The different levels of learning about dying and death: an evaluation of a personal, professional and interprofessional learning journey

Abstract

Background: Although dying and death are common in practice, medical and social work students receive limited teaching on this topic. In addition, they have minimal experience of each others’ role in the process, yet respecting the roles of other professionals in this delicate area is paramount to the delivery of high standards of care. In an attempt to address this, a pilot interprofessional 3 hour dying and death workshop was developed for senior social work and medical students using a constructivist approach to explore their own personal, uniprofessional and interprofessional roles in the dying and death process.

Methods: An expert group of health care professionals designed the workshop through an iterative process. The participants evaluated the workshop in relation to the levels of their learning journey at two time points using a combination of Likert scales and free text.

Results: An afternoon workshop was created comprising a trigger exercise to ascertain the students’ own feelings, simulation of the practical aspects relating to a patient's death (confirmation of death, death certification and last offices), and discussion about the grief process, followed by case studies to consolidate their learning and highlight the interprofessional aspect. Eleven final year social work students and 14 medical students in their fourth year took part. Participants felt they gained most from the interprofessional aspect of their learning journey and suggested other topics for interprofessional learning. All students would recommend the workshop to their colleagues.

Conclusions: This undergraduate interprofessional pilot dying and death workshop was well received and enabled learning on three levels—personal, professional and interprofessional. It promoted a greater understanding of the role of each student's own profession and appreciation of the role of other professionals in the dying and death process.

Introduction

Death of a patient is a common occurrence with over 550 000 deaths registered each year in England and Wales alone (Office for National Statistics 2005). The dying and death process is complex, involving the palliative care of the patient, their death, the diagnosis and certification of death, the performance of last offices and the supporting of relatives through the stages of bereavement. It is recognized as a highly emotive topic for professionals involved in the delivery of healthcare (Fallowfield 1993; Maguire & Pitceathly 2002; Redinbaugh et al. 2003; Dinsdale 2004). Despite the expectation that professionals should be competent to deal with all levels of the death journey once qualified, undergraduate teaching in this area is at the very least, variable (Downe-Wambolt & Tamlyn 1997; Field & Wee 2002).

Appreciation of the complexity of the dying and death journey has increased over the past fifty years, along with the acknowledgement of the need to understand sociological and psychological theories related to the topic (Small, 2001). In addition, the roles of social workers and counsellors, as well as doctors and nurses, involved in this journey are now more explicit.

Table

Practice points
•The design of this workshop was successful in leading the students to discover their personal, professional and interprofessional roles and will be repeated for future workshops.
•Appreciation of the roles of other professions can be promoted by interprofessional learning at an undergraduate level.
•The workshop promoted the opportunity for interprofessional learning and working in practice areas.
•The enthusiasm shown by the students for a wide range of additional topics for interprofessional workshops is extremely encouraging.

In delivering ‘a good death’ it is essential that each professional has a clear understanding of their role and responsibilities and that there is a collaborative approach to provide the most appropriate care for patients and relatives. However, teaching and learning often occurs in uniprofessional settings. This is despite all the strategic initiatives and recommendations highlighting the need to learn about interprofessional working and teamwork, (General Medical Council 2002; General Social Care Council 2002; Nursing and Midwifery Council 2004), about professional roles (Barr 1998) and the recognition of the need for collaboration and partnership across professional boundaries (Department of Health 2000). There is also some evidence that starting this process early can be beneficial (Ponzer et al. 2004) and yet as stated, teaching is patchy and often not integrated into the undergraduate programme.

This paper shares the development of a pilot interprofessional workshop on dying and death designed for senior social work and medical students to enable them to explore safely the different levels of personal, uniprofessional and interprofessional understanding of the dying and death journey. It also shares both the immediate and intermediate evaluation of the workshop.

Background

The death of a patient/client can affect the professional involved personally (Novack et al. 1999). Being aware of one's feelings prior to supporting patients and relatives through a very emotive time is an essential component of self awareness and part of professional development (Nelson et al. 2000; Williams et al. 2005). Taking on a professional role in the process can involve specific responsibilities at one level and liaison with other members of the healthcare team at another.

In the core undergraduate medical programme at this institution, dying and death are explored opportunistically through clinical placements, resulting in variable exposure for the students. They receive specific communications skills teaching in ‘breaking bad news’ as part of their surgical attachment, and are exposed to some of the ethical issues relating to the end of life process in their medical attachments but there is currently no coordinated standardised programme teaching the topic as a whole. Social work students also have varying practical experience of death depending on their practice learning opportunities but all receive teaching about the theories of the grief process.

Dundee University has a joint Faculty of Medicine, Dentistry and Nursing, in addition to a joint Faculty of Social Work and Education and both faculties recognized the learning opportunities of an interprofessional dying and death workshop. There have been previous interprofessional learning collaborations where there were obvious shared learning outcomes (Edwards & Preece 1999; Mires et al. 2001; Ker et al. 2003).

Methods

The methodology focused on two areas:

1. the development of an interprofessional workshop on dying and death;

2. the evaluation of the workshop.

(1) Development of content and process of the workshop Development of content

Review of the literature

Current literature on interprofessional education and learning about dying was used to structure the discussion on the design of the workshop. This included literature on the benefits and challenges of interprofessional education at an undergraduate level in addition to articles on the teaching terminal care (Barnard et al. 1999; Small 2001; Dickenson et al. 2003; Torke et al. 2004; Olthuis & Dekkers 2003; Smith 2002; Winter et al. 2003; Fineberg et al. 2004; Pollard et al. 2004; Oandansan & Reeves 2005a, 2005b; Hind et al. 2003).

Expert group.

An expert group of health and social care professionals was formed to identify the main features of the dying and death process and agree the content of the workshop. The group consisted of 3 university lecturers in social work, 2 doctors working in undergraduate medical education and a senior lecturer in nursing. Within the group, the personal and professional experience of death was shared. In light of the communication teaching that existed elsewhere in the undergraduate curriculum (in dedicated workshops for the medical students) and the breadth of this topic, the group agreed that the dying and death workshop should focus on the practical aspects of dying and death and the professionals involved. A relative lack of knowledge about each others’ professional role within this interested group emphasised the need to enable interprofessional exploration within the workshop.

Design of process

The recognition of the components of the dying and journey, and the development of the different levels of learning was achieved through an iterative process, with the meeting of the expert group, review of the output, and subsequent refinement. Consensus on initiating the workshop by exploring the students’ own experience, and taking them along the whole ‘death journey’ from personal, through professional, and interprofessional role was achieved (see Figure 1). This was based on identifying their own professional roles and responsibilities, along with those of other professionals using a social constructivist approach. Constructivism is based on Piaget's work which suggests learners construct their understanding of the world through their interactions and build new experiences into their cognitive networks either through a process of assimilation or accommodation. In an interprofessional setting this approach has key advantages in enabling students from different professional experiences to enrich, modify and elaborate both their cognitive and affective concepts (Watts & Bentley 1987). Vygotsky (1978) added to our understanding of constructivism by suggesting an additional benefit to learning from social interaction. In focusing on a journey of exploration into personal professional and interprofessional learning a social constructivist approach is the most appropriate.

Figure 1. Levels to be achieved in interprofessional learning.

(2) Evaluation of the workshop

A triangular evaluation was designed to determine the students’ perception of both the process and their reflections on the content of the workshop at two time points, Time 1 (day of workshop) and Time 2 (8 weeks later) (Appendix 2) reflecting Kirkpatrick's first level of educational evaluation (Kirkpatrick 1959). The first questionnaire comprised predominantly open questions, while the second focused on the individual sessions using a Likert scale for process evaluation of the workshop. The questionnaires addressed the different personal, professional and interprofessional levels of the dying and death journey. Questions focused on their professional group, their reason for attending the workshop, their previous experience of dying and death, their opinions of the workshop, the interprofessional nature of the workshop and what further interprofessional workshops they felt would be helpful (Appendix 3).

Tutor evaluation used a focus group following the workshop to discuss impact and suggestions for improvements.

Results

Subjects

Students

The pilot workshop consisted of 11 final year social work students and 14 fourth year medical students.

Social work students

The social work students selected the workshop from one of three interprofessional workshops available. All of those who chose this workshop were female.

Medical students

The medical students volunteered for the workshop and attended in their study time during a clinical attachment in Ageing and Health. Eleven female students and 3 male students participated. The workshop was limited by numbers and students were recruited on a first come basis. There was an overwhelming response with additional students being turned away.

Tutors

The tutors consisted of 4 members of the focus group (3 female, one male), representing the social work, nursing and medical professions.

Implementation

Outcomes

The shared outcomes of the workshop agreed by the expert group are detailed below.

At the end of the workshop students should be

• aware of the impact of loss on individuals both personally and professionally

• aware of the different stages of the grieving process

• able to recognize the different professional roles they each have in relation to death and loss in the current NHS and social care systems

• able to identify the practical and legal responsibilities of their own profession

• aware of each profession's value base and how these can complement the working relationship and lead to collaborative working in the dying and death process.

The workshop was designed to span half a day (3 hours) (Table 1), taking the students from their personal experience, through their professional and interprofessional roles and responsibilities (Figure 1).

Table 1.  Workshop timetable

Trigger exercise	(30 minutes)
Death journey	(45 minutes)
• Confirmation of death
• Death certification
• Last offices
• Grief process
Case studies	(40 minutes)
Case study feedback	(30 minutes)

Session 1: Personal exploration—Level 1

Students were reminded that any personal experiences discussed in the workshop were confidential and encouraged to voice their experiences of dying and death. They were divided into 3 mixed professional groups with one tutor per group.

A trigger questionnaire served as both an ‘ice-breaker’ and a method of stimulating the students to reflect on and discuss their own experiences. The questions posed in the trigger exercise were based around the students’ first experience of death, burial rituals and grief. More probing questions were related to future deaths that would be difficult to cope with and the reasons for this (Appendix 1). Each group was facilitated by a tutor who also took part, encouraging reflective discussion within the group.

Session 2: Professional exploration—Level 2

This session was devoted to the practical learning of the dying and death journey. A scenario based around the death of an elderly gentleman was introduced, and a manikin used to facilitate the confirmation of death by the role-playing doctor with the last offices performed by the role playing nurse. Students in their interprofessional groups then participated in an experiential exercise of completing the death certificate. The bereavement process was then described and general discussion followed relating to grief and loss, who it affects and how. This session was facilitated by the group of tutors sharing their different professional responsibilities and perspectives.

Session 3: Interprofessional exploration—Level 3

Each interprofessional group of students was given one of three case scenarios anonymized from a real death journey (death of a patient in residential accommodation for the elderly, death of a teenage drug addict in the care of social services, stillbirth of a child born to immigrant parents with a history of domestic violence). Case discussions took place in breakout rooms, without the facilitators. Each group discussed the needs of the situation and the role of the different professions. The students were asked to focus on a particular case and to feedback to the whole group.

Session 4: Personal (Level1), Professional (Level 2) and Interprofessional (Level 3) Reinforcement

A resource pack was given to the students at the end of the workshop to provide reinforcement of their learning at the three different levels. Information pertaining to the diagnosis of death, death certification, legal responsibilities and post mortem examination was included. The pack also contained examples of cremation certificates, forms for organ donation and articles on loss and grief.

Students' evaluation

This reflected the students’ thoughts on the different levels of the dying and death process. All 25 (100%) of the available students completed the first evaluation and 18/25 (72%) returned the second one which was sent out by post and email.

Workshop overall

All 25 of the students thought that the workshop was worthwhile and would recommend it to their colleagues. Eighteen suggested that it should be a compulsory part of the curricula, while the remaining 7 believed that it should remain voluntary. There were no comments to explain their rationale.

Personal exploration—Level 1

8/25 students cited the reason for attending the workshop as having a particular personal interest in the grief process (free text question) (see Figure 2). Following the workshop, the majority of students (15/18) rated the trigger exercise very useful (5) or useful component (10) (see Figure 3).

Figure 2. Reasons for attending workshop (3 students gave > 1 reason).

Figure 3. Students evaluation of individual components.

Professional exploration—Level 2

Fourteen students attended the workshop because they had identified a lack in their professional knowledge about dying and death. The medical students in particular were concerned about the legal issues. Three social work students felt that they had not had any other teaching in the subject in their course. One medical student complained about the limited undergraduate experience. The ‘death journey’ session predom-inantly explored the individual professional roles and was noted most useful component by the students (14 very useful, 2 useful, 1 unsure, 1 not useful).

Interprofessional exploration—Level 3

The interprofessional nature of the workshop was mentioned by only 3 participants as a reason for attending (in free text part of questionnaire). The benefit of it however was acknowledged in response to an open question by 16 (64%) (8 social work, 8 medical students) as what they learned most (see Figure 4). The small group case discussion and case study feedback focussed on both the professional and interprofessional roles, with 94% of students rating this as very useful or useful (1 unsure) using a Likert scale (see Figure 4).

Figure 4. What students learned most from the workshop (1 social work student gave no answer, 8 medics gave >1 answer).

Two of the medical students would have preferred the workshop to have been uniprofessional, but the other 16 respondents enjoyed having students from other professions. In particular they commented on the benefit of it, and that it challenged pre-conceived ideas. Sixtyeight percent (17/25) students stated that they would have liked to have had nursing students involved. Other professions suggested included health visitors, police officers, health care assistants and legal representatives.

As the theme of interprofessional learning featured so positively within the group of students, following the reflection period they were asked whether they felt other interprofessional workshops would be useful. There were many suggestions, with ‘breaking bad news’ and ‘child protection’ mentioned by several participants. Their suggestions are listed in Table 2.

Table 2.  Suggested topics for interprofessional workshops

Medical students	Social work students
Ethics
Breaking bad news
Confidentiality issues
Appropriate referring	Child protection
How to trigger services	Mental health
Legal obligations	Collaborative working
Dealing with difficult patients and relatives	Working with the elderly
Role of the pharmacist	Addiction
Discharge planning–elderly/psychiatric

Tutor evaluation of workshop

Personal exploration—Level 1

Initial reluctance by some of the students to discuss personal experiences was soon overcome by encouraging them to complete the trigger questionnaire. Although the first death experienced for many of them was that of a pet rather than a person, the links between the two were significant. Students commented on the process of death being important to how they felt about it, in particular whether their relative or pet was in distress and how the doctor or vet dealt with it. One of them described feeling distraught when she saw her hamster thrown in the bin by the vet, even although she realized that putting the hamster down was the best thing for it. Another commented on being upset at the way the nurses talked in the presence her unconscious relative. One medical student described being very upset at the age of 10 when her grandmother died, not because of her loss, but because everyone else was crying. How loss would affect them personally was brought out best when asked about the death of a person now living that would affect them most. Parallels were drawn by the students between these experiences and how they should be remembered when dealing with death in a professional capacity.

The death experiences discussed can be divided into four categories:

• loss of a relative/friend;

• loss of a pet;

• distress related to other people's grief;

• distress related to the process of dying (the nature of the death itself, and how professionals reacted.

The tutors thought that this session worked extremely well in allowing the students to work through their own feelings and in some way allow them to progress to the next level. Although a few of the students became tearful, the groups were able to support them, and discussion flowed.

Professional exploration—Level 2

Within the group, only a very few students had seen the confirmation and certification of death before, and no student was aware of what was involved in the last offices. All students engaged in the activity of completing the certificate though only medical students would be required professionally. As none of them had done it before, this appeared to promote collaboration. Many questions were asked during the ‘death journey’ about what the individual professional roles would be in certain situations.

Interprofessional exploration—Level 3

Feedback presentation of the case scenarios by the interprofessional groups identified key learning areas.

Students identified:

• a stronger awareness of their professional role;

• an improved knowledge of the scope of the role of the other.

Much of this session was led by the students themselves, and on many occasions the students were able to answer each others’ questions. Ethical debates made the session very lively. The tutors felt it was important that they represented each professional group in order to clarify any questions (especially true in relation to social work legal issues).

Discussion

This paper shares the development and evaluation of a pilot interprofessional dying and death workshop. The workshop was designed to complement current clinical/practice experience and learning. It was extremely well received by the students with all of them stating they would recommend it to their colleagues. The authors believe that this novel approach of taking the students on their own journey of exploration of the issues around death, from personal through professional and interprofessional perspectives has contributed to its impact.

The students have made positive statements pertaining to their increased awareness of the issues of death after ‘triggering their own thoughts’ and have commented upon the greater insight and understanding they now have of their own professional role as a component of the overall process. Their recognition and embracing of the benefits of interprofessional learning has enthused the authors.

Asking for volunteers for a pilot study may have lead to selection bias in the evaluation and the numbers of students involved was relatively small. However, the rush of students to subscribe to the workshop held in their free time, and the fact that they would all recommend it to their colleagues provides encouragement for future sessions. There was a predominance of female students compared to the year as a whole. Potential reasons may include increased importance attributed to the subject by female students or perhaps reflect differences between the sexes in registering for non-curricular workshops.

If this workshop is to be taken further, then it must be integrated into the curriculum at the most relevant and appropriate time which may prove to be difficult. This should perhaps be an introduction at senior undergraduate level during their clinical years. Some students commented that they would have preferred the workshop to have been longer, particularly to allow more case discussions and information about the surrounding legal issues which adds further timetabling problems.

In developing the interprofessional aspect of the workshop the aim is to include nursing students. The participants also suggested other professionals they would like to see involved, but increasing the numbers of professions is likely to make this organizationally more complicated.

The interprofessional nature of the workshop was not perceived as the main attraction for registering for the workshop by students who participated. Learning about, and appreciating other professionals’ roles however, features highly in what they gained from it. Is this purely related to this student group, or does it reflect the predominantly uniprofessional nature of undergraduate training and a lack of awareness of the importance of collaborative learning and working?

There are undoubted difficulties associated with interprofessional learning, not least the perceived hurdles of separate codes of ethics, distinct bodies of knowledge, profession-specific skills and uniprofessional curricula (McNair 2005). The best time to introduce students to it is also unknown and the debate surrounding when to introduce it continues (Rudland & Mires 2005; Tanaka & Yokode 2005). The authors feel that by leading the student through the dying and death journey, from the personal through professional and onto interprofessional aspects allows for this workshop format to be used at any stage as it links to a constructivist approach to learning.

Conclusion

An undergraduate's professional experience of dying and death, whether they are studying social work or medicine, is currently primarily dependent on their clinical placements. This varies significantly between students, yet all doctors and a large number of social work students will be expected to deal with it from day one in their first year of practice. As commented on during this workshop, some students' perceptions are that they have had no teaching on this topic. Equally, although some students have experience of interprofessional working (e.g. in student selected modules or during their clinical attachment/practice learning), there are currently very few opportunities for the students to explore interprofessional learning in relevant topic areas in a safe and systematic way.

The ultimate measure of success of an undergraduate interprofessional dying and death workshop is a positive effect on the interprofessional working relationship of the participants when caring for the dying and bereaved on qualification. In this pilot workshop the social work and medical students enjoyed the experience, worked well together in their groups, believe that they have learnt more about their own feelings, feel more confident in their own professional roles and have learnt more about each others’ roles in this process. They also indicated they would like more workshops using the same framework—a positive foundation on which to build.

Additional information

Notes on contributors

L. McIlwaine

Dr LOUISA MCILWAINE is a Clinical Lecturer in the Clinical Skills Centre, University of Dundee with a clinical background in Haematology. Current research interests include simulation and assessment of competence.

V. Scarlett

Ms VALENTINE SCARLETT is an Accredited Practice Teacher in Social Work. The focus of her career has largely been around development of innovative methods of practice in a variety of fields e.g. education, children at risk, inter-professional working.

A. Venters

Mr ALAN VENTERS leads the Cancer and Palliative Care Academic Team within the School of Nursing and Midwifery and is actively involved in teaching all aspects of dying and death at undergraduate and post graduate levels. Prior to entering nurse education the author had a clinical background in oncology.

J. S. Ker

Dr JEAN KER is Director of the Clinical Skills Centre at the University of Dundee. She still practices as a general practitioner. Her interests in medical education include use of simulation in clinical skills, assessment, reflection and undergraduate medical education.

Appendix 1. Trigger questionnaire

T1. The first death I remember was the death of:
T2. I was age:
T3. At the time I remember feeling:
T4. The first funeral (or other ritual service related to death) I attended
was for:
T5. I was aged:
T6. The thing I remember most about the experience was:
T7. My most recent loss by death was (person, time, circumstances)
T8. I coped with this loss by:
T9. The most difficult death was the death of:
T10. It was difficult because:
T11. Of the important people in my life now living, the most difficult
death for me would be the death of:
T12. It would be most difficult because:
T13. My main way of coping with loss is:
T14. I know my grief is resolved when I:

Appendix 2. First evaluation form (Time 1)

Q1. What profession are you training in?
Q2. Why did you come today?
Q3. What gaps in your knowledge had ou identified prior to coming?
Q4. Do you feel it has been helpful/worthwhile? Yes/No
Q5. If so, in what way?
Q6. Did you find any parts of the session unhelpful/not worthwhile?
Yes/No
Q7. If so, which part in what way?
Q8. Would you recommend this workshop to your colleagues? Yes/No
Q9. Do you think it should be a compulsory part of your curriculum? Yes/No
Q10. Are there any other professions you would like to see involved in the
Q11. How will you consolidate your knowledge of the death and dying process?

Appendix 3. Second evaluation form (Time 2)

Q1. What profession are you training in?

Q2. Have your read the resource pack?

Q3. Would you prefer to have been given it before the workshop? Yes/No

Q4. If you had been given it in advance, do you think you would have read it? Yes/No

Q5. What did you think of it? (Likert scale)

Q6. What else do you think it should have included?

Q7. Have you had any experience of death and dying since the workshop?

Q8. What effect did it have on your practice?

Q9. When you think back to the workshop, how would you rate the individual components. (Likert scale)

Q10. Would you have preferred this workshop with just your own profession?

Q11. What other topics would you like to cover in interprofessional workshops?

Q12. Any other comments?