Table 2 Overview of the Studies included in the Systematic Review

Selman et al. (2017) [24]

London, UK

The study aimed to explore GP’s educational needs, preferred learning methods, and acceptable methods of evaluation.

28 General practitioners (18 trainees; 10 General practitioners)

Qualitative data analysis

Motivation to learn: Generalists must be specialist at end-of-life care,

Attrition of skills and with symptom management and use of syringe drivers due to inconsistent exposure, (Ability to) deal with complexity of end-of-life care. Learning needs: Symptom management, need for identifying local palliative care resources, and communication skills caring for patients with non-malignant conditions; and paediatric palliative care. To handle difficult conversation around denial and bargaining, handle emotionally burdensome, care in alignment with patient’s wishes. Learning style: They preferred experiential learning in a mentored environment from palliative care specialists/experienced general practitioners, most preferred placements at hospices and opportunities to shadow or discussion of cases with specialist palliative care team, Also learning from relatives/family members of patients. Case studies preferred over didactic learning style; E-learning had mixed views while it was cost effective and flexible Facilitators of training: They preferred multi-disciplinary mentors and peers such as specialist palliative care/GP mentors Feedback preference: Behavioural assessment using videotaping or even simulated behaviour assessment was not effective Self-assessment questionnaire was of limited use if it was not lengthy or burdensome. They were in favour of patient and family feedback if done sensitively, some felt inappropriate to ask a feedback from a relative about their general practitioner who looked after their dying patient Timing patient and family outcome measurement sensitively was considered important. Barriers for learning: When specialists lacked trust in general practitioners.

32

Pype at al. (a) (2014) [25]

Belgium

The study explored current experiences of General practitioners, CME providers and PHCT members with palliative-care education for General practitioners

Their views on and preferences for future palliative-care education for General practitioners according to General practitioners, CME providers and PHCT members respectively

29General practitioners

Qualitative research method using

Focus group discussion

Motivation for learning: General practitioners felt palliative care as a part of their job; Felt the need for a shift in attitude from “cure to care” to look beyond the usual framework of a diagnosis, a therapy, making somebody better. Self-conception, roles and responsibilities were perceived by the practitioner

Desired life-long learning for knowledge updation and to prevent volatility. Learning needs:

Preferred to remain generalists, keeping patients free of pain and discomfort, up scaling their communication skills, Learning style: General practitioners were not enthusiastic about CMEs as they felt it was theoretical and did not match their actual training needs. Better way to address their needs were by workplace learning, trial and error, learning by doing, reflecting on one’s practice and being mentored by specialists. Learning by the bedside under the supervision of specialists They also felt learning from carers as equally important. Co-manage a patient with palliative home care teams helped learn to shift from reactive style to a more proactive style. Case-based interactive discussions and peer discussions, had better and prolonged retention of information. They expressed the need for experiential learning by practising and training in small groups, and role-play, and with simulated patients and with inputs from specialists as an ongoing process. They felt benefited from planning meetings as it involved professionals and exchange of ideas. They preferred case-based discussion in small groups. Facilitators of learning: Sharing of experience with peers in the group, mentorship by specialists Feedback on action and doing from specialists and peers. They needed a respectful (safety and trust), non-intimidating and non-judgemental learning environment, off bedside not exposing their deficiencies to patient/family Barriers of learning: Limited involvement in palliative care, care as time consuming and emotionally exhausting, lack of clarity in roles and responsibilities, felt inhibited when the care of their patients was taken over by specialists. Challenges of not being able replicate hospital/hospice based practice in the community due to lack of same structure and resources in community. Solo practice

30

Pype et al. (b) (2014) [26]

Belgium

To explore General practitioners and PHCT nurses learn during collaborative practice?

To explore General practitioners and PHCT nurses learn during collaborative practice?

To explore General practitioners and PHCT nurses learn during collaborative practice?

267General practitioners

73nurses

Survey

Motivation to learn: Experienced general practitioners preferred learning. Attrition of knowledge and skills. The science of palliative care as ever evolving warranting continuous upgradation. Learning needs: General practitioners preferred to learn about physical and psychological symptom management. Other topics such as religion and spirituality, teamwork and organisational items were preferred. Learning style: General practitioners preferred discussion and reflection followed by observation and didactic learning. They preferred work place learning, felt comfortable learning from palliative home team nurse/community nurse followed by patients/family and GP colleagues. They preferred learning by listening and observing for topics such as teamwork building, religious and psychosocial topics) and by discussion and reflection on psychosocial topics. Facilitators of learning: General practitioners learnt from patients followed by nurses, [referred learning from mentor, peers and general practitioner colleagues. Feedbacks and learning from mistakes were preferred by some as this needed a high degree of trust between team members. Barriers for learning: Solo practice

31

Hermann et al. (2019) [38]

Australia

To explore Australian General practitioners’ perceptions of barriers and enablers to the provision of palliative care.

25General practitioners

Inductive content analysis

Motivations to learn: Felt palliative care as central to caring, emotional attachment with patients and family, sense of responsibility towards their patients/family. Learning needs: Need for training as to when to initiate EOLC, how to discuss treatment when patient/family are in denial, lack of knowledge on available resources for palliative care guidelines especially not knowing symptom management and when to stop drugs that were once therapeutic, resources for training, accessibility to specialist palliative care team. Need for debriefing in case of emotionally draining situation in practice. Learning styles:

They “gained by doing”and felt integrating training in routine clinical practice under the mentorship of experienced general practitioner/specialist palliative care team. They felt this could be done through small group problem based discussion at their practice site; locally available resources. Online courses benefited rural GPs. Facilitators of training: General practitioners reported that education programs should involve repeated information sessions, during and out of business hours, with additional follow-ups to allow for further discussion, promoting Palliative care as a sub-speciality in general practice.

Barriers for learning: Palliative care as time consuming, palliative care as being complex and emotionally burdensome, lack for clearly defined roles and responsibilities, lack of recognition/appreciation of their work by specialists, mistrust in their service provision by specialist and patients/family, poor communication from specialists about the intent of treatment, poor remuneration, lack of knowledge about the available opportunities for training, lack of standardisation and accreditation of palliative care.

30

O’Connor and Le-Steere [39]

(2006)

Australia

To explore General practitioners’ attitudes to palliative care in a rural center of Western Australia

To understand factors contribute to General practitioners attitudes to palliative care in a rural center of Western Australia

To explore the perceived barriers to the provision of palliative care in a rural center of Western Australia

10General practitioners

In-depth interview

Qualitative data analysis

Motivation for learning: General practitioners felt palliative care and pain relief was their core responsibility; their guilt and remorse of not having been able to alleviate symptoms in end-of-life care; their need to support patients who they had cared for a prolonged period of time and developed an emotional bond with. Learning needs: General practitioners expressed the need for training in pain and symptom management followed by communication skills training as they dealt frequently and intimately with patients/family. They expressed the need for enhancement of skills, tacts, diplomacy in dealing with delicate situation with patient and family. They felt the need for training in dealing with spiritual issues of patients and psychological issues such as depression and emotional problems. They expressed the need for communication skills training in case of denial or bargaining, learning self- care and coping with the situation especially when caring for dying younger patients whom they had known for long, general practitioners with young off-springs of similar age as their dying patient. Need to deal with family’s denial about terminal illness, resolution of conflict and supporting family’s with anticipatory grief. Learning style: General practitioners felt a need for team approach in palliative care as it provided emotional support, and aided in time and management plans. Telephonic or web based training may be a better option for rural practitioners. Barriers for learning: General practitioners might have less consistent support system, may be temporary at work due to family and personal commitments, or lack time due to work pressure. Palliative care can be emotionally draining and depressing, loss of control on their patients with palliative care becoming a specialised field, perception of no newer developments in palliative care.

30

O’Connor and Breen [40]

(2014)

Australia

The study aimed to explore General practitioners’ understandings of bereavement support and their educational and professional developmental needs in relation to providing bereavement care

19General practitioners

In-depth interview using social constructionism approach

Motivation for learning: Being human to patient concerns, personal experience of loss and personal grieving process, long standing relationship with patient and bereft family, sense of responsibility to support bereaved family. Learning need: General practitioners felt ill-equipped with counselling family with complicated grief, were not able to distinguish between grief reaction and depression. Learning style: Minority of General practitioners preferred ‘on the job’ experiential learning over CPD or self-learning. They felt learning the theoretical principles of grief counselling, applying them in practice and learning from patient feedback for betterment in the service. Barriers for learning: Challenges of learning from specialist psychologists/psychiatrists (with incomplete reporting by the latter), unawareness of local resources for counselling.

30

Assing Hvidt et al. (2016) [41]

Denmark

What were the points of agreement and disagreements among General practitioners in Denmark concerning how the existential dimension is understood, and when and how it is integrated in general practice?

31 General practitioners

General practice setting

Hermeneutic-phenomenological research methodology

Motivation to learn: General practitioners felt the need for whole person care and emphasised the importance of addressing suffering as integral to health and illness. Learning needs: They felt the need for systematisation and standardisation in providing spiritual care, challenged as to not knowing the right moment to refer their patient to chaplain. Learning style: They felt that spirituality is intuitive and it grows over years of practice and relationship with patient. Barriers to learning: They had apprehensions about discussing death and dying as they felt it would mean causing discomfort to the patient or perceived as taboo, felt a lack of specialist competence in addressing spirituality as they felt they were treading an unknown territory, They feared intruding into patient’s privacy by broaching the topic of spirituality

27

Becker et al. (2010) [42]

Austria

To identify the preferences of the General practitioners’ and nurses’ regarding the specific design of training seminars in palliative care

To gain insight into which educational topics, timeframe, location and group designs are likely to attract a majority of different professional groups

897 General practitioners

933 Nurses

Survey

Learning needs: General practitioners felt the need for training in pain and symptom management followed by handling psychosocial and ethical issues and coping strategies

Facilitators of training: General practitioners especially rural general practitioners preferred evening courses and weekend courses, were to pay for their training, willing to travel for training (including traveling abroad), preferred a mentors and peers from a multidisciplinary team for training

26

Straatman and Miller (2013) [43]

Canada

To assess the experience with and confidence of practicing family/GP and paediatricians in providing paediatric palliative care

43General practitioners

56General paediatricians

14pediatric subspeciality

Survey

Motivation to learn: Rarity of the life limiting illness, complexity of illness and prolonged care, current medical knowledge and experience as inadequate to meet the needs of paediatric palliative care patients, Learning needs: Management of other symptoms followed by management of pain and nutrition, self-care and care of the team, training in spirituality to cater to self and the team, debriefing with colleagues and teamwork. Learning style: They preferred remote learning such as internet based or correspondence learning followed by workshops. Facilitators of learning: They preferred to attend workshops over weekends

24

Slort et al. (2011) [44]

Netherlands

(1) To understand facilitators for GP–patient communication in palliative care are reported by General practitioners

(2) To understand the barriers for GP–patient communication in palliative care are reported by General practitioners

20 GENERAL PRACTITIONERS

Focus group discussion

Qualitative data analysis

Motivation for learning: Willingness to provide palliative care, positive attitude towards helping their patients, paying regular home visits; honouring the patient’s dignity, autonomy, wishes, and expectations; ensuring continuity of care; longstanding GP–patient relationship. Learning needs: They expressed difficulty in dealing with patient’s fears and emotional distress. Need for training in handling a troublesome relationship with the patient and conflicts within the family. Communications skills training as aide to elicit patient’s wishes and expectations. They felt ill equipped in controlling their patient’s symptoms adequately

25

Taubert et al. (2011) [45]

Cardiff, UK

To explore problems relating to palliative care and symptom control in out of hours setting

9 General practitioners

Interpretative Phenomenological analysis

Motivation to learn: General practitioners feared treading the unknown territory of end-of-life care

Learning needs: Gaps in knowledge or skills forgotten especially in out-of-hours care, lack of knowledge appeared to have an effect on their prescribing habits, perhaps making them less inclined to increase a patient’s drug dose. Due to lack of continuity in out-of-hours care they lacked confidence on prescribing and escalating dose of opioids. Learning style: They preferred problem-based learning by following up on their patients, reflective learning so to learn from mistakes/non- success, referring to internet and textbooks for learning palliative care. Some felt the need for previous experience for a better performance. Some even felt exposure to hands on training in palliative care was beneficial in end-of-life care. Barriers of learning: They felt insecure to broach the topic on lack of knowledge, out-of-hours practice and shift jobs gave them minimum opportunity to reflect on their practice, most feared harming the patient or being medico-legally recriminated. Most training occurred “in-hour” which did not help out-of-hours care.

25

Rhee et al. (2008) [46]

Australia

Study aimed to determine the level of participation of Australian urban General practitioners in palliative care, and to determine the main barriers facing them in providing this care.

269General practitioners

Survey

Motivation for learning: Strong emotional bond with patients, long years of practice, more clientele, more older and sicker patients motivated learning. Learning needs: Needed training in use of syringe drivers, providing psychosocial care or complex symptoms in terminal care. Learning styles: General practitioners preferred workshops followed by written material and online learning Barriers for learning: Lack of time due to work pressure followed by home visits, family/personal commitment, younger general practitioners, poor remuneration, demoralised when specialists take over the care

28

Rhee et al. (2018) [47]

Australia

Study explored the views on the role that General practitioners should play in the planning and provision of end of life care in Australia and

Important barriers and facilitators to their involvement including suggestions on what could be changed or improved.

11General practitioners

10SPCC

In-depth interview

Motivation for learning: General practitioners who had inclination to provide end-of-life care and advance care planning, supported the patients/family for a prolonged period of time, reciprocation and appreciation from family of feeling supported, long term relationship with patient and family, sense of responsibility towards patient and community. Learning style: General practitioners wanted real-life exposure to gain confidence in skills. They felt the need for working in collaboration with specialist palliative care, easy access to specialists and ongoing communication with specialists. They desired training under an experienced General practitioners or in a palliative care centre. Barriers for learning: General practitioners catering to younger population had less sick patients who may not follow up to build a long term relationship which may challenge end-of-life care discussion in this population that resulted in less involvement in palliative care

25

Meijler et al. (2005) [48]

Netherlands

A study to explore concerns of GENERAL PRACTITIONERS in relation their educational needs in palliative care

40General practitioners

Focus group discussion

Qualitative data analysis

Motivational factors for learning: Palliative care as a valuable part of their care. Being trained in palliative care makes one a good physician. Learning needs: Pain was one of the most difficult problems especially certain specific aspects of pain management such as “when” and “how” to start opioids, challenges of subcutaneous administration of opioids (use of combination of medications), effects and side effects of nerve blocks, Other issues included use of parenteral nutrition/PEG feeding, diagnosing and management of delirium with special emphasis on subcutaneous midazolam administration, depression/insomnia and difficulty in distinguishing adjustment disorder and sadness, Insomnia as an area of concern as General practitioners found challenge in distinguishing the cause as delirium, fear of dying, or anxiety. Communication was frequently mentioned as being complex especially when patients transitioned from curative to palliative phase of treatment, addressing caregiver concerns, need for training in conflict resolution and denial especially the use of right attitude in dealing with these issues

They expressed the need for debriefing sessions and understanding of “how to develop and discuss” and share ethical aspects of care with other professionals. Learning style: They felt the need to learn to reduce complex problems to solvable solution through problem-based education. Barriers for learning: Non recognition of their role, lack of clarity in roles and responsibilities, care as time consuming, complexity of care, land up spending more time to compensate for the helplessness led to neglect of other patients, feared medico-legal recrimination.

25

Junger et al. (2010) [49]

Germany

To examine potential barriers, incentives, and the professional self-image of general paediatricians with regard to paediatric palliative care

Pediatricians in general practice

Sequential exploratory methods:

Qualitative indepth interview- 5pediatricians

Quantitative method using survey methods-293

Motivational factor for learning: To help the child as a person rather than a diseased, experience in clinical practice as being essential component of care, Intuition that they will be able to extend the care of the dying child, Trusted key person who accompanied the family for many years. Learning needs: Most lacked knowledge as to what diseases are included in palliative care, decision-making in children with life limiting illness can be complicated thus had challenges of integrating palliative care, underreporting of pain and fear of side effects of opioids, apprehensions about discussing death and dying with patients/family, need for coping and self-care, debriefing and mutual support. Preferred learning style: Seminars were most frequently mentioned followed by self-study and lectures. Barrier for learning: Felt vulnerable discussing on transition to end-of-life, emotional burden of caring for a dying child, poor support by specialist, solo practice, unawareness of specialist palliative care team, fear of medico-legal recrimination

27

Magee and Koffman (2016) [50]

UK

To examine the perceived confidence of OOH General practitioners in symptom control, end of life prescribing, communication skills, and to identify their educational needs and preferences.

203 General practitioners

Survey

Learning needs: Educational preference was closely linked to low confidence in palliative care emergencies, symptom control in non-cancer palliative care and use of syringe driver. Frequently requested training in end-of-life care pathways, opioid prescribing, management of breathlessness, agitation/confusion. Learning style: E-learning was the preferred style followed by workshops, Interactive case-based discussion, learning on the job and didactic lectures. Facilitators of training:

Workshops with multiprofessional lecturers and other General practitioners participants

28

Barcley et al. (2003) [51]

Wales, UK

To investigate the training in palliative medicine of General practitioners throughout Wales during their careers.

590 General practitioners

Mixed setting

Survey

Motivation to learn: More experienced as a general practitioner, past experience in home care and care of the dying had a higher predilection for training in end-of-life care. Continuity of care as a central role of general practitioner. Learning needs: They preferred training in pain and symptom management, use of syringe drivers, bereavement care.

22

MA Wakefield et al. (1993) [52]

Australia

To assess Australian General practitioners assessment on opinions and management practices in palliative care for terminally ill patients

108 General practitioners

Survey

Learning needs: General practitioners felt a lack of competence in managing psychosocial issues of terminally ill patients and dealing with emotional distress of the relatives, felt incompetent in managing pain, had anxieties about use of opioids and side effects of opioids, management of tolerance to opioids, management of other symptoms such as hypoxia and insomnia, training in communication skills with dying patients, and bereavement counselling. Facilitators of training: Felt the need for training under the mentorship of specialist palliative care team

20

Shipman et al. (2001) [53]

London UK

The study explored the General practitioners’ educational preferences in palliative care, focusing particularly on variations in preferences by location of practice (inner-city, urban and rural General practitioners)

640 General practitioners

Survey

Motivation for learning: General practitioners who were more confident in prescribing analgesia were more likely to prefer further training. Learning needs: They needed training in symptom control for non-cancer patients due to prolonged period of care they provided to non-malignant patients. They wanted training in use of analgesics, syringe driver, nausea/vomiting management, counselling skills, communication skills and breaking bad news. Barriers of learning: General practitioners perceived barrier in training as most trainings were oncology focussed which did not help in managing non-malignant palliative care which comprised major part of their practice

23

Shipman et al. (2002) [54]

London UK

To understand the General practitioners use of and attitude towards specialist palliative care in different geographical context

49General practitioners IDI

8GENERAL PRACTITIONERS one FGD

Indepth interview and FGD

Qualitative data analysis

Motivation to learn: General practitioners learnt from specialists only if their preference were in alignment with those of the specialist’s Learning style: They contacted specialists for support through telephone/face-face for updating their knowledge on a case to case basis, used the hospice symptom control book for updating knowledge, they contacted specialists for guidance on symptom control and emotional support, some attended courses in hospice or palliative care centres. Facilitators of learning: General practitioners involved themselves in joint care with specialists if the encounter was amicable. Barriers of learning: Low incidence of palliative care cases in practice may inhibit learning. They kept away from learning from specialists when they felt uncomfortable working together or when they feared accusation, had past bitter experience or feared conflict in care

20

Samaroo (1993) [55]

Canada

The survey was conducted to identify physicians’ and nurses’ perceived educational needs related to death and dying et al.

102General practitioners

263RN

Survey

Learning needs: Pain, dyspnoea, restlessness and confusion were most discomforting for the physicians followed by anger and demanding behaviour of patients/family. Withdrawal avoidance were most discomforting with regards emotional/behavioural component. Learning style: Physicians desired specialized training with the hospital based palliative care team Facilitators of training: they preferred quarterly topical in-services, self-learning modules, extension courses for credit, and one-day on-site programs, quarterly case rounds, and half-day workshops.

19

Lloyd-Williams et al. (2006) [56]

North Wales, UK

A study to evaluate palliative care provision and training needs of general practitioner in rural areas of North Wales

94General practitioners

Survey

Motivations for learning: Younger General practitioners had keen interest in palliative care; felt palliative care as a part of their care provision; felt central to coordinating palliative care for patients; relationship with family and longer duration of this association with patients and family triggered the need to enhance their skills. Learning needs: They felt the need for training in pain and symptom management followed by dose titration of opioids, breaking bad news, psychosocial needs and bereavement care. Learning style: General practitioners felt the need for experiential learning over didactic lectures; placements within hospice or palliative care team as beneficial as observing and discussing difficult cases helped better uptake of knowledge. Facilitators of training: General practitioners preferred evening meetings. They appreciated learning from peers such as colleagues, palliative care team, and palliative care nurse. Barriers for learning: Solo practice, lack of support system, Time constraint due to busy practice

20

Jhonston et al. (2001) [57]

Northern Ireland

To carry out an educational needs assessment in palliative care of general practitioners and community nurses.

611 General practitioners

Survey

Motivation for learning: General practitioners were motivated by their current palliative care practice, and felt that palliative care was a core element of their practice. Learning needs: Symptom management other than pain such as fatigue, anorexia, unpleasant smell, anxiety and depression followed by pain management, use of syringe driver, bereavement care and dealing with complexities of spiritual care. Learning styles: Order of preference: lectures by specialists, case discussion with specialists, experiential learning in hospice, research and audit as need for reflection on practice and self-learning through computer and information material. Facilitators of learning: Preferred a multidisciplinary learning by multidisciplinary team; interactive learning and video-feedback. Barriers in learning: lack of locally based courses, lack of dedicated time and the expense of providing locums or of self-funding courses.

23