End-of-life (EOL) education is imperative, with professional organizations requiring the integration of EOL and palliative care competencies in curricula. In medicine, for instance, a directive by the Liaison Committee on Medical Education stipulates that EOL care be included in medical school curricula (Horowitz, Gramling, & Quill, 2014). Competencies in EOL communication with families and patients, EOL care management, and collaborative care are described across the spectrum of advanced practice nursing (APN) organizations (American Association of Colleges of Nursing, 2010; American College of Nurse-Midwives, 2014; National Organization of Nurse Practitioner Faculties, 2014). For pharmacy students, the Strategic Planning Summit for Pain and Palliative Care Pharmacy Practice 2012 consensus statement stipulates that case studies in all areas of pain and palliative care using interprofessional simulation should be developed and incorporated in curricula (Herndon et al., 2012).
Ensuring student competency in collaborative care is a critical competency, as clear evidence exists that communication gaps between caregivers are the single greatest source of medical errors (Khairat & Gong, 2010). Such a lack of collaboration in EOL care leads to physical and psychological complications and erosion of health potential and reflects disorganized EOL care management. A joint effort was undertaken by pharmacy and nursing faculty members at the University of Florida Colleges of Pharmacy and Nursing, Jacksonville to develop and assess a collaborative EOL simulation experience
The dying process in the United States is costly, both in the patient experience and in its financing. In 2013, the age-adjusted death rate for all races was 821.5/100,000 population (Xu, Murphy, Kochanek, & Bastian, 2016). The percent of Medicare enrollee deaths (age range 65 to 99) occurring in U.S. hospitals in 2012 was 22.1%. Further, in the final 6 months of life, an average of 10 days is spent in a skilled nursing facility prior to death (Dartmouth Atlas of Health Care, 2014). Although deaths in acute care hospitals decreased since 2003, specialty care and intensive care unit (ICU) use in the last month of life increased from 24.3% to 26.3%, with hospice use increasing from 21.6% to 42.2%. However, hospice stays were short, with 28.4% using hospice for 3 or fewer days (Goodman, Esty, Fisher, & Chang, 2011; Teno et al., 2013).
Nearly 33% of health care expenditures spent in the final year of life occur in the final month (Liesegang et al., 2002). Zhang et al. (2009) found the mean aggregate cost of care for patients who reported no EOL discussion with their physician was $2,917, greater than one and a half times the cost for those with EOL discussions about their plan of care ($1,876). Further, those with higher costs had a lower quality of death in their final week of life (Zhang et al., 2009). The national average cost for terminal inpatient spending per decedent during the hospitalization stay in which death occurred was $4,171 (Dartmouth Atlas of Health Care, 2014).
Typical sites of death include the home, an acute care hospital, and a nursing home, but a rising number are found in freestanding hospice care facilities or in-hospital hospice units (Teno et al., 2013). These care transitions often occur in the final 90 days of life, are preceded by an ICU stay (40.3%), and have increased from 2.1 to 3.1 per decedent (Teno et al., 2013). Overall, EOL care is expensive, poorly coordinated, and overly aggressive, and appropriate resources are underused.
EOL Transitional Care Needs
Since the mid-1990s, multiple initiatives have called for better coordinated and communicated plans for EOL care. These include the National Hospice Study, the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment, and the National Priorities Partnership. Subsequently, hospice programs grew from 2,300 to 3,500 between the years of 2000 and 2009 (Teno et al., 2013). However, studies still indicate the need for improved collaboration and communication in EOL care, especially in terms of facilitating patient transition and appropriate resource use.
Basic expectations for EOL care include an assessment of the patient's preferences for life-prolonging care, the determination of their advanced directive status, and the identification of a surrogate for health-related decision making. Fridh (2014) reported a 30-year history of consistent inattention to these EOL care components, blaming a lack of interdisciplinary collaboration and communication in the transition from cure to comfort care. In their survey study, Heyland et al. (2013) reported a profound lack of engagement by health care providers in EOL discussions with elderly clients. Although most participants (mean age = 80 years) report thinking of EOL care, of those who voice their feelings, only 30.3% and 55.3% do so with their physician or any health care team member, respectively (Heyland et al., 2013). Allison and Sudore (2013) described the failure of communication between patients and their physicians, reported in the study by Heyland et al. (2013) as an egregious medical error because it leads to treatments (e.g., CPR, intubation) that conflict with patients' wishes.
Interprofessional Education in EOL Care
The National Quality Forum, the Institute of Medicine, and the National Institutes of Health all promote an interdisciplinary approach to the use of palliative and EOL care for those with advanced illness (Johnson, Snaman, Cupit, & Baker, 2014). Outcomes of EOL communication and decision making depend on a shared mental model among all involved (i.e., the patient, patient's family, and caregiver team) to generate a patient-centric plan of care (Sinuff et al., 2015).
Multiple strategies are used to deliver EOL care education. An extensive review article by Gillan, van der Riet, and Jeong (2014) described those used with undergraduate nursing students and concluded that the best strategies are those that are purposely selected, include group discussion and reflection, and consider the level of student involved. Active and experiential learning is especially productive (Gillan, Jeong, & van der Riet, 2014). In a subsequent review of 16 studies focused solely on simulation in EOL care education, Gillan, Jeon, and van der Riet (2014) found four consistent findings:
- Simulation increases knowledge of EOL care through experiential learning.
- Use of family members in the simulations positively influences student learning.
- Debriefing is a critical component of the learning process.
- Methodological issues are inherent in simulation.
Of note, Gillan, Jeong, and van der Riet (2014) emphasized the importance of a structured debriefing process, focusing on objectives and clinical reasoning.
An interprofessional approach to EOL care education is one that is not as well-studied, especially in the arena of simulation. A literature review revealed how independent the approach to EOL care education is in the health care professions. Targets include surgical residents (Chipman, Beilman, Schmitz, & Seatter, 2007; Parickh et al., 2015), nursing students (Fluharty et al., 2012; Leighton & Dubas, 2009; Malloy, Paice, Virani, Ferrell, & Bednash, 2008), and pharmacy students (D'Souza, Lempicki, Mazan, O'Donnell, & Sincak, 2015; Gilliland, Frei, McNeill, & Stovall, 2012). Despite investigators acknowledging the importance of interprofessional approaches, most did not include roles outside of their own profession in their simulation studies. When they did (Gilliland et al., 2012), the roles were played by faculty rather than incorporating students from another profession.
Koo et al. (2014) evaluated the pedagogy of interprofessional simulation, focusing on pharmacy and nursing students, finding use of prescenario preparation, facilitator prompts during simulation, and facilitated debriefings to be useful strategies, echoing the findings of Gillan, Jeong, and van der Riet (2014). A pilot study of a comprehensive interprofessional (i.e., medicine, nursing, pharmacy, and physiotherapy) EOL simulation measured the impact of the experience on self-perceived changes in knowledge, psychomotor skills, self-efficacy, and competence in EOL communication, finding that only knowledge was significantly affected (Efstathiou & Walker, 2014). Investigators questioned the benefit versus the time and financial resources required by the endeavor.
The purpose of this project was to measure the impact of a paired interprofessional education (IPE) intervention and a simulation intervention on students' perceived EOL learning needs and EOL competencies as compared with a non-IPE traditional approach to educating students in EOL care competencies. In addition, for the subgroup exposed to IPE intervention, student perceptions of the interprofessional experience were assessed.
Kirkpatrick's four-level evaluation model was selected to frame the outcome measurement plan. Kirkpatrick described four levels at which learning processes could be evaluated. At level 1 (reacting), participant feelings and perceptions (e.g., satisfaction) are one measure of the simulation's effectiveness (Schumann, Anderson, Scott, & Lawton, 2001). Level 2 outcomes (learning) focus on assessing whether skills, knowledge, or attitudes change as a result of the learning activity. Level 3 (changing) is assessed by measuring the ability of the learner to put into practice the newly learned skills, and level 4 measures the impact of that performance on desired outcome domains, such as cost, quality, efficiency, and more. Although acknowledging the desire to assess the effectiveness of the simulation pedagogy on performance in the clinical settings and its impact on patient outcomes, such an assessment was determined to be beyond the scope of this project. Instead, the authors focused the evaluation of the pre- and postassessment of attitudes in those exposed to a simulation approach and a traditional paper-based case study approach to EOL care and, therefore, used a level 2 approach.
A focus on EOL care grew out of a collaborative partnership between faculty in the Colleges of Pharmacy and Nursing at the University of Florida. Faculty members selected EOL care as a high-priority area needing further integration in both curricula and sought to collaborate in an education experience that would engage both nursing and pharmacy students. The rationale echoed that of others, in that an interprofessional approach would facilitate participants' learning about each other's roles in EOL care, thus facilitating collaboration in later encounters with EOL care delivery (Lazenby, Ercolano, Schulman-Green, & McCorkle, 2012; Otis-Green et al., 2009). An interprofessional project team of five faculty members grew to include a statistician and nursing staff with experience with EOL curricula and simulation expertise.
A presurvey–postsurvey design with multiple groups was selected to assess students' perceived EOL learning needs (level 2 evaluation) before and after exposure to a series of four case-based EOL scenarios. For one group, the scenarios were delivered using simulation. The rest were exposed to traditional paper-based versions of the same scenarios. The education activity took place on four University of Florida campuses (A, B, C, and D). On the first three campuses (A, B, and C), only pharmacy students were exposed to the paper-based cases. On the D campus, both pharmacy and nursing students were exposed to interprofessional simulated versions of the case scenarios. Participants on all four campuses were exposed to the same pre-intervention preparatory materials, including the Oregon Death With Dignity Law, an online lecture describing the concept and competencies of EOL care, and background case information on the four scenarios used in the education activity. Approval for the study was sought, and exempt status was granted by the University of Florida Institutional Review Board (UFJ2014-179) at campus D.
The convenience sample consisted of 203 students. Of these, 158 were pharmacy students enrolled across the A, B, and C campuses. Another 37 pharmacy students were located on the D campus, as were the APN students enrolled in the Doctor of Nursing Practice program. The educational activity was part of the pharmacy students' curriculum. Eight APN students were recruited on a volunteer basis, with the educational intervention offered as an opportunity to expand their understanding of EOL care. The activity was not a graded assignment for either group, nor part of the APN curriculum.
The education intervention consisted of simulated EOL case-based scenarios that mirrored the paper counterparts. A standardized set of four case studies that were traditionally used by pharmacy faculty to teach law and ethical concepts in EOL care were modified by two of the authors (C.M., T.S.) for simulation delivery, and reviewed for adherence to the International Nursing Association for Clinical Simulation and Learning Standards of Best Practice, specifically Standard IV: Facilitation (Franklin et al., 2013) and Standard VI: The Debriefing Process (Decker et al., 2013), by project team members with simulation expertise. Modifications to the cases included verbal cues from actors used to prompt verbal responses from student participants. Both live actors and high-fidelity simulators were used.
Four case scenarios addressed common EOL care events, including:
- Demand for diagnostic surgery on a dying patient by a family member to a physician.
- A patient with a deteriorating disease who is being pressured by family members to continue an unwanted, painful, and futile treatment.
- Parents refusing life support, including tube feedings for their newborn with multiple anomalies.
- Unrelenting pain and suicide risk.
On the intervention day (October 29, 2014), students arrived to the simulation setting on campus D, or to their respective classroom on the A, B, or C campuses for the paper-based activity. Four bays within the simulation setting were set up to accurately reflect the respective health care setting indicated for each scenario. For instance, the newborn with anomalies scenario used a high-fidelity intubated infant simulator with respiratory and cardiac functions situated in a radiant heat examination bed, with working monitors, oxygen, suction, and other expected components found in the neonatal intensive care unit. On all four campuses, students provided consent and were given access to the online survey tools via Survey Planet® for pre- and postassessment.
The Lazenby's End of Life Professional Caregiver Survey (EPCS) was used on all campuses to assess attitudes toward EOL care. A second survey tool, the Readiness for Interprofessional Learning Scale (RIPLS), was administered pre- and postintervention to the simulation group only. The EPCS is a 28-item, 5-point Likert-scale tool (1 = not at all to 5 = very much). Higher scores reflect greater perceived skill in an EOL care area, and a score of 1 reflects the least, indicating that a learning need exists in that area. The tool is freely available, provided users include its reference. The tool is designed to identify educational needs, so a student responding not at all to the item “I am comfortable talking with other health care professionals about the care of dying patients” indicates that a learning need exists. In the posttest assessment, if the student responds very much to the same item, then it is presumed that learning has occurred and the need is reduced. The difference in pre- and postassessment between the campuses was the main outcome measure. Similarly structured and accessible, the RIPLS tool is a 19-item questionnaire with a 5-point Likert scale (1 = strongly agree to 5 = strongly disagree). The tool measures changes in health care student attitudes toward readiness for interprofessional teamwork and education following an intervention. Psychometric testing established 4 subscales: (a) teamwork and collaboration, (b) negative professional identity, (c) positive professional identity, and (d) roles and responsibilities (McFadyen, 2013). The RIPLS questionnaire was administered only to students in the simulation group at campus D because the other campuses did not include nursing students in the paper-based approach.
Students in the simulation group were divided into four groups of nine to 10, with two APN students and seven to eight pharmacy students per group. Groups rotated to each of the simulated scenarios. The simulated interactions lasted 5 to 8 minutes. For the paper-based groups in campuses A, B, and C, a similar time allotment was provided to review each paper-based case. On all campuses, each simulated or paper case was followed by a 20-minute faculty-facilitated structured discussion using a four-step ethical decision-making framework: (a) clarify the facts, (b) clarify the values, (c) determine the options, and (d) choose an option. For example, one set of questions called on students to frame responses using the Oregon Death With Dignity Act and asked them to describe the feelings expressed by the patient, whether the ordered medications were appropriate for a client who was strongly in favor of assisted suicide, and whether alternative management choices should be considered. After all student groups rotated through each simulation and discussion, both questionnaires were readministered electronically to the simulation group at campus D; participants on the other campuses were readministered the EPCS survey tool only.
Analysis of results from each questionnaire was undertaken. If participants completed only the pre- or the postquestionnaires, their data was removed from analysis. For the EPCS, a total of 175 completed questionnaires were analyzed: 140 from the three distance, paper-based groups and 35 from the simulation group). For each campus, pre- and postquestionnaire differences were analyzed using Wilcoxon signed rank tests.
Data from the A and C campuses were pooled as the tests were done at the same time with the same instructor, using distance technology. Frequency histograms were created and summary statistics were estimated. To compare across sites, Wilcoxon rank sum tests were used to compare the change in scores (posttest scores minus pretest scores) with the 28 questions.
Following the univariate analysis, a Bonferroni adjustment for multiple tests of hypothesis was undertaken to compare each p-value to an adjusted significance level. This is equal to the nominal significance level (e.g., 5%) divided by the number of tests performed (in this instance, 28) to give an adjusted significance level of 0.18% (i.e., the authors looked for any p-value less than or equal to .0018 that remained significant after the Bonferroni adjustment). This helped to control for Type 1 errors by reducing the chance a relationship was claimed where one did not exist.
For the RIPLS survey tool, completed by only the simulation group, 28 usable surveys were analyzed using univariate analysis, and no distinction was made for type of student. Wilcoxon signed-rank tests were used to determine the level of significance of changes from the pretest scores to the posttest scores.
Performance on the EPCS 28 items is organized by the survey tool's three subdomains, with items 1 through 12 reflecting patient and family-centered communication, followed by items 13 to 20 reflecting cultural and ethical values, and finally items 21 to 28 reflecting effective care delivery. Although all four groups experienced significant improvement across multiple items, a comparative analysis of the distant campuses of pharmacy-only students revealed no statistical differences in performance between groups; therefore, only two group comparisons (simulation versus paper) are reported in this article, as well as the performance of just the simulation group on the RIPLS survey tool. Table A (included in the online version of this article) describes the pre- and postperformance on each item for the simulation group. For all but two items, significant improvement existed in the mean scores of participants, reflecting greater perceived skill in an EOL care area.
Pre/Post Perceived EOL Education Needs of Interprofessional Simulation (D) Group
Table B (included in the online version of this article) describes the pre- and postcomparisons between the pooled paper-based groups and the simulation group, with the univariate analysis results listed in the third column. Those that remained significant following the Bonferroni adjustment are indicated in the fourth column of Table B. Overall, six items remained significant following the Bonferroni adjustment, with two in the patient and family communication subdomain and the rest in the culture and ethical values subdomain. None of the items in the effective care delivery subdomain demonstrated a significant difference between the simulation and paper groups.
Comparison of Interprofessional Simulation Versus Traditional Paper-Based Case Study Approach on Pre/Post Perceived End-of-Life Education Needs with Bonferroni Adjustment
Analysis of the RIPLS tool results demonstrated no significant differences in pretest and posttest scores on any of its 19 items. A particular weakness of the data was the lack of completion of the postsurveys by participants (two APN and 15 pharmacy students), requiring their exclusion from analysis. Due to small numbers, performance by the different types of students was not compared.
The primary focus of this education intervention was to assess the impact of pharmacy and nursing students collaborating to address simulated EOL ethical scenarios on perceived EOL learning needs. The EOL scenarios incorporated a number of best practices described in the simulation literature to bring traditional paper-based case studies to life for a cohort of pharmacy and APN students. This included use of prescenario preparation, integrating family members into three of the four scenarios, and postscenario facilitated discussion, which incorporated principles of simulation debriefing.
With nearly across-the-board improvement in perceived EOL learning needs in the simulation group, the results suggest that the simulation-based education experience proved useful in enhancing learning and attitudes in EOL care. Unfortunately, the anticipated role that an interprofessional environment would play in influencing those changes, however small, did not materialize, based on the RIPLS questionnaire results. Instead, the change in attitudes by students in the simulation group was more likely to have been influenced by the teaching strategy, simulation. The data do suggest that the traditional, paper-based case study format on the three distant campuses, although considered an active learning experience, was less influential on perceived learning compared with exposure to a lived experience with live actors and simulators. Of note, after statistical tests to reduce Type I errors, four of the six items remaining significant were in the ethical domain, the focus of the lesson.
An issue with which the project team became aware as the simulations unfolded was the considerable differences in foundational knowledge and experience between the pharmacy and APN students. Most of the APN students were experienced nurses, and some were previously exposed to and managed similar scenarios in their work setting. As a result, some jumped in eagerly during the scenarios or discussion afterward to counter statements put forward by pharmacy students. In essence, the perspective of the real world was proffered by the nursing students and the idealistic and often medically framed perspective of the pharmacy students.
Recent additions to International Nursing Association for Clinical Simulation and Learning's Standards of Best Practice for simulation include a new standard, Simulation Standard VIII: Simulation-Enhanced Interprofessional Education (Sim-IPE) (Decker et al., 2015). The authors emphasize the need for multiple experiences integrated throughout the curricula of the participants, as well as an assessment of institutional support and resources. In the current study, the authors were fortunate to have access to the simulation resources and personnel of the Center for Simulation Education and Safety Research that facilitated their efforts. As far as multiple experiences go, the team is collaborating on ways to integrate more interprofessional simulation efforts based on health care issues common not only to pharmacy and nursing but to medicine as well. A current focus of interest is on medication management.
The authors recognize that a number of limitations played a role in the outcomes that were generated. The data suggest it was the use of simulation, not the interprofessional aspect of the education intervention, that contributed to changing attitudes toward EOL learning needs in the group exposed to simulation. An explanation for this is failure to match the participant types. A better type of nursing student to involve in the simulations might be students enrolled in an accelerated Bachelor of Science in Nursing program, putting the different professional students on similar footing. In the future, the authors would also include the simulation as a part of the nursing curriculum, as it is for the pharmacy students. In addition, the entire education intervention lasted approximately 2 hours, and this may not be sufficient time for the different types of professional students to develop an appreciation for each other's roles.
It was apparent during the simulations that some students had not completed all the presimulation preparatory learning activities. An objective means of assessing student's preparation for the simulations is warranted to ensure all participants not only complete the preparatory activities but also achieve a baseline level of understanding before starting the simulation. Further, a knowledge-based posttest would be a more objective measure of learning from the perspective of Kirkpatrick's evaluation model rather than assessing perceived learning needs. Further research in this area should include a level 3 indicator, as well.
Simulation has well-established efficacy as an educational approach that facilitates a safe learning experience for students. IPE has a similar track record. Currently, evidence is growing so much that the synergy created by interprofessional simulation generates improvements in understanding each other's roles, team communication processes, and others, all leading to improved patient outcomes (Decker et al., 2015). Although the current study contributed to the impact that simulation has on changing learning needs about EOL care from an ethical perspective, the authors were unable to demonstrate similar evidence related to the interprofessional aspect. Additional research with greater attention to design features is warranted.
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Pre/Post Perceived EOL Education Needs of Interprofessional Simulation (D) Group
|Domain||Questionnaire Item||Pre Mean (SD)||Post Mean (SD)||p value|
|P1||I am comfortable helping families to accept a poor diagnosis.||1.66||2.46||<.0001|
|P2||I am able to set goals for care with patients and families.||2.40||2.57||.3936|
|P3||I am comfortable talking to patients and families about personal choice and self-determination.||2.40||2.74||.0841|
|P4||I am comfortable starting and participating in discussions about code status.||1.43||2.26||<.0001|
|P5||I can assist family members and others through the grieving process.||1.83||2.71||<.0001|
|P6||I am able to document the needs and interventions of my patients.||2.46||2.83||.0495|
|P7||I am comfortable talking with other health care professionals about the care of the dying patient.||2.26||2.91||.0006|
|P8||I am comfortable helping to resolve difficult family conflicts about end-of-life care.||1.31||2.63||<.0001|
|P9||I can recognize impending death (physiologic changes).||2.06||2.77||<.0001|
|P10||I know how to use non-drug therapies in management of patients' symptoms.||2.14||2.74||.0008|
|P11||I am able to address patients' and family members' fears of getting addicted to pain medications.||2.26||2.86||.0004|
|P12||I encourage patients and families to complete advanced care planning.||2.11||2.97||<.0001|
|C1||I am comfortable dealing with ethical issues related to end of life/hospice/palliative care.||1.54||2.57||<.0001|
|C2||I am able to deal with my feeling related to working with dying patients.||2.17||2.74||.0147|
|C3||I am able to be present with dying patients.||2.46||2.97||.0007|
|C4||I can address spiritual issues with patients and their families.||1.83||2.57||.0004|
|C5||I am comfortable dealing with patients' and families' religious and cultural perspectives.||1.94||2.60||.0012|
|C6||I am comfortable providing grief counseling for families.||1.31||2.43||<.0001|
|C7||I am comfortable providing grief counseling for staff.||1.34||2.40||<.0001|
|C8||I am knowledgeable about cultural factors influencing end-of-life care.||1.69||2.49||.0002|
|E1||I can recognize when patients are appropriate for hospice referral.||1.74||2.60||<.0001|
|E2||I am familiar with palliative care principles and national guidelines.||1.91||2.49||.0024|
|E3||I am effective at helping patients and families navigate the health care system.||1.43||1.91||.0059|
|E4||I am familiar with the processes hospice provides.||2.00||2.74||<.0001|
|E5||I am effective at helping to maintain continuity across care settings.||1.83||2.60||<.0001|
|E6||I feel confident addressing requests for assisted suicide.||0.86||1.77||<.0001|
|E7||I have personal resources to help meet my needs when working with dying patients and families.||1.37||2.31||<.0001|
|E8||I feel that my workplace provides resources to support staff who care for dying patients.||1.97||2.60||.0012|
Comparison of Interprofessional Simulation Versus Traditional Paper-Based Case Study Approach on Pre/Post Perceived End-of-Life Education Needs with Bonferroni Adjustment
|Domain||Questionnaire Item||p-value||Adjusted p-value|
|P1||I am comfortable helping families to accept a poor diagnosis.||.0173||N.S.|
|P2||I am able to set goals for care with patients and families.||.9999||N.S.|
|P3||I am comfortable talking to patients and families about personal choice and self-determination.||.9999||N.S.|
|P4||I am comfortable starting and participating in discussions about code status.||.0048||N.S.|
|P5||I can assist family members and others through the grieving process.||<.0001||<.0001*|
|P6||I am able to document the needs and interventions of my patients.||.9999||N.S.|
|P7||I am comfortable talking with other health care professionals about the care of the dying patient.||.0057||N.S.|
|P8||I am comfortable helping to resolve difficult family conflicts about end-of-life care.||<.0001||<.0001*|
|P9||I can recognize impending death (physiologic changes).||.0498||N.S.|
|P10||I know how to use non-drug therapies in management of patients' symptoms.||.9999||N.S.|
|P11||I am able to address patients' and family members' fears of getting addicted to pain medications.||.0347||N.S.|
|P12||I encourage patients and families to complete advanced care planning.||.0123||N.S.|
|C1||I am comfortable dealing with ethical issues related to end of life/hospice/palliative care.||.0007||.0007*|
|C2||I am able to deal with my feeling related to working with dying patients.||.0153||N.S.|
|C3||I am able to be present with dying patients.||.0116||N.S.|
|C4||I can address spiritual issues with patients and their families.||.0177||N.S.|
|C5||I am comfortable dealing with patients' and families' religious and cultural perspectives.||.0009||.0009*|
|C6||I am comfortable providing grief counseling for families.||.0007||.0007*|
|C7||I am comfortable providing grief counseling for staff.||.0011||.0011*|
|C8||I am knowledgeable about cultural factors influencing end-of-life care.||.0163||N.S.|
|E1||I can recognize when patients are appropriate for hospice referral.||.0231||N.S.|
|E2||I am familiar with palliative care principles and national guidelines.||.9999||N.S.|
|E3||I am effective at helping patients and families navigate the health care system.||.9999||N.S.|
|E4||I am familiar with the processes hospice provides.||.0216||N.S.|
|E5||I am effective at helping to maintain continuity across care settings.||.0034||N.S.|
|E6||I feel confident addressing requests for assisted suicide.||.9999||N.S.|
|E7||I have personal resources to help meet my needs when working with dying patients and families.||.9999||N.S.|
|E8||I feel that my workplace provides resources to support staff who care for dying patients.||.9999||N.S.|