Table 1
Levels of affordances in narratives of memorable learning
|
Supports |
Constraints | |
|---|---|---|
|
Personal factors |
– Past involvement with death and dying: personal or professional – Actively defining learning needs – Seeking learning opportunities – Established reflective practice |
– No exposure (or negative exposure) to palliative care during undergraduate medical education – Lack of experience with palliative care as a concept and/or clinical practice – Fatigue and burnout during residency |
|
Interpersonal influences |
– Professional support – Positive relationships: patients and families, mentors, role models – Positive non-professional relationships for support and reflection |
– Lack of professional support – Communication challenges with patient and families: language, culture, family conflict, high negative emotional tone – Inadequate communication with interprofessional team about patient and family |
|
Systemic conditions |
– Well-structured and identified palliative care clinical learning opportunities – Time for communication – Continuity with patients and families – Formal curriculum: tutorials, lectures, books, online resources – Identification of and access to community-based resources |
– Lack of identified and supported palliative care clinical learning opportunities – Lack of time for communication – Fragmentation of care – Obligatory referral of patients to specialized teams – Biomedical focus – Lack of access to interpreters |
Table 2
Exemplars of factors supporting or constraining learning at personal, interpersonal and systemic levels
|
PERSONAL SUPPORTS AND CONSTRAINTS | ||
|---|---|---|
|
Support |
Past experience with palliative care, death and dying |
“… as a [clinical] clerk … we went to the palliative care unit and it was just very overwhelming … beyond the understanding of a med student at that time … but I think that might of shaped my view on palliative as a resident being more comfortable with these medications and everything” … P4 |
|
Active engagement |
“We had this blue book about palliative care and I just forced myself to read all the chapters basically to be more comfortable because I knew that it was one of the things I was not good in.” P9 | |
|
Constraint |
Lack of experience with palliative care, death and dying |
“I studied medicine in [another country] … palliative care was non-existent at the time.” P14 |
|
Challenge concept of palliative care |
“… what I reflected on was that I still wanted to do active care like I still I wasn’t used to just focusing on goals of care … “ P1 | |
|
INTERPERSONAL SUPPORTS AND CONSTRAINTS | ||
|
Support |
Understanding social relationships within a community |
“I knew her family … so it was a very intimate connection to the family. It was … a powerful thing for me …” P12 |
|
Interprofessional team |
“… we had meetings with nurses, with the pharmacist, with … the rest of the palliative care physicians … so definitely I never felt alone …” P13 | |
|
Constraint |
Language, cultural barrier and lack of team support |
“… there was a huge cultural component … language component … and then trying to shoot off a little one liner sentence in morning rounds … when everyone really doesn’t have the time to listen …“ P10 |
|
Uncertainty and negative emotions |
“a big challenge is becoming involved in a situation where the family has expectations, the patient has expectations, there’s probably a lot of fear about what is going on and then … [I] show up without all the information and are expected to make a recommendation or a decision.” P5 | |
|
SYSTEMIC SUPPORTS AND CONSTRAINTS | ||
|
Support |
Well-structured clinical experience |
“We do a family medicine palliative rotation … which is good because it shows you how you could fit palliative care into your family practice. You go to the hospice and then you come back and do your clinic and then you’re on call for the hospice so that’s good way to reflect what it might be like to do palliative care in the community later on.” P1 |
|
Community supports |
“… there’s a very good support system for family doctors with the [pain and symptom management team] …“ P13 | |
|
Constraint |
Lack of opportunity for holistic compassionate care |
“… total pain … depression, … the spiritual aspect … it wasn’t addressed … we just didn’t have the opportunity to work with patients enough to … have that discussion …“ P10 |
|
Multiple competing demands in the workplace |
“For me it wasn’t too bad, but I have heard for other residents … they didn’t always have their patients blocked in the afternoon … they’d have a full patient roster scheduled in the afternoon and then they’d have a hospice admission and they’d be like ‘Oh well someone forgot to schedule my patients off and I’ve got to see patients ’till 5:30, then go to [hospice] and maybe do an admission and then I’ve got to go home to my family.’” P11 | |