Palliative care and the arts: vehicles to introduce medical students to patient-centred decision-making and the art of caring

Impact of a longitudinal course on medical professionalism on the empathy of medical students

OBJECTIVE

Medical education should enhance empathy. We examined, using self-assessment instruments and standardized patients (SPs), the impact on empathy, of a multi-year intervention (years 4-6 of medical training) that uses reflective learning approaches.

METHODS

241 final-year medical students participated; 110 from the 2018 graduation class (non-intervention group) and 131 from the 2019 graduation class (intervention group). Participants completed two self-reported empathy questionnaires - the Jefferson Scale of Empathy-Students (JSE-S) and the Interpersonal Reactivity Index (IRI) - and a personality questionnaire, the NEO Five-Factor Inventory. Additionally, SPs in a simulated station assessed participants' empathy with two patient-reported instruments: the Consultation and Relational Empathy (CARE) scale and the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE).

RESULTS

Empathy scores were significantly higher in the intervention group compared to the non-intervention group when assessed by the SP (p < 0.001). No differences were found in self-reported questionnaires between the two groups.

CONCLUSION

A longitudinal, multi-year reflection-based intervention enhanced empathy amongst medical students as assessed by SPs, but not when assessed by student self-reported measures.

PRACTICE IMPLICATIONS

Multi-year reflective learning interventions during clinical training nurture empathy in medical students. Assessments completed by SPs or patients may enhance the evaluation of empathy.

Character and virtue development in medical learners: another role for the arts?

Medical education serves to teach students how to think and act as future physicians. Doing so successfully requires supporting learners' acquisition of clinical skills and knowledge, but also attending to their character education and virtue development. The arts and humanities are widely embraced as a fundamental component of a complete medical education. While not frequently touted as a useful pedagogical tool for teaching character and virtue, we argue the integration of arts-based activities into medical education can promote virtue development. In this article, we use the virtues framework from the Jubilee Centre for Character and Virtues at the University of Birmingham to review existing empirical studies of arts-based programs for each of these virtue domains of intellectual, moral, civic, and performance virtues. Learners may benefit from further exploration-both conceptual and empirical-of how the arts can scaffold character development in medical education.

Learning Harmony: Medical Student Reflections on the Intersection of the Arts & Humanities and Medicine, A Mixed Methods Study

Background

The arts and humanities form a critical part of medical education. In this study, we explore medical students' reflections following an arts and humanities experience. An intensive day and a half long program focused on music and reflection was designed for first-year students at Harvard Medical School.

Methods

Students completed an evaluation of the experience with both open-ended and Likert scale questions. Data were analyzed using a mixed methods approach. Descriptive statistics were used to analyze quantitative data and inductive content analysis for qualitative data.

Results

168 first-year medical and dental students participated in the activity. Survey response rate was 73% (n =122). Quantitatively, the overall quality of the experience was assessed at a mean value of 4.86 points (SD = 0.37 points) out of a maximum of 5, with 5 being excellent. The qualitative evaluation illustrated how the arts and humanities experience encouraged students to reflect on their leadership and doctoring skills, taking a holistic approach to their medical education, and integrating the lessons of the arts and humanities into their medical practice.

Conclusion

The arts and humanities program encouraged student reflection on profound questions in medicine related to empathy, vulnerability, and authenticity. This experience broadened students' perspectives regarding the relationship between medicine and the arts and humanities.

Palliative care stay room - designing, testing and evaluating a gamified social intervention to enhance palliative care awareness

INTRODUCTION

The message of palliative care can be promoted using creative thinking and gamification. It can be an innovative strategy to promote changes in behaviour, promote thinking, and work on skills such as empathy.

AIM

Design, test and evaluate a gamified social intervention to enhance palliative care awareness among young university students from non-health background.

METHODS

Participatory action research study with mixed methods, Design Thinking and using the Public Engagement strategy. Forty-three undergraduate students participated in a Palliative Care Stay Room and completed the Test of Cognitive and Affective Empathy (TECA) before and after the game. At the end of the game, a ten-minute debriefing was held with the participants, which was concluded with an open conversation. The content analysis was done independently and the sum of the scores of each dimension was compared before and after the activity.

FINDINGS

The Stay Room improved the participants' knowledge and new perspectives about palliative care. Before the game, their views focused on the end of life and after the game on their values, highlighting the dedication of the healthcare professionals who do not treat death but the life until death. After de game, participants (N = 43: female = 23; male = 20; x̄ 19.6 years old) presented higher values in perspective adoption (intellectual ability to put oneself in the other's place) p = 0.046 and in emotional understanding (ability to recognize emotional states) p = 0.018, and had high scores on empathic joy (p = 0.08).

CONCLUSION

Gamification can be used in teaching and transmitting positive attitudes. Palliative Care and can help young university students to think positively about care issues.

The benefits of rotating through palliative care: A qualitative study

PURPOSE

This is a qualitative study of written reflection projects by medical learners who completed a clinical rotation in Palliative Care (PC) at an academic tertiary care center.

METHODS

Upon completing their rotation in PC, medical learners were asked to complete an open-ended reflection project that captured their overall impressions of this training and experience. Fourteen reflections were coded and analyzed.

RESULTS

Upon analyzing the reflections, 5 main themes emerged. The first theme is that this rotation helped the learners become more empathetic and compassionate towards patients and their families. Second, the learners were able to recognize the humanity in their patients, regardless of their medical condition. Third, each of the learners in this study had meaningful interactions with numerous patients and really felt that they played a supportive and important role in the death of patients with whom they were working. Fourth, this experience challenged the learners to think and act in ways that they have not been taught in medical school. Lastly, the learners experienced a sense of transformation and a new-found appreciation for all of the emotions involved with working with dying patients.

CONCLUSIONS

Rotating through PC and reflecting upon that experience can be very meaningful for medical learners who have not worked much with dying patients and their families.

Visual art-based training in undergraduate medical education: A systematic review

BACKGROUND

Visual art has been increasingly incorporated into medical education and has been shown to enhance important competencies, such as empathy. However, limited evidence on effective visual art program design and evaluation processes remain. This systematic review examines the format, content, and espoused outcomes of visual art-based training programs in undergraduate medical education.

METHODS

A comprehensive literature search of MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and ProQuestERIC on undergraduate medical education and visual arts retrieved 1703 articles published from 2014 to 2020. After reviewing inclusion and exclusion criteria, 23 articles were chosen for full review and synthesis.

RESULTS

Program format and content varied, ranging from 1-day specific competency focused programs to well-structured comprehensive 6-12-week programs. 6 areas of program foci were identified: observation skills, empathy, tolerance to uncertainty, cultural sensitivity, team building and collaboration, and wellness and resiliency. Although several programs used validated measures to assess skills acquisition, they seldom addressed long-term outcomes.

CONCLUSIONS

Our findings indicate that visual art-based education hold a promise to enhance important competencies in medical education, particularly empathy. Clinical observation, in particular, had the strongest evidence of its effectiveness compared to the other competencies. Future programs incorporating visual arts will benefit from a longitudinal (greater than 6 weeks) program which incorporates guided artworks, reflection exercises, and a group discussion to provide a stronger foundation for the development of core competencies. We propose using validated scales to measure outcomes in future studies and follow-up with participants to better assess Kirkpatrick Level 3 and 4 outcomes.

Optimising planned medical education strategies to develop learners' person-centredness: A realist review

CONTEXT

Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful.

METHODS

A realist review was conducted with a search of Medline, Embase, HMIC and ERIC databases and the grey literature using the terms 'medical education' and 'person-centred' and related synonyms. Studies that involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focused on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness.

RESULTS

Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome configuration (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focused on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness.

CONCLUSION

Our findings offer explanations as to why communication skills-based interventions may be insufficient to develop learners' person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policymakers testable theory to inform the development of medical education strategies that aim to support person-centredness.

Arts engagement facilitated by artists with individuals with life-limiting illness: A systematic integrative review of the literature

BACKGROUND

Living with life-limiting illness significantly impacts quality of life. A growing body of evidence suggests that arts engagement facilitated by artists promotes well-being. However, no synthesis of the literature exists to describe arts engagement delivered by artists with individuals receiving palliative care.

AIM

To systematically review and synthesize evidence to identify outcomes and key knowledge gaps to inform future research and practice.

DESIGN

A systematic integrative literature review was conducted using a pre-defined search strategy and reported using PRISMA guidelines. Analysis was conducted iteratively and synthesis achieved using constant comparison to generate themes.

DATA SOURCES

PubMed/MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, and Embase were searched for studies published between database inception and August 2020. Search terms included variations on arts/artists; patients/service users; and palliative or end-of-life care. Eligibility criteria was applied and study quality assessed.

RESULTS

Seven reviewed studies explored literary, performing, and visual arts engagement in hospitals, hospice and community settings in England, the United States, France, and Canada. Study designs, interventions and findings were discussed. Themes identified across studies associated arts engagement with (1) a sense of well-being, (2) a newly discovered, or re-framed, sense of self, (3) connection with others, and (4) challenges associated with practice.

CONCLUSION

Recommendations for future research were offered in order to maximize benefits, minimize risks and address complexity of artists' engagement in palliative care including: (1) consistency in methods and reporting; (2) inclusion of wider perspectives; and (3) key considerations for adapting the arts by health condition and art form.

Health Humanities curriculum and evaluation in health professions education: a scoping review

BACKGROUND

The articulation of learning goals, processes and outcomes related to health humanities teaching currently lacks comparability of curricula and outcomes, and requires synthesis to provide a basis for developing a curriculum and evaluation framework for health humanities teaching and learning. This scoping review sought to answer how and why the health humanities are used in health professions education. It also sought to explore how health humanities curricula are evaluated and whether the programme evaluation aligns with the desired learning outcomes.

METHODS

A focused scoping review of qualitative and mixed-methods studies that included the influence of integrated health humanities curricula in pre-registration health professions education with programme evaluate of outcomes was completed. Studies of students not enrolled in a pre-registration course, with only ad-hoc health humanities learning experiences that were not assessed or evaluated were excluded. Four databases were searched (CINAHL), (ERIC), PubMed, and Medline.

RESULTS

The search over a 5 year period, identified 8621 publications. Title and abstract screening, followed by full-text screening, resulted in 24 articles selected for inclusion. Learning outcomes, learning activities and evaluation data were extracted from each included publication.

DISCUSSION

Reported health humanities curricula focused on developing students' capacity for perspective, reflexivity, self- reflection and person-centred approaches to communication. However, the learning outcomes were not consistently described, identifying a limited capacity to compare health humanities curricula across programmes. A set of clearly stated generic capabilities or outcomes from learning in health humanities would be a helpful next step for benchmarking, clarification and comparison of evaluation strategy.

Insight and Inner Peace in Palliative Care Professionals after an Art Therapy Workshop Focused on Personal Self-Care: A Preliminary Experience

Background: Emotional exhaustion is a problem many palliative care (PC) professionals face during their activity. Art therapy is emotionally beneficial for palliative patients who experience suffering, but its impact on professionals' experience of suffering has not been researched. Objective: To examine the immediate reactions of professionals after an art therapy workshop focused on personal self-care, also considering previously used coping strategies. Design: A four-hour art therapy workshop was designed including a generic qualitative study of participants. Participants were PC professionals and their reactions were examined using an ad hoc questionnaire with open-ended questions. Descriptive analysis of quantitative variables and thematic analysis of open-ended questions were conducted. Results: Seventeen professionals participated voluntarily. They rated the workshop positively, using words such as "calm" and "relaxation" to express the effects of the workshop, which they considered therapeutic and a source of self-awareness. For some, it allowed them to release emotions; for others, it enabled introspection and opened up a more elaborated emotional response. They thought artistic expression would be useful for their colleagues, or even for their own personal development. In the workshop, professionals opened up and explained how they face intense moments on a day-to-day basis: how they approach the situation, or how they try to control their surroundings; how they disconnect/distance themselves; and how they consider circumstances as a learning process and source of self-nurturing. Participants described art therapy as calming, healing the most intense feelings, and feeding the soul. Conclusion: Professionals reacted immediately with enthusiasm to art therapy, positively assessing its effects. Some attributed effects are in line with daily strategies of connecting with one's inner self. Others are about promoting self-awareness and inner peace, while providing healing opportunities. Art therapy may play a role in self-care for the PC professional, and should be researched further. Research Ethics Committee of the Universidad de Navarra approved the study (Number: 2019.167).

Experiences of Bereaved Family Members Receiving Commemorative Paintings: A Qualitative Study

IMPORTANCE

Although family members of patients who die in the intensive care unit commonly experience long-term psychological distress, end-of-life bereavement support programs for such relatives are uncommon. Whether art influences the grief experience of families is largely unexplored.

OBJECTIVE

To explore the influence of personalized paintings created to honor deceased critically ill patients on family members' bereavement experience.

DESIGN, SETTING, AND PARTICIPANTS

A qualitative descriptive analysis was conducted of semistructured interviews of grieving relatives who received a painting after the death of their loved one. The deceased patients were from a 21-bed medical-surgical intensive care unit. Eleven families were invited to receive a painting, of whom 1 family declined. A total of 22 family members of 10 patients who died in the intensive care unit were interviewed in the study between July 11, 2017, and May 19, 2019.

INTERVENTIONS

Patients were enrolled in an end-of-life care program that elicits and implements wishes of patients and their families to bring peace during the dying process. Selected families of 10 decedents were invited to receive a painting to honor their loved one 1 to 10 months after the patient's death. Using details about the patient's life story, the artist created individualized paintings to commemorate each patient.

MAIN OUTCOMES AND MEASURES

The experiences of family members receiving a personalized painting and its reported influence on their grieving experience.

RESULTS

The family members of 10 decedents (mean [SD] age, 60 [14] years; 5 women [50%]; 8 White patients [80%]) were interviewed. The central theme of art to facilitate healing was illustrated through the following domains: the cocreation process, painting narratives, postmortem connections, and legacy. The process of cocreating the paintings with the artist and family members involved reminiscing, storytelling, and creativity. Family members emphasized the role of art to facilitate healing, exemplified through connections with images portrayed that deeply resonated with memories of their loved one. Participants indicated that the paintings validated that the patient was remembered, helped families feel less alone during a time of grief, honored the loved one's life, and enhanced connections between family members and clinicians.

CONCLUSIONS AND RELEVANCE

This qualitative study's findings suggest that the creation of personalized paintings commemorating the lives of patients may help foster legacy and postmortem connections with clinicians and may help family members in their healing process.

Integrating drawings into health curricula: university educators' perspectives

The literature has identified promising findings regarding the application of arts-based initiatives to enhance healthcare professional (HCP) training. Research shows that drawings offer a window into the authentic, insider view of health and illness, with potential to be a platform for healthcare student and HCP learning. In addition, drawings may also have a place in health communication. Our previous work provides support for the educational application of patients' drawings in bringing HCPs closer to the patient's lived experience. Subsequently, this study aimed to explore university educators' opinions regarding the implementation of drawings as an educational tool for higher education healthcare students. The objective of this study was to explore pathways for using drawings as an art form in an educational context, and provide recommendations for developing curricula and resources for further evaluation. Findings from focus group interviews with nine university educators revealed support for the use of drawings as a novel medium as they offer rich insights into the patient's perspective while encouraging creative and critical thinking. Key perceived benefits were that drawings foster student appreciation of (1) the holistic impact of illness, (2) the importance of patients' priorities and (3) the value of learning from the patient. Patients' drawings of their experiences would offer needed opportunities for students to explicitly reflect about the 'person' holistically rather than view the patient as a 'biomedical problem'. Shifting students' perspectives and possible assumptions to be better aligned with and appreciative of the patient's experiences was noted as central to adopting a person-centred approach to healthcare practice. Our findings suggest that incorporating drawings, or indeed other art forms, as educational tools would be a valuable addition to the health curricula.

Thermal Infrared Imaging to Evaluate Emotional Competences in Nursing Students: A First Approach through a Case Study

During university studies of nursing, it is important to develop emotional skills for their impact on academic performance and the quality of patient care. Thermography is a technology that could be applied during nursing training to evaluate emotional skills. The objective is to evaluate the effect of thermography as the tool for monitoring and improving emotional skills in student nurses through a case study. The student was subjected to different emotions. The stimuli applied were video and music. The process consisted of measuring the facial temperatures during each emotion and stimulus in three phases: acclimatization, stimulus, and response. Thermographic data acquisition was performed with an FLIR E6 camera. The analysis was complemented with the environmental data (temperature and humidity). With the video stimulus, the start and final forehead temperature from testing phases, showed a different behavior between the positive (joy: 34.5 °C-34.5 °C) and negative (anger: 36.1 °C-35.1 °C) emotions during the acclimatization phase, different from the increase experienced in the stimulus (joy: 34.7 °C-35.0 °C and anger: 35.0 °C-35.0 °C) and response phases (joy: 35.0 °C-35.0 °C and anger: 34.8 °C-35.0 °C). With the music stimulus, the emotions showed different patterns in each phase (joy: 34.2 °C-33.9 °C-33.4 °C and anger: 33.8 °C-33.4 °C-33.8 °C). Whenever the subject is exposed to a stimulus, there is a thermal bodily response. All of the facial areas follow a common thermal pattern in response to the stimulus, with the exception of the nose. Thermography is a technique suitable for the stimulation practices in emotional skills, given that it is non-invasive, it is quantifiable, and easy to access.

Student's Inventory of Professionalism (SIP): A Tool to Assess Attitudes towards Professional Development Based on Palliative Care Undergraduate Education

Introduction: Quality medical education, centered on a patient's needs, is crucial to develop the health professionals that our society requires. Research suggests a strong contribution of palliative care education to professionalism. The aim of this study was to design and validate a self-report inventory to measure student's professional development. Method: Sequential exploratory strategy mixed method. The inventory is built based on the themes that emerged from the analysis of four qualitative studies about nursing and medical students' perceptions related to palliative care teaching interventions (see Ballesteros et al. 2014, Centeno et al. 2014 and 2017, Rojí et al. 2017). The structure and psychometrics of the inventory obtained is tested in two different surveys with two different groups of medical students. Inventory reliability and construct validity are tested in the first survey group. To verify the inventory structure, a confirmatory factor analysis is performed in a second survey group. Results: The inventory has 33 items and seven dimensions: a holistic approach, caring for and understanding the patient, personal growth, teamwork, decision-making, patient evaluation, and being a health care professional. Cronbach's-alpha was 0.73-0.84 in all seven domains, ICC: 0.95. The confirmatory factor analysis comparative fit index (CFI) was 1 with a standardized root mean square Index 0.088 (SRMR) and obtained a 0.99 goodness-of-fit R-square coefficient. Conclusions: this new inventory is grounded on student's palliative care teaching experiences and seems to be valid to assess student's professional development.

Palliative care teaching shapes medical undergraduate students' professional development: a scoping review

PURPOSE OF REVIEW

The aim of this review is to understand how palliative care teaching (PCT) as a patient-centered learning model, influences medical undergraduate students' professional development.

RECENT FINDINGS

To study PCT medical undergraduate students' learning experiences, we have employed the medical teaching concept, 'hidden curriculum,' as a way of describing attitudes and behavior conveyed implicitly by palliative care educators. Fifteen studies were selected: ten of those studies used a qualitative approach; two are theoretical explanations of the topic explored, one guideline, one review and just one quantitative study, made up the review. Medical undergraduate students reported that after PCT, they felt they had acquired better attitudes for effective integration with the patient, such as empathy or holistic care; ethical principles, such as respect or humanization of their clinical practice; and commitment to an improvement in competences, such as self-awareness or self-esteem. They also reported improved behavior in effective integration with patients, such as communication, caring for patients' families, and when addressing psychosocial, cultural and spiritual aspects; their commitment to improvement in competences, such as dealing with emotions and uncertainty; they learned team work as an effective way to interact within the health system; and to become more reliable, making themselves more available and dedicating enough time to each patient.

SUMMARY

PCT seems to be an effective way of fostering medical undergraduate students' patient-centered professional development.

Understanding illnesses through a film festival: An observational study

Audio-visual materials play a fundamental role in the context of education, care and clinical treatment, as they seem to have a high impact on public awareness. This study aims to describe what messages are perceived by the society at an International Festival of Short Films and Art on Diseases that may help to understand difficult topics, such as illness, dying and suffering.

Through an observational, descriptive, cross-sectional study, using full participant observation and an open, self-administered questionnaire, 32 short films were analysed during a healthcare art festival. Categories were developed using inductive content analysis. The message perceived by the participants, after the viewing of the shorts and reflection of the debates among the attendees, were considered in four categories: i) creative and positive education is possible; ii) awareness of preconception and practical duties; iii) meaning of life changes the experience of illness; iv) family and caregivers also experienced suffering. The short films are considered as an excellent tool to generate social dialogue and debate. Public events can be understood as an opportunity to acquire, in an emotional and critical manner, other competencies for public awareness. Together, they are capable of communicating difficult messages through a fast, positive, and creative way.