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Nurse Educator Vol. 41, No. 1, pp. 25-28 Copyright * 2016 Wolters Kluwer Health, Inc. All rights reserved.

Dedicated Education Unit Model in a Hospice and Palliative Care Setting Joanne Q. Chmura, MS, RN, FNP-BC This article describes adapting the dedicated education unit model to the hospice/palliative care setting. The purpose of this qualitative study was to demonstrate how this unique academic service model helps to address the void that exists in hospice and palliative care in the clinical education of prelicensure nursing students. Keywords: dedicated education unit; hospice; nursing education; palliative care

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tudies have shown that prelicensure nursing programs do not adequately prepare students with the skills and competencies required to deliver highquality care to individuals in need of hospice or palliative care.1,2 Nursing students and graduate nurses are not prepared to communicate with terminally ill patients and cope with dying patients and their caretakers.3 Professional nurses may not be confident in their knowledge about end-of-life care.4 In an early survey, only 3% of nursing programs had end-of-life courses, and only 2% of nursing texts contained topics related to end-of-life care.5 There have been increased efforts to strengthen preparation for end-of-life care, but much of the effort has focused on the curriculum versus clinical setting.6 In 2007, in a survey of 408 respondents from both nursing and medical schools, 54% indicated that their learning about end-of-life care was limited to lecture.7 Students in the clinical setting may not have the opportunity to care for a dying patient and family.8 Thus, it is not surprising that practicing nurses have identified the need for more education in pain and symptom control as well as interdisciplinary communication with the dying patient, family, and caregiver. In 1997, the American Association of Colleges of Nursing (AACN) published Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Care.9 This project included the development of competencies in endof-life care for use in educating nursing students and nurses.4 In 2000, AACN partnered with City of Hope and others and developed the End-of-Life Nursing Education Consortium (ELNEC). Since 2001, ELNEC has continued to develop, revise, and Author Affiliation: Clinical Nursing Instructor, School of Nursing, University at Buffalo, State University of New York, Buffalo; and Nurse Practitioner, Private Practice, Internal Medicine, Williamsville, New York. The author declares no conflicts of interest. Correspondence: Ms Chmura, School of Nursing, University at Buffalo, State University of New York, 327 Wende Hall, 3435 Main St., Buffalo, NY 14214-8010 ([email protected]). Accepted for publication: May 23, 2015 Published ahead of print: July 3, 2015 DOI: 10.1097/NNE.0000000000000193

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disseminate a curriculum to prepare students and nurses in end-of-life care. Clinical placements in a palliative care site are ideal but not realistic for many nursing programs.10 One undergraduate program developed an elective nursing course using the ELNEC curriculum. This course placed students in various clinical settings, hospice, dementia care, and hospital units, and students indicated that their clinical learning experiences were rewarding. Some nursing programs have turned to simulation as an alternative to clinical placement. The use of simulation is helping to bridge the gap between academia and the clinical setting.11 When simulation is used in conjunction with direct patient care, it can effectively prepare students to provide safe care by exposing them to a variety of clinical scenarios in a supportive learning environment.8 One baccalaureate nursing program performed a pilot study using an end-oflife simulation with a small group of juniors. Students’ gain in knowledge and self- efficacy suggested that simulation was an effective instructional technique for teaching end-of-life.6 In another project, a school of nursing implemented a death and dying simulation along with a bundle of other teaching methods.12 The question still remains: how can clinical educators best provide nursing students and soon-to-be novice nurses with a meaningful experience in a palliative care or end-of-life setting?

Hospice/Palliative Care Dedicated Education Model In 2009, the University of Buffalo School of Nursing collaborated with the Center for Hospice and Palliative Care of Buffalo, New York, and tailored the dedicated education unit (DEU) model to this clinical setting. During the first 6 rotations, 48 senior nursing student journals were analyzed using a qualitative descriptive content analysis approach.13 This inductive analysis began with open coding and progressed to building categories of related codes and identification of themes.14 Volume 41 & Number 1 & January/February 2016

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A DEU is designed as a venture among administrators, nurse clinicians, and faculty to create an optimal and efficient learning environment for students. The DEU model is built on mutual respect, open communication, and collaborative relationships.15 One of the unique attributes of the DEU model is the ability to adapt to a variety of clinical settings and nursing programs. The Center for Hospice and Palliative Care was a perfect setting to implement a DEU, providing experiential learning of the nursing role in end-oflife care. Thus, tailoring the DEU model into the hospice and palliative care community provides a positive step in helping to fill the void that exists in clinical nursing education.

Roles and Responsibilities Successful implementation of the DEU model requires a clear understanding of each individual’s role and responsibilities. The DEU nurse, an expert nurse and clinical role model, functions as the clinical instructor (CI) and is key to successful implementation of the DEU. Nurses who are identified by hospice administration as appropriate DEU nurses complete a tailored orientation program to prepare them for their new role as CIs/preceptors. Students in each clinical rotation attend a 1-day intensive orientation given by the director of the Hospice Education Department, which includes a review of hospice philosophy, successful steps for a home visit, and pain and symptom management. This is followed by focused clinical orientation given by the clinical faculty coordinator (CFC). Students, after their orientation, meet their CI (DEU nurse) and with the CI make home visits as well as visits to designated assisted living or skilled palliative care units. Unlike hospital-based units, where the nurse-to-student ratio is usually 1:2, students in the hospice DEU rotation are afforded the opportunity to work 1:1 with their assigned nurse. Clinical rotations are 5 weeks long, two 8-hour days a week. Students learn that executing care on a patient’s ‘‘turf’’ is different from hospital-based health care. They learn they are guests in the patient’s home, and the need for acceptance of the home environment, the culture, and other situations is key to developing a trusting relationship. In addition, the students have the unique opportunity of working for 1 day with 1 of the nurses in the hospice in-house unit where patients are admitted for symptom management and respite care. The CFC needs to be an experienced nurse educator and leader who is capable of establishing a working relationship with the service partner and nurses. The role of the CFC is to support the teaching and learning of the nursing students in this clinical setting while providing for the ongoing professional development of the DEU nurse who is functioning as the CI. The CFC organizes the rotation, provides an orientation for the students that coincides with the orientation from hospice, performs site visits, and guides assignments. The CFC also moderates a weekly conference where the students are able to present their patients to the group and share their experiences. The DEU nurses are encouraged to participate in conferences. At any given conference, whether 1 or all of the nurses are able to be present, their contribution to the discussion is invaluable. The CFC is also responsible for the resolution of problems should they occur and ultimately the final evaluation of the student. The CFC uses student site visits, written assignments including 26

the daily journals, conferences, and collaboration with the CIs throughout the rotation to accomplish evaluations. The service partner is instrumental to the success of this endeavor. The administrative, nursing, and education departments of the Center for Hospice and Palliative Care have been receptive to the faculty and students. It is the responsibility of the director of the education department to identify nurses, if they agree, to become the CI. In this particular setting, this is done on a voluntary basis without financial compensation. The CIs then have an orientation with the CFC regarding the DEU model, course, and expectations.

What the Students Tell Us Journals written by the students reveal recurring themes that have an impact on them: the nurse as a role model, interdisciplinary collaboration, therapeutic communication, holistic care, death and dying, and the influence of this experience on their career paths.

Role Model In 1 study of 214 students, faculty characteristics found to be essential in students’ transition from novice to expert were respectful interpersonal relationships followed by professional competencies, personality, and teaching ability.16 Likewise, in another study, attributes that students valued in their clinical preceptors were passion, honesty, cooperation, flexibility, and openness to students’ responses.17 DEU journals and evaluations reflected these same attributes. Students consistently described nurses’ professionalism, empathy, knowledge base, communication skills, and flexibility. Interdisciplinary Collaboration Every student commented on how he/she learned from the collegiality and working relationships among members of the health care team especially between nurses and other providers. For many students, this was the first time they had witnessed a physician as an equal member of the team. One student wrote, ‘‘I attended a team meeting today and felt this experience tied everything together. The team showed me the true meaning of collaboration.’’ Similarly, another student commented, ‘‘This is the first time I saw an interdisciplinary team effectively provide patient centered care.’’ Students described how their nurses collaborated with various members of the team throughout the day depending on their patients’ needs. Therapeutic Communication Students’ reflections were rich with appreciation for the value of therapeutic communication with both the patients and caregivers. Students learned the importance of tailoring the teaching to the patient and/or caregiver needs. They also learned that every patient has his/her own story and to avoid misconceptions. Another, and often undervalued, lesson learned was how to listen. A student who was caring for a patient with advanced dementia commented, ‘‘You learn to listen and use therapeutic communication especially with [patients with] dementia and problems that affect quality of life.’’ Another student explained, ‘‘I found it interesting that even in skilled and geriatric settings, nurses are uncomfortable with death and dying, especially communicating with the families. Hospice nurses have so much skill in working with families.’’

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Dealing With Death and Dying Years ago, Kubler-Ross18 stated that it was a gift, a privilege, to work with the dying and the bereaved. Students are often initially surprised to find that their nurses also champion this sense of honor and privilege. Students learn the stages of grief in the classroom as a series of phases, but they are now able to witness the experience. They are able to appreciate that palliative care means helping people live as well as they can, for as long as they can.19 Students also learn that the goal of hospice care is neither to prolong nor hasten the dying process but rather to maximize the patients’ quality of life.20 Some students’ reflections included the initial fear of not knowing ‘‘what death looks like.’’ For others, early fears related to becoming too attached and learning how to cope with the loss. Still others worried whether hospice nurses simply became indifferent over time. Students voiced different views over the course of their rotation in both their journals and in conferences. One student commented, ‘‘I had never seen anyone die before. I was not sure how I would react, but I handled it well. I was able to support this woman and her family in the moments before and after. I found I was able to continue my day providing care to the other patients.’’ Another student reported, ‘‘It is interesting to see all the ways hospice eases a family’s transition through death of a loved one even in a nursing home setting.’’ A critical learning experience described by a student was: ‘‘An important thing I learned from my nurse, which is vital to providing good hospice care, is to find out what will bring peace to patients before they die.’’ Impact on Career Paths Throughout the journals, students made various references to how this rotation affected their own philosophy of nursing and how it would influence their careers. One student wrote, ‘‘This choice [hospice nursing] seems very rewarding. It would be a true honor to care for patients in their final months and help their families through a difficult time.’’ Another student shared, ‘‘I never thought in a million years that this would be a part of nursing that I would embrace.’’

Other Benefits of Experience The in-home hospice visits also provided students with a unique learning environment where there is limited technology. Students learn quickly to develop and rely on their assessment skills and to think critically and prioritize. Students commented on the key role of their nurses as patient advocates. The goal for every student by the end of the rotation is to successfully conduct a full visit, whether in the home, assistedliving, or skilled nursing facility, including interviews, medication reviews, physical examinations, and implementation/ revision of the nursing plan under the guidance of the CI. In their program evaluations, the DEU nurses reported that this experience was beneficial to them professionally; their communication skills improved, and they developed a new enthusiasm for teaching. The nurses reported that they enjoyed watching students gain a new insight and understanding as they progressed through the rotation. These observations parallel findings from hospital-based DEUs.15,21

Challenges The number of nursing students per rotation is limited. Another challenge is the need for a 1:1 student-nurse ratio, reNurse Educator

quired by hospice taking into consideration the number of people entering into a patient’s home. Both the students and nurses alike prefer this ratio and believe it is effective for student learning. Therefore, 8 hospice nurses participate per rotation. Another area that many of the students recommended was involvement in palliative care of the pediatric population. In 2002, the Institute of Medicine published When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families.22 That report addressed the need for improvements in pediatric nursing education of children at the end of life and their families. Open discussion of involving the pediatric hospice population in the clinical rotations has taken place. However, the fluctuating number of pediatric patients presents a challenge to offer this experience on a consistent basis.

Summary The hospice and palliative care DEU provides for meaningful and positive experience in the clinical education of nursing students. This successful venture is 1 way in which we can help fill the void that exists in nursing education regarding hospice and palliative care. This experience is beneficial to students no matter what career path they follow. The preparation for nurses in end-of-life care, not only in the classroom but also in the clinical setting, is important as our population ages and cancer survivorship increases. Acknowledgments The author gratefully acknowledges the contributions of Kelley Clem, RN, MS, Linda Steeg, DNP, RN, ANP-BC, Grace Dean, PhD, RN, and Mary Ann Meeker, DNS, RN.

References 1. White K, Coyne P, Patel U. Are nurses adequately prepared for end of life care? J Nurs Scholarsh. 2001;33(2):147-151. 2. Marra S. Initiative to improve end of life care influences on nursing education. WV Nurse. 2000;4(1):11. 3. Matzo ML, Sherman DW, Sheehan DC, et al. Communication skills for end of life nursing care: teaching strategies from the ELNEC curriculum. Nurs Educ Perspect. 2003;24(4):176-183. 4. End-of-life nursing education consortium (ELNEC) fact sheet. American Association of Colleges of Nursing Web site. 2014. Available at http://www.aacn.nche.edu/ELNEC/factsheet.htm. Published 2014. Accessed February 15, 2014. 5. Caton A, Klemm P. Introduction of novice oncology nurses to end of life care. Clin J Oncol Nurs. 2006;10(3):604-608. 6. Moreland S, Lemieux M, Myers A. End-of-life care and the use of simulation in a baccalaureate nursing program. Int J Nurs Educ Scholar. 2012;9(1):1-16. 7. Kwekkeboom K, Vahl C, Erland J. Impact of a volunteer companion program on nursing students’ knowledge and concerns related to palliative care. J Palliat Med. 2006;9(1):90-98. 8. Fabro K, Schaffer M, Scharton J. The development, implementation, and evaluation of an end-of-life simulation experience for baccalaureate nursing students. Nurs Educ Perspect. 2014;35(1):19-25. 9. American Association of Colleges of Nursing. Peaceful death: recommended competencies and curricular guidelines for endof-life care. 1997. Available at http://www.aacn.nche.edu/elnec/ publications/peaceful-death. Accessed June 26, 2015. 10. Jeffers S, Ferry D. Nursing care at the end of life a service learning course for undergraduate nursing students. Nurs Educ. 2014; 39(6):307-310. 11. Sperlazza E, Cangelosi P. The power of pretend using simulation to teach end of life care. Nurs Educ. 2009;34(6):276-280. Volume 41 & Number 1 & January/February 2016

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12. Carman M. Bundling the death and dying learning experience for prelicensure nursing students. Nurs Educ. 2014;39(3):135-137. 13. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107-115. 14. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334-340. 15. Moscato S, Miller J, Logsdon K, et al. Dedicated education unit: an innovative clinical partner education model. Nurs Outlook. 2007;55(1):33-37. 16. Tang FI, Chou SM, Chiang HH. Students’ perceptions of effective and ineffective clinical instructors. J Nurs Educ. 2005;44(4): 187-192. 17. Chow F, Suen LK. Clinical staff as mentors in pre-registration undergraduate nursing education: students’ perceptions of the mentors’ roles and responsibilities. Nurs Educ Today. 2010;21(5):350-358.

18. Kubler-Ross E. On Death and Dying. New York: MacMillan Co; 1969. 19. Temel J, Gallagher E, Jackson V, et al. Early palliative care for patients with metastatic non-small lung cancer. N Engl J Med. 2010;363(8):733-742. 20. Blackhall L, Erickson J, Brashers V, et al. Development and validation of a collaborative behaviors objective assessment tool for end-of-life communication. J Palliat Med. 2014;17(1): 68-74. 21. Rhodes MM, Meyers C, Underhill M. Evaluation outcomes of a dedicated education unit in a baccalaureate nursing program. J Prof Nurs. 2010;28(4):223-230. 22. Field M, Behrman R. When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families. Washington, DC: The National Academies Press; 2003.

Supporting Students With Disabilities The White Paper on Inclusion of Students With Disabilities in Nursing Educational Programs for the California Committee on Employment of People With Disabilities, by Beth Marks and Sarah Ailey, describes issues that prevent applicants with disabilities from entering nursing programs. These include outmoded admission standards and misconceptions about the ability of students with disabilities to be effective in clinical practice. The white paper also discusses barriers and supports for students with disabilities and misunderstandings of nursing faculty about technical standards and essential functions. Another part of the paper examines accommodations for nursing students. You can find the white paper at http://www. aacn.nche.edu/faculty/tool-kits/accommodating-students-with-disabilities. Other resources for nurse educators are available at the National Organization of Nurses With Disabilities (NOND) (http://www.nond.org/) and the Alliance of the Office of Disability Employment Policy and NOND (http://www.dol.gov/odep/alliances/nond.htm) Web sites. The Alliance provides videos that would be valuable for faculty to view and discuss. Other Web sites include the Americans With Disabilities Act National Network (www.adata.org), Association on Higher Education and Disability (www.ahead.org), and Job Accommodation Network Occupation and Industry Series: Accommodating Nurses With Disabilities (http://askjan.org/media/nurses.html). The Southern Regional Education Board has identified implications for nursing programs of the Americans With Disabilities Act. This document is available at http://www.sreb.org/page/1390/the_americans_with_disabilities_act.html. Nurse educators have been given a ‘‘call to action’’ to identify and implement best practices to support the success of students with disabilities. Begin by educating yourself with these resources. Submitted by: Marilyn H. Oermann, PhD, RN, ANEF, FAAN, Editor-in-Chief, [email protected]. DOI: 10.1097/NNE.0000000000000231

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Volume 41 & Number 1 & January/February 2016

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Nurse Educator

Dedicated Education Unit Model in a Hospice and Palliative Care Setting.

This article describes adapting the dedicated education unit model to the hospice/palliative care setting. The purpose of this qualitative study was t...
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