To support older Australians living in residential aged care and community care as they come to the end of their life, there needs to be a high-quality and well-prepared health workforce. This workforce comprises, registered and enrolled nurses, careworkers, allied health professionals and GPs. The quality of care a person receives is influenced by the knowledge of the carers, the conditions in which they work, the level of organisational support, and carer engagement.  Education is a key part of the initial training and preparation, and of ongoing professional development of the workforce.  This workforce comprises, registered and enrolled nurses, careworkers, allied health professionals and GPs.
This synthesis utilised evidence from twenty-four systematic reviews. Four dealt specifically with topics relating to palliative care in aged care while seventeen were either aged care only or palliative care only. The overall quality of the systematic review evidence was good with appropriate searches and methods for extraction and analysis. Few reviews included prospective controlled trials.
Education for the aged care workforce
There are different types and modalities of education reported in the literature from one-off events to sustained programs with specified learning outcomes. Assessing the effectiveness of education can focus on staff knowledge and practice, and on patient related outcomes. Reports of activity are common but there is less rigour in the evaluation of the effect and outcomes. Although education is widely regarded as the single most important way of improving end-of-life care delivered by nursing home staff, educational provision for nursing home staff is poor and existing educational interventions appear unlikely to promote better patient outcomes. Evidence to demonstrate their effectiveness is not robust.  There is a need to design credible educational interventions and evaluate their impact on the person, their families and staff in nursing homes with economic evaluation.
However, despite the widespread use of careworkers, little is known about the roles they play in palliative and end-of-life care in the community. Their work is located at the intersection between professional and informal care. Five core domains have been highlighted where care workers contribute to the care of older people: personal care, emotional and social support, domestic support, respite care for family carers and collaborating with professional and family carers. A substantial proportion have no nationally recognised qualification, no training on appointment and have felt inadequately prepared for their job. [2,3] These issues are particularly relevant in the care of older people with dementia, yet many care workers lack the necessary skills and knowledge and so care tends towards a task-based model of care.  However, two recent reviews found that effective teaching methods for community careworkers incorporated opportunities to share and exchange new information, and utilise peers and colleagues for support, mentorship, and exchange of knowledge. [5,6] Intervention components that focused on a needs-based model of care versus a task-based model of care were found to be more highly valued by care staff. 
It is important that outcomes of educational interventions are not limited to perception of improved care but are measurable and meaningful.  There are a number of tools available that have been identified to evaluate current palliative care competency among nursing assistants.  One of these instruments measured nursing assistants' level of comfort in providing end-of-life care. The six remaining instruments measured palliative care knowledge, palliative care practice, self-efficacy, knowledge and attitudes towards people with advanced dementia, beliefs and attitudes to death, dying, palliative and interdisciplinary care across the aged care workforce. Usefulness of identified tools may be limited by language skill and literacy skills of many workers. The tools included:
- The Comfort Scale
- Palliative Care Quiz for Nurses (PCQN)
- Tool 2.1
- The Questionnaire on Palliative Care for Advanced Dementia (qPAD)
- The German Bonn Palliative Care Knowledge Test (BPW)
- An Instrument to Measure Beliefs and Attitudes to Death Dying and Palliative and Interdisciplinary Care
- The Palliative Care Survey
There are many challenges recognised in the implementation of staff training and education, including time, resource allocation, and high staff turnover. However, organisational attitude and overt management support are key predictors to educational intervention success.  Therefore, given the aged care workforce characteristics, training interventions that focus not only on knowledge but on organisational support for workers may be critical in improving and sustaining workforce capacity and preparedness. [1,9]
Palliative care education
Nursing students also feel unprepared to deal with issues related to death and dying and there are indications that schools of nursing may not be adequately educating nursing students to care for people at the end-of-life.  Palliative care education for nurses is delivered at a variety of stages in their nursing program, using a mix of both didactic and experiential educational strategies. [11,12] Course facilitators span palliative care specialists, educators who have attended ‘train-the-trainer’ courses in palliative care, and nurses with hospice experience. Education underpinned by transformative and experiential learning theories is reported as effective in improving students’ attitudes towards care of the dying.  Experiential learning strategies, such as simulated based learning experiences (SBLE) , and practical experience provide students with opportunities to integrate knowledge and experience and promote meaningful learning experiences through reflection. [10,14]
Continuing professional development is an important part of ongoing education and training for nursing and this may be especially important for those in rural and remote locations.  Interprofessional educational effectiveness is also being explored. 
There are indications that there is greater consistency in the content being delivered as part of end-of-life care education within medical schools.  In medical curricular, palliative care topics included patient assessment, communication, pain and symptom management, psychosocial and spiritual needs, bioethics and the law, role in the health care system, interdisciplinary teamwork, and self-care.  A wide variety of interventions have also been used to build residents awareness, knowledge and skills in end-of-life care including didactics, group discussions, debriefings, designated rounds, clinical experiences, simulations, roleplays, and decision support tools. Training programs need to develop and implement more effective role modelling, simulation, and feedback methodologies to better support residents. 
Including palliative care in undergraduate education is an important way of providing knowledge, skill, and competences about palliative care and can improve attitudes toward caring in advanced disease and at the end-of-life. Experiential learning appears to be valuable, however there is only indirect evidence that palliative care training at university leads to better clinical care of people receiving palliative care. [18,20] A lack of universally applicable validated questionnaires to assess the effectiveness of undergraduate palliative care education also limits evaluation. 
Patient-professional communication education
Communication education is the focus of education and training studies. Three core themes relating to education around patient-professional communication have been identified: using education to enhance professional communication skills, using communication to improve patient understanding, and using communication skills to facilitate advance care planning.  There is some evidence that specific educational interventions around communication for health care professionals (HCPs) may improve self-efficacy, knowledge and communication scores compared to no formal training. 
The health professional’s role in providing education to patients and their families has also been noted. 
End-of-life care simulation is an innovative strategy that may help to prepare undergraduate nursing students to provide quality end-of-life care.  Computer-aided education has been used for advance care planning training. 
While interdisciplinary care is considered the ‘gold standard’ for delivery of palliative care, education is often monodisciplinary. Collaborative or interdisciplinary educational interventions have been shown to be have perceived benefits for careworkers, including greater awareness and confidence in the skills required in a palliative approach. However, interdisciplinary learning must ensure interventions for careworkers are transferable to care settings. 
Evidence that continuing professional development (CPD) impacts positively on patient and families is necessary to sustain an on-going investment in learning activities. In order to optimise the opportunities afforded by emerging web-based technology, rural nurses' need to develop and maintain their computer competencies. Further investigation of the impact of specialist clinical placements on rural nurses' palliative care capabilities is also indicated. 
- There is a need for a tool to assess the effectiveness of palliative care education.
- Educational assessment needs to address patient outcomes as well as knowledge outcomes.
- The possibilities associated with simulated learning in palliative care needs to be explored. 
- The impact of clinical placements on palliative care capabilities needs to be assessed and patient outcomes needs to be assessed.
- Understanding the impact of consumer, carer and patient input into education interventions is lacking.
- Allied health education with regard to end-of-life care in the aged care industry is not well researched.
Page updated 08 June 2021