Introduction
Background of the Gap in Nursing Education
The complex care needs of patients with terminal conditions can be a significant stressor in any clinical setting. The purpose of end-of-life (EOL) care is to manage the impact of the illness through effective symptom management, emotional support, and sensitivity to cultural beliefs and practices (Institute of Medicines (IOM), 2015).
Unfortunately, many student nurses are not well prepared for EOL care as they enter practice. The IOM (2015) article on the status of EOL education indicated that palliate medicine is not addressed adequately by discipline-specific curricula. Hence, an educational gap exists that needs to be tackled to improve their preservice knowledge base, emotional balance, communication skills, and attitudes towards EOL care.
Key contributors to gaps in hospice/palliative care are the lack of specialized education and fear that makes providers feel ill-prepared for EOL practice. At the Methodist hospital where I work, student nurses are hesitant to step up in caring for a dying patient. This problem began due to insufficient effort by educators, clinicians, and researchers to offer learners preservice direction and exposure to EOL care.
For the last four months, I have noticed that many of the student nurses at my facility lack clinical and communication skills that are required at the end of patient’s life. In particular, initiating discussions about the goals of care after the assessment, communicating the different treatment options, and addressing the physical, emotional, and spiritual, concerns of individuals are a challenges. According to Jill, a faculty member at Hennepin Technical College (HTC), clinical sites for palliative care are not available.
Securing a clinical site where nursing students can learn, observe, or participate in care is difficult; privacy is one reason that most patients and families request as they go through the dying process, and having students and nurses increases their anxiety. A second condition contributing to this problem is the lack of time. The curriculum does not address this topic in general compared to other courses like maternal health or adult health; so, students end up graduating without any knowledge or skills.
Lack of mentors for student nurses has become a factor, as there are not many EOL proficient nurses that are available to take the role. These trends reinforce the need for professional EOL care training of nursing students to address this educational gap and enhance the quality of hospice care (A. Jill, personal communication, July 08, 2019).
The Problem Statement in Nursing Education
The complexity of EOL care can take a heavy toll on unprepared nurses who are expected to be effective advocates of quality EOL service through direct inpatient care or referral. However, inadequate educational preparation, professional mentorship, and exposure to hospice practicum experiences have contributed to gaps in EOL care(Jackson & Motley, 2014). This issue is broad in scope, affecting the nurses’ decision-making and creating negative attitudes toward actual EOL practice. Specifically, symptom management, communication, and cultural sensitivity, which are critical competencies expected of nursing professionals, are lacking in new nurses.
Palliative/hospice nursing as a specialty practice is not a core focus of curricular development and standardization by most academic institutions. Further, opportunities and time for practical experience with a dying patient are lacking (Jackson & Motley, 2014). As a result, student nurses have entered practice without adequate professional training in this area, which is evidenced by moral distress when caring for terminally ill patients.
Another factor that could account for the gap in EOL practice skills among nursing students is inadequate communication practices to ensure shared decision-making and emotional balance. According to Jackson and Motley (2014), a nurse’s presence, active listening, and support are critical in advanced care planning. Part of nursing care involves taking care of the dying or those in critical care, and therefore, having the opportunity to see dying patients in any setting is imperative in preparation for practice. Access to EOL care for most people with terminal conditions is limited, despite 75% of US hospitals offering hospice programs (Jackson & Motley, 2014).
The growing demand for these services is an impetus for the adequate educational preparation of nurses to care for EOL patients and their families. Experiential training will ensure productive EOL conversations and manage patient/family anxiety that is often associated with dying.
Description of Course
The proposed EOL training program is designed to enhance the educational preparation of the nursing staff providing end-of-life care. It is expected that nursing students with no prior EOL training or experience will acquire practical skills in hospice care. The course, which is modeled around the End-of-Life Nursing Education Consortium (ELNEC) competency goals, will be delivered by nurse faculty and guest speakers at the facility’s nursing school through lectures and PowerPoint presentations.
The specific modules that will be covered include EOL nursing, communication, cultural/spiritual aspects, stages of the grieving process, ethical concerns, and preparing patients/families for imminent death (Jackson & Motley, 2014). Lectures will encompass a brief description of the philosophical foundations of palliative care and psychosocial aspects of EOL care. The course will also include experiential content; learning will involve interactive simulations and case studies. Students will also complete reflective journal activities, return demonstration, role play, and give presentations of their EOL experiences in class.
Furthermore, each learner will be assigned a hospice patient to care for as a part of his or her clinical experience. He or she will be required to spend 10 hours with the patient/family spread over the entire semester. The time spent per visit will depend on the patient’s state and integrated care needs. Learners will be allowed to make home and hospice center calls. They will then share their emotional experiences with EOL care and reflections weekly in class. Additionally, students will discuss how they addressed the psychosocial and spiritual needs of patients and families during each session.
The orientation of the learners to hospice experiences will be critical to achieving the learning outcomes of the EOL course. A case manager at our facility will orient them to the institution’s policies and their scope of practice, which will not include activities of daily living. He/she will also assign patients and arrange patient visits to allow students to apply classroom EOL knowledge in practice.
The proposed intervention (EOL course) will address the gap in end-of-life nursing care skills and competency. Through the clinical practicum, learners will spend time with individuals facing imminent death and develop their affective and emotional domains. In two-hour visits, they will learn to converse and empathize with terminally ill patients and their families. The goal is to develop competencies in therapeutic communication with people from different backgrounds, initiating discussions on spiritual matters, and navigating EOL care decisions to improve physical and psychosocial care in hospice settings. Thus, the educational intervention has the potential to address current gaps in EOL nursing skills and communication.
Among the anticipated learning outcomes is that nursing students will acquire fundamental EOL care knowledge and practice skills such as effective communication with terminally ill patients, self-care, and advocacy. The participants’ attitudes towards death are expected to improve after interventions. As a result, they will be prepared to meet the complex needs of patients /families and improve their outcomes.
An intended outcome of this project is that students will become smarter and be able to use their critical thinking abilities to provide compassionate care. Additionally, through the course, students will demonstrate effective communication with patients, family, and the healthcare team. Most nursing students face a challenge initiating a conversation on palliative care because of limited education, practical experience with EOL, and self-confidence (IOM, 2015). Supportive communication is an essential skill; therefore, the student’s capacity to discuss EOL issues comfortably with the patient or family will be enhanced due to the experiential opportunities provided. They will be able to guide the dying to make informed decisions, offer emotional and spiritual support, and provide quality EOL care.
Students’ attitudes towards dying are also anticipated to improve after the didactic EOL education. They will develop less anxiety caring for EOL individuals. Another intended outcome is that students will provide patient-centered care. They will be able to listen to patients and treat them with dignity and respect. Students will also learn to maintain emotional balance while providing compassionate care. It is anticipated that the experiences gained in hospice care environments will change their view of death and dying. They will also demonstrate more self-assuredness and confidence in providing holistic, palliative care.
The core learning objectives are: first, students will demonstrate effective communication with patients, family, and healthcare team, second, they will be able to perform a physical assessment and recognize signs of pain and discomfort, and third, they will demonstrate proficiency in patient-centered care. Learners will demonstrate better affective qualities when caring for a terminally ill patient. Key outcomes include improved readiness and confidence to provide EOL care and effective coping strategies by the learners. The implementation plan includes reading materials and resources on palliative care, the clinical orientation of nursing students to EOL situations, patient visit schedules, and the timetable for the classes as well as evaluation criteria.
The EOL course will be offered in four weeks, two hours weekly. The experiential component (spending time with an assigned patient) will take a cumulative period of 10 hours. The students’ EOL knowledge and affective skills will be evaluated at the end of the course.
Rationale
Despite a growing demand for EOL care, there exists a large practice gap in this area. The nursing role includes caring for patients with terminal conditions. However, most nurses lack the skills and knowledge to provide optimal palliative care to patients/families. Besides, negative attitudes, anxiety, and fear contribute to a gap in EOL practice, which will be addressed by the proposed EOL course. A study involving students established that most pre-service nurses feel “unprepared and anxious” when caring for a patient who is dying (Ek et al., 2014, p. 513).
The research also found that a majority of new RNs (less than 5 years experience) also lack self-confidence, emotional balance, and knowledge to provide optimal care to dying individuals. Fewer nursing schools have included palliative care in their curricula, and textbook content on EOL practice is limited (Ek et al., 2014). Thus, the palliative care course is recommended to specifically address knowledge gaps and attitudes to prepare student nurses for EOL care better.
Review of the Literature
Ten Credible Sources
A comprehensive literature search was done in two databases – PubMed and Google Scholar – to obtain relevant and quality studies to be included in this review. The key terms used were end-of-life care education, hospice care knowledge and attitudes, critical care preceptorship, and palliative care misperceptions. Recent researches (published within the last five years) were chosen and filtered to obtain those examining EOL skills gaps in new nurses or those in training. The articles selected centered on end-of-life educational preparedness of student nurses, and EOL training, and were written in English. Ten publications meeting these criteria were selected for the literature review synthesis below and cited in the final reference list.
Literature Review Synthesis
EOL Knowledge Gaps
Nursing students often experience discomfort and anxiety, which impairs critical thinking skills when caring for a terminally ill patient. The fear of the unknown stems from inadequate educational preparation that leads to poor emotional responses to EOL needs (Ek et al., 2014). Knowledge and experience with hospice patients can modulate these emotions, resulting in better quality care. Didactic and experiential learning can improve self-confidence and allow nursing students to recognize and address fundamental EOL needs (Ek et al., 2014).
Thus, knowledge and experience can decrease anxiety about death and dying, promoting critical thinking, self-efficacy, and overall learning. Further, EOL care competencies, such as effective communication and self-awareness of attitudes and beliefs about dying, can be acquired through relevant didactic content.
EOL care education decreases the anxieties that learners face when caring for terminally ill patients and their families. As a result, their transition into practice and preparedness for a palliative role are enhanced. According to Hussein, Everett, Ramjan, Hu, and Salamonson (2017), up to 60% of graduate nurses entering critical care nursing change careers within the first year due to insufficient preparation, high-acuity patients, and understaffing.
Thus, EOL courses that involve a clinical component offered in hospice settings can enhance student preparedness for practice. Practicum experiences are associated with increased nursing students’ self-confidence and communication efficacy, team spirit, task completion, critical thinking, and ability to recognize changes in patient health (Hussein et al., 2017). However, these skills can only be realized if the student learns to develop an emotional balance when caring for EOL patients.
EOL Clinical Experiences
Spending time with the terminally ill individual, which is the suggested practicum component of the project – has also been shown to be effective. Hagelin et al. (2016) found that being with a patient facing imminent death improves students’ skills and perception of dying. Similar outcomes can be obtained through role-play, journal reflections, and case studies. These real or simulated experiences support affective learning; they promote emotional balance and self-awareness on how to handle EOL scenarios in practice (Hagelin et al., 2016).
Being with the patient can lead to improved self-confidence. It provides students with opportunities to reevaluate and adjust their thoughts, feelings, and interactions for optimal psychosocial care. Thus, visiting and spending time with the patient is supported by literature as a valid EOL educational intervention.
Providing end-of-life care skills can enable nursing students to better cope with emotions. According to Lai, Wong, and Ching (2018), nurses can discover emotional aspects related to EOL by spending time with a terminally ill patient allows. They can learn about the psychosocial needs of the individual and in the process, acquire affective skills necessary to care for a dying person. They can identify and relate to the experiences of an EOL patient at a personal level (Ranse, Ranse, &Pelkowitz, 2018). The secondary psychological outcomes may include improved satisfaction levels and professional development in EOL care.
Effective Teaching Strategy and Content
The project proposes to use didactic and experiential training interventions to build EOL knowledge and affective domains in nurses in training. Studies on end-of-life care education examine different teaching strategies to deliver content. Lippe and Carter (2015) found that the topics commonly taught in educational interventions are the fundamentals of hospice care, pain and symptom management, communication, the grieving process, and final rites of the dead.
The most used teaching method was the in-class activities that involved lectures. The study also found that entire courses on EOL care contribute to higher learning outcomes, such as improvements in “attitude, knowledge, self-efficacy, and awareness or appreciation of end-of-life practice” (Lippe& Carter, 2015, p. 35). Thus, dedicated programs delivered through didactic methods are useful in preparing pre-licensure nurses before taking up professional roles in EOL.
Clinical experiences and simulation-based learning have also been shown to complement in-class activities in building essential skills. Effective preceptor partnerships assist students to benefit from experiential learning, becoming humanistic clinicians. According to Wittenberg, Ragan, Ferrell, and Virani (2016), narrative medicine trains nurses to listen to lived experiences, connect with the patient at a personal level, and learn to appreciate those stories.
It is consistent with the principles of reflective practice, which can lead to ethical/cultural sensitivity, improved communication skills, and patient-centered care. Nurses are encouraged to write journals about their EOL experiences (Wittenberg et al., 2016). This reflective journaling approach can help address moral distress and build the requisite emotional resilience to care for dying patients and their families. Similar outcomes can be realized through simulation-based learning experiences (SBLEs). Smith et al. (2018) found that high-fidelity simulations can increase student nurses’ communication skills. SBLEs mimic real-life scenarios or patients, conditioning learners to EOL practice.
Effective Preceptorship Models
A smooth orientation of students in training to the EOL care environment is critical. It requires partnerships between learners, clinical nurses, and the faculty to ensure instruction in hospice settings is congruent with in-class training (Siela, Twibell, Mahmoodi, &Mahboubi, 2015). Different supervision models exist with varying levels of efficacy. The traditional approach in which the teaching staff supervises a student, while the clinician provides guidance has been found to be ineffective due to high faculty workloads and time constraints (Siela et al., 2015). A more feasible model is having the preceptor supervise the learner.
The preceptor has the role of providing practical teaching to the student while performing his or her duties. A smooth preceptorship in EOL can help nurses in training to build a strong knowledge base, develop critical thinking competencies, and learn to communicate effectively to meet practicum goals (Payne, Heye, & Farrell, 2014). Those with fewer skills or experiencing emotional distress will benefit from extra guidance and support.
Best Practices
In order to give optimal care to terminally ill patients, nurses in training require adequate EOL education to prepare them for practice. An educational intervention provides them with the knowledge to manage pain and symptoms, learn to communicate effectively, engage in care planning, and develop the requisite emotional resilience when working in hospice settings (Ek et al., 2014; Lai et al., 2018). Further, education has a positive impact on personal values, attitudes, critical thinking, and reflective practice, changing how nurses view and respond to EOL matters.
An effective educational intervention must combine didactic and experiential learning for the best outcomes. Practicum experiences where a student nurse is tasked with caring for a dying patient constitute a best practice for reinforcing self-efficacy, communication, critical thinking skills, and emotional balance (Hagelin et al., 2016; Hussein et al., 2017). Spending time in hospice care settings helps learners become effective clinicians.
They learn to listen to patient’s experiences, connect with him or her at an individual level, develop cultural sensitivity, and be supportive to the family. The students’ affective and clinical skills in EOL care can also be improved through simulation-based learning combined with reflective journaling (Smith et al., 2018; Wittenberg et al., 2016). A best practice in this area is using high-fidelity simulations that mimic real-world scenarios to help nurses acquire skills in EOL care in a safe environment.
Experiential learning must be supplemented with didactic methods or lectures for optimal outcomes. Core topics that should be included in an EOL course include principles of hospice care, pain and symptom management, communication, grief, and rituals for the dead (Lippe& Carter, 2015). Clinical instruction and guidance must be congruent with in-class activities. A best practice in preceptorship is having the clinician supervise a learner in EOL settings (Siela et al., 2015). In this way, student nurses will have ample time to apply classroom knowledge in practice and develop critical thinking and communication skills.
Recommendation
The proposed EOL curriculum will be offered through a didactic approach and practicum experiences to address the knowledge gap in the educational preparation of student nurses. The content for in-class activities will include fundamentals of hospice care, pain/symptom management strategies, communication, and the grieving process. Lectures, interactive role-plays, SBLEs, and case studies will be used in classroom instruction for four weeks, two hours weekly.
Students will be provided with learning materials and resources for this course. The learners will be evaluated at the end of the module to assess their EOL knowledge. The evaluation criteria will be based on a validated tool – self-assessment of clinical competency and concerns in end-of-life care.
The practicum experience will involve students spending a cumulative time of 10 hours in EOL settings. Each individual will be assigned a dying patient and will be required to visit and care for him or her for two hours weekly for five weeks. If a student’s patient dies before this period is over, he or she will be given another one. In each session, a student’s roles will include pain and symptom management, listening to the client’s lived experiences, and supporting the family in EOL decisions. Assessment of the practicum will entail monitoring provider activities and evaluation of reflective journals.
References
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Hagelin, C. L., Melin-Johansson, C., Henoch, I., Bergh, I., Ek, K., Hammarlund, K., …Browall, M. (2016). Factors influencing attitude toward care of dying patients in first-year nursing students. International Journal of Palliative Nursing, 22(1), 28-36. Web.
Hussein, R., Everett, B., Ramjan, L. M., Hu, W., &Salamonson, Y. (2017). New graduate nurses’ experiences in a clinical specialty: A follow up study of newcomer perceptions of transitional support. BMC Nursing, 16(42), 1-9. Web.
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