Harmony or dissonance? The affordances of palliative care learning for emerging professional identity

Several metaphors have been used to describe how learning happens including: acquisition, participation and becoming [6, 9]. The acquisition metaphor, where individuals acquire knowledge and skills, is the most common metaphor for learning in medicine [10]. More recently, interest has been directed towards understanding the sociocultural influences on learning through workplace participation [2]. While neither metaphor is completely exclusive in its focus, each privileges a perspective: acquisition privileges individual agency, participation privileges social interactions and structures [9]. Conceptualizing learning as a process of becoming overcomes the limitation in the focus of these models by underlining that learning is, at all times, the intentional and unintentional interplay between individuals, social interactions and the culture of the learning environments [6]. This brings us to our earlier point that affordances are not taken up in the same way by different trainees. An important outcome of learning within this metaphor is the development of professional identity.

Along with acquisition of knowledge and skills, professional identity is increasingly recognized as a goal of medical education [10‐13]. Different perspectives on identity have been presented ranging from singular, owned and stable; to dynamic, constructed and multiple [14]. For the purposes of this study we adopted the latter view, as developed by Jenkins: identification is a process not a thing, this process involves an individual, social interactions and cultural influences, and the individual is the character at the center of this complex process realizing him/herself in different ways in different contexts [14]. Jenkins asserts that “we should always be concerned with processes of identification, trajectories of being and becoming” (2014, p. 99). The way we think about learning can attune us to different features of this process, thus rendering previously unseen aspects of learning evident. In shifting the way we conceptualize how learning happens we can illuminate challenges that have not been considered and ask new questions as we work towards the goal of supporting learners’ emerging professional identity [15].

Helmich and colleagues proposed four paradigms that describe the interplay between emotion, meaning making and identity for medical students: insecurity, complying, developing and participating [16]. The paradigms of insecurity and complying, which did not support professional identity formation, were characterized as lacking engagement in meaningful participation, a focus on structural and procedural aspects of care and minimal opportunity for reflection. Developing and participating paradigms supported professional identity formation and were described as situations where: learners could actively explore the emotional dimensions of their work; there was developmental space for reflection to safely be curious, explorative and accept uncertainty; learners made active contributions to care and identified their learning needs. Our previous work highlights that these paradigms resonate with postgraduate learners as well as with medical students [7].

Embedded within the metaphor of learning as becoming is the broader notion that all experience contributes to learning, whether intended or unintended, thereby influencing emerging professional identity. From this perspective a question can be posed: what conditions support identity development for the desired outcome? Using the practice of palliative care as the case to explore this approach adds complexity. Palliative care requires a patient-centered holistic approach encompassing biomedical competence and compassionate caring. The domain of palliative care can be emotionally evocative and a cultural shift away from the disease-based, curative model that may challenge how learners see themselves as emerging practitioners [7, 17‐26]. In most published literature on palliative care education, learning is considered as individualistic, following the acquisition metaphor. Reviews of palliative care learning have identified a myriad of ways that palliative care is taught in undergraduate and postgraduate medical education. Teaching and assessment of learning is conceptualised almost exclusively as learner acquisition, consistent with the dominant learning theory and traditional research methods [2, 27‐30]. This perspective results either in minimizing relational and cultural issues in learning or viewing them as individual competencies with individual solutions [15, 31‐33].

Demographics in many countries indicate a pressing need for physicians, generalist and specialist, who are competent in and embrace the practice of palliative care as part of their professional identity [26, 34, 35]. Deepening the understanding of how learners become physicians capable of providing compassionate palliative care is critical. Learning as a process of becoming that concurrently attunes to personal, interpersonal and systemic factors provides the framework to consider learning in a broader sense, with palliative care learning as a specific case, and to explore how affordances can support or constrain the emergence of professional identity for palliative care practice.

Participants were recruited through a purposive sampling strategy [41]. An email invitation was sent by an administrative assistant to all 62 family medicine residents based at three urban training sites and who were preparing for their final certification exams during their last 6 months of training.

Participants were asked to recount stories of memorable learning in palliative care, aided by an interview guide following the structure of the personal incident narrative [25, 42]. All interviews were conducted by one interviewer known to participants but not in a position of power or authority (D.A.). Immersion in the data happened through listening to interview recordings and executing multiple close readings of each transcript. Three initial transcripts, representing one participant from each site, were reviewed by two researchers (F.K., R.A.), to identify discrete NMLs within each interview. The defining feature of a narrative that is key to its use in this study is the consequential linking of events to create meaning and give shape to things that might otherwise appear random [37, 38]. Each NML was analyzed to inductively develop themes and sub-themes for a coding framework [37, 38, 43]. The framework was discussed and refined iteratively to reach a shared understanding. The principal investigator (F.K.) undertook coding of all data using NVivo qualitative data analysis software version 10 (QSR International Pty Ltd., 2014). Coding was reviewed and discussed regularly with the team who brought diverse perspectives and roles to the analysis: insider (F.K., D.A.) and outsider (R.A.) views of the residency program, clinician teacher (F.K.) and education researchers (R.A., D.A.). Disagreements were resolved through discussion about theme and sub-theme definitions and the understanding of a contested quotation’s meaning. In order to deepen the understanding of the affordances of learning within individual NMLs, an in-depth narrative analysis was undertaken by R.A. and F.K. who interrogated and discussed each NML. Through close attention to how participants structured their stories, alongside what they said, the interplay between personal factors, interpersonal influences and systemic conditions were illuminated [37].

Past involvement with death and dying enabled palliative care learning: in formal medical education, in previous domains of study or careers and in personal life experience. The consequences of these experiences for participants were described as increased understanding of the concept of palliative care, more comfort and confidence to participate in care of the dying and a sense of personal meaning derived from the work. An individual disposition towards actively engaging in defining learning needs, seeking learning opportunities and accessing both human (the interprofessional team) and formal curricular (books, tutorials, online tools) resources for palliative care supported learning. In contrast, lack of or negative past experience with palliative care as a concept and a practice were identified as personal barriers to learning. More globally, feeling fatigued and burnt-out during residency training interfered with learning.

Positive relationships with colleagues, interprofessional team members, supervising physicians, patients and families were frequently identified as factors enabling learning. This supported effective communication, relationship building and a holistic approach to care. Having positive mentors, role models and supervisors, and observing their participation in the workplace supported learning and contributed to creating positive learning environments. Positive relationships outside of the workplace, such as close friends and family members with whom participants could reflect upon their work and its personal repercussions, were identified as strategies that supported learning. Lack of perceived support from supervisors, colleagues or other team members interfered with learning. Reasons for this included lack of time and interest by team members, a focus on acute curative care and differing points of view that were not resolved. Communication challenges were described as a result of language and cultural barriers, uncertainty about a patient’s history and disease trajectory, difficult family dynamics and high emotional tone.

Systemic enablers to learning were described as having well-structured and well-scheduled opportunities to participate in clinical palliative care, both core and elective, in hospitals, residential hospices, outpatient clinics and homes. Resources that enabled these clinical experiences were: time to spend with patients and families; formal curricular elements such as books, tutorials and on-line tools; access to community-based interprofessional teams; and access to in-hospital specialist palliative care teams. Having continuity with patients and families along the illness trajectory supported learning. Conversely, lack of identified palliative care opportunities in primary care practices, specialist rotations or in specialized palliative care units hindered learning. Lack of time to spend with patients and families, particularly around unexpected or catastrophic changes, and multiple competing demands due to the nature of clinical rotations and scheduling interfered with learning. Several participants remarked on the absence of any home-based care during their medical education and how this was a barrier to learning to practice community-based palliative care. Within some tertiary care settings, fragmentation of care or the requirement to transfer patient care to a specialized palliative care team with subsequent loss of continuity was identified as a barrier to learning.

We illustrate three vignettes that highlight how factors at multiple level align, misalign or collide within an NML influencing professional identity. Participant 7 (Infobox 1), an individual with prior experiences of death and dying, described taking up affordances within the environment such as actively engaging in defining learning needs, seeking learning opportunities, and accessing both human (the interprofessional team) and formal curricular resources (books, tutorials, online tools) for palliative care. In contrast, for Participant 5, lack of past experience with palliative care as a concept and a practice were identified as personal barriers interfering with learning. In other NMLs this resulted in lack of confidence and feeling overwhelmed and uncertain about being able to engage in this practice in the future. For Participant 5, this personal barrier was offset by interpersonal and systemic conditions supporting learning (Infobox 2). Confusion resulted when an individual with positive personal experiences of death and dying confronted interpersonal and/or systemic challenges to participating in this care that were overwhelming (Infobox 3).

Participant 7 described her familiarity with palliative care, recalling the physician who cared for her grandfather and describing previous palliative care learning (formal and workplace). These personal and systemic factors supported her emerging identity for palliative care practice. She further describes multiple positive interpersonal factors supporting her within the NML: interactions with interprofessional colleagues and family members. She was afforded and seized the opportunity for meaningful engagement. This enabled her to deal with uncertainty and emotions and opened a reflective space. She narrates her story as an active care provider for this dying man and his family.

Participant 5 had no experience with palliative care during his undergraduate medical education and although he heard about this practice through classmates, he was uncertain about what it was and what it entailed. Thus, he arrived at his first clinical palliative care experience as a postgraduate trainee. Despite his uncertainty and lack of confidence, he was curious and self-directed and was able to establish relationships with patient, family and team members to fully participate in this care. The structure of the workplace and schedule allowed him time to overcome these barriers, engage his curiosity, deal with uncertainty, and fully participate in the care of this man and his family. This resulted in memorable learning, satisfaction, and his presentation as someone capable of engaging in this care.

Participant 13 described herself as someone who is familiar with palliative care from several perspectives: family, past jobs and her previous health profession. Her NML is a dramatic story of challenging interpersonal interactions with a family in crisis, exacerbated by systemic factors of multiple responsibilities while on duty. Despite her personal disposition and awareness of palliative care practice, the need to comply with the pervasive systemic challenges and resulting unresolved emotions caused frustration. She described feeling conflicted and compromised about how she aspired to be and to act in this interaction, asking, ‘how is this ok?’. The sociocultural factors in this NML collide with her individual dispositions. While she presents herself as a caring and compassionate person, the conditions under which she was working did not allow her to express nor resolve this. The result is confusion about who she is and how she acted in this circumstance.

Viewing learning as a becoming allows teachers, clinicians and educators, through story, to: attune to the multiple constructions of learner identity, attend to and embrace uncertainty in learners, allow and explore the emotions experienced through learning in complex clinical contexts, and consider how the interplay of the individual and their relationships within the culture of the learning environment supports or hinders emerging professional identity. Situations that confuse or present mixed messages to learners can be identified and addressed at the appropriate level. Opening a space for reflection and reflexive engagement and valuing this as learning will contribute to the process of becoming physicians.

This study was limited by having participants from urban sites within one residency program. The non-urban perspective was not included. The voices of those who may have had negative or traumatic experiences or who did not identify with this area of practice may not have been heard and their absence may have illuminated different patterns of intersection. This study considered the case for palliative care learning. Further study will be required to consider this approach in other clinical learning domains.