JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 2, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2013.0158
Introducing Palliative Care into Entry-Level Physical Therapy Education Pauline E. Chiarelli, PhD, Catherine Johnston, MAppSc, and Peter G. Osmotherly, MMedSci
Abstract
Background and Objective: There is a paucity of information related to teaching palliative care to entry-level physical therapy students. The aim of this study was to evaluate the impact of an undergraduate course in palliative care on the preparedness of entry-level physical therapy students to practice within the palliative care setting. Methods: Participants were all entry-level undergraduate students enrolled in the third year of a 4-year undergraduate degree. All students enrolled in the course, ‘‘Physiotherapy Through Lifestages’’ took part in the learning modules relating to the care of patients undergoing palliative care. A survey instrument was used in the study, a modified version of an existing unpublished written questionnaire previously used to evaluate palliative care education in other allied health professions. Results and Conclusions: Participation in the course resulted in an increase in self-rated knowledge and confidence for working in the palliative care setting for entry-level physical therapy students and is considered to provide a useful ongoing resource for the presentation of this topic material. Although the impact of the delivery of this education module may be considered successful in this regard, it would appear that some of the underlying attitudes and emotional responses to this area of physiotherapy practice were less easily influenced. Further research is required to understand the influences on emotional preparedness of students to undertake this area of study and practice and to determine the optimal stage of study for delivery of this content.
Introduction
P
hysical therapists are members of the interdisciplinary, holistic, and compassionate team of practitioners providing palliative or end-of-life care.1 The management aims of physical therapy for people undergoing palliative care in general relate to the maintenance of functional ability and independence and the provision of evidence-based interventions for symptom relief.2–5 Improved functional levels, independence, and quality of life have been demonstrated with physical therapy intervention.6 An understanding of a palliative approach to care is a core skill for clinicians and therefore content relating to palliative care would be expected to be included in all physical therapy entry-level programs. Challenging students’ misconceptions about palliative care is viewed as an important part of medical undergraduate education7 and should be seen as equally important for student physical therapists preparing for their role in the interdisciplinary management of people with lifelimiting illnesses.8 Although the management of people undergoing palliative care should be considered an essential
skill for practicing clinicians, the availability of physiotherapists with acknowledged expertise in this area is limited. This subsequently limits the pool of expertise available for undergraduate teaching in this area. A national scoping study exploring the inclusion of palliative care within curricula of Australian university health faculties found few allied health programs included palliative care concepts to any major degree, and there was little standardization in the content or the teaching methods of palliative care in physical therapy. Some institutions do not include teaching related to palliative care within their curricula at all.8 The inclusion of specific entry-level training relating to palliative care in various health care professions has been shown to increase student knowledge levels,9,10 improve student preparedness to work in the field,11 and enhance selfefficacy in palliative care.12 Other studies, however, suggest that palliative care teaching has little effect on students’ attitudes toward end-of-life care.13 The Palliative Care Curriculum for Undergraduates (PCC4U) is an initiative funded by the Australian Federal Department of Health and Ageing through the National Palliative Care
School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia. Accepted September 18, 2013.
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PALLIATIVE CARE IN PHYSICAL THERAPY EDUCATION Program. The PCC4U project promotes the inclusion of palliative care training in the undergraduate education of all health care professionals and aims to improve knowledge and skills in relation to caring for people with life-limiting illnesses including those receiving palliative care. The PCC4U course includes a series of case-based modules with associated questions, reflections, and links to further information. The development of a new academic subject focusing on physical therapy across the life stages provided an opportunity to include the PCC4U palliative care course within the curriculum at the University of Newcastle in Australia. There is a paucity of information related to teaching palliative care to entry-level physical therapy students and therefore the aim of this study was to evaluate the impact of the PCC4U course on the preparedness of entry-level physical therapy students to practice within the palliative care setting. Methods Survey instrument The survey instrument used in the study was a modified version of an existing unpublished written questionnaire previously used to evaluate palliative care education in other allied health professions (see online supplementary questionnaire at htpp://www.liebertonline.com). The questions in the existing unvalidated survey were reviewed and modified for their use in a physiotherapy context. The paper-based survey instrument was completed anonymously. Two versions of the survey instrument were developed: a ‘‘premodule’’ survey containing 40 questions and a ‘‘post-module’’ survey containing 47 questions. The content of both surveys was identical, with the addition to the ‘‘post’’ version of extra questions relating to specific evaluation of the palliative care course. Survey sections included: general demographics, knowledge of palliative care and the role of physical therapy, confidence in undertaking interactions associated with caring for people with life-limiting illnesses, emotional impact of caring for people with life-limiting illness, and evaluation of the learning resources and delivery process. The majority of response options were formatted as 5-point Likert scales. Participants Participants were all entry-level undergraduate students enrolled in the third year of a 4-year undergraduate degree. Students were enrolled in the academic course, ‘‘Physiotherapy Through Lifestages’’ at The University of Newcastle (n = 89). All students enrolled in the course were invited to participate; there were no exclusion criteria. Intervention All students enrolled in the course, ‘‘Physiotherapy Through Lifestages’’ took part in the learning modules relating to the care of patients undergoing palliative care. An initial review of the PCC4U resources was undertaken by academics and content deemed appropriate was delivered to the students as part of the palliative care academic content. The content of the PCC4U course is presented in Table 1. The course consists of four modules with each module containing multiple sections. All sections contain a number of different activities, all of which are completed by students undertaking the course. All sections are based around individual patient
153 case studies, which are presented using a DVD. Students are guided through the case study and associated activities and information. In all sections, students are required to complete stimulus content that is formatted as specific questions requiring answers. Students are also expected to make notes and complete reflective tasks for each section. The format of delivery was primarily online with an introductory face-to-face teaching session. Each student received a DVD and a structured process for working through and completing the activities associated with the resources. Content relating to palliative care was included within the final written examination for the subject. Data collection/study process The study had a pre-course and post-course design utilizing an anonymous written survey instrument. The survey was delivered either side of the intervention, being provision of the PCC4U course. Approval for this study was granted by the University of Newcastle Human Research Ethics Committee. Prior to the commencement of the palliative care course, the ‘‘pre-module’’ survey was distributed to the enrolled students. The survey was distributed and collected by an academic unrelated to the research project. Respondents were asked to either complete the survey in the allocated class time or to complete it at a later time and return it to a marked box for collection. The ‘‘post-module’’ survey was delivered after the completion of the PCC4U course to the same enrolled students during another class session. The process of completion of this survey was the same as for the ‘‘pre-module’’ survey. Both were completed anonymously but were coded for interpretation and follow-up of nonresponses. Responses could not be matched to individual participants. E-mail reminders were sent at 2 weeks after delivery of each survey. Return of the surveys was taken to indicate consent. Data analysis Analysis was only undertaken for completed surveys. Likert scale responses for each response were converted to numerical scores. A low score indicated a negative response and a high score indicated strong agreement. Paired Likert data were then analyzed using the methods proposed by Roberson et al.14 whereby a variable describing the direction magnitude of change for participants on each item was calculated by subtracting an individual’s pre-study score from their post-study score. Pre/post study module changes were then analyzed using the Sign test to evaluate the occurrence of any significant directional shift in individual responses. Demographic and change score variables were reported using descriptive statistics. Results Seventy-nine participants completed the ‘‘pre-module’’ survey and 63 of these returned the ‘‘post-module’’ survey, with response rates of 89% and 71%, respectively. Characteristics of participants are presented in Table 2. Participant self-ratings of their knowledge of caring for people with life-limiting conditions and the role of physical therapy in this setting all significantly improved following the delivery of the intervention, with median responses
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CHIARELLI ET AL. Table 1. Description of the PCC4U Course, Modules, and Sections
Module title Principles
Communication
Assessment
Section title
Content
Death and dying Caring The team Standards
The aims of this module are to help students develop an understanding of the social and personal experiences of people with life-limiting illnesses and their families.
Diagnosis Support Children Specific stresses Spirituality End of life Self-care
The aims of this module are to develop student skills in communicating with people with life-limiting illnesses and their families.
Illness trajectory Common symptoms Symptom management
The aims of this module are to help students develop knowledge and skills in order to identify the health needs of people with life-limiting illnesses and help develop an understanding of principles for managing common clinical problems in palliative care.
Module content includes: Core principles of palliative care Community and individual perceptions and beliefs about death and dying Care contexts and the role of the interdisciplinary team
Module content includes: Principles of communication when interacting with people with life-limiting illnesses and their families Sources of support (psychological, social, spiritual) for people with lifelimiting illnesses and their families How personal values and beliefs affect interactions with people with lifelimiting illnesses and their families
Module content includes: Epidemiological and clinical features of specific life-limiting illnesses Principles for assessing and managing common symptoms and health problems associated with life-limiting illnesses Optimization
Experiencing loss Goals of care Optimization Caregiving
The aims of this module are to help develop understanding of how to provide support for people with life-limiting illnesses and their families particularly issues of loss, goals of care, and the effect of caregiving. Module content includes: Emotional responses of people with life-limiting illnesses and their families Strategies for collaborative decision making on care goals Interventions to optimize physical, psychological, and social function for people with life-limiting illnesses and their families Effect of caregiving on families
increasing one scale increment from ‘‘low’’ to ‘‘moderate’’ (Table 3), each change being statistically significant ( p < 0.001). Median perception of the relevance of physical therapy to palliative care practice did not significantly alter among the participants following the intervention. Self-rating of confidence to undertake a variety of nominated interactions or strategies associated with caring for people with life-limiting illnesses improved for each item. The
Table 2. Characteristics of Survey Respondents Characteristic
Pre-course (n = 79)
Gender (n, %) Female 52 (66) Male 27 (34) Age (mean [SD]) 22.8 (4.7) Previous palliative care training Yes 16 (20) No 64 (80) SD, standard deviation.
Post-course (n = 63) 40 (63) 23 (37) 22.9 (4.9) 23 (37) 40 (63)
magnitude of change of the median score for each questionnaire item was one scale increment from ‘‘low’’ to ‘‘moderate,’’ with the direction of change being statistically significant for each item (Table 4). Many of the participants’ median self-ratings regarding their emotional preparedness for caring for patients with lifelimiting illnesses demonstrated a statistically significant directional change following the intervention (Table 5). Awareness of personal coping strategies to be used while working in a palliative care environment demonstrated a marked increase in student rating with the median score increasing two scale increments ( p < 0.001). Two items, however, remained unchanged: eagerness to work in a palliative care environment and comfort with discussing death and dying with patients. Discussion This is the first study to evaluate the impact of an academic course on entry-level physical therapy students’ preparedness for practice in palliative care in Australia. Following completion of the PCC4U course, students’ self-rated knowledge,
PALLIATIVE CARE IN PHYSICAL THERAPY EDUCATION
155
Table 3. Participant Self-Rating of Their Knowledge of Palliative Care and the Role of Physical Therapy Pre-intervention N (%) Participant self-rating
None/not at all Low/poor Moderate
Current knowledge of 17 (21.5) 48 (60.8) caring for people with life-limiting conditions Level of understanding of 9 (11.4) 40 (50.6) the role of physical therapy in caring for people with life-limiting conditions 16 (20.3) 47 (59.5) Confidence caring for people with life-limiting conditions Relevance of palliative 1 (1.3) 2 (2.5) care to the practice of physical therapy
Post-intervention N (%) High
None/not at all Low/poor Moderate
High
P value for difference
13 (16.5)
1 (1.3)
1 (1.6)
8 (12.7) 52 (82.5)
2 (3.2)
p < 0.001
30 (38.0)
0 (0.0)
0 (0.0)
12 (19.1) 49 (77.8)
2 (3.3)
p < 0.001
15 (19.0)
1 (1.3)
1 (1.6)
22 (34.9) 36 (57.1)
4 (6.4)
p < 0.001
0 (0.0)
11 (17.5) 37 (58.7) 15 (23.8)
48 (60.8) 27 (34.2)
confidence, and emotional preparedness increased, indicating an increase in academic understanding and readiness; however, responses indicated that students continued to find this area of practice emotionally confronting. The findings of improvement in knowledge and attitudes regarding this area of
p = 0.054
clinical practice are consistent with those of Kumar et al.9 in evaluating their education intervention in Indian physiotherapy students. The response rate for physical therapy students completing both the before (89%) and after (71%) components of the
Table 4. Participant Self-Rating of Confidence in Their Ability to Undertake Aspects of Care for People with Life-Limiting Illness Pre-intervention N (%) Self-rated level of confidence Answering patients’ questions about what will happen to them during the dying process Supporting the patient or family member when they become upset Informing patients and family of support services available Knowing about different environmental options Responding to reports of pain from the patient Responding to reports of other symptoms from the patient Responding to patient reports of decreasing functional status Negotiating changing goals with the patient to correlate with his/her stage of illness Adapting care interventions to suit patients’ changing stage of illness
None/not at all Low/poor Moderate
Post-intervention N (%) High
None/not at all Low/poor Moderate
High
P value for difference
1 (1.3)
3 (4.8)
27 (42.9) 32 (50.8)
1 (1.3)
p < 0.001
11 (13.9) 41 (51.9) 24 (30.4) 3 (3.8)
2 (3.2)
20 (31.8) 37 (58.7)
4 (6.4)
p < 0.001
24 (30.4) 31 (39.2) 22 (27.9) 2 (2.5)
0 (0.0)
15 (23.8) 36 (57.1) 12 (19.1)
p < 0.001
18 (22.8) 32 (40.5) 27 (34.2) 1 (1.3)
0 (0.0)
10 (15.9) 42 (66.7) 11 (17.5)
p < 0.001
8 (10.1) 33 (41.8) 38 (48.1) 0 (0.0)
0 (0.0)
16 (25.4) 40 (63.5)
7 (11.9)
p = 0.001
12 (15.2) 39 (49.4) 27 (34.2) 1 (1.3)
0 (0.0)
20 (31.8) 39 (61.9)
4 (6.4)
p = 0.002
8 (10.1) 32 (40.5) 37 (46.8) 2 (2.5)
0 (0.0)
9 (14.3) 50 (79.4)
4 (6.4)
p < 0.001
8 (10.1) 49 (62.0) 19 (24.1) 3 (3.8)
0 (0.0)
15 (23.8) 43 (68.3)
5 (7.9)
p < 0.001
11 (13.9) 42 (56.2) 25 (31.7) 1 (1.3)
0 (0.0)
17 (27.0) 40 (63.5)
6 (9.5)
p < 0.001
33 (41.8) 42 (53.2)
3 (3.8)
I am not comfortable caring for a dying patient. I am not comfortable talking to families about death. Dying patients make me feel uneasy. I feel helpless when I have to care for patients with a life-limiting illness. Managing a patient with life-limiting illness traumatizes me. I don’t look forward to being the physical therapist of a patient with a life-limiting illness. When patients begin to discuss death, I feel uncomfortable. I do not like talking about death and dying with patients. I am aware of personal coping strategies I can use while working in palliative care.
Participant view 25 (31.7)
17 (21.5)
23 (29.1) 16 (20.3)
36 (45.6)
28 (35.4)
32 (40.5)
20 (25.3)
38 (48.7)
2 (2.5)
5 (6.3)
5 (6.3)
7 (8.9)
6 (7.6)
6 (7.6)
4 (5.1)
5 (6.4)
Disagree
6 (7.6)
Strongly disagree
19 (24.4)
28 (35.4)
18 (22.8)
27 (34.2)
25 (31.7)
28 (35.4)
22 (27.9)
29 (36.7)
31 (39.2)
Not sure
10 (12.8)
25 (31.7)
22 (27.9)
15 (19.0)
11 (13.9)
28 (3.4)
25 (31.7)
31 (39.2)
15 (19.0)
Agree
Pre-intervention N (%)
3 (3.9)
2 (2.5)
1 (1.3)
3 (3.8)
0 (0.0)
2 (2.5)
3 (3.8)
0 (0.0)
1 (1.3)
Strongly agree
3 (3.9)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (1.3)
0 (0.0)
1 (1.3)
Missing responses
1 (1.6)
3 (4.8)
3 (4.8)
3 (4.8)
7 (11.1)
1 (1.6)
6 (9.5)
2 (3.2)
3 (4.8)
Strongly disagree
10 (15.9)
27 (42.9)
26 (41.3)
28 (44.4)
33 (52.4)
34 (54.0)
26 (41.3)
26 (41.3)
29 (46.0)
Disagree
13 (20.6)
18 (28.6)
20 (31.8)
20 (31.8)
21 (33.3)
22 (34.9)
16 (25.4)
22 (34.9)
26 (41.3)
Not sure
34 (54.0)
15 (23.8)
14 (22.2)
12 (19.1)
2 (3.2)
6 (9.5)
15 (23.8)
12 (19.1)
5 (7.9)
Agree
Post-intervention N (%)
4 (6.4)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (1.6)
0 (0.0)
Strongly agree
1 (1.6)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
Missing responses
Table 5. Participant Self-Rating of Their Emotional Preparedness for Caring for People with Life-Limiting Illness
p < 0.001
p = 0.013
p = 0.592
p = 0.054
p = 0.018
p < 0.001
p = 0.003
p < 0.001
p = 0.035
P value for difference
156 CHIARELLI ET AL.
PALLIATIVE CARE IN PHYSICAL THERAPY EDUCATION survey is high in comparison with equivalent studies published evaluating the response of medical students to palliative care education packages. Evaluation of education modules by Auret and Starmer15 in Australian medical students achieved 28% follow-up. Similar surveys of medical undergraduates in the United Kingdom had rates that ranged from 35%9 to 65%.12 Physical therapists are integral members of the palliative care team with particular roles in symptom relief, education in energy conservation, and the optimization and maintenance of independent functioning for people with life-limiting illnesses.16,17 Palliative care education for entry-level physical therapy students should specifically highlight and focus on the roles and responsibilities of the physical therapist within the palliative care team. All members of the palliative care team require sound background knowledge and high-level interaction, communication, and practical management skills.8,10,12,18,19 Not only do professionals working within this field draw upon the technical elements of care within their scope of practice, but they must also integrate the spiritual, psychological, and counselling needs into their own care for people at the terminal stage of illness.1,4,20,21 Prior to completion of the PCC4U course students rated their knowledge, confidence, and emotional preparedness for practice in palliative care as low. This is not surprising given their age and likely minimal prior exposure to palliative care content or practical experience. Palliative care academic content for entry-level health professionals including physical therapists is often limited, and students frequently feel unprepared, lack confidence, and are often unwilling to enter practice in this area.13,21,22 Despite the recognition of the need for increased end-of-life education in undergraduate curricula for all health professionals,12,18 palliative care education has remained underrepresented in the curricula of allied health programs in Australia. In surveying university programs across Australia, Hegarty et al.8 noted that few allied health programs incorporated palliative health concepts to any major degree, with 38.5% of allied health courses failing to address palliative care at all. This is reinforced by the findings of Meredith,11 who reported that 54.2% of surveyed occupational therapists employed in palliative care in Australia and New Zealand had received no undergraduate education in palliative care. Following completion of the PCC4U course, student selfrated knowledge regarding palliative care and the role of physical therapy increased as did self-rated confidence in the ability to undertake interactions and interventions for people with life-limiting illnesses. The magnitude of change is consistent with the implementation of previous palliative care education packages for students in other health professions. Auret and Starmer15 measured the effectiveness of structured clinical instruction modules for Australian undergraduate medical students using Likert scales to assess self-rated knowledge and skills. Similar to our findings, self-rated assessment of knowledge and competence related to palliative care practice improved by one scale increment following completion of the series of modules. Mason and Ellershaw12 also demonstrated improvements in knowledge and communication and patient management skills following the introduction of an extended palliative medicine education program for undergraduate medical students in Britain. These students also reported improved confidence in their self-rated ability to meet the needs of the patient at the end-of-life stage
157 of care. Similar results have been obtained in implementing palliative care initiatives in nursing courses. Arber10 was able to demonstrate significant improvements of assessed knowledge using the Palliative Care Quiz for Nurses instrument in final-year undergraduate nurses following the introduction of a specific palliative care education module. The PCC4U course, although not specific for physical therapy students, appeared to achieve the broad aims of improving background knowledge and enhancing confidence for practice. Interestingly, completion of the PCC4U course failed to alter students’ perception of the relevance of palliative care to physical therapy practice. Students initially rated their perception of the relevance of palliative care to physical therapy practice as moderate and this did not change following the learning modules. Whether this is due to lack of specificity or inadequacy of the PCC4U resources, paucity of clinical practice exposure, or it is a function of particular characteristics of those students undertaking physical therapy study is unknown and requires further investigation. Not all of the students’ emotional responses to working in palliative care were changed following the learning modules. Practice as a health professional in palliative care may be confronting and emotionally challenging.23 Students rated their emotional preparedness for working in palliative care as low pre-module. Post-module, students remained apprehensive about undertaking practice in a health care setting requiring involvement with people with life-limiting illnesses. Students reported that they were particularly uncomfortable in entering discussion involving impending death and dying with patients and carers. Although academic learning modules are able to affect change in knowledge and confidence in employing discipline specific skills, attitudes and emotional responses may be less responsive to significant change with delivery of an educational package. External factors including upbringing, personal beliefs, and life experience are more likely to have a greater impact on emotional responses to dealing with death and dying, which are greatly influenced by personal experiences and individual perspectives.23 This is consistent with the findings of Lloyd-Williams and Dogra,13 who found little difference in the attitudes of preclinical medical students toward caring for dying patients following completion of a palliative care study unit. Possibly, a greater impact on emotional preparedness for practice in the area may be gained by gradual immersion in the clinical setting through specific palliative care placements. Moriarty and colleagues19 provide some preliminary evidence of the usefulness of this approach in a small-scale analysis of seven students undertaking a half-day palliative care attachment. Based upon journal analysis, the students in this study reportedly recognized a reduction in their apprehension in dealing with people in a palliative care hospice situation. The effect of further graded immersion in the clinical setting could form the basis of future research in this area. A limitation of this study is the reliance on self-reporting, particularly for measures of student knowledge. No summative measure of knowledge, for example response questions to a case vignette, was undertaken. There were also no measures of change in actual skill level in the practical environment. Corroboration of the students’ own assessment with objective measures of performance would improve the veracity of our findings. Additionally, an evaluation of the
158 survey instrument through a formal validation process would have improved the rigor of this study. In conclusion, participation in the PCC4U course resulted in an increase in self-rated knowledge and confidence for working in the palliative care setting for entry-level physical therapy students and is considered to provide a useful ongoing resource for the presentation of this topic material. Although the impact of the delivery of this education module may be considered successful in this regard, it would appear that some of the underlying attitudes and emotional responses to this area of physiotherapy practice were less easily influenced. Further research is required to understand the influences on emotional preparedness of students to undertake this area of study and practice and to determine the optimal stage of study for delivery of this content. Author Disclosure Statement No competing financial interests exist. References 1. Michel T: Do physiotherapists have a role in palliative care? Physiother Res Int 2001;6:v–vi. 2. Cobbe S, Nugent K, Real S, Slattery S, Lynch M: A profile of hospice-at-home physotherapy for community-dwelling palliative care patients. Int J Palliat Nurs 2013;19:39–45. 3. Goodhead A: Physiotherapy in palliative care: The interface between function and meaning. Eur J Palliat Care 2011;18:190–194. 4. Frost M: The role of physical, occupational and speech therapies in hospice: Patient empowerment. Am J Hosp Palliat Care 2001;18:397–402. 5. Kumar S, Jim A: Physical therapy in palliative care: From symptom control to quality of life. A critical review. Indian J Palliat Care 2010;16:138–146. 6. Laakso EL, McAuliffe AJ, Cantlay A: The impact of physiotherapy intervention on functional independence and quality of life on palliative patients. Cancer Forum 2003;27:15–20. 7. Arolker M, Barnes J, Gadoud A, Jones L, Johnson MJ: ‘‘They’ve got to learn’’: A qualitative study exploring the views of patients and staff regarding medical student teaching in a hospice. Palliat Med 2010;24:419–426. 8. Hegarty M, Currow D, Parker D, et al.: Palliative care in undergraduate curricula: results of a national scoping study. Focus Health Prof Educ 2010;12:97–109. 9. Kumar S, Jim A, Sisodia V: Effects of palliative care training on knowledge, attitudes, beliefs and exeriences among student physiotherapists: A preliminary quasi-experimental study. Indian J Palliat Care 2011;17:47–53. 10. Arbor A: Student nurses’ knowledge of palliative care: Evaluating an education module. Int J Palliat Nurs 2001;7:597–603.
CHIARELLI ET AL. 11. Meredith PJ: Has undergraduate education prepared occupational therapy students for possible practice in palliative care? Aust Occup Ther J 2010;57:224–232 12. Mason SR, Ellershaw JE: Undergraduate training in palliative care medicine: Is more necessarily better? Palliat Med 2010;24:306–309. 13. Lloyd-Williams M, Dogra N: Attitudes of preclinical medical students toward caring for chronically ill and dying patients: Does palliative care teaching make a difference? Postgrad Med J 2004;80: 31–34. 14. Roberson PK, Shema SJ, Mundform DJ, Holmes TM: Analysis of paired Likert data: How to evaluate change and preference questions. Fam Med 1995;27: 671–675. 15. Auret K, Starmer DL: Using structured clinical instruction modules (SCIM) in teaching palliative care to undergraduate medical students. J Cancer Educ 2010;23: 149–155. 16. Marcant D, Rapin C-H: Role of the physiotherapist in palliative care. J Pain Symptom Manage 1993;8:68–71. 17. Rashleigh L: Physiotherapy in palliative oncology. Aust J Physiother 1996;42:307–312. 18. Gibbins J, McCoubrie R, Maher J, Wee B, Forbes K: Recognizing that it is part and parcel of what they do: Teaching palliative care to medical students in the UK. Palliat Med 2010;24:299–305. 19. Moriarty H, McKinlay E, Tanne L: Early palliative care attachment—a transformative educational experience for medical students. Focus Health Prof Educ 2006;8:40–48. 20. Mackey KM, Sparling JW: Experiences of older women with cancer receiving hospice care: Significance for physical therapy. Phys Ther 2000;80:459–468. 21. Morris J, Leonard R: Physiotherapy students’ experiences of palliative care placements—promoting interprofessional learning and patient-centred approaches. J Interprof Care 2007;21:569–571. 22. Torsell L, Rushby E: Palliative care in the undergraduate curriculum: A medical student’s perspective. Palliat Med 2010;24:839–840. 23. MacLeod RD, Parkin C, Pullon S, Robertson G: Early clinical exposure to people who are dying: Learning to care at the end of life. Med Educ 2003;37:51–58.
Address correspondence to: Pauline E. Chiarelli, PhD School of Health Sciences The University of Newcastle Callaghan, New South Wales 2308 Australia E-mail: [email protected]
Introducing Palliative Care into Entry-Level Physical Therapy Education Pauline E. Chiarelli, PhD, Catherine Johnston, MAppSc, and Peter G. Osmotherly, MMedSci
Abstract
Background and Objective: There is a paucity of information related to teaching palliative care to entry-level physical therapy students. The aim of this study was to evaluate the impact of an undergraduate course in palliative care on the preparedness of entry-level physical therapy students to practice within the palliative care setting. Methods: Participants were all entry-level undergraduate students enrolled in the third year of a 4-year undergraduate degree. All students enrolled in the course, ‘‘Physiotherapy Through Lifestages’’ took part in the learning modules relating to the care of patients undergoing palliative care. A survey instrument was used in the study, a modified version of an existing unpublished written questionnaire previously used to evaluate palliative care education in other allied health professions. Results and Conclusions: Participation in the course resulted in an increase in self-rated knowledge and confidence for working in the palliative care setting for entry-level physical therapy students and is considered to provide a useful ongoing resource for the presentation of this topic material. Although the impact of the delivery of this education module may be considered successful in this regard, it would appear that some of the underlying attitudes and emotional responses to this area of physiotherapy practice were less easily influenced. Further research is required to understand the influences on emotional preparedness of students to undertake this area of study and practice and to determine the optimal stage of study for delivery of this content.
Introduction
P
hysical therapists are members of the interdisciplinary, holistic, and compassionate team of practitioners providing palliative or end-of-life care.1 The management aims of physical therapy for people undergoing palliative care in general relate to the maintenance of functional ability and independence and the provision of evidence-based interventions for symptom relief.2–5 Improved functional levels, independence, and quality of life have been demonstrated with physical therapy intervention.6 An understanding of a palliative approach to care is a core skill for clinicians and therefore content relating to palliative care would be expected to be included in all physical therapy entry-level programs. Challenging students’ misconceptions about palliative care is viewed as an important part of medical undergraduate education7 and should be seen as equally important for student physical therapists preparing for their role in the interdisciplinary management of people with lifelimiting illnesses.8 Although the management of people undergoing palliative care should be considered an essential
skill for practicing clinicians, the availability of physiotherapists with acknowledged expertise in this area is limited. This subsequently limits the pool of expertise available for undergraduate teaching in this area. A national scoping study exploring the inclusion of palliative care within curricula of Australian university health faculties found few allied health programs included palliative care concepts to any major degree, and there was little standardization in the content or the teaching methods of palliative care in physical therapy. Some institutions do not include teaching related to palliative care within their curricula at all.8 The inclusion of specific entry-level training relating to palliative care in various health care professions has been shown to increase student knowledge levels,9,10 improve student preparedness to work in the field,11 and enhance selfefficacy in palliative care.12 Other studies, however, suggest that palliative care teaching has little effect on students’ attitudes toward end-of-life care.13 The Palliative Care Curriculum for Undergraduates (PCC4U) is an initiative funded by the Australian Federal Department of Health and Ageing through the National Palliative Care
School of Health Sciences, The University of Newcastle, Callaghan, New South Wales, Australia. Accepted September 18, 2013.
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PALLIATIVE CARE IN PHYSICAL THERAPY EDUCATION Program. The PCC4U project promotes the inclusion of palliative care training in the undergraduate education of all health care professionals and aims to improve knowledge and skills in relation to caring for people with life-limiting illnesses including those receiving palliative care. The PCC4U course includes a series of case-based modules with associated questions, reflections, and links to further information. The development of a new academic subject focusing on physical therapy across the life stages provided an opportunity to include the PCC4U palliative care course within the curriculum at the University of Newcastle in Australia. There is a paucity of information related to teaching palliative care to entry-level physical therapy students and therefore the aim of this study was to evaluate the impact of the PCC4U course on the preparedness of entry-level physical therapy students to practice within the palliative care setting. Methods Survey instrument The survey instrument used in the study was a modified version of an existing unpublished written questionnaire previously used to evaluate palliative care education in other allied health professions (see online supplementary questionnaire at htpp://www.liebertonline.com). The questions in the existing unvalidated survey were reviewed and modified for their use in a physiotherapy context. The paper-based survey instrument was completed anonymously. Two versions of the survey instrument were developed: a ‘‘premodule’’ survey containing 40 questions and a ‘‘post-module’’ survey containing 47 questions. The content of both surveys was identical, with the addition to the ‘‘post’’ version of extra questions relating to specific evaluation of the palliative care course. Survey sections included: general demographics, knowledge of palliative care and the role of physical therapy, confidence in undertaking interactions associated with caring for people with life-limiting illnesses, emotional impact of caring for people with life-limiting illness, and evaluation of the learning resources and delivery process. The majority of response options were formatted as 5-point Likert scales. Participants Participants were all entry-level undergraduate students enrolled in the third year of a 4-year undergraduate degree. Students were enrolled in the academic course, ‘‘Physiotherapy Through Lifestages’’ at The University of Newcastle (n = 89). All students enrolled in the course were invited to participate; there were no exclusion criteria. Intervention All students enrolled in the course, ‘‘Physiotherapy Through Lifestages’’ took part in the learning modules relating to the care of patients undergoing palliative care. An initial review of the PCC4U resources was undertaken by academics and content deemed appropriate was delivered to the students as part of the palliative care academic content. The content of the PCC4U course is presented in Table 1. The course consists of four modules with each module containing multiple sections. All sections contain a number of different activities, all of which are completed by students undertaking the course. All sections are based around individual patient
153 case studies, which are presented using a DVD. Students are guided through the case study and associated activities and information. In all sections, students are required to complete stimulus content that is formatted as specific questions requiring answers. Students are also expected to make notes and complete reflective tasks for each section. The format of delivery was primarily online with an introductory face-to-face teaching session. Each student received a DVD and a structured process for working through and completing the activities associated with the resources. Content relating to palliative care was included within the final written examination for the subject. Data collection/study process The study had a pre-course and post-course design utilizing an anonymous written survey instrument. The survey was delivered either side of the intervention, being provision of the PCC4U course. Approval for this study was granted by the University of Newcastle Human Research Ethics Committee. Prior to the commencement of the palliative care course, the ‘‘pre-module’’ survey was distributed to the enrolled students. The survey was distributed and collected by an academic unrelated to the research project. Respondents were asked to either complete the survey in the allocated class time or to complete it at a later time and return it to a marked box for collection. The ‘‘post-module’’ survey was delivered after the completion of the PCC4U course to the same enrolled students during another class session. The process of completion of this survey was the same as for the ‘‘pre-module’’ survey. Both were completed anonymously but were coded for interpretation and follow-up of nonresponses. Responses could not be matched to individual participants. E-mail reminders were sent at 2 weeks after delivery of each survey. Return of the surveys was taken to indicate consent. Data analysis Analysis was only undertaken for completed surveys. Likert scale responses for each response were converted to numerical scores. A low score indicated a negative response and a high score indicated strong agreement. Paired Likert data were then analyzed using the methods proposed by Roberson et al.14 whereby a variable describing the direction magnitude of change for participants on each item was calculated by subtracting an individual’s pre-study score from their post-study score. Pre/post study module changes were then analyzed using the Sign test to evaluate the occurrence of any significant directional shift in individual responses. Demographic and change score variables were reported using descriptive statistics. Results Seventy-nine participants completed the ‘‘pre-module’’ survey and 63 of these returned the ‘‘post-module’’ survey, with response rates of 89% and 71%, respectively. Characteristics of participants are presented in Table 2. Participant self-ratings of their knowledge of caring for people with life-limiting conditions and the role of physical therapy in this setting all significantly improved following the delivery of the intervention, with median responses
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CHIARELLI ET AL. Table 1. Description of the PCC4U Course, Modules, and Sections
Module title Principles
Communication
Assessment
Section title
Content
Death and dying Caring The team Standards
The aims of this module are to help students develop an understanding of the social and personal experiences of people with life-limiting illnesses and their families.
Diagnosis Support Children Specific stresses Spirituality End of life Self-care
The aims of this module are to develop student skills in communicating with people with life-limiting illnesses and their families.
Illness trajectory Common symptoms Symptom management
The aims of this module are to help students develop knowledge and skills in order to identify the health needs of people with life-limiting illnesses and help develop an understanding of principles for managing common clinical problems in palliative care.
Module content includes: Core principles of palliative care Community and individual perceptions and beliefs about death and dying Care contexts and the role of the interdisciplinary team
Module content includes: Principles of communication when interacting with people with life-limiting illnesses and their families Sources of support (psychological, social, spiritual) for people with lifelimiting illnesses and their families How personal values and beliefs affect interactions with people with lifelimiting illnesses and their families
Module content includes: Epidemiological and clinical features of specific life-limiting illnesses Principles for assessing and managing common symptoms and health problems associated with life-limiting illnesses Optimization
Experiencing loss Goals of care Optimization Caregiving
The aims of this module are to help develop understanding of how to provide support for people with life-limiting illnesses and their families particularly issues of loss, goals of care, and the effect of caregiving. Module content includes: Emotional responses of people with life-limiting illnesses and their families Strategies for collaborative decision making on care goals Interventions to optimize physical, psychological, and social function for people with life-limiting illnesses and their families Effect of caregiving on families
increasing one scale increment from ‘‘low’’ to ‘‘moderate’’ (Table 3), each change being statistically significant ( p < 0.001). Median perception of the relevance of physical therapy to palliative care practice did not significantly alter among the participants following the intervention. Self-rating of confidence to undertake a variety of nominated interactions or strategies associated with caring for people with life-limiting illnesses improved for each item. The
Table 2. Characteristics of Survey Respondents Characteristic
Pre-course (n = 79)
Gender (n, %) Female 52 (66) Male 27 (34) Age (mean [SD]) 22.8 (4.7) Previous palliative care training Yes 16 (20) No 64 (80) SD, standard deviation.
Post-course (n = 63) 40 (63) 23 (37) 22.9 (4.9) 23 (37) 40 (63)
magnitude of change of the median score for each questionnaire item was one scale increment from ‘‘low’’ to ‘‘moderate,’’ with the direction of change being statistically significant for each item (Table 4). Many of the participants’ median self-ratings regarding their emotional preparedness for caring for patients with lifelimiting illnesses demonstrated a statistically significant directional change following the intervention (Table 5). Awareness of personal coping strategies to be used while working in a palliative care environment demonstrated a marked increase in student rating with the median score increasing two scale increments ( p < 0.001). Two items, however, remained unchanged: eagerness to work in a palliative care environment and comfort with discussing death and dying with patients. Discussion This is the first study to evaluate the impact of an academic course on entry-level physical therapy students’ preparedness for practice in palliative care in Australia. Following completion of the PCC4U course, students’ self-rated knowledge,
PALLIATIVE CARE IN PHYSICAL THERAPY EDUCATION
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Table 3. Participant Self-Rating of Their Knowledge of Palliative Care and the Role of Physical Therapy Pre-intervention N (%) Participant self-rating
None/not at all Low/poor Moderate
Current knowledge of 17 (21.5) 48 (60.8) caring for people with life-limiting conditions Level of understanding of 9 (11.4) 40 (50.6) the role of physical therapy in caring for people with life-limiting conditions 16 (20.3) 47 (59.5) Confidence caring for people with life-limiting conditions Relevance of palliative 1 (1.3) 2 (2.5) care to the practice of physical therapy
Post-intervention N (%) High
None/not at all Low/poor Moderate
High
P value for difference
13 (16.5)
1 (1.3)
1 (1.6)
8 (12.7) 52 (82.5)
2 (3.2)
p < 0.001
30 (38.0)
0 (0.0)
0 (0.0)
12 (19.1) 49 (77.8)
2 (3.3)
p < 0.001
15 (19.0)
1 (1.3)
1 (1.6)
22 (34.9) 36 (57.1)
4 (6.4)
p < 0.001
0 (0.0)
11 (17.5) 37 (58.7) 15 (23.8)
48 (60.8) 27 (34.2)
confidence, and emotional preparedness increased, indicating an increase in academic understanding and readiness; however, responses indicated that students continued to find this area of practice emotionally confronting. The findings of improvement in knowledge and attitudes regarding this area of
p = 0.054
clinical practice are consistent with those of Kumar et al.9 in evaluating their education intervention in Indian physiotherapy students. The response rate for physical therapy students completing both the before (89%) and after (71%) components of the
Table 4. Participant Self-Rating of Confidence in Their Ability to Undertake Aspects of Care for People with Life-Limiting Illness Pre-intervention N (%) Self-rated level of confidence Answering patients’ questions about what will happen to them during the dying process Supporting the patient or family member when they become upset Informing patients and family of support services available Knowing about different environmental options Responding to reports of pain from the patient Responding to reports of other symptoms from the patient Responding to patient reports of decreasing functional status Negotiating changing goals with the patient to correlate with his/her stage of illness Adapting care interventions to suit patients’ changing stage of illness
None/not at all Low/poor Moderate
Post-intervention N (%) High
None/not at all Low/poor Moderate
High
P value for difference
1 (1.3)
3 (4.8)
27 (42.9) 32 (50.8)
1 (1.3)
p < 0.001
11 (13.9) 41 (51.9) 24 (30.4) 3 (3.8)
2 (3.2)
20 (31.8) 37 (58.7)
4 (6.4)
p < 0.001
24 (30.4) 31 (39.2) 22 (27.9) 2 (2.5)
0 (0.0)
15 (23.8) 36 (57.1) 12 (19.1)
p < 0.001
18 (22.8) 32 (40.5) 27 (34.2) 1 (1.3)
0 (0.0)
10 (15.9) 42 (66.7) 11 (17.5)
p < 0.001
8 (10.1) 33 (41.8) 38 (48.1) 0 (0.0)
0 (0.0)
16 (25.4) 40 (63.5)
7 (11.9)
p = 0.001
12 (15.2) 39 (49.4) 27 (34.2) 1 (1.3)
0 (0.0)
20 (31.8) 39 (61.9)
4 (6.4)
p = 0.002
8 (10.1) 32 (40.5) 37 (46.8) 2 (2.5)
0 (0.0)
9 (14.3) 50 (79.4)
4 (6.4)
p < 0.001
8 (10.1) 49 (62.0) 19 (24.1) 3 (3.8)
0 (0.0)
15 (23.8) 43 (68.3)
5 (7.9)
p < 0.001
11 (13.9) 42 (56.2) 25 (31.7) 1 (1.3)
0 (0.0)
17 (27.0) 40 (63.5)
6 (9.5)
p < 0.001
33 (41.8) 42 (53.2)
3 (3.8)
I am not comfortable caring for a dying patient. I am not comfortable talking to families about death. Dying patients make me feel uneasy. I feel helpless when I have to care for patients with a life-limiting illness. Managing a patient with life-limiting illness traumatizes me. I don’t look forward to being the physical therapist of a patient with a life-limiting illness. When patients begin to discuss death, I feel uncomfortable. I do not like talking about death and dying with patients. I am aware of personal coping strategies I can use while working in palliative care.
Participant view 25 (31.7)
17 (21.5)
23 (29.1) 16 (20.3)
36 (45.6)
28 (35.4)
32 (40.5)
20 (25.3)
38 (48.7)
2 (2.5)
5 (6.3)
5 (6.3)
7 (8.9)
6 (7.6)
6 (7.6)
4 (5.1)
5 (6.4)
Disagree
6 (7.6)
Strongly disagree
19 (24.4)
28 (35.4)
18 (22.8)
27 (34.2)
25 (31.7)
28 (35.4)
22 (27.9)
29 (36.7)
31 (39.2)
Not sure
10 (12.8)
25 (31.7)
22 (27.9)
15 (19.0)
11 (13.9)
28 (3.4)
25 (31.7)
31 (39.2)
15 (19.0)
Agree
Pre-intervention N (%)
3 (3.9)
2 (2.5)
1 (1.3)
3 (3.8)
0 (0.0)
2 (2.5)
3 (3.8)
0 (0.0)
1 (1.3)
Strongly agree
3 (3.9)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (1.3)
0 (0.0)
1 (1.3)
Missing responses
1 (1.6)
3 (4.8)
3 (4.8)
3 (4.8)
7 (11.1)
1 (1.6)
6 (9.5)
2 (3.2)
3 (4.8)
Strongly disagree
10 (15.9)
27 (42.9)
26 (41.3)
28 (44.4)
33 (52.4)
34 (54.0)
26 (41.3)
26 (41.3)
29 (46.0)
Disagree
13 (20.6)
18 (28.6)
20 (31.8)
20 (31.8)
21 (33.3)
22 (34.9)
16 (25.4)
22 (34.9)
26 (41.3)
Not sure
34 (54.0)
15 (23.8)
14 (22.2)
12 (19.1)
2 (3.2)
6 (9.5)
15 (23.8)
12 (19.1)
5 (7.9)
Agree
Post-intervention N (%)
4 (6.4)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (1.6)
0 (0.0)
Strongly agree
1 (1.6)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
Missing responses
Table 5. Participant Self-Rating of Their Emotional Preparedness for Caring for People with Life-Limiting Illness
p < 0.001
p = 0.013
p = 0.592
p = 0.054
p = 0.018
p < 0.001
p = 0.003
p < 0.001
p = 0.035
P value for difference
156 CHIARELLI ET AL.
PALLIATIVE CARE IN PHYSICAL THERAPY EDUCATION survey is high in comparison with equivalent studies published evaluating the response of medical students to palliative care education packages. Evaluation of education modules by Auret and Starmer15 in Australian medical students achieved 28% follow-up. Similar surveys of medical undergraduates in the United Kingdom had rates that ranged from 35%9 to 65%.12 Physical therapists are integral members of the palliative care team with particular roles in symptom relief, education in energy conservation, and the optimization and maintenance of independent functioning for people with life-limiting illnesses.16,17 Palliative care education for entry-level physical therapy students should specifically highlight and focus on the roles and responsibilities of the physical therapist within the palliative care team. All members of the palliative care team require sound background knowledge and high-level interaction, communication, and practical management skills.8,10,12,18,19 Not only do professionals working within this field draw upon the technical elements of care within their scope of practice, but they must also integrate the spiritual, psychological, and counselling needs into their own care for people at the terminal stage of illness.1,4,20,21 Prior to completion of the PCC4U course students rated their knowledge, confidence, and emotional preparedness for practice in palliative care as low. This is not surprising given their age and likely minimal prior exposure to palliative care content or practical experience. Palliative care academic content for entry-level health professionals including physical therapists is often limited, and students frequently feel unprepared, lack confidence, and are often unwilling to enter practice in this area.13,21,22 Despite the recognition of the need for increased end-of-life education in undergraduate curricula for all health professionals,12,18 palliative care education has remained underrepresented in the curricula of allied health programs in Australia. In surveying university programs across Australia, Hegarty et al.8 noted that few allied health programs incorporated palliative health concepts to any major degree, with 38.5% of allied health courses failing to address palliative care at all. This is reinforced by the findings of Meredith,11 who reported that 54.2% of surveyed occupational therapists employed in palliative care in Australia and New Zealand had received no undergraduate education in palliative care. Following completion of the PCC4U course, student selfrated knowledge regarding palliative care and the role of physical therapy increased as did self-rated confidence in the ability to undertake interactions and interventions for people with life-limiting illnesses. The magnitude of change is consistent with the implementation of previous palliative care education packages for students in other health professions. Auret and Starmer15 measured the effectiveness of structured clinical instruction modules for Australian undergraduate medical students using Likert scales to assess self-rated knowledge and skills. Similar to our findings, self-rated assessment of knowledge and competence related to palliative care practice improved by one scale increment following completion of the series of modules. Mason and Ellershaw12 also demonstrated improvements in knowledge and communication and patient management skills following the introduction of an extended palliative medicine education program for undergraduate medical students in Britain. These students also reported improved confidence in their self-rated ability to meet the needs of the patient at the end-of-life stage
157 of care. Similar results have been obtained in implementing palliative care initiatives in nursing courses. Arber10 was able to demonstrate significant improvements of assessed knowledge using the Palliative Care Quiz for Nurses instrument in final-year undergraduate nurses following the introduction of a specific palliative care education module. The PCC4U course, although not specific for physical therapy students, appeared to achieve the broad aims of improving background knowledge and enhancing confidence for practice. Interestingly, completion of the PCC4U course failed to alter students’ perception of the relevance of palliative care to physical therapy practice. Students initially rated their perception of the relevance of palliative care to physical therapy practice as moderate and this did not change following the learning modules. Whether this is due to lack of specificity or inadequacy of the PCC4U resources, paucity of clinical practice exposure, or it is a function of particular characteristics of those students undertaking physical therapy study is unknown and requires further investigation. Not all of the students’ emotional responses to working in palliative care were changed following the learning modules. Practice as a health professional in palliative care may be confronting and emotionally challenging.23 Students rated their emotional preparedness for working in palliative care as low pre-module. Post-module, students remained apprehensive about undertaking practice in a health care setting requiring involvement with people with life-limiting illnesses. Students reported that they were particularly uncomfortable in entering discussion involving impending death and dying with patients and carers. Although academic learning modules are able to affect change in knowledge and confidence in employing discipline specific skills, attitudes and emotional responses may be less responsive to significant change with delivery of an educational package. External factors including upbringing, personal beliefs, and life experience are more likely to have a greater impact on emotional responses to dealing with death and dying, which are greatly influenced by personal experiences and individual perspectives.23 This is consistent with the findings of Lloyd-Williams and Dogra,13 who found little difference in the attitudes of preclinical medical students toward caring for dying patients following completion of a palliative care study unit. Possibly, a greater impact on emotional preparedness for practice in the area may be gained by gradual immersion in the clinical setting through specific palliative care placements. Moriarty and colleagues19 provide some preliminary evidence of the usefulness of this approach in a small-scale analysis of seven students undertaking a half-day palliative care attachment. Based upon journal analysis, the students in this study reportedly recognized a reduction in their apprehension in dealing with people in a palliative care hospice situation. The effect of further graded immersion in the clinical setting could form the basis of future research in this area. A limitation of this study is the reliance on self-reporting, particularly for measures of student knowledge. No summative measure of knowledge, for example response questions to a case vignette, was undertaken. There were also no measures of change in actual skill level in the practical environment. Corroboration of the students’ own assessment with objective measures of performance would improve the veracity of our findings. Additionally, an evaluation of the
158 survey instrument through a formal validation process would have improved the rigor of this study. In conclusion, participation in the PCC4U course resulted in an increase in self-rated knowledge and confidence for working in the palliative care setting for entry-level physical therapy students and is considered to provide a useful ongoing resource for the presentation of this topic material. Although the impact of the delivery of this education module may be considered successful in this regard, it would appear that some of the underlying attitudes and emotional responses to this area of physiotherapy practice were less easily influenced. Further research is required to understand the influences on emotional preparedness of students to undertake this area of study and practice and to determine the optimal stage of study for delivery of this content. Author Disclosure Statement No competing financial interests exist. References 1. Michel T: Do physiotherapists have a role in palliative care? Physiother Res Int 2001;6:v–vi. 2. Cobbe S, Nugent K, Real S, Slattery S, Lynch M: A profile of hospice-at-home physotherapy for community-dwelling palliative care patients. Int J Palliat Nurs 2013;19:39–45. 3. Goodhead A: Physiotherapy in palliative care: The interface between function and meaning. Eur J Palliat Care 2011;18:190–194. 4. Frost M: The role of physical, occupational and speech therapies in hospice: Patient empowerment. Am J Hosp Palliat Care 2001;18:397–402. 5. Kumar S, Jim A: Physical therapy in palliative care: From symptom control to quality of life. A critical review. Indian J Palliat Care 2010;16:138–146. 6. Laakso EL, McAuliffe AJ, Cantlay A: The impact of physiotherapy intervention on functional independence and quality of life on palliative patients. Cancer Forum 2003;27:15–20. 7. Arolker M, Barnes J, Gadoud A, Jones L, Johnson MJ: ‘‘They’ve got to learn’’: A qualitative study exploring the views of patients and staff regarding medical student teaching in a hospice. Palliat Med 2010;24:419–426. 8. Hegarty M, Currow D, Parker D, et al.: Palliative care in undergraduate curricula: results of a national scoping study. Focus Health Prof Educ 2010;12:97–109. 9. Kumar S, Jim A, Sisodia V: Effects of palliative care training on knowledge, attitudes, beliefs and exeriences among student physiotherapists: A preliminary quasi-experimental study. Indian J Palliat Care 2011;17:47–53. 10. Arbor A: Student nurses’ knowledge of palliative care: Evaluating an education module. Int J Palliat Nurs 2001;7:597–603.
CHIARELLI ET AL. 11. Meredith PJ: Has undergraduate education prepared occupational therapy students for possible practice in palliative care? Aust Occup Ther J 2010;57:224–232 12. Mason SR, Ellershaw JE: Undergraduate training in palliative care medicine: Is more necessarily better? Palliat Med 2010;24:306–309. 13. Lloyd-Williams M, Dogra N: Attitudes of preclinical medical students toward caring for chronically ill and dying patients: Does palliative care teaching make a difference? Postgrad Med J 2004;80: 31–34. 14. Roberson PK, Shema SJ, Mundform DJ, Holmes TM: Analysis of paired Likert data: How to evaluate change and preference questions. Fam Med 1995;27: 671–675. 15. Auret K, Starmer DL: Using structured clinical instruction modules (SCIM) in teaching palliative care to undergraduate medical students. J Cancer Educ 2010;23: 149–155. 16. Marcant D, Rapin C-H: Role of the physiotherapist in palliative care. J Pain Symptom Manage 1993;8:68–71. 17. Rashleigh L: Physiotherapy in palliative oncology. Aust J Physiother 1996;42:307–312. 18. Gibbins J, McCoubrie R, Maher J, Wee B, Forbes K: Recognizing that it is part and parcel of what they do: Teaching palliative care to medical students in the UK. Palliat Med 2010;24:299–305. 19. Moriarty H, McKinlay E, Tanne L: Early palliative care attachment—a transformative educational experience for medical students. Focus Health Prof Educ 2006;8:40–48. 20. Mackey KM, Sparling JW: Experiences of older women with cancer receiving hospice care: Significance for physical therapy. Phys Ther 2000;80:459–468. 21. Morris J, Leonard R: Physiotherapy students’ experiences of palliative care placements—promoting interprofessional learning and patient-centred approaches. J Interprof Care 2007;21:569–571. 22. Torsell L, Rushby E: Palliative care in the undergraduate curriculum: A medical student’s perspective. Palliat Med 2010;24:839–840. 23. MacLeod RD, Parkin C, Pullon S, Robertson G: Early clinical exposure to people who are dying: Learning to care at the end of life. Med Educ 2003;37:51–58.
Address correspondence to: Pauline E. Chiarelli, PhD School of Health Sciences The University of Newcastle Callaghan, New South Wales 2308 Australia E-mail: [email protected]
