|Year : 2022 | Volume
| Issue : 1 | Page : 23-27
Evaluation of palliative care training program for medical interns in a tertiary care teaching hospital, South India
Suguna Elayaperumal1, Vinayagamoorthy Venugopal2, S Adinarayanan3, Amol R Dongre4
1 Department of Community Medicine, Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India
2 Department of Community and Family Medicine, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
3 Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
4 Department of Extension Programme, Pramukhswami Medical College, Karamsad, Gujarat, India
|Date of Submission||17-May-2021|
|Date of Acceptance||10-Oct-2021|
|Date of Web Publication||30-Jun-2022|
Department of Community and Family Medicine, All India Institute of Medical Sciences, Deoghar, Jharkhand
Source of Support: None, Conflict of Interest: None
Introduction: The Department of Community Medicine has been training medical interns for providing hospital-based palliative care (HBPC) and community-based palliative care (CBPC) services with an interprofessional team. This study was done to evaluate the training program on palliative care developed for medical interns.
Material and Methods: It was a retro-pre type of program evaluation done among 172 interns between January 2016 and December 2017. One day program was conducted for the interns by faculty trained in palliative care, followed by placement in HBPC and CBPC program. At the end of training, self-perceived improvement in knowledge was collected on a five-point Likert scale. Certificates were issued on completion. Data were entered and analyzed using Epi Info (version 22.214.171.124) software. Wilcoxon signed-rank test was applied between pre- and post-scores. Manual content analysis was done for open-ended questions.
Results: The mean age of the participants was 22.5 ± 0.8 years, with 76 (44.2%) males and 96 (55.8%) females. There was statistically significant improvement in perceived knowledge scores after attending the training. Areas of learning, values learned, and uses of learning in future career and suggestions for improving the training program were the categories obtained.
Conclusion: The training program improved the self-perceived knowledge on palliative care among medical interns. The exposure to HBPC and CBPC program had a positive effect on their attitude and perceived skills for caring of chronically ill patients. Such programs can be initiated by other palliative care providing institutions for training medical interns.
Keywords: Interprofessional team, medical interns, palliative care, training
|How to cite this article:|
Elayaperumal S, Venugopal V, Adinarayanan S, Dongre AR. Evaluation of palliative care training program for medical interns in a tertiary care teaching hospital, South India. Indian J Community Fam Med 2022;8:23-7
|How to cite this URL:|
Elayaperumal S, Venugopal V, Adinarayanan S, Dongre AR. Evaluation of palliative care training program for medical interns in a tertiary care teaching hospital, South India. Indian J Community Fam Med [serial online] 2022 [cited 2022 Aug 17];8:23-7. Available from: https://www.ijcfm.org/text.asp?2022/8/1/23/349380
| Introduction|| |
Medical Council of India envisions that an Indian medical graduate should be able to provide palliative care along with preventive, promotive, curative, and rehabilitative care. The training of medical interns is important since they are expected to function as primary care doctors, and they face challenges in managing chronic pain and in communication skills. There is an avoiding attitude among them regarding death or breaking a bad news. This is due to lack of formal training during the undergraduate period. The major domains proposed for palliative care training include basics of palliative care, psychosocial and spiritual, ethical and legal, communication skills, teamwork, and professionalism. The Attitude, Ethics and Communication module introduced in the undergraduate curriculum has case-based discussions about terminally ill patients and death. It has been implemented from professional year 1 in many medical schools with protected time slots. This has created an opportunity to train medical students on attitude, ethics, and communication skills for caring terminally ill patients and caregivers and discuss scope of palliative care. This requires trained team of faculty to handle small-group teaching sessions. However there is no palliative care training and assessment available for medical undergraduate students routinely. Inclusion of palliative care education in the undergraduate period has shown to improve clinical patient care by imparting knowledge, attitude, and skills for caring of chronically ill patients. We have been training medical interns on palliative care for the last four years. As a part of it, we wanted to evaluate the effectiveness of the structured training program on palliative care developed for medical interns in a tertiary care teaching hospital.
| Material and Methods|| |
This study was conducted in the Department of Community Medicine (DCM) in a tertiary care teaching hospital, Puducherry. We have been providing hospital-based and community-based palliative care (HBPC and CBPC) services with a team comprising trained palliative care physician, staff nurse, and medical social workers along with medical interns posted in the department. We provide care for elderly and chronically ill patients in hospital setting through palliative care clinic and in eight villages of our service areas through one home care team. The duration of the study was 2 years from January 2016 to December 2017. It was a retro-pre type of educational program design that evaluated the newly developed palliative care training program with Kirkpatrick level I evaluation framework. In retrospective pre–post design, data are collected at the same point in time (i.e. at the conclusion of training); thus, the ratings of understanding before (“retrospective pre”) and after (“post”) the intervention use the same metric. This design takes considerably less time than traditional pre–post data collection and eliminates the impact of response-shift bias., All the medical interns posted in the department underwent this mandatory training program during the study period of 2 years. Each batch consisted of 18–20 medical interns posted for 2 months. Twelve batches completed the posting in 2 years from 2016 to 2017. Out of the total 205 interns posted, 172 interns completed the training program. Remaining 33 interns could not join the training program. It was 1-day training program conducted in the 1st week of their posting in DCM as described in [Table 1]. The average attendance on training was 18 interns per batch excluding the absentees. The program consisted of four sessions: introduction to palliative care including communication skills, management of chronic pain, nursing care for bedridden patients, and community participation. Each topic was covered for a period of 60–90 min. The sessions were made interactive, with self-made videos, as well as group activities such as role-play and case-based discussions based on faculty experiences of providing care in hospital and community. The sessions were facilitated by faculty who completed basic certificate course in palliative medicine at Institute of Palliative Medicine, Kerala, and who are involved in the provision of palliative care in the evaluation setting. At the end of 1-day training, a retro-pre feedback form was administered to the study participants. It consisted of six questions to be rated on a five-point Likert scale from 0 to 5 (0 being lowest score and 5 being highest score) before and after the training. It captured the perceived improvement in knowledge of each session before and after attending the training program. The feedback form also included two open-ended questions on what they learned from the training program and how they were planning to apply the learning in their future and suggestions for improving the training program. After attending the training program, the medical interns were placed in the hospital and community to learn the core skills in palliative care under supervision for two months. A completion certificate was given to interns who underwent the training program and the placement. The certification was done in collaboration with Sanjeevan (a joint venture of Sri Aurobindo Society, Puducherry, and Institute of Palliative Medicine, Kerala). Clearance was obtained from the SMVMCH Institution Ethics Committee.
The data were entered and analyzed using Epi Info (version 126.96.36.199) software (Developed by Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, Georgia, U.S.A). Frequencies and percentages were calculated for sociodemographic variables. Mean ± standard deviation was calculated for continuous variables and median score for discrete variables. Wilcoxon signed-rank test was applied to find statistical significance between pre- and post-scores. Manual content analysis was done by first and second author for responses of the open-ended questions. Codes were derived from significant text information, and similar codes were grouped together forming categories. Statements within double quotes indicate direct quotations mentioned by the respondents.
| Results|| |
A total of 172 students completed the training program. The mean age of the participants was 22.5 ± 0.8 years. There were 76 (44.2%) male and 96 (55.8%) female medical interns. The median (IQR) perceived score for knowledge on introduction to palliative care increased from 2 (1–3) before training program to 4 (4–5) after training program (P < 0.05). The median (IQR) score on chronic pain management was 2 (2–3) and 4 (4–5) before and after the training program, respectively (P < 0.05). There was a statistically significant improvement in the median score on knowledge about community participation (P < 0.05). The median score for knowledge on nursing care improved from 2 (1–4) to 4 (3–5), and the difference was statistically significant (P < 0.05). The pre- and post-median score for the overall usefulness of the training program was 2 (2–4) and 5 (3–5) which was statistically significant (P < 0.05) [Table 2]. Three categories emerged from the content analysis, namely, areas of learning, values learned, and uses of learning in future career and suggestions for improving the training program. The five codes under areas of learning were scope of palliative care, chronic pain management, nursing care, community participation, and communication skills. Regarding scope of palliative care, study participants mentioned that they learned the importance and need for palliative care, how to identify a patient who needs palliative care, and when to initiate care. They were able to understand the psychological, social, and spiritual problems faced by patients other than physical problems. The medical interns expressed the need for good pain management for patients with chronic incurable illness, and they said that they learned rational prescription of medications for the management of chronic pain according to the World Health Organization analgesic ladder. They felt happy that they were taught how to provide nursing care for bedridden patients and nursing care for fungating wound and ostomy. They understood the roles and responsibilities of the community in helping people with incurable illness and problems faced when working in the community. Under the code on communication skills, one participant said, “I learned that good words and care are more powerful than medicine.” The study participants were able to appreciate the importance of communication skills while talking to a patient with incurable illness or their family. They could appreciate listening skills, value of spending time talking with patients, and ways to provide emotional support and breaking bad news. Attitude, empathy, and confidence were the codes derived from the category “values.” They felt that they developed caring attitude toward old people and patients and willingness to help them. One participant mentioned that “I feel really guilty that what I have been prescribing for pain so far was not entirely right.” They expressed that the training program enabled them to empathize with patients and made them confident to care for old people. There were six codes under uses of learning in future career, namely, to undergo further training, to offer financial support, volunteering, provision of palliative care, and caring family and friends. Many participants expressed their interest to attend further training in palliative care through workshops/courses/fellowship after their internship period. The participants were willing to offer financial support to patients and family facing difficulties in accessing their basic needs. A large number of them realized this opportunity as their social responsibility and willingness to volunteer to support patients in their own community. One participant mentioned that “I would like to spend some time with old age people as a volunteer” and another participant said that “I realized my responsibility as a human being now.” The participants said that the knowledge gained from this training program would help them to take care of their own parents, grandparents, and neighbors and would want to share this knowledge with everyone. The participants suggested for increasing the duration of the training program, to use more videos and pictures, to provide hand-outs/reading materials, and to introduce this training program before internship [Table 3].
|Table 2: Perceived improvement of knowledge on palliative care by medical interns before and after the training program, (n=172)|
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|Table 3: Content analysis of responses for open-ended questions obtained from the medical interns|
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| Discussion|| |
The present study found perceived improvement in the knowledge of palliative care among medical interns after attending the training program. Analysis of qualitative data revealed that the program improved their knowledge, attitude, and percieved skills to care for patients with advanced diseases. The interns suggested that the training on palliative care should be introduced during the early undergraduate period, increasing the duration of the training, and providing them with reading materials. There was a self-perceived improvement in knowledge on palliative care among medical students who underwent the training program in the present study which was similar to the studies done in India and Western countries.,,,,,,, The training program in the present study included group activities such as role-play and case discussions that were based on the cases seen in our context. This helped them to appreciate the core skills in palliative care better as compared to large-group teaching. The reinforcement of knowledge gained by giving hands-on experience in HBPC and CBPC in the hospital and community, respectively, ensured a suitable environment for learning nursing care, chronic pain management, and communication skills from the home care team., The exposure also positively influenced their attitude toward suffering people. They were exposed to work as a part of the interprofessional team in providing care for patients under supervision. This training program was later integrated with the mainstream orientation program conducted for medical interns in DCM. We have evaluated the CBPC services in our field practice villages 2 years after its implementation. The results showed that medical interns found the 1-day training program during the start of internship useful in providing care for patients needing palliative care. It was reassuring to learn that medical interns had gained hands-on experience in providing care, especially pain management, nursing care, and communicating with patients and family. The medical interns voluntarily contributed some items such as walking stick and bedpan for patients who could not afford. They were able to appreciate the role of community participation and emotional problems of patients while working with the home care team. The home care enabled medical interns to work as a part of an interprofessional team during home care visit.,
The strengths of the study were that the training program was followed by hands-on exposure in the hospital and community, sessions being handled by trained faculty, small-group activity on topics, and sharing real patient experiences. It was a one-time evaluation of the training program, and absence of objective structured clinical examination assessment for clinical competencies acquired were the limitations of the study. We also did not have a control group who did not attend the training program to help us compare the study findings.
| Conclusion|| |
Overall, the training program was well received by the medical interns. The results of this study helped us to refine the training program. This program can serve as a guide for other medical colleges providing palliative care to train medical interns for caring of elderly people and patients with incurable illness.
We would like to acknowledge “Sanjeevan” for issuing completion certificate to medical interns. We would like to thank our management for supporting us in conducting the training program.
Financial support and sponsorship
This training program was funded by the management of SMVMCH.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]