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Palliative care access; Medical education; Palliative care education; Quality of life; Illness

Introduction

Palliative care is assuming greater significance in Austria, notably with the introduction of two pivotal laws in 2022. The Hospice and Palliative Fund Act (Hospiz- und Palliativfondsgesetz) establishes funding mechanisms nationwide and encourages Palliative Care through dedicated grants [1]. Additionally, the Dispositions of Dying Act (Sterbeverfügungsgesetz) now permits medically assisted suicide under specific circumstances. However, Hospiz Österreich and Österreichische Palliativgesellschaft, two Austrian organizations for Hospice and Palliative Care, emphasize that assisted suicide should not be the sole recourse for patients and their families at the end of life. Instead, comprehensive, high-quality access to palliative care is a fundamental requirement. Palliative care, as defined by the World Health Organization, aims to enhance the quality of life for patients and their families confronting life-threatening illnesses, addressing physical, psychosocial, and spiritual aspects. The ideal approach involves early integration of palliative care and an interprofessional team, enabling professionals from diverse backgrounds to collaborate in enhancing care [2]. The expansion of palliative care has been discussed at the national and international levels, with health professional education emerging as a central strategy. At the postgraduate level in Austria, specialization in palliative care has been available since 2017, and a variety of palliative care courses have been introduced in recent years. However, palliative care extends beyond specialized facilities, with approximately 10% of emergency admissions in Austria involving individuals with palliative needs. The demand for palliative care is escalating due to demographic shifts, such as increased cancer prevalence and an aging population.

Basic palliative care knowledge, skills, and attitudes should not be the exclusive purview of postgraduate and specialized physicians. International studies indicate that many young physicians feel illprepared for palliative care during their medical studies [3]. Palliative courses in undergraduate studies have proven to enhance students' competence and well-being when caring for patients with palliative care needs, leading to recommendations for the integration of palliative care into the undergraduate curriculum. The European Association for Palliative Care (EAPC) has also called for palliative care teaching in medical studies and developed curriculum guidelines. To further the expansion of palliative care in Austria, it is crucial to assess the current state of teaching, which has received limited investigation in the country [4,5]. In light of the recent legislative changes, this mixedmethods study, employing interviews and questionnaires, seeks to examine undergraduate palliative care education in Austrian medical schools for the first time.

Methods

This study employs a mixed-methods approach with an embedded concurrent design. Two data sets were collected simultaneously using different methods, with one serving as primary data and the other as secondary data. This approach combines the depth of qualitative data with the structured nature of quantitative data to provide a comprehensive understanding of the state of teaching.

Participants

For this study, eligible respondents are considered "experts" in undergraduate palliative care education in Austria. These individuals either have a direct role in palliative care teaching at an Austrian university, are responsible for it, or have an external overview of palliative care education in Austria. The primary qualitative data collection involved expert interviews, with careful consideration given to factors contributing to information power, including the broad study objective, a cross-case outcome analysis, high specificity through purposive sampling, theory-based study, and variable quality of dialogues. To ensure adequate information power, the aim was to interview two key persons per university and two to three external key persons. The secondary data, quantitative in nature, was collected through a closed web questionnaire. To ensure representativeness and maintain participants' anonymity, one participant per university was invited to complete the questionnaire, with the best-informed key person in palliative care teaching being the preferred choice. To identify key persons at universities and external experts, the Austrian association Hospiz Österreich played a crucial role [6 ]. The recruitment process aimed to minimize contact and prevent drop-outs by simultaneously recruiting participants for both interviews and questionnaires.

Primary data-qualitative interviews: Qualitative data was collected through semi-structured expert interviews, guided by an interview guide with open-ended questions. The guide was developed based on a similar study in China and adapted for the Austrian context [7 ,8]. The interviews were conducted via the Zoom platform due to the COVID-19 pandemic, allowing flexibility in scheduling and ensuring high-quality audio-visual recordings. Field notes were taken after each interview, recording details of the setting, atmosphere, emotional aspects, and interview performance. The interviews were conducted in German, the native language of the interviewer and all participants. The interviewer had no prior relationship with the participants, and they were provided with a cover letter and an informed consent form before the interviews. The interviewer's background and the study's purpose, methodology, data protection requirements, and intent to publish results were communicated to the participants.

Secondary data-quantitative questionnaire: The quantitative component of this study involved a closed questionnaire that was accessible to a selected sample. Invitations to complete the questionnaire were sent via email to the presumed best-informed key person at each university. Participants were provided with the opportunity to review the questionnaire in advance [9]. The questionnaire, adapted for the Austrian context, was developed based on prior studies from other countries and contained 29 questions covering aspects of palliative care teaching infrastructure, organization, content, formats, examination criteria, and formats at the respective universities. The questionnaire primarily featured multiple-choice or dichotomous selection questions, with some including open text fields for additional comments. The online survey was administered using the free research tool, SoSci Survey. To streamline the questionnaire and reduce its length, adaptive questioning was utilized. More detailed questions appeared based on prior responses, ensuring relevant queries were asked. The online survey comprised between one and four items per page across seven to 17 pages, with the order of items following a fixed sequence. The questionnaire underwent technical functionality testing, a pre-test, and multiple checks in line with the cherries checklist, the standard for reporting online surveys [10]. To prevent multiple submissions from the same university, personalized links were provided to participants via email, ensuring a one-time completion. Informed consent was obtained from respondents at the beginning of the questionnaire, and participants could review, modify their answers, and pause and resume the questionnaire.

Analysis: The analysis of interview data was performed using MAXQDA 2022 Analytics Pro software. The corresponding author transcribed the interviews, and initial codes, representing the smallest functional units of the transcripts, were generated inductively, based on the available data. These codes were then categorized into themes and sub-themes, with this process repeated iteratively. The thematic analysis identified ten main themes in a contextualist manner, considering both the content and the broader social context [11]. The transcripts were pseudonymized for thematic analysis and further anonymized for this article and future archiving. The questionnaires, collected and anonymized using the SoSci Survey tool, were analyzed descriptively and statistically in Excel by the corresponding author. A subset of questions was selected for this paper based on their informativeness and relevance. Some questions, such as the duration of palliative care teaching at the respective university, were excluded as they were closely linked to the age of the medical faculty and could not be independently assessed. Additionally, certain questions were omitted to protect participant anonymity and due to low response rates.

Integration of qualitative and quantitative results: In this mixedmethods study with an embedded concurrent design, qualitative and quantitative data were collected concurrently. A concurrent approach was chosen to minimize participant contact and obtain complementary information in a timely manner. After separate analysis, the research findings from both methods were integrated and discussed together. Such comparisons may reveal contradictions and provide complementary insights [12-15]. To present the data, quantitative and qualitative results for each topic were combined, enhancing the breadth and depth of information. The outline of this paper follows a selected subset of the questionnaire, with additional insights from interviews included for each item. Themes identified in the interviews, such as influencing factors, barriers, and opportunities, were not elaborated in this paper but are reserved for future publication. The collected data from the questionnaire and interview statements were translated into English for this article. Additionally, language in citations was standardized for clarity. A supplementary table with original language quotes is available upon reasonable request. Reporting adheres to the standards for reporting qualitative research (SRQR) and consolidated criteria for reporting qualitative research (COREQ) guidelines.

Results

A total of 22 out of the 26 invited key persons took part in the study. Among these participants, seven engaged in both the interview and the questionnaire, one exclusively completed the questionnaire, and fourteen solely participated in the interview. The questionnaire received responses from eight university representatives, representing a 100% response rate. Out of these participants, seven identified themselves as physicians with advanced training or specialization in palliative care, while one was a member of the university's business administration department. In total, twenty-one interviews were conducted, with each interview lasting between 24 to 45 minutes. Alongside the four external experts, one to three key persons from each university contributed to the interviews.

Discussion

This study represents the first comprehensive investigation of palliative care in the undergraduate medical curriculum in Austria. Currently, palliative care is offered at seven universities, with plans to introduce a palliative care curriculum at one more in 2023. However, significant disparities were identified in terms of the number of teaching hours, organizational structures, and teaching formats. Palliative care education in Austrian medical schools lacks standardized regulation and falls short of meeting the minimum standards recommended by the European Association for Palliative Care (EAPC) guidelines. The study reveals that there is a need for more coordinated efforts and countrywide collaboration to enhance the quality of palliative care education.

Part of the challenge may be that many perceive palliative care as terminal care primarily provided in hospices rather than at university clinics. The teaching of palliative care at Austrian universities displays notable heterogeneity. Universities offering mandatory palliative care instruction differ in the number of teaching units, ranging from two to 15 units of 45 minutes each. These hours are significantly below the recommended 40 teaching units outlined in the 2013 EAPC curriculum or the 72 hours of training proposed by the EDUPALL project. It's worth noting that this situation is not uncommon when compared to other European countries, as data from the EAPC Atlas 2019 indicates. Out of the 51 countries surveyed, only five countries had more than half of their universities offering over 20 hours of palliative care education, with 35 countries having no university teaching more than 20 hours of palliative care. The literature and interviews in our study, as well as the EAPC Recommendations, emphasize the importance of not overburdening the medical curriculum with palliative care content. Instead, horizontal integration is recommended, allowing students to encounter palliative care concepts in various subjects without overwhelming the medical curriculum. The EAPC Recommendations highlight specific categories for teaching content in palliative care education, including the fundamentals of palliative care, pain and symptom management, psychosocial and spiritual aspects, ethical and legal considerations, communication, and teamwork and self-reflection. The weightage given to each category varied across universities and, in some cases, deviated significantly from the recommended distribution. Nonetheless, all six categories were covered in the curriculum of all universities.

A scoping review conducted in 2022 showed that previous research in Austria primarily focused on identifying universities where palliative care was a mandatory subject. According to the 2019 EAPC Atlas, palliative care was mandatory at seven out of seven medical faculties in Austria. However, our study identified eight medical faculties, and palliative care was mandatory at six universities at the time of the survey. This variation could be attributed to the timing and methodology of data collection. For instance, one university initiated a bachelor's degree in human medicine for the first time in the 2019/20 winter semester, a development not accounted for in the 2019 EAPC Atlas. Furthermore, the data collected from experts at each university for this study may provide more accurate and up-to-date information than data collected centrally for the EAPC Atlas. The study also identified three palliative care chairs in Austria, representing a slight increase from older sources. However, there is criticism that too few efforts have been made to establish such chairs. Ideally, universities should have palliative care chairs whose occupants can simultaneously oversee palliative care units and conduct palliative care research. While some suggest that having a "champion" for palliative care who is well-connected can compensate for the absence of a chair, the study's participants pointed out the challenges of sustaining palliative care education without the necessary structural support. Palliative care teaching is a unique task that necessitates accepting the diversity and individuality of each patient and caregiver, which may challenge the personal beliefs and values of both educators and students. Good clinical teachers are expected to organize learning, be knowledgeable in the field, be open to learning themselves, lead by example, and be genuine. Proper training, support, and time are required for teachers, and universities need to invest in their faculties to improve the situation. Palliative care in Austria is primarily taught through lectures, seminars, small-group courses, practical training, and bedside teaching. The combination of different teaching formats, especially active ones, is recommended to convey content in a more sustainable and practical manner, taking into account the diverse learning styles of students. Bedside teaching, while valuable, presents challenges and rules that need to be considered. When concerns about patient well-being exist, high-fidelity simulation is an alternative to real patient contact, as demonstrated in a study by Hawkins. Examination and assessment of palliative care were found to be limited in emphasis, although both Gibbins and the EAPC Recommendations stress the importance of assessment tools to reinforce learning. While some Austrian universities have implemented interesting concepts in interprofessional teaching, the overall perception is that very few courses are conducted in collaboration with multiple professional groups. Interprofessional teaching is highly recommended for palliative care in the EAPC Recommendations and other literature. Effective teaching in an illustrative and interactive manner is essential. Networking and consultation were recurring themes in the study, with participants expressing motivation to promote the expansion of undergraduate palliative care education. It is crucial to enhance communication and collaboration among key persons at different universities to facilitate mutual support and curriculum optimization. Despite potential limitations, such as inaccuracies in individual responses, the study's strength lies in its presentation of both qualitative and quantitative data, providing a comprehensive view of palliative care education in Austria. The high participation rate and comprehensive data collection methods enhance the representativeness of the findings. Additionally, the study's digital approach allowed for participant engagement despite the challenges posed by the COVID-19 pandemic, contributing to the positive atmosphere reported during the interviews.

Conclusion

A mandatory palliative care program is set to be introduced at all medical faculties in Austria in the coming years, with most universities already having established it at the time of the survey. While a few universities have appointed a dedicated chair for palliative care, several others have gained access to palliative care units. As of now, undergraduate palliative care education in Austria exhibits significant heterogeneity, particularly in terms of the number of mandatory teaching hours. While lectures are a common component of palliative care education across all universities, some institutions have adopted more active teaching formats like small-group courses and bedside teaching. The aspiration for interprofessional and interdisciplinary teaching is evident in many places, but its implementation varies. Enhanced coordination and networking, both within and between universities, would be instrumental in expanding and improving the quality of palliative care education.

Acknowledgement

Not applicable.

Conflict of Interest

Author declares no conflict of interest.

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