Nurses spend more time in direct contact with patients and their families than any other medical professionals (Iglesias, Pascual, & Vallejo, 2013). Because 76% of dying patients are receiving nursing care at the time of their death, nursing students need to be prepared with the skills, knowledge, and attitudes to provide compassionate care and impart dignity to those who are dying (Moreland, Lemieux, & Myers, 2012). A review of the literature indicates that not only do many nurses feel underskilled and uncomfortable providing end-of-life care (Fallon & Foley, 2012), but 62% rated overall content on end-of-life care in their nursing curricula as inadequate (Hebert, Moore, & Rooney, 2011) and deficient in promoting the development of the necessary attitudes to care for dying patients (Wallace et al., 2009). Although some schools include death and dying issues throughout the curriculum, the average time devoted to death and dying is less than 15 hours (Dickinson, 2007). The most recent data report only 3% of nursing programs require end-of-life courses, leaving nursing students unprepared to handle death and to care for dying patients and their families (Peterson, Johnson, Scherr, & Halvorsen, 2013; Wallace et al., 2009), forcing most nurses to rely on job experience to fill the gap (Caton & Klemm, 2006).
Attitudes toward caring for dying patients can affect the quality of care provided to patients and their families at the end of life (Peters et al., 2013). An ill-prepared nursing student is more likely to avoid terminally ill patients, thus creating a sense of isolation in the dying patient (Huang, Chang, Sun, & Ma, 2010). Improving the quality of care for a dying patient includes providing for a peaceful death by offering an empathetic presence, listening, and implementing comfort measures and symptom control (Aradilla-Herrero, Tomas-Sabado, & Gomez-Benito, 2012). For these reasons, it is imperative that nursing students display positive attitudes toward caring for dying patients.
The International Council of Nurses (2012) mandates that nurses have a responsibility to be knowledgeable and skilled in providing care to dying patients and their families, but a survey of United States nursing faculty revealed that students are not prepared to provide end-of-life care (American Association of Colleges of Nursing [AACN], 2016). The AACN (1998) identified 16 palliative care competencies that every nursing student needs to attain prior to graduation.
One approach that may have the potential to address end-of-life care is the use of simulation. Simulation is defined as a recreation of a clinical scenario in an artificial setting (National Council of State Boards of Nursing, 2009). As an active learning strategy, simulation can introduce novice students to the process of being able to identify individual aspects of patient care situations that may alter the manner in which nursing care is provided (Bambini, Washburn, & Perkins, 2009). Sperlazza and Cangelosi (2009) noted that simulated experiences are specifically beneficial when handling emotionally charged issues, such as end-of-life care. Study results by Smith-Stoner (2009) show that simulations offer important opportunities for students to explore their own ideas about death and what it means to care for patients who are dying, to overcome fears, and to develop clinical skills. However, more research with this population is needed. Therefore, the current study examines baccalaureate nursing students' attitudes toward caring for dying patients and their families before and after participating in an end-of-life care simulation exercise. The study addresses the following research question: Will participation in an end-of-life care simulation result in more positive attitudes in nursing students toward caring for dying patients and their families?
The transformational learning theory, used to guide the study, postulates changing existing assumptions, attitudes, and beliefs using rational discourse and critical reflection (Mezirow, 2000). This theory provides a guide for educators to influence attitudes using critical reflection and focuses on attitudes as an important component in learning (Morris & Faulk, 2012).
Design and Participants
Institutional review board approval was obtained prior to the study, and a pretest–posttest 1-group design was used. Participants were a convenience sample of second-semester baccalaureate sophomore nursing students (N = 57) enrolled in a fundamentals nursing course in a metropolitan school of nursing. Students were informed about the study purpose, that participation was voluntary and would not affect their grade, and that the data would be reported in aggregate form with no identifiers to link them to their responses. Students were asked to complete a Likert-scale survey instrument pre- and postparticipation in an end-of-life care simulation exercise.
Attitudes toward caring for dying patients were measured pre- and postsimulation using the Frommelt Attitudes Toward Care of the Dying Scale-Form B (FATCOD-B) after obtaining written consent from the author (Frommelt, 2003). The FATCOD-B has been used nationally and internationally in prior research with nurses and undergraduate nursing student populations (Dobbins, 2011; Hasheesh, AboZeid, El-Said, & Alhujaili, 2013; Lange, Thom, & Kline, 2008; Leombruni et al., 2014). The FATCOD-B is a self-reported questionnaire consisting of 30 items scored on a 5-point Likert scale with an equal number of positively and negatively worded statements (Leombruni et al., 2014). Twenty items relate to nurses' attitudes toward the dying patient (e.g., feelings and beliefs about end-of-life care), including patient decision making, emotional involvement with the patient's experience, and pain management. Ten items relate to attitudes toward the patient's family (e.g., care of the patient's family and the family's role in care of the dying patient; Frommelt, 1991; Leombruni et al., 2014). Possible scores can range from 30 to 150, with a higher score indicating a more positive attitude toward caring for dying patients (Hasheesh et al., 2013). Psychometric properties of the FATCOD-B have been assessed multiple times in the literature. In a study by Ho, Barbero, Hidalgo, and Camps (2010), the FATCOD-B yielded a content validity index of 1.0, a Pearson's coefficient of 0.927, and an interrater agreement of 1.0. Principal component analysis of the FATCOD-B yielded four factors and questionable internal consistency in a study by Leombruni et al. (2014). Cronbach's alpha for nine items described as Factor I “Emotional Engagement,” was .72, for six items describing Factor II, “Beliefs About End-of-Life Care,” was .68, for four items describing Factor III, “Beliefs about Professional Boundaries,” .71, and for six items described as Factor IV, “Beliefs and Feelings about Dying,” .11. Items 9, 12, 23, 27, and 30 had loadings below the cut-off of .40 in the analysis.
Procedure and Implementation
An end-of-life care simulation was developed by the author. Jeffries' framework (2005) was used to design, implement, and evaluate the simulation. The simulation included high-fidelity simulation, Laerdal SimMan® 3G as a dying patient with terminal lung cancer, and a standardized actor who portrayed the patient's wife. The standardized actor received a written script and provided learner support by cueing students to meet the simulation objectives. The objectives focused on three of the AACN (1998) palliative care competencies:
- Competency 2: promote the provision of comfort care to the dying as an active, desirable, and important skill, and an integral component of nursing care.
- Competency 3: communicate effectively and compassionately with the patient, family, and health care team members about end of life issues.
- Competency 4: recognize one's own attitudes, feelings, values, and expectations about death and the individual, cultural, and spiritual diversity in these beliefs and customs.
Prior to this simulation experience, students had no other experience with simulation. Students were oriented to the Sim-Man® 3G and presented the patient scenario in case study format immediately before participation in the simulation.
Case. Mr. John Roberts is a 59-year-old Catholic Caucasian man who is admitted today to the inpatient hospice unit for end-of-life care with a diagnosis of end-stage metastatic lung cancer. His current medication includes Roxanol® 10 mg sublingual every 4 hours. He has a Do Not Resuscitate order. His wife is at the bedside crying and asking, “Is he going to die now?” She states she could not take care of him at home, saying “It was too much for me.”
Students participated in the scenario in groups of three and assumed the roles of nurse, nursing student, and observer. The actual simulation scenario lasted 15 minutes. The patient demonstrates physical signs and symptoms of imminent death and begins as being restless. The scenario progresses and the patient becomes lethargic, exhibits a decrease in heart rate, Cheyne–Stokes respirations, skin mottling, increased respiratory secretions, and decreased urine output, and then the patient dies. The patient's wife is crying and asks, “Is he gone?” After responding, the expectation was that students would offer to contact a clergy member for spiritual support.
Students participated in a 20-minute debriefing session, using the debriefing for a meaningful learning model, immediately following the simulation scenario. The debriefing for meaningful learning is a process that uses reflection to generate new ways of thinking from simulation experiences (Dreifuerst, 2012). The total time to complete all phases was 40 minutes.
Data analyses were performed using SPSS-version 21 software. Descriptive statistics were calculated for characteristics of the student participants. Pre- and post-FATCOD-B mean scores were compared using repeated measures of ANOVA. The significance level was set at p < .05. Factor structure and Cronbach's alpha were computed as described in the literature (Leombruni et al., 2014).
Participants were predominantly young (72% were between ages 18 and 22 years), were Catholic (61%), and were women (88%) who had no personal experience with death (67%). Although 74% reported having previous education on death in the classroom, 75% had no experience caring for the dying. The vast majority (i.e., 94.7%) were not anticipating a loss at the present time. The 30-item FATCOD-B posttest mean score of 4.21 was significantly different than the mean on the pretest of 4.05, p < .001. The mean posttest score on Factor IV (3.85) was significantly different than the mean on the pretest (3.54), p < .001, and was responsible for explaining 37% of the changes from pretest to posttest. Factor I (p = .009) and Factor II (p = .007) were also significantly larger from pre- to posttest. These results demonstrate that Factors I, II, and IV and on the overall 30-item FATCOD-B, students reported a more positive attitude toward caring for dying patients postintervention. In contrast, Factor III resulted in decreased scores from pretest (4.37) to posttest (4.31), p = .26 (Table). Cronbach's alpha was .79 for Factor I, .61 for Factor II, .44 for Factor III, and .46 for Factor IV, and are comparable to Leombruni et al. (2014).
Repeated Measures of ANOVA for Pretest and Posttest Scores on the Frommelt Attitudes Toward Care of the Dying Scale-Form B (FATCOD-B)
During the debriefing session, students verbalized experiencing emotions of fear, helplessness, and anxiety during the simulation (AACN Competency 4, 1998). Students reported valuing life and an ambivalence toward administering pain medication fearing hastening death. After the simulation, students expressed greater confidence in recognizing the signs and symptoms of imminent death, conducting a physical and psychosocial assessment, providing comfort care, and communicating with a dying patient and his or her family (AACN Competencies 2 and 3, 1998).
The results indicated that the overall attitudes of students improved significantly from the pretest to posttest following a simulation exercise on end-of-life care. The findings are consistent with findings from previous studies that showed simulation improves nursing student attitudes. Students who participate in simulation are more confident and have decreased anxiety levels, and these experiences facilitate the development of enhanced communication skills and challenge students' attitudes toward situations (Alfes, 2011; Bremner, Aduddell, & Amason, 2008; Gilliland, Frei, McNeill, & Stovall, 2012). As a result, students are better prepared and possess more positive attitudes toward caring for dying patients and their families.
Several limitations were identified within this study. A small convenience sample (N = 57) from a single institution limits the generalizability of the research findings. Self-reported data from surveys that may be influenced by response bias is another limitation. Changes in student attitudes were measured short term, and it cannot be inferred that attitudes are transformed long term. In addition, it is also impossible to determine other confounding variables that may have influenced student attitudes such as prior knowledge (N = 42 reported death education was included in other courses).
Nursing education has shifted toward ensuring nursing students meet competencies regarding end-of-life care. The AACN (2016) has established competencies related to end-of-life care and recognizes the dynamic changes in population demographics, health care economics, and service delivery that necessitate improved professional preparation for end-of life-care. Despite these efforts, end-of-life care in nursing curricula is often neglected. End-of-life education is essential and should be purposefully included in every nursing curriculum.
This research project strongly supports the use of simulation as an active learning strategy to teach end-of-life care and improve nursing students' knowledge and attitudes toward caring for dying patients and their families. Some studies suggest having a positive attitude may improve the quality of care at the end of life but further research is needed in this area (Hasheesh et al., 2013; Peters et al., 2013). It is recommended that student attitudes continue to be measured over time to determine whether repeated interventions are needed to effect long-term changes in attitudes. It is also recommended that the simulation exercise could serve as a model to other schools of nursing and foster more positive attitudes in nursing students toward caring for dying patients. In addition, replicating this research using a larger sample would only strengthen the research findings.
There is overwhelming evidence in the literature that nurses are not prepared to care for dying patients. The findings of this research study suggest that incorporating an end-of-life care simulation exercise into nursing curricula significantly improved student attitudes toward caring for dying patients. Research has demonstrated that attitudes related to end-of-life care are formulated during a nursing student's educational program (Kurtz & Hayes, 2006). Therefore, to improve quality of care at the end of life, nurses must demonstrate the knowledge, skills, and attitudes to care for these patients and their families. Simulation is an active learning strategy to incorporate end-of-life care in nursing curricula and improve student attitudes toward caring for dying patients.
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Repeated Measures of ANOVA for Pretest and Posttest Scores on the Frommelt Attitudes Toward Care of the Dying Scale-Form B (FATCOD-B)
|Factors (FATCOD-B)||Pretest Mean||Posttest Mean||F(1,56 df)||Probability||Partial Eta Squared|
|I. Emotional Engagement||3.95||4.11||7.44||.009||.12|
|II. Beliefs about End-of-Life Care||4.30||4.49||7.79||.007||.12|
|III. Beliefs about Professional Boundaries||4.37||4.31||1.31||.260||.02|
|IV. Beliefs and Feelings about the Dying||3.54||3.85||32.97||<.001||.37|