Effects of end-of-life education on baccalaureate nursing students

AORN Journal, Sept, 2005 by Gelene T. Thompson

In 2003, the Last Acts Campaign, a large coalition working for better end-of-life care, released the results of a survey in which respondents rated every state in the United States as mediocre or worse in the care of people who are dying. (1) Nearly half the respondents rated health care providers' ability to provide emotional support for patients who are near death and the patients' family members as fair or poor. (1) These results point to the need to improve education for health care professionals about death and dying. Most nurses must deal with death and dying at some time during their careers; however, many schools of nursing do not require end-of-life issues as a separate subject in the curriculum. This article explores the experiences of a group of practicing nurses working toward a baccalaureate degree who completed an elective course on end-of-life issues.

LITERATURE REVIEW

Little specific information is available regarding the effects of education about death and dying on undergraduate nursing students. A Canadian study found that students who had personal experiences with death benefited more from didactic training than experiential learning; experiential programs involving discussion and role play tended to revive old feelings of sadness related to their personal experiences. Students who did not have personal experiences with death benefited more from experiential training in end-of-life nursing care. (2) The authors also cited an older study, which found that a specific course on the subject is more effective than integrating end-of-life content into other courses. (2)

A study from Scotland discussed themes identified by six student nurses who experienced the sudden death of a patient. The themes included

* dying with dignity,

* the suddenness of deterioration and death,

* the vulnerability of caring,

* guilt, and

* lack of support from staff members.

Most of these students were not supported with debriefing, and one student explained, "The next day no one mentioned it. There was nothing." (3(p7))

A more recent qualitative study noted that before taking an elective course on death and dying, senior baccalaureate students said that "leaving the family and patient alone to provide privacy" (4(p887)) was the only appropriate option with which they were comfortable. After taking the course, the students all believed that the nurse should remain with and be available to the patient and the patient's family members. Students in this study expressed six important aspects of dealing with patients who are dying, including

* being present at the time of death,

* helping the patient and family members cope,

* learning new ways to think about dying,

* overcoming old fears about dying,

* achieving self-growth, and

* understanding the role of the chaplain.

The chaplain who participated in this course said,

   ... nurses are privileged to have the
   unique and special opportunity to be
   present at the most remembered events
   during one's life--both birth and
   death. How you handle these situations
   ... will always be remembered. (4(p890))

Author John Rowe, RN, PhD, described how nursing students are taught empathy but learn little about their personal responses and their own suffering. (5) He described the three phases that health care providers typically experience in response to these situations as

* being silent and isolated;

* talking about how they are suffering; and

* finally finding ways to change the systems with solidarity in political action and by researching best practices.

He concluded that although suffering is painful, there is much to be learned from the process. He recommended that students receive specific training in how to cope with the emotional aspects of nursing, and he emphasized that clinical faculty members should be especially alert for opportunities to help students work through their responses to situations in which a patient is dying.

Another group of authors recommended that medical students also should gain experience in end-of-life care. They suggested that medical students spend time with a dying patient in their first clinical year to learn to care more effectively. (6)

The End-of-Life Nursing Education Consortium (ELNEC) has established train-the-trainer educational programs and materials to help nursing faculty members teach care of the dying patient. (7) Faculty members can offer the course as an elective, offer a separate certificate course for RNs, or integrate the material into other courses throughout the curriculum. (7) The three-day instructor-training program includes modules on

* nursing care,

* pain management,

* symptom management,

* ethical and legal issues,

* cultural considerations,

* communication,

* grief and loss,

* preparation for and care at the time of death, and

* achieving quality care at the end of life. (8)

Classroom teaching strategies include videotaped role playing, exercises in active listening and goal-directed conversation, and film clips with handout questions. All the training modules include case studies and questions for discussion.