Educational strategies in palliative care for healthcare professionals

Abstract

Although palliative care is expanding in Brazil, there are still weaknesses related to professional training and continuing education. This study mapped the main educational strategies regarding palliative care for healthcare professionals in Brazil. A scoping review was conducted in three databases, in which original articles, experience reports, theses, dissertations and case studies were found, totaling 39 documents published between 2002 and 2022. Data analysis resulted in three categories: institutional strategies, formal teaching processes and continuing education strategies. Results show that many initiatives are still analogous to the logic of continuing education and poorly integrated with the teaching-service perspective, generating a need to promote continuing education actions in everyday work at all levels of healthcare.

Palliative care; Health human resource training; Professional training; Teaching

Resumo

Embora os cuidados paliativos estejam em expansão no Brasil, ainda há fragilidades relacionadas à formação profissional e à educação continuada. Neste estudo foram mapeadas as principais estratégias educativas e suas temáticas direcionadas a profissionais da saúde utilizadas nos cuidados paliativos no Brasil. Para tanto, foi realizada revisão de escopo em três bases de dados, nas quais foram encontrados artigos originais, relatos de experiência, teses, dissertações e estudos de caso, totalizando 39 documentos, publicados entre 2002 e 2022, que resultaram numa divisão em três categorias: estratégias institucionais, processos de ensino formais e estratégias de educação permanente. Os dados revelam que muitas iniciativas ainda são análogas à logicidade da educação continuada e pouco integradas à perspectiva do ensino-serviço, gerando necessidade de promover ações de educação permanente no cotidiano do trabalho, em todos os níveis de atenção à saúde.

Cuidados paliativos; Capacitação de recursos humanos em saúde; Capacitação profissional; Ensino

Resumen

Aunque los cuidados paliativos se están expandiendo en Brasil, aún existen debilidades relacionadas con la formación profesional y la educación continua. En este estudio se mapearon las principales estrategias educativas y sus temáticas dirigidas a los profesionales de salud empleadas en los cuidados paliativos en Brasil. Para ello, se realizó una revisión de alcance en tres bases de datos, en las que se encontraron artículos originales, informes de experiencias, tesis, disertaciones y estudios de caso, con un total de 39 documentos, publicados entre el 2002 y el 2022, que resultaron en una división en tres categorías: estrategias institucionales, procesos de enseñanza formales y estrategias de educación permanente. Los datos revelan que muchas iniciativas aún son análogas a la lógica de la educación continuada y están poco integradas a la perspectiva de enseñanza-servicio, lo que genera la necesidad de

Cuidados paliativos; Capacitación de recursos humanos en salud; Capacitación professional; Enseñanza

As defined by the World Health Organization¹, palliative care is an approach that seeks to improve the quality of life of patients and family members who face problems associated with life-threatening diseases. In this health care model, the objective is to prevent and alleviate suffering by means of early identification, correct evaluation and treatment of pain and other physical, psychosocial and spiritual problems. From a multidisciplinary perspective, palliative care is provided both in a specialized and non-specialized way, provided that the professional is trained in a basic level of supervised care ².

In Brazil, Resolution 41/2018, of the Ministry of Health (MS), provides for guidelines for organizing palliative care in the Brazilian Unified Health System (SUS) ³. Article 3 determines that multidisciplinary teamwork should be encouraged, that palliative care courses and syllabus content should be instituted in undergraduate and specialization programs for health professionals, that permanent education should be provided to health workers in the SUS, and that information on palliative care should be disseminated in society ³.

In article 5, the resolution defines that palliative care should be provided at any point of the health care network: primary health care, home care, outpatient care, urgency and emergency care, and hospital care. Subsequently, article 6 establishes that palliative care specialists working in the health care network may be a reference and potential matrix for the other services in the network, which can be provided in person or through distance communication technologies ³.

In addition to legal provisions, the current Brazilian socio-sanitary situation indicates a demographic transition, with population aging and epidemiological changes that show the increased prevalence of chronic-degenerative diseases. This conjuncture confirms the importance of care at the end of life, leading to the need to reorganize health care services ⁴. Consequently, there is a growing number of patients in need of palliative care and an increased demand for professionals specialized in palliative care ⁵.

Still in the Brazilian context, data from the English magazine The Economist, published in the 2015 Quality of Death Index, which ranks countries as to the palliative care provided to their population, enable us to elaborate other reflections. Considering criteria such as health setting and palliative care, human resources, professional training, quality of care, and community engagement, among 80 countries, Brazil ranked 42nd in the ranking. Moreover, among some characteristics shared by the countries that presented the best quality of death index, extensive training was observed for the professionals involved ⁶.

According to Brazil’s National Palliative Care Academy (ANCP) ⁷, in 2018 Brazil had 177 palliative care services and, in 2019, more than 190. These numbers represent a significant increase, although insufficient to position the country in the group of nations with the best level of coverage in palliative care. Despite the evident expansion of palliative care in the country, there are professional training and continuing education-related deficiencies, which are associated with the scarcity of investments in services and education to meet the demands of those in need ⁸.

Focusing on educational and training aspects, studies propose to address teaching tools employed during undergraduate medical and multiprofessional programs. Mendes, Pereira and Barros ⁵ discuss the importance of teaching palliative care during undergraduate medical programs and point out the deficiencies in bioethics and palliative care education in the curricula of Brazilian universities. Seeking new curricular models is suggested as an educational strategy, aiming at the provision of basic skills in bioethics and palliative care.

Similar results were found by Pereira, Andrade and Theobald ⁹ regarding the insufficient theoretical content observed in the curriculum of most nursing and medical programs, which do not include palliative care training. Consequently, there are students who are psychologically and emotionally unprepared to deal with this type of care. Therefore, the authors suggest the theory-practice dynamics as a means to introduce palliative care in the training process of health programs.

These data confirm the need for professional training, and it is essential to develop skills in palliative care during the training of future health professionals ¹⁰. From a historical perspective, health professionals had their training associated with the presumed need to make every possible therapeutic effort to cure patients ⁸. Thus, in conjunction with investment in teaching during the health students’ training period, it is also essential to discuss palliative care training tools with already trained professionals.

One of the resources that meet the demands listed is the National Policy for Permanent Education in Health (PNEPS), established by MS Ordinance 198/2004, constituting an important strategy of SUS ¹¹. PNEPS is aimed at organizing services and improving and transforming health care practices through the training and development of health professionals and workers, in order to integrate teaching and service ¹².

Continuing health education can be understood as a process of learning at work. Learning and teaching are incorporated into the daily routine of organizations and into work, based on meaningful learning and the possibility of transforming the practice of health workers. Meaningful learning is understood as the learning process that provides the construction of knowledge from previous knowledge and experiences, coordinately with the issues experienced in the reality of work ¹¹.

Given the deficiencies in the training processes and the growing demand for specialized care, it is necessary to understand the extent of the matter at the national level. Accordingly, this study researches which palliative care education strategies have been used for professionals working in health care, in primary, secondary or tertiary health care. We found no studies that mapped the evidence regarding the scoping review and the results from the subject under study.

Method

This is a scoping review that enables mapping the main topics worked with the target public in the context under research. The research was developed based on the guidelines of the Joanna Briggs Institute (JBI) ¹³, which has methodologies for conducting reviews, and the scope delimitation followed the population, concept, and context (PCC) mnemonic strategy, as indicated by JBI ¹³. Health professionals constituted the population, whether or not they were members of a team specialized in palliative care.

The concept of interest used was educational strategies, and the context analyzed was palliative care in Brazil, at all levels of health care. Based on the PCC definitions, the research question was defined as: “What educational strategies have been used for health professionals in the context of palliative care in Brazil?”. As a subquestion, the following was defined: “What palliative care subjects have been addressed in the educational strategies?”.

The inclusion criterion was to have been carried out in Brazil, since the provision of palliative care is still considered an exception in the Brazilian health care system, in addition to the lack of professional training, according to the demand ⁷. We included original articles, experience reports, theses, dissertations and case studies dealing with palliative care education for health professionals.

In turn, the following were excluded: duplicate texts, reviews, complete articles unavailable, and studies that addressed educational strategies at the undergraduate level, given the large number of existing publications. There was no time limit for selection.

The bibliographic survey was carried out from October to November 2022 in the databases: SciELO, Virtual Health Library (VHL), and Journals Portal of the Coordination for the Improvement of Higher Education Personnel (CAPES). For the electronic search, we used the following Descriptors in Health Sciences (DeCS): “palliative care,” “health human resource training,” “professional training,” and “teaching.” The Boolean operator “and” was applied for cross-examination between the descriptors.

We opted for the methodology of the international guide Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) ¹⁴, according to the guidelines of JBI ¹³. Thus, the studies were pre-selected by reading the titles and abstracts and were later read in full, reaching the final sample (Figure 1). In order to extract the data and identify essential elements of the articles, a structured tool was used in Microsoft Excel, considering these variables: title, year of publication, region of the country, reference, educational strategy used, and the palliative care subject that the study addressed.

Figure 1
Flowchart of the study selection according to the PRISMA-ScR method

Results

After identifying and selecting the studies, 39 articles published between 2002 and 2022 were included. The results originated the following categories: institutional strategies, formal teaching processes and continuing education strategies, which are presented below together with the mapped strategies and found palliative care subjects.

Characteristics of the studies

It was found that the highest frequency of publications occurred in 2019, 2021 and 2022 and that most of the studies were developed in Rio de Janeiro, São Paulo, Rio Grande do Sul and Minas Gerais. Multidisciplinary learning was predominantly reported in the sample of nurses, physicians, social workers, nursing technicians, psychologists, nutritionists, physiotherapists, pharmacists and speech therapists. Among the care regimens, the hospitalization sector stood out, followed by primary health care and the intensive care unit, outpatient care and home care.

The most prevalent subjects addressed in the educational strategies referred to general issues of palliative care ¹⁵-²². There was also the emergence of significant topics related to palliative care in oncology, in a generalist way ²³-²⁷, and specifically related to therapeutic impossibility ²⁸,²⁹, pain ³⁰, principles ²⁴, decentralized models ³¹, and early palliative care ³². Similarly, the pediatric clinic was significantly observed, focusing on the limitation of life support ³³ and at the end of life ³⁴, which, although in smaller numbers, were also highlighted among the studies ³⁵-³⁸.

Institutional strategies

This category highlights the educational strategies promoted by different institutions. The findings indicated the organization of lectures, conversation circles and training sessions ²⁴, as well as the holding of symposia ¹⁹ for teaching and training. The educational role of the Federal Council of Medicine (CFM) and regional councils was specifically pointed out as to CFM Resolution 1,995/2012, which provides for patient advance directives or living wills. Among the actions conducted, the aforementioned document was disseminated and events, forums, seminars and lectures were held to improve the knowledge of this professional public ³⁹.

In this sense, Guerra ³⁸ indicated that it is a duty of professional organizations in the health area, especially councils and associations, to discuss ethical and legal issues, as well as to organize forums and lectures. The results also indicate the creation of instrumentalization resources, such as palliative care protocols in institutions ²⁴ and protocols focused on limiting life support ³³.

Formal education processes

This category includes formal education initiatives, such as the curricular implementation of palliative care and its principles in graduate programs ²²,²⁴,⁴⁰, which was suggested in the materials studied. The proposal to develop specific guidelines in graduate medical programs to improve end-of-life care training also emerged ³³. Data from this research show the need to foster specializations ²¹,²⁴,²⁷,⁴¹, especially the inclusion of specific training in pain control ¹⁹, and to review the contents taught at this level of training ⁴².

Other studies highlight specific points that should be addressed in graduate programs, such as ethical and bioethical reflection ¹⁶, death ²⁹ and communication in the process of dying ⁴⁰. In the same teaching mode, the bioethics of protection subject was included, in order to raise questions about human action and inform the thought and practice of professionals ⁴³. In addition, themes about scientific competence, bioethics and the humanities were considered necessary at this level of education ³⁵.

Regarding geriatrics specifically, it is suggested to integrate the matrix of general and essential palliative care competencies into graduate programs, in addition to review of the syllabus content by geriatric residency services. In addition to such strategies, the early introduction and training of essential and desirable skills ⁴⁴. Also from the perspective of formal education, it was proposed the organization of academic leagues with graduate programs ¹⁵ and the implementation of a consulting team linked to graduate programs, in order to enhance palliative care and end-of-life care education ⁴⁵.

For the purpose of implementing palliative care lines, another initiative included a continuing education program, through the encouragement of participation in face-to-face and distance education (DE) programs and by carrying out regular training ⁴⁶.

Strategies such as organization of annual events, investment in scientific production, research projects and extension projects were also pointed out ²⁷ as facilitators in the educational processes.

Continuing education strategies

This category comprises strategies developed in service consistent with the concept of continuing health education, so different collective strategies were pointed out, such as lectures ⁴⁷, debates ⁴⁸, roundtables and panel discussions, focused on the experiences of the members ¹⁵,²⁴,³¹,⁴⁷,⁴⁹ and systematized according to clinical cases ⁴⁸,²⁵, and debates on situations related to death and ethical aspects ³⁷.

A similar proposal was observed in an intervention characterized as a problematizing educational process, which incorporated an educational session and a clinical case ¹⁸. Other strategies listed were the following: lectures ¹⁵,⁴⁹, workshops ⁵⁰, dynamic activities and general collective activities ⁴⁹, in addition to meetings and periodic training with the team, which was observed in three materials ²⁹,⁴⁸,⁵¹.

Data from this study highlight the provision of courses on general and diverse issues related to palliative care ¹⁹,²⁸,³¹,⁴⁸, while others present these specific topics: communication in palliative care ⁵², death and dying ⁴¹, education for death ⁵³ and spirituality ²⁰. Different themes were found in a proposal for technical and psychological training: communication of bad news, coping strategies, hypodermoclysis and pain control ³⁴. A pedagogical tool containing active methodologies was pointed out in an awareness-raising course on palliative care.

In the same sense, there was the use of problem-based and team-based learning in a given intervention, in addition to problematization, skills training with the use of role-playing and collaborative learning ¹⁷. Active methodologies were also proposed by Dutra ²³, using a workshop carried out with problem-based learning, playful games, logbooks, group dynamic activities, interactive murals and plays ²³. The problematizing education approach with the application of the reflection-action-reflection method was found in a material ¹⁵ and, from the same perspective, Juan Charles Maguerez’s arc of problematization was indicated for education at work ³⁰.

Early palliative care was focused on the execution of a multiprofessional plan, which used multidisciplinary training and conversation circle as a strategy ³². Another research ⁵⁰ highlights the simulated execution of the technique by the participants, similarly to the proposal of Santos ²⁹, which addresses the application of realistic clinical simulations.

Modes mediated by information and communication technologies were also found, such as tele-education ¹⁹ and video resource ¹⁸, in addition to Brandão’s complementary proposal ²⁶, which suggested the use of educational technology through a blog related to the humanized care of patients under palliative care ²⁶. The delivery of educational content was observed in the form of booklets, oral presentation and multimedia exhibition ⁴⁷.

Discussion

The discussion of educational content on palliative care for professionals is related to a positive impact on the provision of palliative care in the future, since the professionals’ training has gaps that need to be identified and addressed ⁵⁴. This research enabled us identify more recent publications, which may reflect PNEPS, in addition to fostering the discussion on palliative care in society. There was a predominance of the hospital setting in the conduct of educational actions, which also seems to be in line with the Brazilian reality, in which tertiary health care still occupies a priority space in health care networks ⁸.

On the other hand, primary health care was also significant in the literature mapping, which represents an efficient movement, as it is understood as a strategy with lower cost and greater impact on the health of the population ⁸. The higher incidence of the oncological theme in the publications seen in the results is frequent in other publications, since the origin of palliative care is related to the care of oncological patients. In turn, the incidence of pediatric clinic in the data found requires emphasis and visibility, since the provision of palliative care in pediatrics is not a reality in Brazil and few services have this qualification ⁸.

Seeking to fill these gaps, the National Council of Education approved on November 3, 2022 the amendment to CNE/CES Resolution 3/2014, instituting new National Curriculum Guidelines for undergraduate medical programs ⁵⁵. This document provides for students to receive education and training on specific competencies, covering principles and practices of palliative care.

These initiatives represent an important advance, supporting the results presented in the first category of this review. These findings show the various strategic possibilities and the significance of the movements of institutions, such as representative bodies and entities, in addition to the legitimacy and visibility conferred to the palliative approach. As Santos, Ferreira and Guirro ⁸ point out, the advent of ethical and technical resolutions on palliative care represents the growth of this type of approach.

Regarding specifically the professionals, a study by Ferreira, Nascimento and Sá ⁵⁶ found that most of the respondents had not received adequate academic training to deal with end-of-life patients. In the sample, it was observed that most of the learning occurred autonomously and empirically during professional practice, which can generate losses in the production of health care.

Nevertheless, the non-integration of the multidisciplinary team also results from the scarcity of professional training in end-of-life care and from educational deficiencies of undergraduate health programs in general, which work with the conception of a health care still restricted to the specificities of each category.

Such findings are shown by the isolation of professional categories, lack of communication, debates or questioning, or by the fragile notion of comprehensive patient care and horizontal relationships in teams. In the same sense, it is clear that feeling well trained is a source of greater security and confidence for employees ⁵⁷. In this study, the strategies geared to formal education processes composed a significant part of the articles found, in resources that are in line with the data collected by ANCP, which associates the gaps in the training of physicians and health professionals with the lack of quality medical residency and specialization and graduate programs ⁸.

On the other hand, it is observed that such educational proposals are consistent with the logic of continuing education, conceived as a process of sequential and cumulative acquisition of technical-scientific information, through the formal schooling of experiences, work experiences and participation within or outside the institutional scope ⁵⁸.

Currently, it is understood that continuing education is insufficient to meet the present demands. Supporting the results found, another research observed a predominance of the conception of instrumental education, with emphasis on technical and knowledge update actions that are in line with the precepts of continuing education ⁵⁹.

In this research, it was observed a conceptual confusion between the terms permanent health education and continuing education, unawareness as to permanent health education practices and the conservation of actions focused on continuing education. In the authors’ view, part of the lack of understanding stems from the period of professional training in undergraduate programs, based on the hegemonic medical model and permeated by the culture of a fragmented education at the level of service management. The consequence is the devaluation of permanent health education initiatives, which favors their non-implementation and the valuation of continuing education practices ⁵⁹.

Although practices oriented by the traditional model are preserved, it is important to advance the use of technological resources and reflective practices in the daily work routine that propose integrating teaching-service into permanent health education initiatives ⁵⁹. Such advances were also observed in the findings, with predominantly participatory strategies that predominated over the more traditional teaching styles.

It should also be considered that, despite the unequivocal advances in the formulation of policies and resolutions, these policies do not guarantee their full implementation. Similarly, according to data in ANCP ⁸, there are still disparities in public policies, added to differences at the state and federal levels.

In addition, the incorporation of digital technology in palliative care education provides diverse opportunities and possibilities, and should be considered in the development of educational programs. Furthermore, it is an alternative form of flexible learning, assisting those who cannot access palliative education in traditional settings ⁶⁰. Although still incipient, there is thus a gradual maturation of concepts—moving from educational proposals that resemble the logic of continuing education to the logic of permanent health education—and the consequent applicability of strategies in health care services and actions.

One of the limitations is the limited number of articles whose tools were aimed at instrumentalizing family management, which is recommended in the principles of palliative care. A similar result was found in a study by Teixeira and collaborators ⁵⁴, through which the authors indicate that it is necessary to better consider family caregivers in the training of health professionals, with educational programs in which family caregivers are the theme.

Finally, no publications were found that pointed to multiprofessional residency programs as a possible strategy, even if it is considered a fruitful space to conduct permanent health education actions.

Final considerations

This study investigated the educational strategies employed by Brazilian health professionals in the context of palliative care and the themes addressed in these models. In this sense, although there is a diversity and a combination of initiatives, many of them are still analogous to the logic of continuing education, focused on formal practices and poorly integrated with the teaching-service approach. Thus, this is possibly the main challenge, resulting in the urgent need to promote permanent education actions in the daily work routine, at all levels of health care.

It is considered that the study results contribute to mapping the current context of palliative care educational resources, enabling new data to be generated and serve as input for new research, in addition to expanding the knowledge and discussion on the subject. It is believed that the results can contribute to institutions, managers and professionals involved with health, in order to foster educational practices. It is concluded that reflecting on the enhancement of the health care of individuals and on the improvement of health care services is to discuss the strengthening of the training of professionals.

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Publication Dates

• Publication in this collection
  18 Dec 2023
• Date of issue
  2023

History

• Received
  1 Feb 2023
• Reviewed
  12 June 2023
• Accepted
  9 Oct 2023
• Corrected
  31 Jan 2024