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Teaching medical undergraduates basic clinical skills in hospice—is it practical?
  1. Alison L Franks
  1. Leicestershire Hospice, Leicester, UK
  1. Dr Alison L Franks, Oncology Department, Walsgrave Hospitals NHS Trust, Coventry CV2 2DX, UK

Abstract

AIM Basic clinical skills teaching to medical undergraduates was a new departure for the hospice stimulated by the changing philosophies and organisation of students' training. This study was undertaken to assess the practicalities of the venture.

METHOD Questionnaires were designed for each of the three major groups of people involved, namely the students, the patients, and the hospice nurses. Involved patients completed theirs after teaching sessions, while the students and nurses were given two different questionnaires each, one at the start and another at the end of the academic year.

RESULTS All students completed both questionnaires. Overall they had acquired adequate skills to pass their end of year assessments and considered themselves more comfortable with difficult situations than may otherwise have been the case. The majority of patients had enjoyed the experience and found it personally educational and a change to hospice routines. The nurses' response rates were very poor, limiting any conclusions that could be drawn.

CONCLUSION The venture was successful, stimulating, and practical for patients and students. Its impact on the nurses remains uncertain but, by their unusual lack of opinion expression, it can be inferred tentatively that this was minimal.

  • medical students
  • clinical skills
  • education
  • patient enthusiasm

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Medical undergraduate training is undergoing a profound metamorphosis throughout the UK.1-3 The traditional didactic format of two years of preclinical and three years of clinical teaching is being transformed into a topic and problem based format, encouraging students towards greater participation and independent learning.1 3-6 With this approach, the preclinical/clinical divisions are blurring and patient contact is being introduced earlier, requiring more clinical placements.7-9 For Leicester students, the basic clinical skills of history taking and examination are taught in the second year. They are assigned in groups of six or eight to clinical tutors with whom they meet weekly to consolidate the theory pertaining to that week's “topic” and to learn the associated practical clinical skills.

In the 1995/6 academic year, one of these groups of students was assigned to the hospice. Although training and trained health professionals have always been welcomed at the hospice, this new teaching participation generated many verbal concerns and reservations, particularly from the nursing staff. Thus it was considered important to assess the impact and educational effectiveness of the venture on the individuals most intimately involved. This paper reports the findings.

Method

The medical school coordinated the programme of lectures (covering anatomy, physiology, pathology, and clinical issues) on each week's topic, for example respiratory system, followed by ward based sessions, for which six students were allocated to a hospice consultant tutor. Ward staff identified potentially suitable patients. Several days before sessions they were invited to participate, the tutor seeing them again immediately before the students' arrival to ensure their continuing willingness and suitability to take part.

Questionnaires for each of the involved groups, that is nurses, patients and students, using restricted (“yes/no”) and free text response questions, were designed and critically assessed by several staff members before the study. Formal piloting was not undertaken. Responses were anonymous. All the nurses were sent a pre-emptive questionnaire with another at the end of the year (appendix ). The students were required to complete separate questionnaires on their first and last days (appendix ) and after each session participating patients were asked their opinions about the experience (appendix ).

Results

All six students (100%) returned both questionnaires completed. Of the 40 nurses, 13 (32.5%) returned the first questionnaire and eight (20%) the second (some incomplete) despite reminders. Twenty two of 25 (88%) patient questionnaires were returned (inadvertently tutors had not always remembered to hand them out; no record of these “missed” patients was kept).

MEDICAL STUDENTS

Four had had previous hospice contact. Three were concerned that the deaths of patients they had met could be upsetting; one was anxious not to intrude; two denied any apprehensions about the attachments. They thought that the hospice would offer valuable overall experience but less problem diversity than their hospital based colleagues would encounter.

By the year end the students all considered that there had been adequate opportunity to learn their basic clinical skills, though histories were often complicated. In addition they appreciated the importance of, and felt fairly confident in, developing good physician/patient rapport and in broaching sensitive topics. They appreciated the importance of ensuring a common understanding and having respect for others. In their “end of year” assessment there was no evidence of them having been disadvantaged relative to their colleagues. The experience had reinforced the career motivation for two. Their only problem of the attachment was that of travel.

Box 1: Quotes from nurses regarding impending second year medical students attachment

  • The earlier you educate in communication skills, hospice awareness, etc, the better.

  • May learn about communication from our example.

  • May help them learn how to relate to and treat patients as individuals.

  • Patients with very little left shouldnot be bothered by second year students or any other unnecessary professionals.

  • Invades patients' privacy and choice.

  • Students asking us questions is good forus too.

PATIENTS

Suitable and willing patients were available on all but three weeks (when tutor and students transferred to the hospital oncology ward instead). Most (16, 73%) had encountered students previously. Although five found it tiring, 20 (91%) enjoyed the involvement and 21 (95%) would take part again (see fig 1). One found the number of people overwhelming.

Figure 1

Reasons patients would take part in teaching again.

NURSES

Nine (69%) were aware of the impending student attachment; five thought it a good idea, five did not (box 1). Potential problems were foreseen for the students, the patients, and themselves (box 2). By the end of the attachment four (50%) considered the students' presence had been obvious: “mostly by numbers...”; two thought they had been intrusive “sometimes”, and three considered they had been “hardly noticeable”. One thought patients had enjoyed the experience, seven did not comment. As regards problems, three knew of none; others commented: “the students are too young”; “I don't have time to look after medical students”; “those patients that obviously weren't up to talking were targeted too much”; “one relative did question whether it was necessary for a husband to be subjected to this”. Overall, four (50%) thought it a good initiative. All eight thought medical students should visit hospices during their training preferably by “repeated visits over time”, “later in their training”. A final comment was “....too early in their training to learn anything here”.

Box 2: Potential problems foreseen by the nurses

For the students
  • May be overwhelmed by facing dying patients so early on.

  • May be a lack of suitable patients.

    For the patients
  • Too time consuming.

  • May feel pressurised to volunteer.

  • May see similarities between a normal hospital ward and the hospice.

    For themselves
  • More pressure on us.

  • Rush to get patients ready in time.

  • Have to pick up the pieces after....

  • ....takes time away from patient care.

Discussion

The findings from this study suggest that, although there can be a dearth of suitable patients, a hospice is a practical setting for at least some basic clinical skills teaching.10 The students found the attachment rewarding, stimulating a broad appreciation and understanding of patients'/people's needs. The patients generally welcomed the opportunity to help in the training of new doctors, making them feel still valued members of society and enhancing their hospice routine. Though many of the nurses expressed major reservations verbally about this new venture, response rates to their questionnaires were disappointingly low limiting the conclusions that can be drawn. However all the responders agreed to the importance of students having at least some hospice experience during their training.11

With any new venture an element of scepticism and questioning is valuable and appropriate. Staff should be encouraged to air their concerns, which must then be responded to. Potential concerns however should be pre-empted by a full explanation to all staff of the aims and methods of the venture. As we were hoping that the teaching would become a regular commitment, and in response to the nurses' reservations, it was considered essential to seek the involved patients' opinions. This revealed much more enthusiasm and positive feedback than had been perceived/anticipated by the nurses. The patients enjoyed the company, found it educational, and stated that it helped to pass the time, suggesting that periods as an inpatient, though physically necessary, can be lacking in mental stimulation for some.12 Involvement in the teaching appeared to provide both an intellectual challenge and a feeling of being valued citizens so essential to people, particularly in societies such as ours in which the elderly and/or the sick are frequently marginalised.13These are very positive attributes for a venture that was viewed at least initially with great scepticism by many staff. It is, however, important to acknowledge that almost a third of the nurses who returned the first questionnaire denied prior knowledge of the impending students. Thus we can infer that their responses were based on assumptions rather than on knowledge about the venture. This reiterates the importance of in-house communication to keep everyone informed of proposed developments, so enabling them to feel included and empowered to express their opinions, which may in turn stimulate them into playing an active role in the venture so enhancing its value/effectiveness for all.

As anticipated by some, there was a lack of sufficiently fit patients for some sessions, but this did not hinder the students' acquisition of the basic clinical skills as demonstrated by their results in the end of year assessments.10 As a bonus they encountered conditions considered oncological emergencies, for example superior mediastinal obstruction, spinal cord compression and hypercalcaemia which, though uncommon, require early recognition and prompt treatment to maintain patients' quality of life. They also said that they felt less uneasy in encounters with the dying and addressing sensitive issues than may otherwise have been the case. The drawbacks were geographical (the hospice being over two miles from the medical school) and the history complexities/multiple symptomatologies of most of the patients, adding to the students' learning challenge!4 9These, it could be argued, are reasons for hospice patients not being suitable for students trying to master the basics rather than more senior students enhancing their skills. However facing such complex and challenging situations early on, as long as the students are suitably supervised and tutored, should be challenging and stimulating—two aims of the new style curricula.3-7 9 Furthermore when later tackling more straightforward problems their confidence and hence self esteem will hopefully be enhanced after these initial encounters. These attributes of training are central to the aims of the new curriculum planners. They, among others, have levelled criticisms at “traditional” teaching, often said to have had maximum effect by humiliating students, potentially breaking their spirit and shattering their enthusiasm for medicine, even risking disillusionment and abandonment of the profession.3 6 9 14-16

With regard to the potential dearth of suitable patients, this can be addressed either by having a preplanned alternative venue as here, or via a list of fitter outpatients or day unit attendees who would be willing to step in at short notice. Overall the gains for the students were much greater than any losses, which should be readily resolved during subsequent clinical attachments in the remainder of their training.5 The patients also viewed the experience positively but it is vital to acknowledge that such involvement is not appropriate for all patients. They must not be pressurized into agreeing to take part and should be empowered to withdraw without penalty. As to the nurses, their low written response rate at the venture's conclusion suggests that the presence of the students was not particularly intrusive or disruptive and certainly there were no “pieces to be picked up” as had been anticipated. One nurse did, however, feel that patients who were not up to talking were targeted too much (see results), possible implying that the doctors were less sensitive to the mental fitness of the patients than the nursing staff. However, as stated earlier, all potential patients to be involved in this teaching were initially identified by the ward nursing staff as generally they have more contact with the patients than the doctors, and so are in a better position to assess the potential suitability for involvement and to avoid “over use” of individuals. A fuller evaluation of the impact of the venture on the nurses though is rather limited because of their disappointing written response rate. This should not, however, be interpreted as implying that the nurses can be ignored/not consulted when contemplating a new undertaking on the wards, whether in a hospice or a hospital—communication is the key.

Questionnaire to nurses

1. Before

  • Were you aware, prior to this letter, that junior medical students would be coming to the hospice weekly for the next few months? Yes/no

  • Do you think it a good initiative? Yes/no (please explain)

  • Do you foresee any problems, and if so what? For (A) students, (B) patients, (C) nurses.

  • Have you any suggestions about particular aspects of hospice patient care that should be emphasised?

  • What do you think may be the most valuable message(s) to get over to these students?

  • Any other comments?

2. After

  • Prior to this letter, were you aware that we had been teaching a group of six second year medical students on the ward? Yes/no

  • If “yes”, did you find their presence:

     Obvious? Yes/no
     Intrusive? Yes/no
     Noticeable? Yes/no
  • Do you think the patients involved found it:

     Enjoyable? Yes/no
     Intrusive? Yes/no
     Appropriate? Yes/no
     Tiring? Yes/no
     Other comments?
  • Do you feel there have been any particular problems related to this initiative for: (A) patients? (B) you or the other nurses? (C) students?

  • What about the other ward patients/relatives?

  • Other than learning the basic clinical skills, what else do you hope these students will have learnt by being taught at thehospice rather than on hospital wards?

  • Overall, do you think this has been a good initiative? Yes/no

  • Do you think medical students should visit hospices? Yes/no

  • If “no”, why? If “yes”, at what stage? How often? etc, and why?

  • Any other comments?

Questionnaire to medical students

A. Day 1

  • Have you been to a hospice before? Yes/no (please describe)

  • Do you know anyone who's been treated in a hospice? Yes/no (please expand)

  • Do you know what a hospice is? Yes/no (please explain)

  • What sort/group of patients do you think a hospice is for?

  • What sort/group of patients do you think a hospiceshould be for?

  • Do you think a hospice is the same as a hospital? Yes/no

  • If “no”, what aspects may differ?

  • What do you understand to be the role(s) of hospices?

  • Do you expect hospices to be religious places? Yes/no (can you explain why?)

  • Do you expect it to be a happy or sad place? Why?

  • Are there any aspects of coming here weekly that worry you?

  • Do you expect your experiences and learning here to be any different to those of your friends on hospital attachments? Yes/no (if so, please explain)

  • Have any of your colleagues made any comments to you about:

     The hospice? Yes/no
     Your attachment here? Yes/no (please  expand)
  • What were your first impressions of the hospice when you came through the front door?

B. Last day

  • What do you now understand is the role of a hospice?

  • What patients is it mostly for?

  • Can you describe the atmosphere you have experienced here?

  • Have you found coming here difficult in any way? Yes/no (please explain)

  • Have you found the attachment adequate for learning the basic clinical skills? Yes/no (please explain)

  • Do you think your experiences by coming here have differed from those of your hospital based colleagues? Yes/no (please explain)

  • What has/have been the most valuable aspects of the attachment to you?

  • Have you talked about any aspects of the attachment with colleagues? Yes/no (please expand)

  • What have been the most difficult parts of learning clinical skills here for you?

  • Do you wish you had been allocated elsewhere? Yes/no/indifferent/don't know (please try to explain)

  • Would you recommend other students to come here? Yes/no (why?)

  • Other than clinical skills, what else do you think you have learnt during your time here?

Questionnaire to patients

  • Have you had medical students talk with you/examine you before (perhaps at one of the hospitals)? Yes/no

  • Were the students today:

     Courteous? Yes/no
     Shy? Yes/no
     Anxious? Yes/no
     Relaxed? Yes/no
  • Do you think they found it easy to talk with you? Yes/no (please explain)

  • Did you find it easy to talk with them? Yes/no (please explain)

  • Did you find it tiring? Yes/no

  • Did you enjoy having them come to see you? Yes/no (please explain)

  • Are you happy you agreed to see them? Yes/no (please explain)

  • Do you wish you had not had them come to see you? Yes/no (can you say why?)

  • Would you agree to seeing students again? Yes/no (please explain)

  • Do you think it a good idea for young student doctors to come to a hospice during their training?

  • What do you think are the most important things for us at thehospice to teach them?

References

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