Nurse Educator Vol. 39, No. 6, pp. 307-310 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Educator
Nursing Care at the End of Life A Service Learning Course for Undergraduate Nursing Students Stephanie Jeffers, PhD, RN & Dawn Ferry, MSN, RN, CHSE An elective course titled ‘‘Nursing Care at the End of Life’’ was designed for fourth-year nursing students in a baccalaureate nursing program. This course, taught by the authors, was designed to teach students about caring for the dying patient. Students were required to complete service learning with patients in a hospice or hospital setting. Students reported having a positive learning experience and gaining new knowledge and a deeper understanding of the needs of dying patients and their families. Keywords: death and dying; end of life; hospice; nursing education; service learning
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istorically, nursing education programs have inadequately prepared nurses for end-of-life care. This has been reported in research studies focusing on RNs as well as nursing students.1 Lack of end-of-life education appears to be related to an increase in death anxiety of students and nurses, as well as negative attitudes toward dying patients.2,3 This combination of inadequate knowledge and skill and poor attitudes of the nurse may adversely affect patient care at the end of life. An end-of-life nursing care course is an important first step in educating future nurses about endof-life care and issues related to death and dying and exposing them to hospice nursing care.
Review of Literature The literature review on RNs and nursing students reveals that there is a lack of knowledge and understanding about end-of-life concepts, which may lead to anxiety and negative attitudes toward caring for a dying patient. Both nurses and students have reported that they do not feel prepared to address the concerns of dying patients and their families.4 Efforts to improve education at the prelicensure level should occur to provide nurses with education and tools to care for this patient population in a meaningful and effective manner. The rapidly aging population combined with multiple comorbidities require nurses to have an added skill set and education on death and dying.5 Author Affiliations: Assistant Professor (Dr Jeffers), and Director (Ms Ferry), School of Nursing, Center for Simulation and Computerized Testing, Widener University, Chester, Pennsylvania. The authors declare no conflicts of interest. Correspondence: Dr Jeffers, School of Nursing, Widener University, One University Place, Chester, PA 19013 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: August 13, 2014 DOI: 10.1097/NNE.0000000000000088
Nurse Educator
In response to the need for education on end-of-life care for nurses, in 2001, Ferrell6,7 and the American Association of Colleges of Nursing developed the End-of-Life Nursing Education Consortium (ELNEC). This education model uses a ‘‘train-thetrainer’’ approach in teaching end-of-life content to nurses. The 22-day seminars are taught to nurses across the country as well as internationally to develop trainers who will then disseminate this information to other nurses at their hospitals or nursing schools. This program has been highly successful and provides seminars specific to such nursing specialties as geriatric, pediatric, and critical care.6,7 The American Association of Colleges of Nursing reported that 18 300 RNs and other healthcare providers such as social workers have received ELNEC training.8 Several studies have investigated ELNEC integration and outcomes within associate degree and baccalaureate nursing education programs. Using both quantitative and qualitative methods, researchers examined knowledge and attitudes of nursing students toward death and dying following a course on end-of-life care. The courses described included various topics based on the ELNEC curriculum including communication, pain management, spiritual care, bereavement, and cultural considerations. Findings from these studies illustrated that the students gained further knowledge of end-of-life topics, and attitudes toward the dying patient improved. The researchers also reported that students often had a transformative experience and appreciated having the opportunity to care for a dying patient in their nursing education program.9-11 In addition to research on ELNEC integration in nursing curricula, researchers published numerous studies on the use of various teaching strategies to educate nursing students about end-of-life care. Reflection in the form of writing or verbal communication following the use of film or literature in the classroom can promote affective learning by the student.12,13 Simulation on end-of-life scenarios has also been reported in the literature, with greater frequency in recent years. Providing students with a simulated dying patient has shown Volume 39 & Number 6 & November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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to improve student knowledge of end-of-life issues and increase comfort level with dying patients.14-16 Outside the classroom, students may pair up with a patient in an acute care setting, hospice, or patient home to have more hands-on experience with a dying patient. Studies have shown that communicating directly with a dying patient, listening to their story, and encouraging a life review benefitted the patient as well as the student. In addition to improved knowledge on end-of-life care, students involved directly with dying patients reported a change in their view of dying patients, increased comfort level when communicating with dying patients, and an improved attitude toward dying patients and their families.17-20 The student-patient experiences reported in the literature were more of a clinical nature. There is a paucity of research on service learning activities in nursing programs that link students with hospices or other community groups, which serve patients and their families in the final hours or after the patient has died. Service learning is a mutual engagement between a student and community site; the student provides service to the community, and in return, the student learns valuable lessons about the population they serve. Reflection is a significant element of service learning; students are required to think about their feelings regarding their experiences at the community site. Reflection activities include written assignments and group discussion.21,22 Benefits of service learning include nursing role development, greater understanding of how team players interact, cultural diversity awareness, improved critical thinking, and increased compassion for those who are living through the dying process.23
Course on Nursing Care at the End of Life We provided a new nursing course, Nursing Care at the End of Life, as an elective for senior-level nursing students. The purpose of this elective was to impart new insight on the important role of nurses in caring for patients at the end of life. Students were able to choose this course among several other nursing electives, which covered different topics. A total of 25 students were enrolled in this 3-credit course, which met 2 days a week for a total of 3 hours weekly. The Table 1 lists the course objectives. Based on the ELNEC curriculum, topics chosen for class discussion included physical, psychosocial, and spiritual assessment of the dying patient; cultural and religious considerations;
therapeutic communication; and ethical and legal issues. The full list of class topics is found in Table, Supplemental Digital Content 1, http://links.lww.com/NE/A169. Rather than traditional lecture, students were engaged in thought-provoking discussions and completed in-class group activities, which allowed them to learn about end-of-life care. Additional methods of instruction for this class included assigned readings, films (‘‘How to Die in Oregon, HBO Documentary,’’ and ‘‘Evan Mayday’s Good Death’’), games, and debates. Written assignments for the class included a formal paper based on a topic of the student’s choice such as palliative care, terminal sedation, end of life in the media, and advance directives, to name a few. Supplementary assignments were related to service learning; students were required to write a prejournal about their expectations of service learning and 1 goal to achieve during the service learning. A postjournal was required once service learning hours were completed; students reflected on activities during the semester, whether expectations were met and knowledge gained from the experience and how the student contributed to quality end-of-life care. The final assignment was a PowerPoint slide presentation, which students presented to the class, describing their service learning site and experience. Students were evaluated in the course based on their written assignment of a research paper, 12 service learning hours completed, and their presentation to the class on their service learning project and experience. The students were responsible for identifying a service learning partner to complete their hours and develop a project for the nursing staff, patients, or families. Examples of sites used for the service learning hours included inpatient hospice settings, nursing homes, hospital palliative care programs, bereavement education, and even a neonatal ICU (NICU). After spending time with the patients, families, and nurses, the students created projects to complete with patients or educational sessions to provide to patients and nurses. Two students paired up with a patient in an inpatient hospice unit to spend time with a patient recommended by a nurse. The students conducted a life review and, during their conversation with the patient, realized that the patient enjoyed scrapbooking activities. The students bought the materials for a scrapbook and, together with the patient, started to create a memory book that the patient had planned on leaving for her family. Unfortunately, the patient died before completing
Table 1. Course Objectives (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
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Utilize evidence-based clinical decision making using the nursing process, research, and technology to plan care for patients at the end of life. Examine personal feelings about death and dying and how these feelings impact care of patients at the end of life. Appraise the philosophy and principles of hospice and palliative care that can be integrated across healthcare settings. Apply assessment strategies specific to patients at the end of life. Identify pharmacological treatment strategies to address symptom management at the end of life. Develop therapeutic communication skills with the individual patient, family, population, faculty, peers, and healthcare team. Formulate a plan for the education of patients, families, or staff with end-of-life issues. Compare various cultural beliefs of patients regarding end-of-life care. Evaluate the role of spirituality assessment in end-of-life care. Analyze ethical and legal issues related to end-of-life nursing care.
Volume 39 & Number 6 & November/December 2014
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the scrapbook; however, the students presented it to the family and stated it was an experience they would never forget. Another group of students connected with a nurse who was the palliative care nurse coordinator at a local medical center. With the assistance of this nurse, the students developed an education session on bereavement for the nursing staff. Education also was provided by students to nurses and staff in another hospital with the palliative care team. Approximately 12 students dedicated their time in a dementia unit, situated within a nursing home, which provided hospice services. An in-service program developed by hospice taught students on how to use sensory activities such as music and crafts to assist with recalling memories and increase comfort. The students then spent time talking with patients and reviewing the patients’ assessment forms, which helped them find out what patients liked such as leisure activities, food, and music. The students in this setting were surprised that the patients were walking around and able to communicate, because it was their assumption that dying patients were nonverbal, unconscious, and bedbound. Therefore, this was an opportunity for students to learn that hospice care involves care of the dying patient up to 6 months in advance of the final hours. Lastly, 1 student had an opportunity to provide bereavement services to patients’ families in a NICU. This student’s project included making gowns by hand for babies who had died. The babies were photographed in the gowns, and the gowns were then placed in a memory box for the parents to take home. These handmade gowns were brought to class to demonstrate to the other students how her project was carried out. The student made approximately 6 gowns and donated them to the NICU.
Course Evaluation and Future Recommendations While no empirical data were collected, students who participated in this elective nursing course reported that they learned a great deal about end-of-life nursing care and felt more at ease with communicating with dying patients and their families. One student stated, ‘‘This course really made me more aware of how to treat and care for dying patients. It also made me realize that sometimes there is nothing more we can do, but give patients a dignified death.’’ Through the numerous course activities, students gained insight into process of planning care for a dying patient and their family. The authors believe that a major strength of the course was the service learning component. The students indicated that service learning was rewarding; however, they also would have liked a list of service learning sites from which to choose, rather than finding the site on their own. Therefore, connections with service learning partners in the community will be established in advance by the faculty members to assist students with identifying a location that interests them. In future courses, interdisciplinary guest speakers may be sought to illustrate their role in end-of-life care. Physicians, social workers, and chaplains would provide valuable insight into their positions within the team caring for a dying patient. Topics that could be addressed include pain management, bereavement support, hospice placement, and spirituality assessment. In addition, the authors are collaborating with a faculty member in social work who shares the same interest Nurse Educator
in end-of-life education. Sharing lecture time or having the 2 groups of students work together on a project is a consideration for the course in the future. Incorporating evidence-based teaching strategies and new student projects would be recommended. Life reviews could be combined with creating a scrapbook or other tangible product that the patient and family could keep once the course has ended.17 Role playing in the classroom and using the simulation laboratory to practice nursing skills related to care of the dying patient and family may also be valuable learning tools.24 Literature as a teaching strategy is also considered; students who read about patient or family experiences may gain a deeper understanding of the dying experience. Critical reflection on the reading may enhance perspective transformation.3,25
Implications for Nursing Education RNs believe they are inadequately prepared to handle the complex nature of end-of-life care in clinical practice. Education on end-of-life topics as well as practice in a clinical setting would provide the foundation for nurses’ ability to care for dying patients and their families in a competent and compassionate manner.26 McSteen and Peden-McAlpine27 suggested that a nurse’s role is to support dying patients during the end-of-life period. This includes educating the patients and families so that they can make informed decisions about the treatment they want to receive at the end of life. The nurse should facilitate communication about psychosocial and spiritual issues of the patients and their families. If the patient is unable to communicate or does not have family readily available, the nurse acts as a voice or advocate for the patient to the healthcare team. This can be done more effectively if the nurse caring for the dying patient has been educated on end-of-life issues and is comfortable discussing these issues with the healthcare team. Communication about end-of-life issues with patients, their families, and the healthcare team is a critical aspect of end-of-life nursing care, which allows students to obtain an assessment of psychosocial and spiritual issues of the dying patient. Listening to the patients’ fears, concerns, and feelings about grief and loss would facilitate student understanding of the patient’s point of view. Faculty should allow time in a clinical or service learning setting to be present with the student and dying patient. This would enable the faculty member to provide support to both the student and patient and to evaluate how the student is communicating with the patient.28 Finally, nursing care at the end of life should be addressed in every nursing specialty across the life span. Death can occur at the beginning of life as well as in the elderly population. This was witnessed by students in the class who participated in service learning in a NICU setting as well as in a long term care facility. Research has shown that students who have an experience such as the one in this course have less anxiety about caring for a dying patient and an increase in knowledge pertaining to communication, medications, and comfort and pain management at the end of life.9,29
Conclusion End-of-life nursing care is a growing field that requires education of future nurses; it is contingent on the adequate preparation of our professionals who are going to deliver this Volume 39 & Number 6 & November/December 2014
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care. This course was offered as an elective to senior nursing students to engage them in learning about caring for a dying patient both in the classroom and in hospice or hospital settings. Although it is not a clinical course, students were still able to connect with patients, families, and nursing staff, providing the students with a valuable lesson on the role of nurses in end-of-life care. Nursing faculty should realize the importance of assigning a dying patient to a nursing student so that future nurses will provide care to the dying with more knowledge and understanding and less fear and anxiety.
References 1. Barrere C, Durkin A. Finding the right words: the experience of new nurses after ELNEC education integration into a BSN curriculum. Medsurg Nurs. 2014;23(1):35-53. 2. Carman M. Bundling the death and dying learning experience for pre-licensure nursing students. Nurse Educ. 2014;39(3): 135-137. 3. Sakalys J. Literary pedagogy in nursing: a theory-based perspective. J Nurs Educ. 2002;41(9):386-392. 4. McCourt R, Power J, Glackin M. General nurses’ experiences of end-of-life care in the acute hospital setting: a literature review. Int J Palliat Nurs. 2013;19(10):510-516. 5. Todaro-Franceschi V. Critical care nurses’ perceptions of preparedness and ability to care for the dying and their professional quality of life. Dimens Crit Care Nurs. 2013;32(4):184-190. 6. Ferrell B. Topics in Advanced Practice Nursing Ejournal. 2008;7(2). Available at http://www.medscape.com/viewarticle/559790_print. Accessed October 1, 2008. 7. Kelly K, Thrane S, Virani R, Malloy P, Ferrell B. Expanding palliative care nursing education in California: the ELNEC geriatric project. Int J Palliat Nurs. 2011;17(4):188-194. 8. End-of-life nursing education consortium (ELNEC) fact sheet. American Association of Colleges of Nursing Web site. 2014. Available at http://www.aacn.nche.edu/ELNEC/factsheet.htm. Published 2014. Accessed June 30, 2014. 9. Barrere C, Durkin A, LaCoursiere S. The influence of end-of-life education on attitudes of nursing students. Int J Nurs Educ Scholarsh. 2008;5(1):1-18. 10. Dobbins E. The impact of end-of-life curriculum content on the attitudes of associate degree nursing students toward death and care of the dying. Teach Learn Nurs. 2011;6:159-166. 11. Wallace M, Grossman S, Campbell S, Robert T, Lange J, Shea J. Integration of end-of-life care content in undergraduate nursing curricula: student knowledge and perceptions. J Prof Nurs. 2009; 25(1):50-56. 12. DiBartolo M, Seldomridge L. Cinemeducation: teaching end-of-life issues using feature films. J Gerontol Nurs. 2009;35(8):30-36.
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13. Jansen B, Weckmann M, Nguyen C, Parsons C, Hughes C. A cross-national cross-sectional survey of the attitudes and perceived competence of final-year medicine, nursing and pharmacy students in relation to end-of-life care in dementia. Palliat Med. 2013; 27(9):847-854. 14. Fabro K, Schaffer M, Scharton J. The development, implementation, and evaluation of an end-of-life simulation experience for baccalaureate nursing students. Nurs Educ Perspect. 2014;35(1):19-25. 15. Smith-Stoner M. Using high-fidelity simulation to educate nursing students about end-of-life care. Nurs Educ Perspect. 2009;30(2): 115-120. 16. Twigg R, Lynn M. Teaching end-of-life care via a hybrid simulation approach. J Hosp Palliat Nurs. 2012;14(5):374-379. 17. Davis-Berman J. Creating a memory book: undergraduate student experiences with end-of-life interviews. Death Stud. 2014;38: 85-90. 18. Gidman J. Listening to stories: valuing knowledge from patient experience. Nurse Educ Pract. 2013;13:192-196. 19. Keall R, Butow P, Steinhauser K, Clayton J. Discussing life story, forgiveness, heritage, and legacy with patients with life-limiting illnesses. Int J Palliat Nurs. 2011;17(9):454-460. 20. Price J, Dornan J, Quail L. Seeing is believing—reducing misconceptions about children’s hospice care through effective teaching with undergraduate nursing students. Nurse Educ Pract. 2013;13(5):361-365. 21. Gillis A, MacLellan M. Service learning with vulnerable populations: review of the Literature. Int J Nurs Educ Scholarsh. 2010; 7(1):1-27. 22. Williams S, Bihan S. Application of an innovative, autonomous, creative teaching modality through service-learning in a communityhealth nursing course. J Nurs Educ Pract. 2013;3(5):116-127. 23. Murray B. Service learning in baccalaureate nursing education: a literature review. J Nurs Educ. 2013;52(11):621-626. 24. Baile W, Panfilis L, Tanzi S, Moroni M, Walters R, Biasco G. Using sociodrama and psychodrama to teach communication in end-of-life care. J Palliat Med. 2012;15(9):1006-1010. 25. Crawley J, Ditzel L, Walton S. Using children’s picture books for reflective learning in nurse education. Contemp Nurse. 2012; 42(1):45-52. 26. Hamilton C. The simulation imperative of end-of-life education. Clin Simulat Nurs. 2010;6(4):e131-e138. 27. McSteen K, Peden-McAlpine C. The role of nurse as advocate in ethically difficult care situations with dying patients. J Hosp Palliat Nurs. 2006;8(5):259-269. 28. Malloy P, Virani R, Kelly K, Mune´var C. Beyond bad news' communication skills of nurses in palliative care. J Hospice Palliat Nurs. 2010;12(3):166-174. 29. Jensen A, Curtis M. A descriptive qualitative study of student learning in a psychosocial nursing class infused with art, literature, music, and film. Int J Nurs Educ Scholarsh. 2008;5(1):1-9.
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Nurse Educator
Nursing Care at the End of Life A Service Learning Course for Undergraduate Nursing Students Stephanie Jeffers, PhD, RN & Dawn Ferry, MSN, RN, CHSE An elective course titled ‘‘Nursing Care at the End of Life’’ was designed for fourth-year nursing students in a baccalaureate nursing program. This course, taught by the authors, was designed to teach students about caring for the dying patient. Students were required to complete service learning with patients in a hospice or hospital setting. Students reported having a positive learning experience and gaining new knowledge and a deeper understanding of the needs of dying patients and their families. Keywords: death and dying; end of life; hospice; nursing education; service learning
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istorically, nursing education programs have inadequately prepared nurses for end-of-life care. This has been reported in research studies focusing on RNs as well as nursing students.1 Lack of end-of-life education appears to be related to an increase in death anxiety of students and nurses, as well as negative attitudes toward dying patients.2,3 This combination of inadequate knowledge and skill and poor attitudes of the nurse may adversely affect patient care at the end of life. An end-of-life nursing care course is an important first step in educating future nurses about endof-life care and issues related to death and dying and exposing them to hospice nursing care.
Review of Literature The literature review on RNs and nursing students reveals that there is a lack of knowledge and understanding about end-of-life concepts, which may lead to anxiety and negative attitudes toward caring for a dying patient. Both nurses and students have reported that they do not feel prepared to address the concerns of dying patients and their families.4 Efforts to improve education at the prelicensure level should occur to provide nurses with education and tools to care for this patient population in a meaningful and effective manner. The rapidly aging population combined with multiple comorbidities require nurses to have an added skill set and education on death and dying.5 Author Affiliations: Assistant Professor (Dr Jeffers), and Director (Ms Ferry), School of Nursing, Center for Simulation and Computerized Testing, Widener University, Chester, Pennsylvania. The authors declare no conflicts of interest. Correspondence: Dr Jeffers, School of Nursing, Widener University, One University Place, Chester, PA 19013 ([email protected]). Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.nurseeducatoronline.com). Accepted for publication: August 13, 2014 DOI: 10.1097/NNE.0000000000000088
Nurse Educator
In response to the need for education on end-of-life care for nurses, in 2001, Ferrell6,7 and the American Association of Colleges of Nursing developed the End-of-Life Nursing Education Consortium (ELNEC). This education model uses a ‘‘train-thetrainer’’ approach in teaching end-of-life content to nurses. The 22-day seminars are taught to nurses across the country as well as internationally to develop trainers who will then disseminate this information to other nurses at their hospitals or nursing schools. This program has been highly successful and provides seminars specific to such nursing specialties as geriatric, pediatric, and critical care.6,7 The American Association of Colleges of Nursing reported that 18 300 RNs and other healthcare providers such as social workers have received ELNEC training.8 Several studies have investigated ELNEC integration and outcomes within associate degree and baccalaureate nursing education programs. Using both quantitative and qualitative methods, researchers examined knowledge and attitudes of nursing students toward death and dying following a course on end-of-life care. The courses described included various topics based on the ELNEC curriculum including communication, pain management, spiritual care, bereavement, and cultural considerations. Findings from these studies illustrated that the students gained further knowledge of end-of-life topics, and attitudes toward the dying patient improved. The researchers also reported that students often had a transformative experience and appreciated having the opportunity to care for a dying patient in their nursing education program.9-11 In addition to research on ELNEC integration in nursing curricula, researchers published numerous studies on the use of various teaching strategies to educate nursing students about end-of-life care. Reflection in the form of writing or verbal communication following the use of film or literature in the classroom can promote affective learning by the student.12,13 Simulation on end-of-life scenarios has also been reported in the literature, with greater frequency in recent years. Providing students with a simulated dying patient has shown Volume 39 & Number 6 & November/December 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
307
to improve student knowledge of end-of-life issues and increase comfort level with dying patients.14-16 Outside the classroom, students may pair up with a patient in an acute care setting, hospice, or patient home to have more hands-on experience with a dying patient. Studies have shown that communicating directly with a dying patient, listening to their story, and encouraging a life review benefitted the patient as well as the student. In addition to improved knowledge on end-of-life care, students involved directly with dying patients reported a change in their view of dying patients, increased comfort level when communicating with dying patients, and an improved attitude toward dying patients and their families.17-20 The student-patient experiences reported in the literature were more of a clinical nature. There is a paucity of research on service learning activities in nursing programs that link students with hospices or other community groups, which serve patients and their families in the final hours or after the patient has died. Service learning is a mutual engagement between a student and community site; the student provides service to the community, and in return, the student learns valuable lessons about the population they serve. Reflection is a significant element of service learning; students are required to think about their feelings regarding their experiences at the community site. Reflection activities include written assignments and group discussion.21,22 Benefits of service learning include nursing role development, greater understanding of how team players interact, cultural diversity awareness, improved critical thinking, and increased compassion for those who are living through the dying process.23
Course on Nursing Care at the End of Life We provided a new nursing course, Nursing Care at the End of Life, as an elective for senior-level nursing students. The purpose of this elective was to impart new insight on the important role of nurses in caring for patients at the end of life. Students were able to choose this course among several other nursing electives, which covered different topics. A total of 25 students were enrolled in this 3-credit course, which met 2 days a week for a total of 3 hours weekly. The Table 1 lists the course objectives. Based on the ELNEC curriculum, topics chosen for class discussion included physical, psychosocial, and spiritual assessment of the dying patient; cultural and religious considerations;
therapeutic communication; and ethical and legal issues. The full list of class topics is found in Table, Supplemental Digital Content 1, http://links.lww.com/NE/A169. Rather than traditional lecture, students were engaged in thought-provoking discussions and completed in-class group activities, which allowed them to learn about end-of-life care. Additional methods of instruction for this class included assigned readings, films (‘‘How to Die in Oregon, HBO Documentary,’’ and ‘‘Evan Mayday’s Good Death’’), games, and debates. Written assignments for the class included a formal paper based on a topic of the student’s choice such as palliative care, terminal sedation, end of life in the media, and advance directives, to name a few. Supplementary assignments were related to service learning; students were required to write a prejournal about their expectations of service learning and 1 goal to achieve during the service learning. A postjournal was required once service learning hours were completed; students reflected on activities during the semester, whether expectations were met and knowledge gained from the experience and how the student contributed to quality end-of-life care. The final assignment was a PowerPoint slide presentation, which students presented to the class, describing their service learning site and experience. Students were evaluated in the course based on their written assignment of a research paper, 12 service learning hours completed, and their presentation to the class on their service learning project and experience. The students were responsible for identifying a service learning partner to complete their hours and develop a project for the nursing staff, patients, or families. Examples of sites used for the service learning hours included inpatient hospice settings, nursing homes, hospital palliative care programs, bereavement education, and even a neonatal ICU (NICU). After spending time with the patients, families, and nurses, the students created projects to complete with patients or educational sessions to provide to patients and nurses. Two students paired up with a patient in an inpatient hospice unit to spend time with a patient recommended by a nurse. The students conducted a life review and, during their conversation with the patient, realized that the patient enjoyed scrapbooking activities. The students bought the materials for a scrapbook and, together with the patient, started to create a memory book that the patient had planned on leaving for her family. Unfortunately, the patient died before completing
Table 1. Course Objectives (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
308
Utilize evidence-based clinical decision making using the nursing process, research, and technology to plan care for patients at the end of life. Examine personal feelings about death and dying and how these feelings impact care of patients at the end of life. Appraise the philosophy and principles of hospice and palliative care that can be integrated across healthcare settings. Apply assessment strategies specific to patients at the end of life. Identify pharmacological treatment strategies to address symptom management at the end of life. Develop therapeutic communication skills with the individual patient, family, population, faculty, peers, and healthcare team. Formulate a plan for the education of patients, families, or staff with end-of-life issues. Compare various cultural beliefs of patients regarding end-of-life care. Evaluate the role of spirituality assessment in end-of-life care. Analyze ethical and legal issues related to end-of-life nursing care.
Volume 39 & Number 6 & November/December 2014
Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the scrapbook; however, the students presented it to the family and stated it was an experience they would never forget. Another group of students connected with a nurse who was the palliative care nurse coordinator at a local medical center. With the assistance of this nurse, the students developed an education session on bereavement for the nursing staff. Education also was provided by students to nurses and staff in another hospital with the palliative care team. Approximately 12 students dedicated their time in a dementia unit, situated within a nursing home, which provided hospice services. An in-service program developed by hospice taught students on how to use sensory activities such as music and crafts to assist with recalling memories and increase comfort. The students then spent time talking with patients and reviewing the patients’ assessment forms, which helped them find out what patients liked such as leisure activities, food, and music. The students in this setting were surprised that the patients were walking around and able to communicate, because it was their assumption that dying patients were nonverbal, unconscious, and bedbound. Therefore, this was an opportunity for students to learn that hospice care involves care of the dying patient up to 6 months in advance of the final hours. Lastly, 1 student had an opportunity to provide bereavement services to patients’ families in a NICU. This student’s project included making gowns by hand for babies who had died. The babies were photographed in the gowns, and the gowns were then placed in a memory box for the parents to take home. These handmade gowns were brought to class to demonstrate to the other students how her project was carried out. The student made approximately 6 gowns and donated them to the NICU.
Course Evaluation and Future Recommendations While no empirical data were collected, students who participated in this elective nursing course reported that they learned a great deal about end-of-life nursing care and felt more at ease with communicating with dying patients and their families. One student stated, ‘‘This course really made me more aware of how to treat and care for dying patients. It also made me realize that sometimes there is nothing more we can do, but give patients a dignified death.’’ Through the numerous course activities, students gained insight into process of planning care for a dying patient and their family. The authors believe that a major strength of the course was the service learning component. The students indicated that service learning was rewarding; however, they also would have liked a list of service learning sites from which to choose, rather than finding the site on their own. Therefore, connections with service learning partners in the community will be established in advance by the faculty members to assist students with identifying a location that interests them. In future courses, interdisciplinary guest speakers may be sought to illustrate their role in end-of-life care. Physicians, social workers, and chaplains would provide valuable insight into their positions within the team caring for a dying patient. Topics that could be addressed include pain management, bereavement support, hospice placement, and spirituality assessment. In addition, the authors are collaborating with a faculty member in social work who shares the same interest Nurse Educator
in end-of-life education. Sharing lecture time or having the 2 groups of students work together on a project is a consideration for the course in the future. Incorporating evidence-based teaching strategies and new student projects would be recommended. Life reviews could be combined with creating a scrapbook or other tangible product that the patient and family could keep once the course has ended.17 Role playing in the classroom and using the simulation laboratory to practice nursing skills related to care of the dying patient and family may also be valuable learning tools.24 Literature as a teaching strategy is also considered; students who read about patient or family experiences may gain a deeper understanding of the dying experience. Critical reflection on the reading may enhance perspective transformation.3,25
Implications for Nursing Education RNs believe they are inadequately prepared to handle the complex nature of end-of-life care in clinical practice. Education on end-of-life topics as well as practice in a clinical setting would provide the foundation for nurses’ ability to care for dying patients and their families in a competent and compassionate manner.26 McSteen and Peden-McAlpine27 suggested that a nurse’s role is to support dying patients during the end-of-life period. This includes educating the patients and families so that they can make informed decisions about the treatment they want to receive at the end of life. The nurse should facilitate communication about psychosocial and spiritual issues of the patients and their families. If the patient is unable to communicate or does not have family readily available, the nurse acts as a voice or advocate for the patient to the healthcare team. This can be done more effectively if the nurse caring for the dying patient has been educated on end-of-life issues and is comfortable discussing these issues with the healthcare team. Communication about end-of-life issues with patients, their families, and the healthcare team is a critical aspect of end-of-life nursing care, which allows students to obtain an assessment of psychosocial and spiritual issues of the dying patient. Listening to the patients’ fears, concerns, and feelings about grief and loss would facilitate student understanding of the patient’s point of view. Faculty should allow time in a clinical or service learning setting to be present with the student and dying patient. This would enable the faculty member to provide support to both the student and patient and to evaluate how the student is communicating with the patient.28 Finally, nursing care at the end of life should be addressed in every nursing specialty across the life span. Death can occur at the beginning of life as well as in the elderly population. This was witnessed by students in the class who participated in service learning in a NICU setting as well as in a long term care facility. Research has shown that students who have an experience such as the one in this course have less anxiety about caring for a dying patient and an increase in knowledge pertaining to communication, medications, and comfort and pain management at the end of life.9,29
Conclusion End-of-life nursing care is a growing field that requires education of future nurses; it is contingent on the adequate preparation of our professionals who are going to deliver this Volume 39 & Number 6 & November/December 2014
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care. This course was offered as an elective to senior nursing students to engage them in learning about caring for a dying patient both in the classroom and in hospice or hospital settings. Although it is not a clinical course, students were still able to connect with patients, families, and nursing staff, providing the students with a valuable lesson on the role of nurses in end-of-life care. Nursing faculty should realize the importance of assigning a dying patient to a nursing student so that future nurses will provide care to the dying with more knowledge and understanding and less fear and anxiety.
References 1. Barrere C, Durkin A. Finding the right words: the experience of new nurses after ELNEC education integration into a BSN curriculum. Medsurg Nurs. 2014;23(1):35-53. 2. Carman M. Bundling the death and dying learning experience for pre-licensure nursing students. Nurse Educ. 2014;39(3): 135-137. 3. Sakalys J. Literary pedagogy in nursing: a theory-based perspective. J Nurs Educ. 2002;41(9):386-392. 4. McCourt R, Power J, Glackin M. General nurses’ experiences of end-of-life care in the acute hospital setting: a literature review. Int J Palliat Nurs. 2013;19(10):510-516. 5. Todaro-Franceschi V. Critical care nurses’ perceptions of preparedness and ability to care for the dying and their professional quality of life. Dimens Crit Care Nurs. 2013;32(4):184-190. 6. Ferrell B. Topics in Advanced Practice Nursing Ejournal. 2008;7(2). Available at http://www.medscape.com/viewarticle/559790_print. Accessed October 1, 2008. 7. Kelly K, Thrane S, Virani R, Malloy P, Ferrell B. Expanding palliative care nursing education in California: the ELNEC geriatric project. Int J Palliat Nurs. 2011;17(4):188-194. 8. End-of-life nursing education consortium (ELNEC) fact sheet. American Association of Colleges of Nursing Web site. 2014. Available at http://www.aacn.nche.edu/ELNEC/factsheet.htm. Published 2014. Accessed June 30, 2014. 9. Barrere C, Durkin A, LaCoursiere S. The influence of end-of-life education on attitudes of nursing students. Int J Nurs Educ Scholarsh. 2008;5(1):1-18. 10. Dobbins E. The impact of end-of-life curriculum content on the attitudes of associate degree nursing students toward death and care of the dying. Teach Learn Nurs. 2011;6:159-166. 11. Wallace M, Grossman S, Campbell S, Robert T, Lange J, Shea J. Integration of end-of-life care content in undergraduate nursing curricula: student knowledge and perceptions. J Prof Nurs. 2009; 25(1):50-56. 12. DiBartolo M, Seldomridge L. Cinemeducation: teaching end-of-life issues using feature films. J Gerontol Nurs. 2009;35(8):30-36.
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13. Jansen B, Weckmann M, Nguyen C, Parsons C, Hughes C. A cross-national cross-sectional survey of the attitudes and perceived competence of final-year medicine, nursing and pharmacy students in relation to end-of-life care in dementia. Palliat Med. 2013; 27(9):847-854. 14. Fabro K, Schaffer M, Scharton J. The development, implementation, and evaluation of an end-of-life simulation experience for baccalaureate nursing students. Nurs Educ Perspect. 2014;35(1):19-25. 15. Smith-Stoner M. Using high-fidelity simulation to educate nursing students about end-of-life care. Nurs Educ Perspect. 2009;30(2): 115-120. 16. Twigg R, Lynn M. Teaching end-of-life care via a hybrid simulation approach. J Hosp Palliat Nurs. 2012;14(5):374-379. 17. Davis-Berman J. Creating a memory book: undergraduate student experiences with end-of-life interviews. Death Stud. 2014;38: 85-90. 18. Gidman J. Listening to stories: valuing knowledge from patient experience. Nurse Educ Pract. 2013;13:192-196. 19. Keall R, Butow P, Steinhauser K, Clayton J. Discussing life story, forgiveness, heritage, and legacy with patients with life-limiting illnesses. Int J Palliat Nurs. 2011;17(9):454-460. 20. Price J, Dornan J, Quail L. Seeing is believing—reducing misconceptions about children’s hospice care through effective teaching with undergraduate nursing students. Nurse Educ Pract. 2013;13(5):361-365. 21. Gillis A, MacLellan M. Service learning with vulnerable populations: review of the Literature. Int J Nurs Educ Scholarsh. 2010; 7(1):1-27. 22. Williams S, Bihan S. Application of an innovative, autonomous, creative teaching modality through service-learning in a communityhealth nursing course. J Nurs Educ Pract. 2013;3(5):116-127. 23. Murray B. Service learning in baccalaureate nursing education: a literature review. J Nurs Educ. 2013;52(11):621-626. 24. Baile W, Panfilis L, Tanzi S, Moroni M, Walters R, Biasco G. Using sociodrama and psychodrama to teach communication in end-of-life care. J Palliat Med. 2012;15(9):1006-1010. 25. Crawley J, Ditzel L, Walton S. Using children’s picture books for reflective learning in nurse education. Contemp Nurse. 2012; 42(1):45-52. 26. Hamilton C. The simulation imperative of end-of-life education. Clin Simulat Nurs. 2010;6(4):e131-e138. 27. McSteen K, Peden-McAlpine C. The role of nurse as advocate in ethically difficult care situations with dying patients. J Hosp Palliat Nurs. 2006;8(5):259-269. 28. Malloy P, Virani R, Kelly K, Mune´var C. Beyond bad news' communication skills of nurses in palliative care. J Hospice Palliat Nurs. 2010;12(3):166-174. 29. Jensen A, Curtis M. A descriptive qualitative study of student learning in a psychosocial nursing class infused with art, literature, music, and film. Int J Nurs Educ Scholarsh. 2008;5(1):1-9.
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