Abstract
Background:
The WHO has proclaimed that palliative care (PC) should be integrated as a routine element of all undergraduate medical and nursing education. The EDUPALL Erasmus+project produced a PC curriculum for undergraduate medical education based on the European Association for Palliative Care (EAPC) recommendations for undergraduate training. This was tested in four Romanian Faculties of Medicine: Universities of Transilvania, Iasi, Targu Mures, and Timisoara. The aim of this study is to describe teachers' satisfaction and views on the effectiveness of the EDUPALL curriculum and supporting learning materials.
Methods:
We conducted nine semistructured interviews with teachers involved in EDUPALL implementation in their universities. Interviews were transcribed and collected data underwent thematic analysis. Kirkpatrick's four-level evaluation model of training was employed to synthesize the outcomes into final categories of reaction, learning, behavior, and results.
Results:
Data were categorized against Kirkpatrick's four levels as follows: Level 1 (Reaction) EDUPALL curriculum—a good standard with achievable goals; Level 2 (Learning) Personal appraisal and development needs of the teaching faculty; Level 3 (Behavior) Application of competencies and student feedback; and Level 4 (Results): Faculty- and country-level Impact of the EDUPALL project.
Conclusion:
EDUPALL curriculum is a good and adaptive model to teach PC at Faculties of Medicine, considered by teachers as a way of bridging an existing training gap for medical students in building essential competencies in symptom management, communication, spirituality, and self-awareness.
Background
Basic palliative care (PC) training should be integrated as a routine element of all undergraduate medical and nursing professional education according to the Resolution of the 67th World Health Assembly entitled Strengthening of palliative care as a component of comprehensive care throughout the life course. 1 PC education is increasingly included in Medical School curricula across European countries. However, the percentage of medical schools delivering PC training per country and the way PC is taught varies greatly. 2 Implementing a PC curriculum in a medical school engenders both challenges and barriers. 3
Medical undergraduate students report they acquire better attitudes for connecting with the patient, such as empathy or holistic care; ethical principles, such as respect or humanization of their clinical practice; and commitment to an improvement in competencies, such as self-awareness or self-esteem after PC training. 4 They report improved behavior in delivering patient-centered care. They learn team work as an effective way to interact within the health system. The most efficient and sustainable strategy to teach these PC skills and knowledge in undergraduate medical students is yet to be determined.
Teachers play a crucial role in PC education. Faculty are expected to organize the learning, know the field and state of art, be ready to learn, lead by example, and embody and practice the principles of PC. 5 Equipping teachers with evidence-based curricula, clearly defining teaching goals, method toolkits and performance assessment strategies are likely to facilitate PC education in medical schools.
PC in Romania
In Romania, PC was established in 1992 and recognized as a medical subspecialty in 2000. 6 Since then, over 600 physicians have graduated with 18 months of subspecialty training and over two-thirds of them are working in PC services either full time or part time. At the undergraduate level in 2018, 11 of the 12 medical schools have academic staff trained in PC, with 2 having chairs. Since 2017, the standards concerning quality in higher education require that all medical and nursing faculties in Romania must have PC as a compulsory self-standing discipline. 7 Accordingly, 2 of the 12 medical universities in Romania have now included compulsory PC training for medical (and nursing) students, with both theoretical classes and bedside training. Three other universities have included PC as optional courses with credit points.
The EDUPALL project
The EDUPALL project aims to develop and test a complete program for undergraduate medical student education in PC. The project developed a blended undergraduate PC curriculum based on the European Association for Palliative Care (EAPC) recommendations for undergraduate training. 8 To increase the capacity of teaching faculty, the EDUPALL curriculum contains novel teaching methods, assessment techniques, and materials to enhance the teaching faculty's mentoring skills, including examples of training materials in both Romanian and English for face-to-face and online training. The EDUPALL toolkit for trainers includes 31 lesson plans for all topics included in the curriculum, 14 PowerPoint presentations for the theoretical courses, 28 lesson plans for seminars with case studies, exercises, and role plays.
To implement the EDUPALL program, faculty academic trainers received tuition through three short-term training sessions. During the academic year 2019–2020, the EDUPALL curriculum was implemented in four Romanian Faculties of Medicine who were partners in the EDUPALL project. The blended curriculum was tested with 1500 medical students. In this study, we report the results of qualitative evaluation of trainers' experiences in implementing the curriculum.
Methods
Design
This is a qualitative explorative study using semistructured interviews to develop new knowledge of medical faculty's experiences of teaching PC.
Participants and setting
All members of the medical faculties from four Romanian medical schools implementing the new EDUPALL PC curriculum and materials were invited by e-mail to participate in the study. The invitation contained an explanation, interview questions, the purpose of the data collection, and a request for consent. An appointment was then made for the interview. All interviews were conducted using online video conference tools. Introductory conversations were held before the sound and video recording. Consent to record was obtained orally.
Ethics approval
The study was part of an assessment and evaluation of the EDUPALL curriculum from the perspective of medical students and academic staff. It received ethics approval from the Ethics Board of Hospice Casa Sperantei, the partner in charge of monitoring the quality of the EDUPALL project implementation.
Data collection
Initially, face-to-face interviews were planned, but due to the Covid-19 outbreak, the interviews were conducted one to one, through a video conferencing tool. It has been demonstrated that in-person interviews generate a greater depth of discussion, but a similar breadth of topics. 9 The interviews were conducted in English since all teachers use English in either undergraduate or postgraduate programs in their medical schools. The interview guideline consisted of four main questions (Table 1).
The Interview Guideline
Data analysis
The interviews were transcribed verbatim following the transcription rules of Kuckartz soon after finishing each interview. 10 The collected data underwent a three-step adaption of the thematic analysis suggested by Braun and Clarke. 11 This is a flexible research strategy since no linear process is assumed. In step 1, the unit of meaning within the text was defined. In step 2, the meaning units were paraphrased to codes and themes. (Screening for curriculum usefulness, teaching areas, teaching methods, lesson plans, teaching materials, curriculum impact, and teacher perceived student feedback.) 12 The authors collaborated during the data analysis process until themes were finalized. In step 3, Kirkpatrick's four-level evaluation model of training was employed to synthesize the outcomes into final categories of reaction, learning, behavior, and results.13,14 The steps of textual analysis are described in Figure 1.
The steps of textual analysis. Color images are available online.
Rigor
Two authors (A.N. and P.P.) collaborated in coding the data and discussed the analysis process until themes were finalized. The three-step analysis achieved a plausible and coherent description and interpretation of the study phenomena. Triangulation was employed through comparison of the data to the Kirkpatrick's evaluation model and available literature to provide a more nuanced and contextualized interpretation of the data through writing. The data findings were confirmed by the other authors of this article (C.P. and D.M.) familiar with the EDUPALL project and teaching of PC in Romania.
Results
Nine out of the 10 medical teachers who implemented the curriculum gave their consent to participate in the study and completed the interview. The demographic data of interview participants are listed in Table 2.
Participants Demographics
PC, palliative care.
We conducted nine interviews, which lasted between 20 and 40 minutes, most of them lasted around 30 minutes. Seven teachers were female and two were male. They were drawn from the Faculties of Medicine of the following Universities of Romania: Transilvania, Iasi, Targu Mures, and Timisoara.
Table 3 provides an overview of the EDUPALL curriculum. Only one university implemented (all the lessons and seminars from the full EDUPALL curriculum). Two universities delivered 6 and 11 hours of large group lessons, and 15 and 12 seminar hours. The remaining university taught seven hours of lessons to large groups that focused on pain management and spiritual care. Pain and communication topics were the most well covered. All four universities were able to provide some bedside PC teaching.
EDUPALL Curriculum Overview
Outcomes of the qualitative inquiry
The results are reported in four categories (Table 4)
Outcomes of Qualitative Inquiry: Themes and Quotes
Level 1 reaction: EDUPALL recommendation—a good standard with achievable goals
The EDUPALL curriculum was perceived as setting a good standard with achievable standardized goals. It provided specific teaching strategies and materials for each topic and contained a wealth of information. The EDUPALL curriculum was felt to be adaptive and thus, allowed modifications needed to meet local requirements and resources, although it was recognized that it takes a certain number of training hours to make a difference. The interactive teaching methods and online components were perceived to enable student-oriented learning. All faculty members agreed that being part of the EDUPALL project was a positive experience personally. The curriculum development was felt to be an enriching and fruitful but challenging process.
Level 2 learning: Personal appraisal and development needs of the teaching faculty
Gratitude was expressed toward learning from each other. Meeting people with the same interest and networking was seen as a positive experience enabling personal and professional growth. The experience was described “as a mirror” that made evident how important it is to learn from each other and how important it is to develop personal teaching skills.
The materials and new teaching methods were helpful. The flipped classroom technique worked well. Set tasks and objectives supported teachers in determining effective learning goals and made teaching much easier.
Familiarity with the learning materials was described by all as essential. For many the meaning of embedded assessment strategies became clearer. Nevertheless, some topics, such as loss, grief and bereavement, and spirituality were difficult to teach. It became evident that to teach well, the teacher had to have mastered the materials.
The faculty needed to improve their teaching skills. Exchange between the faculty was seen as very important to be prepared and to have similar teaching standards.
Level 3 behavior: Application of competencies and student feedback
Students told the faculty they appreciated the “new” topics. EDUPALL fostered and enabled change in the students. However, the faculty noted that students were learning generalist, not specialist, skills in PC. The number of students being taught together was a challenge. For example, certain topics caused emotional responses in individual students. It was a challenge to respond to the individual who needed further exploration and support. Teachers also recognized that personal experiences with PC were relevant and could provide another important source of learning. Students were perceived to have demonstrated high interest in PC and were confident regarding their end-of-life competencies. Students appeared to be very open-minded toward online learning; they seemed to appreciate the case studies.
Students seemed most critical of the performance assessment, which many faculty believed came too late to support their learning. Teachers agreed that the assessment strategy must be in place from the very beginning.
Level 4 results: Faculty- and country-level impact of the EDUPALL project
In terms of improvements, the EDUPALL curriculum expanded the medical curriculum in key areas, such as psychosocial and spiritual aspects, communication, and grief management. Some universities covered all topics; the others taught a selection.
The Covid-19 pandemic affected the implementation of the curriculum. Bedside teaching was hindered, but the online component, which was described as innovative and helpful, supported the curriculum roll-out.
On the other hand, communication and role play were not perceived to be very effective online. Teachers argued that teaching attitude is difficult online.
A number of barriers were described. Universities needed to allocate new time to teach PC. It became evident that the medical faculty needs PC training. The provision of a limited number of hours to teach the subjects was also a challenge. In addition, there were too few teaching faculty.
The participants perceived they were challenged to advocate for the inclusion of PC in the medical school curriculum. Other colleagues appeared not to understand the need for the PC. Younger colleagues seemed to be better informed about the need for PC education than older colleagues. They noted that, when PC education is not mandatory, implementation opportunities were limited.
Discussion
Studies about introducing PC into medical schools, mostly evaluate the curricula from the medical students' point of view.15–19 The teaching faculty themselves are less studied. 20 The evaluation revealed faculty perceived they could grow as educators, create team bonds, and experienced their participation as rewarding. Participants recognized the need for further developments and refinements based on the assessment of this first EDUPALL curriculum. Concerns were also raised on the need for recognition, manpower, and resources assigned to the implementation of this curriculum. 3
As an immediate outcome of the EDUPALL project in 2020, three additional Romanian universities have included PC as optional courses with credit points into their undergraduate programs. A resolution to utilize the PC curriculum and the teaching materials was signed by two other Romanian medical schools. As a result, seven medical faculties have increased their educational offerings in PC and adapted their curriculum to meet actual demographic and health problems, including the Covid-19 pandemic.
There were several limitations. The Covid-19 outbreak led to changes in both the way in which the EDUPALL project was delivered. Only one university was able to implement the full EDUPALL curriculum. The Covid-19 outbreak also affected how interviews were conducted with faculty. The need to support some faculty members to improve their confidence and competence in delivering certain parts of the PC curriculum was noted. The interviewers were part of the development of the curriculum. Some of the interview questions were phrased in a positive manner. This may have introduced a positive bias to the interviews. In addition, conducting the interviews in Romanian might have interviews in necessary changes in the EDUPALL delivery, and evaluation would need to be considered when making future recommendations in further adoption of the EDUPALL curriculum.
Interviews in Romanian may have enabled them to better articulate their thoughts.
Conclusion
The nine faculty teaching the EDUPALL curriculum in four medical schools in Romania found the materials to be useful and effective. Modifications that are partly in the control of the faculty, and partly not in their control, will be required for further dissemination.
Footnotes
Funding Information
The work was carried out as part of Erasmus+ Project Strategic partnership Ref. no.: 2017-1-RO01-KA203-037382 Palliative Care Standardized Curriculum—Translating International Recommendations into Undergraduate Palliative Care Curriculum (EDUPALL).
Author Disclosure Statement
No competing financial interests exist.