This study’s results show that the case study and group discussion among the participants positively affected undergraduate students' attitudes toward palliative care and multidisciplinary teamwork and collaboration.
As presented in Table 2, the paired t-test revealed significant differences in the mean FATCOD scores pre- and post-intervention. The literature showing EOL programs' effect on the students also supports our findings. Lewis et al. [20] evaluated the impact of a simulation intervention on attitudes toward end-of-life care among nursing and medical students; 19 volunteer students participated, and the simulation of palliative/EOL care positively influenced nursing and medical students' attitudes toward EOL care [20].
Some studies have reported similar results using FATCOD [21] and FATCOD-B [11, 22, 23]. However, these studies mostly used mixed methods: a specific educational program [10], an online multimedia training program [21, 22], and simulation [21, 23].
We previously reported that the practical palliative/EOL approach for enhancing medical students' confidence in palliative care was yet unknown because many studies used mixed approaches, making it difficult to reveal the mechanism behind the change [24]. This study is therefore particularly important considering that students showed significant changes with this simple approach using case study and group discussion, which enables adaptation to a broad range of medical students.
Dimoula et al. [25] surveyed the knowledge and attitudes about palliative/EOL care in a cross-sectional study of nursing students and found that more than 60% of participants had positive feelings about caring for patients and their families, but their knowledge of EOL was poor. The subscale analysis showed a significant difference in the perceptions of the patient and family-centered care in the FATCOD-B-J subscale for the EOL group. Therefore, we suggest that the intervention group's knowledge about palliative/EOL care was supplemented through the case study, and that knowledge may have contributed to the improvement in the scores of this subscale. At the same time, the other subscales of the FATCOD-B-J did not show any significant changes. Henoch et al. [26] surveyed undergraduate nursing students and reported that the attitudes toward the care of a dying patient become more open and positive in the final year of studies. Our study was conducted as a part of a mandatory course in third-year education. Therefore, further learning opportunities may be needed to effect changes in attitudes toward dying patients. In addition, the definitions and correspondence of subscales in the factor analysis in translating the FATCOD-B are different in the palliative/EOL studies, and most studies did not conduct further subscale analysis [21, 23, 27, 28]. Although the Japanese version of Nakai et al.'s [13] factor analysis indicated three factors, “attitudes toward death” is a single item. The score’s range was narrower than other factors. The respondents in the study had high scores in the pre-test, which suggests that this intervention's effect may not yet be fully detected.
A significant difference was observed in the RIPLS in both groups. In the present study, significant changes were observed in the teamwork and collaboration subscale for students who participated, regardless of whether they were EOL cases. Similar effects of RIPLS have been observed in other EOL studies [29] and interprofessional work case studies [30]. This supports our result that case study and group discussion are effective for building teamwork and collaboration within the medical college for education in multiple professions.
DAI was the outcome that showed no change at the post-test. This scale was developed to quantify Japanese cultural attitudes toward life and death [16]. In our study, group discussions were conducted from the perspective of patient care. We believe that the EOL case studies in this study could positively affect perceptions of care for dying patients and their families and teamwork but are unlikely to effectuate changes in perceptions about an individual’s death.
There are limitations to this study that are important to acknowledge. We randomized the grouping process. However, the facilitators could not be blinded to the fact that the EOL cases were in the intervention group. Double-blind testing would have been optimal, but it was not possible in this study because all case information was shared among the students and facilitators. Therefore, there was a risk of bias in the expectation of improvement for participants assigned to the intervention group.
We encouraged all students to participate in a mandatory subject in the third year of the course. However, the response rate at the post-test was 59% (n = 232). Data were collected for all the departments targeted, but not all students are reflected. Response rates also differed by department. For example, the response rates were high for nursing, occupational therapy, and physical therapy but were low for acupuncture and moxibustion, clinical engineering, and clinical laboratory testing. It is also necessary to recognize that this was a small study conducted at a single institution of higher education. Therefore, caution should be considered when applying statistical inferences.
One possible reason for the observed effect in the EOL group was the quality of the facilitator's intervention. In this study, the four teachers who were in charge of the EOL group received six hours of training. However, a single teacher was not assigned to all of the EOL groups. Many other teachers were also involved, and unified group discussion rules were established, which were disseminated to all teachers in charge of the group and implemented across the groups. Therefore, differences in intervention quality should not be a concern.
Significant differences in post-test, which were not found in the control group, were observed in the intervention group, but there were no significant differences between groups. Further study is needed to determine the effectiveness of EOL education.