pallium 1 l.e.a.p learning essential approaches to palliative care

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PALLIUM

L.E.A.PLearning Essential Approaches

to Palliative Care

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Course Goals• Empower Primary Care• Introductory course on providing care

for the terminally ill for primary health professionals.– Knowledge, skills & attitudes

• Promote interprofessional collaboration.• Showcase/credibility local palliative

care coordinators & resources• Identify local champions.• Catalyze local change.• Educate local community- Press release

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Considerations• Principal target learners: MDs, RNs, Pharmacists• Target various settings.• Ability to repackage course.

– Divided into parts/series.– Various settings (undergraduate, postgraduate)

• Ability to vary audience– Hospital-based MDs, RNs, etc

• Ability to use components.– Medical, nursing, pharmacy students & residents. – Objects (online repository)

• Master copy of modules

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Considerations• Basic principles & essentials• Refer to more advanced materials

– E.g. Ian Anderson, Victoria Course, Hamilton interdisciplinary course

• Not just cancer• CPD credits

Evidence-best practices based.• Interprofessional

– but also respect needs of individual disciplines• Not TTT model• Iterative design process

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Curriculum DevelopmentKern’s Model

Problem Identification. General needs assessment

Needs assessment of targeted learners

(& technology)

Goals & objectives

Education strategies

Implementation

Evaluation & feedback

Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum development for medical education: a six-step approach. The Johns Hopkins University Press, Baltimore. USA. 1998.

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Course development history

• Pallium Phase I– Initial course draft (Mazuryk & Pereira)– Advice from Dr. Jocelyn Lockyer (PhD, CME)– Pilot phase of 6 courses- (ongoing revisions based

on evaluations: Cheryl Smith, Shannon Pyziak, Cornie Woelk, Ron Spice, Fiona Crow, Robert Wedel, Doreen Oneschuk).

• Phase II– Curriculum working group

• Romayne Gallagher (MD), Cheryl Smith (SW), Shannon Pyziak (RN), Pat Tichon (Pharm), Gillian Fyles (MD), Fraser Black (MD), Doreen Oneschuk (MD), Ron Spice (MD), Jocelyn Lockyer (PhD).

• To date: 4 major revisions.

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Revision August 2004• Blind review process

• Romayne Gallagher MD (BC.)• Cheryl Smith RN (MB)• Shannon Pyziak RN (MB)• Pat Trozzo Pharm. (MB)• Gillian Fyles MD (BC.)• Fraser Black MD (BC.)• Ron Spice MD (AB)• Robin Love MD (BC.)• Merle Teetaert RN (Sk)• Rob Wedel MD (AB)• Jose Pereira MD (AB)

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Pedagogical undercurrents • Various learning styles.• Reflective learning & constructivism• Combination of learning methods.

– “Theory bursts”.• Cognitive psychology: inductive, forward vs

hypothetico-deductive processes.• Hooks

– Case-based Group learning • Apply theory, nurture reflection, prompt discussion. • Lead by experienced facilitator/content expert• Constructive learning

– Large group discussions• Interprofessional dialogue

– Reflective exercises• Self-awareness, suffering.

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Pedagogical undercurrents• Trigger tapes & video vignettes

– "ill-structured situations“ – NOT ideally modeled, uses "reflective

questions" to prompt "reflective conversation"

• a.. What is going on here? • b.. What issues does this raise for you? • c.. What could have been done differently?

J Moon. Reflection in Learning and Professional Development. (1999, London: Kogan Page)

• Integrating & weaving themes throughout course– Ethical decision-making, communication.

• Repetition

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Course materials

• Local planning guide• Facilitator’s kit

– Manual: Facilitator notes (suggested questions, reminder of key points, theory & evidence)

– Videos, posters

• Participants’ manual

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Module Themes Learning Activities Suggested Delivery

Time

1 Creating Context Self-awareness exercise

What dying people want

Defining palliative care

Orienting ourselves to the work (video)

1 hour

2 Gastro-intestinal problems

Ethical decision-making

(artificial feeding)

Theory bursts

Case discussions

Video discussion

2 hrs

25 min

3 Pain Management Prescription exercise

Theory burst

Case Discussion

2 hrs

35 min

4 Respiratory Problems Theory burst

Case discussion

1 hr

5 Communication Socio-drama based videos that prompt discussion.

2 hrs

6 Depression, Anxiety & Suffering.

Theory burst

Video and group discussion

1 hr

7 Grief & Bereavement Theory burst 30 min

8 Delirium Theory burst

Case discussion

1hr

10min

9 Palliative Sedation Theory burst

Large group discussion

30min

10 Last days & Hours Video discussion

Theory burst

30 min

11 Working as a Team Large group discussion 30 min

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Module Themes Learning Activities Suggested Delivery

Time

1 Creating Context Self-awareness exercise

What dying people want

Defining palliative care

Orienting ourselves to the work (video)

1 hour

2 Gastro-intestinal problems

Ethical decision-making

(artificial feeding)

Theory bursts

Case discussions

Video discussion

2 hrs

25 min

3 Pain Management Prescription exercise

Theory burst

Case Discussion

2 hrs

35 min

4 Respiratory Problems Theory burst

Case discussion

1 hr

5 Communication Socio-drama based videos that prompt discussion.

2 hrs

6 Depression, Anxiety & Suffering.

Theory burst

Video and group discussion

1 hr

7 Grief & Bereavement Theory burst 30 min

8 Delirium Theory burst

Case discussion

1hr

10min

9 Palliative Sedation Theory burst

Large group discussion

30min

10 Last days & Hours Video discussion

Theory burst

30 min

11 Working as a Team Large group discussion 30 min

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“Theory burst”

• Short• Main messages• Limit intense discussions but do

not stifle questions or discussion either.

• Introduce personal clinical experiences & short stories- not too many and not too long.

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Group facilitation

• Role of facilitator– PBL in purist form

Studies show no superiority over other methods with respect to knowledge & skills, but more enjoyable and consistent with constructive learning theory.

– Process facilitator vs content expert vs process & content facilitator

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Group Facilitation

• Going from “sage on the stage” to “guide on the side”– Don’t give “answers” right away.– Pose reflective questions.– Don’t “shoot down” what appears to be

“incorrect” – Do provide alternative perspective.

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Group facilitation

• Key messages– “This is an important point-this is a take-

home message”.– 4 or 5 key take home messages for each

module– Identify “take home messages” during

discussion– Facilitator notes are at times

comprehensive- you do not have to cover each point in notes. Pick out main message.

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Group facilitation• Respect input. • Reframe if necessary.• Ask questions that prompt reflection.• Attitudinal objectives:

– Don’t have to agree or disagree (unless unsafe practice), but introduce different perspective.

– Find common values.– Reframe discussion: “This is what we will

experience when dealing with a difficult patient/family/colleague situation. SO how can we process through this?”

• Need not agree but acknowledge.• Highlight practical ideas.• Focus on the problem, not the person

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Course Evaluation (Dr. J Lockyer & CME Unit

at U of Calgary)• Learners’ reactions• Modifications of attitudes• Acquisition of knowledge/skills• Change in individual behaviour• Change in organizational behaviour• Benefit to patients• Changes in organization itself to systematize

palliative care- i.e. new policies & procedures, new equipment, community education, increased team work, fundraising etc

• Costs

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Course evaluation

• Pre-course survey– Demographics– Comfort level– Identify learning needs– Knowledge quiz– (Attitude survey)

• Post Course– Course evaluation – Comfort levels– Knowledge quiz– Commitment to change– (Attitude survey)3-6 mths Post Course– Commitment to change review– (Comfort levels)– (Knowledge test)– (Attitude survey)