Death is an inevitable consequence of life and can occur at any phase of the life span and in any setting. Of all health care professionals, nurses are the most likely to be present at the time leading up to the death, during dying, and immediately after the death. Nursing programs are focused on the pathophysiology, assessment, and treatment and cure. However, lesser emphasis is placed on caring for individuals for whom there is no cure. In the past century, science has made possible longer life spans, cures for infections, and remissions for many chronic diseases, all of which have led to the development of an attitude toward death as a failure of the treatment modality, rather than as a natural and unavoidable part of life. With an aging population and a shortage of health care resources, new nurses need to be comfortable handling the issues of death and dying in all practice settings, yet many nurses feel ill-prepared to care for dying patients (Allchin, 2006; Chen, Del Ben, Fortson, & Lewis, 2006; Shlairet, 2009; Wallace et al., 2009).
Deficiencies in end-of-life (EOL) content in undergraduate nursing curricula were identified more than 20 years ago (Beck, 1997; Frommelt, 1991; Kaye, Gravely, & Loscalzo, 1994). Ferrell, Virani, and Grant (1999) reviewed 50 nursing textbooks for EOL content and found little content except that related to care of the body after death. Symptom management of the dying patient or bereavement needs of the grieving family were not addressed.
An 11-year review of the literature published from 1999 to 2010 revealed limited studies related to the implementation of educational strategies for EOL care into nursing curricula; most studies relied on descriptive designs and used samples of fewer than 100 participants. Narrative descriptions of undergraduate curricula suggest a reliance on didactic content, with limited to no experience with dying patients and their families. Only two studies described outcomes resulting from clinical experiences with dying patients (Allchin, 2006; Kwekkeboom, Vahl, & Eland, 2005), but these had inconsistent clinical experiences, a self-selected small sample (n < 20), and researchers who were course faculty. Five studies reported on the effects of didactic content only (Barrere, Durkin, & LaCoursiere, 2008; Ferrell et al., 2005; Robinson, 2004; Wallace et al., 2009; Walsh & Hogan, 2003). Some studies included an experiential component of writing poetry (Dakin, 2003), seeing cadavers (Birkholz, Clements, Cox, & Gaume, 2004; Mallory, 2003), visiting funeral homes (Birkholz et al., 2004; Thompson, 2005), and role-play (Frommelt, 2003). Inclusion of EOL content into existing curricula improved the comfort levels (Allchin, 2006; Kwekkeboom et al., 2005; Thompson, 2005), knowledge (Birkholtz, 2004; Kwekkeboom et al., 2005; Wallace et al., 2009), and attitudes (Barrere et al., 2008; Frommelt, 2003; Kwekkeboom et al., 2005; Mallory, 2003) of nursing students toward death and dying. However, those studies represented small samples, weak designs, minimal or no experience in patient and family care settings, and tested only for knowledge of didactic content. The purpose of the current study was to examine the effects of a clinical hospice experience on senior-level nursing students’ attitudes toward death and their perceived competency in providing EOL care.
This mixed-methods study used an experimental pretest–posttest design to evaluate the effects of the hospice experience within and between groups and included a qualitative component. Demographic characteristics and pretest scores for the intervention and control groups were analyzed for the impact of potentially confounding variables, such as age, religion, ethnicity, and previous experience with death.
The setting for the current study was a required Leadership/Management course in a faith-based university in the southwestern United States. The course was offered in the final semester of the baccalaureate nursing program. The university is a federally designated Hispanic population–serving institution. This study was approved by the university’s institutional review board.
A convenience sample of 61 students was recruited over two consecutive semesters. Students were randomly assigned to two groups. Both groups participated in the hospice experience, with Group A participating in the first 2 weeks of the semester, and Group B participating in the second 2 weeks. More than half of the students were Hispanic (n = 36; 59%), and the majority were female (n = 56; 92%), Catholic (n = 36; 59%), and 25 years or younger (n = 42; 69%).
Two self-administered instruments were used for data collection. The Attitudes Towards Death Survey (Strumpf, 1999) is a 28-item Likert scale questionnaire with five choices for each item, ranging from 1 = strongly agree to 5 = strongly disagree. The instrument is divided into three subscales, with one subscale measuring attitudes and the other two subscales measuring problems in EOL care and improvements needed in EOL education. Statements in the attitude subscale include “I am not comfortable caring for dying patients” and “When a patient dies, I feel something went wrong.” The tool is scored so that the lower the number in the attitude subscale, the better the attitude. The tool has been used by the current study’s author in an unpublished pilot study, and the Cronbach’s alpha reliability coefficient was 0.717 in a sample of 27 students. The Cronbach’s alpha for the current study was 0.741 when analyzed at the second data collection point.
The second instrument—the End-of-Life Competencies Survey—was developed by the City of Hope as part of the End-of-Life Nursing Education Consortium (ELNEC) project. The tool consists of five demographic items (age, gender, religion, ethnicity, prior death experience) and 14 Likert-type questions, regarding perceived competency, with a choice of five responses for each item, ranging from 1 = not at all effective to 5 = very effective. Questions include “How effective do you believe you are in pain management?” and “How effective do you believe you are in communicating with terminally ill patients?” The tool is scored so that the higher number reflects more competence. When this tool was used by the current study’s researcher in an unpublished pilot study of 27 nursing students, the Cronbach’s alpha was 0.900. Internal consistency reliability analysis for this study revealed a Cronbach’s alpha of 0.906 at baseline and 0.878 at the midpoint collection.
Data were collected from student reflection assignments. Student reflections, which were completed at the end of the 2-day experience, addressed attitudes, skills, anxiety about the experience, and a discussion of how the experience may change future action. These qualitative data were analyzed for themes to supplement quantitative findings.
The purpose of the study was described to potential student participants orally and in writing by the researcher, who was not involved in teaching the course, on the day of clinical orientation. Those students who volunteered completed the instruments. Students in each class were randomly assigned using an SPSS® software feature to either group A or group B. Following baseline data collection, one half of the group (group A) started the 2-day hospice experience (one 8-hour day each week for 2 weeks), whereas group B continued with scheduled clinical experiences. At the end of 2 weeks, the tools were readministered to both groups during a scheduled class time. Group B then participated in the 2-day hospice intervention. The instruments were administered a third time to all the study participants after group B had completed the hospice experience and 2 weeks after group A had completed their hospice rotation.
Preceptors were recruited at a staff meeting at a hospice agency before the students began their clinical experience. Preceptors served as role models for the students.
No statistically significant differences were found between the two groups at baseline in demographics or related to mean scores for attitudes and competencies. No statistically significant relationship was found between age, ethnicity, religion, and previous experience with death and attitudes or competencies at baseline for all students.
Quantitative data were analyzed using descriptive statistics, and a paired t test was used to assess differences in pre- and post-hospice experience mean scores. A statistically significant difference was noted in mean scores of attitudes from before the hospice experience (M = 25.24, SD = 3.69) and after the hospice experience (M = 23.19, SD = 3.64 [t = −4.29; df = 57; p < 0.001]. These results suggest a positive change in attitude toward death following the hospice experience. Although competency scores improved slightly after the intervention, the difference was not statistically significant.
Student reflections supported quantitative findings and provided evidence or explanation for the effects of the hospice rotation on student attitudes and perceived competencies. Some students indicated an interest in working in hospice care, which they had not considered before the experience. Many student reflections indicated more comfort in caring for the dying patient, less need to avoid the rooms where patients are dying, and feeling empowered to actively engage in the care of a dying patient. One student summarized:
I believe that I will now be more comfortable addressing death. It does not seem as much of a taboo to me as it did before. I believe that I am more comfortable with talking about death, informing patients and families that death may be the end result of a condition, and I now better understand how to talk to families about death. I have been in death situations before when I avoided the patients family (in clinical); however, I now know how to speak with the family and provide comfort and coping techniques.
In addition, all students reported learning new skills during the clinical experience in the hospice setting, which contradicts quantitative findings related to competencies. Of note, in their reflections, the skills the students reported learning (i.e., compassion, caring, roles) were not skills measured in the survey. Students learned about the roles of the social worker and chaplain and the importance of including the family in the care plan. They also learned about compassion. One student wrote:
I witnessed an amazing level of compassionate bedside manner, along with appropriate use of therapeutic touch. I think these are priceless qualities that each and every nurse must have no matter what area of the nursing profession they are working in.
Student reflections were saturated with comments about changed attitudes about death. One student said:
The experience I had today in hospice really opened my eyes to the reality of the end stage of life. The day led me to look deeper into my beliefs and spirituality, and I felt that it not only strengthened my faith but gave me a fresh outlook on the palliative aspect and the need for comfort for a dying patient.
Another student reflected:
I believe that a hospice rotation is the only reason why I have any beliefs about caring for dying patients. Before, the beliefs were all speculation and not based on any real-world experience I have had. After hospice I can say that there is no way to cure every patient. For most nurses and health care professionals, it is sometimes hard to cope with the fact that medicine can only do so much [and that] death is inevitable for us all. Now I know that death is not always sad. For some families, death is a way to end the suffering their loved ones are going through, and for some it is still hard to let go. Even though we cannot cure some dying patients, we can still keep them from pain and suffering. This has definitely helped me to see death in a different way.
Hospice is an appropriate placement in the final semester of a student’s nursing curriculum, although it requires strong advocacy by faculty to achieve inclusion. Two days for the hospice experience is a short time; a longer period would be better, except for the already overflowing curriculum. This study found that a 2-day planned experience with dying patients in a hospice setting had a statistically significant effect on attitudes toward death. The competencies (as measured by the End-of-Life Competencies Survey), although not significant, showed evidence of improvement after the intervention. An objective test of knowledge before and after the intervention may be a more accurate way to assess competencies than self-report. A larger sample or a longer intervention may have a greater effect on competence.
The analysis of student comments for a changed attitude toward death overwhelmingly supported the quantitative findings. The new skills learned that were most frequently mentioned in student reflections related to compassion, caring, and family involvement, which were not competencies measured on the quantitative tool.
Research on outcomes of educational strategies in EOL care is scarce. More research is needed on how nursing education can best prepare students to function in EOL situations. It is important for students to have an experience with dying patients built in to the curriculum. More studies with larger heterogeneous samples are needed to test the relationship of the length of time of immersion in the experience and attitudes. In addition, longitudinal studies are needed to determine whether the change in attitude is sustained over time.
Increased knowledge and newly transformed attitudes about death have the potential for improving EOL care for dying patients in all practice settings.
- Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice and Palliative Nursing, 8, 112–117. doi:10.1097/00129191-200603000-00015 [CrossRef]
- Barrere, C.C., Durkin, A. & LaCoursiere, S. (2008). The influence of end-of-life education on attitudes of nursing students. International Journal of Nursing Education Scholarship, 5(1), Article 11. doi:10.2202/1548-923X.1494 [CrossRef]
- Beck, C.T. (1997). Nursing students’ experiences caring for dying patients. Journal of Nursing Education, 36, 408–415.
- Birkholz, G., Clements, P.T., Cox, R. & Gaume, A. (2004). Students’ self identified learning needs: A case study of baccalaureate students designing their own death and dying course curriculum. Journal of Nursing Education, 43, 36–39.
- Chen, Y.C., Del Ben, K.S., Fortson, B.L. & Lewis, J. (2006). Differential dimensions of death anxiety in nursing students with and without nursing experience. Death Studies, 30, 919–929. doi:10.1080/07481180600925351 [CrossRef]
- Dakin, C.L. (2003). Encouraging student nurses’ creative expression about end-of-life experiences. Nurse Educator, 28, 149–150. doi:10.1097/00006223-200307000-00001 [CrossRef]
- Ferrell, B., Virani, R. & Grant, M. (1999). Analysis of end-of-life content in nursing textbooks. Nursing Oncology Forum, 26, 869–876.
- Ferrell, B.R., Virani, R., Grant, M., Rhome, A., Malloy, P., Bednash, G. & Grimm, M. (2005). Evaluation of the End-of-Life Nursing Consortium undergraduate faculty training program. Journal of Palliative Medicine, 8, 107–114. doi:10.1089/jpm.2005.8.107 [CrossRef]
- Frommelt, K.H. (1991). The effects of death education on nurses’ attitudes toward caring for terminally ill persons and their families. The American Journal of Hospice and Palliative Care, 8(5), 37–43. doi:10.1177/104990919100800509 [CrossRef]
- Frommelt, K.H. (2003). Attitudes toward care of the terminally ill: An educational intervention. American Journal of Hospice and Palliative Care, 20, 13–22. doi:10.1177/104990910302000108 [CrossRef]
- Kaye, J., Gracely, E. & Loscalzo, G. (1994). Changes in students’ attitudes following a course on death and dying: A controlled comparison. Journal of Cancer Education, 9, 77–81.
- Kwekkeboom, K.L., Vahl, C. & Eland, J. (2005). Companionship and education: A nursing student experience in palliative care. Journal of Nursing Education, 44, 169–176.
- Mallory, J.L. (2003). The impact of a palliative care educational component on attitudes towards care of the dying in undergraduate nursing students. Journal of Professional Nursing, 19, 305–312. doi:10.1016/S8755-7223(03)00094-2 [CrossRef]
- Robinson, R. (2004). End-of-life education in undergraduate nursing curricula. Dimensions of Critical Care Nursing, 23, 89–92. doi:10.1097/00003465-200403000-00009 [CrossRef]
- Schlairet, M.C. (2009). End-of-life nursing care: Statewide survey of nurses’ education needs and effects of education. Journal of Professional Nursing, 25, 170–177. doi:10.1016/j.profnurs.2008.10.005 [CrossRef]
- Strumpf, N. (1999). Attitudes Towards Death Survey. Retrieved from http://www.promotingexcellence.org/pennsylvania/downloads/up03.pdf
- Thompson, G. (2005). Effects of end-of-life education on baccalaureate nursing students. AORN Journal, 82, 434, 437–440. doi:10.1016/S0001-2092(06)60339-6 [CrossRef]
- Wallace, M., Grossman, S., Campbell, S., Robert, T., Lange, J. & Shea, J. (2009). Integration of end-of-life care content in undergraduate nursing curricula: Student knowledge and perceptions. Journal of Professional Nursing, 25, 50–56. doi:10.1016/j.profnurs.2008.08.003 [CrossRef]
- Walsh, S.M. & Hogan, N.S. (2003). Oncology nursing education: Nursing students’ commitment of “presence” with the dying patient and the family. Nursing Education Perspectives, 24, 86–90.