INTRODUCTION: Patient demographics demand physicians who are competent in and embrace palliative care as part of their professional identity. Published literature describes ways that learners acquire knowledge, skills and attitudes for palliative care. These studies are, however, limited by their focus on the individual where learning is about acquisition. Viewing learning as a process of becoming through the interplay of individual, social relationships and cultures, offers a novel perspective from which to explore the affordances for professional identity development.
METHODS: Qualitative narrative methods were used to explore 45 narratives of memorable learning (NMLs) for palliative care recounted by 14 graduating family medicine residents in one family medicine residency program. Thematic and narrative analyses identified the affordances that support and constrain the dynamic emergence of professional identity.
RESULTS: Participants recounted affordances that supported and/or constrained their learning acting on personal (e.g. past experiences of death), interpersonal (e.g. professional support) and systemic (e.g. patient continuity) levels. Opportunities for developing professional identity were dynamic: factors acted in harmony, were misaligned, or colliding to support or constrain an emerging professional identity for palliative care practice.
CONCLUSION: Findings highlight how individual factors interplay with interpersonal and structural conditions in the workplace in dynamic and emergent ways that may support or constrain the emergence of professional identity. Viewing learning as a process of becoming allows teachers, curriculum developers and administrators to appreciate the complexity and importance of the interplay between the individual and the workplace affordances to create environments that nurture professional identity for palliative care practice.
Background: One of the most difficult and stressful tasks faced by health science students is having to cope with death and dying due to the emotional burden of the same. Furthermore, the moral, ethical and professional values of future health professionals are influenced by the cultures where they live.
Purpose: This study sought to compare and analyze the perception on end of life among a sample of health science students in Spain and Bolivia.
Methods: A descriptive, cross-sectional and multi-centric study. The total sample (548 students) was comprised of three groups: medical, nursing and physiotherapy students, of whom 245 were from Bolivia, and 303 were Spanish students. The measurement instruments used were the Bugen’s Coping with Death Scale and the Death Self-Efficacy Scale by Robbins.
Results: No statistically significant differences were observed between Spanish and Bolivian students (t (546) = - 0.248, p = 0.804) using the Bugen scale. This implies that there are no differences between the perception of both groups of students and that both groups use similar strategies to cope with death. Additionally, the beliefs and attitudes of both groups were similar, with Bolivian students presenting a trend towards improved scores. No differences were found between Spain and Bolivia in the results obtained on the Robbins scale, with students from both countries displaying similar skills and capabilities for facing death.
Conclusions: The beliefs on death of health science students from Spain and Bolivia were not affected by the respective cultures, type of degree studied, students’ age, or the country of origin, however, we found that students in Bolivia value death as something more natural than their Spanish counterparts.
To appropriately prepare students for this topic, education on coping with death and dying must be included within the university curriculum.
Objectives: In an ageing society, community-based medical education in a home care setting needs to be developed. Drawing on Kolb's experiential learning theory, this study aimed to explore the learning processes in overnight home care by medical trainees in terms of their understanding of terminally ill patients and their conceptualization of themselves as future physicians.
Methods: An overnight home care program in which a trainee had to take care of terminally ill patients on his/her own under the supervision of a healthcare team was conducted. Nineteen trainees, including eight medical students and 11 residents, participated in this study. Text data of reflective reports written after the overnight care were collected and thematically analyzed.
Results: The trainees' learning experiences in the program were categorized into four stages: predeparture, concrete experience, reflective observation and abstract conceptualization. Although they had mixed feelings, including anxiety, fear and expectations, at the predeparture stage, they could be actively involved in providing medical care and daily life support and in taking care of dying patients at the patients' homes overnight. By reflecting on their experiences, they gained a sense of achievement and identified the aspects upon which they should improve as future physicians. Subsequently, based on their reflective observation, they conceptualized their approaches to home care and the roles/responsibilities of physicians as healers, which led to professional identity formation.
Conclusions: Overnight home care by medical trainees has the potential as an educational strategy to promote their realistic understanding of home care and facilitate professional identity formation.
This study focuses on the impact of common spiritual beliefs regarding metaphysical questions in agreeability with the practice of hastened death. A sample of 497 Portuguese medical students was collected. Differences between genders and religions, predictors for agreeability with hastened death and the association between spiritual beliefs and opinion towards hastened death cases were assessed. Respondents were mostly favourable to the practice of hastened death. Formal religious affiliation and higher levels of religiosity significantly associated with lesser agreeability with hastened death. Statistically significant association was found between every hastened death scenario and multiple of the spiritual beliefs used. A number of spiritual beliefs were predictors of agreeability. We discuss the implications of religion and spirituality in agreeability with hastened death. Further research is required to better understand the true weight of spirituality in one's opinion towards this ethical dilemma.
Background: High-fidelity simulation is being considered as a suitable environment for imparting the skills needed to deal with end-of-life (EOL) situations. The objective was to evaluate an EOL simulation project that introduced communication skills to nursing students who had not yet begun their training in real healthcare environments.
Methods: A sequential approach was used. The "questionnaire for the evaluation of the end-of-life project" was employed.
Results: A total of 130 students participated. Increasing the time spent in high-fidelity simulation significantly favored the exploration of feelings and fears regarding EOL (t = -2.37, p = 0.019), encouraged dialogue (t = -2.23, p = 0.028) and increased the acquisition of communication skills (t = -2.32, p = 0.022).
Conclusions: High-fidelity simulation promotes communication skills related to EOL in novice nursing students.
BACKGROUND: End-of-life discussions are associated with improved quality of care for patients. In the UK, the General Medical Council outlines a requirement for medical graduates to involve patients and their families in discussions on their care at the end-of-life. However medical students feel ill-equipped to conduct these discussions.
METHODS: In 2018, Sheffield Medical School introduced a small group role-play session on end-of-life discussions for all final year medical students. Scenarios were devised to improve confidence in the following learning domains: communicating prognosis with patients and family; ascertaining patient's goals, values and preferred place of death; discussing escalation of treatment, discussing do not attempt resuscitation orders, care in the dying phase of illness and pre-emptive prescribing. Evaluation was conducted over 16 weeks with a before and after questionnaire. Students rated their confidence in the above learning domains on a Likert-style scale and explained their ratings in free-text boxes.
RESULTS: There was a 76% response rate to the questionnaire and analysis showed statistically significant improvements in confidence across all learning domains following the session. Qualitative analysis of free-text responses showed that prior to the sessions, students expressed low confidence due to lack of experience and fear of upsetting patients. After the session students felt they had gained skills but expressed persistent anxiety and a desire for further practice.
CONCLUSIONS: Our innovation suggests that the opportunity to experience end-of-life discussions through role-play can significantly improve students' confidence in conducting these conversations. However, repeated sessions are likely necessary for students to feel prepared upon graduation.
There are few formal training opportunities that exist for RNs interested in the rapidly growing field of hospice and palliative care. To address this, the curriculum for a nurse residency program was developed and delivered to 12 nurses over 1 year. The nurse residents, as well as their clinical supervisors and interprofessional colleagues, were surveyed to obtain feedback on the overall program. Skill acquisition of the nurses was also assessed. The results indicate that the nurse residents had increased levels of confidence in caring for dying patients, communication with other clinicians, and delegation and management of treatment teams and families. According to supervisors and colleagues, strengths of the program included support for new nurses, integration of the interprofessional team, and solid preparation for new hospice nurses. These findings provide nursing educators and administrators with needed insight into the development and evaluation of an RN residency program in hospice and palliative care.
Background: More medical residents and fellows outside of palliative care (PC) will need to be trained in primary PC (PPC) to meet an increasing patient need.
Objective: To systematically review surveys of program leadership in postgraduate medical training programs and their respective PPC curricula.
Methods: This review included all studies of program leadership surveyed about their PPC curricula in U.S. graduate medical education programs, published in English, and listed on MEDLINE, CINAHL, and EMBASE through January 2020.
Results: Data were extracted from eight studies that met the selection criteria out of 221 reviewed texts. PC domains of communication, symptom management, and end-of-life care were taught in all medical specialties most commonly through didactics and PC rotations. Program leadership supported expanding PPC curriculum, with lack of time being the most common barrier. There were differences by specialty in which trainees were exposed to PPC education, with most programs not using a formal curriculum.
Conclusions: Generally, there are positive attitudes about PPC education, but there remain significant numbers of trainees with no exposure, and heterogeneity in the content and delivery of PPC education across specialties. PPC Education in U.S. Residencies and Fellowships: A Systematic Review of Program Leadership Perspectives.
THEORY: Empathy has a potentially complicated relationship with dealing with death and dying. Having clinical empathy can improve interactions with dying, but educational interventions aimed at fostering empathy may cause medical students to connect emotionally with dying patients and behave unprofessionally out of self-defense. Cognitively-based clinical empathy should lead to positive attitudes toward death and dying by adhering to the principles of detached concern and professionalism. Hypotheses: The main components of cognitively-based clinical empathy are negatively correlated with (1) difficulty communicating with dying patients and their relatives, and (2) avoidance of death and dying.
Method: This cross-sectional study included 372 medical students from two universities in Konya, Turkey. Data were collected via a survey consisting of three parts: socio-demographic information, the Turkish version of Jefferson Scale of Empathy-Student Version (JSE-S), and the Turkish Approach to Death and Dying Patients Attitude Scale. Independent samples t-test and one-way analysis of variance were used for comparative analysis. Bivariate and partial correlation analyses were used to assess the associations between variables.
Results: Perspective-taking and compassionate care were significantly and moderately positively correlated with difficulty communicating with the dying and their relatives. Perspective-taking and compassionate care had significant, but weak positive correlations with avoiding death and dying. There was no significant correlation between standing in the patient's shoes and either communication or avoidance.
Conclusions: Both hypotheses were rejected. The present findings raise questions regarding whether the JSE-S is an effective operationalization of cognitively-based clinical empathy. Perspective-taking and compassionate care as measured by the JSE-S may reflect a propensity to engaging emotionally that leads to negative attitudes toward death and dying in medical students. If so, reducing the negative effects of emotional engagement seems crucial for developing positive attitudes toward death and dying in medical students.
The aim of this study is to explore nursing students' experiences with death and terminal patients during clinical education. A secondary analysis of qualitative data that were collected through 11 focus group interviews with nursing students was performed. Data obtained from the interviews were analyzed using thematic analysis. There were a total of 9 themes across 3 contexts. Data were grouped under the following themes: feelings experienced when encountering death for the first time, reactions to the first encounter with death, factors affecting the reactions to death, involvement in terminal patient care, being informed about the physical process that terminal patients are going through, students' approach toward terminal patients and their relatives, health professionals' approach toward terminal/dying patients/their relatives, changes in the ideas about death, and changes in the ideas about terminal/dying patients. The study shows a lack of guidance on the part of teachers who also avoid patients and families who are considered terminally ill.
This study aimed to analyze the schools that teach ethical and legal aspects within the subject of palliative care in the degrees of medicine and nursing in Spain.
MATERIAL AND METHODS: Descriptive Analysis of the palliative care subject and their ethical and legal curricular competencies in the Spanish Nursing and Physicians undergraduate. The training received in legal ethical aspects related to palliative care was compared with the criteria established by the European Association for Palliative Care (EAPC).
DATA SOURCES: The National Conference of Nursing Deans, The National Conference of Spanish Medical Faculty Deans and The Ministry of Science, Innovation, and Universities databases were searched.
RESULTS: Twenty-one universities have an undergraduate in medicine with palliative care in their curricular training explicitly. The degree in nursing is present in fifty-six universities, palliative care is present in 62.5% of the cases. The degrees of nursing and medicine receive approximately the same level of training in ethical and legal aspects of palliative care.
CONCLUSION: The specific training received in ethical and legal issues of palliative care must be improved in medical and nursing to meet the EAPC levels.
OBJECTIVES: Death is a significant event that affects healthcare providers emotionally. We aimed to determine internal medicine (IM) and paediatric (PD) residents' responses and the impact on the residents following patient deaths, and to compare any differences between IM and PD residents. We also aimed to determine whether sufficient resources and measures were in place to support residents through their grief process.
METHODS: This is a single-centre, cross-sectional study involving residents from IM and PD programmes from an academic tertiary hospital in Singapore. The residents completed a questionnaire regarding their responses and emotions after experiencing patient deaths.
RESULTS: A total of 122 residents (85 IM and 37 PD, equally distributed between year 1 to year 4 of residency training) participated, with 100% response rate. Only half (57%) felt they would be comfortable treating a dying patient and 66.4% reported feeling sad following their patient's death. Most (79.5%) were not aware of support resources that were available and 82% agreed that formal bereavement training should be included in the residency curriculum. PD residents had more negative symptoms than IM residents, with poor concentration (PD 35.1% vs IM 16.5%, p=0.02) and lethargy (PD 35.1% vs IM 9.4%, p<0.01) being the most common.
CONCLUSION: In our Asian context, residents are negatively affected by patient deaths, especially the PD residents. There is a need to incorporate relevant bereavement training for all residents.
Background: The medical profession increasingly recognizes the growing need to educate nonpalliative physicians in palliative care.
Objective: This study aims to provide a scoping review of the primary palliative care (PPC) education currently available to graduate medical trainees in primary and specialty tracks.
Design: Studies of PPC interventions in U.S. residency or fellowship programs of all subspecialties published in English and listed on MEDLINE, CINAHL, and EMBASE through January 2020 were included. To meet admission criteria, studies had to describe the content, delivery methods, and evaluation instruments of a PPC educational intervention.
Results: Of 233 eligible full texts, 85 studies were included for assessment, of which 66 were novel PPC educational interventions and 19 were standard education. Total number of publications evaluating PPC education increased from 8 (2000-2004) to 36 (2015-2019), across 11 residency and 10 fellowship specialties. Residency specialties representing the majority of publications were emergency medicine, general surgery, internal medicine, and pediatric/medicine-pediatrics. PPC content domains most taught in residencies were communication and symptom management; the primary delivery method was didactics, and the outcome assessed was attitudes. Fellowship specialties representing the majority of publications were pediatric subspecialties, nephrology, and oncology. The PPC content domain most taught in fellowships was communication; the primary delivery method was didactics and the outcome evaluated was attitudes.
Conclusions: While PPC education has increased, it remains varied in content, delivery method, and intervention evaluations. Future studies should include more widespread evaluation of behavioral outcomes, longitudinal persistence of use, and clinical impact.
The purpose of this pilot was to identify the effects of a 4-credit interdisciplinary undergraduate course focused on communication strategies to enhance spiritual care at the end of life. The course provided students with opportunities to enhance their ability to communicate empathically with individuals facing the end of life. Evidence-based content focused on ways to live each day with hope and gratitude, strengthen relationships, create a legacy, and find meaning and purpose in life and death. Narayanasamy's (1999) Actioning Spirituality and Spiritual Care Education and Training in Nursing model guided project development. The study used a prospective, pretest/posttest design. Participants included undergraduate students (n = 34) from nursing, premedicine, athletic training, business, economics, and religious studies at a Midwest liberal arts college. Statistically significant differences were found in students' attitudes toward and knowledge of spirituality/spiritual care (P < .0001, Cohen's d = 0.59), spiritual care competence (P < .0001, Cohen's d = 0.79), and level of response empathy through role play (P < .0001, Cohen's d = 0.92). Many students referred to this course as “life changing” and “healing.” As our students go out into the community, they may intimately touch the lives and hearts of future patients, family, and friends who face the end of life with their compassionate words.
Nearly all reports of interprofessional education (IPE) in palliative care have excluded pharmacy students. This article describes an IPE event between pharmacy and nursing students and assesses its impact on IPE competencies. Second-year nursing students and third-year pharmacy students participated in an evening-long event, focused on a married couple who each require palliative care—one for end-of-life planning and one for chronic disease progression. The impact of the event was assessed using the Interprofessional Collaborative Competency Attainment Scale (ICCAS) and qualitative feedback. Two hundred nine (96.7%) completed the ICCAS, and 16 of the 20 statements of the ICCAS showed large positive effect sizes (Cohen d >= 0.8), with the remaining 4 showing moderate positive effect sizes (Cohen d >= 0.5). The greatest effect sizes were related to improved awareness of complementary skillsets and knowledge between the professions. Addressing team conflict and including the patient/family in decision-making showed the least improvement. While ongoing interactions are ideal for the development of skills related to conflict and team development, this article demonstrates that even a 1-time activity can have an impact on students' interprofessional care competence.
BACKGROUND: As the global population ages, palliative care is ever more essential to provide care for patients with incurable chronic conditions. However, in many countries, doctors are not prepared to care for dying patients. Palliative care education should be an urgent concern for all medical schools all around the world, including Latin America and Brazil. Advances in palliative care education require robust assessment tools for constant evaluation and improvement of educational programmes. Bandura's social cognitive theory proposes that active learning processes are mediated by self-efficacy and associated outcome expectancies, both crucial elements of developing new behaviour. The Self-Efficacy in Palliative Care (SEPC) and Thanatophobia Scales were developed using Bandura's theory to assess the outcomes of palliative care training.
OBJECTIVES: We aimed to translate and validate these scales for Brazilian Portuguese to generate data on how well doctors are being prepared to meet the needs of their patients.
DESIGN: Cross-sectional study.
SETTING: One Brazilian medical school.
PARTICIPANTS: Third-year medical students.
METHODS: The authors translated the scales following the European Organisation for Research and Treatment of Cancer's recommendations and examined their psychometric properties using data collected from a sample of 111 students in a Brazilian medical school in 2017.
RESULTS: The Brazilian versions of SEPC and Thanatophobia Scales showed good psychometric properties, including confirmatory factor analysis, replicating the original factors (factor range: 0.51-0.90), and acceptable values of reliability (Cronbach's alpha: 0.82-0.97 and composite reliability: 0.82-0.96). Additionally, the Brazilian versions of the scales showed concurrent validity, demonstrated through a significant negative correlation.
CONCLUSIONS: The Brazilian version of the scales may be used to assess the impact of current undergraduate training and identify areas for improvement within palliative care educational programmes. The data generated allow Brazilian researchers to join international conversations on this topic and educators to develop tailored pedagogical approaches.
Objectives: Euthanasia, i.e. Physician Assisted Suicide, is a highly taboo topic, which has grown unusually over the past decade in concomitance with swift advancement in medical care of terminally ill patients. The aim of this study was to assess the knowledge, awareness and attitude of Health Professions Students (HPSs) towards Euthanasia.
Methods: This cross-sectional study was carried out in all Colleges of King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Jeddah Campus was conducted from November & December 2019. A predesigned questionnaire written in English containing essential elements about Euthanasia was adopted to achieve the purpose of the study.
Results: A total of 522 students responded positively to the dispensed survey. 290 (55.6%) of respondents were males while 232 (44.4%) were females with a ratio of 1:1.25. We found that majority of HPSs (57%, n=298) were aware of the term euthanasia and the concept behind it. 65.1% (340) of the HPSs understood the accepted definition of euthanasia as “Physician Assisted Suicide”. However, only 19.9% (104) of HPSs agreed to ever favor euthanasia if given a choice while 47.9% (250) of them disagreed. Also, majority of them (61.4% among males and 51.7% among females) agreed that practicing religion influenced their responses to this survey.
Conclusions :The awareness about the euthanasia was fairly good among HPSs of KSAU-HS however this study identifies a dire need of introducing the bioethical concepts of practicing euthanasia and the legal issues surrounding it within the curriculum.
Introduction: An acute shortage of senior mentors saw the Palliative Medicine Initiative (PMI) combine its novice mentoring program with electronic and peer mentoring to overcome insufficient mentoring support of medical students and junior doctors by senior clinicians. A three-phased evaluation was carried out to evaluate mentees’ experiences within the new CNEP mentoring program.
Methods: Phase 1 saw use of a Delphi process to create a content-valid questionnaire from data drawn from 9 systematic reviews of key aspects of novice mentoring. In Phase 2 Cognitive Interviews were used to evaluate the tool. The tool was then piloted amongst mentees in the CNEP program. Phase 3 compared mentee’s experiences in the CNEP program with those from the PMI’s novice mentoring program.
Results: Thematic analysis of open-ended responses revealed three themes–the CNEP mentoring process, its benefits and challenges that expound on the descriptive statistical analysis of specific close-ended and Likert scale responses of the survey. The results show mentee experiences in the PMI’s novice mentoring program and the CNEP program to be similar and that the addition of near peer and e-mentoring processes enhance communications and support of mentees.
Conclusion: CNEP mentoring is an evolved form of novice mentoring built on a consistent mentoring approach supported by an effective host organization. The host organization marshals assessment, support and oversight of the program and allows flexibility within the approach to meet the particular needs of mentees, mentors and senior mentors. Whilst near-peer mentors and e-mentoring can make up for the lack of senior mentor availability, their effectiveness hinges upon a common mentoring approach.
To better support the CNEP program deeper understanding of the mentoring dynamics, policing and mentor and mentee training processes are required. The CNEP mentoring tool too needs to be validated.
Background: The ability to perceive care goals of the dying may be an indicator of future quality patient-centered care. Research conducted on end-of-life goals indicates discrepancies between patients and physicians.
Objective: The aim of this study is to compare end-of-life care goals of hospice patients and medical student perceptions of patient care goals.
Design: Hospice patients and medical students were surveyed on their care goals and perceptions, respectively, using an 11-item survey of goals previously identified in palliative care literature. Medical student empathy was measured using the Interpersonal Reactivity Index.
Settings/Participants: Eighty hospice patients and 176 medical students (97 first-year and 79 third-year) in a New York State medical school.
Results: Medical students ranked 7 of the 11 care goals differently than hospice patients: not being a burden to family ( p < .001), time with family and friends ( p = .002), being at peace with God ( p < .001), dying at home ( p = .004), feeling that life was meaningful ( p < .001), living as long as possible ( p < .001), and resolving conflicts ( p < .001). Third-year students were less successful than first-year students in perceiving patient care goals of hospice patients. No significant differences in medical student empathy were found based on student year.
Conclusions: Medical students, while empathetic, were generally unsuccessful in perceiving end-of-life care goals of hospice patients in the psychosocial and spiritual domains. Differences impeding the ability of medical students to understand these care goals may be generationally based. Increased age awareness and sensitivity may improve future end-of-life care discussions. Overall, there is a need to recognize the greater dimensionality of the dying in order to provide the most complete patient-centered care.
Background: Voluntary active euthanasia represents one of the key topics in the contemporary world medicine, law, religious, ethical and moral issues. Serbia considers legalization of this procedure. Between the others, it is important to examine the student’s attitudes regarding this issue.
Methods: Data were obtained from the faculties of law and medicine, from the universities of Kragujevac and Niš, Serbia. Data were collected during the second half of 2017. The research included 214 students. Due to the nature, subject and hypothesis of the research, the authors used descriptive method and the method of the theoretical content analysis.
Results: Generally, 54% of the students are in favor of legalization of the voluntary active euthanasia. 62, 4% would take part in the referendum on the legalization euthanasia.
Conclusion: The results obtained in the survey on euthanasia on a sample of law and medical students in Niš and Kragujevac indicate that choice of the faculty (law or medicine) influences the structure (share) of responses to particular questions to some extent. However, this influence does not provide ground for conclusion that students’ opinion on legalization and application of euthanasia depends on fact they study law or medicine.