Abstract
Abstract
Background:
End-of-life care has become a priority in medical education internationally. A previous study of hospice patients and staff regarding medical students teaching in a hospice showed positive responses from patients and hospice staff. However concern was expressed by some staff regarding medical students' welfare, contributing to gatekeeping by professionals. Studies have shown that medical students feel underprepared to care for the dying by the time they qualify.
Objective:
The study's objective was to explore in more detail the views and experience of medical students who had spoken with patients during their hospice placement.
Design:
This was a qualitative study.
Setting/Subjects:
The study was carried out with 14 Hull York Medical School (HYMS) students who had responded in an electronic survey that they had spoken with patients during their hospice placement.
Measurement:
Semistructured interviews provided the study's data.
Results:
Although students expressed some anxieties prior to their hospice visit about meeting patients who were near the end of life, they felt that the overall experience, and the time spent with patients in particular, provided valuable learning about palliative care and preparation for caring for dying patients.
Conclusions:
We would encourage staff to not be overprotective but to support students to take every opportunity to meet with patients in a hospice.
Introduction
Available evidence suggests students learn most from clinical encounters in this area and feel underprepared and lacking in exposure to dying patients.6,9–15
A search of the Australian education index, British education index, ERIC, Medline, PsychINFO, EMBASE, and ASSIA databases using the MeSH terms related to and including ‘attitudes/perceptions,’ ‘hospice/palliative care,’ and ‘medical education’ found a number of questionnaire studies, reviews of reflective logs/student essays, and just three interview based qualitative studies. None of the interview based studies involved looking at the attitudes or perceptions of students meeting patients in a hospice setting.
A qualitative study of hospice patients and staff regarding medical student teaching in a hospice showed positive responses from patients, but staff expressed concerns regarding patient and student welfare, leading to gatekeeping. 16
In view of concerns expressed for student welfare by hospice staff, this study aimed to explore in detail the views and experience of medical students who had spoken with patients during their hospice placement.
Method
Research design
Semistructured interviews were carried out with third- and fourth-year Hull York Medical School (HYMS) students who had met at least one patient while at a hospice.
Setting
HYMS provides palliative care teaching to third-year medical students as part of their cancer block in one of five hospices. Some students spend further time in a hospice during optional student-selected components (SSCs).
Sample strategy
All third- and fourth-year medical students who had completed their cancer block were invited by a posting on Blackboard, a virtual learning platform, to take part in a brief electronic survey about their experience. Twenty-six out of thirty students (87%) indicated that they had seen a patient while at a hospice. The four students who did not see a patient indicated that it was due to lack of opportunity. Twenty of these students responded to the invitation to take part in the interview study. Three students approached the interviewers directly, having heard of the study via fellow students. Data saturation was reached after 14 interviews.
Data collection
Trained researchers carried out the interviews using a topic guide (see Appendix 1). The interviews were audiorecorded and professionally transcribed.
Data analysis
After initial immersion in all the transcripts, six transcripts were individually coded using line-by-line microanalysis.17,18 Four major themes with corresponding subthemes were obtained. These themes were used to analyze all the transcripts using Nvivo 9.2 (QSR International, Melbourne, Australia). This was undertaken by two researchers working independently. Final coding was agreed by consensus with the research team. 17 These themes were then individually analyzed across all the transcripts, which led to further reordering and the final themes presented in the paper (see Figure 1).
Flow chart of major themes.
Rigor
Ethical approval was obtained from the HYMS research ethics committee. Students were interviewed by researchers not involved in teaching them at the hospices.
Results
Student demographics
Demographic details of the participants are detailed in Table 1. The main themes can be described by a shared pattern of student experience and outcomes, illustrated in the flow chart (see Figure 1).
Preconceived ideas and fears about how they would cope
A strong theme was the level of students concern prior to their placements. Concerns included how they would cope emotionally with the environment, fears about seeing dying patients, and worries about their communication skills and upsetting vulnerable patients.
“Its almost a bit awkward when you first go into it because you don't want to say the wrong thing and you don't want to upset them, but then you don't want to get upset…. There is so much stuff going through your head and you're just a bit worried about it all.”
Hospice placement
Just getting over the hurdle of being in a hospice allayed the majority of those fears.
“With anything unexpected you are always a bit uncertain or a bit scared. But then you get over the initial hurdle and after that you are fine.”
The effect of being in a hospice was so significant because of a number of factors:
Memorable patients
All students recalled meeting patients that had taught and inspired them. Communicating with ‘memorable’ patients was the most important aspect of the hospice visit and vital to the impacts described below.
“She had breast cancer that had spread, and she was the most amazing woman I have literally ever spoken to…. She was so philosophical about everything. I think that's what made me write my reflective essay on her, she was just ridiculously calm and, I don't know, I don't know what I expected, but she was just so accepting of everything.”
Environment
The hospice was described as a “tranquil peaceful, lovely setting.” This was specifically in comparison to their expectations of a sad morbid place and compared to the more clinical settings in hospitals.
Staff
Staff were described as welcoming and providing a supportive environment that was different from hospital placements.
Organization of placement
Those that had the ‘normal’ curriculum exposure felt that it was not enough. They would have liked longer, and those doing selected student components (SSC) felt they learned significantly more.
“I think one visit to the hospice perhaps isn't enough…. The first time you go there it's a bit of a shock I guess…so the next time you go you know what to expect…and the patients will be more familiar with you as well. So they'll be perhaps more open speaking to you.”
The majority, but not all students, felt they would have wanted to see a ‘dying’ patient; they all recognized it's something they need to face.
“I think it is very individual. I suppose it depends on, sort of exposure you've had…. It's completely various, some have never seen anything. I think it's just something that noone should be worried about introducing to students.”
Impact (changed views and allayed fears)
The impact of the hospice placements can be broken down into three areas.
Learning about palliative care
Students left with an understanding of the core principles of palliative care. Importantly, preconceptions regarding hospices were shattered and they recognized they would be able to reassure patients with similar misperceptions about hospices when they are junior doctors.
“The way that I thought about hospices actually changed quite a lot…. Going into my training, that was really important, to be able to know that just because you've got a terminal illness doesn't mean that you've only got minutes, days, hours, and that actually life does continue after that diagnosis…. I was amazed at how it wasn't kind of doom and gloom and, and was a lot more positive.”
Views about dying also changed. To some extent dying was normalized. There remained a healthy worry about dealing with dying patients, but in general they felt better prepared to be a junior doctor caring for dying patients.
Improved skills
Students were worried about having difficult conversations without causing offense. Meeting hospice patients improved their communication skills and left them less worried but not overconfident about their abilities.
“I think the communication skills you learn from being in a hospice, from thinking about palliative care as a concept, and also from, from meeting patients who are terminally ill are hugely valuable.”
There was an emotional burden from meeting patients, but students felt they learned about how to cope with these emotions. Students were most likely to seek support from their peers to deal with the emotions that came up.
“I think I thought I'd be more, not upset but I think that I thought I'd find it harder to deal with than I did. So I think that was good to know, that I don't crumple…. I'm not saying it didn't affect me but I could cope with it quite easily. So I think that's a good thing to know about yourself.”
Students also acknowledged that they learned how holistic care works in practice and identified the hospice as a unique setting to learn this.
“Hospice setting is just so different from anywhere else in medicine, I think. Because you're so focused on just the needs of the patient and patient centered care, which I know we're taught a lot in HYMS, but you don't really see a lot in hospitals. But in the hospices that I've been in they're really just centered on patient centered care which you see makes a massive difference on patient care, and I think that was a massive thing to take away from it.”
Advice to future students
The overwhelming advice was to make the most of opportunities and not to be afraid of the hospice and dying patients.
“Just ask to do things and don't be scared of taking opportunities if they present themselves.”
Discussion
This is the first interview based study, as far as we are aware, looking at the attitudes or perceptions of students meeting patients in a hospice setting. It demonstrates that despite an emotional burden student find their hospice placement well supported, enjoyable and a valuable learning opportunity. The patient encounters were found to be inspiring and central to the impacts described in the results section. The importance of the patient encounter fits with the literature regarding learning about palliative care which shows the most effective learning is experiential.14,19 The overwhelming advice to students is not to worry and make the most of the opportunity.
Hospice staff should be reassured that students do cope. The supportive environment created by hospice staff plays a key role in allowing this to happen. We encourage staff to not be overprotective as this may contribute to a lack of exposure to dying patients which students recognise is something they need to go through and should happen in a supportive environment as a student rather than in the less supported environment that a busy junior doctor would face. Our concern is for those students whose fears are not allayed, perhaps because they do not go through this process. This could be due to lack of opportunity to speak to patients due to short placements, avoiding opportunities because of preconceived fears or due to overprotective staff. This could have a negative outcome for the students as they remain anxious about talking to dying patients and lacking the skills to care for them effectively.
One solution is to have an integrated approach using a spiral curriculum with repeated and gradually increasing levels of exposure to palliative care, rather than relying on one block or visit.4,20 Ways to allay fears prior to placements should be considered.
There are limitations to the study. We had a self-selected and likely interested group. It was at one medical school in the United Kingdom and experiences of other students may be different. Only three men expressed an interest in being interviewed, not all hospices were represented and only students that had seen a patient were interviewed. It is therefore not possible to generalise to all medical students even within HYMS. Students with negative experiences or those with fears and concerns that were not alleviated by the placement may well have not volunteered to take part in the study. Further research should be directed at this group as well as students who miss the opportunity to meet patients.
Conclusions
Our research indicates that hospice placements and particularly meeting with a hospice patient is important to help students learn valuable principles of palliative care, learn how to communicate with and care for dying patients and learn to cope with their emotions.
We encourage staff to not be over protective and to support students to take every opportunity to meet with patients in a hospice. We also encourage course organisers to consider an integrated approach to palliative care teaching with repeated and gradually increasing levels of exposure.
Footnotes
Acknowledgments
The authors would like to thank all the students who took part in this study. We are also grateful to those who reviewed the topic guides. We acknowledge with gratitude the work of the authors of the previous study interviewing patients and staff about medical student teaching.
Author Disclosure Statement
No competing financial interests exist.