7 Interdisciplinary Education and Training

Katharine E. Brock, Jennifer Hwang, Marsha Joselow, Blyth Lord, Janet Duncan, and Deborah A. Lafond

Interdisciplinary Education and Training

Language

In the literature, online collaboratives, curriculum repositories, evaluation tools, and fellowship training programs, two terms are used: “interdisciplinary” and “interprofessional.” These are often used interchangeably, with interdisciplinary the preferred convention for referring to two or more disciplines in pediatric palliative care, and interprofessional more common in education, evaluation methods, teamwork, and policy literature. For the purpose of this chapter, we will use the term “interdisciplinary” except when “interprofessional” is included as a formal title, policy, survey assessment tool, or direct quote.

Principles of Adult Education

Much of the day-to-day learning in the healthcare environment happens organically in the process of caring for children and their families. That said, it is valuable to think about the educational principles that can make this experience most successful, whether the learning environment is the ward, clinic, or classroom. The experiential learning of clinical training in all disciplines can be described through the work of David Kolb.^1,2

Kolb described a cycle in which a learner has an experience. The experience leads to reflection. The reflection leads to formulation of abstract concepts and congruent generalizations. These concepts and generalizations are then applied during a new situation which permits learners to test their new understanding. This testing in another clinical encounter is followed by another cycle of reflection, abstraction/generalization, and application which perpetuates the cycle.^1,2

Palliative care providers will recognize that this cycle plays out in their own clinical practice multiple times per day. Every patient we meet generates reflection on the part of a palliative care provider (e.g., Why is the patient’s pain refractory to opioids?). This leads to a formulation of concepts and generalizations (Perhaps the pain is a manifestation of non-physical factors?). In the next clinical encounter, this hypothesis leads to additional exploration which unveils additional information (i.e., the patient also has deep spiritual and psychological stressors).

Beyond recognizing the constant cycles of experiential learning in clinical training and practice, considerable work has been done over the past 30 years to characterize adult learning or andragogy. Initially described by Malcolm Knowles and adapted and refined by many others, adult learners are described as having six unique needs for learning.³

When learners seek out palliative care training, their justification often reveals Knowles’s principles of andragogy. They have had experiences or anticipate experiences in patients with refractory symptoms, complex communication, or care for patients with life-limiting illnesses which motivate them to seek additional knowledge and skills. There is no learner more motivated than practitioners who anticipate they will need knowledge they do not possess during their upcoming clinical shift. The just-in-time training provided by palliative care teams to primary teams every day reflects this reality. Similarly, learners who seek additional training through lectures, seminars, conferences, clinical rotations, or advanced fellowship typically come to these experiences with personal life experiences and motivations that define the lens through which they view palliative care education.

The World Health Organization (WHO) defines palliative care for children as “the active total care of the child’s body, mind and spirit, and also defines giving support to the family.”⁴ This charge to care for body, mind, spirit, and family, by definition, requires an interdisciplinary team. While multidisciplinary teams are created simply by putting health professionals with different professional backgrounds together to care for the same patient, interdisciplinary teams are defined by the collaboration over time of health professionals with different professional backgrounds to care for the patient (see Figure 7.1).⁵ Body, mind, spirit, and family are integrated in the patient and thus require the integrated and collaborative practice of an interdisciplinary team.

Team leadership is another place where multidisciplinary and interdisciplinary teams often differ. Multidisciplinary teams tend to have a single leader who gathers input from team members prior to making a decision. Interdisciplinary teams have more fluid leadership in which all members may lead the team in the care of specific children and their families based on the needs of the patient and the unique skills of each team member. Multidisciplinary teams have a clear “head of the table” whereas interdisciplinary teams sit at a round table where leadership may come from any team member and may even change between different members of the interdisciplinary team depending on the unique needs of the patient, family, and/or clinical situation.

Interdisciplinary team practice is a learned skill that has only recently gained attention in the education of medical professionals. Much of the focus has been on interdisciplinary education during training in recognition that these skills are easier to cultivate in novice learners. According to the WHO, interprofessional education (IPE) is an experience that “occurs when students from two or more professions learn about, from, and with each other” (see Figure 7.2).⁶

Experiential learning, either in simulated settings or direct patient care, is the primary element of interdisciplinary education. Thibault explains experiential learning as students entering a practice environment to gain understanding in how to work collaboratively in “real-life” situations. Thibault also highlighted that true interdisciplinary education “requires purposeful integration and collaboration among the disciplines.”⁷

Unique Dynamics of Pediatric Palliative Care

Pediatric palliative care (PPC) presents unique challenges in educating clinicians from different disciplines and varied levels of experience. Some of these unique dynamics to be considered include

• Death is not “normal” in pediatrics, as compared to the relative normalcy of expected death in adulthood, particularly in the geriatric population.

• Children have a wide variety of serious, often chronic, medical conditions that are amenable to integration of palliative care.^8,9 In the adult population, cancer and chronic cardiorespiratory illnesses are common entry points for palliative care.^10,11

• The trajectory of serious illness in pediatrics may be over years, while the average length of enrollment for adults in hospice is just 76.1 days.¹²

• PPC crosses developmental stages, from perinatal to young adults, contributing to challenges in assessment. Self-report measures for pain and nonpain symptoms often cannot be used or may not be appropriate.^10,11

• Pediatric care is often cure- or disease-directed, even when quality of life may be compromised. Children have increased use of medical technology, as compared to adults, often under the provision of concurrent care.¹³

• Parents or legal guardians serve as surrogate decision-makers for children under the legal age of majority or for those with developmental/cognitive delays.

• There is a lack of evidence-based pharmacokinetic and pharmacodynamic data in prescribing medications for the pediatric population.

• Pediatric patients often continue care by multiple medical specialties while enrolled with concurrent palliative care services, while adults most often receive their primary care from the hospice team once enrolled.

• As a child ages into young adulthood, transition of care from pediatric providers to adult providers may be challenging when adult providers lack expertise in childhood-related serious illnesses.

• There are substantially fewer trained pediatric home care, palliative care, and hospice clinicians as compared to those who care for the adult population.

When hospice and palliative medicine became an official medical subspecialty in 2006, a group of clinician-educators was asked to create a list of competency-based outcomes for fellowship training by the Accreditation Council of Graduate Medical Education (ACGME). These competencies were to inform the Next Accreditation System of the ACGME, which uses competency-based outcomes to assess trainees. These competencies did not take into account the unique needs of PPC and so a new list of pediatric competencies was developed based on the original competencies document (http://aahpm.org/competencies/ped-competencies).¹⁴

In 2014, the American Academy of Hospice and Palliative Medicine (AAHPM) brought together a group of hospice and palliative medicine (HPM) fellowship directors to create the Entrustable Professional Activities that define the work of a hospice and palliative care physician (http://aahpm.org/uploads/HPM_EPAs_Final_110315.pdf). Entrustable Professional Activities (EPAs) define the key tasks of a subspecialty and require a combination of knowledge, skills, and attitudes.¹⁵ This group went on to create Curricular Milestones to help program directors organize curriculum and create a standard for what should be taught as part of an HPM medical fellowship (http://aahpm.org/uploads/HPM_Curricular_Milestones.pdf).¹⁶ Both the EPAs and the Curricular Milestones were designed to address the comprehensive needs of both pediatric and adult hospice and palliative care patients across the life span. Finally, Reporting Milestones were created as a tool to provide semi-annual feedback to the ACGME about the developmental skill acquisition of fellows over the course of their fellowship.

Competencies, EPAs, and milestones all evolved from the ACGMEs transition to a competency-based model of accreditation. While the ACGME is specifically focused on postgraduate medical training, these documents still offer guidance for the nonphysician members of an interdisciplinary team. As previously described in this chapter, the day-to-day clinical roles of nurse practitioners and physicians often are very similar. This means that these documents can offer guidance in the training of advanced practice providers.

Team Interdisciplinary Education and Training

Clinicians in PPC must develop an exemplary individual toolkit of knowledge and skills in caring for pediatric patients with serious illness and their family, yet the highest quality of care is best provided by an interdisciplinary team to address all domains of suffering: physical, psychosocial, spiritual, and environmental. Education of interdisciplinary teams may take several approaches to foster the development of knowledge, attitudes, and skills in PPC. Formal education methods, such as didactic lectures, serve as a basis of knowledge acquisition. Simulation provides practice and adoption of skill-based learning. Mentoring serves as a path for attitude change. Use of these strategies is a catalyst for team interdisciplinary education and training.^17,18

Strategies

Knowledge

Team knowledge is often based on didactic learning in either in person or online education through programs such as the End-of-Life Nursing Education Curriculum–Pediatrics (ELNEC-PPC), Education in Palliative and End-of-Life Care–Pediatrics (EPEC-Peds), Palliative Care Education and Practice-Pediatric Track (PCEP-Peds), Pediatric Pain Master Class, concurrent and preconference sessions at the American Academy of Hospice and Palliative Medicine/Hospice and Palliative Care Nurses Association Annual Assembly (AAHPM/HPNA), the Center to Advance Palliative Care (CAPC) and the National Hospice and Palliative Care Organization (NHPCO), International Children’s Palliative Care Network (ICPCN), various state coalition webinars, and other local, regional, and national conferences (Table 7.1). Appropriate for individual learning, these offerings encourage team participation and cooperative group learning.

Skills

Simulation is the hallmark of skill-based learning and can be actualized as high- or low-fidelity simulation, role-play, prescribing exercises, and case-based discussion.^19,20 In addition, simulation can be used for ongoing learning, to maintain and improve competencies through quality improvement and break down barriers of departmental and discipline silos.²¹ Specifically in palliative care, interdisciplinary communication has been demonstrated to be positively impacted by simulation.^22,23 Simulation is described in more detail in the section, “Models of Training.”

Attitudes

Attitudes can be influenced by knowledge and skill-based learning, however, mentoring often serves as the catalyst for lasting adoption of attitude change and helps facilitate adaptive coping skills, potentially mitigating the emotional aspects of caring for children with serious illness. While this can be positive or negative adoption, engaging in nurturing teamwork can improve patient safety, communication, staff support, situational awareness, and leadership style, Team STEPPS, developed by the Agency for Health Care Quality (AHRQ) and the Department of Defense (DOD) (https://www.ahrq.gov/teamstepps/instructor/index.html), is an example of team-based learning and mentoring that has demonstrated impact on team attitudes.²⁴ Mentoring across disciplines embraces the interdisciplinary nature of palliative care, where clinicians are often faced with addressing physical, psychosocial, spiritual, and environmental aspects of suffering.²⁵ Engaging in interdisciplinary mentoring encourages collaboration and partnerships in care.²⁶

Models of Training

One size does not fill all teams. The purpose, dynamics, and structure of teams vary. Finding the training model that works best for each unique team, from novice to expert, is essential to success.^24,27 Utilizing an interdisciplinary team approach to learning provides opportunities for members to learn from one another and appreciate differing perspectives.^28,29 This section outlines several models of interdisciplinary training in PPC but is not all inclusive.

An Interdisciplinary Palliative Care Training Model: Tri-Discipline Approach

Training of future clinicians and leaders in the field of PPC should be offered in the model in which care is delivered. This model of training is exemplified in the Boston Children’s Hospital/Dana-Farber Cancer Institute Pediatric Advanced Care Team’s tri-discipline fellowship training program. Physicians, nurse practitioners, and social workers train side by side as PPC fellows in this unique learning experience.³⁰ Fellowship is 1 year, and fellows are each salaried with benefits.

Each clinician learner brings to the fellowship his or her own discipline-specific training and experience. By the end of the fellowship, the goal is that all clinicians will have gained core palliative care knowledge, begin to master interdisciplinary teamwork, and hone their skills in their unique disciplines to contribute fully to the caregiving team.

All fellows participate in core curriculum didactic training, both alone and with the adult palliative care fellows (physicians, nurse practitioners, and pharmacists). The core curriculum includes intensive training in communication, pain and symptom management, ethics, bereavement, and processing moral distress. Here, “moral distress” is defined as the cognitive-emotional dissonance that arises when one feels compelled to act against one’s moral requirements.³¹ As a result, pediatric fellows learn from each other and have the added value and perspective gained from their adult palliative care counterparts. The multiple perspectives of interdisciplinary learners and instructors contribute to the deep understanding of these didactic offerings.

The vast majority of training occurs in the clinical field under the guidance of highly skilled interdisciplinary clinicians who model best care and communication practices. Fellows move toward independent clinical work, ultimately leading rounds, new consults, and directing patient care under the watchful mentorship of experienced discipline-specific clinicians with feedback from the entire interdisciplinary team.

This fellowship aims to have learners leave with advanced practice training and clinical experience. The goal is to prepare fellow graduates to move on to independent clinical practice and program leadership and position them to become leaders in research and education. They also leave with a deep understanding and appreciation of the value of interdisciplinary care in caring for children with serious illnesses and their families.

Multidisciplinary Psychosocial Fellowship

While the core triad of a palliative care interdisciplinary team is a nurse, a physician, and a social worker, there are many other disciplines that deeply enrich the care provided. Psychosocial team members, which may include chaplains, child life specialists, psychologists, psychiatrists, and creative/expressive arts therapists, often provide extensive support to a patient and family before, during, and after death. While their contributions are invaluable, the ability for psychosocial providers to access advanced training with an interdisciplinary PPC team is rare. The Y.C. Ho/Helen & Michael Chiang Foundation has funded the Multidisciplinary Psychosocial Fellowship at the Children’s Hospital of Philadelphia and the social work fellowship at Boston Children’s Hospital/Dana-Farber Cancer Institute.

Social workers, chaplains, child life specialists, and creative/expressive arts therapists are all eligible to apply to this 1-year funded fellowship for one psychosocial provider. Formal supervision is provided by the whole psychosocial team, with added support from the team member who shares the primary discipline of the psychosocial fellow. Fellows participate in the care of inpatient, outpatient, and home hospice patients with a focus on psychosocial support provided in the home environment. The psychosocial fellow joins the medical fellowship cohort for didactics and support. Mentored educational scholarship, including presenting at palliative care grand rounds, is required in hopes of encouraging interdisciplinary teaching. This fellowship aims to have psychosocial providers develop skills and comfort in providing psychosocial support to patients, siblings, and their families as well as bereavement support for siblings and families after the child’s death.

Interdisciplinary education simulation enables learners of all levels and disciplines to gain an appreciation for one another’s role, improve teamwork, and perform hands-on skills.³² Students in interdisciplinary simulations experience cognitive and behavioral changes after learning about the core principles and concepts that contribute to other disciplines.³³

Simulated experiences prepare healthcare workers for clinical situations and contribute to safe and efficient care of patients.³⁴ While most interdisciplinary simulations have focused on acute events such as resuscitation, a growing number are using high-fidelity (highly realistic, often using actors) simulations in the palliative care field, including those focusing on spiritual assessments, discontinuation of life-sustaining technology, disclosure of death, and palliative care communication with interpreters.^{20,22,35,36,37,38,39,40,41,42} Interdisciplinary education occurs in two places: (1) during the simulation scenario, in the form of combining two or more disciplines (physician, nurse, social worker, interpreter, pharmacist, psychologist, or chaplain), and (2) during the debrief, which can also include actor/parent and clinician participation. Participants can portray their own discipline or another to better understand the unique challenges of others’ roles. TeamTalk, an interdisciplinary adaptation of VitalTalk, utilizes physicians, nurses, chaplains, and/or social workers and can be adapted to include interpreters, physical therapists, and other disciplines.³⁷

In its most advanced form, interdisciplinary education is built into the health education system itself, blending interdisciplinary teaching with a multidisciplinary audience of learners.^{39,42,43,44,45} The Institute for Professionalism and Ethical Practice (IPEP) conducts programs focusing on difficult conversations among clinicians, patients, and families.⁴⁶ IPEP, which has trained more than 6,000 individuals, uses a validated approach to hands-on learning, the Program to Enhance Relational & Communication Skills (PERCS). PERCS incorporates ethics and practice, simulation using skilled actors, and patient and family voices. Workshops bring together interdisciplinary participants including patients, family members, staff, and facilitators in a model that dissolves barriers and models team communication.^47,48,49 This model was adapted for busy hospital-based practices by moving sessions into the hospital.⁴⁹

Mededportal Interprofessional Education Collection

The Interprofessional Education Collaboration (IPEC) was founded in 2009, by representatives from medical, nursing, pharmacy, osteopathic medicine, dentistry, and public health.⁵⁰ Core competencies focus on four domains: values and ethics, roles and responsibilities, interprofessional communication, and teams and teamwork.⁵¹ IPEC partnered with MedEdPORTAL, the American Psychological Association, Physician Assistant Education Association and American Physical Therapy Association, to create the Interprofessional Education Collection.⁵² One palliative care example is “Incorporation of an Interprofessional Palliative Care-Ethics Experience Into a Required Critical Care Acting Internship.” The collection fosters the identification, development, and deployment of educational resources aimed at supporting the team-based care essential to training an interdisciplinary workforce.⁵² The collection creates a national repository of curriculum resources for interdisciplinary education.

Mock No Codes

Mock code training has been a standard in medical and nursing education since the 1990s and has improved survival outcomes.⁵³ Yet there is little training on how to respond to requests for code interventions when the clinical situation does not warrant intensive, life-sustaining interventions. Clinicians may have differing education on resuscitation in these complex scenarios, which may impact team cohesiveness and family education.⁵⁴ Nurses and respiratory therapists often report little to no education on do-not-resuscitate (DNR) orders.⁵⁵ While physicians and advanced practice nurses report some education, only 44% of medical students report retaining knowledge regarding DNR and advance care planning, with only 16% retaining knowledge of how to respond to religious and cultural issues surrounding death and dying.⁵⁶ In other studies, graduating pediatric residents reported not feeling adequately trained to fulfill the responsibilities associated with providing palliative and end-of-life care for children.^57,58

One method of addressing these complex issues is to consider “mock no-code” simulation. Similar to communication skill–based simulation training, this approach utilizes pediatric cases that illustrate how not intervening with intensive, life-sustaining interventions may be in the patient’s best interest to promote comfort and optimize quality of life given the advanced nature of the underlying serious illness. Utilizing skilled critical care and palliative care clinicians as facilitators aids bedside clinicians in addressing requests for resuscitation interventions in various simulated situations. Examples include but are not limited to

• When previously the family and/or patient stated their wishes to have a do not attempt resuscitation order in place

• The clinical situation no longer warrants intensive, life-sustaining interventions, as agreed upon by the primary and specialty teams involved

• Stopping ventilatory or circulatory support that is no longer clinically indicated

• Family members have conflicting goals of care

• Addressing religious and/or cultural norms

• Ethical situations that impact resuscitation

• Death pronouncement

Specialty PPC is a well-established model of care delivery; however, access to specialty PPC teams may be limited by geographic availably, hours of service, team members, and confusion with multiple medical teams involved in care and decision-making. The specialty PPC team is used for complex cases or refractory pain and symptom management. Primary PPC is defined as training bedside clinicians in the basic tenets of PPC. Primary PPC education and training improves access to care, mitigates symptom distress, and reduces moral distress for clinicians.^59,60 In addition to the models described in this chapter, one such model at Children’s National Hospital utilizes a 12-month education and mentorship program comprised of didactic interdisciplinary group learning, self-directed learning, mentoring, and unit-based quality improvement projects to address knowledge acquisition, changing the culture of PPC within the unit or organization, and skill-based workshops to improve attitudes and skills. This program has trained 271 interdisciplinary clinicians, in four cohorts, and has demonstrated significant increases (p <0.001) in self-reported confidence in introducing PPC, pain and symptom management, communication, end-of-life care, and accessing resources. In addition, nearly 100% of participants stated the training was valuable, and they have made significant changes in their own clinical practice to integrate palliative care earlier for children with advanced, serious illness. Self-reported moral distress decreased by 33% across all four cohorts. Findings have been sustained over 2 years to date.⁵⁹ This model has been replicated in several other healthcare systems across the United States with similar preliminary findings.

In this curriculum, the quality improvement projects and mentoring were key to changing culture and sustaining impact. Engaging participants in what matters most to them in their clinical work prompted change in policy and procedures in caring for children with serious illness and their families. One example is integrating PPC into a specialty neuro-oncology clinic, which increased early hospice referrals, demonstrated increase in advance care planning, and improved communication between specialty teams.⁶¹ Opportunities for rounding with the specialty PPC team also provided opportunities for interdisciplinary mentoring, while one-on-one or small-group mentoring by one or two PPC leaders provided opportunities for exploring moral distress and initiatives to promote resilience.⁶²

Hospice Team Education

There are few stand-alone PPC programs, most likely due to patient volumes. Although many adult hospices have pediatric specialty teams, their volume is often low, and, as a result, professionals may lack confidence in their care of children.^63,64,65 Several approaches for educating hospice providers may be helpful. Hospices may partner with local tertiary care pediatric centers, especially those with specialty PPC teams, to join in collaborative education programs.⁶⁶ The primary PPC program illustrated in the previous section includes community hospice partners in this education program. This has improved communication and collaboration across care settings. Shared interdisciplinary education programs improve understanding of roles, sharing of resources, and collaboration in care.

Other options for education for hospice providers include offering PPC training within their local hospice, such as ELNEC-PPC or EPEC-Peds, or inviting members from the local tertiary care center specialty PPC teams to present in-services and workshops. Given the limited staffing and not-for-profit nature of the financial structure of hospices, it may be difficult for hospice providers to be relieved of patient care duties to attend all-day or multiday conferences. Another option to address this issue includes self-directed or online learning curriculums for PPC. One such program is available through the California State University and offers online education toward a certificate in PPC for nurses and other interdisciplinary team members and includes a team education option.⁶⁷ Several other programs are in development, and ELNEC-PPC and EPEC-Pediatrics have online learning options that can be adapted for the hospice audience. AAHPM and HPNA also host pediatric webinar learning opportunities. The NHPCO and the CAPC have online pediatric learning opportunities. There are several state PPC coalitions that provide educational opportunities such as webinars and conferences. Other examples of educational resources are included in Table 7.1, although this is not an exhaustive list.

Project ECHO: “Moving Knowledge, Not People”

Project ECHO (Extension for Community Healthcare Outcomes) is a telementoring medical education program designed to disseminate knowledge and increase the capacity of local clinical teams to provide best practice care. Founded in 2003, at the University of New Mexico,⁶⁸ it is now an international program, serving more than 70,000 learners in 37+ countries and all 50 states.⁶⁹ Project ECHO uses video-conferencing and virtual clinics to allow specialist teams to mentor local community providers and staff. There is no direct patient care. Instead, a community of healthcare professionals share knowledge, experience, and best practices to work on specific clinical cases and future cases. The standardized ECHO clinic methodology includes an “interdisciplinary analysis of the case conducted in a participatory manner.”⁷⁰

Project ECHO is being used in more than 49 programs across 10 countries to foster exceptional palliative and hospice care.^70,71,72 Within pediatric palliative and hospice care, programs are located in Canada, Northern Ireland, Uruguay, India, and England.^72,73,74 Programs have included medical staff, nurses, students, healthcare attendants, social workers, chaplains, and administrative staff. ECHO Palliative Care programs have demonstrated improved nursing and staff confidence and self-efficacy.^75,76

Parents and Families as Teachers

Bereaved Parent Educators in Interdisciplinary Education

The experience was so formed, enhanced, and illuminated by the parents’ presence, generosity, input, and sharing. I was truly blessed by what they brought to our learning. I’m blown away and [as a physician] will never be or teach the same.⁷⁷

Related posts:

Quality in Pediatric Palliative Care Program Development The Language of Pediatric Palliative Care Practical Aspects of Palliative Care Communication Advanced Heart Disease Children’s Voices: The Experience of Patients and Their Siblings

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