End-of-Life Care Education as Blended Learning Approach for General Practitioners: a Scoping Review

General practitioners (GPs) are critical in providing primary palliative care in the community. Apprehensions about managing a dying person at home, difficulties in goals of care discussion, limited resources and lack of palliative care education often hinder end-of-life care provision in the community. This review focused on the end-of-life care training programs accessed by GPs and sought to understand if the training programs’ content and mode of delivery aligned with their preferred needs. MEDLINE, EMBASE, CINAHL, and PsycINFO were searched to identify articles published in English between 01 January 1990 and 30 September 2022. Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts. The reviewers screened the titles, abstracts, and full text to identify eligible studies and extracted textual data to analyse and generate themes. Out of 5532 citations initially accessed, 17 studies were included in the review. Six themes were generated: knowledge translation, skill development, a change in attitude, self-efficacy, satisfaction, and patient outcomes. The GPs’ end-of-life care knowledge, skills, attitude, self-efficacy, and patient outcomes were better when their training had a combination of small-group interactive workshops, trigger case-based reflective learning, mentor-facilitated experiential learning, web-based modules, and peer learning. The synthesis of review findings supports blended learning as a training approach for general the practitioners’ end-of-life care education as it facilitates learning and patient outcomes. Supplementary Information The online version contains supplementary material available at 10.1007/s13187-023-02358-w.


Introduction
Worldwide, over 56.8 million people need palliative care annually, and 76% reside in low-and middle-income countries (LMIC) [1].Palliative care needs, estimated using the prevalence of serious health-related suffering, are projected to increase by 87% in 2060 [2].However, it is challenging to know the number of people accessing palliative care due to a lack of national databases in most parts of the world [3].Home-based palliative care reduces hospital utilisation [4] and enhances the quality of life in patients with cancer [5] and heart failure [6] whilst improving patient and caregiver satisfaction [5,6].However, patients' preference for homebased care often depends on availability [5].General practitioners are critical to delivering primary palliative care in the community [7].They are well-positioned to ensure patient coordination and continuity of care at the end of their lives [7].Despite their role in end-of-life care, they lack confidence in managing pain and physical symptoms, addressing patients' and caregivers' psychological needs, conducting goals of care discussions, and facilitating advance care planning [8,9].These apprehensions may negatively influence end-of-life care provision in the community and mandate urgent evidence-based end-of-life care training [10,11].
Two systematic reviews have been published in 2006 and 2020 that focused on end-of-life care education for primary care physicians [12,13].The reviews included a mixed population of primary care physicians at various career trajectories, with a narrow focus on general practitioners providing end-of-life care in the community [12,13].It highlighted gaps in end-of-life care training, like goals of care discussion and advance care planning [9].However, past reviews have not addressed GPs' preferences for end-of-life care training, patient outcomes, and satisfaction.GPs will seek a training programme only if it aligns with their perceived value and is relevant to clinical practice [4].Furthermore, there is a need to explore the impact of end-of-life care training on patientreported outcomes, as it influences physician performance and improves adherence to recommended clinical practice guidelines [14].
The current review focused on scoping end-of-life care training programs for GPs, their learning preferences, and perceived outcomes.Furthermore, it also focused on the training programs' content and mode of delivery and whether it aligned with their preferred needs [10].

Review Question
What types of end-of-life care education programs are accessed by general practitioners, and how do they impact clinical practice outcomes?

Review Design
The review aimed to systematically synthesise and report the range of end-of-life care education programs accessed by general practitioners and their impact on clinical practice outcomes [15,16].A scoping review is conducted where there is a heterogeneous body of literature in an understudied field.Exploring them informs the breadth of published literature on the phenomenon explored [15,16].It also identifies gaps in the research and enables the identification of types and sources of evidence that inform practice, policy, and future research [15].The studies were reported using the PRISMA ScR checklist extension for scoping studies [17].The review adopted and combined the steps described by Arksey and O'Malley [16] for scoping reviews and the Levac et al. enhancements [18].The Levac et al. [18] enhancements included identifying the research question in conjunction with the purpose of the review and clearly defining the context, concept, and population studied.It helps identify relevant studies, including the justification for limiting the scope of the search.It also facilitates charting the data using descriptive analysis as an ongoing process and collating results [18].Moreover, the PAGER (patterns, advances, gaps, evidence for practice and research recommendations) framework was used as a reflective tool for analysing and reporting scoping reviews [19].It helped enhance the rigour of the scoping reviews by providing a framework for consistently presenting the findings [19].

Search Strategy
Databases like MEDLINE, EMBASE, CINAHL, and Psy-cINFO were searched to identify articles published in English between 01 January 1990 and 30 December 2022 (Supplementary File 1).Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts.The search was performed using a thesaurus and free-text terms specific to the database, and the terms were combined using Boolean operators [20].The bibliography of included studies was searched to identify additional relevant studies.

Inclusion and Exclusion Criteria
Studies were included in the review if they met the eligibility criteria outlined in Table 1.

Data Extraction and Analysis
Citations from database searches were exported to a reference manager, and duplicates were removed.The two reviewers (SA and NS) screened titles, abstracts, and full text to identify eligible studies.Reviewers discussed conflicts regarding the eligibility of studies for inclusion in the review with an independent review supervisor.A data extraction sheet was used to tabulate and summarise information.The data included author(s), year of publication, country of origin, study aim, study design and sample, population characteristics, educational intervention, content, mode of delivery, and key findings.

Knowledge Translation
Knowledge translation is an ongoing dynamic process that includes knowledge construction through social interaction, dissemination of information, and ethical application of this knowledge to improve the health and well-being of patients [42].It also aids in strengthening the healthcare system through the effective delivery of healthcare services [42].In the knowledge translation process, it is essential to consider the interrelationship between context, relevance, meaning, evidence, and cost [42].
Evidence from studies included in this review suggests that knowledge improvement was mainly determined using the pre-post-test questionnaire [22, 25-29, 31, 36], followed by the GP's self-perception of change in knowledge postintervention [21,25,37].Eleven studies explored the effect of end-of-life care training programs on knowledge enhancement.Training that included a combination of small-group interactive workshops, mentor-facilitated experiential learning, and reflective learning through trigger cases demonstrated significant improvement in the GPs' knowledge in the following domains: identification of patients with palliative care needs [27], pain [26,28,37] and symptom management [21,25,31], communication [36], advance care planning [22,25], bereavement care [35], and knowledge on local palliative care resources [25,29].Combining multiple learning methods and a longer training duration showed better education outcomes regarding gain in end-of-life care knowledge.

Skill Development
Skill is an individual's potential to coordinate the acquired knowledge into performance efficiently [43].The skilful transformation of knowledge into practice requires internal  [43].
Evidence from studies included in this review suggests that the GP's self-perception about change in skills postintervention was the most common assessment [21,23,25,37,39], followed by a pre-post-test questionnaire [22,[26][27][28]35].Fourteen studies explored the effect of educational intervention on skills acquired post-intervention.Training programs that included a combination of smallgroup interactive workshops, mentor-facilitated experiential learning, reflective learning through trigger cases, and learning through peer collaboration demonstrated significant improvement in the GPs' skills in identifying patients with palliative care needs [27], pain [25,26] and symptom management [21,26,36], advance care planning [39], bereavement care [35], interprofessional collaboration [25,27], and the use of a surprise question [23].Combining multiple learning methods and a longer training duration showed better education outcomes regarding the GPs' skill enhancement.

Change in Attitude
Attitude is a cultivated habit or a mental state of preparedness to act consistently towards a context or a situation [44].Attitudinal shifts and behavioural change can be complex and mediated by learners' age, years of experience, personal disposition, and organisational factors [44].Majority of the GPs were satisfied with the content of the sessions and mode of delivery, support received and applicability of training, and goals and measures to monitor the progress Physicians with greater than two-GP practice had highest satisfaction (p < 0.01) Women GPs rated the general impact of the EOL module on their practice, and their patients are higher than the men GPs perceived that the module helped bring changes in their practice and were more satisfied with their practice.This improved their patient care and also increased the knowledge of local resources.It improved their comfort in caring for EOL patients, improved collaborative work, and built trust and stronger relationship More experienced GPs gave lower objective ratings for the module At 3-6 months post-training: Although there was a significant rise in the GPs maintaining patient registry (from 7.9% at baseline to 65.9% at 3 months), but there was a drop by 13.5% at 6 months follow-up (p < 0.05) There was a significant rise in the number of GPs maintaining an action plan for the GPs from 28.3% at baseline to 68.9% at 3 months to 83.7% at 6 months (p < 0.001) There was a significant rise in the number of GPs accessing current palliative care guidelines from 61.7% at baseline to 88.8% at 3 months to 94.3% at 6 months (p < 0.001).There was, however, a decline in the collaborative work in the initial 3 months but did become more frequent during the follow-up period (p < .001)Although the frequency of home visits increased in the initial 3 months (p < 0.01), but there was no further rise at 6 months follow-up.physicians in two-GP practice conducted Confidence with EOL-related skills and knowledge There was a statistically significant (p < 0.001) improvement in the confidence of the physicians in identifying and initiating conversation on EOL with patient/family, support of patient/family in terminal event, goals of care discussion, collaborate with specialists/other teams, and support of family during bereavement phase   No differences between the intervention and control group in the number of contacts with the GP out-ofhours cooperative in that last three months, nor in the number of contacts a patient had with their own GP in the last month, hospitalisations in the last three months, dying at home, or dying in the hospital Identified patients had more contacts with their own GP in the last month of life (13.00versus 7.48).Also the location of death differed: the identified patients died at home more often (67 versus 45%) and less often in the hospital (14 versus 32%) A smaller percentage of the identified patients had had at least one hospitalisation in the last three months of their life as compared to the other patients (42 versus 61).The mean number of hospital admissions of identified patients was also lower (0.60 versus 0.89) The number of contacts that identified patients had with their own GP in the last month before death (p = 0.0006).They were less often hospitalized in the last three months of life (p = 0.0437), and died less often in the hospital (p = 0.0449).Although they also died more often at home, this difference was not statistically significant (p = 0.0572)  The ACA scale measures the extent to which the GP was available for and discussed important issues with the patient There was no significant reduction in the scales between groups noted The lower scores we found in both groups for one RPS and a few ACA items suggest that GPs might take more initiative to discuss the following end-of-life issues: unfinished business, prognosis and possible complications, the actual process of dying, including the preferred place of death, and end-of-life decisions The studies assessed attitude using a pre-post-test questionnaire [24,29,31] and the GP's self-perception [22,30].Training programs that ranged from 3 h to 1 year and that used a combination of small-group interactive workshops, reflective learning through trigger cases, a simulated learning environment, and self-learning demonstrated a significant improvement in the participants' attitudes towards interprofessional collaborative work [29], symptom management [24], pain [31], advance care planning [22], and coping with managing dying patients [24].

Self-Efficacy
Self-efficacy is the individual's ability to perform a task to accomplish desired goals [45].The belief in one's capability and the dynamic interplay between environmental and behavioural factors to achieve the task influence the choice of action, level of effort, and persistence, which have the potential to inform practices [45].
Findings from the studies included in this review suggest that the GPs' self-efficacy was assessed using a pre-posttest questionnaire [23,25,26,28,29,32,34,35,38,40] followed by the GPs' self-perceived confidence [22,27,31,37] and pre-post-test questionnaire [28,40].Fifteen studies investigated the effect of training programs on GPs' selfefficacy in delivering end-of-life care.Training programs that used a combination of small-group interactive workshops, simulated learning environments, learning through peer collaboration, and self-learning demonstrated significant improvement in self-efficacy in the following domains: nutritional intervention [31], pain [32,36] and symptom management [25,28,29,32,34], communication [32,38], fulfilling patients' desires to die at home [38], coping with managing dying patients [32], and ethics in end-of-life care [26].The duration of the intervention ranged from a minimum of 3 h to a maximum of 24 months.Combining multiple learning methods and a longer training duration showed better education outcomes regarding the GPs' self-efficacy.

Satisfaction
Satisfaction is an individual's subjective appraisal of the training program to evaluate if the training experience aligns with academic expectations [46].Many variables are associated with the subject's satisfaction, such as the value attributed to the context of the training programme, the relevance of the training to clinical practice, teaching strategies, the learning environment, and faculty expertise [46].
Data from the studies included in this review suggests that the GPs' self-perceived satisfaction was used to determine satisfaction with training [24,25,29,31,32].Five studies investigated the GPs' satisfaction with the educational intervention.There was wide variation in the duration of training programs, ranging from a minimum of 5 h to a maximum of 24 months.The GPs were satisfied with the training programs when they combined small-group interactive workshops, reflective learning through trigger cases, mentor-facilitated experiential learning, and regular followup and feedback [24,25,29,31,32].

Patient Outcomes
Patient-reported outcomes include multidimensional and subjective feedback grounded in the patients' perceptions, which are then objectively quantified [14].These capture patient feedback on symptom control, their feelings, the experience of the clinical journey, and the effects of prescribed treatment as a measure of quality care delivery [14].It will ensure a safer practice environment for patients and providers and improve patient safety [14].
Evidence from studies included in this review suggests patient outcomes were measured using a questionnairebased survey [30,36,41] and self-reported scales [27,35].Training programs that used a combination of small-group interactive workshops, reflective learning through trigger cases, and learning through peer collaboration reduced hospital utilisation at the end-of-life [34].The interventions also enabled GPs to fulfil the patient's desire to die at home at the end-of-life [27,30,34].Furthermore, combining interventions that included online training, self-learning, a smallgroup interactive workshop, and a simulated learning environment improved patient outcomes regarding the control of pain and psychological symptoms and enhanced the quality of life [34][35][36]41].These interventions also improved the discussion and documentation of advance care planning [39].Also, improving the GP's knowledge and skills in endof-life care enhanced patients' and caregivers' satisfaction [41].There was wide variation in the duration of the intervention, ranging from a minimum of 5 h to a maximum of 15 months; however, combining multiple learning methods and a longer training duration showed better education outcomes in terms of patient outcomes.

Discussion
Contemporary training programs are rapidly adopting blended learning modules [47].Blended learning uses a mix of instructional designs and delivery modes and combines traditional face-to-face, distance, and self-paced learning [47].It is the preferred mode of delivery due to the ease of delivery concerning time and pace [47].Face-to-face interaction helps reduce feelings of isolation and the likelihood of learners losing interest [47].The blended learning in the reviewed studies included small-group interactive workshops, reflective learning through trigger cases, mentor-facilitated experiential learning, mentored online training, and learning through peer collaboration.The blended learning in the reviewed studies demonstrated significant improvements in the GPs' knowledge, skills, attitude, and self-efficacy in delivering end-of-life care.These interventions also enabled GPs to alleviate the patients' physical and psychological symptoms, reduce hospital utilisation rates, fulfil the patients' desire to die at home at the end-of-life, mitigate caregiver anxiety, and enhance their satisfaction.
A recent systematic review explored the GP's preference for end-of-life care learning [10].It revealed that GPs preferred a multi-modal approach to learning, with self-learning, reflective, and experiential learning as the preferred styles [10].Their learning preferences varied with personal disposition, professional and organisational challenges, and their relationship with the specialist palliative care teams or GP colleagues experienced in end-of-life care [10].
The findings of our review corroborated the results of a study by Lennaerts-Kats et al., which showed that a blended-learning programme positively impacted knowledge acquisition and improved collaboration between primary care physicians and palliative care teams [48].Furthermore, elderly GPs, GPs with many years of clinical practice experience, GPs with a higher clientele of end-of-life care patients, and those involved in group practice were highly motivated to undergo training in end-of-life care and had a higher likelihood of attending the training programs [10,48].It could explain the significant improvement in knowledge and interprofessional collaboration with the palliative care teams after the training [48].Three other studies mirrored the findings in our review [49][50][51].The studies investigated the effect of digital and experiential learning and reflective learning on healthcare professionals' attitudes, self-efficacy, and skills [49,50].The interventions changed the healthcare professionals' attitudes towards end-of-life patients [49], mitigated their fear [49][50][51], improved their self-efficacy in managing difficult communication [49][50][51], and enhanced their skills in managing physical and psychological symptoms [51] and handling difficult communication [49,50].
Blended learning allows learners to flexibly utilise the tools according to their needs [47].The e-learning component enables learners to explore sensitive issues surrounding death and dying, reduces stigma or judgement, and increases accessibility to a larger group of healthcare professionals, especially for those accessing from rural and remote areas [52,53].The face-to-face interaction component allows learners to discuss issues with colleagues and course facilitators, adds depth to their understanding through a mutual exchange of views, feelings, and ideas and facilitates the legitimate integration of knowledge into practice [52,53].Despite training, GPs were apprehensive about using syringe drivers, discussions surrounding advance care planning, or resolving ethical dilemmas [26].Mentor-facilitated experiential learning, reflection on trigger cases, and learning through peer collaboration improved their self-efficacy and skills in managing the challenges mentioned above [54,55].Also, learning through peer collaboration on an ongoing basis resulted in the early initiation and proactive documentation of advance care planning [22,23,26,39].Learning through peer collaboration is also known to benefit GPs who have a solo practice, work in a resource-constrained setting, or work in remote or rural areas [23,26].Learning through peer collaboration can strengthen palliative care delivery as this exposes the learner to diverse clinical approach to caring for patients, thereby increasing their understanding of the critical role that each member in the team plays in providing palliative care [56,57].Training programs must be ongoing to drive behavioural change [23,26,48].Also, the learners must have the opportunity to receive regular follow-ups and feedback from mentors and GP champions [23,26,48].It will ensure knowledge and skill retention and continuous performance improvement [23,26,48].The follow-up that includes reflection on one's practice will enhance the knowledge, skill, and self-efficacy of the GPs and translates into better quality care [23,26,48].
A systematic review of training programs in end-oflife care showed that training had beneficial effects on  [26] physician-reported self-efficacy and attitude towards palliative care but had limited impact on their performance and patient outcomes [30,58].Patient-reported outcomes offer an evidence-based approach to detecting symptoms, which can provide critical information to healthcare professionals and improve healthcare delivery [59].The patient-reported outcome is the reporting of a patient's status that comes directly from the patient, without the interpretation of the patient's response by a healthcare professional [59].Integrating patient-reported outcomes in clinical practice acts as an aid to clinicians in monitoring patient symptoms, identifying unmet needs and concerns, and prioritising and tailoring the treatment to individual needs [60].Additionally, it can foster communication between healthcare professionals and patients, assist in discussions surrounding disease progression and end-of-life care, and facilitate optimal delivery of end-of-life care [60].Patient-reported outcomes trigger proactive identification of symptoms, improve the patient's physical function, reduce caregiver dependence, promote better symptom control, reduce emergency room visits and subsequent hospitalisations, improve patient satisfaction, and are cost-effective [34,59,60].

Limitations and Strengths
A few studies included in this review had a mixed population of general practitioners and nurses working in a community setting [28,36,37].It was challenging to disaggregate their views.Studies were restricted to training programs for end-of-life care in general practice.General practitioners trained in a hospital setting were excluded.Furthermore, the synthesis was limited to published endof-life care training programs.Although studies did mention the use of a combination of modes of training delivery, there was no rationale for using a particular approach.Also, the duration of the interventions varied, ranging from a minimum of 3 h to a maximum of 24 months.Concluding the effect of a particular combination of the mode of delivery and the duration of the training programs on outcome measures was difficult.
The strength of the scoping review is the use of a comprehensive search strategy based on a broad research question.The reviewers used a systematic method to conduct the study using a robust criteria-based selection of literature.Furthermore, the methodological rigour of the review was enhanced using the PAGER framework.

Implications for Policy and Research
Learners' preference for a particular learning style depends on their learning needs and varies with the learning environment [61].It may be essential for educators to conduct a pre-test evaluation that will explore the learner's knowledge, their learning needs, and their preferences for learning styles.It will help educators determine the learning objectives and design training programs based on the learners' preferences.
For training programs to bring discernible improvement in the GPs' performance, the programs must be conducted over an extended period.Furthermore, the programs must include regular contact sessions with palliative care specialists and have an in-built feedback and reflective learning mechanisms.Patient-reported outcomes are vital and are known to improve healthcare delivery [14,60].Future training programs and research must incorporate patient feedback about end-of-life care delivery by GPs as one of the outcome indicators, as there is very little information on the patients' confidence and satisfaction with GP intervention.

Conclusion
The review demonstrated that a blended-learning approach that combined small-group interactive workshops, reflective learning through trigger cases, mentor-facilitated experiential learning, mentored online training and learning through peer collaboration with regular follow-up post-training significantly improved the GPs' knowledge, skills, attitude, and self-efficacy in providing end-of-life care.The training programs also translated into better patient outcomes and patient and caregiver satisfaction.This review also contributed to new knowledge by exploring the effect of the training programme on patient-reported outcomes, as patient-reported outcomes contribute to quality healthcare delivery and enhance patient safety [60].

Fig.
Fig. 1 PRISMA SCR Flow Diagram for studies included in scoping review program included an interactive session with interprofessional team of 3-4 face-toface learning session (4 h each) interspersed with a 3-4-monthlong experiential learning with GP champion or regional leader Self-perceived satisfaction Perceived impact on practice EOL objective scale-practice change At 3 months of module learning:

Table 1
Eligibility criteria

Table 3
Details of training programsDomains assessed

Table 4
Impact of the training programs on outcomes Landers et al. (2022))

Table 4
(continued) + Change observed − No change seen * Statistically significant