Palliative care training for healthcare professionals in ethnic minority regions of China: a qualitative study of training needs, barriers and practice translation

Abstract

Background

Palliative care training is essential for strengthening workforce capacity, yet little is known about training needs, barriers, and practice translation in ethnic minority regions. In China, these regions are often marked by cultural diversity, geographical remoteness, limited resources, and uneven health-system capacity, all of which may shape how palliative care training is accessed, delivered, and used in practice. This study explored palliative care training needs, barriers, and practice translation across multiple ethnic minority regions in China.

Methods

A qualitative study was conducted using focus group discussions in nine ethnic minority regions of China between January 2024 and March 2025. Purposive sampling was used to recruit 65 participants from seven stakeholder groups, including healthcare professionals, hospital teaching directors, trainers, researchers, hospital managers, primary healthcare managers, and policy makers. Eight mixed-stakeholder focus groups were conducted. Data were analysed using reflexive thematic analysis.

Results

Four interrelated themes were identified. First, access to training was constrained by structural factors, including limited opportunities, uneven distribution of resources, workforce shortages, and weak institutional and policy support. Second, existing training was often poorly aligned with local realities, having been developed largely for mainstream settings and insufficiently adapted to local cultural, linguistic, religious, and service contexts. Third, training was difficult to translate into routine practice because of weak service conditions, limited multidisciplinary support, and the absence of sustained organisational reinforcement.Fourth, participants identified training needs for culturally responsive, practice-oriented, and locally grounded capacity-building approaches, supported by local trainers, local teams, and longer-term reinforcement mechanisms.

Conclusions

Palliative care training needs and barriers in ethnic minority regions of China extend beyond limited training provision alone. They are shaped by the intersection of structural constraints, inadequate contextual adaptation, and difficulty translating learning into practice. Strengthening training in these settings will require more than expanding course provision; it will require culturally responsive, practice-oriented, and sustained forms of local capacity building. These findings may also inform palliative care training development in other resource-constrained, culturally diverse, and remote settings.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12904-026-02249-z.

Introduction

As populations age and disease profiles shift increasingly towards chronic non-communicable conditions, health systems worldwide are under growing pressure to respond to the needs of people living with serious illness and approaching the end of life [1, 2]. Palliative care is increasingly recognised as an essential component of high-quality health care because it relieves suffering, improves quality of life, and supports more person-centred and integrated models of care [3–5]. However, palliative care cannot be strengthened through policy endorsement or service expansion alone. Its reach and quality depend fundamentally on whether health workers are equipped with the competencies required for symptom control, communication about deterioration and dying, psychosocial support, ethical judgement, and culturally responsive care [6–8].

Within the Chinese health system, healthcare workforce development is generally organised through undergraduate medical and nursing education, standardised post-graduate training, continuing professional education, specialist training, and targeted capacity-building programmes [9]. For palliative care, workforce development has mainly relied on continuing education, hospital-led training, short courses, specialist workshops, pilot programmes, and project-based capacity building [10]. Unlike more established clinical fields, however, palliative care training has not yet been fully embedded into a mature and uniformly implemented national workforce development system, and access remains uneven across regions and institutions.

Ethnic minority regions in China represent a particularly important context for examining these training challenges. In this study, the term refers to regions with substantial ethic minority populations and distinctive linguistic, cultural, religious, and geographical characteristics, including autonomous regions such as Guangxi, Ningxia, Xinjiang, Xizang, and Inner Mongolia, as well as ethnically diverse provinces such as Yunnan, Guizhou, Qinghai, and Jilin. These regions should not be understood as a single uniform setting. They differ considerably in ethnic composition, language environments, religious traditions, geography, health-service infrastructure, and the development of palliative care [11, 12]. Many include remote mountainous, border, or economically underdeveloped areas where health systems have long faced constraints related to resources, workforce capacity, and access to sustained professional training [13, 14].

Palliative care training in these settings is not entirely absent. In some regions, training activities have been introduced through hospital-based programmes, continuing education, pilot projects, and external expert support [10]. The central problem is therefore not simply a lack of training provision, but the uneven availability, limited continuity, insufficient contextual adaptation, and uncertain translation of training into routine practice [15]. Training developed for mainstream urban or better-resourced settings may not adequately address local language use, cultural norms, religious beliefs, family decision-making patterns, limited multidisciplinary support, or the practical realities of care in county-level and primary healthcare institutions [16, 17].

In this context, palliative care training in China’s ethnic minority regions cannot be approached simply as a standardised educational intervention that can be transferred unchanged across settings. Existing workforce development models, including generalist-specialist, specialist outreach or mentorship, continuing education, and train-the-trainer approaches, provide important reference points [18–20]. These models have been used to extend palliative care knowledge and skills to rural, remote, and underserved communities in many countries, including settings where specialist teams support generalist providers working outside major urban centres [21, 22]. The issue addressed in this study is therefore not whether such models are useful, but how they are adapted, constrained, and translated into practice in China’s ethnic minority regions. In these settings, training is shaped by uneven service capacity, limited local trainers, weak multidisciplinary support, linguistic and cultural diversity, and the practical conditions of frontline care [10, 23]. A more context-sensitive account is therefore needed to understand how workforce development operates when general training models encounter specific local health-system and sociocultural conditions.

Although previous research has examined palliative care in China from multiple perspectives, including service accessibility, policy development, educational needs, and workforce capacity building, the specific dynamics of palliative care training in ethnic minority regions remain insufficiently understood [24–27]. Existing studies and local programmes indicate that training needs and training activities do exist, but less is known about how healthcare professionals and relevant stakeholders perceive these needs, what factors constrain training delivery and participation, and how training is or is not translated into everyday care. This gap limits the development of training strategies that are not only educationally relevant, but also context-sensitive, sustainable, and practically grounded.

This study therefore explores palliative care training needs, barriers, and practice translation in China’s ethnic minority regions, focusing on how training is accessed, delivered, adapted, and used in everyday care. By examining these issues in context, the study aims to deepen understanding of the challenges involved in building palliative care capacity in culturally diverse and underserved settings, and to support the development of training approaches that are more responsive to local realities. In doing so, it also speaks to a wider international concern: how palliative care training can be strengthened in settings where workforce shortages, limited resources, and cultural diversity intersect.

Methods

Study design

This study used a qualitative design and drew on focus group discussions as the primary method of data collection to explore barriers to palliative care training needs, barriers, and practice translation in ethnic minority regions of China. Because the study sought to understand how healthcare professionals and relevant stakeholders interpreted, experienced, and responded to training within specific cultural and frontline care contexts, a qualitative approach was well suited to capturing the complexity and situated nature of the issue. Compared with individual interviews, focus group discussions allow participants to engage with one another’s accounts, generating richer insights into shared experiences, divergent perspectives, and collective reflections on everyday challenges [28]. This made them particularly appropriate for examining palliative care training as a multi-stakeholder issue involving clinical practice, training, management, research, and policy perspectives. Data were analysed using reflexive thematic analysis informed by Braun and Clarke’s approach [29], as detailed in the Data analysis section. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

Study settings

The study was conducted across multiple ethnic minority regions in China, including Guangxi Zhuang Autonomous Region, Ningxia Hui Autonomous Region, Xinjiang Uygur Autonomous Region, Xizang Autonomous Region, Inner Mongolia Autonomous Region, as well as Yunnan, Guizhou, Qinghai, and Jilin provinces. Together, these areas include several of the ten largest ethnic minority populations in China and reflect substantial regional and ethnic diversity. They encompass a wide range of geographical, institutional, and sociocultural settings, many of them marked by relative resource constraints, uneven workforce development, and limited opportunities for sustained professional training. This diversity provided an important empirical basis for examining how palliative care training is shaped by local realities across ethnic minority regions in China.

Participants and sampling

Purposive sampling was used to recruit key stakeholder groups with direct relevance to palliative care training in ethnic minority regions of China. Participants were drawn from seven groups: (1) healthcare professionals involved in palliative care or related care provision; (2) directors of hospital teaching departments or staff responsible for continuing professional education; (3) teachers or organisers involved in palliative care training; (4) researchers working in palliative care or related fields; (5) hospital managers or personnel responsible for nursing or medical administration; (6) managers or key staff from primary health-care institutions; and (7) personnel from local health administrative departments or those involved in relevant policy development and management. Eligibility criteria were defined for each group, as detailed in Table 1.

Table 1.

Eligibility criteria by participant group

Participant group	Eligibility criteria
Healthcare professionals	Physicians, nurses, or other frontline staff involved in palliative care, hospice care, oncology care, geriatric care, chronic illness management, or end-of-life care; worked in a health facility in one of the study regions for at least 2 years; had participated in palliative care-related training or undertaken care activities closely aligned with palliative care training content.
Directors of hospital teaching departments or continuing education staff	Held education, training, or staff development roles in hospitals in ethnic minority regions; had held these roles for at least 1 year; had direct involvement in training planning, organisation, coordination, or evaluation.
Teachers or training organisers	Had delivered, organised, or coordinated at least one palliative care training activity for healthcare providers in ethnic minority regions within the past 3 years; had a defined teaching or organisational role; could comment on training content, delivery, and implementation challenges.
Researchers	Had conducted relevant research within the past 3 years; had experience related to palliative care, ethnic minority regions, primary care, health equity, or cultural adaptation; could contribute evidence-informed perspectives on training needs and gaps.
Hospital managers or nursing/medical administration personnel	Held mid-level or senior management roles in hospitals serving ethnic minority regions; had been in post for at least 2 years; were familiar with staffing, training resources, and institutional priorities.
Managers or key staff from primary health-care institutions	Worked in community health centres, township health centres, village clinics, or similar facilities in ethnic minority areas; had worked in such settings for at least 1 year; were familiar with frontline training needs, participation barriers, and the use of training in routine care.
Policy-related participants	Worked in local health administrative departments, continuing education authorities, programme management offices, or similar bodies; had direct experience in palliative care, continuing professional education, primary care capacity building, or related programme management; could comment on policy support, resource allocation, and broader institutional conditions.

Recruitment procedures

Participants were recruited through the research team’s collaborative networks with health institutions, universities, training programmes, and health administrative bodies in ethnic minority regions of China. The research team first contacted relevant hospitals, primary health-care institutions, training teams, and local health authorities in each study region to introduce the study aims, scope, and eligibility criteria, and to seek assistance in identifying potentially eligible participants. Once potential participants had been identified, formal invitations were sent by telephone, WeChat, or email. These invitations included information on the purpose of the study, the focus group format, the expected duration of participation, audio-recording procedures, and informed consent. For those who expressed interest, eligibility was further confirmed by the research team, and focus groups were organised according to participants’ professional backgrounds and availability. Recruitment continued until the main stakeholder groups had been adequately represented and the data were judged to have reached saturation.

Data collection

Data were collected between January 2024 and March 2025. Because the study focused on barriers to palliative care training in ethnic minority regions of China, the focus groups were organised using a mixed-stakeholder approach. Each group included participants from different stakeholder backgrounds, allowing interaction across clinical practice, training, management, primary care, research, and policy perspectives. We recognised that mixed-stakeholder groups could also introduce power dynamics, including the possibility that frontline providers might be less willing to discuss institutional weaknesses in the presence of managers or policy-related participants, or that primary care staff might defer to tertiary hospital experts. To reduce this risk, the facilitator emphasised at the beginning of each discussion that all perspectives were equally valuable, that there were no right or wrong answers, and that participants could speak from their own experience rather than on behalf of their institution. The facilitator actively invited contributions from less vocal participants, used follow-up probes to elicit frontline and primary care perspectives, and monitored whether any participant or stakeholder group dominated the discussion. Field notes were used to record group dynamics and issues requiring further clarification.

Focus group discussions were conducted through a combination of face-to-face and online meetings, depending on participants’ location, work schedules, and practical availability. Each focus group included 7–9 participants, balancing depth of discussion with diversity of views. All discussions were guided by a semi-structured topic guide and facilitated by H.W., who had training and experience in qualitative health research and palliative care-related research, which is provided as Supplementary Appendix 1. X.X. was present as a second researcher to document key points of discussion, interactions among participants, and issues requiring further clarification. The topic guide focused on participants’ understandings of palliative care training, prior training experiences, perceived training needs, the relevance of training content and format, practical difficulties in organising or participating in training, the use of training in routine work, and suggestions for future improvement. Before formal data collection began, the guide underwent several rounds of review and refinement within the research team to ensure clarity, internal coherence, and suitability for mixed-stakeholder discussion.

All discussions were conducted in Mandarin Chinese. Each session lasted approximately 120 min and was audio-recorded with participants’ consent, with field notes taken alongside recording. Audio recordings were transcribed verbatim within 24 h of each discussion, and identifying information was removed during transcription to protect confidentiality. A total of eight focus group discussions were conducted. Throughout data collection, the research team monitored the recurrence of issues and themes across groups; recruitment ceased when additional discussions no longer generated substantively new information and the dataset was judged to have reached saturation.

Data analysis

Data were analysed using reflexive thematic analysis informed by Braun and Clarke’s approach [29, 30]. We selected this approach because it supports the systematic development of patterns of meaning across qualitative data while recognising the active interpretive role of researchers in coding, theme development, and analytic decision-making. We followed contemporary guidance on good practice in reflexive thematic analysis reporting, including methodological coherence, transparent theme development, and reflexive engagement with the analytic process [29]. The analysis was primarily inductive, in that codes and themes were developed from participants’ accounts rather than applied from a pre-existing coding framework. At the same time, analysis was sensitised by the study aims and by the broader literature on palliative care training, workforce development, and culturally responsive care.

Transcripts were imported into NVivo to support data management, coding, retrieval, and documentation of theme development. H.W. and X.W. independently coded all transcripts in duplicate. Both coders had experience in qualitative health research. H.W. had a background in health policy and palliative care-related research, while X.W. had experience in health policy, health services research, and qualitative data analysis. The coders first read all transcripts repeatedly to become familiar with the dataset and then conducted open coding by labelling meaningful segments of text related to palliative care training needs, barriers, contextual influences, and practice translation. Codes were recorded in NVivo, and coding memos were used to document analytic decisions, emerging interpretations, and uncertainties. After initial coding, the two coders compared coding outputs, discussed similarities and differences, refined code labels, and developed a shared working codebook. Related codes were then grouped into candidate subthemes and themes through iterative comparison across transcripts. Theme development involved repeated movement between coded data, candidate themes, and the original transcripts to ensure that themes captured patterned meanings rather than simply summarising topics. Themes were compared across stakeholder groups, including healthcare professionals, teaching directors, trainers, researchers, hospital managers, primary healthcare managers, and policy makers, to examine areas of convergence, divergence, and stakeholder-specific emphasis. The research team held seven analytic meetings to review coding, discuss thematic boundaries, refine theme names, and assess whether each theme was grounded in the data. The final theme concerning the need for context-sensitive and locally grounded training approaches was retained because it was supported by recurring participant accounts about cultural responsiveness, flexible delivery formats, local trainers, repeated training, follow-up guidance, and institutionalised capacity building; it was therefore treated as an analytic theme arising from the data rather than only as a recommendation.

Translation of quotations

The analysis was conducted in Chinese to preserve the original meanings of participants’ accounts. Representative quotations were translated into English after themes had been finalised. Initial translation was undertaken by X.X. and checked independently by Y.T., both of whom are bilingual researchers familiar with the study context. Where quotations included culturally specific terms, expressions related to illness, dying, family responsibility, religion, or local service arrangements, the bilingual team reviewed the translation to ensure that the meaning was preserved rather than translated literally. Discrepancies were discussed within the research team until consensus was reached. The final English quotations were checked against the Chinese transcripts to ensure accuracy, contextual meaning, and consistency with the analytic interpretation.

Rigour and trustworthiness

Several steps were taken to enhance rigour and trustworthiness. The study included multiple stakeholder groups from clinical care, training, management, primary care, research, and policy, allowing comparison across perspectives and supporting a more comprehensive understanding of palliative care training in ethnic minority regions. Data collection used a common semi-structured topic guide, and the facilitator actively managed mixed-group discussions to reduce the influence of hierarchy and encourage participation from frontline and primary care participants. During analysis, transcripts were coded independently in duplicate by two researchers, coding and theme development were documented in NVivo, and seven analytic meetings were held to review codes, compare stakeholder perspectives, examine divergent cases, refine thematic boundaries, and ensure that the final themes were grounded in the data. Reflexive discussion was maintained throughout the study, with attention to how the researchers’ professional backgrounds, prior knowledge of palliative care and ethnic minority regions, and assumptions about training needs might shape interpretation. Detailed descriptions of the study setting, participant composition, data collection procedures, analysis process, and translation procedures are provided to support credibility and transferability.

Ethical considerations

The study was approved by the Ethics Committee of Guangxi Academy of Medical Sciences (IIT-2023-79). All participants were informed of the purpose of the study, the discussion procedures, the use of audio-recording, and the measures taken to protect confidentiality before taking part in the focus group discussions. Participation in this study was voluntary, and all participants provided written informed consent before taking part. Because data were collected through focus group discussions, participants were known to one another during the discussions and full anonymity could not be guaranteed. However, all participants were informed of the importance of respecting the confidentiality of information shared within the group. During data handling, transcription, analysis, and reporting, identifying information was removed, transcripts were anonymised, and quotations were presented without personally identifiable details. The data were used solely for the purposes of this study.

Results

Participant characteristics

A total of 65 participants took part in eight focus group discussions. Table 2 reports their characteristics. Of these, 35 (53.85%) were male and 30 (46.15%) were female. Most participants were aged 31–50 years (n = 41, 63.08%). In terms of education, 29 (44.62%) held a master’s degree, 21 (32.31%) held a PhD, and 15 (23.08%) held a bachelor’s degree. Participants represented seven stakeholder groups relevant to palliative care training in ethnic minority regions, most commonly healthcare professionals (n = 13, 20.00%), directors of hospital teaching departments (n = 11, 16.92%), and teachers and training organisers (n = 10, 15.38%). They were drawn from nine regions, with the largest numbers from Guangxi (n = 12, 18.46%) and Yunnan (n = 10, 15.38%).

Table 2.

Participant characteristics

Characteristics	Number	Percentage
Gender
Female	30	46.15%
Male	35	53.85%
Age
25–30 years	11	16.92%
31–40 years	21	32.31%
41–50 years	20	30.77%
51–60 years	13	20.00%
Education
Bachelor	15	23.07%
Master	29	44.62%
PhD	21	32.31%
Stakeholder group
Healthcare professionals	13	20.00%
Directors of hospital teaching departments	11	16.92%
Teachers and training organisers	10	15.38%
Researchers	9	13.85%
Hospital managers	9	13.85%
Managers from primary healthcare institutions	6	9.23%
Policy makers	7	10.77%
Region
Guangxi	12	18.46%
Ningxia	7	10.77%
Xinjiang	5	7.69%
Xizang	6	9.23%
Inner Mongolia	5	7.69%
Yunnan	10	15.39%
Guizhou	8	12.31%
Qinghai	5	7.69%
Jilin	7	10.77%

Key themes characterising palliative care training needs, barriers, and practice translation

Analysis of the focus group data generated four interrelated themes that characterised palliative care training needs, barriers, and practice translation in ethnic minority regions of China: (1) structural constraints limiting access to training; (2) misalignment between existing training and local realities; (3) difficulties in translating training into routine practice; and (4) training needs identified by participants for context-sensitive and locally grounded capacity building. Table 3 summarises these analytical themes.

Table 3.

Analytical themes on palliative care training needs, barriers, and practice translation in ethnic minority regions of China

Theme	Subtheme	Analytical interpretation
Structural constraints limiting access to training	Limited training opportunities and uneven access	Training opportunities were scarce and unevenly distributed across regions, institutions, and levels of care. Access was more likely to be available in tertiary hospitals, better-resourced institutions, or project-connected settings, while county hospitals, township health centres, and community-based services had fewer opportunities for structured or continuous training.
	Workforce shortages and heavy workload as barriers to participation	Even where training was available, participation was constrained by staffing shortages, heavy clinical workload, ward duties, outpatient work, administrative responsibilities, and on-call demands. For managers, releasing staff for training also created organisational pressure in already understaffed facilities.
	Insufficient institutional and policy support for sustained training	Palliative care training was often treated as optional or secondary rather than as a core part of workforce development. Stable funding, dedicated organisational mechanisms, local training platforms, and long-term policy support were insufficient, making training dependent on temporary projects or individual initiative.
Misalignment between existing training and local realities	Training content was often developed for mainstream settings	Existing training often reflected assumptions from urban hospitals, specialist services, or better-resourced institutions, including clearer role divisions, multidisciplinary teams, established referral pathways, and stronger institutional recognition of palliative care. These assumptions did not always fit county-level or primary care settings in ethnic minority regions.
	Limited attention to cultural, linguistic, and religious contexts	Training paid insufficient attention to how local culture, language, religion, family decision-making, and customary practices shaped palliative care. This affected practical issues such as prognosis communication, discussion of dying, symptom expression, family preferences, comfort care, hospitalisation, home care, and decisions about life-sustaining treatment.
	Mismatch between training assumptions and local frontline service capacity	Some training introduced standards, examples, and role expectations based on better-resourced hospitals, including assumptions about specialist consultation, psychological support, opioid access and monitoring, family meetings, referral pathways, or multidisciplinary care. Local facilities often lacked the staff, time, equipment, professional mix, or institutional arrangements needed to enact these models.
Difficulties in translating training into routine practice	Gaps between training knowledge and service conditions	Training could improve awareness and clarify professional standards, but local service conditions often did not support practice change. Frontline clinicians faced time pressure and established routines; primary care managers highlighted weak referral support; hospital managers noted the absence of formal service pathways; and policy-related participants pointed to weak integration between training, service standards, and assessment.
	Limited multidisciplinary support and weak service coordination	Palliative care required collaboration across professional roles and institutions, but referral pathways, specialist support, psychosocial services, and multidisciplinary teamwork remained underdeveloped in many ethnic minority regions. As a result, individual learning was difficult to translate into coordinated care.
	Training alone was insufficient to change practice	One-off training was not enough to sustain practice change. Participants emphasised the need for reinforcement, follow-up, supervision, organisational support, and space within routine service structures for new ways of working.
Training needs identified by participants: context-sensitive and locally grounded capacity building	Need for culturally responsive training content	Participants called for training that incorporated local understandings of illness, dying, family responsibility, communication, religious beliefs, and customary practices. They emphasised the need for local cases, culturally specific communication scenarios, and guidance on working with families in minority communities.
	Need for flexible and practice-oriented delivery formats	Participants preferred training that was organised around local work rhythms, local cases, realistic staffing conditions, role responsibilities, levels of care, and everyday service arrangements. Training was seen as more useful when it narrowed the gap between abstract principles and feasible frontline practice.
	Need for sustained local capacity building	Participants emphasised that training should move beyond one-off sessions and become part of longer-term local capacity building. They called for repeated training, follow-up guidance, local trainers, local teams, and institutionalised arrangements that could be maintained within local systems.

These themes did not operate in isolation. Structural constraints shaped who could access training and how regularly they could participate. When training was available, its content and delivery often reflected assumptions from urban, specialist, or better-resourced settings, limiting its relevance to local cultural, linguistic, religious, and service realities. Even when training improved awareness, weak service conditions, limited multidisciplinary support, and insufficient follow-up constrained translation into routine practice. Participants’ calls for locally grounded training therefore reflected what they saw as missing from existing training arrangements.

Theme 1: Structural constraints limiting access to training

Limited access to training was a central barrier to palliative care capacity building. Participants described not only a shortage of training activities, but also uneven access shaped by geography, institutional hierarchy, workforce pressure, and weak institutionalisation of palliative care within local workforce development systems. Training opportunities tended to reach tertiary hospitals, better-resourced institutions, or staff connected to project-based programmes more easily than county hospitals, township health centres, or community-based services.

Different stakeholder groups emphasised different dimensions of this problem. Frontline clinicians and primary care staff focused on workload and the difficulty of leaving clinical duties to attend training. Teaching directors and trainers highlighted the lack of stable training platforms, local trainers, and sustained funding. Hospital managers described the organisational cost of releasing staff when staffing was already tight. Policy-related participants framed the issue as weak integration of palliative care training into continuing professional education and local capacity-building plans.

Limited training opportunities and uneven access

Participants repeatedly pointed to the scarcity and uneven distribution of training opportunities. Training resources were often described as concentrated in higher-level hospitals or better-resourced areas, while primary care and lower-level facilities had fewer opportunities for structured or continuous training.

As one primary healthcare manager put it:

“What we lack most at the primary care level is not willingness, but opportunity. Many training programmes simply do not reach us.” (FGD 3).

Others linked this unevenness to the project-based nature of training. A hospital teaching director noted:

“This kind of training is often delivered only when there is a project. Once the project ends, the training stops, and it is very difficult to establish continuity.” (FGD 1).

Workforce shortages and heavy workload as barriers to participation

Even where training was available, participation was difficult. Facilities in ethnic minority regions, especially county-level and primary care institutions, often operated with limited staffing. Clinical staff described wanting to attend training but being constrained by ward duties, outpatient work, administrative tasks, and on-call responsibilities.

One healthcare professional stated:

“It is not that people are unwilling to learn; it is that clinical work is so demanding that there is simply no uninterrupted time to take part.” (FGD 7).

A hospital manager described the same issue organisationally:

“Staffing is already tight. If we send even one person for training, the workload for everyone else becomes even heavier.” (FGD 5).

Insufficient institutional and policy support for sustained training

Participants also connected restricted access to weak institutional and policy support. In many settings, palliative care training was treated as optional or secondary rather than as a core part of service capacity building. Without stable funding, dedicated organisational mechanisms, and long-term planning, training depended heavily on individual initiative or temporary projects.

A teacher commented:

“If training is to be sustained over the long term, it cannot rely solely on temporarily invited experts or one-off projects.” (FGD 4).

A policy maker similarly observed:

“Without sustained policy support, it is difficult for primary-level institutions to place this kind of training high on their agenda.” (FGD 1).

Theme 2: Misalignment between existing training and local realities

The second theme concerns whether available training was relevant and usable in local practice. Participants repeatedly suggested that training developed for mainstream urban hospitals, specialist services, or better-resourced institutions often travelled poorly into ethnic minority regions, where staffing patterns, service organisation, cultural expectations, and patient-provider communication differed substantially.

Training content was often developed for mainstream settings

A frequent concern was that training content reflected the assumptions of large hospitals or specialist palliative care services. Such training often assumed clearer role divisions, multidisciplinary teams, established referral pathways, and stronger institutional recognition of palliative care than were available in many county-level or primary care settings.

One participant summarised this mismatch:

“Much of the training is clearly designed around the circumstances of large hospitals, but it differs greatly from the realities of primary health-care institutions in ethnic minority regions like ours.” (FGD 8).

Trainers tended to interpret this as a curriculum-design problem, while primary care participants described it as a gap between what was taught and what their facilities could realistically provide. Hospital managers emphasised that specialist-oriented training models were difficult to reproduce without dedicated palliative care departments or stable multidisciplinary teams.

Limited attention to cultural, linguistic, and religious contexts

Participants also reported that training paid insufficient attention to the cultural, linguistic, and religious contexts in which care was delivered. This was not an abstract concern about “culture”; it affected concrete aspects of practice, including prognosis communication, discussion of dying, family decision-making, symptom expression, and expectations about comfort care, hospitalisation, home care, and life-sustaining treatment.

Participants noted that communication training often taught relatively direct approaches to discussing diagnosis, deterioration, or end-of-life preferences. In some local communities, however, direct discussion of death could be considered inappropriate, harmful, or disrespectful. In multilingual settings, older patients and families could have difficulty expressing symptoms, emotional distress, or care preferences in Mandarin. Religious beliefs, funeral customs, and family obligations also shaped how families understood palliative care and what they expected from clinicians.

One participant explained:

“The communication methods taught in training are often quite generic, but in ethnic minority regions with different cultural customs, many things cannot be said so directly.” (FGD 7).

This issue was emphasised most strongly by frontline clinicians and primary care staff, who directly managed patient-family communication. Trainers and researchers also recognised the issue, but framed it mainly as a lack of local cases, culturally specific scenarios, and guidance on family or religious decision-making in training materials.

Mismatch between training assumptions and local frontline service capacity

The third subtheme concerns the mismatch between training assumptions and local service capacity. It was retained under Theme 2 because participants were not only describing post-training implementation difficulties; they were also questioning whether the content, standards, examples, and role expectations built into training were designed for local frontline realities.

Some training introduced models based on better-resourced hospitals, including assumptions about specialist consultation, psychological support, opioid access and monitoring, family meetings, referral pathways, or multidisciplinary care. However, many local facilities lacked the staffing, time, equipment, professional mix, or institutional arrangements needed to enact these models.

One participant stated:

“After the training, we may know what the standards are, but once we return to frontline practice, we still find that medical and workforce conditions in many respects are not sufficient to support them.” (FGD 2).

This subtheme therefore captures a design-level misalignment: training did not always show providers how to adapt standards to their actual roles, teams, and facilities. Theme 3, by contrast, focuses on what happened after training when providers attempted to use what they had learned within routine service systems.

Theme 3: Difficulties in translating training into routine practice

Participants also described what happened after training. Training could increase awareness and clarify professional standards, but still fail to produce sustained changes in care. This theme differs from Theme 2 because it concerns the organisational and system conditions needed to carry learning into everyday practice.

Gaps between training knowledge and service conditions

Many participants returned from training with a clearer sense of what palliative care should involve, but found that local service conditions did not support implementation. Frontline clinicians emphasised time pressure, competing clinical priorities, and difficulty changing established routines. Primary care managers highlighted weak referral support and limited capacity to manage complex symptoms. Hospital managers focused on the absence of formal service pathways and incentives, while policy-related participants pointed to weak integration between training, service standards, and institutional assessment.

One participant captured this gap directly:

“Although attending training increased my awareness of palliative care, it was still very difficult to change my day-to-day practice.” (FGD 5).

Limited multidisciplinary support and weak service coordination

Participants repeatedly described palliative care as work requiring collaboration across professional roles and institutions. Yet referral pathways, specialist support, psychosocial services, and multidisciplinary teamwork remained underdeveloped in many ethnic minority regions.

One participant explained:

“Although we learned the principles and methods of palliative care, many aspects were difficult to implement because referral pathways, specialist support, psychological support, and team collaboration were lacking.” (FGD 1).

Another participant framed the same issue systemically:

“It is not enough for one person to learn. The system does not support it, because we have not established a multidisciplinary mechanism for collaboration.” (FGD 3).

These accounts show that training could not be translated into practice through individual competence alone. It use depended on whether the surrounding service system could support coordinated care.

Training alone was insufficient to change practice

Participants were clear that training, while necessary, was rarely sufficient on its own. Its longer-term value depended on reinforcement, follow-up, supervision, institutional support, and space within everyday service structures for new ways of working.

One participant reflected:

“The training itself is useful, but without follow-up, reinforcement, and organisational support, it is very difficult to sustain in the long term.” (FGD 5).

Another added:

“To turn training into practice, what is needed is ongoing guidance, institutional support, or follow-up supervision, rather than a single episode of learning.” (FGD 6).

These accounts suggest that training should not be understood as a self-contained intervention. Its effects depended on whether it was embedded within wider processes of service development, institutional reinforcement, and local capacity building.

Theme 4: Training needs identified by participants: context-sensitive and locally grounded capacity building

The fourth theme differs from the first three. Rather than describing another barrier, it captures participants’ accounts of what was missing from existing training and what forms of training would be more usable in ethnic minority regions. Participants did not simply call for more training. They called for training that could respond to local culture, fit local service capacity, and be sustained through local teams and institutions.

Need for culturally responsive training content

Participants argued that palliative care training should engage more directly with local understandings of illness, dying, family responsibility, communication, and religious or customary practice. They emphasised the need for local cases, communication scenarios, and examples of how to work with families when direct disclosure, decision-making authority, and expectations about end-of-life care differ from mainstream training assumptions.

One participant stated:

“The cultural customs and religious beliefs of ethnic minority communities mean that training needs to respond more fully to local cultural practices, language environments, and ways of expressing illness and dying.” (FGD 7).

Another added:

“Training should pay greater attention to the influence of local beliefs, family decision-making patterns, and religious practices on care.” (FGD 7).

Need for flexible and practice-oriented delivery formats

Participants favoured training formats that were flexible and closely tied to daily work. In settings marked by workforce shortages and uneven service capacity, training was seen as more useful when organised around local cases, realistic staffing conditions, role responsibilities, and the level of care that local institutions could provide.

One participant observed;

“Training that is better suited to local conditions should be organised around local work rhythms, levels of medical care, local cases, and the practical arrangements of everyday service delivery.” (FGD 2).

Need for sustained local capacity building

Participants favoured training formats that were flexible and closely tied to daily work. In settings marked by workforce shortages and uneven service capacity, training was seen as more useful when organised around local cases, realistic staffing conditions, role responsibilities, and the level of care that local institutions could provide.

One participant put this succinctly:

“Rather than one-off courses, what is needed is sustained support, repeated training, and follow-up guidance.” (FGD 8).

Another linked sustainability to local capacity and institutionalisation:

“If training is to be sustained, it requires local teams, local trainers, and more institutionalised arrangements.” (FGD 6).

These accounts indicate that participants did not see better training as a matter of scale alone. They called for a model that could be carried and maintained within local systems rather than imported episodically from outside.

Discussion

This study examined palliative care training needs, barriers, and practice translation across multiple ethnic minority regions in China. Rather than showing a simple absence of training, the findings point to a more complex problem: training opportunities were uneven and weakly institutionalised; available training was often insufficiently adapted to local cultural, linguistic, religious, and frontline service realities; and training gains were difficult to translate into routine practice without multidisciplinary support, follow-up supervision, and organisational reinforcement. Given the heterogeneity of the regions included in this study and the absence of detailed comparison across specific ethnic groups or localities, we do not claim to provide an exhaustive account of palliative care training across all ethnic minority regions in China. Instead, the study offers cross-regional qualitative evidence on recurring training challenges and the mechanisms through which they shape practice translation.

The findings support and extend previous research on palliative care education and workforce development. Existing studies have shown that palliative care training can improve healthcare professionals’ knowledge, awareness, and confidence, but that educational provision alone is often insufficient to change practice unless training is embedded within service systems, organisational routines, and continuing professional development structures [6, 17]. In China, previous research has focused more often on palliative care awareness, service development, educational needs, or urban institutional settings, while less is known about how training is implemented and translated in ethnically diverse and resource-constrained regions [24, 25]. Our findings extend this literature by showing how training barriers are produced through the intersection of geography, workforce shortages, institutional hierarchy, cultural diversity, and uneven service infrastructure. The problem was not only that training opportunities were limited; it was also that training was often episodic, project-based, and detached from the conditions under which providers were expected to use what they had learned.

The study also resonates with international literature on culturally responsive palliative care. Cross-cultural palliative care education has been identified as necessary because clinicians increasingly care for patients and families whose language, family structures, religious practices, and understandings of illness and dying differ from dominant biomedical assumptions [31–33]. Semlali et al. showed that cross-cultural education in palliative care requires practical strategies for curriculum design rather than only general awareness of cultural difference [31]. A qualitative systematic review by Burke et al. similarly found that healthcare practitioners providing palliative care to culturally diverse patients face challenges related to communication, family involvement, cultural and religious beliefs, and service flexibility [32]. More recent qualitative work on cultural diversity in end-of-life care has also emphasised that cultural competence must be enacted in concrete communication, decision-making, and relational practices rather than treated as an abstract professional attribute [33]. Our findings support these arguments by showing that cultural responsiveness in China’s ethnic minority regions involved practical questions: how to talk about deterioration and death, how to work with family-centred decision-making, how to interpret symptom expression across language environments, and how to respect religious and customary expectations around dying and care.

This finding also connects with Indigenous and culturally safe palliative care research in Aotearoa New Zealand and Australia. Work associated with the Te Ārai Palliative Care and End of Life Research Group, has highlighted the importance of community-centred, family-oriented, and culturally safe approaches to palliative and end-of-life care [34]. Although the sociopolitical and cultural contexts differ from China’s ethnic minority regions, this literature provides an important comparative insight: culturally responsive palliative care cannot be achieved through technical training alone. It requires attention to relationships, language, family authority, community knowledge, and local meanings of illness, dying, and care. Our study extends this insight to the Chinese context by showing that palliative care training in ethnic minority regions needs to move beyond generic communication skills or standardised curricula and include local cases, culturally specific communication scenarios, and mechanisms for building local training capacity.

The findings also align with literature on implementing palliative care training in rural, regional, and resource-limited settings. Studies in rural and regional health-care settings have shown that barriers to translating palliative care knowledge into practice include limited staffing, service fragmentation, lack of organisational support, weak specialist backup, and limited opportunities for ongoing learning [35]. Our findings support this evidence and show that similar implementation problems arise in China’s ethnic minority regions. However, the present study adds that these barriers are compounded when training content is insufficiently adapted to local service capacity. Participants did not simply report difficulty applying what they learned; they questioned whether training models designed around better-resourced hospitals, specialist consultation, multidisciplinary teams, and formal referral pathways were appropriate for county-level and primary care facilities with limited personnel, time, and institutional support. This distinction helps clarify why practice translation should be understood not only as a post-training implementation issue, but also as a training design issue.

The study further suggests that palliative care workforce development in ethnic minority regions should be understood as a system-building process rather than a sequence of discrete training events. The first three themes showed how barriers accumulate: limited access restricts who can learn; poor contextual fit reduces the usefulness of what is taught; and weak service infrastructure prevents learning from becoming routine practice. The fourth theme, therefore, should not be read merely as a set of recommendations. It reflects participants’ analysis of what was missing from existing training arrangements: cultural responsiveness, flexible and practice-oriented delivery, local trainers, repeated learning, follow-up guidance, and institutionalised capacity building. This finding supports broader implementation literature suggesting that professional education is more likely to influence practice when it is reinforced by supervision, organisational support, peer learning, and service redesign [35].

Policy implication

These findings highlight the need to move beyond a model of palliative care training built around one-off course provision and towards a more context-responsive training infrastructure in ethnic minority regions. First, training content needs to shift from generic knowledge delivery to closer engagement with local realities, bringing language difference, cultural customs, religious beliefs, family decision-making patterns, and frontline care conditions into the core of programme design rather than treating them as peripheral concerns. Second, delivery formats need to fit more closely with local work rhythms, with greater emphasis on case-based discussion, scenario-based learning, workplace-integrated teaching, and staged forms of training that are more accessible and usable in practice.

More importantly, training should be approached as part of local capacity building rather than as an isolated educational activity. This implies the need to develop local trainers, establish locally anchored support teams, and embed palliative care training more firmly within continuing professional education, primary care strengthening, and institutional planning. Training is more likely to have sustained practical effects in ethnic minority regions when its content, delivery, and organisational support are strengthened together.

Contribution and limitation

This study has both theoretical and practical contributions. Theoretically, it provides one of the first cross-regional qualitative examinations of palliative care training needs, barriers, and practice translation in China’s ethnic minority regions. It extends a literature that has focused more often on palliative care service provision, general educational needs, or urban settings by showing how training is shaped by the interaction of structural constraints, cultural and linguistic diversity, local service capacity, and implementation conditions. Practically, the study offers guidance for improving palliative care training in ethnic minority regions by showing that progress will depend not only on expanding training opportunities, but also on strengthening cultural adaptation, practice orientation, local trainer development, follow-up support, and institutional reinforcement. These insights are directly relevant to ethnic minority regions in China and may also inform training development in other culturally diverse, rural, remote, and resource-constrained settings.

The study also has several limitations. First, this was a qualitative study designed to provide in-depth understanding rather than statistically representative estimates, and the findings should therefore be interpreted primarily in explanatory and contextual terms. Second, although the study covered multiple ethnic minority regions in China, substantial variation remains across these settings in terms of health resources, ethnic composition, language, religion, and cultural traditions. The study was not designed to compare specific ethnic groups or regions in depth, and future research could undertake more fine-grained comparative work. Third, the study focused on stakeholders connected to training and did not include patients or family members, which means that the implications of training barriers for patient and family experiences were not examined directly. Future research could incorporate the perspectives of patients, families, and community members to deepen understanding of culturally responsive palliative care capacity building in ethnic minority settings.

Conclusion

This study shows that barriers to palliative care training in ethnic minority regions of China cannot be explained by limited training provision alone. They arise from the intersection of structural constraints, inadequate local adaptation, and difficulty translating training into practice. Restricted access to training, the limited fit of existing models with local cultural and frontline service realities, and the lack of sustained organisational support together constrain palliative care capacity building. Strengthening training in these settings will require more than expanding courses or relying on short-term projects; it will require culturally responsive, practice-oriented, and sustained forms of local capacity building. Although situated in ethnic minority regions of China, these findings are also relevant to other settings facing similar combinations of resource constraint, cultural diversity, and workforce limitation.

Authors’ contributions

H.W. contributed to drafting and critically reviewing the manuscript, and to data coding and interpretation. X.L. contributed to drafting the manuscript and data organisation. X.W. contributed to data coding and analysis. M.L., Y.T. and L.D. contributed to participant recruitment, data collection, and data extraction. X.X. contributed to the conceptualisation and design of the study, supervised the analysis, and critically reviewed the manuscript. All authors read and approved the final manuscript.

Funding

This research was supported by Guangxi Science and Technology Program (2026GXNSFAA00641259). The funder has no role in the design of the study and collection, analysis, and interpretation of the data, nor in writing the manuscript.

Data availability

The data are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted with the approval of the Ethics Committee of Guangxi Academy of Medical Sciences (IIT-2023-79). All procedures involving human participants were performed in accordance with relevant guidelines and regulations, including the Declaration of Helsinki. Participation in this study was voluntary, and all participants provided written informed consent before taking part. All data used for analysis and reporting were anonymised. Because the study used focus group discussions, full anonymity among participants could not be guaranteed; however, participants were asked to respect the confidentiality of information shared within the group.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.