The complex care needs of patients with terminal conditions can be a significant stressor in hospice settings. 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 nurses are not well prepared for EOL care. 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 knowledge base, emotional balance, communication skills, and attitudes towards EOL care.
End-of-life care is emerging as a significant public health issue. At the Methodist hospital, MN, nurses are not well prepared to care for dying patients. When working with new nurses in the oncology unit, I have noticed that many of them lack clinical and communication skills that are required at the end of patient life. They are unable to keep up with family and patient demands. In particular, initiating discussions about the goals of care after the assessment, communicating the different treatment options, and addressing physical, emotional, and spiritual concerns of individuals are a challenge to new nurses. 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.
Explanation of Causes
Nurses can 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). Proficiency in pain relief, communication, and cultural sensitivity are key practice competencies in this area. Palliative/hospice nursing as a specialty practice is not a core focus of curricular development and standardization by academic institutions. Further, opportunities and time for practical experience with a dying patient are lacking (Jackson & Motley, 2014). As a result, new nurses at the oncology unit often indicate 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. Experiential training will ensure productive EOL conversations and manage patient/family anxiety that is often associated with dying.
Identification of Target Audience
This proposed solution (EOL training) is designed to enhance the educational preparation of the nursing staff providing end-of-life care. The target audience will include Associate Degree in Nursing (ADN) students at Rasmussen College, Blaine Campus. This target audience was addressed because future nursing practitioners must be well-prepared to manage inter-professional teams caring for terminally-ill patients. As more Americans continue to seek EOL services, achieving core palliative care competencies included in the nursing curriculum – communication, self-care, and advocacy – will enhance the capacity of nurses to offer quality, compassionate EOL care.
Characteristics of Target Audience
ADN students in their second year that are expected to take a fundamental course in palliative or EOL care will be the target population. They will include those who have not enrolled in hospice care courses or completed practicum experience involving a dying patient. The setting will be Rasmussen College, Blaine Campus. The target audience will receive integrated EOL education that includes a clinical experience component to enhance their knowledge and skills in this area.
Providing classroom and experiential EOL training will enhance nursing students’ competency in palliative care. Through exposure to terminally-ill patients or simulations, the learners with no previous experience in death will focus on improving their affective skills and become more effective in comforting them and their families. Role-plays and simulators mimicking a clinical setting will provide a safe environment to build skills and develop critical thinking. As a result, they will be able to recognize and address the psychosocial needs of individuals under hospice care. Further, the nursing students will assume their responsibility as advocates and comforters of patients at EOL (Jackson & Motley, 2014).
Thus, they will learn to execute these roles and initiate critical EOL conversations with the family about EOL decisions. They will become skillful and compassionate communicators and sensitive to the patient’s spiritual or cultural concerns. The educational intervention will allow participants to offer quality EOL care while strengthening their competence in practice.
Nursing students with no prior EOL training or experience will acquire skills in hospice care. The palliative course will be taught for four weeks, two hours weekly. The school’s nurse educators and guest speakers will deliver the educational content modeled around the ELNEC competency goals. 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). The proposed solution will also include experiential content; learning will involve interactive simulations and case studies. Students will also complete reflective journal activities and give presentations of their EOL experiences in class.
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 health 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 the session.
The orientation of the learners to hospice experiences will be critical to achieving the learning outcomes of the EOL course. A case manager in a palliative care 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 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 psychosocial care in hospice settings. Thus, the educational intervention has the potential to address current gaps in EOL nursing skills and communication.
It is anticipated that the EOL educational project will enhance the nursing student’s fundamental EOL care knowledge and practice skills in line with course competencies, which include communication, self-care, and advocacy. The participants’ attitudes towards death are expected to improve after the intervention. As a result, they will be well prepared to meet the complex needs of patients and families grappling with degenerative illnesses at home or assisted living facilities. As the IOM (2015) report indicates, the provision of adequate EOL education via discipline-specific curricula can lower the pain and distress of critically ill individuals in non-hospice environments. An intended outcome of this project is enhanced EOL knowledge and experience of future nurses in integrated palliative care.
Another expected result from the educational intervention is improved communication about end-of-life concerns. Most nursing students and nurses face a challenge initiating conversations 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. The two hours spent weekly with a dying patient will enable students to empathize, listen, and recognize the supportive validity of effective communication. It is expected that these skills will, in practice, improve psychosocial care received by terminally ill patients and their families.
Students’ attitudes towards dying are also anticipated to improve after the didactic EOL education. They will develop less discomfort caring for EOL individuals. Another outcome is improved practice due to better affective skills acquired through the experiential component of the project. Nursing students will learn to maintain emotional balance while providing compassionate care. It is anticipated that the experiences gained at 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.
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 OEL 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 core competencies, such as communication and self-awareness of attitudes and beliefs about dying, can be acquired through relevant didactic content.
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 death.
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.
EOL care education decreases the anxieties that learners face when caring for terminally ill clients and their families. As a result, their transition into practice and preparedness for a palliative role is 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.
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 the 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 outcomes may include improved satisfaction levels and professional development in EOL care.
Plan of Action
Specific activities will be addressed in consultation with the advisor for the successful development of the educational proposal. Upon acceptance and review of the specific topic (EOL education), I will schedule a meeting with the preceptor to discuss the format of the project and review the current gap. Subsequent activity will entail developing an initial research submission with peer-reviewed sources or bibliography supporting the project. I will then create a draft of the proposal for the preceptor to review. Based on the reviewer’s comments, I will write the final submission for approval.
The next activity will involve the development of the content and lesson plans for the module. The course name (EOL education), topic, learning objectives and outcomes, and teaching/instructional strategies will be developed at this point. Among the focus areas include pain/symptom management, supportive communication, and emotional considerations in EOL. The core learning objectives are; first, students should demonstrate knowledge and practice skills in palliative care, and second, learners must show 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. Didactic and experiential teaching or instructional methods will be used to deliver content, including lectures, interactive role-plays, and case study reviews. An implementation plan that includes reading materials and resources, the clinical orientation of nursing students to EOL situations, patient visit schedules, and the timetable for the classes as well as evaluation criteria will be developed.
The entire capstone project is estimated to take eight weeks. The review of the research gap with the advisor will occur in weeks 1-2. The development of a bibliography, first draft, and final submission for approval will be completed in week 3. The formulation of course content – lesson topics, learning objectives and outcomes, and teaching strategies – and implementation plan will be accomplished in week 4. The EOL course will be taught in weeks 5-8, 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.
Resources and Personnel
Adequate facilities and staff will be required to support the implementation of the proposed EOL course. Personnel will be an indispensable resource in student teaching and learning. Instructors from the faculty will deliver didactic content through lectures, role-plays, and simulations. Case managers in hospice facilities will guide students through experiential learning in EOL settings. Auxiliary staff, such as librarians and computer technicians, will also be required to help with setup. Financial support from the department will be needed to develop and implement the EOL course. Other resources necessary include a classroom space with desks and a whiteboard, printing costs for hardcopy notes and reading materials, public address equipment, and high-fidelity simulators for the lab sessions.
Proposed Change Theory
EOL course implementation will be a change process driven by the need to address a gap in hospice nursing care. Lewin’s three-step model will be used to implement the project. The first phase is the unfreezing stage, which entails overcoming resistance and ingrained organizational norms to establish the readiness for change (Wojciechowski, Murphy, Pearsall, & French, 2016). Brainstorming sessions will be held with students and faculty to diagnose the current challenges new nurses face in caring for dying patients and what aspects of EOL education should be changed. Teams will develop specific content or equipment required to make the course more relevant to EOL practice. This inclusive approach will help overcome restraining forces such as negative attitudes towards end-of-life care, fear of the unknown, and resource constraints.
The second step is changing or movement. Once people become receptive to change, the initiative can start. However, the initial stages will involve a learning curve and significant time and resource investment (Wojciechowski et al., 2016). In this view, transitioning to the EOL course will require supportive orientation of the students. The didactic and experiential content will then be delivered according to the lesson plan and learning objectives. The third step is refreezing, which entails efforts to make the effects of the change last. By involving faculty and students in the development and implementation of the EOL course and preparing preceptors in hospice settings, the change will become a part of the nursing curricula offered by the school.
Barriers to Implementation
The project may encounter challenges related to time, people/personnel, and finances during its implementation. The didactic and experiential content will be delivered within four weeks. This time may not be adequate for nursing students to acquire EOL competency and better affective states. However, a preceptor in a hospice center will be involved to help with experiential training. Another institution-level barrier relates to people. Reduced adaptation to change by preceptors and faculty and inflexibility will affect the implementation of the project. Education and communication will help address this challenge. Limited finances may constrain the development of the EOL course and the acquisition of facilities and equipment such as simulators. This barrier will be mitigated by collaborating with a hospice facility to support the project.
Ek, K., Westin, L., Prahl, C., Österlind, J., Strang, S., Bergh, I.,… Hammarlund, K. (2014). Death and caring for dying patients: Exploring first-year nursing students’ descriptive experiences. International Journal of Palliative Nursing, 20(10), 509-515. Web.
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.
Institute of Medicine (IOM). (2015). Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press.
Jackson, M. J., & Motley, C. L. (2014). End-of-life educational seminar in a prelicensure bachelor of science in nursing program. Journal of Hospice & Palliative Nursing, 16(6), 348-354. Web.
Lai, X. B., Wong, F. K. Y., & Ching, S. S. Y. (2018). The experience of caring for patients at the end-of-life stage in non-palliative care settings: A qualitative study. BMC Palliative Care, 17(116), 1-11. Web.
Ranse, K., Ranse, J., & Pelkowitz, M. (2018). Third-year nursing students’ lived experience of caring for the dying: A hermeneutic phenomenological approach. Contemporary Nurse, 54(2), 160-170. Web.
Wojciechowski, E., Murphy, P., Pearsall, T., & French, E. (2016). A case review: Integrating Lewin’s Theory with Lean’s System Approach for change. The Online Journal of Issues in Nursing, 21(2), 1-14. Web.