Implementing an interprofessional palliative care education program to speech-language therapy and dietetic students

Figures & data

Table 1. Aspects of learning students valued or wanted to retain or enhance.

Global topics	Sub-topics	Illustrative quotes
Clinical Education	1. More observational learning desired2. Self-care, debrief and reflection are important	‘hearing the supervisor talking helped’‘I saw my supervisor and saw it doesn’t get easier with time’‘even though we have had lectures on it but you know some more practical’‘I needed more experience’ ‘self-care is important’‘make sure your looking after yourself um because it can be quite heart breaking’
Classroom Education	3. Theoretical learning and reading was good 4. Patient experiences would be useful 5. Emotional aspects of palliative care	‘more education on what palliative care is’ ‘I wanted the lecturers to tell me what to do’ ‘hearing family experiences could be useful’ ‘workshops of people who have been in the situations share your different experiences’ ‘them [educators] talking about what the impact it has on them, very very big emotional loads hearing how they have gone through would probably normalize it’
Awareness of Supports	6. Legal protection 7. Supervision 8. Safety with protocols	‘knew who to talk to’ ‘how to get proper guidance’ ‘I would ask a bit more from my supervisor in ways that I could improve’ ‘being patient centered and that’s fine that is still ethical and that is practicing safely’

Table 2. Students self-reported key learnings from educational and professional experiences.

Global topics	Sub-topics	Illustrative quotes
Personal Strategies/Philosophy	Previous experience of death Personal Reflection Religion and culture	‘it is what it is. You shouldn’t need to creep around it’ ‘the medical approach helps’ ‘I had a little prayer afterwards’ ‘I think about death a whole lot more now’ ‘death happens’
Client-centered	Maintain pleasures Respecting client’s choices	‘small pleasures like have ice-cream if you like’ ‘I mean, let me eat, I say’
Team	Transition of care into community from hospital Different viewpoints Trust Family as part of the team	‘trust is needed’ ‘different viewpoints are good but communication is important’
Terminology/Definitions	Medical labels Advanced care planning	‘who are we talking about? what is it? Is it a specific thing? people are treated differently because of the word’ ‘taboo of being “on” palliative care’
Family	Family-focused care Taking time with family Focus on interaction rather than content	‘need to convince the family a student can be trusted’ ‘how do we say things to the family?’ ‘I learnt from my supervisor to really listen and reflect’
Roles	Client-centered care Interprofessional care Student role Changing role over time	‘I could have been more interdisciplinary and had more in-depth conversations with other professionals’ ‘careful you aren’t getting out of role’ ‘is it appropriate to intervene?’ ‘my professional role was more towards education and having that discussion around comfort feeding’
Feelings	Fear and pressure of incompetence Confidence Emotionality Discomfort Purposeful	‘as a student … awkward would be the right word … sometimes lost’ ‘I never felt thrown in’ ‘always critiquing every little thing I do and maybe next time not being so negative or critical of myself’ ‘too much for me at times’ ‘not sure if I made a difference’ ‘it was heart breaking’ ‘letting people down’ ‘do I know what I’m doing?’ ‘I felt I can’t do anything for them’ ‘privileged about making something positive happen for the patient and their family’ ‘I had clarity of purpose – giving pleasure in comparison to the risk adverse pathway’

Table 3. Overview of the palliative care education program.

Phase of learning (Mathisen et al., 2011)	Education experience	Curriculum content	Learning objectives
Sensitization	Online education module	Introduction to palliative care Terminology in relation to death and dying	1. Gain knowledge of context, purpose, and key terminology relating to palliative care
Personalization	Online education module	Values/assumptions/experiences	1. Reflect on own experiences of death and dying
Professionalism	Didactic talk from expert in field	Professional roles and responsibilities - legal, ethics	1. Gain knowledge of the diverse professionals involved. 2. Understand the principles of holistic assessment for symptom management 3. Acknowledge the importance of recognizing dying 4. Gather resources to support coping with grief and loss
Integration	Simulated-learning experience	Clinical/communication skills	1. Demonstrate therapeutic communication skills 2. Apply knowledge of the roles of different team members in an interprofessional team 3. Apply ethical, professional, and culturally responsive practice in a simulated palliative care case.

Table 4. Palliative care interprofessional simulation description.

Structure	Student activity	Focus/instructions
Pre-session	Provided with written information/top tips for successful family meetings to read.	Written information available as a guide through the scenario, if needed
Introduction to scenario patient	Watched a video of a patient – Kirsty with motor neurone disease describing her disease and her worries and reflections of her deteriorating condition and of dying.
Introduction to simulated learning scenario	Introduced to the simulated learning environment – a interdisciplinary outpatient clinic and to the patient and her case history. It was explained that a family meeting is planned to discuss ‘Kirsty’s’ current situation.	Students informed that focus of simulation is not on clinical intervention and knowledge and rather on professional roles, communication and having difficult conversations.
Scenario – Phase 1 Interdisciplinary pre-meeting	Allocated professionals roles (SLT, DT, physiotherapist, and occupational therapist). For each role, students were provided with brief written key information about their own character.	Students were asked to maintain role unless they felt distressed or uncomfortable, but if they needed, they could pause the scenario for support. The educator could pause the scenario at appropriate points for ‘pause and reflect’ opportunities to allow reflective group discussions before starting the scenario again. Educators encourages reflection and then repeating a phase for experiential learning. Students were encouraged to ensure all voices were heard.
Scenario – Phase 2 Family meeting introductions	Family (Kirsty, Kirsty’s husband, sister, or mother) and professionals meet. For each role, students were provided with brief written key information about their own character.
Scenario – Phase 3 Family meeting sharing information and developing consensus on treatment options	Swapped roles to give them the opportunity to see the situation from another lens.
Scenario – Phase 4 Family meeting wrap up	Allocated new roles to give them the opportunity to see the situation from another lens.	Students encouraged to practice comfort, console and conclude and to ensure the family does not feel abandoned or with questions unanswered.
Debrief	Each student can reflect, and speak within the group.	Small group discussion includes self-care and cultural reflections. Students then encouraged to meet and share food and drink at cafe with the whole team.

Table 5. Phase 3 student demographics (n = 62).

Demographics and experience of death and dying		Responses (n=62)
Age (years)	18–22	13
	23–27	39
	28–35	8
	36–45	1
	56–65	1
Sex		4 Male (6%)
My religious beliefs …	Are a strong influence on my attitude toward death and dying	18 (29%)
	Are a minor influence on my attitude toward death and dying	15 (24%)
	Do not influence my attitude toward death and dying	31 (50%)
Profession	Speech-language Therapy	39 (63%)
	Dietitian	23 (37%)
Previous education on death and dying		10 Yes (16%)
Previous experience with terminally ill persons	I have cared for terminally ill persons and their family members	17 (27%)
Previous experience of loss	I have lost someone close to me within the past year	28 (45%)
Present experience	I am presently anticipating the loss of a loved one	9 (15%)

Pre-program FATCOD scores showed great variation in attitudes toward dying among students but with most students believing giving care to a dying person would be a worthwhile experience (Table 6).

Table 6. FATCOD scores for Phase 3 students (pre-program n = 68).

FATCOD Question	n*	Strongly disagree		Disagree		Uncertain		Agree		Strongly Agree
1. Giving care to the dying person is a worthwhile experience.	66	0		0		5	8%	15	23%	46	70%
2. Death is not the worst thing that can happen to a person.	63	0		12	19%	17	27%	22	35%	12	19%
3. I would be uncomfortable talking about impending death with the dying person.	67	3	4%	10	15%	20	30%	34	51%	0
4. Caring for the patients’ family should continue throughout the period of grief and bereavement.	68	0		1	1%	3	4%	18	26%	46	68%
5. I would not want to care for a dying person.	66	17	26%	34	52%	11	17%	4	6%	0
6. The nonfamily caregivers should not be the one to talk about death with the dying person.	65	6	9%	35	54%	19	29%	2	3%	3	5%
7. The length of time required giving care to a dying person would frustrate me.	64	20	31%	32	50%	10	16%	1	2%	1	2%
8. I would be upset when the dying person I was caring for gave up hope of getting better.	66	5	8%	11	17%	28	42%	17	26%	5	8%
9. It is difficult to form a close relationship with the dying person.	66	19	29%	29	44%	15	23%	3	5%	0
10. There are times when the dying person welcomes death.	66	0		0		3	5%	37	56%	26	39%
11. When a patient asks, “Am I dying?” I think it is best to change the subject to something cheerful.	66	26	39%	34	52%	6	9%	0		0
12. The family should be involved in the physical care of the dying person.	64	2	3%	4	6%	28	44%	21	33%	9	14%
13. I would hope the person I’m caring for dies when I am not present.	66	5	8%	22	33%	31	47%	7	11%	1	2%
14. I am afraid to become friends with a dying person.	66	16	24%	32	48%	9	14%	9	14%		0%
15. I would feel like running away when the person actually died.	67	10	15%	23	34%	25	37%	7	10%	2	3%
16. Families need emotional support to accept the behaviour changes of the dying person.	65	0		0		2	3%	28	43%	35	54%
17. As a patient nears death, the nonfamily caregiver should withdraw from his/her involvement with the patient.	65	14	22%	35	54%	14	22%	1	2%	1	2%
18. Families should be concerned about helping their dying member make the best of his/her remaining life.	65	2	3%	5	8%	8	12%	35	54%	15	23%
19. The dying person should not be allowed to make decisions about his/her physical care.	65	35	54%	23	35%	4	6%	0		3	5%
20. Families should maintain as normal an environment as possible for their dying member.	64	0		2	3%	25	39%	26	41%	11	17%
21. It is beneficial for the dying person to verbalize his/her feelings.	66	0		0		5	8%	25	38%	36	55%
22. Care should extend to the family of the dying person.	65	0		0		3	5%	23	35%	39	60%
23. Caregivers should permit dying persons to have flexible visiting schedules.	34	0		0		9	26%	8	24%	17	50%
24. The dying person and his/her family should be the in-charge decision-makers.	66	0		3	5%	4	6%	34	52%	25	38%
25. Addiction to pain relieving medication should not be a concern when dealing with a dying person.	66	0		4	6%	26	39%	27	41%	9	14%
26. I would be uncomfortable if I entered the room of a terminally ill person and found him/her crying.	65	5	8%	22	34%	18	28%	18	28%	2	3%
27. Dying persons should be given honest answers about their condition.	66	0		0		4	6%	36	55%	26	39%
28. Educating families about death and dying is not a nonfamily caregiver responsibility.	65	18	28%	30	46%	12	18%	5	8%	0
29. Family members who stay close to a dying person often interfere with the professional’s job with the patient.	64	14	22%	29	45%	13	20%	6	9%	2	3%
30. It is possible for nonfamily caregivers to help patients prepare for death.	63	0		0		1	2%	38	60%	24	38%

* note varying numbers per question as some students skipped some questions..

Figure 1. Student self-rating of (a) knowledge and (b) confidence over time.

Table 7. Education program feedback from students.

Education content (1=do not agree, 5=agree)			Immediately post- (Median (Range))	6-months post-
This education program was well organized			4 (3–5)	-
The content was appropriate			5 (2–5)	-
The overall standard of instruction was high			5 (3–5)	-
The course was highly realistic			4 (2–5)	-
The following components of the course were very useful		Online module	4 (1–5)	3.4 (1–5)
		Talk from Hospice	5 (2–5)	4.5 (3–5)
		Simulations/role-plays	5 (2–5)	4 (2–5)
		Simulation reflective discussions	5 (2–5)	4.5 (3–5)
How suitable do you think simulation training will be/is for teaching how to work with someone who is dying? (1 = not at all, 10 = very much so)			8 (4–10)	8 (6–10)
Qualitative content	Illustrative quotes – immediately post		Illustrative quotes − 6 months post
What did you like most about the day?	‘the scenarios. I feel a lot more confident about how to approach this topic with clients’ ‘the talk from the hospice nurse as she has real experience’ ‘how the simulations got us to practice our skills (not be afraid to try things) due to the comfortable environment’ ‘taking theory and being able to practice and then reflect immediately’ ‘getting more comfortable talking about death and dying’		‘The simulations and conversations made it more real. No one is going to be fully confident due to the nature of the topic but the practical situations helped confidence’ ‘The role plays and that it was interdisciplinary’ ‘The supportive environment in which we learned the content in’ ‘. I liked that it included both self-reflection and an emphasis on MDT roles/approach. It was great having students from other disciplines join us.’
What did you like least about the day?	‘the online prep modules took far too long and were unrealistic for Masters students who are busy’ ‘that out of necessity it had to touch on very raw emotions’ ‘I felt it could touch more on culture’ ‘not enough discussions around grief and bereavement’		‘online module – I have zero memory of the online memory’ ‘feeling vulnerable as it was a subject that meant my emotions were on the surface’ ‘I thought it was all great.’
If you were to teach the course, what would you do differently?	‘I did not enjoy the nurse’s te whare tapa wha demonstration. She warned that it would be really confronting and it was! The exercise felt uncomfortable as I do not like to purposely imagine what if scenarios especially regarding my own death’ ‘since it was over a whole day, I might arrange something light-hearted and fun for the two professions to join in together to redirect difficult emotions before the afternoon session’ ‘provide tough questions that the students have to practice answering in the simulations. Perhaps ask someone to come in and share their palliative care story/experience and their interactions with the SLTs/DT’		‘more paediatric content’ ‘more open discussion time to explore thoughts’ ‘more time in simulation’ ‘more external speakers who can share their perspectives’
What do you feel you will do differently having participated in this training day?	‘be more confident in a room with a dying person’ ‘more holistic with this population’ ‘be more prepared’ ‘be more willing to engage and list to difficult conversations’ ‘communicate with empathy’		N/A

Mathisen, B., Yates, P., & Crofts, P. (2011). Palliative care curriculum for speech-language pathology students. International Journal of Language and Communication Disorders, 46(3), 273–285. https://doi.org/10.3109/13682822.2010.495739

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