The nursing role includes providing compassionate care at the end of life, yet many nurses feel unprepared to provide care for seriously ill or dying patients (American Nurses Association, 2016). With the increase in prevalence of serious illness and the aging of the worldwide population, palliative care programs have grown in number (Dumanosky et al., 2016). Fewer than 18,000 of the three million nurses in the United States, however, have specialty certification in hospice and palliative care (Hospice and Palliative Credentialing Center, 2018). Primary palliative nursing care (i.e., skills that all nurses should have) includes assessment and management of the symptoms of serious illness; communication skills to help patients and families understand and cope with illness throughout the disease trajectory; advocacy skills to ensure patient-centered care aligns with individual goals and values; and, skills to provide respectful care for the dying patient and support for the bereaved (National Consensus Project for Quality Palliative Care, 2013). To create a guiding framework for these skills, nursing leaders and experts developed a comprehensive list of palliative care nursing competencies, known as CARES that can be used by nurse educators to develop content for students to successfully attain primary palliative care knowledge (Ferrell, Mazanec, Malloy & Virani, 2016). Observing positive role models in palliative care clinical practice can enhance student learning (Anderson, Kent, & Owens, 2015). Applying the principles of experiential learning (Kolb, 2015), we believe students internalize the key nursing concepts of caring and compassion by interacting with patients and families receiving palliative care. To this end, we developed the Comfort Shawl Project, an experiential service-learning project that immerses senior nursing students in palliative care (Glover, Horgas, Castleman, Turpening, & Kittelson, 2017). In this study, we examine the outcomes related to nursing student attitudes toward death, levels of empathy, and confidence in providing primary palliative care during their yearlong involvement in the project.
Students involved with the Comfort Shawl Project attend the interdisciplinary team meetings of the palliative care consult service, gift handcrafted shawls to patients receiving palliative care, and participate in extracurricular events focused on palliative care, attitudes toward death and dying, and engagement with the local community. The handcrafted shawls are made by volunteers, including community volunteers, alumni, and nursing students. Along with nurses, physicians, social workers, and others on the palliative care team, students identified patients and families that might like to receive a shawl. Students went on weekly rounds in pairs to gift the shawls, visiting with each patient for 5-15 minutes. Patients were shown multiple shawls and asked if they would like to choose one. In cases where the patient was unresponsive, students interacted with the family or the nurse caring for the patient. In addition to the direct patient/family interaction, students engaged in a variety of educational activities and experiences that prepared them to provide compassionate and patient-centered nursing care to those facing serious illness.
Methods:
At the beginning, mid-point, and end of their immersion experience students completed the following measures: attitudes toward death, empathy (empathic concern and perspective-taking), and the CARES competencies. The research was conducted at a large academic medical center in the southern United States. All procedures were approved by the university Institutional Review Board. Data was analyzed using SPSS (IBM, version 25).Participants were nine female white senior nursing students who voluntarily participated in the Comfort Shawl Project and this study between June 2016 and April 2017. During this time, the students gifted a total of 214 comfort shawls to patients receiving palliative care in the hospital. Shawl recipients included 118 women and 96 men ranging in age from 9 days to 103 years old, hospitalized for a variety of illnesses including cancer, heart disease, dementia, stroke and congenital conditions.
Results:
The Death Attitudes Profile (Wong, Reker, & Gesser, 1994) is a 12-item survey with two subscales: Fear of Death and Death Acceptance. Items are rated on a Likert scale where 1- “strongly agree” and 5 = “strongly disagree.” Items were reverse scored so that higher scores of the Death Acceptance subscale indicate improved death acceptance and lower scores on the Fear of Death subscale indicate less fear of death. Item scores were summed to create total fear and total acceptance scores. Participants’ mean fear of death significantly reduced from baseline (M = 16, SD = 3.6) to the midpoint (M = 14, SD = 4.1; paired t = -2.9, df = 8, p = .02). Participants’ mean acceptance of death significantly increased from baseline (M = 18, SD = 1.2) to the midpoint (M = 19, SD = 1.2) (paired t = 2.4, df = 8, p = .04).
We also used two subscales (14 items) from the Interpersonal Reactivity Index (Davis, 1983): Empathic Concern and Perspective Taking. Items are rated on a Likert-type scale where 1 = “does not describe me well” and 5 = “describes me very well” and summed. Paired t-tests were conducted to examine change in empathy over a one-year period. For Perspective Taking, the results showed no significant increase from baseline to midpoint or from midpoint to end of program. However, there was a statistically significant increase in perspective taking from baseline (M = 18.9, SD = 5.0) to end of program (M = 21.6, SD = 4.5; t = -2.4, df = 8, p = .04). For Empathic Concern, the results show no significant increase from baseline to midpoint or from baseline to end of program. However, there was a trend for significant increase in empathic concern from midpoint (M = 23.7, SD = 2.4) to end of program (M = 24.9, SD = 2.4; t = -2.3, df = 8, p = .056).
Students were also asked to rate their perceived competency on fourteen CARES competencies (Ferrell et al., 2016) that aligned with the goals of the Comfort Shawl Project. Items were rated on a Likert scale where 1 = “not at all” to 7 = “very much.” A one-way repeated measures ANOVA was conducted to examine the effect of the palliative care immersion experience on the CARES competencies over time. There were significant increases in CARES competency scores between each measurement time point. The CARES scores significantly increased from baseline (M = 62, SD = 11.2) to the midpoint of the program (M = 80, SD = 8.3) (p = .003); from midpoint to end of program (M = 85, SD = 8.9) (p = .045); and from baseline to end of program (p = .002).
Conclusion:
In summary, participation in the immersion in palliative care resulted in less fear, greater acceptance of death, and an increase in one aspect of empathy – Perspective Taking, among senior nursing students. In addition, students demonstrated increased confidence in the CARES competencies, especially collaboration with the interdisciplinary team, respect for patient diversity, and compassionate and competent communication. Ongoing work focuses on increasing the sample size and inclusion of a control group. Providing immersion experiences in palliative care can supplement didactic teaching methods and may help students to connect with the fundamental human importance of providing care and comfort as central to their role as a nurse.