What, how and from whom do health care professionals learn during collaboration in palliative home care: a cross-sectional study in primary palliative care

Palliative care is complex care. To address different needs of palliative patients and their families, interdisciplinary collaboration is advised [1]. When caring for terminally and chronically ill patients at home, collaborative practice results in higher satisfaction, fewer clinic visits, fewer symptoms and patients’ overall improved health [2]. Joining competencies of professionals from different disciplines in a well-organized home care team results in a more comprehensive and holistic approach [3]. Care coordination and interdisciplinary teamwork has been listed as one of the ten core competencies in palliative care [4],[5]. In primary care, general practitioners (GPs) often collaborate with specialized palliative home care teams (PHCTs), resulting in high quality palliative care [6],[7]. Besides improving patient care quality, working together offers learning opportunities where professionals learn with, from and about each other [8]-[11]. Knowledge and expertise is shared and professionals not only `learn from’ each other but also `teach’ each other in a reciprocal way: workplace learning (WPL). Many known definitions of WPL state the following aspects: mostly informal, embedded in daily practice, requires personal engagement, and knowledge is socially constructed [12]-[16]. Furthermore WPL is driven by actual learning needs, offers immediate possibility to put learning into practice, is a continuous and natural process which requires less or no planning, and (peer) mentors are readily available [9],[17]-[19]. Therefore WPL might be a valuable complement to current education and training for health care professionals as it seems to address knowledge gaps and skills required for patient care directly. Throughout undergraduate and graduate training, practice experience has proven to be of value and is generally accepted and promoted. The importance of inter-professional WPL during professionals’ careers is less clear. The literature provides no benchmark on how much and in what way professionals learn during inter-professional collaboration. Therefore, before promoting this way of learning, we need to further explore it, as it is currently unknown to what extent (how much and in what way) WPL occurs in primary palliative care (care for palliative patients in primary health care, i.e., by GPs and the primary health care team). This study aims to Explore the Learning Impact of Collaboration in Inter-professional health care Teams (ELICIT-study). We draw on existing standards (e.g., the European Association for Palliative Care curriculum suggestions for content) and theoretical frameworks (e.g., a typology of workplace learning activities) to decide on the selected variables. This will further be explained in the Methods section. This study seeks to fill the literature gap by answering the following research questions (RQ):

Since there is no well-designed mandatory undergraduate education in palliative care for medical students in Belgium and as the current offer of continuing medical education (CME) in palliative care shows to be insufficient, the exploration of complementary workplace learning merits attention [25]. Our study shows that GPs and PHCT nurses do learn during inter-professional collaboration, thereby confirming that working and learning are inseparable as found in the literature.

In answer to our first research question, both GPs and PHCT nurses learn more about patient related topics (physical and psychosocial) than non-patient related topics (e.g., teamwork, palliative care organization), although all topics are mentioned. This is in line with national surveys on quality of dying and the difficulties in controlling patients’ symptoms in the final stage of life, thereby identifying physicians’ learning needs on this [26]. GPs’ preferences towards palliative care education confirm the importance of dealing with patient related symptoms [27],[28]. However, other research identifies care coordination as a major learning need for GPs [29]. Our study participants do not mention teamwork and collaboration as something they learn through collaboration. This needs further attention as the current CME offer is equally insufficient on these two topics [25]. Communication as a means to optimize both teamwork and care coordination is an important learning need in some studies and might inspire communication trainers [30].

The second research question examines the way participants learned through collaboration. The most mentioned learning activities were `listening and observing’ and `discussion and reflection’. Both activities can be part of the daily collaboration between professionals and are therefore easy-to-use learning activities. Because these activities are part of the normal interactions between professionals, they might not be acknowledged as being learning activities. Our study shows that professionals, without specific training in WPL, are able to recognize these activities as learning strategies, when asked about it. Training professionals to be attentive toward these strategies might optimize the effectiveness of WPL. Other strategies, like `receiving feedback’ and `learning from mistakes’, are known to be effective educational strategies [31],[32]. It is regrettable that they are used less often. However, a high level of trust is required between team members to use practice mistakes as learning moments. A health care team with ever changing members, as often occurs in primary care, should make special efforts to accomplish this since `mutual performance monitoring’ is a core component to successful teamwork, leading to continuing improving quality in health care delivery [33],[34]. Receiving training in techniques of clinical incident analysis could be useful to stimulate health care professionals to adopt this way of learning and might also enhance team-functioning [35],[36].

In answering the third research question (who they learned from), both GPs and PHCT nurses state they learn most from the patient and his family. This sounds logical since palliative care is very much patient-centered and therefore problems and their solutions are patient-focused. Health care professionals but also educators (undergraduate as well as CME) should be aware of the learning aspect of communicating with patients. As our study shows family members to be a major learning source for professionals, we might regard them as part of the care team. Family members have a major caregiving task and as such have to collaborate with professional caregivers [37]. Making professionals and family members aware of the learning effect of collaboration, might stimulate the latter and provide extra satisfaction. A drawback of the predominant focus on patient-related topics might be that the acquired knowledge is tied up with patient details. Making knowledge transferable to other patient situations requires a de-contextualization of the knowledge which is not always easy [38]-[40]. GPs also learn from PHCT nurses. Being the experts, the nurses have an advisory role and GPs seem to learn from it. This confirms the results from previous focus-group research where GPs describe the collaboration as a teaching/learning interaction [41]. This is supported by literature, describing the newly qualified doctors’ informal learning from nurses. Our study shows that even experienced doctors (though not all of them and not always) acknowledge the nurses’ expertise and declare they learn from them [42].

In answer to the fourth research question, participants associate different types of learning activities and different persons to learn from, with the learning topic at stake. This indicates that participants are able to switch between different learning activities when needed and find expertise among different stakeholders. This makes sense since certain topics are more suited to certain ways of learning than others, e.g., learning to handle a syringe driver by observing a PHCT nurse versus learning about a patient’s fear through discussions with family members. Our study does not show how participants choose these learning activities and learning sources and whether their choice makes WPL effective or not.

The fifth and sixth research questions consider the amount of learning through collaboration. There is no significant difference between the amount of learning by GPs and by PHCT nurses, although the latter are considered to be the experts. Nurses mostly mention learning psychosocial issues from patients and their families. This might account for the high amount of learning they mention since the individual contextual characteristics of palliative patients require continuous attention and learning despite their general expertise in palliative care. Proxy criteria of high expertise, such as years of experience, age and previous education in palliative care, are not associated with the amount of learning. This can be explained in various ways. Positively we could state that even experienced professionals stay eager to learn and to gain new knowledge and expertise through collaboration, on a deeper level. Negatively we might presume that professionals forget what they have learned and need to `learn it again’ on the next occasion. A third hypothesis is that the science of palliative care is quickly evolving and requires continuous learning. Our study however does not allow us to draw conclusions on this. The low adjusted R² of 0.07 and 0.01 indicate that personal characteristics are not the major influencing variables explaining the amount of learning. The statistical significant effect of, e.g., gender must therefore be put in this perspective. It might be worthwhile exploring other variables (e.g. team dynamics and inter-professional relationships) for their influence on the amount and quality of workplace learning.

Conclusion: Both GPs and PHCT nurses state they learn a lot during collaboration in primary palliative care. Different learning activities are used and all caregivers, professional and non-professional (family members), share their expertise.

Practice implications: Identifying the content of WPL might help providers of training and education adapt their curriculum in an anticipatory way. Getting insight into the characteristics of WPL can inform future studies investigating the effectiveness of it. All health care professionals should be aware of this kind of learning and adopt the attitude of sharing expertise during collaboration.

Future research: The effect of workplace learning has to be objectively assessed by means of measuring competence of health care providers and quality of patient care.

PP conceived of the study, performed the data collection and analysis and drafted the manuscript. WP participated in the design of the study and performed the statistical analysis. JW participated in the design of the study and reviewed the initial drafts. AS was involved in questionnaire development and reviewed the initial drafts. BV participated in the design of the study and reviewed the initial drafts. MD conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.