's Guide, with accompanying presentation slides, 3) trigger videos and cases used for discussion purposes, and 4) evaluation tools.
Each module was developed through the following sequences: 1) translation of EPEC material by a TFT member, 2) Adaptation of the material to Korean contexts, particularly in terms of cultural norms and the medical system, 3) review and feedback by 3∼5 reviewers (including other TFT members and expert external reviewers), and 4) revision and another round of review for confirmation. Trigger videos were made by translation of EPEC trigger videos and addition of Korean subtitles. Small group discussion, cases for role play, and evaluation tools for pre- and post- tests were developed based on course materials, and involved clinical vignettes.15–17
Pilot test
To evaluate the feasibility of the program, particularly in terms of new teaching methods, we performed a pilot test. Three different modules with different recommended teaching methods were chosen, and delivered to a total of 23 professionals who had previously attended other palliative care education courses and who volunteered to participate in the pilot test. Trainers were TFT members who had received training through the EPEC Trainer program; when comparing their experience with that of previous courses, they generally expressed high satisfaction with both contents and teaching methods. 18
Train-the trainers
To expand the trainer pool for the standard education demonstration program, a full-day train-the trainer workshop was designed. As we limited participation to those who demonstrated significant career in hospice and palliative care, we chose to emphasize different aspects of adult learning and enhancement of specific teaching skills. Lectures on principles of adult learning and specific teaching skills were delivered by professors of medical education. Exercises for development of specific training skills – interactive lecture, small group discussion, and role play- were guided by TFT members who received training through the EPEC Trainer program. The curriculum also included an overview of the purpose and development process of the Standard Hospice & Palliative Care Education Program, so that participants could obtain a better understanding of the context. Even though the workshop was rather short for purposes of ensuring the competency of each participant's training skills, feedback from participants indicated that the workshop was a good opportunity for adult learning, and also for reflection on their own teaching skills.
Workshop for standard hospice and palliative care education program delivery
To share the development process for the standard program and to identify the most effective strategy for its delivery, we held a full-day workshop. Those responsible for professional education in 9 Regional Cancer Centers and key members of the Korean society for hospice and palliative care were invited. Goals, strategies, and developmental processes for the standard education program were shared, along with the possibility of more advanced training for each type of professional in the future. Following that discussion, many practical aspects of the standard education programs – including basic RCCs requirements for operation of standard education programs, eligibility criteria of potential participants, possible practical benefits of completing the program, organizational aspects, financing and costs, and support needs from the National Cancer Center – were discussed.
Demonstration of the standard hospice and palliative care education program
Two different sets of demonstration programs were conducted from 2008 to 2009 at the National Cancer Center and Daejeon Regional Cancer Center. The aim was to assess the feasibility and effectiveness of the standard education program, and to examine course materials, so that they might be revised and completed. Applicants were required to submit their resume along with a short essay describing their reasons for applying to the standard program. In our final selection of participants, we gave priority to professionals working in hospices or palliative care units without proper education. The program was delivered once a week on weekday evenings (140 minutes/week) for 18 weeks, in addition to field study at hospices & palliative care units. When small group discussion or role play was adopted as a teaching method for the session, participants were separated into 3 groups, and each group was guided by the main session trainer and two other facilitators who were also trainers.
Evaluation of the demonstrating standard training program
We developed 3 evaluation instruments: 1) A session evaluation questionnaire, 2) A pre-post questionnaire, and 3) an overall course evaluation questionnaire. Session evaluation questionnaires were designed to rate 1) relevance and usefulness of the contents, 2) teaching skills of the trainers, and 3) self-reported confidence regarding the topic. These were administered after each session, and rated using a 5 point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). Confidence items were rated using a 5 point Likert scale (1 = very low, 5 = very high). Pre-post test questionnaires were designed to evaluate the effectiveness of each lecture in regard to delivery of knowledge. Questionnaires consisted of 2∼4 multiple choice items that addressed key points of each subject, and were administered prior to and following each section in order to assess changes in knowledge of palliative care. Pre-post test questionnaires were not developed for the module known as ‘Legal Issues' and ‘Advance Care planning’, as it is still being debated, and the correct answer is not yet well established in Korea. The overall course evaluation questionnaire was administrated on the last day of the program. Items included questions related to overall program satisfaction, whether or not the course met personal objectives, usefulness of the material, usefulness of the pre-post test, whether or not the time commitment was worthwhile, and whether or not they would recommend the course to others. For each evaluation instrument, there was space for free comments.
Analyses were mainly descriptive. Paired t-test was used for analysis of the pre-post test. Analyses were conducted using SAS Version 9.1 (SAS Institute, Cary, NC).
Results
Respondents
A total of 105 professionals participated in the course, including 55 at NCC and 50 at Daejon RCC (Table 4); 22 (21%) were physicians, 59 (56%) were nurses, and 15 (14%) were social workers. The remaining 9 (9%) were either members of the clergy or other public health officials; 41 (39%) were working in palliative care units or hospices designated by the Ministry of Health, Welfare, and Family Affairs. Evaluation data were gathered from participants who attended each session. Response rates for session evaluation questionnaires varied with median value of 69%, due to variable attendance rate to the weekly sessions (range: 75 - 96%) and moderate compliance of participants. Response rate for the overall course evaluation questionnaire was 63%.
MW, Ministry of Health, Welfare, and Family Affairs.
Relevance and usefulness of program contents
Relevance and usefulness of the program were evaluated with 4 questions for each module that pertained to the following (Table 5): whether or not objectives were clear, whether or not important concepts were highlighted, whether or not contents were easy to follow and understand, and whether or not contents were clinically relevant. A majority of respondents identified educational contents as relevant and useful. Mean overall ratings were 4.1, ranging from 4.1-4.2 for the 4 areas; there was greater variation across modules, ranging from 3.6-4.5.
Scale:1 = strongly disagree, 5 = strongly agree.
Ratings of trainers' teaching skills
Teaching skills of the trainers were evaluated with 6 questions for each module, encompassing a wide spectrum of teaching behaviors. The mean ratings for the each question are as follows: 1) whether or not the trainer demonstrated thorough knowledge of the topic (4.2), 2) whether or not the lecture was clear and well organized (4.1), 3) whether or not the trainer stimulated enthusiasm for the topic (4.1), 4) whether or not the module was taught at an appropriate level and provided adequate detail (4.2), 5) whether or not the trainer used an effective method of teaching (4.0), 6) whether or not the trainer invited questions and participation from participants (4.0). Mean overall rating was 4.1. However, greater variation in ratings was observed across various modules, ranging from 3.6 to 4.4. The following comments from some participants demonstrated their satisfaction with teaching skills:
“It was not a one-way lecture. The interactive lecture, small group discussion, and trigger video tape helped participants to concentrate more fully on the topic.”
“Small group discussion stimulated interest and enthusiasm for the topic, and I participated more actively.”
Impact on knowledge and self-confidence
On pre- and post- test of knowledge of each module, participants demonstrated significant improvement in their knowledge of 6 of the 17 modules, which included “Gaps in End-of-life Care”, “Pain management”, “Systemic symptoms & Other symptoms”, “Working with Families”, “Last hours of living”, and “Bereavement Care” (Table 6).
Scale: 1 = very low, 5 = very high.
Pre- and Post- test scores were linearly transformed to 0-100, and higher score indicate higher knowledge.
by Paired t-test of difference between pre- and post- test score.
After each session, participants reported that they had gained confidence in their ability to perform the palliative care practices related to the topic. Overall rating was 4.0, and ranged from 3.6 to 4.3 across the different modules (Table 6). The following comments from participants demonstrate a significant impact on their confidence level:
“I became more confident in taking care of my dying patients and the education was useful for hospice practice.”
“I came to understand the concept of hospice and palliative care, and now I can confidently explain it to others.”
“I found difficulties in communicating with patients, but now I think I can better communicate with my patients without worry.”
Overall course evaluation
Overall, most participants agreed that the program met the educational goals (87%). They agreed on usefulness of the material (83%), and reported high satisfaction with facilities (93%), teaching methods (79%), and time schedule (73%). However, they showed relatively low agreement in regard to usefulness of the pre-post test (52%). Overall, they evaluated the program highly (86%), and reported that they would recommend the course to their colleagues (83%). Some free comments from participants regarding improvement of the course include the following:
“Each session length (70 minutes) was too short, particularly when small group discussion was involved. Session time should be more flexible.”
“The weekly schedule of the course makes the entire length of the course too long and inefficient. Change to a shorter and more intensive course would improve efficiency”
“Some trigger videos were not adequate for our culture and situations; other trigger videos suitable to our situation must be developed”
“Some trainers need better training to perform the education in their teaching skills.”
“The curriculum is well organized and the trigger tapes and clinical cases are useful”
“Participants were too heterogeneous in regard to their job and current knowledge level of hospice and palliative care. For some participants, it was too easy and already well-known. It will be necessary to develop advanced courses for each professional as a next step”
Discussion
Compared to education programs for hospice and palliative care professionals in other countries, development and implementation of the Standard Hospice & Palliative Care Education Program in Korea have several remarkable characteristics.
First, program development was driven by government initiative. Until national policies for palliative care and resources, both fiscal and manpower, are implemented for services and training programs, progress in palliative care education within a country is likely to be slow. 19 In Korea, the Ministry of Health, Welfare, and Family Affairs established policy for promotion of hospice & palliative care, including training for professionals, as part of its second-term 10-Year National Cancer Control Plan Strategy, which could therefore be integrated with other components of the national cancer control plan. For example, according to the WHO's national cancer control planning framework, a core step includes development of reference centers that can provide in-service training to community caregivers. In Korea, the Ministry of Health, Welfare, and Family Affairs has designated regional cancer centers in each area, and our standard hospice & palliative care education program could be rapidly disseminated throughout. Based on the successful results of our demonstration programs, we are currently in the process of implementing the Standard Hospice & Palliative Care Education Program through 5 Regional Cancer Centers.
Second, our development of a standard hospice and palliative care program was managed in a low-to-moderate resource setting. Many excellent palliative care education programs, such as Palliative Care Education and Practice (PCEP) at Harvard Medical School, The Stanford Faculty Development Center's (SFDC) End-of-Life Care Program, and the End-of-Life Nursing Education Consortium (ELNEC) in developed countries, which is usually targeted for specific types of professionals. These programs were developed by experts in palliative care and medical education, with adequate funding and a sufficient developmental period.
However, infrastructure of palliative care in Korea was very weak when educational needs were discussed in 2005; there were few experts, and funding, as well as the period provided for program development were insufficient. When initiating a palliative care program in a low-or middle-income country, education and training should be provided for all health workers in the target area. 20 Therefore, in consideration of cost-effectiveness and policy perspectives, we decided to develop the program for basic training of all types of professionals, primarily by adaption of foreign materials for relevance in a Korean context. Therefore, development and implementation of a high quality educational program could be achieved with minimal human and financial resources in a relatively short period of time.
Overall results from evaluation of the demonstration program were excellent. Relevance and usefulness of the program were rated highly, and teaching skills of trainers were generally highly evaluated. Improvement of knowledge and confidence of participants was demonstrated. They felt that the program met its educational goals, and most were highly satisfied and demonstrated their intent to recommend the program to their colleagues. However, as our results are preliminary, and are based on one demonstration program, caution should be exerted in interpretation of our results, and further evaluation will be necessary. First, a control or comparison group was not available; therefore, reported improvements from this intervention may be due to factors other than the intervention. In our continuing study, we plan to make a comparative assessment of program results. Second, our evaluation was based on self-reports, and some of them could have lead to bias. A significant problem with many educational program evaluations is that they are overly dependent on self-assessed competencies and impact. 10 Impact of standard education on hospice and palliative care practice as well as on patients' quality of life should be studied as a next step. Currently, a study project on evaluation of quality of palliative care is ongoing, 21 and would be a platform for such outcomes research in the future.
After all, development and implementation of the Standard Hospice & Palliative Care Education Program was evaluated as quite successful. A recent survey by the National Cancer Center and the Korean Society of Hospice & Palliative Care indicated that most hospice & palliative care professionals (89%) responded to the necessity of a standardized education program. 22 However, participants in the demonstration program also revealed areas that will require further development.
First of all, the need for development of a formal train-the-trainer program was addressed. Although we held a one day trainer workshop before the demonstration program, the course was not well prepared. Although participants demonstrated a high level of satisfaction, course contents and the exercise of specific training skills were not standardized. In fact, wide variations in mean ratings (range; 3.0 to 4.6) were demonstrated across various modules delivered by different trainers. Effective teaching not only requires expertise in clinical content, but also a range of pedagogic competencies, including proficiency in a variety of didactic and interactive teaching methods.10,11,23,24 Admitting to the need for more standardized and specialized training for trainers, we decided to develop a standardized trainer training program, in collaboration with the department of medical education, college of medicine, Yonsei University. At the time of writing, 3 trainer training courses were provided for regional cancer centers, to assist their implementation of standard education programs.
Second, the need for an advanced course and for certification was addressed. After completing the demonstration program, many participants expressed a need for advanced courses for each type of professional. A recent survey by the National Cancer Center and the Korean Society of Hospice & Palliative Care indicated 80∼90% of current palliative care professionals agreed with the need to develop certification system by advanced training. 22 As there is no formal certification system for palliative care education, except for that of ‘Hospice professional nurse’, which requires a 2 and one half year master course and master thesis, some participants suggested certification courses for professionals in the field. At the time of writing in 2009, another TFT was launched with ELNEC (End-of-Life Nursing Education Consortium) trainers as members and development of an advanced course for nurses is ongoing through additional funding from the Ministry of Health, Welfare, and Family Affairs. Demonstration project is planned in 2010-2011 period. Development of an education course for physicians and certification for hospice & palliative care professionals are under discussion.
In summary, development of the Standard Hospice & Palliative Care Education Program and its demonstration program was successful, and made a large impact on hospice & palliative care education in Korea. During the process, many opportunities and areas for further improvement were identified. We are taking steps toward better preparation for hospice & palliative care professionals, which should lead to better quality of end-of-life care. We hope that comments regarding our experience in Korea would be helpful to efforts in other countries, particularly those with limited resources for hospice and palliative care.
Footnotes
Acknowledgment
The EPEC curriculum provided the framework of our standard hospice and palliative care education. We acknowledged this in our education material as following: “This education material was developed through modifying the EPEC material to conform the Korean context”.
Author Disclosure Statement
No conflicting financial interests exist.