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End-of-life decision planning is difficult, and a process which the need for is often unrecognized or neglected. Ninety percent of people think it’s important to talk about end of life care (IHI, 2014). Although 60% of people would like to have their end of life wishes honored, the reality is that only 23%-30% of persons have completed advanced directives, and often no conversation was ever initiated with their families (Morhaim & Pollack, 2014; Rao, Anderson, Lin, & Laux, 2014; The Conversation Project, 2013). Rao (2014) reported a significant disparity on completion of advanced directives among Black and Hispanic participants with only approximately 17% completing them compared to their white counterparts. According to Morhaim (2014), the most common reason given for not having completed advanced directives was a lack of awareness. Persons identified healthcare providers as the preferred way to get information regarding end of life care (Morhaim et al., 2014; Rao et al., 2014). End-of-life conversations and advanced care planning are important processes that support personhood and may diminish the need for unwanted costly care.
Nurses are often in a position to educate and advocate for persons and their families regarding advanced directives and therefore need to play an integral role in end of life decision making processes. However, according to Kroning (2014) nurses lack knowledge about advanced directives, don’t feel competent in discussing them, and don’t necessarily perceive these conversations to be important. Studies regarding nursing students and end of life communication and advanced care planning in education are limited. A survey of undergraduate nursing curriculum in North Carolina indicated a deficiency in end of life care content, with 86.7% of programs indicating that there was no specific material actually dedicated to advanced directive care planning (Connell & Mallory, 2007). Although the previously cited study was completed in 2007, a more current study of thirty-one graduating senior nursing students expressed that they felt inadequately prepared regarding end of life communication and advanced directives (Josephsen & Martz, 2014). Additionally, Conner, Loerzel, and Uddin (2014) identified that nursing students have inconsistent preparation related to end of life care communication and also noted a lack of cultural competence, which could be a confounding factor in the disparity among racial and ethnic minority end of life care planning and completion of advanced directives.
Nursing students may have little experience regarding end-of-life issues and nursing school may represent their initial engagement with respect to this topic. Barrere, Durkin, & LaCoursiere (2008), reported that approximately 60% of nursing students in their study had no prior experience related to “death care” and that the attitudes of students 18-22 years of age were significantly impacted by targeted end-of-life education. Just having students complete their own advanced directives contributed to an increased confidence in recommending advanced directives and improving competence around the process (Hall & Grant, 2014).
Little is known about the actual experience of nursing students engaging in end-of-life care discussions and how that might impact knowledge, skills, and attitudes that are carried into professional practice. In addition, the experiences of culturally diverse nursing students’ may create insight related to cultural disparities noted in end of life conversations and advanced care planning. Educational strategies focused on end-of-life conversations in the undergraduate nursing curricula are critical in creating professionally competent nurses, as these critical and vulnerable conversations often provide moments where caring can be expressed and patients can be supported. It is hoped that the results of this study will contribute to gaps in understanding the experience of nursing students’ engaging in critical end-of-life conversations and advanced care planning impacting practice.
Research Design/Methods
This is a qualitative study utilizing a descriptive phenomenological method to analyze written reflection papers completed by the participants with semi-structured guidance. The philosophical underpinning of this study is based on the work of Edmund Husserl and seeks to describe the “lived experience” from the transcendental phenomenological perspective (McConnell-Henry, Chapman, & Francis, 2009). Since little is known about how nursing students experience end of life conversations as part of advanced care planning, it is felt that Husserl’s philosophical views best address exploration of this phenomenon. Giorgi’s (2009) modified five-step method based on Husserl’s philosophy will be employed as the approach to identify themes within the data.
Culturally diverse junior nursing students enrolled in the “Chronic Care” course in the fall semester of 2014 were asked to complete the following assignment after receiving a classroom lecture on end of life care:
- Review the Institute for Healthcare Improvement’s (IHI) video on “Basic Skills for Conversations about End-of-Life Care” as an adjunct to the topic of end of life care conversations.
- Use the IHI’s “Conversation Project” toolkit as a guide to interviewing a person of the students own choosing related to end of life decisions and advanced care planning.
- Create a 600-800 word reflection paper about the interview experience using the following statements for consideration: 1) what you learned, 2) how you felt talking about this topic with someone, 3) anything you found challenging, 4) were your perceptions of end of life care impacted, 5) did the tool contribute to your conversation, 6) how was caring reflected.
The proposal for the research study was submitted to the Institutional Review Board and was given exempt status. The group of nursing students, who had completed the above referenced assignment, was asked to participate in the study. Those students choosing to participate in the study provided consent and submitted their de-identified reflection paper and demographics sheet to a third party.
Results
Of the 79 students who completed a reflection paper, 56 choose to participate in the study. Emerging themes will be identified and correlated with demographic data which includes: Age, relationship of person interviewed, ethnicity, race, and religion. Analysis of the data is in progress. However, preliminary results support both personal and professional transformation. In addition, there is indication that the “conversation starter kit” served as an important tool related to empowerment and confidence.
Discussion
End-of-life conversations and advanced care planning is an important process that supports personhood and may diminish the need for unwanted costly care. Nurses are often in a position to educate and advocate for persons and their families regarding advanced directives and therefore play a critical role in end-of-life decision making processes. Therefore, engaging nursing students in end-of-life discussions and advanced care planning can lead to a greater understanding of what these conversations entail and in the process enhance professional competence.
Nursing Implications
Experiential learning can serve as a transformative process for nursing students, especially related to end-of-life conversations and advanced care planning. Providing these kinds of learning opportunities enhances professional competence and can support a greater engagement of nurses in these important discussions.