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R E S E A R C H A R T I C L E Open Access
The required competencies of physicians
within palliative care from the perspectives
of multi-professional expert groups: a
qualitative study
Hanna-Leena Melender
1*
, Minna Hökkä
2
, Tiina Saarto
3,4
and Juho T. Lehto
5,6
Abstract
Background: Although statements on the competencies required from physicians working within palliative care
exist, these requirements have not been described within different levels of palliative care provision by multi-
professional workshops, comprising representatives from working life. Therefore, the aim of this study was to
describe the competencies required from physicians working within palliative care from the perspectives of multi-
professional groups of representatives from working life.
Methods: A qualitative approach, using a workshop method, was conducted, wherein the participating professionals
and representatives of patient organizations discussed the competencies that are required in palliative care, before
reaching and documenting a consensus. The data (n= 222) was collected at workshops held in different parts of
Finland and it was analyzed using a qualitative content analysis method.
Results: The description of the competencies required of every physician working within palliative care at the general
level included 13 main categories and 50 subcategories in total. ‘Competence in advanced care planning and decision-
making’was the main category which was obtained from the highest number of reduced expressions from the
original data (f= 125). Competence in social interactions was another strong main category (f = 107). In specialist level
data, six main categories with 22 subcategories in total were found. ‘Competence in complex symptom management’
was the main category which was obtained from the biggest number of reduced expressions (f = 46). A notable
association between general level and specialist level data was related to networking, since one of the general level
categories was ‘Competence in consultations and networking’(f = 34) and one of the specialist level categories was
‘Competence to offer consultative and educational support to other professionals’(f = 30). Moreover, part of the
specialist level results were subcategories which belonged to the main categories produced from the general level
data.
(Continued on next page)
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* Correspondence: hanna-leena.melender@vamk.fi
1
Department of Social and Health Care, VAMK University of Applied Sciences,
Wolffintie 27-31, 65200 Vaasa, Finland
Full list of author information is available at the end of the article
Melender et al. BMC Palliative Care (2020) 19:65
https://doi.org/10.1186/s12904-020-00566-5
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(Continued from previous page)
Conclusions: The competencies described in this study emphasize decision-making, social interactions and
networking. It is important to listen to the voices of the working-life representatives when planning curricula.
Moreover, the views of the working-life representatives inform how the competencies gained during their
education meet the challenges of the ordinary work.
Keywords: Palliative medicine, Palliative care, Professional competence, Clinical competence, Curriculum,
Education, Qualitative research
Background
About 20 million people worldwide are annually in need
of palliative care and this demand is increasing in Eur-
ope due to the ageing population and the high preva-
lence of noncommunicable diseases [1]. The Assembly
from the Council of Europe calls on Member States to
strengthen palliative-care services and to ensure the ad-
equate training of palliative care for health-care profes-
sionals [2,3].
Palliative care services can be categorized into a mini-
mum of two or three levels. They are named as the pallia-
tive care approach, general palliative care and specialist
palliative care [4,5]; or primary, secondary and tertiary
palliative care [6]. To provide quality palliative care,
health-care professionals of all levels should have suffi-
cient competencies in palliative care [7,8].
The concept of ‘competence in medicine’may be de-
fined as a holistic combination of the knowledge, skills,
values or attitudes required for the effective performance
of specified activities [9]. In the White Papers published
by the European Association for Palliative Care (EAPC),
important competencies for clinical practice in palliative
care are presented for all practitioners, with 10 core
interdisciplinary competencies [4,10]. The EAPC has
also presented recommendations for the development of
undergraduate curricula in palliative medicine at Euro-
pean medical schools, and many taskforces have con-
ducted surveys on the education in palliative medicine
for physicians in Europe [11]. In Ireland, the Palliative
Care Competence Framework was published in 2014 [5].
In a subsequent survey [12], mainly positive results were
found when assessing the knowledge, attitude and be-
havior of the key competencies of physicians. However,
there was also some variation in the scores.
In Finland, a national quality criterion complying with
the recommendations of the EAPC [7,8] defines that
within the specialized level of palliative care, the
personnel should have a special education of palliative
care and work as a multi-professional expert team, while
the undergraduate education for health care profes-
sionals should provide the ground level of competency
to work within the basic level of palliative care [13].
Health-care units providing a specialized level of pallia-
tive care include palliative care units in hospitals,
hospices and palliative home-care units (hospitals at
home). All other units, such as ‘ordinary’hospital wards
or nursing homes, provide a general level of palliative
care [14]. In this study, the expression ‘specialized level
competencies’refers to competencies needed when pro-
viding palliative care in specialized level units as defined
here. The expression ‘general level competence’refers to
competencies needed by all physicians when providing
basic palliative care, for example, at ‘ordinary’hospital
wards or nursing homes.
Education in palliative care varies in Finland. Out of the
five faculties of medicine, only two have a curriculum and
chair in palliative medicine. No postgraduate education in
palliative care for physicians is available at the universities,
although special competence in palliative medicine,
awarded by the Finnish Medical Association, has been
available since 2007. To meet these educational chal-
lenges, the EduPal project (Developing Palliative Nursing
and Medical Education through Multidisciplinary Cooper-
ation and Working-life Collaboration), funded by the
Ministry of Education and Culture in Finland, aims to de-
velop national recommendations for both undergraduate
and specialist (postgraduate) education in palliative medi-
cine, among other areas. As a part of the project, the re-
quired competencies of professionals working within
palliative care at the general and specialist levels, described
above in a Finnish context, were explored in multi-
professional workshops.
Methods
The aim of this study was to describe the required compe-
tencies of physicians working within different levels of pal-
liative care, from the perspectives of multi-professional
groups of representatives from working life.
The study is a descriptive qualitative research design
with written material provided by multi-professional
groups working in workshops arranged for the purpose
of the study.
Data collection and sample
The data was collected in workshops attended by a pur-
posive sample of professionals working within the field
of palliative care, in order to present a diversity of health
care organizations, as well as representatives of patient
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organizations (Table 1). To find the best informants,
managers were contacted and asked to propose the best
representatives of their personnel to describe the re-
quired competencies of professionals in palliative care.
Based on the managers’recommendations, an invitation
letter was sent to the persons proposed. The letter in-
cluded information about the purpose of the study pur-
pose, the reasons for the study and the persons
responsible for it.
A descriptive qualitative approach was adopted. No
particular disciplinary or methodological roots are
claimed. The intention is to simply present a compre-
hensive summary of the phenomenon of interest [15].
The features of the research group members are pre-
sented in Table 2.
The 21 workshops were organized by the teachers of
the participating universities of applied sciences (UAS)
and they took place either at the UASs or at the work-
places of the workshop members. Some workshops cov-
ered more than one working group (WG), because in
some cases, a general level group and a specialist level
group were invited to the same workshop. All in all, data
was obtained from 36 WGs in 21 workshops. The
teachers of the UASs acted as moderators. Of the re-
search team members, one (H-L.M.) acted as a moder-
ator in one workshop. The participants were informed
that all the moderators had an interest in developing
palliative care through the development of the profes-
sionals’education. The moderators did not establish any
relationship with the participants prior to commence-
ment of the study. In addition to the participants and
the moderators, no other persons were present in the
workshops.
The workshops started with a presentation about the
project and instructions for the workshop activities. The
WGs received a questionnaire which had been devel-
oped for the purposes of this project. This included 10
open-ended questions regarding the required competen-
cies of health care professionals and other aspects
concerning the development of palliative care. The ques-
tionnaire had been pre-tested among one WG. Based on
the pre-test, no changes had been made to the question-
naire and the pre-test data was included in the research
data. The workshop members worked through the ques-
tionnaire, discussing their views on the topics with the
other group members and documenting their answers,
mostly on paper and in some cases with a computer.
The moderators were available for the purpose of clarify-
ing any questions, but they did not participate in the dis-
cussions. However, they did observe the discussions and
made field notes. The duration of the workshops varied
between 2 and 4 h.
This paper reports on the findings of the data retrieved
from the following questions on the physicians’compe-
tencies in palliative care:
1. What are the required competencies of every
physician in palliative care at the general level?
2. What are the required competencies of a
specialized physician in palliative care at the
specialist level?
Data analysis
The original workshop data was transcribed verbatim
and placed into a matrix which was presented in a Word
document. In the analysis of the material, a qualitative
content analysis method [16] was used. The data analysis
was performed manually, i.e. using no software.
For the general level data, an inductive approach for
the analysis was used, meaning that the categories
emerged from the data and no theoretical framework
was used in the analysis [16]. In the analysis of the spe-
cialist level data, deductive and inductive approaches
fluctuated: the first part of this data was first analyzed
using a deductive approach, followed by an inductive
approach. The second part of the data was analyzed
inductively. (Table 3.)
Analysis of the general level data
The inductive content analysis of the general level data
was performed in three phases: reducing, clustering and
abstracting. Words, phrases, sentences or units of mean-
ing containing more than one sentence were used as
units of analysis. In the reduction phase, the coding of
the meaningful expressions was guided by the research
Table 1 Professionals who participated in workshops
Profession Number of
professionals
Physician on general level of palliative care 12
Physician on specialist level of palliative care 16
Registered nurse on general level of palliative
care
63
Registered nurse on specialist level of palliative
care
69
Licenced practical nurse on general level of
palliative care
25
Licenced practical nurse on specialist level of
palliative care
10
Expert of a third sector organization 7
Elderly care professional 1
Social worker 3
Physiotherapist 3
Nursing manager 9
Spiritual care professionals 4
Total 222
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question [16]. The material was read through and fol-
lowing questions were asked: “What are the required
competencies of every physician in palliative care at the
general level?”and “What are the required competencies
of a specialized physician in palliative care at the special-
ist level?”. The codes were such expressions which gave
answers to the questions. Coding was conducted manu-
ally in the matrix by coloring the codes. The codes were
also restored for the clustering phase by copying and
pasting them into a new cell of the matrix. An example
of the coding process is provided in Table 4.
In the clustering phase, the codes were grouped to-
gether based on the similarity of the content and then
finally, the clusters were abstracted. Abstracting meant
that the clusters were shaped into sub-categories and
main categories which were named based on their con-
tents [16] (Table 5). Only the manifest content was ana-
lyzed, which means that only “what had been written”
was analyzed and no interpretation about the latent in-
tentions of the participants, for example, was done [17].
The phases were not entirely separate [17], since already
during the reduction phase, clustering and abstracting
started to take shape. One researcher (H-L.M.) coded
and categorized the material. After that, two other mem-
bers of the research group (M.H. and J.L.) studied the
material and critically checked the analysis. The contents
of the categories were specified together [18]. The fre-
quencies (f) of the codes (reduced expressions) which
constituted each category were counted to show the
noteworthiness of the category in relation to the entirety.
The number of codes in total was 573 for the general
level data and 150 for the specialized level data; in both
cases the data was saturated. Saturation can be defined
as the point in coding where the researcher finds that no
new codes occur in the data. This can be seen as a point
where no new data would be needed [19]. In this study,
the entire data of the 36 WGs was collected before the
analysis started. During the analysis of the general level
data, saturation was noticed during the coding and sort-
ing of the codes of the WG 34 data when the same
codes started to appear in the data and no new codes
emerged to create any new categories in the subsequent
coding. For the specialized level data, a similar notifica-
tion of data saturation occurred during the coding and
sorting of the codes of the WG 33 data. However, a deci-
sion was made to analyze all the data and not close the
analysis at the saturation point, since we wanted to use
all the valuable material that the participating WG mem-
bers had provided in order to ensure that everyone’s
voices would be heard.
Analysis of the first part of the specialist level data
The specialist level data was reduced with the same
principles as the general level data described above. In a
deductive approach, a structured or unconstrained
matrix of analysis is operationalized based on previous
knowledge such as a model or theory [16]. The choice to
use this approach when analyzing the first part of the
Table 2 Features of the research team members
Author
(gender)
Credentials Occupation at the time of the
study
Education on qualitative research methods Experience on qualitative research
methods
H-L.M.
(female)
RNM, PhD, Docent
Principal Lecturer at a University of Applied
Science
Docent in a University
Formal Master and PhD level courses on
qualitative research methods
Has used qualitative methods in research
work earlier.
Has teaching and thesis supervisor
experience on qualitative research
methods.
M.H.
(female)
RN (Master), MNSc, PhD-student
Senior Lecturer and Project Manager at a
University of Applied Science
Formal Master and PhD level courses on
qualitative research methods
Has used qualitative methods in research
work earlier.
Has teaching and thesis supervisor
experience on qualitative research
methods.
T.S.
(female)
MD, PhD
Professor in a University and Chief Physician
in a University Hospital
Informal learning activities to embrace the
principles of qualitative research methods
Has used qualitative methods in research
work earlier.
Has thesis supervisor experience on
qualitative research methods.
J.L.
(male)
MD, PhD, Docent
Clinical teacher in a University and Chief
Physician in a University Hospital
Informal learning activities to embrace the
principles of qualitative research methods
Has used qualitative methods in research
work earlier.
Table 3 Approaches used in the analysis of different datasets
Data Approach
1. The general level data
(all)
Inductive approach: no theoretical
framework; the categories emerged from the
data (Table 5)
2.The specialist level
data (first part)
Deductive approach: the categorization of
the general level competencies was used as
a framework of the analysis (Table 6)
3.The specialist level
data (second part)
Inductive approach: no theoretical
framework; the categories emerged from the
data which did not fit into the framework of
the general level categorization (Table 6)
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specialist level data was based on the fact that many
WGs expressed in their answers that the specialist level
physicians should have all the same competencies as the
general level physicians, and moreover, under the same
main categories, they should have some advanced com-
petencies associated with the main categories. Based on
this, the categorization of the general level competencies
was used as a framework to build a structured matrix for
the analysis of the first part of the specialist level data.
At first, this data was coded for correspondence with the
general level main categories of the framework. After
that, only codes including new information, which was
unique to the specialist level, were chosen for further
analysis. Codes including information which had already
been found in the general level data were not chosen to
the specialist level categorization. The new codes were
then grouped together on the basis of the similarity of
the content and abstracted inductively into new sub-
categories which belonged to the main categories which
had already been created at the general level data ana-
lysis (Table 6).
Analysis of the second part of the specialist level data
The second part of the specialist level data consisted of
codes which were so unique for the specialist level phys-
ician work and differed so much from the general level
data that they did not fit into the framework of the gen-
eral level categorization. These codes were categorized
inductively in the same way as for the general level data,
by producing new main categories including relevant
sub-categories (Table 6).
Results
The required competencies at the general level of
palliative care
The description of the required competencies of every
physician in palliative care at the general level included
13 main categories with a total of 50 subcategories
(Table 5).
‘Competence in advanced care planning and decision-
making’was the main category from the biggest number
of codes (f = 125). Examples of the original data are
given below:
“Clear instructions about the future and medication
(what shall we do when the nausea increases, what
shall we do when the pain increases, what shall we
do if the medication does not help anymore) so that
we could then react rapidly, when the situations
change or the symptoms change or increase.”(WG 7)
“Having enough courage to make a decision about the
transfer to palliative care/end-of life care.”(WG 18).
“Withholding therapies and making care decisions.
Making decisions about end-of-life care timely.
Knowing basic things about symptom management,
advanced care planning”(WG 20).
‘Competence in social interactions’was another strong
main category, as it was found in 107 codes. The follow-
ing citations are examples of the original data:
“…to be able to bring up the death coming close.”
(WG 15).
“When it comes to psychologically and emotionally
difficult decisions about care and policy, the phys-
ician has to be able to understand the need of an
unhurried discussion with the patient and the family
Table 4 An example of the coding procedure: how the
subcategory ‘Methods of pain management’was produced
inductively
Examples of the substantive
material
Reduced expressions
(codes)
Subcategory
management of cancer pain
catastrophizing (WG 1)
management of cancer
pain catastrophizing
Methods of
pain
management
morphine-based pain
medication (WG 2)
morphine-based pain
medication
basic morphine pain pump
(WG 2)
basic morphine pain pump
pain pump* (WG 3) pain pump
to be able to manage pain
symptoms (WG 6))
manage pain symptoms
Non-pharmacological pain
management (WG 12)
Non-pharmacological pain
management
Physician’s sufficient
medical competence when
it comes to symptom
management: pain
medication (WG 14)
pain medication
Physicians sufficient medical
competence, for example,
knowing how to prescribe
the pain medication and
having courage to do that.
(WG 14)
prescribe the pain
medication... having
courage to do that
Medication: few opioids (no
fear of addiction, dosing,
adverse effects, change
from p.o. to s.c. etc.) (WG
15)
Medication: few opioids
(no fear of addiction,
dosing, adverse effects,
change from p.o. to s.c.
etc.)
Starting the use of a pain
pump (WG 21)
the use of a pain pump
Competence in pain
management. Basic
methods, for example, pain
pump –the physician has
to know it (WG 22)
pain management. Basic
methods …pain pump
*) In Finland, ‘pain pump’is a commonly used expression for equipment for
patient-controlled analgesia
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…An ability to take up the position of the patient
when explaining difficult things with as ordinary
spoken language as possible (not with medical terms)
…Respectful encounter.”(WG 27).
“The art of listening and discretion.”(WG 30).
“Knowing how to react to the shame of the patient.”
(WG 36).
The required competencies at the specialist level of
palliative care
The first part of the specialist level results, which are
subcategories belonging to the main categories produced
from the general level data, are shown in the first part of
Table 6. Out of them, the biggest number of codes fell
into the subcategory ‘Special methods and techniques of
pain management’.
As some WGs expressed:
Table 5 Required competencies for the general level
Main categories Subcategories
(1.) Competence in advanced care
planning and decision-making (f =
125)
(1.) Withholding therapies and
setting goals of care (f = 62)
(2.) Timely decision-making (f = 38)
(3.) Advanced care planning (f = 19)
(4.) Coordination of care (f = 6)
(2.) Competence in social
interactions (f = 107)
(5.) Encountering patients and
significant others (f = 37)
(6.) Verbal communication (f = 16)
(7.) Social interactions as part of a
physician’s work in palliative care
(f = 15) **
(8.) Sensitivity and empathy (f = 15)
(9.) Breaking the bad news (f = 11)
(10.) Professional behaviour (f = 6)
(11.) Social interactions with special
groups (f = 5)
(12.) Active role in social
interactions (f = 2)
(3.) Competence in basics of
palliative care (f = 79)
(13.) Holistic attention of patient’s
physical, psychosocial and
existential needs (f = 22)
(14.) Involvement of the significant
others with care (f = 12)
(15.) Recognition of the need for
palliative care and practicing
palliative care based on the
guidelines (f = 10)
(16.) Knowledge on basic principles
of palliative care (f = 9)
(17.) Recognition of the dying
patient (f = 9)
(18.) Definitions of palliative and
end-of-life care (f = 8)
(19.) Palliative care in different
diseases (f = 5)
(20.) Practices related to patient’s
death (f = 4)
(4.) Competence in the
management of other symptoms
than pain (f = 74)
(21.) Methods of management of
different symptoms (f = 45)
(22.) Recognition of symptoms (f =
13)
(23.) Symptom management as
part of a physician’s work within
palliative care (f = 11) **
(24.) Evaluation of the patient’s
drug therapy within palliative care
(f = 5)
(5.) Competence in consultations
and networking (f = 34)
(25.) Recognition of the need for a
consultation (f = 17)
(26.) Skills in networking (f = 11)
(27.) Consultations in a physician’s
work within palliative care (f = 6)
(6.) Competence in pain
management (f = 31)
(28.) Management of pain as part
of a physician’s work within
palliative care (f = 14) **
(29.) Methods of pain management
(f = 11)
(30.) Assessment of pain (f = 6)
(7.) Juridical and ethical
competence (f = 30)
(31.) Respect of patient’s rights (f =
13)
(32.) Patient’s autonomy (f = 6)
(33.) Respect of a human being
(f = 4)
(34.) Honesty (f = 3)
(35.) Doing good (f = 2)
Table 5 Required competencies for the general level
(Continued)
Main categories Subcategories
(36.) Patient’s freedom of choice
(f = 1)
(37.) Accountability (f = 1)
(8.) Patient education competence
(f = 26)
(38.) Guidance of a patient and
significant others as part of a
physician’s work in palliative care
(f = 19) **
(39.) Conduct of guidance (f = 7)
(9.) Competence in
multidisciplinary teamwork (f = 21)
- (No subcategories)
(10.) Competence in
documentation (f = 18)
(40.) Documentation of goals and
limits of care (f = 9)
(41.) Documentation as part of a
physician’s work within palliative
care (f = 3) **
(42.) Making medical certifications
and verdicts (f = 3)
(43.) Detailed and real time
documentation (f = 2)
(44.) Responding to notes (f = 1)
(11.) Competence at existential
dimension (f = 12)
(45.) Relieving existential suffering
(f = 7)
(46.) Encountering death (f = 5)
(12.) Cultural competence (f = 10) (47.) Significance of a cultural
perspective within palliative care
(f = 8)
(48.) A member from another
culture in a team (f = 2)
(13.) Competence in taking care of
one’s own professional
competence and well-being at
work (f = 6)
(49.) Taking care of one’s own
professional competence (f = 3)
(50.) Taking care of one’s own well-
being at work (f = 3)
**) Subcategories number 7, 23, 28, 38 and 41 constituted from very short and
simple expressions about the thing named in the beginning of the
subcategory’s name. Thus, the analysers concluded that the experts just
expressed the importance of the issue within palliative care
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“Mastery of invasive pain management methods.”
(WG 12).
“To be able to see what’s behind the pain –if there is
mental agony or anxiety in the background.”(WG 6).
The second part of the specialist level results are six
main categories with 22 subcategories in total, which are
unique for the specialized level only (the second part of
Table 6). ‘Competence in complex symptom manage-
ment’was the main category which was derived from
the biggest number of codes (f = 46). As some work-
groups expressed:
“…to be capable of providing symptom manage-
ment; pleural paracentesis, sedation (for example, in
psychological restlessness or anxiety). And have the
courage to make the decision of sedation. The phys-
ician must be capable to see if there is emotional
agony or anxiety behind the pain.”(WG 6).
“Management of catastrophic situations.”(WG 12).
‘Research and development competence’was obtained
from 31 expressions. The following citations are exam-
ples of the original data:
Table 6 Required competencies for the specialist level
Main categories (1, 2, 3 and 6 produced already for the general
level) (see Table 5)
Subcategories (Subcategories documented with Bold were created from the
specialist level data)
(1.) Competence in advanced care planning and decision-making
(f = 125 on the general level)
(f = 126 on the general and specialist levels in total)
Four subcategories on the general level (see Table 5)
(51.) Demanding decision-making (f = 1) (a specialist level subcategory)
(2.) Competence in social interactions
(f = 107 on the general level)
(f = 110 on the general and specialist levels in total)
Eight subcategories on the general level (see Table 5)
(52.) Special skills in social interactions (f = 3) (a specialist level
subcategory)
(3.) Competence in basics of palliative care
(f = 79 on the general level)
(f = 81 on the general and specialist levels in total)
Eight subcategories on the general level (see Table 5)
(53.) Children as significant others (f = 2) (a specialist level subcategory)
(6.) Competence in pain management
(f = 31 on the general level)
(f = 40 on the general and specialist levels in total)
Three subcategories on the general level (see Table 5)
(54.) Special methods and techniques of pain management (f = 9) (a
specialist level subcategory)
Main categories (Inductively produced for the Specialist level
only)
Subcategories (Specialist level only)
(14.) Competence in complex symptom management (f = 46) (55.) Widespread and specialized symptom management as part of advanced
competencies (f = 16) ***
(56.) Evidence based management of symptoms (f = 14)
(57.) Therapeutic procedures within palliative care (f = 10)
(58.) Management of emergencies within palliative care (f = 5)
(59.) Making home visits (f = 1)
(15.) Research and development competence (f = 31) (60.) Developing palliative care (f = 23)
(61.) Performing research (f = 4)
(62.) Coordination of palliative care pathway (f = 4)
(16.) Competence to offer consultative and educational support to
other professionals (f = 30)
(63.) Offering and coordinating consultations (f = 18)
(64.) Offering education to other professionals (f = 12)
(17.) Competence to offer palliative care to all patients, including
special groups (f = 14)
(65.) Children and adolescents in palliative care (f = 6)
(66.) Patients with substance abuse in palliative care (f = 1)
(67.) Mentally handicapped patients in palliative care (f = 1)
(68.) Psychiatric patients in palliative care (f = 1)
(69.) Spinal cord injury patients in palliative care (f = 1)
(70.) Patients with respiratory diseases in palliative care (f = 1)
(71.) Patients with heart diseases in palliative care (f = 1)
(72.) Special aspects of palliative care in cancer (f = 1)
(73.) Patients with rare diseases in palliative care (f = 1)
(18.) Verifiable competence to work on a specialized level of palliative
care (f = 12)
(74.) Formally acquired educational competence to work on a specialized
level of palliative care (f = 8)
(75.) Adequate working experience needed for specialized level of palliative
care (f = 4)
(19.) Competence in providing specialist level of psychosocial support
(f = 2)
- (No subcategories)
***) Subcategory number 55 constituted from very short and simple expressions, such as “widespread symptom management”or “specialized symptom
management”. Thus, the analysers concluded that the experts just expressed that specialist level physicians should have broad competence in
symptom management
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“Readiness to participate in research projects and
development work.”(WG 19).
“Readiness to conduct research in the contexts of
palliative care and end-of-life care”(WG 26).
Discussion
This study aimed to describe the required competencies
of physicians in palliative care from the perspectives of
multi-professional groups of representatives from work-
ing life. As a result, a comprehensive description of the
required competencies based on the workshop data was
presented. Earlier competence descriptions [4,5,10]or
recommendations for the development of undergraduate
curricula within palliative medicine at European medical
schools, as well as surveys on the postgraduate education
within palliative medicine for physicians [11], have re-
ported some similar competencies that were also de-
scribed as main categories in this study.
General level competence needs
Within the general level, ‘Competence in advanced care
planning and decision-making’was the main category
emerging with the highest number of reduced expres-
sions. In the consensus papers by EAPC, the core com-
petencies in palliative care include the expressions
‘tailored plan of care’,‘decision-making’and ‘care co-
ordination’[4,10]. However, advanced care planning
(ACP) is not mentioned as clearly as it was in this study,
which emphasizes the need for well-timed decision-
making and ACP as basic skills for every physician to
enable high-quality palliative care. Likewise, the Irish
Palliative Care Competence Framework states that as a
health care professional, all physicians should demon-
strate an understanding of ACP, and when they receive
more training, the requirements for their competence in-
crease to achieve skills in facilitating and leading ACP
[5]. Development in medicine has increased the possibil-
ities of taking care of patients with very advanced dis-
eases but attempts to prolong life at any cost may be
futile [20]. Recognizing the need for palliative care plays
a key role in good quality care. A recent qualitative study
on European experts by Paal et al. [21] reported an abil-
ity ‘to design care plans based on patients and families
wishes integrating multiprofessional and interdisciplin-
ary approaches’as one key learning goal of postgraduate
palliative care education for all healthcare providers in
Europe. Thus, the WGs’views in this study that skills in
ACP are highly relevant already within the general level
of palliative care are in line with previous studies and
recommendations.
‘Competence in social interactions’was another strong
main category, including many diverse subcategories
describing the multifaceted nature of this competence
area. ‘Verbal communication’was one of the subcategor-
ies, including similar things that were found by Paal
et al. [21] who reported a learning goal ‘to listen and
self-reflect’. This competence has been presented already
in earlier papers [3,10,11]. In particular, communica-
tion skills have long been recognized as a major compe-
tency needed in palliative care [5,11]. Today, shared
decision-making with patients, families and physicians is
considered the preferred model when it comes to mak-
ing complex clinical decisions [22,23]. The practice of
ACP and making truly shared decisions call for skilful
communication. Therefore, it is understandable why our
participants emphasized competencies both in decision-
making and social interactions, e.g. verbal communica-
tion. Social interactions also included aspects of team-
work, although this also had its own main category
(multidisciplinary teamwork). Thus, teamwork probably
had a stronger overall importance than could be stated
purely by the expressions clearly related to it.
‘Competence in documentation’was partly related to
the care plan and partly related to other aspects of the
physician’s work. Our result seems to highlight the im-
portance of a written plan and decisions (e.g. DNR-
orders) allowing the continuum of care between differ-
ent care providers. Documentation has also been pre-
sented as a recommended learning content by EAPC
[11].
Competencies in symptom control (management of
pain and other symptoms) were expectedly important in
basic level competencies, but the frequency of the codes
related to these competencies were lower than those of
decision-making and social interactions. This is not
quite in line with the EAPC recommendations for
undergraduate education in palliative care, where man-
agement of symptoms has the largest proportion of the
total teaching time [11]. In addition, the Irish Palliative
Care Competence Framework states that all physicians
should understand how the palliative care approach can
enhance the assessment and management of symptoms
[5]. We suggest, however, that our result may reflect the
significant problem in decision-making and planning
palliative care as well as social interactions in Finland,
rather than diminish the importance of symptom
control.
Specialist level competence needs
As for specialist level competencies, in addition to the
competencies which are required on the general level,
the WGs described specialized competencies which are
required on this level only. ‘Competence in complex
symptom management’, reported also in other papers [5,
12,21], comprised the biggest number of reduced ex-
pressions. Although some of the expressions did not
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specify complex symptom management, expressions that
did emerge were therapeutic procedures, taking care of
emergencies and especially, the evidence base of the
management. The latter is in line with the ‘Research and
development competence’. This may reflect poor re-
search activity in the field of palliative medicine, not
only in Finland but worldwide. For the future develop-
ment of palliative care, however, research and improve-
ment in the academic position of palliative medicine are
vital. Evidence-based practice, research and development
are presented also as indicators of competence in the
Irish Palliative Care Competence Framework [5].
Participants’statements to require ‘Verifiable compe-
tence to work on a specialized level of palliative care’are
probably related to the current state of specialization
within palliative medicine in Finland. There has been a
special competency in palliative medicine since 2007 in
Finland. This training, including 150 h of theoretical stud-
ies and a 6 months’working period in a specialized pallia-
tive care unit, is arranged by the Finnish Association for
Palliative Medicine and the Finnish Medical Association
gives a certification for this special competency [24]. How-
ever, universities are not responsible for or formally in-
volved in this education. Thus, palliative medicine is not a
specialty in Finland as it is in some other European coun-
tries [25]. This might have influenced the participants’
needs to emphasize the formal special education in the
specialized level of palliative care.
Competence needs within both the general and specialist
level
Consultations and networking emerged as categories
‘Competence in consultations and networking’within
the general level of palliative care and ‘Competence to
offer consultative and educational support to other pro-
fessionals’within the specialized level. Consultation has
been presented as an indicator of competence of all phy-
sicians in palliative care in the Irish Palliative Care Com-
petence Framework [5]. Moreover, similar things have
been presented, for example, as ‘to act as a resource to
others in the team’[10]. However, ‘Networking’as a
concept has not been presented before. Similar expres-
sions have been presented earlier, for example, ‘fostering
greater communication within the team and with other
professional colleagues’[10]and‘establish collegial part-
nerships and in the context of palliative care contribute
to the professional development of students, peers, col-
leagues and others through consultation, education,
leadership, mentorship and coaching’[5]. One plausible
explanation for these results, related to consultations
and networking in this study could be due to the rela-
tively poor palliative care service network in Finland so
far. This, in combination with a poor education level in
this area, increases the need for consultation.
In our study, the need for organizing palliative care
pathways and networks, both within the general and spe-
cialized level, emerged. This was in addition to shared
decision-making and consultation. It is possible that our
participants were already aware of the recently published
recommendations by the Ministry of Social Affairs and
Health [14] regarding palliative care, and this may have
partly affected their perception of the need for palliative
care in Finland.
Strengths and limitations of the study
The trustworthiness [18] of this study was strengthened
by the method being suitable for the purposes of the
study. As the sample was large and presented diverse
professions, it can be estimated that the data represents
the whole phenomenon of interest quite well. Because
the managers proposed the best representatives of their
personnel, we do not know if there were refusals. None
of the professionals whose contact details we received
refused to participate when we contacted them. The
workshop questionnaire was carefully designed and pre-
tested, which strengthens the trustworthiness. The se-
lected unit of analysis was appropriate for the purposes
of this study, because it was neither too narrow nor too
broad [18]. The results clearly represent the views of the
participants of this study, since we analyzed only the
manifest content [16].
Because the workshops were organized only once,
there was no possibility to ask any further questions
about the topic in order to gain a deeper understanding
of the phenomenon of interest. The transcripts were not
returned to the participants for comments and/or cor-
rection, nor were the findings returned so that they
could provide feedback. These aspects all weaken the
trustworthiness of the study. Although the sample pre-
sented diverse professions, a limitation is that the group
of nurses in total was so much bigger compared with
other professions and thus, the results may reflect their
views more than it would reflect the others’views.
Within the Finnish health care sector, the managers are
responsible for the human resource management of phy-
sicians [26] and nurses [27]. Based on this, they are sup-
posed to know the competencies of their personnel and
thus, it can be assumed that the managers succeeded at
choosing the best representatives of their units for the
workshops. However, it could be possible that some
good experts have not been included in the sample.
One experienced qualitative researcher analyzed the
whole data. Two other researchers examined the analysis
made by her. The researchers exchanged views on the
analysis and interpretation of the findings to create cat-
egories in a meaningful way [18]. All the authors
checked that there would not be any overlap in the
categorization and that it was logical. The results were
Melender et al. BMC Palliative Care (2020) 19:65 Page 9 of 11
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
presented for a multidisciplinary group of professionals
within palliative care (n= 44). This group confirmed that
the results were plausible, which confirmed the face val-
idity of the findings. Consolidated criteria for reporting
qualitative research (COREQ) guidelines [28] were ad-
hered to ensure explicit and comprehensive reporting of
the study.
At both the general and specialist level, some subcat-
egories consisted of a small number of codes. Although
these subcategories do not appear as central as the
stronger ones, they are, however, important, as they
show the rich and diverse nature of the competencies re-
quired in palliative care.
Conclusions
This study adds to the knowledge by describing the per-
spective of Finnish multi-professional groups of repre-
sentatives from working life who qualitatively described
the required competencies of physicians working within
different levels of palliative care. The competencies de-
scribed in this study emphasize decision-making, social
interactions and networking. Symptom management,
which is often emphasized in curricula, also appeared in
this study, but with a smaller emphasis. This may have
been due to the informants considering symptom man-
agement so self-evident that they did not name it, or be-
cause the lack of competence in it may not be such a big
problem in working-life, compared with the lack of other
competences mentioned above. It is important to listen
to the voices of the working-life representatives when
planning curricula. The views of them inform how the
competences gained during education meet the chal-
lenges of the ordinary work.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12904-020-00566-5.
Additional file 1.
Abbreviations
ACP: Advanced care planning; COREQ: Consolidated criteria for reporting
qualitative research; EAPC: European Association for Palliative Care;
WG: Working group
Acknowledgements
The authors wish to thank all the professionals of palliative care who
participated in this study.
Ethics approval and informed consent to participate
The Ethical Committee of North Ostrobothnia’s Hospital District was
contacted regarding the need for an application for an ethical approval. The
Ethical Committee stated that formal approval was not needed for this
study. Participation in the study was voluntary and a written informed
consent was obtained from all participants. All research material was coded
with the workshop group numbers, not with the personal details of
individual participants, and confidentiality was reassured for the participants.
Authors’contributions
H-L.M., M.H., T.S. and J.L. designed the study methodology. H-L.M., M.H. and
J.L. collected and analyzed the data. H-L.M., M.H., T.S. and J.L. drafted and re-
vised the manuscript. Furthermore, all the authors read and approved the
final manuscript.
Funding
This work was funded by the EduPal-project, which was funded by the Minis-
try of Education and Culture (Decision 29.3.2018 OKM/258/523/2017) in
Finland and the participating higher education institutions. The funders had
no role in the design of this study, in the collection, analysis and interpret-
ation of data, or in writing the manuscript. The content of this article reflects
only the EduPal group members’views and the funders are not liable for
any use that may be made of the information contained herein.
Availability of data and materials
The datasets generated during and/or analyzed during the current study are
not publicly available due to the reassurance to the study participants that
the data will be retained confidentially Within the limits of confidentiality,
more detailed, but anonymous, data is available from the corresponding
author on reasonable request. The English language version of the cover
letter and the questionnaire developed specifically for use in this study are
presented in the Supplementary material.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Social and Health Care, VAMK University of Applied Sciences,
Wolffintie 27-31, 65200 Vaasa, Finland.
2
School of Health, Kajaani University of
Applied Sciences, PL 52, Ketunpolku 4, 87101 Kajaani, Finland.
3
Faculty of
Medicine, University of Helsinki, Helsinki, Finland.
4
Helsinki University Hospital,
Cancer Center, PL 180, 00029 HUS Helsinki, Finland.
5
Faculty of Medicine and
Health Technology, Tampere University, Tampere, Finland.
6
Department of
Oncology, Palliative Care Unit, Tampere University Hospital, Teiskontie 35,
R-building, 33520 Tampere, Finland.
Received: 21 October 2019 Accepted: 22 April 2020
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