G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS Australian Critical Care xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
Research paper
Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation Holly L. Northam RN, RM, M Critical Care Nursing, MACN a,∗ , Gylo Hercelinskyj RN, PhD a , Laurie Grealish RN, PhD, FACN b , Anita S. Mak Registered Psychologist, PhD a a b
Faculty of Health, University of Canberra, Australia Griffith Health Institute, Griffith University & Gold Coast Hospital and Health Service, Australia
article information Article history: Received 1 September 2014 Received in revised form 19 December 2014 Accepted 22 December 2014 Available online xxx Keywords: Critical care Communication Cultural competency Education End-of-life Multicultural Multi-disciplinary Pilot study
a b s t r a c t Background: Australia’s immigration policy has generated a rich diverse cultural community of staff and patients in critical care environments. Many different cultural perspectives inform individual actions in the context of critical care, including the highly sensitive area of end of life care, with nurses feeling poorly prepared to provide culturally sensitive end of life care. Purpose: This article describes and evaluates the effectiveness of an educational innovation designed to develop graduate-level critical care nurses’ capacity for effective interpersonal communication, as members of a multi-disciplinary team in providing culturally sensitive end-of-life care. Methods: A mixed method pilot study was conducted using a curriculum innovation intervention informed by The Excellence in Cultural Experiential Learning and Leadership Program (EXCELL),1 which is a higher education intervention which was applied to develop the nurses’ intercultural communication skills. 12 graduate nursing students studying critical care nursing participated in the study. 42% (n = 5) of the participants were from an international background. Information about students’ cultural learning was recorded before and after the intervention, using a cultural learning development scale. Student discussions of end of life care were recorded at Week 2 and 14 of the curriculum. The quantitative data was analysed using descriptive statistical analysis and qualitative data was thematically analysed. Results: Students demonstrated an increase in cultural learning in a range of areas in the pre-post surveys including understandings of cultural diversity, interpersonal skills, cross cultural interactions and participating in multicultural groups. Thematic analysis of the end of life discussions revealed an increase in the levels of nurse confidence in approaching end of life care in critical care environments. Conclusion: The EXCELL program provides an effective and supportive educational framework to increase graduate nurses’ cultural learning development and competence to manage culturally complex clinical issues such as end of life care, and is recommended as a framework for health care students to learn the skills required to provide culturally competent care in a range of culturally complex health care settings. © 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction This paper describes a pilot study of an intervention designed to develop graduate nursing students’ competency to deliver culturally sensitive end of life care in critical care environments. The
∗ Corresponding author. Tel.: +61 0412289 295. E-mail address: [email protected] (H.L. Northam).
intervention was instigated in response to one universities’ graduate nursing students identified need to learn more about how to provide family centred culturally sensitive end of life care for patients in emergency and intensive care settings. The students’ needs had been previously identified through reflective journals and workshop discussions about caring for critically ill patients as well a review of the curriculum content by the academic lecturer. Critical care nurses are required to effectively communicate and act in sensitive and complex situations, such as in the provision
http://dx.doi.org/10.1016/j.aucc.2014.12.003 1036-7314/© 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
2
of safe, culturally appropriate end of life care in technologically complex environments. Johnstone2 identifies the importance of recognising the influence of cultural difference in the provision of end of life care. The provision of culturally competent health care improves equity and safety for patients, ensures appropriate resource utilisation3 and helps address power imbalance.4 Critical care nurses who practice in countries with substantial cultural diversity require a high level of intercultural communication skills as well as a willingness to examine one’s own, and be open to others’ cultural beliefs, experiences, and practices around death and dying. Therefore, they require education to develop the skills required to address the needs of patients and families, in an ethically and culturally sensitive manner and to meet practice competencies.3,5–7 Cultural sensitivity and competence are crucial for nurses supporting patients and families through emotion-laden end-of-life issues involving difficult decisions, where mistrust may contribute to suffering.4,8 Cultural sensitivity is particularly relevant to contemporary Australian health care settings where almost 28% of the resident Australian population are born overseas.9 Studies have shown that critical care nurses feel unprepared to provide supportive care for dying patients and their families in the critical care environments10–12 and have sought more education on this topic.13,14 Shannon et al.15 built on existing health care communication tools to provide strategies to assist nurses in approaching conversations at end of life, whilst others have developed a interdisciplinary learning program to address issues of moral distress and other challenges in providing end of life care.16 Crump et al.17 sought to identify nurses’ perceived barriers to providing quality end of life care, and found that knowledge and skills of cultural competency were ranked amongst the highest educational need sought by critical care nurses. To the authors’ knowledge there are no educational interventions that specifically integrate strategies to teach cultural competency together with sensitive family centred end of life care. Enhancing health professionals’ cultural competency contributes to improved outcomes for patients and their families3 and supports effective professional communication and teamwork which may contribute to improved safety and quality of care in intensive care units.18 In this article, we will outline how we structured an intervention using components of EXCELL1 together with Thomas’19 approach to culturally competent nursing practice, to frame the philosophy and teaching of cultural sensitivity in end of life care for nurses in complex health care environments. We will describe how, as nurse educators in a graduate nursing program on critical care, we encouraged and modelled culturally sensitive practice in the classroom, which in turn provided a safe and supportive group environment for explicit teaching and learning of key intercultural communication competencies relevant for end of life care, over a 14-week period. We will report the preliminary findings of a pilot trial of this educational innovation in terms of a cohort of graduate nursing students’ self-reports of cultural learning before and after the intervention. While this article report results from a small sample size (n = 12), this study contributes to knowledge about the provision of safe and high quality end of life care in Australian acute care environments.20
2. Methods A pilot mixed method interventional study was conducted with all graduate nursing students in critical care (n = 12) enrolled in two consecutive clinically based units of study, which spanned semester one and semester two of one year at one university. Nurse educators incorporated an innovative teaching and learning intervention based on the Excellence in Cultural Experiential Learning and Leadership (EXCELL) Program1 into the graduate critical care nursing
Table 1 Alignment of the EXCELL skills with Thomas19 cultural learning approach. The EXCELL skills
Thomas (2001) cultural learning approach used to structure the unit teaching and learning.
Seeking information
Sharing personal story around end of life care for own cultural group: “learn their own history and culture” (Thomas, 2001, p. 44).
Making a social contact
Linking personal expectations to context of how end of life care is delivered in their clinical experience: “Develop a helping relationship with the terminally ill individual and his or her support network” (Thomas, 2001, p. 44).
Participating in a group
Exploring the support within the team: “Care in acquiring translation services” (Thomas, 2001, p. 44).
Refusing a request
Uncovering personal and professional power to advocate and challenge: “Helping people to live a quality life and have a quality death is the goal” (Thomas, 2001, p. 45).
Expressing disagreement
Developing a personal set of tools to engage and empower families, challenge paradigms and seek feedback and support. “a personal understanding of the role that culture plays throughout the course of one’s life.” (Thomas, 2001, p. 45).
course. A survey instrument21 was used to evaluate student learning before and after the intervention and data was analysed using descriptive statistical analysis. Qualitative data of students’ views about culture and end of life care collected before and after the intervention were thematically analysed.22 This study was approved by the University’s Human Research Ethics Committee (Project number 11-70) and was part of a larger action research project funded by the Australian Learning and Teaching Council (ALTC PP10-1080), the “Internationalising at Home or IaH Project”23 an innovation designed to enhance the intercultural capability of staff and students by embedding intercultural competency development in the curriculum. The project aims to internationalise the learning and teaching practices of teachers and students in Business and Health higher education.23 An important IaH project outcome is the development and dissemination of adaptable intercultural curriculum involving the integration of discipline-specific critical incident scenarios with existing intercultural competency development tools based on the EXCELL Program.1 For more IaH project information, visit https://sites.google.com/site/internationalisationathome. The EXCELL Trainers Manual24 provides structure for teaching innovation to enable the students to develop skills in identifying a “key sociocultural framework”, to participate in “alliance building” and “cultural mapping” within their clinical practice environments and communication networks of patients, families and their nursing and multidisciplinary colleagues. The EXCELL tools build student confidence in ‘seeking information, making a social contact, participating in a group, refusing a request, expressing disagreement and getting feedback’. Theory to guide culturally sensitive end of life care19 was embedded in the unit teaching, learning and assessment plan. The curriculum change involved restructuring the unit content to deliver the intervention and align it to curriculum content. The curriculum content which underpinned the students learning of theory of culturally sensitive end of life care, was used as a vehicle to ‘carry’ the introduction and embedding of the EXCELL skills. The EXCELL skills and Thomas’19 strategies are listed in Table 1. A research assistant (RA) distributed written information about the study to all the students during class in the previous semester. The information sheet invited students to participate in the study and the RA answered any student questions. The students were
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
provided with time to consider their participation and to complete the consent documentation, which was returned to the RA within the same class period. All students (n = 12) agreed to participate in the study. Survey data was collected at two points in 2012: before and after the intervention. The participants responded to a 13-item cultural learning measure survey instrument adapted from MacNab and Worthley’s25 measure of cultural intelligence development and Mak’s26 measure of students’ cultural learning. The instruments were also used in the associated IaH studies to evaluate the participants’ educational and intercultural experience. Participants were asked 13 items about their cultural learning from the unit, for example, “With regards to (unit)-I have developed a better understanding of cross-cultural interpersonal skills.” Responses were scaled from 1 (strongly agree) to 5 (strongly disagree), so that lower scores indicated greater cultural learning This same cohort of participants were surveyed again at the end of Semester 2, 2012 (n = 9), following completion of the intervention. Eleven students completed the pre-test survey during class time late in semester one. One student was absent for this survey. The post-test was conducted following the intervention, near the end of semester two. The same group of participants completed both the pre and post survey. Two participants were absent at the posttest and were unable to complete the instrument, therefore nine participants completed the survey. Participants were also asked to complete a written survey called either “Domestic Students’ Educational and Intercultural Experiences” or “International Students’ Educational and Intercultural Experiences”, depending on whether the participant was a domestic or an international student. The survey has been used in other settings and contains 12 closed-ended items and one open-ended question asking for background information (e.g., about country of birth), interactions with domestic and international students, and evaluative ratings of the extent to which the unit of study just completed effectively developed and promoted intercultural competence skills. The surveys were distributed by the RA and took 10–15 min to complete. Qualitative data from these surveys were analysed separately to the data collected by the nurse educators. The nurse educators collected qualitative data in week 1 and week 14 of Semester 2. In week 1, all students were asked to reflect on their practice and to identify their greatest learning need regarding care of critically ill patient at end of life with the question, “What worries you most when caring for a dying patient and their family?” The student answers were provided to the nurse educator as an anonymous ‘Message in a bottle’. The responses to this question generated a student ‘wish list’ which were collected and collated. All notes were treated as one set of data and analysed.10 The nurse educator used information from these notes to focus students learning outcomes. At the conclusion of the intervention the nurse educator took notes of student discussions about how the students felt about the students learning about providing competent end of life care, which was initiated by the prompt question, “What have you learned?” This data was also thematically analysed10 as one data set.
3. Intervention The teaching innovation was structured in three layers within the teaching and learning plan as follows. Core to the intervention, the EXCELL skills were incorporated into workshop teaching and learning. Then cultural mapping and alliance building concepts and strategies were layered into the teaching plan. Assessment was constructively aligned to the unit learning objectives and academic content. The students were required to participate in each of the weekly structured workshops, which comprised workshops which
3
integrated curriculum teaching and learning with structured support for delivering culturally sensitive care in complex situations. These included nurse advocacy and communication at an interdisciplinary level when providing end of life care, incorporating awareness of cultural, religious, ethical and legal considerations as seen in Table 2. Drawing from the work of Thomas19 each week the EXCELL skills (see Table 1) were embedded into activities and assessment tasks. Each student in the group was provided with an opportunity to share a story of their experience of their own culture and experience of death, which provided a base for them to “learn their own history and culture” (p. 44).19 Their personal story was then used as a discussion prompt to enable them to link personal expectations to the context of their experience of how end of life care is delivered in their clinical practice. These stories opened a new understanding between the students of the knowledge and insights that their colleagues contributed to their workplace, thereby supporting the nurses to “develop a helping relationship with the terminally ill individual and his or her support network” (p. 44).19 The students were encouraged to develop a set of intellectual, practical and emotional support strategies to use as a personal ‘tool box’ for managing challenging clinical situations. These were collaboratively developed by the students using their own experience based scenarios within the workshop environments which enabled them to practice ‘safe testing’, by saying the words and making the actions in a safe environment which was linked to theory in preparation for practice. The nurse educator provided guidance to the intervention to ensure that all students were provided with opportunities to practice the EXCELL skills and use their reflective skills. Hesitant students were encouraged and prompted, and provided with constructive feedback to build their confidence. The students sought knowledge and skills to competently approach culturally sensitive communication in the technologically intrusive environments of critical care. They did not need or seek scripts which they recognised would not be authentic to their practice relationships. Cultural mapping helped the students to recognise their own perspective, role, and interconnectedness to those around them professionally and in their communities, and made explicit why the use of appropriate human and professional resources could contribute to building their confidence and competence in providing culturally sensitive end of life care. Cultural mapping provided them with cues for non-verbal and verbal communication using the EXCELL stages of approach, bridging, communication and departure.21 A particular emphasis was made on using effective and ethical communication and the appropriate use of interpreters, social history and in not assuming information; highlighting the need for, “Care in acquiring translation services” (p. 44).19 The role of each nurse and the potential for them to practice with cultural sensitivity was underlined when the nurses were encouraged to actively uncover their personal and professional power to challenge and advocate, thus achieving Thomas, 2001 goal of “Helping people to live a quality life and have a quality death” (p. 45).19 The students were encouraged to explore the support available to them in complex scenarios as part of alliance building within the team. For this intervention invited experts were able to provide their insights about the scope of resources that are available to provide culturally sensitive end of life care and the specific needs of diverse populations within the local region. Multidisciplinary health care experts and consumers were invited to interact with the students throughout the course of study, which provided students with opportunities to build cultural knowledge and sensitivity, and also strengthen student’s confidence in communicating. Relationships between the individual students were strengthened and mentoring and modelling support was provided by lecturers who encouraged the students to see themselves as valued members of
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
4 Table 2 Weekly teaching and learning plan. Week
Workshops: Normal teaching and learning sessions with integrated and aligned intervention utilising the EXCELL tools
1
Introduction and overview of the unit and its learning objectives. Overview: EXCELL intervention and ‘toolbox’: Reflection: ‘What worries you most when caring for a dying patient and their family? Submit anonymous note ‘message in a bottle’ to the nurse educator
2
Communication 1: Caring with sensitivity’ Different to us: Stories from our past – how they link to the present and become part of ourselves: The students were encouraged to discuss and consider the influence their personal experiences, culture and expectations related to critical illness, dying and death within their own family. Each student was invited to discuss within the group how their personal experience contributed to how • they think about and interact in the health care environment • this influences their interpretation of the needs of those they care for • how they communicate the needs of their patients to others Lectures and discussions integrated into the standard teaching component included: ethical challenges, mental health, cultural and religious. Displaced People: By refugee health care worker regarding communication and the context of health for displaced people and cultural and religious sensitivities for different communities located within the local community. Resources such as interpreter support service, teaching regarding the issues faced by this cohort of the population such as survival following torture and other contextually relevant aspects of cultural sensitivity were presented. Care with an Indigenous lens: issues facing indigenous peoples in emergency and intensive care environments and ways of providing culturally competent care, and appropriate resources to support that care.
3
Communication 2: Continuum of critical illness and outcomes of critical illness Focus group led by key questions “What is the most difficult part of caring for people who are mentally ill for you?” ICU Research on staff expectations and the provision of culturally competent care The development of an ICU death policy Death in the ICU, film by staff and patients’ family about ‘good’ death in the ICU
4
Day 1 Emergency presentations Advanced Care Directives: Intensivist with expert practical and legal knowledge
5
Day 2 Emergency presentations and management ED Trauma Case Reviews: Including the involvement of the family and outcomes Discussion: Ethics of complex care scenarios and resource utilisation, disaster management
6
Simulation and cases Care of the critically ill child: Emergency consultant, Intensivist, social worker, Multidisciplinary team communication Intensivist, social worker and actor as mother, who are present at the resuscitation bed for the assessment and stabilisation of a critically ill child in the emergency department
Table 3 A range of vignettes were developed as prompts to trigger discussion around end of life care and complex needs of patients and families. Vignette
Actions
A new admission to ICU of a critically ill patient when death is probable
Competent patient and family centred care:
Establishing communication with a distressed family at the bedside
Use ‘Excell skills’ and ‘tool box’ of resources which include: Knowledge, policy and guidelines • contemporary evidence based recommendations drawn from scholarly sources • ethical frameworks • legal requirements including advanced care plans and directives • end of life wishes including organ and tissue donation
Care of a child undergoing resuscitation in the emergency department and communication with the mother Interaction with family members who want to visit their relative where the next of kin have very limited ability to communicate in English language Care of the deceased in the emergency department in Coroners cases
Professional relationships: work in partnership with • co-workers, team leader and interdisciplinary team • Social worker/Seek linguistic support through interpreter service, spiritual and cultural support through local agencies • Pastoral care/Aboriginal Liaison Officer Family relationships work in partnership with the patient and family: • Acknowledge family distress, show compassion • Build relationship of mutual trust with patient and their family
Care of a patient and family when clinical signs indicate the patient is brain dead and the patient is of an indigenous back ground Bedside care and communication with the family and multidisciplinary team when there are indications that withdrawal of life sustaining treatment may be in the patients best interests Communicating with families of suicide victims and survivors
7
Metabolic failure and nutritional requirements for the critically ill patient. Critical care considerations in pharmacotherapy Student contribution
the health care team, and active collaborators in building alliances themselves the patients, their families, and their co-workers. A range of vignettes were developed as prompts to trigger discussion around end of life care and complex needs of patients and families (see Table 3).
9
Obstetric emergencies and management of the critically ill woman and babe
4. Results
10
Managing multi-organ failure
11
Australasian Donor Awareness Professional Training Program ICU family experiences of making an organ donation decision for their deceased son: led by consumer
13
Simulation, complicated cardiogenic shock, chest opening How to manage the fear (staff, patient and family)
14
Course review, assessment review. Focus group wrap up: “What have you learned?”
All participants were employed as registered nurses in critical care areas and were enrolled as domestic students. Forty two percent of participants described their educational background as a country other than Australia, which is consistent with the changing demographic profile of staff working in Australian critical care environments. The participants had come to Australia from countries such as Nepal, India, China, Nigeria and ‘other’ and comprised 8 females, three males and one with unspecified gender, aged between 24 and 36 years. Participants’ Cultural Learning from the Curriculum was assessed using the 13-item cultural learning measure survey
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model
ARTICLE IN PRESS
AUCC-260; No. of Pages 7
H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx Table 4 Comparing students’ cultural learning scores pre and post Excell intervention. Statement
Pre-Excell % agreeda (n = 11)
Post-Excell % agreeda (n = 9)
I have developed a greater awareness of cultural diversity. I have developed a better understanding of cross-cultural interpersonal skills. I have gained awareness of the role of culture in my chosen field of study. I am now more conscious of the cultural knowledge I use when interacting with people with different cultural backgrounds. I am now more conscious of the cultural knowledge I apply to cross-cultural interactions. I am better prepared to adjust my cultural knowledge as I interact with people from an unfamiliar culture. I am now better equipped to enjoy living in cultures that are unfamiliar to me. I am now more confident that I could socialise with locals in a culture that is unfamiliar. I am now more certain that I could deal better with adjusting to a culture that is new to me. I have become more confident with communicating with people from culturally different backgrounds. I have become more ready to make social contact with culturally different others. I have become more comfortable participating in multicultural groups. I enjoy interaction with people from different cultures.
27.3
44.4
27.3
62.5
54.5
55.6
27.3
55.6
27.3
55.6
54.5
55.6
36.4
55.6
27.3
55.6
36.4
66.7
54.5
66.7
45.5
66.7
18.2
55.6
45.5
66.7
a
Percentage of respondents who agreed or strongly agreed.
instrument adapted from MacNab and Worthley’s25 measure of cultural intelligence development and Mak’s26 measure of students’ cultural learning which demonstrated high internal consistency (Cronbach’s alpha = .95 as reported in Mak and Barker).23 Data analysis revealed an increase in students’ cultural learning scores. The results are tabulated in Table 4. Qualitative data from open-ended responses to the survey revealed an increase in the levels of participant confidence in approaching end of life care in both emergency department and intensive care environments. Two participants, in response to the question about how to apply their learning, indicated that they would use it in patient assessment and management and end-of-life care. 5. Qualitative data: students anonymous ‘message in a bottle’ wish list The pre and post intervention qualitative data was thematically analysed22 by one author (HN) and validated by a second author (GH). The key theme identified in the participant messages related to seeking the skills and the knowledge to communicate and care for patients and their families compassionately and effectively at the end of life. The ideas included the stressors upon participants to deliver culturally sensitive and legally and ethically acceptable end of life care; the changing paradigms around the needs of families of dying patients in critical care environments; the need to identify specific family needs; managing ‘open access’ visitation of patients’ families at the bedside; the place of ‘witnessed resuscitation’ and the participant role in either facilitating family presence or being
5
Table 5 Students ‘wish list’ of things they need help with when approaching culturally sensitive communication about death. • Coming to terms with ‘NFR’ orders, especially in situations in which the patient is considered ‘too young’ to die. . .. • The time when the patient actually takes their final breath and is being pronounced dead! Which I find overwhelming for family members. • How to manage honest information about dying • I am not sure that it is alright to tell the family members that their loved one is dying, and that’s why he or she can’t breathe properly. . .. • What can I do for the family members, when they are so sad because their loved one died? • Explaining death or dying to family members • Caring for a patient when the family member has died as a result of some accident, knowing whether to tell or not to tell immediately, or wait for police confirmation. • How to deal with the actual decision making processes of end of life care especially when you are the RN participating in the family meeting? • Do miracles happen? An often asked question. • Starting a conversation with families is a big task for me. • A better understanding of the family’s attitude towards the process and also how to approach the relatives in doubt? • I find communication with the patient and family around palliation a challenge. • How to encourage doctors to clarify end of life decisions
a barrier to family witnessed resuscitation; and the personal psychological impact of caring for dying patients and their families in a complex care environment. See Table 5. Themes identified in the participant dialogue revealed the participants desire to reduce the psychological impact of the critical care nursing work by building resiliency, managing moral conflict, and pre-empting compassion fatigue. Three key themes ‘Fear’, ‘Inadequacy’ and ‘Taboo’ were identified which represented the participants’ views about caring for patients and families in complex end-of-life care situations. The participants’ greatest challenge when communicating with families was captured by the theme of ‘fear’, which incorporated the relationship between themselves and the patients’ family and in some circumstances the conscious patient. The participant fears included ideas such as that “Caring for their loved one is always so challenging but involving them in that care “scare pact” was most challenging”. This complex fear encompassed the realisation for some participants that their relationship with the dying patient and the patients’ family was almost unified because of the shared experience of traversing the difficult period of the continuum of dying. It included the participant’s role in administering medications upon the order of doctors, in withdrawing life sustaining technology, and in managing evidence of suffering which some participants appeared to experience as a sense of sharing a fear of the approach of death. The participants perceived themselves to have become a part of a nurse/family/patient “fear pact” which heightened the participants’ stress and anxiety, especially when they felt disempowered in their advocacy, and were fearful of offending the patients’ family, the treating doctor or coworkers. The participants expressed a deep sense of inadequacy leading to the theme of ‘Inadequacy’ in being unable to provide the dying patient and their family with privacy in dying, especially in the emergency department environment. One participant expressed regret about not knowing how to appropriately respond when caring for grieving families, “What can I do for family members, when they are so sad because their loved one has died. . .” This theme was particularly apparent in circumstances where it was difficult for the participants to know how best to help the families from a cultural perspective, because the participants felt they effectively balanced between the patient and families emotions and needs against the needs of the organisation, and included such things as pressure to care for other patients, bed occupancy pressure, or of being uncertain of the patient’s needs or wishes.
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
6
Participants expressed a sense of responsibility in better addressing communicating in sensitive competent ways when caring for suicidal patients, or potentially violent patients. This anxiety was particularly reflected by participants who felt a sense of responsibility to manage the perceived personal threat and threat to others within their care. The participants sought support in finding ways to engage with doctors and expressed feelings of inadequacy because of experiences of having been unable to effectively act as the patients advocate between the patients’ family and the treating doctor. For example, the participants believed they were poorly prepared for situations where the family were unable to clearly communicate their concern for cultural or language reasons but were anxious about the provision of pain relief or were concerned about the reasons for the patient undergoing surgery. The theme of ‘Taboo’ represented participants’ ideas of trying to balance their scope of practice with transparency and trust in communication. For example, in situations of death in the emergency department when a patient is determined to be dead on arrival, questions about whether the participant should let the family know or await the arrival of the police. Or when families were asking for information that the participants believed they knew but perceived they were not ‘allowed’ to answer. The concept of withholding information from the family was troubling for the participants, as they balanced their personal, cultural and religious sensitivities and expectations, with what they believed were professional requirements to withhold information. ‘Taboo’ also represented the difficulty faced by participants who were uncertain as how to meet the spiritual and cultural needs of families from diverse cultures when addressing questions of death and dying. At the concluding workshop discussion following the intervention, the participants described feeling better prepared, more aware and alert of potential resources and people to seek support from. They were pleased they had been able to describe their concerns, voicing views that they had been provided with more tools, skills and information to support them in providing culturally competent end of life care. Although several participants highlighted their anxiety that they had still not been required to manage the care of a patient at death, the participants stated that they were now aware of those who could assist them in supporting families. All participants indicated a new understanding of the cultural differences that can affect families’ and other staff interpretation of communication. The participants dialogue suggested that they understood that they still had much to learn and appreciated being able to have their concerns recognised. They expressed the hope that their organisation would also offer them support in these complex situations.
6. Discussion The findings demonstrate that critical care nurses need and seek education to enable them to successfully meet the needs of the patients and their families, and to work as empowered practitioners within the multidisciplinary team environment of contemporary critical care practice. These participants in this study were fearful in approaching end of life care and when communicating in situations of cultural difference. They sought to meet the needs of their patients and their families, but were anxious to do this well. The participants believed their feelings of inadequacy increased the emotional labour of their work,27,28 which they wish to reduce. Participants wanted to build their resilience in managing complex care, and sought strategies to assist them in approaching real and perceived moral conflict. The participants expressed anxiety about how to manage situations when conflict exists within the multidisciplinary team about end of life care decisions and communication about death, especially when difficulty exists in reaching a consensus on the
prognosis and the needs of the patient, which is supported by the literature.29,30 Consistent with other studies, most students had previously received little education about how to communicate about death.31 In terms of diagnosing dying, they had differing perceptions about what should be discussed by doctors with those involved. The differing interpretations of terminology, clinical practices and communications which surround end of life care and death contributed to student confusion and have previously been reported as confounders in sensitive communication about death32,33 and communication to patients, or their families.34 As with other critical care nurses, these participants recognised that they needed to be able to communicate competently with the patient, their family and others, but also with doctors and other multidisciplinary team members who may come from diverse cultural backgrounds. Critical care nurses are required to collaborate and lead within the multidisciplinary team, are accountable for protecting the rights of patients and their loved ones, and for providing information and care according to their dynamic needs.7 Critical care nurses are also required to meet legal requirements for practice in the critical care environment.7 In some circumstances studies have found that nurses caring for patients at the end of life in critical care settings may experience intellectual confusion and moral and emotional distress, which is known to contribute to compassion fatigue and burnout,36 which was supported by these participants’ views. This study has found that critical care nursing students require greater educational support to provide culturally competent care, and we recommend further study into this area. It is recognised that there is a need for more research into end of life care in the Australian intensive care setting.10,12 In their study into intensive care nurses beliefs and practices of end of life care, Ranse et al.10 suggest that critical care nurses are challenged to optimise patient and family experiences of dying within a context of “limited emotional and organisational support” (p. 11). This study supports the notion that critical care nurses seek to pre-empt compassion fatigue by seeking knowledge and skills to empower them to clearly communicate with and advocate for their patients and their families within critical care environments. It is clear that more must be done to address these needs. 7. Study limitations This was a small cohort of students and the survey sample was incomplete when the students were unable to attend sessions due to illness or work commitments. Several students were unable to be present for all the sessions, and the final survey was conducted before the final session of the scheduled intervention. Also, we did not employ a control group comprising nurses not exposed to the Internationalisation Project. It is possible that the increases in various aspects of cultural learning before and at the end of the intervention could have partly been due to the passage of time. However, previous studies incorporating either the entire program or specific components of EXCELL Program into the curriculum of other subjects, where larger samples with control groups were used, identified statistically significant benefits in terms of students’ cultural learning development.37,38 8. Conclusions Restructuring the program to embed content and skills to support culturally sensitive end of life care, has provided a strategy that may empower the students and enable them to provide culturally competent care. The students’ continuing rich dialogue suggests there may be benefits in translating this work into the clinical environment to support critical care teams and others to provide
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
culturally sensitive care. These initial findings although limited by the size and completeness of the sample provide evidence that this intervention was valued by the students and has helped to build their competence in approaching culturally sensitive end of life care. The pre-test which showed that the nurses all believed themselves to be poorly equipped with cross-cultural interpersonal skills is of concern as it is drawn from a sample of nurses currently providing care within Australian critical care environments. It is important to conduct further research into this area of practice and also to provide appropriate skills and education to support culturally competent and sensitive end of life care in critical care environments. Author contributions Northam led the design of the intervention study, conducted the study including data collection and data analysis. She also led the development of this manuscript. Hercelinskyj assisted with the design of the intervention study, provided monitoring of the conduct of the study and has contributed to the development of this manuscript. Grealish assisted with the design of the intervention study, provided monitoring of the conduct of the study and has contributed to the development of this manuscript. Mak provided guidance for the overall project, secured ethical review of the project and assisted with the development of this manuscript. Conflict of interest The authors have no conflict of interest in the conduct of this study. Acknowledgements Vikki Knott PhD for her support as regular contributor to monitoring the project in our shared group. This project was supported as part of the “Internationalisation at Home: Enhancing Intercultural Capabilities of Business and Health Teachers, Students and Curricula” project, funded by the Australian Learning and Teaching Council (ALTC PP10-1080). References 1. Mak AS, Westwood MJ, Barker MC, Ishiyama FI. The ExcelL Program for developing international students’ sociocultural competencies. J Int Educ 1998;9(1):33–8. 2. Johnstone M. Bio-ethics, cultural differences and the problem of moral disagreements in end-of-life care: a terror management theory. J Med Philos 2012;37:181–200. 3. National Health & Medical Research Council. Cultural competency in health: a guide for policy partnerships and participation. Canberra: Commonwealth of Australia; 2006. Available from https://www.nhmrc.gov.au/ files nhmrc/ publications/attachments/hp19.pdf [accessed 31.08.14]. 4. Thackrah RD, Thompson SC. Refining the concept of cultural competence: building on decades of progress. MJA 2013;199(1):35–8. 5. World Federation of Critical Care Nurses. Position statement on the provision of critical care nurse education – Declaration of Madrid, Madrid; 2005. Available from www.wfccn.org/ [accessed 30.06.10]. 6. International Council of Nurses. Position statement: cultural and linguistic competence. Switzerland: International Council of Nurses Geneva; 2013. Available from www.icn.ch [accessed 31.08.14]. 7. Australian College of Critical Care Nurses. Competency standards for specialist critical care nurses. 2nd ed. The Australian College of Critical Care Nurses; 2002. Melbourne, Australia. 8. de Pentheny O’Kelly C, Urch C, Brown E. The impact of culture and religion on truth telling at the end of life. Nephrol Dial Transplant 2011;26(12):3838–42. 9. Australian Bureau of Statistics. Australia’s population by country of birth. Canberra: Commonwealth of Australia; 2013. Available from www.abs.gov.au/ ausstats/[email protected]/Lookup/3412.0Chapter12011-12%20and%202012-13 [accessed 31.08.14].
7
10. Ranse K, Yates P, Coyer F. End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses’ beliefs and practices. Aust Crit Care 2010;25:4–12. 11. Le BHC, Watt JN. Care of then dying in Australia’s busiest hospital: benefits of palliative care consultation and methods to enhance access. J Palliat Care Med 2010;13(7):855–60. 12. Bloomer MJ, Moss C, Cross WM. End-of-life care in acute hospitals. J Nurs Healthc Chronic Illn 2011;3:165–73. 13. Bloomer M, Morphet J, O’Connor M, Lee S, Griffiths D. Nursing care of the family before and after a death in the ICU – an exploratory pilot study. Aust Crit Care 2013;26:23–8. 14. Kilcoyne M, Dowling M. Working in an overcrowded accident and emergency department: nurses’ narratives. Aust J Adv Nurs 2008;25(2):21–7. 15. Shannon S, Long-Sutehall T, Coombs M. Conversations in end-of-life care: communication tools for critical care practitioners. Pract Dev 2011;16(3):124–30. 16. Gordon E, Ridley B, Boston J, Dahl E. The building bridges initiative: learning with, from and about to create an interprofessional end-of-life care program. Dynamics 2012;23(4):37–41. 17. Crump SK, Schaffer MA, Schulte E. Critical care nurses’ perceptions of obstacles, supports, and knowledge needed in providing quality end-of-life care. Dimens Crit Care 2010;29(6):297–306. 18. Chaboyer W, Chamberlain D, Hewson-Conroy K, Grealy B, Elderkin T, Brittin M, et al. CNE article: Safety culture in Australian intensive care units: establishing a baseline for quality improvement. Am J Crit Care 2013;22(2):93–102. 19. Thomas N. The importance of culture throughout all of life and beyond. Holist Nurs Pract 2001;15(2):40–6. 20. Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for safe and high-quality end-of-life care in acute hospitals, consultation draft. Canberra, Australia: Commonwealth; 2014. Available from http://www.safetyandquality.gov.au/wp-content/uploads/2014/ 01/Draft-National-Consensus-Statement-Essential-Elements-for-Safe-andQuality-End-of-Life-Care-in-Acute-Hospitals.pdf [accessed 31.08.14]. 21. Knott V, Mak AS, Neill JT. Teaching intercultural competencies in introductory psychology via reflection and application of the Excellence in Cultural Experiential Learning and Leadership model. Aust J Psychol 2013;65:46–53, http://dx.doi.org/10.1111/ajpy.12008. 22. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77–101. 23. Mak AS, Barker MC. Internationalisation at home: enhancing the intercultural capabilities of business and health teachers, students and curricula; 2013. Retrieved from http://www.olt.gov.au/project-internationalisationhome-enhancing-intercultural-capabilities-business-and-health-teachers[accessed 31.08.14]. 24. Westwood MJ, Mak AS, Barker M, Ishiyama F. Group procedures and applications for developing cultural competencies among immigrants. Int J Adv Counsell 2000;22(4):317–30. 25. MacNab BR, Worthley R. Individual characteristics as predictors of cultural intelligence development: the relevance of self-efficacy. Int J Intercult Rel 2012;36:62–71, http://dx.doi.org/10.1016/j.ijintrel.2010.12.001. 26. Mak AS, Kennedy M. Internationalising the student experience: preparing instructors to embed intercultural skills in the curriculum. Innov High Educ 2012, http://dx.doi.org/10.1007/s10755-012-9213-4. Published in Online First on 20 January. http://dx.doi.org/10.1007/s10755-012-9213-4 [accessed 31.08.14]. 27. Hochschild AR. The managed heart: commercialization of human feeling. Berkeley: University of California Press; 1983. 28. Smith P. The emotional labour of nursing revisited. 2nd ed. Basingstoke: Palgrave Macmillan; 2012. 29. Hillman K. Failure to recognise patients at the end of life in acute hospitals. Acta Anaesthesiol Scand 2014;58:1–2. 30. Truog R, Campbell M, Curtis J, Haas C, Luce JM, Ruberfield G, et al. Recommendations for end-of-life care in intensive care unit: a consensus statement by the American College of Critical Care. Crit Care Med 2008;36(3):953–63. 31. Gibbins J, McCoubrie R, Forbes K. Why are newly qualified doctors unprepared to care for patients at the end of life? Med Educ 2011;45:389–99. 32. Pattison N, Carr S, Turnock C, Dolan S. ‘Viewing in slow motion’: patients’, families’ nurses’ and doctors’ perspectives on end-of-life care in critical care. J Clin Nurs 2013;22:1442–54. 33. Hilton A, Jones D, Bellomo R. Clinical review: the role of the intensivist and the rapid response team in nosocomial end-of-life care. Crit Care 2013;17:224–35. 34. Australia and New Zealand Intensive Care Society. The ANZICS statement on death and organ donation. 3.2 ed. Australian and New Zealand Intensive Care Society; 2013. Available from http://www.anzics.com.au/death-and-organ-donation [accessed 31.08.14]. 36. Stayt C. Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care. J Clin Nurs 2009;18: 1267–75. 37. Mak AS, Buckingham K. Beyond communication courses: are there benefits in adding skills-based EXCELLTM sociocultural training? Int J Intercult Rel 2007;31:277–91. 38. Mak AS, Daly A, Barker MC. Fostering cultural inclusiveness and learning in culturally mixed business classes. SpringerPlus 2014;3(1), http://dx.doi.org/10.1186/2193-1801-3-242. Article 242. Available from http://www.springerplus.com/content/3/1/242 [accessed 31.08.14].
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
ARTICLE IN PRESS Australian Critical Care xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Australian Critical Care journal homepage: www.elsevier.com/locate/aucc
Research paper
Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation Holly L. Northam RN, RM, M Critical Care Nursing, MACN a,∗ , Gylo Hercelinskyj RN, PhD a , Laurie Grealish RN, PhD, FACN b , Anita S. Mak Registered Psychologist, PhD a a b
Faculty of Health, University of Canberra, Australia Griffith Health Institute, Griffith University & Gold Coast Hospital and Health Service, Australia
article information Article history: Received 1 September 2014 Received in revised form 19 December 2014 Accepted 22 December 2014 Available online xxx Keywords: Critical care Communication Cultural competency Education End-of-life Multicultural Multi-disciplinary Pilot study
a b s t r a c t Background: Australia’s immigration policy has generated a rich diverse cultural community of staff and patients in critical care environments. Many different cultural perspectives inform individual actions in the context of critical care, including the highly sensitive area of end of life care, with nurses feeling poorly prepared to provide culturally sensitive end of life care. Purpose: This article describes and evaluates the effectiveness of an educational innovation designed to develop graduate-level critical care nurses’ capacity for effective interpersonal communication, as members of a multi-disciplinary team in providing culturally sensitive end-of-life care. Methods: A mixed method pilot study was conducted using a curriculum innovation intervention informed by The Excellence in Cultural Experiential Learning and Leadership Program (EXCELL),1 which is a higher education intervention which was applied to develop the nurses’ intercultural communication skills. 12 graduate nursing students studying critical care nursing participated in the study. 42% (n = 5) of the participants were from an international background. Information about students’ cultural learning was recorded before and after the intervention, using a cultural learning development scale. Student discussions of end of life care were recorded at Week 2 and 14 of the curriculum. The quantitative data was analysed using descriptive statistical analysis and qualitative data was thematically analysed. Results: Students demonstrated an increase in cultural learning in a range of areas in the pre-post surveys including understandings of cultural diversity, interpersonal skills, cross cultural interactions and participating in multicultural groups. Thematic analysis of the end of life discussions revealed an increase in the levels of nurse confidence in approaching end of life care in critical care environments. Conclusion: The EXCELL program provides an effective and supportive educational framework to increase graduate nurses’ cultural learning development and competence to manage culturally complex clinical issues such as end of life care, and is recommended as a framework for health care students to learn the skills required to provide culturally competent care in a range of culturally complex health care settings. © 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
1. Introduction This paper describes a pilot study of an intervention designed to develop graduate nursing students’ competency to deliver culturally sensitive end of life care in critical care environments. The
∗ Corresponding author. Tel.: +61 0412289 295. E-mail address: [email protected] (H.L. Northam).
intervention was instigated in response to one universities’ graduate nursing students identified need to learn more about how to provide family centred culturally sensitive end of life care for patients in emergency and intensive care settings. The students’ needs had been previously identified through reflective journals and workshop discussions about caring for critically ill patients as well a review of the curriculum content by the academic lecturer. Critical care nurses are required to effectively communicate and act in sensitive and complex situations, such as in the provision
http://dx.doi.org/10.1016/j.aucc.2014.12.003 1036-7314/© 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
2
of safe, culturally appropriate end of life care in technologically complex environments. Johnstone2 identifies the importance of recognising the influence of cultural difference in the provision of end of life care. The provision of culturally competent health care improves equity and safety for patients, ensures appropriate resource utilisation3 and helps address power imbalance.4 Critical care nurses who practice in countries with substantial cultural diversity require a high level of intercultural communication skills as well as a willingness to examine one’s own, and be open to others’ cultural beliefs, experiences, and practices around death and dying. Therefore, they require education to develop the skills required to address the needs of patients and families, in an ethically and culturally sensitive manner and to meet practice competencies.3,5–7 Cultural sensitivity and competence are crucial for nurses supporting patients and families through emotion-laden end-of-life issues involving difficult decisions, where mistrust may contribute to suffering.4,8 Cultural sensitivity is particularly relevant to contemporary Australian health care settings where almost 28% of the resident Australian population are born overseas.9 Studies have shown that critical care nurses feel unprepared to provide supportive care for dying patients and their families in the critical care environments10–12 and have sought more education on this topic.13,14 Shannon et al.15 built on existing health care communication tools to provide strategies to assist nurses in approaching conversations at end of life, whilst others have developed a interdisciplinary learning program to address issues of moral distress and other challenges in providing end of life care.16 Crump et al.17 sought to identify nurses’ perceived barriers to providing quality end of life care, and found that knowledge and skills of cultural competency were ranked amongst the highest educational need sought by critical care nurses. To the authors’ knowledge there are no educational interventions that specifically integrate strategies to teach cultural competency together with sensitive family centred end of life care. Enhancing health professionals’ cultural competency contributes to improved outcomes for patients and their families3 and supports effective professional communication and teamwork which may contribute to improved safety and quality of care in intensive care units.18 In this article, we will outline how we structured an intervention using components of EXCELL1 together with Thomas’19 approach to culturally competent nursing practice, to frame the philosophy and teaching of cultural sensitivity in end of life care for nurses in complex health care environments. We will describe how, as nurse educators in a graduate nursing program on critical care, we encouraged and modelled culturally sensitive practice in the classroom, which in turn provided a safe and supportive group environment for explicit teaching and learning of key intercultural communication competencies relevant for end of life care, over a 14-week period. We will report the preliminary findings of a pilot trial of this educational innovation in terms of a cohort of graduate nursing students’ self-reports of cultural learning before and after the intervention. While this article report results from a small sample size (n = 12), this study contributes to knowledge about the provision of safe and high quality end of life care in Australian acute care environments.20
2. Methods A pilot mixed method interventional study was conducted with all graduate nursing students in critical care (n = 12) enrolled in two consecutive clinically based units of study, which spanned semester one and semester two of one year at one university. Nurse educators incorporated an innovative teaching and learning intervention based on the Excellence in Cultural Experiential Learning and Leadership (EXCELL) Program1 into the graduate critical care nursing
Table 1 Alignment of the EXCELL skills with Thomas19 cultural learning approach. The EXCELL skills
Thomas (2001) cultural learning approach used to structure the unit teaching and learning.
Seeking information
Sharing personal story around end of life care for own cultural group: “learn their own history and culture” (Thomas, 2001, p. 44).
Making a social contact
Linking personal expectations to context of how end of life care is delivered in their clinical experience: “Develop a helping relationship with the terminally ill individual and his or her support network” (Thomas, 2001, p. 44).
Participating in a group
Exploring the support within the team: “Care in acquiring translation services” (Thomas, 2001, p. 44).
Refusing a request
Uncovering personal and professional power to advocate and challenge: “Helping people to live a quality life and have a quality death is the goal” (Thomas, 2001, p. 45).
Expressing disagreement
Developing a personal set of tools to engage and empower families, challenge paradigms and seek feedback and support. “a personal understanding of the role that culture plays throughout the course of one’s life.” (Thomas, 2001, p. 45).
course. A survey instrument21 was used to evaluate student learning before and after the intervention and data was analysed using descriptive statistical analysis. Qualitative data of students’ views about culture and end of life care collected before and after the intervention were thematically analysed.22 This study was approved by the University’s Human Research Ethics Committee (Project number 11-70) and was part of a larger action research project funded by the Australian Learning and Teaching Council (ALTC PP10-1080), the “Internationalising at Home or IaH Project”23 an innovation designed to enhance the intercultural capability of staff and students by embedding intercultural competency development in the curriculum. The project aims to internationalise the learning and teaching practices of teachers and students in Business and Health higher education.23 An important IaH project outcome is the development and dissemination of adaptable intercultural curriculum involving the integration of discipline-specific critical incident scenarios with existing intercultural competency development tools based on the EXCELL Program.1 For more IaH project information, visit https://sites.google.com/site/internationalisationathome. The EXCELL Trainers Manual24 provides structure for teaching innovation to enable the students to develop skills in identifying a “key sociocultural framework”, to participate in “alliance building” and “cultural mapping” within their clinical practice environments and communication networks of patients, families and their nursing and multidisciplinary colleagues. The EXCELL tools build student confidence in ‘seeking information, making a social contact, participating in a group, refusing a request, expressing disagreement and getting feedback’. Theory to guide culturally sensitive end of life care19 was embedded in the unit teaching, learning and assessment plan. The curriculum change involved restructuring the unit content to deliver the intervention and align it to curriculum content. The curriculum content which underpinned the students learning of theory of culturally sensitive end of life care, was used as a vehicle to ‘carry’ the introduction and embedding of the EXCELL skills. The EXCELL skills and Thomas’19 strategies are listed in Table 1. A research assistant (RA) distributed written information about the study to all the students during class in the previous semester. The information sheet invited students to participate in the study and the RA answered any student questions. The students were
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
provided with time to consider their participation and to complete the consent documentation, which was returned to the RA within the same class period. All students (n = 12) agreed to participate in the study. Survey data was collected at two points in 2012: before and after the intervention. The participants responded to a 13-item cultural learning measure survey instrument adapted from MacNab and Worthley’s25 measure of cultural intelligence development and Mak’s26 measure of students’ cultural learning. The instruments were also used in the associated IaH studies to evaluate the participants’ educational and intercultural experience. Participants were asked 13 items about their cultural learning from the unit, for example, “With regards to (unit)-I have developed a better understanding of cross-cultural interpersonal skills.” Responses were scaled from 1 (strongly agree) to 5 (strongly disagree), so that lower scores indicated greater cultural learning This same cohort of participants were surveyed again at the end of Semester 2, 2012 (n = 9), following completion of the intervention. Eleven students completed the pre-test survey during class time late in semester one. One student was absent for this survey. The post-test was conducted following the intervention, near the end of semester two. The same group of participants completed both the pre and post survey. Two participants were absent at the posttest and were unable to complete the instrument, therefore nine participants completed the survey. Participants were also asked to complete a written survey called either “Domestic Students’ Educational and Intercultural Experiences” or “International Students’ Educational and Intercultural Experiences”, depending on whether the participant was a domestic or an international student. The survey has been used in other settings and contains 12 closed-ended items and one open-ended question asking for background information (e.g., about country of birth), interactions with domestic and international students, and evaluative ratings of the extent to which the unit of study just completed effectively developed and promoted intercultural competence skills. The surveys were distributed by the RA and took 10–15 min to complete. Qualitative data from these surveys were analysed separately to the data collected by the nurse educators. The nurse educators collected qualitative data in week 1 and week 14 of Semester 2. In week 1, all students were asked to reflect on their practice and to identify their greatest learning need regarding care of critically ill patient at end of life with the question, “What worries you most when caring for a dying patient and their family?” The student answers were provided to the nurse educator as an anonymous ‘Message in a bottle’. The responses to this question generated a student ‘wish list’ which were collected and collated. All notes were treated as one set of data and analysed.10 The nurse educator used information from these notes to focus students learning outcomes. At the conclusion of the intervention the nurse educator took notes of student discussions about how the students felt about the students learning about providing competent end of life care, which was initiated by the prompt question, “What have you learned?” This data was also thematically analysed10 as one data set.
3. Intervention The teaching innovation was structured in three layers within the teaching and learning plan as follows. Core to the intervention, the EXCELL skills were incorporated into workshop teaching and learning. Then cultural mapping and alliance building concepts and strategies were layered into the teaching plan. Assessment was constructively aligned to the unit learning objectives and academic content. The students were required to participate in each of the weekly structured workshops, which comprised workshops which
3
integrated curriculum teaching and learning with structured support for delivering culturally sensitive care in complex situations. These included nurse advocacy and communication at an interdisciplinary level when providing end of life care, incorporating awareness of cultural, religious, ethical and legal considerations as seen in Table 2. Drawing from the work of Thomas19 each week the EXCELL skills (see Table 1) were embedded into activities and assessment tasks. Each student in the group was provided with an opportunity to share a story of their experience of their own culture and experience of death, which provided a base for them to “learn their own history and culture” (p. 44).19 Their personal story was then used as a discussion prompt to enable them to link personal expectations to the context of their experience of how end of life care is delivered in their clinical practice. These stories opened a new understanding between the students of the knowledge and insights that their colleagues contributed to their workplace, thereby supporting the nurses to “develop a helping relationship with the terminally ill individual and his or her support network” (p. 44).19 The students were encouraged to develop a set of intellectual, practical and emotional support strategies to use as a personal ‘tool box’ for managing challenging clinical situations. These were collaboratively developed by the students using their own experience based scenarios within the workshop environments which enabled them to practice ‘safe testing’, by saying the words and making the actions in a safe environment which was linked to theory in preparation for practice. The nurse educator provided guidance to the intervention to ensure that all students were provided with opportunities to practice the EXCELL skills and use their reflective skills. Hesitant students were encouraged and prompted, and provided with constructive feedback to build their confidence. The students sought knowledge and skills to competently approach culturally sensitive communication in the technologically intrusive environments of critical care. They did not need or seek scripts which they recognised would not be authentic to their practice relationships. Cultural mapping helped the students to recognise their own perspective, role, and interconnectedness to those around them professionally and in their communities, and made explicit why the use of appropriate human and professional resources could contribute to building their confidence and competence in providing culturally sensitive end of life care. Cultural mapping provided them with cues for non-verbal and verbal communication using the EXCELL stages of approach, bridging, communication and departure.21 A particular emphasis was made on using effective and ethical communication and the appropriate use of interpreters, social history and in not assuming information; highlighting the need for, “Care in acquiring translation services” (p. 44).19 The role of each nurse and the potential for them to practice with cultural sensitivity was underlined when the nurses were encouraged to actively uncover their personal and professional power to challenge and advocate, thus achieving Thomas, 2001 goal of “Helping people to live a quality life and have a quality death” (p. 45).19 The students were encouraged to explore the support available to them in complex scenarios as part of alliance building within the team. For this intervention invited experts were able to provide their insights about the scope of resources that are available to provide culturally sensitive end of life care and the specific needs of diverse populations within the local region. Multidisciplinary health care experts and consumers were invited to interact with the students throughout the course of study, which provided students with opportunities to build cultural knowledge and sensitivity, and also strengthen student’s confidence in communicating. Relationships between the individual students were strengthened and mentoring and modelling support was provided by lecturers who encouraged the students to see themselves as valued members of
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
4 Table 2 Weekly teaching and learning plan. Week
Workshops: Normal teaching and learning sessions with integrated and aligned intervention utilising the EXCELL tools
1
Introduction and overview of the unit and its learning objectives. Overview: EXCELL intervention and ‘toolbox’: Reflection: ‘What worries you most when caring for a dying patient and their family? Submit anonymous note ‘message in a bottle’ to the nurse educator
2
Communication 1: Caring with sensitivity’ Different to us: Stories from our past – how they link to the present and become part of ourselves: The students were encouraged to discuss and consider the influence their personal experiences, culture and expectations related to critical illness, dying and death within their own family. Each student was invited to discuss within the group how their personal experience contributed to how • they think about and interact in the health care environment • this influences their interpretation of the needs of those they care for • how they communicate the needs of their patients to others Lectures and discussions integrated into the standard teaching component included: ethical challenges, mental health, cultural and religious. Displaced People: By refugee health care worker regarding communication and the context of health for displaced people and cultural and religious sensitivities for different communities located within the local community. Resources such as interpreter support service, teaching regarding the issues faced by this cohort of the population such as survival following torture and other contextually relevant aspects of cultural sensitivity were presented. Care with an Indigenous lens: issues facing indigenous peoples in emergency and intensive care environments and ways of providing culturally competent care, and appropriate resources to support that care.
3
Communication 2: Continuum of critical illness and outcomes of critical illness Focus group led by key questions “What is the most difficult part of caring for people who are mentally ill for you?” ICU Research on staff expectations and the provision of culturally competent care The development of an ICU death policy Death in the ICU, film by staff and patients’ family about ‘good’ death in the ICU
4
Day 1 Emergency presentations Advanced Care Directives: Intensivist with expert practical and legal knowledge
5
Day 2 Emergency presentations and management ED Trauma Case Reviews: Including the involvement of the family and outcomes Discussion: Ethics of complex care scenarios and resource utilisation, disaster management
6
Simulation and cases Care of the critically ill child: Emergency consultant, Intensivist, social worker, Multidisciplinary team communication Intensivist, social worker and actor as mother, who are present at the resuscitation bed for the assessment and stabilisation of a critically ill child in the emergency department
Table 3 A range of vignettes were developed as prompts to trigger discussion around end of life care and complex needs of patients and families. Vignette
Actions
A new admission to ICU of a critically ill patient when death is probable
Competent patient and family centred care:
Establishing communication with a distressed family at the bedside
Use ‘Excell skills’ and ‘tool box’ of resources which include: Knowledge, policy and guidelines • contemporary evidence based recommendations drawn from scholarly sources • ethical frameworks • legal requirements including advanced care plans and directives • end of life wishes including organ and tissue donation
Care of a child undergoing resuscitation in the emergency department and communication with the mother Interaction with family members who want to visit their relative where the next of kin have very limited ability to communicate in English language Care of the deceased in the emergency department in Coroners cases
Professional relationships: work in partnership with • co-workers, team leader and interdisciplinary team • Social worker/Seek linguistic support through interpreter service, spiritual and cultural support through local agencies • Pastoral care/Aboriginal Liaison Officer Family relationships work in partnership with the patient and family: • Acknowledge family distress, show compassion • Build relationship of mutual trust with patient and their family
Care of a patient and family when clinical signs indicate the patient is brain dead and the patient is of an indigenous back ground Bedside care and communication with the family and multidisciplinary team when there are indications that withdrawal of life sustaining treatment may be in the patients best interests Communicating with families of suicide victims and survivors
7
Metabolic failure and nutritional requirements for the critically ill patient. Critical care considerations in pharmacotherapy Student contribution
the health care team, and active collaborators in building alliances themselves the patients, their families, and their co-workers. A range of vignettes were developed as prompts to trigger discussion around end of life care and complex needs of patients and families (see Table 3).
9
Obstetric emergencies and management of the critically ill woman and babe
4. Results
10
Managing multi-organ failure
11
Australasian Donor Awareness Professional Training Program ICU family experiences of making an organ donation decision for their deceased son: led by consumer
13
Simulation, complicated cardiogenic shock, chest opening How to manage the fear (staff, patient and family)
14
Course review, assessment review. Focus group wrap up: “What have you learned?”
All participants were employed as registered nurses in critical care areas and were enrolled as domestic students. Forty two percent of participants described their educational background as a country other than Australia, which is consistent with the changing demographic profile of staff working in Australian critical care environments. The participants had come to Australia from countries such as Nepal, India, China, Nigeria and ‘other’ and comprised 8 females, three males and one with unspecified gender, aged between 24 and 36 years. Participants’ Cultural Learning from the Curriculum was assessed using the 13-item cultural learning measure survey
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model
ARTICLE IN PRESS
AUCC-260; No. of Pages 7
H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx Table 4 Comparing students’ cultural learning scores pre and post Excell intervention. Statement
Pre-Excell % agreeda (n = 11)
Post-Excell % agreeda (n = 9)
I have developed a greater awareness of cultural diversity. I have developed a better understanding of cross-cultural interpersonal skills. I have gained awareness of the role of culture in my chosen field of study. I am now more conscious of the cultural knowledge I use when interacting with people with different cultural backgrounds. I am now more conscious of the cultural knowledge I apply to cross-cultural interactions. I am better prepared to adjust my cultural knowledge as I interact with people from an unfamiliar culture. I am now better equipped to enjoy living in cultures that are unfamiliar to me. I am now more confident that I could socialise with locals in a culture that is unfamiliar. I am now more certain that I could deal better with adjusting to a culture that is new to me. I have become more confident with communicating with people from culturally different backgrounds. I have become more ready to make social contact with culturally different others. I have become more comfortable participating in multicultural groups. I enjoy interaction with people from different cultures.
27.3
44.4
27.3
62.5
54.5
55.6
27.3
55.6
27.3
55.6
54.5
55.6
36.4
55.6
27.3
55.6
36.4
66.7
54.5
66.7
45.5
66.7
18.2
55.6
45.5
66.7
a
Percentage of respondents who agreed or strongly agreed.
instrument adapted from MacNab and Worthley’s25 measure of cultural intelligence development and Mak’s26 measure of students’ cultural learning which demonstrated high internal consistency (Cronbach’s alpha = .95 as reported in Mak and Barker).23 Data analysis revealed an increase in students’ cultural learning scores. The results are tabulated in Table 4. Qualitative data from open-ended responses to the survey revealed an increase in the levels of participant confidence in approaching end of life care in both emergency department and intensive care environments. Two participants, in response to the question about how to apply their learning, indicated that they would use it in patient assessment and management and end-of-life care. 5. Qualitative data: students anonymous ‘message in a bottle’ wish list The pre and post intervention qualitative data was thematically analysed22 by one author (HN) and validated by a second author (GH). The key theme identified in the participant messages related to seeking the skills and the knowledge to communicate and care for patients and their families compassionately and effectively at the end of life. The ideas included the stressors upon participants to deliver culturally sensitive and legally and ethically acceptable end of life care; the changing paradigms around the needs of families of dying patients in critical care environments; the need to identify specific family needs; managing ‘open access’ visitation of patients’ families at the bedside; the place of ‘witnessed resuscitation’ and the participant role in either facilitating family presence or being
5
Table 5 Students ‘wish list’ of things they need help with when approaching culturally sensitive communication about death. • Coming to terms with ‘NFR’ orders, especially in situations in which the patient is considered ‘too young’ to die. . .. • The time when the patient actually takes their final breath and is being pronounced dead! Which I find overwhelming for family members. • How to manage honest information about dying • I am not sure that it is alright to tell the family members that their loved one is dying, and that’s why he or she can’t breathe properly. . .. • What can I do for the family members, when they are so sad because their loved one died? • Explaining death or dying to family members • Caring for a patient when the family member has died as a result of some accident, knowing whether to tell or not to tell immediately, or wait for police confirmation. • How to deal with the actual decision making processes of end of life care especially when you are the RN participating in the family meeting? • Do miracles happen? An often asked question. • Starting a conversation with families is a big task for me. • A better understanding of the family’s attitude towards the process and also how to approach the relatives in doubt? • I find communication with the patient and family around palliation a challenge. • How to encourage doctors to clarify end of life decisions
a barrier to family witnessed resuscitation; and the personal psychological impact of caring for dying patients and their families in a complex care environment. See Table 5. Themes identified in the participant dialogue revealed the participants desire to reduce the psychological impact of the critical care nursing work by building resiliency, managing moral conflict, and pre-empting compassion fatigue. Three key themes ‘Fear’, ‘Inadequacy’ and ‘Taboo’ were identified which represented the participants’ views about caring for patients and families in complex end-of-life care situations. The participants’ greatest challenge when communicating with families was captured by the theme of ‘fear’, which incorporated the relationship between themselves and the patients’ family and in some circumstances the conscious patient. The participant fears included ideas such as that “Caring for their loved one is always so challenging but involving them in that care “scare pact” was most challenging”. This complex fear encompassed the realisation for some participants that their relationship with the dying patient and the patients’ family was almost unified because of the shared experience of traversing the difficult period of the continuum of dying. It included the participant’s role in administering medications upon the order of doctors, in withdrawing life sustaining technology, and in managing evidence of suffering which some participants appeared to experience as a sense of sharing a fear of the approach of death. The participants perceived themselves to have become a part of a nurse/family/patient “fear pact” which heightened the participants’ stress and anxiety, especially when they felt disempowered in their advocacy, and were fearful of offending the patients’ family, the treating doctor or coworkers. The participants expressed a deep sense of inadequacy leading to the theme of ‘Inadequacy’ in being unable to provide the dying patient and their family with privacy in dying, especially in the emergency department environment. One participant expressed regret about not knowing how to appropriately respond when caring for grieving families, “What can I do for family members, when they are so sad because their loved one has died. . .” This theme was particularly apparent in circumstances where it was difficult for the participants to know how best to help the families from a cultural perspective, because the participants felt they effectively balanced between the patient and families emotions and needs against the needs of the organisation, and included such things as pressure to care for other patients, bed occupancy pressure, or of being uncertain of the patient’s needs or wishes.
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
6
Participants expressed a sense of responsibility in better addressing communicating in sensitive competent ways when caring for suicidal patients, or potentially violent patients. This anxiety was particularly reflected by participants who felt a sense of responsibility to manage the perceived personal threat and threat to others within their care. The participants sought support in finding ways to engage with doctors and expressed feelings of inadequacy because of experiences of having been unable to effectively act as the patients advocate between the patients’ family and the treating doctor. For example, the participants believed they were poorly prepared for situations where the family were unable to clearly communicate their concern for cultural or language reasons but were anxious about the provision of pain relief or were concerned about the reasons for the patient undergoing surgery. The theme of ‘Taboo’ represented participants’ ideas of trying to balance their scope of practice with transparency and trust in communication. For example, in situations of death in the emergency department when a patient is determined to be dead on arrival, questions about whether the participant should let the family know or await the arrival of the police. Or when families were asking for information that the participants believed they knew but perceived they were not ‘allowed’ to answer. The concept of withholding information from the family was troubling for the participants, as they balanced their personal, cultural and religious sensitivities and expectations, with what they believed were professional requirements to withhold information. ‘Taboo’ also represented the difficulty faced by participants who were uncertain as how to meet the spiritual and cultural needs of families from diverse cultures when addressing questions of death and dying. At the concluding workshop discussion following the intervention, the participants described feeling better prepared, more aware and alert of potential resources and people to seek support from. They were pleased they had been able to describe their concerns, voicing views that they had been provided with more tools, skills and information to support them in providing culturally competent end of life care. Although several participants highlighted their anxiety that they had still not been required to manage the care of a patient at death, the participants stated that they were now aware of those who could assist them in supporting families. All participants indicated a new understanding of the cultural differences that can affect families’ and other staff interpretation of communication. The participants dialogue suggested that they understood that they still had much to learn and appreciated being able to have their concerns recognised. They expressed the hope that their organisation would also offer them support in these complex situations.
6. Discussion The findings demonstrate that critical care nurses need and seek education to enable them to successfully meet the needs of the patients and their families, and to work as empowered practitioners within the multidisciplinary team environment of contemporary critical care practice. These participants in this study were fearful in approaching end of life care and when communicating in situations of cultural difference. They sought to meet the needs of their patients and their families, but were anxious to do this well. The participants believed their feelings of inadequacy increased the emotional labour of their work,27,28 which they wish to reduce. Participants wanted to build their resilience in managing complex care, and sought strategies to assist them in approaching real and perceived moral conflict. The participants expressed anxiety about how to manage situations when conflict exists within the multidisciplinary team about end of life care decisions and communication about death, especially when difficulty exists in reaching a consensus on the
prognosis and the needs of the patient, which is supported by the literature.29,30 Consistent with other studies, most students had previously received little education about how to communicate about death.31 In terms of diagnosing dying, they had differing perceptions about what should be discussed by doctors with those involved. The differing interpretations of terminology, clinical practices and communications which surround end of life care and death contributed to student confusion and have previously been reported as confounders in sensitive communication about death32,33 and communication to patients, or their families.34 As with other critical care nurses, these participants recognised that they needed to be able to communicate competently with the patient, their family and others, but also with doctors and other multidisciplinary team members who may come from diverse cultural backgrounds. Critical care nurses are required to collaborate and lead within the multidisciplinary team, are accountable for protecting the rights of patients and their loved ones, and for providing information and care according to their dynamic needs.7 Critical care nurses are also required to meet legal requirements for practice in the critical care environment.7 In some circumstances studies have found that nurses caring for patients at the end of life in critical care settings may experience intellectual confusion and moral and emotional distress, which is known to contribute to compassion fatigue and burnout,36 which was supported by these participants’ views. This study has found that critical care nursing students require greater educational support to provide culturally competent care, and we recommend further study into this area. It is recognised that there is a need for more research into end of life care in the Australian intensive care setting.10,12 In their study into intensive care nurses beliefs and practices of end of life care, Ranse et al.10 suggest that critical care nurses are challenged to optimise patient and family experiences of dying within a context of “limited emotional and organisational support” (p. 11). This study supports the notion that critical care nurses seek to pre-empt compassion fatigue by seeking knowledge and skills to empower them to clearly communicate with and advocate for their patients and their families within critical care environments. It is clear that more must be done to address these needs. 7. Study limitations This was a small cohort of students and the survey sample was incomplete when the students were unable to attend sessions due to illness or work commitments. Several students were unable to be present for all the sessions, and the final survey was conducted before the final session of the scheduled intervention. Also, we did not employ a control group comprising nurses not exposed to the Internationalisation Project. It is possible that the increases in various aspects of cultural learning before and at the end of the intervention could have partly been due to the passage of time. However, previous studies incorporating either the entire program or specific components of EXCELL Program into the curriculum of other subjects, where larger samples with control groups were used, identified statistically significant benefits in terms of students’ cultural learning development.37,38 8. Conclusions Restructuring the program to embed content and skills to support culturally sensitive end of life care, has provided a strategy that may empower the students and enable them to provide culturally competent care. The students’ continuing rich dialogue suggests there may be benefits in translating this work into the clinical environment to support critical care teams and others to provide
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
G Model AUCC-260; No. of Pages 7
ARTICLE IN PRESS H.L. Northam et al. / Australian Critical Care xxx (2015) xxx–xxx
culturally sensitive care. These initial findings although limited by the size and completeness of the sample provide evidence that this intervention was valued by the students and has helped to build their competence in approaching culturally sensitive end of life care. The pre-test which showed that the nurses all believed themselves to be poorly equipped with cross-cultural interpersonal skills is of concern as it is drawn from a sample of nurses currently providing care within Australian critical care environments. It is important to conduct further research into this area of practice and also to provide appropriate skills and education to support culturally competent and sensitive end of life care in critical care environments. Author contributions Northam led the design of the intervention study, conducted the study including data collection and data analysis. She also led the development of this manuscript. Hercelinskyj assisted with the design of the intervention study, provided monitoring of the conduct of the study and has contributed to the development of this manuscript. Grealish assisted with the design of the intervention study, provided monitoring of the conduct of the study and has contributed to the development of this manuscript. Mak provided guidance for the overall project, secured ethical review of the project and assisted with the development of this manuscript. Conflict of interest The authors have no conflict of interest in the conduct of this study. Acknowledgements Vikki Knott PhD for her support as regular contributor to monitoring the project in our shared group. This project was supported as part of the “Internationalisation at Home: Enhancing Intercultural Capabilities of Business and Health Teachers, Students and Curricula” project, funded by the Australian Learning and Teaching Council (ALTC PP10-1080). References 1. Mak AS, Westwood MJ, Barker MC, Ishiyama FI. The ExcelL Program for developing international students’ sociocultural competencies. J Int Educ 1998;9(1):33–8. 2. Johnstone M. Bio-ethics, cultural differences and the problem of moral disagreements in end-of-life care: a terror management theory. J Med Philos 2012;37:181–200. 3. National Health & Medical Research Council. Cultural competency in health: a guide for policy partnerships and participation. Canberra: Commonwealth of Australia; 2006. Available from https://www.nhmrc.gov.au/ files nhmrc/ publications/attachments/hp19.pdf [accessed 31.08.14]. 4. Thackrah RD, Thompson SC. Refining the concept of cultural competence: building on decades of progress. MJA 2013;199(1):35–8. 5. World Federation of Critical Care Nurses. Position statement on the provision of critical care nurse education – Declaration of Madrid, Madrid; 2005. Available from www.wfccn.org/ [accessed 30.06.10]. 6. International Council of Nurses. Position statement: cultural and linguistic competence. Switzerland: International Council of Nurses Geneva; 2013. Available from www.icn.ch [accessed 31.08.14]. 7. Australian College of Critical Care Nurses. Competency standards for specialist critical care nurses. 2nd ed. The Australian College of Critical Care Nurses; 2002. Melbourne, Australia. 8. de Pentheny O’Kelly C, Urch C, Brown E. The impact of culture and religion on truth telling at the end of life. Nephrol Dial Transplant 2011;26(12):3838–42. 9. Australian Bureau of Statistics. Australia’s population by country of birth. Canberra: Commonwealth of Australia; 2013. Available from www.abs.gov.au/ ausstats/[email protected]/Lookup/3412.0Chapter12011-12%20and%202012-13 [accessed 31.08.14].
7
10. Ranse K, Yates P, Coyer F. End-of-life care in the intensive care setting: a descriptive exploratory qualitative study of nurses’ beliefs and practices. Aust Crit Care 2010;25:4–12. 11. Le BHC, Watt JN. Care of then dying in Australia’s busiest hospital: benefits of palliative care consultation and methods to enhance access. J Palliat Care Med 2010;13(7):855–60. 12. Bloomer MJ, Moss C, Cross WM. End-of-life care in acute hospitals. J Nurs Healthc Chronic Illn 2011;3:165–73. 13. Bloomer M, Morphet J, O’Connor M, Lee S, Griffiths D. Nursing care of the family before and after a death in the ICU – an exploratory pilot study. Aust Crit Care 2013;26:23–8. 14. Kilcoyne M, Dowling M. Working in an overcrowded accident and emergency department: nurses’ narratives. Aust J Adv Nurs 2008;25(2):21–7. 15. Shannon S, Long-Sutehall T, Coombs M. Conversations in end-of-life care: communication tools for critical care practitioners. Pract Dev 2011;16(3):124–30. 16. Gordon E, Ridley B, Boston J, Dahl E. The building bridges initiative: learning with, from and about to create an interprofessional end-of-life care program. Dynamics 2012;23(4):37–41. 17. Crump SK, Schaffer MA, Schulte E. Critical care nurses’ perceptions of obstacles, supports, and knowledge needed in providing quality end-of-life care. Dimens Crit Care 2010;29(6):297–306. 18. Chaboyer W, Chamberlain D, Hewson-Conroy K, Grealy B, Elderkin T, Brittin M, et al. CNE article: Safety culture in Australian intensive care units: establishing a baseline for quality improvement. Am J Crit Care 2013;22(2):93–102. 19. Thomas N. The importance of culture throughout all of life and beyond. Holist Nurs Pract 2001;15(2):40–6. 20. Australian Commission on Safety and Quality in Health Care. National consensus statement: essential elements for safe and high-quality end-of-life care in acute hospitals, consultation draft. Canberra, Australia: Commonwealth; 2014. Available from http://www.safetyandquality.gov.au/wp-content/uploads/2014/ 01/Draft-National-Consensus-Statement-Essential-Elements-for-Safe-andQuality-End-of-Life-Care-in-Acute-Hospitals.pdf [accessed 31.08.14]. 21. Knott V, Mak AS, Neill JT. Teaching intercultural competencies in introductory psychology via reflection and application of the Excellence in Cultural Experiential Learning and Leadership model. Aust J Psychol 2013;65:46–53, http://dx.doi.org/10.1111/ajpy.12008. 22. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3(2):77–101. 23. Mak AS, Barker MC. Internationalisation at home: enhancing the intercultural capabilities of business and health teachers, students and curricula; 2013. Retrieved from http://www.olt.gov.au/project-internationalisationhome-enhancing-intercultural-capabilities-business-and-health-teachers[accessed 31.08.14]. 24. Westwood MJ, Mak AS, Barker M, Ishiyama F. Group procedures and applications for developing cultural competencies among immigrants. Int J Adv Counsell 2000;22(4):317–30. 25. MacNab BR, Worthley R. Individual characteristics as predictors of cultural intelligence development: the relevance of self-efficacy. Int J Intercult Rel 2012;36:62–71, http://dx.doi.org/10.1016/j.ijintrel.2010.12.001. 26. Mak AS, Kennedy M. Internationalising the student experience: preparing instructors to embed intercultural skills in the curriculum. Innov High Educ 2012, http://dx.doi.org/10.1007/s10755-012-9213-4. Published in Online First on 20 January. http://dx.doi.org/10.1007/s10755-012-9213-4 [accessed 31.08.14]. 27. Hochschild AR. The managed heart: commercialization of human feeling. Berkeley: University of California Press; 1983. 28. Smith P. The emotional labour of nursing revisited. 2nd ed. Basingstoke: Palgrave Macmillan; 2012. 29. Hillman K. Failure to recognise patients at the end of life in acute hospitals. Acta Anaesthesiol Scand 2014;58:1–2. 30. Truog R, Campbell M, Curtis J, Haas C, Luce JM, Ruberfield G, et al. Recommendations for end-of-life care in intensive care unit: a consensus statement by the American College of Critical Care. Crit Care Med 2008;36(3):953–63. 31. Gibbins J, McCoubrie R, Forbes K. Why are newly qualified doctors unprepared to care for patients at the end of life? Med Educ 2011;45:389–99. 32. Pattison N, Carr S, Turnock C, Dolan S. ‘Viewing in slow motion’: patients’, families’ nurses’ and doctors’ perspectives on end-of-life care in critical care. J Clin Nurs 2013;22:1442–54. 33. Hilton A, Jones D, Bellomo R. Clinical review: the role of the intensivist and the rapid response team in nosocomial end-of-life care. Crit Care 2013;17:224–35. 34. Australia and New Zealand Intensive Care Society. The ANZICS statement on death and organ donation. 3.2 ed. Australian and New Zealand Intensive Care Society; 2013. Available from http://www.anzics.com.au/death-and-organ-donation [accessed 31.08.14]. 36. Stayt C. Death, empathy and self preservation: the emotional labour of caring for families of the critically ill in adult intensive care. J Clin Nurs 2009;18: 1267–75. 37. Mak AS, Buckingham K. Beyond communication courses: are there benefits in adding skills-based EXCELLTM sociocultural training? Int J Intercult Rel 2007;31:277–91. 38. Mak AS, Daly A, Barker MC. Fostering cultural inclusiveness and learning in culturally mixed business classes. SpringerPlus 2014;3(1), http://dx.doi.org/10.1186/2193-1801-3-242. Article 242. Available from http://www.springerplus.com/content/3/1/242 [accessed 31.08.14].
Please cite this article in press as: Northam HL, et al. Developing graduate student competency in providing culturally sensitive end of life care in critical care environments – A pilot study of a teaching innovation. Aust Crit Care (2015), http://dx.doi.org/10.1016/j.aucc.2014.12.003
