Views of general practitioners on end-of-life care learning preferences: a systematic review

Aim of the review

The aim of this systematic review was to explore, synthesise, and analyse the views of GPs on end-of-life care learning preferences.

Review question

What are the views of GPs on end-of-life care educational needs and learning preferences?

The end-of-life care learning preferences of GPs were reviewed using the Population, Phenomenon of Interest, and Context (PICo) framework [21]. The population studied was GP, the phenomenon of interest was views on learning preferences and the context was end-of-life care.

The philosophical paradigm and theoretical framework of research

Constructivist grounded theory was the philosophical paradigm underpinning this review that explored the GP’s experiential views, their actions and interactions, and the implicit meanings attributed to their learning preferences [22]. Social constructivist learning theory was applied to understand how individuals construct knowledge in a social context [8,9,10,11,12]. It is built on three premises: cognitive processing of knowledge, self-directed learning, and social construction of knowledge.

Review design

A scoping search was conducted to determine the breadth of the evidence available on the phenomenon explored. The search showed a heterogeneous mixture of quantitative and qualitative studies. Popay’s narrative synthesis method enables synthesis of the data from a mixed typology of studies into themes [23]. Moreover, it allows using a theoretical framework for the interpretation of review findings and provides flexibility in choosing the methods within each step of the synthesis relevant to the review.

Search strategy

The review question was divided into search concepts, which were further used to conduct an initial scoping review. Scoping review helped derive key search terms relevant to each concept of the review questions. The search identified three papers to test the sensitivity of the search [24,25,26]. The search terms identified from these studies were further expanded into thesaurus terms and free text terms [27]. A search was conducted using electronic databases (MEDLINE, EMBASE, CINAHL, and PsychINFO) to identify articles published in English between 01/01/1990 and 31/05/2021 (Additional file 1), as the first article on palliative care was published in MEDLINE in 1993 [28]. The search was conducted using thesaurus and free-text terms specific to the database, and the terms were combined using Boolean operators [27]. Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts. A list of 12 journals was hand searched for additional citations (Additional file 2). The bibliographies of the full-text articles were screened using the Google Scholar database for any new articles that could be added.

Study eligibility

Selection criteria of studies included is provided Table 1.

Table 1 Selection Criteria of the Studies included in the reviewAssessing methodological rigor of the studies included in the review

As the review included a mixture of qualitative and survey studies, Hawker’s tool was used to assess its methodological rigour [29]. There are a growing number of palliative care systematic reviews that have used this tool [30,31,32]. Hawker’s tool allows systematic appraisal of the study by analysing the title and abstract, introduction and objectives, method and data, sampling, data analysis, ethical aspects, results, transferability/generalizability, and implications of the study [29]. These criteria were scored between 1 and 4 (1 = very poor and 4 = good). A score of 9 was considered a minimum score and a score of 36 as a maximum (Additional file 3) [29]. Although Hawker does not mention a cut-off score, based on the previous studies [31, 33], a cut-off was set at 19. Three studies were excluded from the review as they had a score of less than 19 [34,35,36]. The minimum score of the studies included in the review was 19 and the maximum score was 32. Furthermore, the studies were classified into the following grades: “high quality” (A), 30–36 points; “medium quality” (B), 24–29 points; and + "low quality” (C), 19–23 points [37]. Six studies were of high quality [24,25,26, 38,39,40], ten studies were of medium quality [41,42,43,44,45,46,47,48,49,50] and seven studies were of poor quality [51,52,53,54,55,56,57].

Data extraction

Screening, quality appraisal, and data extraction were conducted independently by two reviewers. The third reviewer helped resolve the conflicts. The initial section of the data extraction sheet had information regarding the country and year of publication. The second section focused on the type of study, that is, survey, qualitative, or mixed-method. In this section, study objectives, population, and study setting were also described. The study sample, participants, inclusion and exclusion criteria, research design, and methods were elucidated in the third section. The fourth section provided information on the study findings and conclusions.

Data synthesis

The review findings were synthesised using Popay’s narrative synthesis [23]. The first step of the narrative synthesis is to identify a theoretical framework, and social constructivist learning theory was used to interpret the findings of the review [9]. It was followed by developing a preliminary synthesis that involved a brief description of the studies in the review. The data gathered was classified into countries, the year of publication, type of population, and the factors involved in constructing knowledge. The words and texts extracted helped the reviewers familiarise with the study findings before analysis. Patterns were identified from the preliminary synthesis, and the reviewers explored the relationships within and between studies in order to generate meaningful categories and themes. The reviewers were mindful of gleaning the similarities and differences in the data generated. The fourth step was to assess the robustness of the synthesis. To ensure this, the reviewers critically reflected on the synthesis process and identified possible sources of bias [23].

Data analysis using social constructivist learning theory

Social constructivist learning theory explicates that knowledge is constructed through social interaction. Thus, using this theory, researcher will interpret the following using social constructivism theory: value that general practitioners attribute to End-of-life care learning and factors that facilitate and impede learning. Social constructivism asserts that learning is an inherently social process rather than a mere acquisition and assimilation of facts and figures, thus helping interpret various styles that GPs adopt in learning end-of-life care.

Review findingsOverview of the studies

Out of 10,037 articles identified from the database searches, 23 articles were included for synthesis (The PRISMA flow diagram-Fig. 1). Eleven studies were qualitative, eleven were surveys, and one was a mixed-method study. Fifteen studies were from Europe (eight from the United Kingdom, two from Belgium, and one each from Denmark, the Netherlands, Austria, Germany, and Ireland), six from Australia, and two from Canada. The qualitative studies were single centric and quantitative studies were combination of single centric and multicentric studies (Table 2). Two studies included combination of GPs and paediatricians involved in general practice [43, 49]. In United Kingdom, Europe, Australia and Canada, the health care system heavily relies on gatekeeping by GPs. The health care system provides universal coverage of health insurance and mandates gatekeeping by GPs in order for patients to access insurance facility. In some countries such as Canada, specialists receive less payment for non-GP referred patients. This could perhaps justify the reason for these countries to have studies on end-of-life care provision by GPs ([58], https://www.commonwealthfund.org/sites/default/files/2020-12/International_Profiles_of_Health_Care_Systems_Dec2020.pdf).

Fig. 1figure 1Table 2 Overview of the Studies included in the Systematic ReviewReview themes

Five themes were generated in the review. These themes were: motivation for end-of-life care learning, end-of-life care learning needs, preference for a learning style, perceived facilitators of learning, and perceived barriers to learning. Refer to Additional files 4 and 5 for the table narrating the themes and thematic diagram.

Theme 1: Motivation for end-of-life care learning

Motivation is defined as an intrinsic trigger that allows for sustained goal-directed activity [59, 60]. Self-directed learning enhances the learner’s competence, and belongingness facilitates motivation [61, 62]. Perceptions of value addition, peer recognition, previous learning experiences, and individual goals all trigger learning [63]. The need to provide palliative care, self-actualisation needs, relevance to practice, sense of responsibility, and therapeutic bond motivated them to learn about end-of-life care.

GPs are internally motivated to enhance their capacity to alleviate the suffering of their patients on the pretext of achieving their self-actualization needs [39, 40, 44, 57]. Also, having a larger clientele of geriatric and sicker patients piqued their interest in end-of-life care learning [44, 46, 49, 51, 57]. Unmet self-actualisation needs included a desire to integrate palliative care into routine care [38, 48, 49, 56], a perceived need for self-transformation [48], coping with own bereavement [39], and a perceived inability to manage symptoms [40], all of which instilled a sense of powerlessness, helplessness, and emotional burden of caring [24, 38,39,40, 48] for which they needed a recourse [48].GPs accessed training only if the training [24, 41, 54] and the trainer’s skills were in alignment with their needs [54] and helped address complex end-of-life care needs [24, 26]. A therapeutic bond developed with their patients over a prolonged period of caring [47, 51, 53], at various stages of their illness [38, 39, 46, 47, 49], instilled a sense of responsibility towards their patients [25, 39,

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