Views of general practitioners on end-of-life care learning preferences: a systematic review

Abstract

Background

General practitioners (GPs) play a pivotal role in providing end-of-life care in the community. Although they value end-of-life care, they have apprehensions about providing care in view of the limitations in knowledge and skills in end-of-life care. This review aimed to explore, synthesise, and analyse the views of general practitioners on end-of-life care learning preferences.

Methods

MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science, and Cochrane were searched for literature on the views of general practitioners on end-of-life care learning preferences from 01/01/1990 to 31/05/2021. Methodological quality was reported.

Results

Of the 10,037 articles identified, 23 were included for the review. Five themes developed from the review. The desire to provide palliative care, as well as self-actualisation needs, relevance to practice, a sense of responsibility, and a therapeutic bond, motivates general practitioners to learn end-of-life care. Some of the learning needs expressed were pain and symptom management, communication skills, and addressing caregiver needs. Experiential learning and pragmatist learning styles were preferred learning styles. They perceived the need for an amicable learning environment in which they could freely express their deficiencies. The review also identified barriers to learning, challenges at personal and professional level, feelings of disempowerment, and conflicts in care.

Conclusion

GPs’ preference for learning about end-of-life care was influenced by the value attributed to learning, context and content, as well as preference for learning styles and the availability of resources. Thus, future trainings must be in alignment with the GPs’ learning preferences.

Key messages

• 1. What is already known?

  • A) General practitioners play a pivotal role in delivering primary palliative care to patients in the community. This helps in a decentralised approach to palliative care delivery which could serve large population of patients in need of it.

  • B) There is substantial evidence that general practitioners provide palliative care. Studies have explored the following: various primary palliative care models, barriers and facilitators in primary palliative care provision, educational interventions through continuing professional developments of GPs in end-of-life care and the challenges of providing palliative care by rural GPs

• 2. What are the new findings?

GP’s learning preferences in end-of-life care are influenced by the value that they attribute to learning and how empowered they feel in providing end-of-life care.

Experience in clinical practice significantly influences their learning preference.

Many GPs prefer to learn by reflecting on their clinical practice under the guidance of specialists or experienced GP colleagues.

They prefer the learning environment to be sensitive to their needs, non-intimidating and trustworthy where they could democratically exchange their challenges in knowledge and skills in end-of-life care

• 3. What is the significance?

Future training programs in end-of-life care could be implemented in alignment with the learning preferences of GPs. The training programs must factor the facilitators and barriers in attending training programs and training styles that best fit their learning needs and fulfills their learning requirements.

Introduction

General practitioners (GPs) assume a central role in delivering end-of-life care in the community [1]. They provide care in alignment with the patient’s wishes, coordinate care with the multidisciplinary team, and prevent unnecessary hospital admissions [2,3,4]. Studies have revealed that despite having played a key role in care provision, GPs felt ill-equipped and lacked confidence in end-of-life care provision [5]. They particularly perceived managing physical symptoms, addressing patients’ and caregivers’ psychological needs, and advance care planning as a daunting experience [1]. GPs prefer to undergo training in End-of-Life care in order to keep themselves abreast of the growing body of evidence and changing guidelines [1]. These factors may influence end-of-life care provision and mandates an urgent evidence-based training programs in end-of-life care in alignment with GPs needs.

GPs access training only if the training program honours their past experience, has relevancy to their clinical practice and adds valuable information to address the gap in their knowledge [6, 7]. The GP’s preference for End-of-life care learning was analysed using the social constructivist learning theory [8,9,10,11,12]. Social constructivist learning theory is built on the premise that learning is a cognitive process that is constructed through social interaction [8,9,10,11,12]. The theory emancipates the learner by emphasising on the importance of learning as being self-directed with learners having the locus of control [8,9,10,11,12].

A scoping review using a multidisciplinary database, SCOPUS [13] identified previous systematic reviews on end-of-life care provision by GPs. They explored barriers and facilitators in palliative care provision [14,15,16], models that supported GPs’ provision of end-of-life care [17], continuing professional developments for GPs in end-of-life care [18], the role and performance of GPs in end-of-life care [19], and the challenges of providing palliative care by rural GPs [20]. Although there are studies that have explored GP’s views on end-of-life care learning preferences, these have not been systematically synthesised and analysed, necessitating the conduct of this review.

Literature review methods

Aim of the review

The aim of this systematic review was to explore, synthesise, and analyse the views of GPs on end-of-life care learning preferences.

Review question

What are the views of GPs on end-of-life care educational needs and learning preferences?

The end-of-life care learning preferences of GPs were reviewed using the Population, Phenomenon of Interest, and Context (PICo) framework [21]. The population studied was GP, the phenomenon of interest was views on learning preferences and the context was end-of-life care.

The philosophical paradigm and theoretical framework of research

Constructivist grounded theory was the philosophical paradigm underpinning this review that explored the GP’s experiential views, their actions and interactions, and the implicit meanings attributed to their learning preferences [22]. Social constructivist learning theory was applied to understand how individuals construct knowledge in a social context [8,9,10,11,12]. It is built on three premises: cognitive processing of knowledge, self-directed learning, and social construction of knowledge.

Review design

A scoping search was conducted to determine the breadth of the evidence available on the phenomenon explored. The search showed a heterogeneous mixture of quantitative and qualitative studies. Popay’s narrative synthesis method enables synthesis of the data from a mixed typology of studies into themes [23]. Moreover, it allows using a theoretical framework for the interpretation of review findings and provides flexibility in choosing the methods within each step of the synthesis relevant to the review.

Search strategy

The review question was divided into search concepts, which were further used to conduct an initial scoping review. Scoping review helped derive key search terms relevant to each concept of the review questions. The search identified three papers to test the sensitivity of the search [24,25,26]. The search terms identified from these studies were further expanded into thesaurus terms and free text terms [27]. A search was conducted using electronic databases (MEDLINE, EMBASE, CINAHL, and PsychINFO) to identify articles published in English between 01/01/1990 and 31/05/2021 (Additional file 1), as the first article on palliative care was published in MEDLINE in 1993 [28]. The search was conducted using thesaurus and free-text terms specific to the database, and the terms were combined using Boolean operators [27]. Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts. A list of 12 journals was hand searched for additional citations (Additional file 2). The bibliographies of the full-text articles were screened using the Google Scholar database for any new articles that could be added.

Study eligibility

Selection criteria of studies included is provided Table 1.

Table 1 Selection Criteria of the Studies included in the review

Assessing methodological rigor of the studies included in the review

As the review included a mixture of qualitative and survey studies, Hawker’s tool was used to assess its methodological rigour [29]. There are a growing number of palliative care systematic reviews that have used this tool [30,31,32]. Hawker’s tool allows systematic appraisal of the study by analysing the title and abstract, introduction and objectives, method and data, sampling, data analysis, ethical aspects, results, transferability/generalizability, and implications of the study [29]. These criteria were scored between 1 and 4 (1 = very poor and 4 = good). A score of 9 was considered a minimum score and a score of 36 as a maximum (Additional file 3) [29]. Although Hawker does not mention a cut-off score, based on the previous studies [31, 33], a cut-off was set at 19. Three studies were excluded from the review as they had a score of less than 19 [34,35,36]. The minimum score of the studies included in the review was 19 and the maximum score was 32. Furthermore, the studies were classified into the following grades: “high quality” (A), 30–36 points; “medium quality” (B), 24–29 points; and + "low quality” (C), 19–23 points [37]. Six studies were of high quality [24,25,26, 38,39,40], ten studies were of medium quality [41,42,43,44,45,46,47,48,49,50] and seven studies were of poor quality [51,52,53,54,55,56,57].

Data extraction

Screening, quality appraisal, and data extraction were conducted independently by two reviewers. The third reviewer helped resolve the conflicts. The initial section of the data extraction sheet had information regarding the country and year of publication. The second section focused on the type of study, that is, survey, qualitative, or mixed-method. In this section, study objectives, population, and study setting were also described. The study sample, participants, inclusion and exclusion criteria, research design, and methods were elucidated in the third section. The fourth section provided information on the study findings and conclusions.

Data synthesis

The review findings were synthesised using Popay’s narrative synthesis [23]. The first step of the narrative synthesis is to identify a theoretical framework, and social constructivist learning theory was used to interpret the findings of the review [9]. It was followed by developing a preliminary synthesis that involved a brief description of the studies in the review. The data gathered was classified into countries, the year of publication, type of population, and the factors involved in constructing knowledge. The words and texts extracted helped the reviewers familiarise with the study findings before analysis. Patterns were identified from the preliminary synthesis, and the reviewers explored the relationships within and between studies in order to generate meaningful categories and themes. The reviewers were mindful of gleaning the similarities and differences in the data generated. The fourth step was to assess the robustness of the synthesis. To ensure this, the reviewers critically reflected on the synthesis process and identified possible sources of bias [23].

Data analysis using social constructivist learning theory

Social constructivist learning theory explicates that knowledge is constructed through social interaction. Thus, using this theory, researcher will interpret the following using social constructivism theory: value that general practitioners attribute to End-of-life care learning and factors that facilitate and impede learning. Social constructivism asserts that learning is an inherently social process rather than a mere acquisition and assimilation of facts and figures, thus helping interpret various styles that GPs adopt in learning end-of-life care.

Review findings

Overview of the studies

Out of 10,037 articles identified from the database searches, 23 articles were included for synthesis (The PRISMA flow diagram-Fig. 1). Eleven studies were qualitative, eleven were surveys, and one was a mixed-method study. Fifteen studies were from Europe (eight from the United Kingdom, two from Belgium, and one each from Denmark, the Netherlands, Austria, Germany, and Ireland), six from Australia, and two from Canada. The qualitative studies were single centric and quantitative studies were combination of single centric and multicentric studies (Table 2). Two studies included combination of GPs and paediatricians involved in general practice [43, 49]. In United Kingdom, Europe, Australia and Canada, the health care system heavily relies on gatekeeping by GPs. The health care system provides universal coverage of health insurance and mandates gatekeeping by GPs in order for patients to access insurance facility. In some countries such as Canada, specialists receive less payment for non-GP referred patients. This could perhaps justify the reason for these countries to have studies on end-of-life care provision by GPs ([58], https://www.commonwealthfund.org/sites/default/files/2020-12/International_Profiles_of_Health_Care_Systems_Dec2020.pdf).

Fig. 1

PRISMA Flow Diagram

Table 2 Overview of the Studies included in the Systematic Review

Review themes

Five themes were generated in the review. These themes were: motivation for end-of-life care learning, end-of-life care learning needs, preference for a learning style, perceived facilitators of learning, and perceived barriers to learning. Refer to Additional files 4 and 5 for the table narrating the themes and thematic diagram.

Theme 1: Motivation for end-of-life care learning

Motivation is defined as an intrinsic trigger that allows for sustained goal-directed activity [59, 60]. Self-directed learning enhances the learner’s competence, and belongingness facilitates motivation [61, 62]. Perceptions of value addition, peer recognition, previous learning experiences, and individual goals all trigger learning [63]. The need to provide palliative care, self-actualisation needs, relevance to practice, sense of responsibility, and therapeutic bond motivated them to learn about end-of-life care.

GPs are internally motivated to enhance their capacity to alleviate the suffering of their patients on the pretext of achieving their self-actualization needs [39, 40, 44, 57]. Also, having a larger clientele of geriatric and sicker patients piqued their interest in end-of-life care learning [44, 46, 49, 51, 57]. Unmet self-actualisation needs included a desire to integrate palliative care into routine care [38, 48, 49, 56], a perceived need for self-transformation [48], coping with own bereavement [39], and a perceived inability to manage symptoms [40], all of which instilled a sense of powerlessness, helplessness, and emotional burden of caring [24, 38,39,40, 48] for which they needed a recourse [48].GPs accessed training only if the training [24, 41, 54] and the trainer’s skills were in alignment with their needs [54] and helped address complex end-of-life care needs [24, 26]. A therapeutic bond developed with their patients over a prolonged period of caring [47, 51, 53], at various stages of their illness [38, 39, 46, 47, 49], instilled a sense of responsibility towards their patients [25, 39, 40, 49]. They believed in helping a patient as a whole person and not as a disease entity [49] and felt the need to address the complex sufferings of patients while honouring their dignity, expectations, and wishes [41, 44].

Theme 2: End-of-life care learning needs

Human beings encounter newer experiences in their journey of life that helps them evolve [64]. Some of these experiences could be in synchrony with their past practices while some could be conflicting [65]. They tackle the unrest arising out of these conflicting thoughts in three ways: by preserving the existing schema and ignoring the new contradictory knowledge; by preserving both the contradictory knowledge and appropriating it as the situation requires; or by constructing a new concept that aids in resolving the contradictory knowledge [65]. Following were the learning needs: accessing palliative care, learning about pain and symptom management, communication skills, compassionate care, addressing the caregiver’s needs, the ethical and medico-legal aspects of end-of-life care, and teamwork.

GPs expressed the need for a framework for accessing local specialist palliative care resources [24, 38, 39, 47, 49], guidelines on out-of-hours care [24], timing and criteria for referral to specialist services [40, 47] and knowledge of a multidisciplinary team approach [24, 39]. Among physical and psychosocial educational needs, pain management [39, 42, 43, 48, 50, 52, 55] and psychosocial issues [26, 39, 46, 52, 56] were perceived as most important aspects of learning followed by fear of death and dying [39, 44, 48, 57], anger and demanding behaviour [55], nutrition [43, 48], spiritual needs [25, 43, 57], and religious concerns [25]. GPs expressed the need for training in communication skills and breaking bad news that enabled them to make decisions on chronic illnesses [49] and facilitate transitions to end-of-life [48, 50]. They appreciated training that might enable them to have the right attitude, diplomacy, and skills [39, 48] to resolve conflict [39, 44, 48], denial, and bargaining [38, 39, 48] and handle vulnerability around death and dying [49]. They expressed the need for training in handling the emotional distress of family caregivers [48, 52], and anticipatory grief [39], and bereavement support [49, 52, 56, 57]. GPs felt a need for guidelines to enable them to provide care in the best interests of their patients [24, 44] and techniques to discuss ethical and medico-legal aspects of care with their patients, families and colleagues [47, 48]. They expressed the need for skills in developing a team and team work, garnering mutual support from colleagues in a multidisciplinary team [43, 49] and for debriefing sessions to cope with emotionally burdensome situations [38, 43, 49].

Theme 3: Preference for a learning style

A learning style is defined as a set of “characteristic cognitive, affective, and psychosocial behaviours that serve as relatively stable indicators of how learners perceive, interact with, and respond to the learning environment” [66]. When individuals become aware of their strengths and weaknesses, they become motivated to learn and become lifelong learners [67]. It may be essential to match learning styles with learning preferences and tailor the style to the content and context of learning in order to enhance learning [68,69,70]. GPs preferred learning styles that were experiential, pragmatist, self-directed, and didactic.

According to GPs, expertise grows with experience [24, 25, 39, 41, 56] and through interaction with patients/families [24,25,26, 41]. They preferred work-based learning under a mentor [24, 26, 38, 40] or co-management with a palliative care team [24, 47]. They wished to reflect on their practice under a mentor [25, 26, 40, 45, 49, 50] either through virtual interaction [24, 54], by the patient’s bedside [47, 55, 57], or through audited data [57]. They also expressed the need for problem-based learning by patient follow-up and learning from mistakes [45, 48]. GPs preferred self-directed learning through web-based or printed resources [26, 38,39,40, 43, 45, 46, 49, 50, 55]. Some of them were computer-based learning [57], correspondence learning [4], guidelines-based learning [54, 55], E-learning [24] and learning by researching [57]. Other forms of learning included lectures [49, 56, 57] and workshops on team building and addressing religious and psychological needs [25, 40].

Theme 4: Perceived facilitators of learning

Facilitation of learning is an essential process that empowers learners to evolve in the learning process through self-evaluation and interchange [71]. According to Brockett, attending, responding, and understanding are important for effective facilitation, which builds a foundation for a constructive and meaningful learning environment [71]. An amicable learning environment, mentorship, appropriate timing, and feedback facilitated end-of-life care learning.

GPs felt the need for an amicable, safe, non-intimidating, non-judgmental, trustworthy and respectful learning environment where their deficiencies were not exposed to their patients [25, 26]. Mentorship is a bidirectional process [72] and provides a safe space for the learners to interact [73]. GPs expressed the need for mentors from a multidisciplinary team [25, 48, 50, 56] and a small group [25, 38] interactive session with multidisciplinary peers [42, 50]. Due to time constraints, solo practice, remote practice, and multiple concurrent responsibilities, GPs are unable to attend educational programs during office hours [74, 75]. GPs felt that learning was a lifelong process [25, 38] and preferred to attend half-day workshops [54], quarterly topical in-service training [55] and quarterly case rounds [55], courses out-of-business hours [38, 42] over the weekend [42, 43]. Goal-directed feedback keeps the learner motivated and engaged in order to strike a balance between one’s goals and the expectations that one can achieve these goals [76]. GPs preferred feedback from specialists and peers in the team [25] and patients and families if it was completed in a time bound manner [24, 40]. They preferred to avoid feedback from dying patients or their families, as this might cause discomfort to the respondents [24].

Theme 5: Perceived barriers to learning

The learner’s decision to participate in learning is influenced by constraining factors that could be dispositional, situational, institutional, or academic in nature [77, 78]. End-of-life care learning was hampered by a lack of resources, individual and professional challenges, disempowerment, conflicts, and training that was not aligned with clinical practice.

GPs had apprehensions about initiating discussions around end-of-life care as this was perceived as taboo by their patients and families [41, 49]. They feared treading into their patients’ or family’s private spiritual space [41] and perceived a lack of competency in addressing end-of-life care concerns [41]. Other limitations included fear of medico-legal recrimination [45, 48] and the emotional burden of care [39]. GPs felt a sense of insecurity when broaching their deficiencies in knowledge [45]. Younger GPs with fewer years of experience had less autonomy to focus on palliative care as a choice of specialty [41, 47, 51]. Some felt they had enough knowledge to address their patients’ palliative care concerns [54] and that there were no new developments in the field that warranted up-gradation of knowledge [39, 40]. Additionally, family and personal commitments gave them less time for palliative care provision [46]. GPs who had solo practice or practiced in remote areas had fewer support systems that precluded access to training [49, 51, 53]. Excess work pressure [41, 54, 57] with the resultant lack of time [24, 25, 38, 39, 46, 48, 54, 57], poor remuneration [38, 46], and the temporary nature of the job [39] were hindrances to training. They were also limited in their access to training programs because they had to self-fund their courses or provide compensation to organise locum GPs in their absence [57]. When specialists took over care [24, 25, 46], GPs felt a loss of control over their patients [39]. They were disillusioned when specialists or patients lacked trust in them [24], or when they were not acknowledged [38, 48]. Lack of clarity in roles and responsibilities led to conflict in care coordination [25, 40, 54]. GPs were apprehensive about confronting specialists for fear of being reprimanded [54]. Furthermore, previous negative experiences and delays in receiving responses from specialists limited future interactions with specialists [2]. Most end-of-life care training programs focused on oncology, providing fewer opportunities for them to learn non-malignant end-of-life care skills, which accounted for a significant portion of their practice [53]. Training occurred mostly during office hours in the hospital setting [45, 57] and skills gained could not be replicated in the community due to differences in the infrastructure in both settings [25].

Discussion of the review findings

Social constructivist learning theory as a framework for interpreting the results

Learning is an internal cognitive progressive process [61]. Learning is contextualised in a lived situation in which the learner constructs meaning to make sense of one’s past beliefs and practices [61, 79]. Social constructivist learning theory enables us to theorise about how individuals attribute value to their learning within a social, emotional, temporal, and cultural context [80, 81]. In this review, the theory was used as a lens to explore GPs’ insights on end-of-life care learning and what processes do they adopt to acquire and construct knowledge in end-of-life care [81].

The therapeutic bond associated with long-term care [82] uniquely positions GPs to address patients’ physical and situational challenges at the end-of-life [83, 84]. GPs expressed a lack of competency in the management of pain and other symptoms and communication skills, which reflected a major gap in the holistic approach to end-of-life care. Their perceived lack of access to the palliative care teams exacerbated their lack of competency [85], which was further compounded by an ambiguous division of roles and responsibilities [86].

Individuals’ progressive experiences sometimes foster contradictions to their present understanding or beliefs, making them insufficient and thus leading to dissonance in the cognitive structure [61]. GPs bring their life and clinical practice experience to the learning environment [61]. Their past experience is put into question when they encounter new knowledge [61]. However, the dissonant thought arising out of this conflicting knowledge will be resolved only if the learner feels empowered [61]. A competency-based trust is the trustor’s belief in the trustee’s ability to complete a task [87]. The assured mutual support and acknowledgement of the specialists motivated GPs to invest in learning, and the contrary led to dissatisfaction and demoralisation. Distrust could undermine one’s self-esteem by questioning one’s capability [88], fracturing interpersonal collaboration [87], and demoralising the individual from task-performance and accessing learning [88].

Learners strive to preserve their knowledge schema [89] and shape the new experience to conform to this schema [6]. In order to reduce the uncomfortable feelings of dissonance arising out of conflicting encounter, they will engineer ways to remove the dissonant cognition [7] by transforming the knowledge structure to accommodate the new knowledge [6]. However, the transformation in the schema will only occur if the history of the experience is honoured and its future is appreciated [6] or if the learner perceives this as valuable information to address the gap in their knowledge [7]. As the evidence base in end-of-life care is ever evolving, there is a constant need for updation in the knowledge of GPs and they access training programs in end-of-life care to resolve the conflicts in their daily practice [41, 88, 90]. Diverse clinical practice scenarios trigger learning [91] through reflective identification of knowledge gaps in the quality of care [92]. In the process of learning, GPs gain multiple perspectives by interacting with mentors and peers in the learning environment or at work [6, 61]. They critically reflect on multiple perspectives, amend their practice, and reflect and consolidate them [6, 61, 93].

Learners constantly acquire and apply knowledge under the guise of autonomously developing, maturing, and enhancing themselves [61] and preserving their identity [85]. GPs in this review felt accountable for the care they provided. They also reported end-of-life care as self-actualising, as it helped them gain inner satisfaction of having embraced their patients’ concerns and addressing them [61].

Learning preference has been considered in this review to include a broader set of factors such as learning styles and intrinsic and extrinsic environmental factors that influence learning, including when and how learners prefer to pursue learning [94]. Although traditional didactic learning styles are presumed to be prescriptive in nature, when the learning occurs in a small group interactive session, it helps to bring an attitudinal shift, integrate multiple thoughts, and lead to better understanding [95]. Similarly, online or e-learning in the current era has cut across geographical barriers. With either the information on web-pages or through online training, learners have the opportunity to construct meaning through active participation and self-directed inquiry [96].

Learning is a self-directed process [61] and learners are provided ample space to democratically express their intellectual and emotional content [61, 89]. Language mediates this expression and helps learners interact with others in the learning environment, probe each other’s thoughts, and understand the way each individual interprets reality [85]. Learners then negotiate, defend their positions, and create meaning on their own terms [89]. Teacher acts as a scaffolding agent, facilitates the interchange within the group, and gives an apportioned degree of emphasis on the contents [61, 85]. The GPs in this review valued experiential and reflective learning under the mentorship of a specialist as it gave them the opportunity to make amends in their practice.

Feedback is an integral component of learning and helps improvise practice. Feedback is a mechanism that improves the thought process of the learner in order for the learner to accurately address the problem at hand, thus enhancing both learning and performance [74]. It can reduce the uncertainties arising from the gap between the current and desired levels of performance [97]. GPs in the review realised the importance of addressing this gap by receiving feedback from specialists and patients/families. However, the studies in the review emphasised the importance of a trustful learning environment, the timing of feedback, and the person who recorded the feedback as having an impact on performance and future learning [98].

Critical reflection on other learning theories that may inform social constructivist learning theory

As per the cognitivist and constructivist theories, GPs explore knowledge with the pretext of enhancing their expertise in delivering end-of-life care [63]. When faced with a conflicting situation in clinical practice, they seek information from multiple resources, decide on the best possible solution, and integrate the new knowledge on their own terms [63]. Bandura’s social cognitive theory extends this theory by including a social and cultural milieu in learning [63]. GPs learn from experienced GP colleagues or palliative care specialists in multidisciplinary team meetings or case discussions [24, 25, 47] in order to draw consensus on the mutually derived path to knowledge and practice [88]. In this way, GPs receive a legitimate endorsement of their practice [88]. Individuals self-regulate their learning, and the learning is influenced by internal and external environmental factors which may facilitate or impede learning [63]. According to Vygotsky, for learning to occur, it has to be within the zone of proximal development [63]. In a conflicting situation, GPs adopt one of the two paths to learning; either they reject the new experience as trivial or they incorporate the new experience into their knowledge schema [6, 7]. Connectivism is yet another theory where learning happens beyond human interactions [99]. GPs connect to their learning environment through human and non-human appliances such as the internet and webpages and thus construct knowledge based on the best possible answer to plural opinions [96].

Limitations and strengths

The search strategies were limited to studies published in English. Some studies explored the learning needs of a mixed population of GPs and nurses involved in general practice. However, the learning needs were clearly disaggregated from one another. Three studies [42, 50, 55] had a poor response rate and five papers had a response rate greater than 50% [25, 46, 51, 53, 57]. Although some studies had a poor response rate, they had a significant number of participants who gave their perception of the learning needs in end-of-life care.

Although the studies included in the review were dated from 1993 to 2019, most studies were published in the last 10 years. The learning preferences of the most recent generation of GPs were not very different from those of their predecessors. Two reviewers independently reviewed the articles, compared the search results, identified the methodological rigour using Hawker’s tool, discussed the discrepancies in the findings, and resolved the discrepancies by mutual consultation with the help of the third reviewer. The results of the review were able to generate themes that were able to satisfactorily answer the review question. Theoretical positions might have influenced theme generation and themes might align closely with the theory. Since we were aiming at exploring multiple perspectives of the GPs, the heterogeneity of the articles, the combination of quantitative and qualitative methods employed, and data obtained from across the continents, increased the depth of our understanding, allowing it to be replicated in different settings.

Future considerations

Four studies in the review revealed that GPs having solo practice had limited access to end-of-life care training [39, 49, 51, 53]. Thus, knowing their learning needs will give a different perspective on factors that may influence their learning. All the studies included in this review were conducted in Europe, Australia, and Canada [39, 49, 51, 53] with no insight from other geographic locations. Moreover, patients’/caregivers’, or palliative care team’s views on the care provided by GPs will further bridge the gaps in end-of-life care provision.

Implications for policy and practice

Patient-related suffering and how empowered GPs feel in addressing them determine their educational needs in end-of-life care. Thus, identifying the challenges that GPs face in physical and psychosocial care, communication skills and coordination/collaboration of care will add relevance to the training program. There is need for a paradigm shift in training programs from a formal training to a more experiential and reflective learning under mentorship in order for training programs to be sustainable over long run. Additionally, every training programs must have an inbuilt feedback and evaluation mechanism as this will ensure sustainability and help GPs amend clinical practice on an ongoing basis.

Conclusion

The review suggests that GPs’ preference for learning end-of-life care was influenced by the value that they ascribed to their learning. GPs who had a sense of responsibility or a therapeutic bond with their patients were motivated to undergo training in end-of-life care. Diffidence in providing end-of-life care, challenges on a personal and professional front, and a feeling of disempowerment inhibited them from accessing training. GPs preferred experiential and reflective learning, under the guidance of specialists. They perceived feedback as an integral component of learning and performance. They preferred feedback if it was provided sensitively and in a respectful, non-intimidating, and trustworthy environment.