Table 6. Extracts from participants' quotes by each theme.

IP-SDM: interprofessional shared decision-making; IPE: interprofessional education; 

Facilitating factors of implementing IP-SDM education in palliative care

“We started to see increasing numbers of patients of this category in the last decade, and I think this specialty is increasing with the number of patients. Therefore, the students will encounter these kinds of patients and fields more frequently rather than or compared to the previous health care practitioners.”  (Policymaker 3) “The demand is increasing, the number of patients is increasing, and the vision does support the needs.” (Policymaker 3) “My work as a geriatrician for the last 16 years and in palliative care exposed us to a point that you need to share decisions regarding patient care with the other team, with other disciplines and with the patient and their families.” (Policymaker 2) “..we have to keep in mind that the new module that the Ministry of Health is going through, which includes one of the six pathways, is palliative care. So, this is, I think, a big element that are influences us to push toward doing that.” (Medicine faculty 1) “If we will talk about our university, the domains are known, which is knowledge, research and community service, and I see this under the three of them. As a knowledge, as a good area of research, and it’s a community service. This project fitted completely the criteria.” (Policymaker 5) “We should now switch gears into specific patient management, not just disease- focused. So patient-oriented evidence and intervention that matters.” (Policymaker 2) “I totally agree that the shared decision-making is very important. But how to implement this? We have to be careful about the implementation.” (Applied medical sciences faculty 3) “Internal, we have Oncology Center, where you have a lot of cases and workloads on oncology and palliative care increasing. So that’s a factor I think it would help to push.” (Policymaker 2) “..and so what I said for it to be done in the undergraduate fashion….. Because there is an oncology center, simulation center and experts in medical education.” (Policymaker 4)

Hindering factors of implementing IP-SDM education in palliative care

“Changing the culture is very difficult. When you are continuously training the faculty, you can change the culture. By default it will change.” (Policymaker 1) “... Gender is also another example.” (Medicine faculty 1) “Caring of the caregiver, because they are dealing with such an advance and such a terrific time with their loved one. Also, … understanding the culture and belief and religion of our patients— this might be added.” (Nursing  faculty 2) “..which you mentioned about professional level might be  good to consider as well on a personal level, considering religion ..” (Medicine student 1). “Now the idea of having it professionally shared decision-making is becoming more fashionable here.” (Policymaker 2) “One of the things is the palliative care is not in all curricula. May be in nursing, medicine, but not in physiotherapy curriculum. This is one of the issues.” (Policymaker 1)  “Different experience in knowledge because we are as nursing students, we learn the palliative care in some aspect, but there are medicine students, for example, they are involved really in the course, but not superficial. Yeah. so, we can see gaps in knowledge. And it’s an elective course in nursing.” (Nursing student 2) “Palliative course should be as a mandatory course in nursing, not elective, because in real practice there are many palliative patients. If some nursing students didn’t take the course, how will they deal with the palliative patients?” (Nursing  student 2) “.. We take palliative care course, but not IPE.” (Applied medical sciences student 3) ''…The other issue is, as I said, preparation of the faculty. Not all the faculty are prepared to do interprofessional education. They need to have enough knowledge and skills and competency in teaching the interprofessional to palliative care shared decision-making.” (Policymaker 2) “The barrier is people accepting the role to be a facilitator or a participant and the different personality related to specialty or related person.” (Policymaker 3) “ First we have to change the people’s mind. Many people find is very difficult to change, like if I want to teach interprofessional, I have to have the people from the clinical nutrition department being very willing to teach the nursing department and the medicine and all together.” (Policymaker 1) “Interprofessional is really a mind switch. I’m a nurse, I’m teaching only nurses. No, that is not true. You are teaching. You can teach everyone skills.” (Policymaker 1) “You cannot teach interprofessional decision-making without interprofessional education.” (Policymaker 4) “ You need to prepare the people intellectually on how to teach interprofessional.” (Policymaker 4) “I think to be honest with you that the concept of the interprofessional is a new concept. We’ve graduated from college and such a term didn’t hear about it. We really need to introduce this term in faculty senior people and to recruit them and to get them engaged in such a new concept.” (Medicine  faculty 1) “..if we built our system based on interprofessional education, it would be much easier. Also, the problem of who’s going to be the boss?” (Policymaker 1) “The whole problem of undergrad that we graduate very competent physicians, very competent physiotherapists, very competent occupational therapists, etc., very competent clinical dietitians, but we don't teach them how to manage things together as a team, how to interact, what is the intersection, the real ability of other health care workers’ specialties and limitation.” (Policymaker 1) “…knowing how to be part of the team, knowing how to lead the team, knowing the dependencies between the team members and thinking about the patient at the end, which is sometimes a really tough formula to achieve.” (Policymaker 3) “I will concentrate in collaboration, especially for function of the team and resolve the conflicts. And I really think as a palliative doctor, these are the most things you are facing: learning how to function with the team and how to resolve the conflict.” (Medicine  faculty 1) “.. we have a lack of exposure with other health care professionals. Our students graduate from the program, they are full loaded with knowledge, but they don’t know the roles and responsibilities of other health care professionals.” (Applied medical sciences faculty 3)

Potential solutions for mitigating the hindering factors

“I want to add also, different culture considerations.” (Applied medical sciences faculty 3) “Education wise, actually, I'm doing the monthly meetings in Arabic Culture Week for the newcomers, staff nurses about the palliative in Kingdom”. (Nursing faculty 2) “They will also need to know about the other perspectives, such as social aspect, culture aspect, gender, and religion. So, they will know a lot of things regarding seeing each other on a daily basis or even dealing with each other during the meeting.” (Nursing  faculty 2) “I think the policymakers should ensure that the curriculum has a good part of focusing on managing patients, tailor management, quality of life, sharing part of the curriculum with other disciplines as for undergrad.” (Policymaker 2) “I think when people have the basic knowledge of their profession, like if they have a basic knowledge of nursing and then the basic knowledge of like clinical nutrition, the basic knowledge of medicine, then we have to introduce the interprofessional education, because if they do not know their own role in their profession, then they do not know how to work interprofessionally… So, I think it has to be introduced the time they introduce the profession knowledge itself. So, it doesn’t have to be in the late phase of each of any program; it has to be in the middle as early as possible.” (Policymaker 1) “..  having an agreement also with the hospitals for the internship students to get a mandatory, I would say, rotation or short rotation for palliative care patients. For example, one, one or two weeks, whatever the hospital is. So, maybe yes, if they get that, this will be a great opportunity for them to prepare them well in how to deal with these kinds of patients.” (Applied medical sciences faculty 3) “Completing each other is a good method if they feel they complete each other in their learning. They succeed very well. They learn very well, practicing everything. And like by clinical training, especially in palliative care, clinical training or bedside training is very useful. They learn from each other, and they learn different techniques. Also, they learn by doing, which is usually a very successful way of learning.” (Policymaker 1) “ I have seen students also are participating in complicated disease, cancer day, or cancer awareness. And then they have to work together to come up with a good education program for the community.” (Policymaker 2) “Utilizing simulation in doing these communication skills or building scenarios that would help the interprofessional decision-making process that would test the team, and they can do that in a simulation fashion and then utilizing briefing and debriefing after that.” (Policymaker 4) “…You have to train faculty, and we have to give them the chance to practice it gradually. First of all, you have to have the qualified staff—staff who are qualified to be or trained in palliative care and trained in interprofessional education.” (Policymaker 1) “Learning from international experience, attending some conferences, even if it's online, regarding the interprofessional palliative care patient management.” (Policymaker 2) “I would make sure that our faculty enhancement unit to work together to develop this course with the resources available at the college level...If you had asked me, I would say yes, I would love to have to see this course for our faculties, including myself, to learn about shared decision-making.” (Policymaker 3) “I think if we’re thinking about specifically palliative care. The grand round and the multidisciplinary round would be a good opportunity to come to a common understanding between the faculty….Having grand round, in the journal club, also looking at studies and measuring the achievement of our patients, for example, the length of stay for palliative care patients after the multidisciplinary team approach.” (Policymaker 2) “I will focus on collaboration in interprofessional teaching how to function with the team. Knowing the teams, knowing the function in the team and the limit of each one, and knowing and resolving their conflicts, and then knowing when to become assertive to become collaborative.”(Medicine faculty 1) “We have to break down those barriers and explain to people that everyone has a job, everybody has a role, and we’re always important to each other and, of course, to the patient. Everybody brings something to the table that's important. And I think some people come to the table without having that idea in their mind.” (Nursing faculty 2) “ Teach respect, cooperation, confidence to share your thoughts and decisions.” (Applied medical sciences faculty 3) “ The most important thing is how to deal with team teamwork, other teams, and how or what values and ethics we should incorporate in the program, like respecting patient values, what he needs, what he thinks of.” (Medicine student 1) “Let's say suboptimal communication between the professions. Um, we are talking about the understanding the importance of the role of each team member.” (Policymaker 5) “ Being in emergency seeing a lot of patients, I am talking about my experience as an emergency physician. We see a lot of patients, that could be all avoided if proper communication among health care professions is done in advance.” (Policymaker 5) “ Knowing the role of each team member is very good, knowing the limits when we ask for help… I'm talking about physicians asking for help, especially sometimes it's an ego issue.” (Medicine faculty 1) “Know other duties and responsibilities of each member of the team.” (Applied medical sciences student 3) “..So the point that I'm trying to raise here is understanding the roles really helps to deliver the best care possible and not following it and not following what you're supposed to do.” (Medicine student 1) “I think the most important is communication skills. During my internship in the rounds, I am having difficulties to communicate with other team members. We didn't take it in specific in undergrad.” (Applied medical sciences student 3) “Be able to communicate, to demonstrate their communication skills, especially with team conflict.” (Nursing  faculty 2) “ Good communication skills, this is the first thing we should be taught about, like we will be able to have better listening, and we can communicate and learn how to provide information and how to facilitate the decision-making and coordinate the care between each of us as a team and learn from other professions.” (Medicine  student 1)