End of Life Care: Gap in Competence

Abstract

Inadequate educational preparation, professional mentorship, and practicum exposure are significant barriers to optimal palliative care. A deficit was noted in the current curricula that focus on ethical issues rather than on building core competencies that will improve patient outcomes. An end-of-life (EOL) course founded in standardized best practices and evidence can improve the self-efficacy and attitudes of prelicensure nurses before entering service.

The purpose of this project was to design and implement an EOL module for students at a nursing school. Collaborative relationships amongst NPs, faculty, the clergy, and psychologists helped develop a palliative care course that addresses EOL knowledge of nurses in training and competencies in communication, pain and symptom management, and support during grief. The interprofessional team will also play a role in implementing the curriculum. The faculty will deliver an 8-hour didactic content through lectures, role plays, and simulations, while the NPS will supervise the practicum component.

The implementation of the course will depend on the team’s clinical expertise and support. The director of nursing and training coordinator will provide resources, including equipment, materials, and staffing, which are required to execute the project. The team’s commitment and support will ensure a successful implementation of the course. Improvement in the students’ EOL knowledge, communication skills, and clinical competencies will lead to quality palliative care and higher outcomes for critically ill patients at the facility. In conclusion, systematic instruction of preservice nurses on EOL practice can improve clinical efficacy and competencies, helping reduce existing curricula gaps.

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 make 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 life. 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. 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 towards 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 the 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 the patient, family, and 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 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.

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 relevantly 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, 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 core 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 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.

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 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.

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 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 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, listen 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.

Implementation Plan

Project Launch

Description of steps

The nine-week EOL course (didactic and practicum experience) will be offered at a hospital-based nursing school. IRB approvals from the College of Health Professions and the medical center will be sought first before participant recruitment. Information flyers will be posted at the nursing school soliciting student nurses’ participation in the exempt course. Participants will complete informed consent and attend preliminary sessions where they can ask questions and register for the module. All student nurses from the host medical school requested to take part in the training. The inclusion criteria will entail undergraduate level, ability to write/speak English, and no prior clinical EOL experience. They will then complete a demographic questionnaire and a pre-course survey to evaluate their EOL knowledge.

The EOL course is aimed at providing in-depth knowledge and experience to help learners deliver quality end-of-life care. It combines didactic content with an experiential component. Before the practicum experiences/simulations, students will receive lectures on caring for the dying. The didactic component will include readings and materials on death, managing symptoms/pain, and communicating with hospice patients and their families.

This introductory content will prepare students for more broad topics on care contained in the learning bundle. Each lecture will include instruction and a one-hour classroom discussion focusing on concerns or questions raised by learners as well as on the management of suffering. Symptom control will center on managing “pain, dyspnea, incontinence, and spiritual distress” (Jackson & Motley, 2014, p. 349).

After the one-hour lecture, a case study or high-fidelity manikins will be provided mimicking the dying process, including breathing difficulties. The preceptor will guide students in the room, while the educator will provide support to overwhelmed learners leaving the simulation environment. The practicum component will involve spending a cumulative period of 10 hours with a dying patient.

Lesson plan

The completed lesson plan components, namely, competency statements, lesson topic, learning objectives, teaching strategies, and required materials for the proposed EOL course, are included in Appendix A.

Collaboration

Identification of interprofessional relationships

In developing this educational proposal, the author reached out and collaborated with final year students, the facility’s director of nursing, nurse practitioners (NPs), faculty members, psychologists, the clergy, and the training coordinator at the Methodist Hospital. Collaborative relationships anchored on shared goals for quality EOL care were built with these participants who provided guidance and direction. A needs assessment involving graduating students will inform decision-making on the areas to be included in the EOL course and future revisions of the curriculum. A faculty member at the Hennepin Technical College highlighted the barriers to the academic preparation of student nurses, contributing to the development of this educational proposal.

The Methodist Hospital’s director of nursing (DON) felt that the lack of adequate provider EOL knowledge resulted in suboptimal care for terminal patients. Experienced NPs helped refine the integral components of the course. For example, they noted that new nurses lack the requisite EOL skills in communication, symptom and pain management, and support during grief. By collaborating with the facility’s training coordinator, the writer was able to determine the time requirements for the in-class and practicum components of the module. For instance, he agreed that ten two-hour visits to a dying patient would give new nurses the confidence and competence to work in EOL settings.

The four individuals will continue playing a significant role in the full-scale implementation of the project as consulting agents and facilitators. They will review the course and provide support for the delivery and evaluation of the educational intervention.

Discussion of relationships

The interprofessional relationships will be critical to the successful implementation of this educational project. The DON will require student nurses to undertake a preservice 9-week EOL course to impart EOL skills. As a medical practitioner holding a leadership position, the DON will play an oversight role and facilitate training resources, for example, LCD projectors and simulators. NPS will provide clinical supervision of student nurses and ensure the alignment of theoretical concepts with practicum experiences. The writer will collaborate with the faculty member to deliver the course and evaluate learning outcomes.

The aim is to ensure that participants gain a deeper understanding of all aspects of EOL care, such as symptom/pain management, communication, ethical issues, and emotional balance required to work in an EOL environment. Decisions related to instructional design, scheduling, and equipment, including simulation models to be used for the module, will involve the training coordinator.

Organizational Sustainability

Implementation support

Organizational support will ensure that the Methodist Hospital maintains and sustains the change, creating a culture of high-quality EOL care. The facility considers resource requirements for a program to protect it against funding shortages or employee turnovers. A short-term goal developed for the intervention entails achieving the implementation timeline for the course, which is nine weeks. Meeting this target will ensure that more students at the nursing school receive the EOL education, addressing the knowledge gap in preservice nurses. Timely completion of the learning activities (lectures and practicum) is another short-term process-based goal of the project.

The delivery of the course content and evaluation must be concluded within nine weeks to ensure optimal use of resources. Positive feedback from key individuals, for example, the faculty, students, clinicians, and patients, constitute another short-term goal of the project. The views of these stakeholders will be used to revise and strengthen the course. Increasing student interest in EOL care at the facility is another short-term goal that will create the impetus for implementing the project.

In addition to the above objectives, the sustainability plan for the proposed intervention entails identifying champions who will rally behind the project goals. For example, early engagement of the DON will facilitate management buy-in and resources for the initial implementation of the change. According to Jackson and Motley (2014), the program champion communicates the project objectives as a priority, solicits staff support, and inspires confidence in the intervention.

Passion and commitment to project goals will enable the DON to influence the management to support the preservice EOL course. The short-term plan will also entail addressing stakeholder concerns. Student anxiety and anxiety, as well as barriers identified by educators and preceptors, will be addressed promptly to ensure project sustainability.

The long-term plan includes outcome-based goals that will be achieved in five or more years. The EOL course is anticipated to increase the preparedness of student nurses for hospice care. Therefore, long-term clinical goals include the delivery of high-quality end-of-life care at the facility, improved nurse-patient communication and support, and better management of pain and symptoms. As a result, the overall quality rating of the facility is expected to improve, as inpatients will be comfortable during the disease process. Other long-term goals are the integration of the EOL module into the nursing school’s curriculum and retaining a team of nurse educators and NPs that will deliver didactic and experiential components of the course for the next five years.

Resources for implementation

This capstone project will take place at the Methodist Hospital. Human resource is an important resource required. Among the people who will implement the educational intervention are a faculty member, an NP/preceptor, and the training coordinator. Educators will deliver routine course content and simulations and assess performance, while the NPS will provide supervision during practicum experiences.

The training coordinator will help with instructional design and development, lesson scheduling, and equipment management. Funds will be needed to develop and deliver the course and learning materials as well as purchase supplies for the training, including notebooks, pens, mannequins, and audio-visual equipment. The facility will be required to dedicate adequate time for the delivery of the course. The didactic content and simulations will be provided in two-hour weekly sessions for four weeks, while the experiential component will take 10 hours, as determined by the training coordinator.

The facility will provide physical resources, including a training room, computers, LCD projectors, and simulations (high-fidelity mannequins). Space or hall should accommodate over 25 students and be fitted with equipment and materials necessary for delivering EOL education. Additionally, a simulation room will be required for the lab sessions.

Evaluation Plan

Evaluation

Discussion of outcomes

A critical measure of the success of this capstone project is an increase in the EOL knowledge of the participants after the module. The student nurses will demonstrate a deeper understanding of the physiologic aspects of the dying process, pain, and symptom management following an EOL course (Jackson & Motley, 2014). Additionally, they will apply the knowledge acquired through this module in EOL practice. For example, a student nurse should use opioids correctly to manage pain and suffering and initiate conversations with dying patients.

Another important outcome-based indicator of the course’s success will be the ability to navigate difficult communication situations. Role-plays, discussions, case study reviews, simulations, and practicum experiences will teach students to communicate effectively with dying patients and their families. The perceived self-efficacy and confidence to break sad news will indicate that the participants learned by observing others modeling communication behaviors in EOL settings (Jackson & Motley, 2014). Skills in grief counseling will be another outcome measure. Verbal clarity, spontaneity in offering unsolicited support, and being comfortable discussing spiritual matters with patients will be evidence of communication efficacy following the EOL course.

An important learning outcome of the module is attitude improvement towards EOL care after the project. According to Carman, Sloane, Molloy, Flint, and Phillips (2016), negative thoughts, fear, and anxiety are critical obstacles to optimal EOL care delivery by nurses. A statistically significant post-course improvement in mental attitudes towards EOL practice from the baseline will be an indicator of success. Students will demonstrate interest and willingness to care for terminally ill patients after the course. Therefore, increased enthusiasm to care for a dying patient is an expected post-course outcome.

Impacts on future outcomes

EOL care curricula at most nursing schools lack experiential training, which is critical for reinforcing core practice competencies, communication skills, and positive attitudes. The proposed course will expose learners to facets of EOL care normally absent informal programs. The development and implementation of this curriculum have implications for future EOL care training and practice at the facility. First, key players from the hospital (DON and NPs) and nursing school (faculty) are included in the entire process.

By involving individuals from different professional backgrounds, collaborative EOL training of student nurses will transcend narrow interests and earn extensive support that will sustain it. Additionally, team diversity is a significant achievement of this project, as it will create an opportunity for faculty, NPs, and administrators to collaborate in training nurses to enhance EOL care.

Second, the inclusion of simulations and practicum exposure will allow the students to personalize the curriculum. The faculty and NPs will share their clinical experiences in hospice care with the students. Involving specialists in EOL practice in teaching the course will enhance its authenticity and validity, promoting learner engagement, and continued support from administrators (Carman et al., 2016).

The experienced facilitators or instructors will identify their weaknesses in delivering the module. For example, the instructor may encounter difficulties conducting simulations despite being experienced in clinical scenarios. Subsequently, training on this technique will be provided to facilitators for better student outcomes in the future. Additionally, the orientation of the trainers by an experienced instructor and NP will create a sense of ownership of the curriculum.

Third, post-course feedback will be obtained from the learners, faculty, and preceptors to evaluate its effectiveness. Based on the responses, their experience of the specific components of the program can be delineated, generating ideas for improving the module in the future. For example, based on the feedback, the communication aspect of the course may require 2.5 more hours than the EOL care component to dedicate more time for role-plays and simulations. Additionally, based on assessment results, the two segments may be considered for future inclusion in a mandatory clinical course that will be offered by the nursing school.

Fourth, the curriculum will lead to longitudinal interventions to expand the EOL skills of students in the long term. The exposure of learners to eight and ten hours of didactic content and practicum experiences may not be sufficient to attain competence in core EOL areas. Thus, in the future, the eighteen-hour course may evolve into several programs to develop palliative skills in key domains. For example, it is anticipated that after this course, a hospice visit will be included in first-year curricula to enable students to develop competence in communication and psychosocial support beyond the therapeutic management of terminally ill patients. An array of interventions are expected to grow out of this module to strengthen the student’s ability to address spiritual challenges encountered in EOL contexts. Moreover, the successes of this curriculum will create a foundation for future EOL care education, an ignored yet important area of nursing practice.

Identification of interprofessional participants

The development of this educational proposal and its implementation will involve collaborative relationships with different professionals. The interprofessional participants that will be engaged include the director of nursing, nurse practitioners, the clergy, psychologists, faculty staff, and the training coordinator at the Methodist Hospital. Collaboration with these individuals will be required in the revision and implementation of the EOL curriculum at the facility. For example, as I develop and implement this course, decision-making on the duration and delivery methods of the module will entail working together with these stakeholders.

First, to organize the course, the faculty will split eligible students into a manageable class of about 10, and an instructor will be assigned to each group. He or she will facilitate learning according to the course objectives and duration of each session. Facilitators will then decide on the time assigned to the didactic components and classroom activities: communication skills and pain/symptom management. The in-class activities and resources, including videos, articles, and simulations to develop knowledge and psychosocial dimensions of EOL care, will entail collaboration with the faculty.

The NPS who will serve as preceptors will determine the number and duration of hospice visits. Further, spiritual aspects to be addressed by the curriculum will be determined from the contributions of the clergy and psychologists.

Second, collaborative relationships will be useful in the development of the evaluation criteria. Assessing the important skills learned during the course and practicum experience will require the faculty to collaborate with NPS to link theoretical knowledge acquisition and its application in EOL contexts. Potential obstacles during the implementation of this module are the misalignment of what is taught in class with opportunities for clinical practice and fragmented evaluation. Close collaboration between the faculty and NPs will ensure a smooth preceptorship and enhance the relevance and effectiveness of hospice visits.

Thus, a two-part evaluation will be possible if instructors collaborate with preceptors at the facility to ensure the expected clinical application of the skills learned in class is met. Additionally, student experience of the course and practicum opportunities should be incorporated into the assessment.

Interprofessional collaboration

A post-course survey of graduating students will inform the effectiveness of the module and the topics that need to be included to strengthen future EOL care courses. The evaluation of the learners’ practicum performance will involve collaboration between faculty and preceptors, informing interdisciplinary assessment modalities. They will give guidance based on their clinical experiences. The interprofessional team will be invited to evaluate the module after its implementation.

The goal is to review the content and learning goals of the proposal and identify its strengths and weaknesses. Their views and suggestions for improving specific aspects of the course will be useful in future projects. For example, they will show if the time allocated to each content area is adequate or whether students need individual attention and debriefing after a role-playing activity or simulation.

Closing the Gap

Student nurses at my facility have no formal training and experience on EOL care, affecting their practice efficacy in this important clinical area. To address this gap, the proposed educational initiative aims to develop competencies for preclinical training by addressing three domains: communication skills, EOL knowledge (pain/symptom management), and attitude towards hospice care. Research evidence supports the need to prepare clinicians for hospice care. Self-knowledge and experience in EOL practice improve self-confidence and efficacy in caring for terminally ill patients (Ek et al., 2014).

Thus, hospice care merits systematic didactic instruction and experiential learning, which are included in the proposed curriculum. In particular, the practicum component of the course will improve the critical thinking, teamwork, and communication efficacy of the learner (Hussein et al., 2017). The module addressed these competencies by including hospice visits (10 hours) and simulations to build student skills in the physical, spiritual, and psychosocial care of dying patients.

Further, the literature supports spending time with terminally ill patients as a recommended best practice. It promotes emotional balance, self-awareness, and professional development (Hagelin et al., 2016; Lai et al., 2018; Ranse et al., 2018). Hospice visits are a major component of this curriculum that will provide students with opportunities to practice their skills and receive feedback. The core topics included in the course (pain/symptom management, communication, and grief) were also developed from studies on similar interventions (Lippe & Carter, 2015). The content included in the curriculum will help attain the learning outcomes and develop the requisite competencies in the participants.

Effective didactic approaches are used to deliver the course. The reflective journals, case study reviews, group discussions, and high-fidelity simulations used in the curriculum have been shown to build emotional resilience and improve cultural sensitivity, communication skills, and patient-centered care (Smith et al., 2018; Wittenberg et al., 2016). A smooth preceptorship is critical, as the course will involve collaboration between faculty and NPs. The course will bring together these professionals in its design and implementation, ensuring that in-class training is congruent with clinical experiences for optimal outcomes (Paye et al., 2014; Siela et al., 2015). The approach will lead to adequate support for each student to build the requisite EOL competencies.

Reflection

Integrated Outcomes

The development and implementation of the EOL course support quality hospice care. The curriculum will impact patient outcomes and reinforce interprofessional collaboration to promote the preservice preparation of nurses for EOL care.

Designing innovative nursing practices to impact quality outcomes of populations

Using research to develop an EOL course for student nurses is an innovative strategy for improving the outcomes of populations with palliative care needs. Experienced faculty, NPs, psychologists, and the clergy were involved in the development of the curriculum to ensure quality training in aspects critical to EOL care. The collaborative approach helped combine diverse clinical expertise with current research evidence consistent with evidence-based training. The topics and clinical exposure developed through this method (communication skills, pain/symptom management, grief, and hospice visits) increase the self-confidence and self-efficacy of nurses to offer quality EOL care.

Constructing interprofessional teams to advance a culture of excellence

The preservice preparation of nurses entailed interdisciplinary collaboration among NPs (preceptors), faculty, the clergy, and psychologists. This interprofessional team will build a culture of excellence by giving guidance to improve the clinical competency of prelicensure nurses. The collaborative efforts will also advance EOL research to boost staff competency in this area for optimal nursing care of critically ill patients.

Appendix A: Lesson Plan

Lesson Plan Template/Instructions

Course Name Specify the name of the course you will develop.

Preservice end-of-life care course

Competency Statements Identify three competency statements for your course.
  1. At the end of the course, students will demonstrate skills in communicating bad news and discuss treatment options with the patient/family.
  2. At the end of the course, students will demonstrate the correct administration of opioids in the appropriate dosage to manage pain/symptoms.
  3. At the end of the course, students will demonstrate interest and willingness to care for dying patients.
Lesson Topic The topic of the lesson plan is end-of-life care. It reinforces appropriate skills, attitudes, and knowledge critical for optimal pain/symptom management, communicating bad news, discussing therapeutic options, and creating interest in EOL care. The two components of the course (didactic and experiential learning) will build clinical competencies required for quality palliative care, resulting in higher patient outcomes.
Learning Objectives Competency:At the end of the course, students will demonstrate skills in communicating bad news and discuss treatment options with the patient/family
Learning Objectives:
  1. Students will role-play in a scenario where they communicate sad news to a patient
  2. Student dyads will role-play discussing treatment options with a dying patient
  3. Students will discuss their values and spiritual beliefs with patients
  4. Students will critique their peer’s communication skills in simulated EOL contexts
Teaching Strategies
  1. Roleplay
  2. Simulation
  3. Lecture
Required Materials
  1. 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.
  2. Wittenberg, E., Ragan, S. L., Ferrell, B., & Virani, R. (2016). Creating humanistic clinicians through palliative care education. Journal of Pain and Symptom Management, 53(1), 153-156. Web.
  3. Jackson, M. J., & Motley, C. L. (2014). End-of-life educational seminar in a prelicensure bachelor of science in the nursing program. Journal of Hospice & Palliative Nursing, 16(6), 348-354. Web.
Lesson Plan Details Key Concepts:A key competency of the course is demonstrating skills in communicating bad news and discuss treatment options with the patient/family. Key concepts include end-of-life care, the dying process, neuropathophysiology of pain, opioids, grief, communication, therapeutic options, patient engagement strategies, psychosocial dimensions of EOL care, and symptom management. These concepts will be explained during the lesson and are aligned with competencies, outcomes, and learning objectives, as follows:
Learning Objective 1:Students will role-play in a scenario where they communicate sad news to a patient
  • End-of-life care
  • Communication
  • The dying process

Learning Objective 2:Student dyads will role-play discussing treatment options with a dying patient

  • Therapeutic options
  • Disease etiology
  • Symptom management
  • Opioids

Learning Objective 3:Students will discuss their values and spiritual beliefs with patients

  • Psychosocial dimensions of EOL care
  • Grief

Learning Objective 4:Students will critique their peer’s communication skills in simulated EOL contexts

  •  Patient engagement strategies

Required Reading:Students will be required to read texts and other resources on pain assessment and management, therapeutic communication, patient engagement, hospice care referral process, and physiological aspects of dying.

Instructions:

  • Learning Activity 1: Experiential:Simulation and role-play will be used to teach students communication skills through scenarios consistent with objectives 1-2. Learners will participate in a simulation exercise in teams of 5. Those overwhelmed with the scenario will receive counseling. Individual debriefing will be conducted after the exercise. The case will depict a dying patient experiencing a diminishing heart rate and breathing difficulties. Students will be expected to manage patient pain and symptoms and break the sad news to the family.
  • Learning Activity 2: Authentic assignment assessment:A case study involving a dying patient will be used to provide students with an opportunity to apply their psychosocial knowledge in practice to meet objective 3. The clinical situation will entail addressing the spiritual and emotional needs of the individual. Students will be expected to read and interpret the case study. They will determine the psychosocial needs of the patient and describe how they will meet them.
  • Learning Activity 3: Critical thinking activity:Direct patient care activities (practicum experiences) and critical reflection (reflective journal presentation) will teach students palliative care skills consistent with objective 4. Through ten-minute presentations and ten hospice visits, learners will acquire relevant competencies and develop positive attitudes towards EOL care.

References

Carman, M. J., Sloane, R., Molloy, M., Flint, E., & Phillips, B. (2016). Implementation of a Learning Bundle to Promote End-of-Life Education for Prelicensure Nursing Students. Journal of Hospice & Palliative Nursing, 18(4), 356–363. Web.

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.

Lippe, M. P., & Carter, P. (2015). End-of-life care teaching strategies in prelicensure nursing education. Journal of Hospice & Palliative Nursing, 17(1), 31–39. Web.

Payne, C., Heye, M. L., & Farrell, K. (2014). Securing preceptors for advanced practice students. Journal of Nursing Education and Practice, 4(3), 167-179. 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.

Siela, D., Twibell, R., Mahmoodi, M., &Mahboubi, S. (2015). Close encounters at the bedside: Partnering among clinical nurses, students, and faculty. American Nurse Today, 10(6), 1-9. Web.

Smith, M. B., Macieira, T. G. R., Bumbach, M. D., Garbutt, S. J., Citty, S. W., Stephen, A., … Keenan, G. (2018). The use of simulation to teach nursing students and clinicians palliative care and end-of-life communication: A systematic review. American Journal of Hospice and Palliative Care, 35(8), 1140-1154. Web.

Wittenberg, E., Ragan, S. L., Ferrell, B., & Virani, R. (2016). Creating humanistic clinicians through palliative care education. Journal of Pain and Symptom Management, 53(1), 153-156. Web.