Mind the Gap: Understanding Palliative Care Clinician Attitudes Toward Mental Health Training

Abstract

Background: Palliative care (PC) clinicians provide mental healthcare to individuals with serious illnesses. Despite this, there is limited knowledge regarding their mental health training opportunities. Methods: To identify predictors of satisfaction with mental health training opportunities and assess the relationship between training opportunities and clinician comfort in managing mental health comorbidities, we conducted a secondary analysis of a nationwide survey involving 708 PC clinicians. Results: Satisfaction with mental health training was moderate (M = 2.75/5, SD = .915). Access to lectures/webinars was the most common training opportunity (54%). Significant predictors of satisfaction with training included access to lectures/webinars (β = .328, P <.001) and case discussions (β = .231, P = .007). Academic practice settings and satisfactory mental health referrals were associated with a greater number of different training opportunities. Clinicians in academic settings had higher odds of accessing various training opportunities, such as lectures/webinars (OR = 2.58, P <.001) and longitudinal training pathways (OR = 4.51, P <.001). A moderate, positive correlation was found between training satisfaction and comfort in managing mental health comorbidities (r = .30, P <.001). Discussion: This study is among the first to elucidate factors influencing PC clinicians’ satisfaction with mental health training. Low-resource training opportunities, such as webinars and lectures, significantly predict satisfaction, suggesting the potential of these scalable solutions to enhance training. The findings underscore the importance of expanding evidence-based mental health training for PC clinicians to improve patient care.

Keywords

palliative care mental health workforce medical education psychiatry hospice

Introduction

Mental health comorbidities are common and impactful among individuals with serious illnesses.¹ Addressing the mental health components of serious illness care is a core component of palliative care (PC).² PC clinicians frequently manage a range of mental health issues spanning normative existential and psychological reactions to serious illness, depression and anxiety, and serious mental illnesses like psychotic disorders.³ Training guidelines and national practice consensus documents emphasize that PC clinicians must achieve competency in managing mental health concerns.² While PC social workers have formal mental health training, PC clinicians from other training backgrounds (eg, physicians, advanced practice providers, and chaplains) are also tasked with addressing the psychological and psychiatric components of PC.³

Despite the role of PC clinicians in improving the mental health of individuals with serious illnesses, little is known about their opportunities for training in the mental health components of palliative care. Understanding PC clinicians’ mental health training opportunities can help educators and professional organizations create educational programming targeted to the needs of practicing PC clinicians. Such data are particularly critical in light of variability in PC physician fellows’ exposure to mental health content during their fellowship training.⁴

This secondary analysis of data generated as part of a nationwide survey of PC clinicians aims to: (1) characterize predictors of satisfaction with mental health training opportunities, (2) assess the influence of practice setting (academic vs other) and access to mental health referrals for patients on clinician training opportunities, and (3) determine the correlation between HPM clinician satisfaction with mental health training and comfort managing mental health comorbidities. Our hypotheses were that: (1) satisfaction with mental health training would be predicted by access to training opportunities, embedded psychiatrist/psychologist team members, and academic practice settings; (2) satisfaction with training would correlate with comfort managing mental health comorbidities; and (3) HPM clinicians practicing in academic settings and those with greater access to mental health referral sources would have more opportunities for mental health training.

Methods

We conducted a secondary analysis of survey data collected from 708 PC clinicians nationally to understand the factors that influence PC clinician satisfaction with mental health training. Details of this study, which focused on mental health integration and delivery in the palliative care setting, have been published previously.³ Survey development and distribution are described in the original report.⁴

Survey Instrument

The survey (see supplement 1 for survey text and original study³ for survey development): (1) included items about respondents’ demographics and practice settings, (2) sought to ascertain the types of mental health issues HPMs clinicians identified and managed in their practices, as well as their comfort doing so, (3) inquired about the mental health resources that were available to respondents, and finally (4) queried respondents about the type of and satisfaction with training opportunities in mental health.

We employed 5-point Likert scales to assess comfort and satisfaction. We assessed comfort managing 9 mental health conditions (depression, anxiety, post-traumatic stress disorder, substance use disorder, psychotic disorders, personality disorders, dementia, delirium, suicidality, and agitation) by asking respondents, “How comfortable do you feel managing [mental health condition] in your palliative care setting?” on a scale from 1 (very uncomfortable) to 5 (very comfortable). These scales were designed to capture a spectrum of perceived efficacy and ease in managing each condition, with higher scores indicating greater comfort. The mental health satisfaction scales yielded a Cronbach’s alpha of .879, indicating high internal consistency.

We assessed satisfaction with mental health training by asking respondents, “How satisfied are you with the mental health training opportunities in your palliative care role?” on a scale from 1 (very unsatisfied) to 5 (very satisfied). We assessed satisfaction with access to mental health referrals for patients by asking respondents, “How satisfied are you with access to mental health referrals for your palliative care patients who require specialist mental health care in your palliative care setting?” on the same 1 to 5 Likert scale as above.

Analyses

Our primary objective in conducting this secondary analysis was to identify factors contributing to PC clinicians’ satisfaction with mental health training. Multiple linear regression analyses were performed incorporating binary variables representing access to various training types and the presence of mental health professionals on the team, as well as the academic nature of respondents’ practice settings. We included years of practice and practice setting (inpatient vs outpatient vs hospice/home care) as covariates. Collinearity diagnostics were performed to assess multicollinearity among predictors.

We constructed ordinal logistic regression models to determine whether practicing in an academic setting or having access to mental health referrals for patients predicted having more mental health training opportunities. The response variable consisted of an ordinal scale reflecting access to 7 specific training resources (0 to 8 reflecting whether a respondent had access to webinars or lectures, case discussions with experts, office hours with experts, support to attend conferences or courses, longitudinal training pathways, learning from embedded social workers, learning from embedded mental health nurse practitioners, and learning from embedded psychiatrists/psychologists). Upon detecting a violation of the proportional odds assumption for the academic setting, we employed a generalized ordered logit model (gologit2). We also conducted a logistic regression analysis to understand the influence of practice setting (academic vs other) on access to each specific type of training opportunity.

Furthermore, Spearman’s rank correlation was used to explore the link between training satisfaction and clinician comfort in managing mental health comorbidities. Clinician comfort was quantified as the mean response to the 9 Likert items on comfort managing various mental health conditions. Analyses were run for comfort managing individual conditions, mean comfort managing all 9 conditions, and mean comfort managing 3 common mental health comorbidities: depression, anxiety, and delirium. The latter 3 conditions were chosen due to their high prevalence and significant impact on patient outcomes in palliative care and because of their being identified by survey respondents as common and often under the purview of PC teams,^3,5-7 aligning with our study’s goals to evaluate palliative care clinicians’ mental health training needs.

Analyses were executed using Stata (Version 18.0) and SPSS (Version 27), with a significance threshold of α = .05.

Results

The analytic sample consisted of 708 respondents, of whom 86% (N = 614) were physicians. Most respondents provided care to adult patients (86%; N = 612). Approximately half of respondents practiced predominantly inpatient palliative care followed by outpatient (19%; N = 132) and hospice (18%; N = 127). Half of respondents practiced in academic settings.

Predictors of Mental Health Training Satisfaction

Respondents reported moderate satisfaction with mental health training opportunities (M = 2.75, SD = .915). Access to training varied, with lectures/webinars being the most accessible (N = 379, or 53.53% with access). Our regression model, which included training opportunity types and academic setting as predictors, accounted for 25.5% of the variance in satisfaction with training opportunities (R² = .255, F (7, 557) = 27.238, P < .001). Significant predictors included access to lectures/webinars (β = .328, P < .001), an integrated psychiatrist or psychologist as a team member or liaison (β = .277, P < .001), access to case discussions with experts (β = .231, P = .007), and longitudinal training pathways (β = .171, P < .005). Adding years of practice and practice setting did not improve the model’s predictive capability.

Predictors of Mental Health Training Opportunities for Palliative Care Clinicians

The mean number of training opportunities available to respondents was 1.97/7 (SD = 1.43). The number of training opportunities was significantly associated with the academic setting and satisfaction with mental health referrals (χ2 (2) = 147.49, P <.001, pseudo-R² = .663). Increased satisfaction with referrals was associated with higher odds of additional training opportunities (z = 6.75, P <.0001). The gologit2 model indicated a differential impact of academic setting across outcome levels, with a pronounced effect on the lower end that tapered off at higher levels of training opportunities.

In our logistic regression analysis, we found that respondents practicing in an academic setting had significantly higher odds of having access to multiple training opportunities compared to non-academic respondents. Specifically, practicing in an academic setting was associated with higher odds of having access to lectures/webinars (OR 2.58; 95% CI 1.83–3.64, P <.001), case discussions with experts (OR 1.78; 95% CI 1.23–2.58, P = .002), longitudinal training pathways (OR 4.51; 95% CI 2.13–9.56, P <.001), and embedded psychiatrists or psychologists (OR 2.12; 95% CI 1.26–3.56, P = .005). Conversely, academic status was associated with lower odds of having support to attend mental health conferences (OR .38; 95% CI .22–.68, P = .001). There was no significant association between academic status and access to education from embedded social workers (OR 1.09; 95% CI .77–1.53, P = .638), embedded mental health nurse practitioners (OR .99; 95% CI .39–2.51, P = .990), or office hours with experts (OR .63; 95% CI .32–1.24, P = .181). See Table 1 for a detailed comparison of training opportunities available to respondents in academic and non-academic settings. See Table 1 for a comparison of training opportunities available to respondents in academic and non-academic settings.

Table 1.

Availability of Mental Health Training to Clinicians in Academic Versus Non-Academic Settings.

Training Opportunity Type	Academic (N = 349, 49.5%)	Non-Academic (N = 356, 50.5%)	Odds Ratio
Mental health lectures or webinars	68% (N = 238)	39% (N = 139)	2.58**
Case discussions with mental health experts	45% (N = 156)	23% (N = 83)	1.78**
Office hours or other opportunities to learn from mental health experts	7% (N = 26)	6% (N = 21)	NS
Financial or logistical support to attend external conferences on mental health	9% (N = 31)	12% (N = 44)	.38**
Longitudinal mental health learning opportunities such as fellowships or site placements	15% (N = 51)	3% (N = 10)	4.51
Embedded social workers on team	70% (N = 245)	63% (N = 225)	NS
Embedded psychiatric mental health nurse practitioners on team	5% (N = 18)	3% (N = 10)	NS
Embedded psychiatrists or psychologists on team	20% (N = 68)	8% (N = 27)	2.11**

NS: Not statistically significant.

**: P <.01.

*: P <.05.

Relationship Between Training Satisfaction in Mental Health and Comfort Managing Mental Health Comorbidities

PC clinician satisfaction with mental health training opportunities showed a positive, moderate correlation with comfort level when managing mental health comorbidities (r = .30, P <.001). This association was consistent, albeit weaker, for comfort managing the 3 most prevalent mental health comorbidities in serious illness: depression, anxiety, and delirium (r = .24, P <.001). Correlations between training satisfaction and individual conditions were all positive and statistically significant except for the correlation between training satisfaction and comfort managing dementia (see Table 2). Correlations were small to moderate, with the strongest correlation between training satisfaction and comfort with suicidality (ρ = .32, P < .001).

Table 2.

Correlation Between Comfort Managing Specific Mental Health Conditions and Satisfaction With Mental Health Training Opportunities.

Mental Health Condition	Correlation With Satisfaction With Mental Health Training Opportunities (Spearman’s ρ)
Major depressive disorder	0.20
Anxiety disorders	0.20
Substance use disorders	0.27
Post-traumatic stress disorder	0.25
Psychotic disorders	0.21
Personality disorders	0.23
Dementia	NS
Delirium	0.17
Suicidality	0.32
Agitation	0.21

NS: Not statistically significant.

**: P < .01.

*: P < .05.

Discussion

To our knowledge, this is the first study to characterize the determinants of PC clinician satisfaction with training in the mental health components of palliative care. Our study, which leverages data collected from a nationwide survey of PC clinicians, identifies high and low-resource training opportunities that predict PC clinician satisfaction with mental health training. Further, we found that satisfaction with training was moderately correlated with comfort managing mental health comorbidities in the palliative care setting. We found that PC clinicians practicing in an academic setting have disproportionate access to training opportunities, which is significant given the relationship we identified between having training opportunities, being satisfied with training, and being comfortable managing mental health comorbidities in patients receiving palliative care.

In terms of predictors of satisfaction with training, we were struck that webinars and lectures, a relatively “low resource” and highly scalable educational approach, outperformed more resource-intensive training opportunities such as formal training pathways or even having mental health specialists embedded in the team. Though our data showed that academic clinicians have much higher odds of having access to lectures and webinars at this time, such resources can easily be made available to community-based and hospice-based clinicians at little to no cost. Innovative e-learning programs such as “HAPC Virtual Didactics” are already making high-quality lectures and webinars delivered by content experts available to clinicians nationally, independent of institutional affiliation.⁸ Our data support the expansion of democratized learning opportunities, which could potentially impact PC clinicians’ satisfaction with training and comfort managing mental health comorbidities.

Our study has several limitations that warrant consideration. Our original data collection methods were subject to selection bias and biases in self-reporting. Furthermore, there are potential confounders that we were unable to measure that may inform the relationships we identified, particularly between academic practice settings and many of our outcomes of interest. These include individuals’ background training (eg, initial specialty training for physicians), practice setup, and topic-agnostic opportunities for training (eg, professional development funding). Though we captured respondents’ desired forms of training (eg, Webinars), we do not know whether these approaches are optimal for improving practice. Similarly, though we found that clinician comfort correlated with training satisfaction, we do not know whether increased comfort managing mental health comorbidities translates to improved clinical outcomes. Rather than generating conclusive findings, we consider our study to be an important step in hypothesis generation and, ultimately, in expanding evidence-based mental health training opportunities for palliative care clinicians in all settings. Our findings should be followed with a more mechanistically oriented inquiry into the drivers of the relationships that we identified. For example, the relationship between academic status and training satisfaction may be mediated by internal opportunities such as grand rounds, funding opportunities to pursue external learning (eg, to attend conferences), closer contact with mental health specialists, or some combination thereof.

In conclusion, we found that among a large sample of practicing PC clinicians, training opportunities (particularly webinars and lectures) correlated with greater mental health training satisfaction. Although respondents practicing in an academic setting had more opportunities and were more satisfied, the significance of webinars and lectures as key predictors of satisfaction suggests that these low-resource and easily disseminated learning resources could improve training access and satisfaction among PC clinicians practicing in rural, underserved, and/or hospice settings. We also found that improving satisfaction may have downstream effects on PC clinician comfort. Further study is needed to confirm these findings, evaluate the impact of webinar and lecture-based mental health didactic interventions, and understand whether improving training satisfaction and comfort with mental health management among PC clinicians enhances patient care.

Supplemental Material

Supplemental Material - Mind the Gap: Understanding Palliative Care Clinician Attitudes Toward Mental Health Training

Supplemental Material for Mind the Gap: Understanding Palliative Care Clinician Attitudes Toward Mental Health Training by Daniel Shalev, Danielle Chammas, Keri O. Brenner, Jerad H. Moxley, M. Carrington Reid, and Leah B. Rosenberg in American Journal of Hospice and Palliative Medicine®.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Redacted for anonymity. National Center for Advancing Translational Sciences; UL1 TR0002384, National Institute on Aging; 5K24AG053462-08.

ORCID iD

Daniel Shalev

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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