Building Primary Palliative Care Capacity Through Education at a National Level: Pallium Canada and its LEAP Courses

Background
\nAll the palliative care needs of a population cannot be met by specialist palliative care clinicians and
\nteams alone. Both primary-level and specialist-level palliative care is needed, particularly if palliative
\ncare is to be provided to persons with cancer and non-cancer illnesses, and should be initiated early
\nin the illness journey. However, many healthcare providers who care for patients with serious
\nillnesses do not have the core competencies to provide a palliative care approach. Education,
\nincluding undergraduate, postgraduate and continuing professional development (CPD) of health
\ncare professionals in practice, therefore remains a key strategy to ensure access to palliative care.
\nPallium Canada (Pallium) is a non-profit organization that was founded in 2000 to build primary
\npalliative care capacity nationally across Canada. It has done this largely through its interprofessional
\nLearning Essential Approaches to Palliative Care (LEAP) courses which target providers across
\nprofessions and settings and aims to equip them with core palliative care competencies. LEAP Core is
\none of over 17 course versions and targets primary care providers.
\nGoals and Objectives
\nThe overall goal of my doctoral work was to gain in-depth knowledge and understanding of the
\ndevelopment and spread of continuing palliative care education programs (using Pallium Canada and
\nits LEAP Core course as case studies), to evaluate the impact of the LEAP courses at various levels,
\nand to identify evaluation and research priorities for Pallium moving forward.
\nI approached the work by establishing a series of questions –:
\nObjective 1: To what extent has Pallium Canada’s LEAP program spread across Canada and
\nwhat has facilitated and impeded that spread?
\nObjective 2: What curriculum development approach has evolved over the years, what are its
\nfeatures and why?
\nObjective 3: What are the instructional design approaches that facilitate spread of an
\ninterprofessional palliative care continuing professional development (CPD)
\ncourse at a national level, including interprofessional learning?
\nObjective 4: What is the learner experience of the different profession groups towards
\nPallium Canada’s LEAP courses?
\nObjective 5: Do LEAP Core learners implement what they have learned into their practice?
\nObjective 6: Do the LEAP Core courses change learners’ knowledge, attitudes and comfort
\nrelated to a palliative care approach?
\n5
\nObjective 7: What is the impact of LEAP courses on patients and the workplace?
\nObjective 8: How should Pallium Canada evaluate and study the LEAP program going into the
\nfuture?
\nMethods
\nA series of case studies (for objectives 1, 2 and 3), two studies (for objectives 4, 5, 6 and 7) and an
\nenvironmental scan (for objective 8) were undertaken to address these questions.
\nObjectives 4, 5 and 6 were addressed with a large analysis, using qualitative and quantitative
\nmethods, of data collected through pre- and post-course instruments that assessed learners’
\nknowledge (K), attitudes (A) and comfort (C) levels related to providing a palliative care approach
\n(2015-2017 Study). Learners completed a course evaluation (which included a survey that explored
\nvarious facets of the learning experience) immediately post-course and made commitment to change
\n(CTC) statements (four things they would change in their practices because of participating in the
\ncourse). Four months later they reviewed their commitments and reflected on the extent to which
\nthey had implemented them (4-month post-course CTC). All learners who had participated in a LEAP
\nCore course from 1 April 2015 to 31 March 2017 were eligible.
\nObjective 7 was addressed with a study of a project called INTEGRATE that included LEAP Core
\ntraining in four family medicine clinics in Ontario. It used mixed methods, including surveys and
\ninterviews, of clinic staff (including doctors and nurses and other professionals) and of patients to
\nassess impact. Four clinics with over 50 staff participated.
\nObjective 8’s environmental scan included input form national and international education and
\nevaluation experts, and a critical review of existing evaluation models, frameworks and approaches.
\nResults
\nThe case studies resulted in three papers. The first mapped out the spread of Pallium across the
\ncountry; 17 courses were delivered in the first 3 years in only 3 provinces, while in 2019 alone over
\n530 courses were delivered to over 10 000 health care professionals across the whole country;
\nnurses made up the majority of learners (about two thirds), followed by physicians (about a quarter)
\nand then other professionals). A number of factors were identified that have accelerated spread, as
\nwell as some that impeded it. The second paper described a unique curriculum development
\nframework that has evolved, includes rapid prototyping methods, and is able to support the
\ndevelopment and maintenance of multiple course versions at the same time. The third paper
\nidentified several instructional design polarities that educators need to navigate to develop short,
\ninterprofessional courses for large scale national deployment.
\nFor the 2015-2017 study, 3045 learners from across professions responded (65.7% response rate).
\nOver 79% to 97% of learners across professions found the courses relevant to their practices. Similar
\nrates were found across the other six questions. Differences were noted across the profession
\ngroups though with similar rates expressed by physicians and nurses as a profession group pair, and
\nby social workers and pharmacists separately. Analyses of the K, A and C surveys found significant
\nimprovements with medium to very large effect sizes across professions. The analysis of the CTC
\nrevealed many examples of learners implementing what they learned into practice.
\n6
\nIn the INTEGRATE study, healthcare providers found the LEAP course helped them to understand and
\nprovide a palliative care approach better and patients with palliative care needs were identified
\nearlier, experience more advance care planning and earlier, and were more often connected to
\nhome care services.
\nThe environmental scan identified emerging trends related to evaluation education programs. A
\nframework that evaluates both impact and implementation was developed, drawing largely on the
\nConsolidated Framework for Implementation Research and Kirkpatrick’s New World Model.
\nConclusions
\nPallium Canada and its LEAP program has seen significant spread across Canada. Room for
\nimprovement remains. There is evidence that the course not only improves knowledge, attitudes and
\ncomfort related to providing a palliative care approach, but what is learned is being implemented
\ninto practice with benefits for patients, colleagues, the clinics and learners themselves.

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