Advance directives (AD) are documents that direct the care of patients and appoint a surrogate for decision-making for future treatment if the patient is unable to communicate their wishes regarding medical treatment that would prolong life. In their literature review, McCourt, Power and Glackin (2013) found six themes relating to implementation and acceptance of AD: lack of education and knowledge, time constraints, barriers related to the hospital culture, communication barriers, management of symptoms, and personal issues of nursing staff. These findings indicate the need to better educate nurses so that they can provide high-quality care to patients at the end of life. According to Lewis (2013), nurses have an important role in encouraging discussions about end of life care as part of patient and family education. Therefore, the nursing curriculum needs to include conscious and transparent content on these topics.
Active learning strategies regarding this subject content have been reported in the literature. Hall and Grant (2014) found nursing students who completed AD as a learning activity showed increased scores on the knowledge, attitudes and experiential survey with AD. Similarly, physician assistant students had positive feedback about completing AD as required coursework (Niebuhr, Eames, Munsell, & Stephenson 2014). Simulation may be another way to incorporate AD into nursing education. When simulation was used with undergraduate nursing students, knowledge about end-of-life care and self-efficacy improved (Moreland et al., 2012). These studies demonstrate the importance of further research about AD in nursing education.
Knowledge transformation is a goal of nursing education and a desired outcome of learning activities. In addition, life experiences and other external factors influence knowledge and application of such knowledge in the clinical arena. Therefore, it is important to assess nursing students’ knowledge, experience and attitudes about AD. At a public, rural, four-year university in the Southeast United States, 166 pre-licensure Bachelor of Science in Nursing (BSN) students were surveyed in a 33-item questionnaire about their knowledge, personal and professional experiences, and personal and professional attitudes regarding AD. The items on the questionnaire were used with permission from previously published studies.
In this study, knowledge progression was investigated across the four levels of the nursing program, to determine if knowledge was static, progressive or regressive. There was a statistically significant progression of knowledge from the junior 1 through the senior 2 semesters, with statistical significance between groups (F(3, 161)=9.493 and p=.000 (p<.01)). At the beginning of the senior year, the average knowledge score decreased, although it was still higher than at the beginning of the junior year. The students have no course work over the summer, which may result in knowledge decay (Dills, Hernández-Julián, R., & Rotthoff, 2016). The highest average knowledge scores about AD were in the final semester of the nursing program, indicating knowledge progression across the curriculum.
In addition, there was a statistical difference in personal attitudes about AD by semesters in the program (F(3, 139)=5.167, p=.002 between groups). The Junior 1 scores were statistically different from the other three semesters of the program (mean difference of -17.431, p=0.018 for Junior 2; mean difference of -15.949, p=0.037 for Senior 1; and mean difference of -18.378, p=0.018 for Senior 2). Using the Pearson Correlations test, there was a statistically significant correlation between personal attitudes and knowledge (r=.255, p=.002) and between personal attitudes and professional attitudes (r=.249, p=.003), but this correlation is weak. No significant correlations were discovered between personal experiences and professional experiences. This indicates that positive knowledge progression occurs as students complete higher program levels, also creating a transformation in attitudes.
Among personal attitudes between races, there was a significant difference in responses when comparing the self-identified White/Caucasian and Black/African American groups (F=6.82, p=.001). Similarly, the findings were significant when comparing professional attitudes about AD among White/Caucasian and Black/African-American students (F=15.494, p=.000). Black/African-American students were less likely to give consent to the attending physician to allow natural death (AND) and were less comfortable with the nurses’ role in facilitating ADs in end-of-life care. This may be an area for future research and consideration in nursing education.
Additionally, students were divided into two groups by age: 18-25 years of age and 26 years of age and older. There was a statistically significant difference between the two age groups in their knowledge of AD (t=-2.412, 164 df, p=.017) and in their professional attitudes (t=-2.626, 164 df, p=.009), with the older students having increased knowledge and professional attitudes that were more likely to respect the end-of-life requests of patients. There was no statistical significance when looking at the age groups and personal attitudes.
It is important to ensure that pre-licensure nursing students are exposed to AD in their educational programs, so that they are better prepared for their professional role as nurses. Implications for nurse educators include the need to be cognizant of potential disparities in attitudes among students, based on the social and demographic composition of the class. In addition, educators must be aware of the need for reinforcement of knowledge after breaks in the academic calendar. Our findings, as well as those reported in the literature, suggest that activities promoting active learning in this subject area should be included in nursing curriculum. Overall, these findings have implications for nursing education in the classroom and clinical setting, not only in the United States but also globally. There is a need for future research on this topic including ways to effectively incorporate AD and end-of-life care into nursing education programs.
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