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Recently qualified doctors learning about end of life care: a socio-cultural perspective
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Date
2022
Authors
Sweeney, Catherine
Journal Title
Journal ISSN
Volume Title
Publisher
University College Cork
Published Version
Abstract
Background
Death and dying are problematic areas in healthcare. In the developed world, socioeconomic and healthcare changes have resulted in increased life expectancy and excessive use of interventions and healthcare resources at the end of life (EoL). Associated with these transformations, there is a wider cultural reluctance to accept the inevitability of death. In the world of contemporary medicine, death can be viewed as failure. Providing care for people approaching and at the EoL is the responsibility of all doctors, not just the remit of a select minority in particular specialties. In the face of increasing specialisation in medicine, generalist competencies can be subverted.
Previous research has focused on knowledge, preparedness, and experiences of medical students and recently qualified doctors (RQDs) in palliative and EoL care. Many studies have identified significant deficits and call for inclusion of more content in both formal and informal curricula. Workplace learning about EoL care has not been as well explored from a socio-cultural perspective. The primary aim of this thesis was to explore and offer insights into how workplace socio-cultural factors influence RQD learning and development of capability in EoL care.
My research questions were:
1. What and how do recently qualified doctors learn within their physician teams about EoL care?
2. How do recently qualified doctors navigate the wider landscape of practice when caring for patients at the EoL?
3. How do consultants support recently qualified doctors and medical student workplace learning about EoL care?
4. How do specialist palliative care consult team (SPCCT) members perceive RQDs’ capability and involvement in the provision of EoL care?
5. How can specialist palliative care consult team members support recently qualified doctors to develop capability in EoL care?
Methodology
I have used a qualitative approach in my programme of research. I adopted a socio-cultural perspective, using the theoretical lenses of Communities of Practice (CoP) and Landscapes of Practice (LoP) for analysis. My research was underpinned by an interpretivist paradigm.
Methods
I conducted 4 studies, each using semi-structured interviews. Participants in studies 1 and 2 were RQDs within the first 4 years of qualification. In study 3, consultants who supervise medical students and trainees were interviewed. In study 4, participants were SPCCT members. I inductively applied Braun and Clarke’s method of reflective thematic analysis. While CoP and LoP theories informed the design of the studies, they were not applied in analysis until phase 3 of Braun and Clarke’s method (generation of initial themes). I sought latent themes and adopted a constructionist approach. In study 3, I also used a realist theory of supervised workplace learning in postgraduate training to examine the data.
Results
Fifteen RQDs, 14 consultants and 12 nursing and non-consultant medical members of acute hospital SPCCTs were interviewed. Cultural aspects in the workplace were powerful mediators of learning about EoL care.
EoL care was not considered to be part of the core business of many physician teams and RQDs were often not supported by senior doctors to learn and develop capability in this area. When patients were identified as dying, what was perceived to be active care was withdrawn and RQDs were often left by their seniors to deliver the medical aspects of EoL care. The RQDs interviewed excused the perceived lack of consultants’ knowledge and skills in this area and their disengagement from patient care at the EoL.
The consultant participants had set the bar high for entrustment in EoL communication. Opportunities for supported learning in the form of observation and less commonly participation, were predominantly reserved for senior trainees. Frequently the consultants interviewed failed to recognise that RQDs were involved in communication with patients and relatives towards the EoL and didn’t support their learning in this area.
There was substantial variation in consultants’ approaches to EoL care. Dying was sometimes diagnosed late. This coupled with a lack of documentation of care plans to inform patient care out-of-hours, resulted in RQDs suffering moral distress when they were required to carry out burdensome investigations and treatments on dying patients. Emotion in a variety of forms was common in RQDs’ accounts. As RQDs moved teams frequently on their training journey they had to do the emotional work of adjusting to the local practice within each physician team. The on-call landscape was even more complex and RQDs had to deal with increased uncertainty and responsibility.
SPCCT participants described their own struggles to gain legitimacy and trust with some physician teams. They noted RQDs’ lack of capability and their struggles in providing EoL care. They supported RQDs to develop knowledge and skills and provided emotional support.
Description
Keywords
Recently qualified doctors , Junior doctors , End of life care , Palliative care , Landscapes of practice , Communities of practice , Socio-cultural theory
Citation
Sweeney, C. 2022. Recently qualified doctors learning about end of life care: a socio-cultural perspective. MD Thesis, University College Cork.