Advanced practice nurses (APNs) play a pivotal role in helping bereaved families in the resolution of their grief (Glass, 1993; Meier & Beresford, 2006; Shea, Grossman, Wallace, & Lange, 2010). Spiritual and religious beliefs and practices may ease an individual's period of crisis during bereavement (Draper, Holloway, & Adamson, 2013). Spiritual bereavement care may also enable people to express their fears and anxieties. Furthermore, spiritual bereavement care provides the opportunity for professional caregivers to assist individuals in finding a purpose in life, regardless of their spiritual or religious beliefs (Bensing, 2013; Lomas, Timmins, Harley, & Mates, 2004). Advanced practice nurses (APNs) have opportunities to address the spiritual needs of the bereaved and to improve the quality of spiritual bereavement care (Chrash, Mulich, & Patton, 2011; Coyne, 2003; Dosser & Nicol, 2014; Glass, 1993; Hardy-Bougere, 2008; National Association of Clinical Nurse Specialists, 2013; Paice et al., 2006). This article describes the integration of spiritually based bereavement care into the master's degree clinical nurse specialist (CNS) and nurse educator degree clinical courses at a southern California faith-based health care teaching institution.
Gaps in Graduate APN Spiritually Based Bereavement Care Education
Despite the development of position statements and national standards, such as the End-of-Life Nursing Education Consortium's (ELNEC, 1999) statement on bereavement education, many graduate programs have not addressed gaps in spiritually based bereavement care education. Specifically, advanced nursing practice curriculums often fail to incorporate spiritual intervention skills. Few resources exist to aid in the development of a spiritual bereavement care curriculum. The development of student learning modules and evaluation plans may aid in improving the quality of graduate APN education and role functioning skills (Paice et al., 2006; Wright, 2011).
Assessment and revision of a graduate advanced practice curriculum provided the impetus for the development of new curriculum modules. Faculty sought to strengthen students' ability to identify and respond to students' personal spirituality and sources of meaning, as well as those of bereaved patients and family members. The new curriculum used the constructivist paradigm of educational theory. Constructivism asserts that students build their understanding of the world through experience and reflections. Students assess, explore, and ask questions to reconcile new information with their knowledge of the world through active teaching techniques and activities. In this way, students engage in real-world problem solving through the guidance of the instructors (Educational Broadcasting Corporation, 2004).
Presession One Assignments
Before session one, faculty asked students to complete specific presession assignments, including required readings, a Web quest activity, and a case study. The Web quest activity provided a contextual understanding of the core content through searching for recent literature outlining spiritually based bereavement care interventions. Students were expected to apply information gained from these assignments to a patient-based case study.
Session One Classroom Activities
Session one focused on the prospective practitioner's personal examination of self, including spiritual histories, attitudes, beliefs, and perspectives. Students examined a variety of spiritual assessment tools to promote student understanding of the importance of spiritual application to one's personal life. Students were asked to conduct a self-assessment, using the JAREL Spiritual Well-Being Scale.
The JAREL Spiritual Well-Being Scale seeks to measure an individual's spiritual well-being and includes 21 statements based on a study of spiritual well-being in older adults. To develop this scale, researchers used factor analysis, conducting 31 in-depth interviews over 18 months and including 150 hours of participant observation of adults age 65 to 85 years, with varying belief systems and settings. From factor analysis, researchers identified the following wide-ranging aspects of spiritual well-being: faith and belief dimension, life and self-responsibility, and life satisfaction and self-actualization. The validity of the categories of emergent data developed through consensus between the researchers (Hungelmann, Kenkel-Rossi, Klassen, & Stollenwerk, 1996).
Following self-assessment, students shared experiences from using the scale, identifying potential personal internal and external strengths and resources. Students reflected on a time in their lives identified as spiritual or deeply meaningful. Included in the dialogue were students' relationships with self and others, nature, and God, and how these processes integrated into the personal dimensions of mind, body, and spirit. Faculty encouraged students to identify potential strengths and weaknesses as a potential professional spiritual caregiver for the bereaved based on students' knowledge of the various needs of bereaved individuals. Faculty provided opportunities for one-on-one and group conversations, allowing students the opportunity to identify more fully the scope of their spirituality (Burkhard & Hogan, 2008; Feldstein, Grudzen, Johnson, & LeBaron, 2008).
Faculty introduced the integration of spirituality into advanced nursing practice using three levels. At a general level, applicable to all clients, instruction sought to strengthen student skills in focusing their attention toward identifying and responding to what matters most for the bereaved. At a second level, students learned to identify family members needing a spiritual bereavement assessment. Students learned to explore sources of hope, strength, and meaning, along with their spiritual and religious beliefs (Matzo et al., 2003). Level three involved follow-up activities that included discussions and interventional application of a scenario describing a client's significant loss progression while undergoing complex management of a chronic, end-of-life illness. At the end of this meeting, students responded on paper and with each other, relating to the process of grief and loss (Egan & Arnold, 2013; Matzo et al., 2003).
Session two focused on the effectiveness of professional caregiver roles and processes. Specifically, this session addressed training in advanced communication skills, coping with difficult situations and gaining greater understandings of the psychological needs and spiritual meaning of the loss to bereaved individuals. Finally, the importance of a caring attitude, the ability to use active listening, and the importance of spiritual application to the bereavement process was acknowledged (Burkhart & Hogan, 2008; Dosser & Nicol, 2014; Feldstein et al., 2008; Johnson, 2015).
Classroom Activities Session Two
Following completion of the required readings, students role-played a hypothetical, spiritually based bereavement care scenario in pairs (one playing the role of the bereaved and the other the role of the advanced practice nurse). During role-play, students were expected to demonstrate appropriate communication skills, as well as the ability to follow through with the expressed spiritual concerns shared by the bereaved individual. Students were then asked to take inventory of personal thoughts, feelings, and perceptions about end-of-life through self-reflection. Finally, students debriefed regarding the learning derived from each role-play scenario.
Session three focused on the need and process for APNs in leading, guiding, and directing spiritually based bereavement programs through the use of multidisciplinary teams. Course objectives sought to provide a discussion of interventions targeting individual levels of grief and the appropriateness of spiritual intervention at each level. Implementation of spiritual bereavement care through a multidisciplinary team also brought up issues of team member roles and the planning of organizational bereavement care programs for a variety of culturally based populations. Session three also addressed concepts such as active listening and therapeutic touch. Information provided sought to improve students' recognition of the meaning of loss to the bereaved from a personal holistic standpoint and the importance of allowing the bereaved time for reminiscence of their individual life story (Bognar & Reichert, 2006).
Classroom Activities Session Three
Following a viewing of a video of three families with terminally ill family members, faculty-guided discussion occurred regarding anticipatory bereavement and spiritual care needs. Meaningful dialogue from each clip provided students with a realistic view of providers' communication techniques when interacting with bereaved individuals. Various scenes provided a brief history of the patient's course of diagnosis, the course of disease and treatment, and family coping at the time of death and following the funeral. Instructors included several discussion questions, adapted from a variety of sources, to stimulate consideration of spiritual bereavement concepts (Bognar & Reichert, 2006; ELNEC, 1999).
Optional Clinical Practicum Experience
The optional clinical practicum experience evolved as students positively responded to the three classroom sessions. Specifically, some APN students expressed interest in finding clinical rotations in the areas of palliative care and hospice. Other APN students chose to apply the spiritually based bereavement care skills within their assigned clinical practicums in various health care settings. Students in palliative care and hospice reported being able to observe and interact with members of a multidisciplinary care team providing spiritual bereavement care. Students, with guidance from their preceptors, performed a variety of evidence-based bereavement care interventions. Evidence-based interventions supported students' ability to demonstrate proficiency and learning during the clinical experience. For example, students were expected to perform a spiritual assessment and follow-up of a family or individual's need for spiritually based bereavement care. In addition, students worked to develop spiritual intervention plans for APN involvement in the improvement of the provision of bereavement care within the facility. Some students identified staff learning needs and were involved in a variety of multidisciplinary team interventions at the organizational level. Although students had been provided with exposure to the variance in spiritual bereavement care needs of culturally diverse patients, the clinical practicum students did not track interventions and outcomes of cultural care.
The course instructor and clinical preceptors remained in constant contact with students to ensure that ongoing guidance occurred throughout the practicum experience. Students kept a written journal, recording the evidence-based interventions implemented, the rationale behind the interventions, and the time spent involved in the intervention. Further, students recorded ongoing reflections and personal thoughts. At the end of the experience, students completed a self-evaluation. Preceptors were also asked to evaluate the overall student clinical experience.
The curriculum is ongoing, and it has been presented to a total of 75 graduate nursing students over a 5-year span. Students have represented a wide variety of cultural, ethnic, religious, and scientific backgrounds. The content core was organized for three class sessions, using lesson plans to map out concepts and activities to ensure consistent content coverage. The method was used during CNS students' final advanced practice clinical course, conducted over a 10-week time frame. The curriculum consisted of 6 hours (three 2-hour sessions) including classroom instruction, directed readings, and submission of a variety of written assignments. In addition, an optional palliative care experience was offered in the hospital setting. During this time frame, CNS faculty taught the course as a team. Students collaborated in clinical rotations with palliative care teams at various local acute care facilities affiliated with the nursing school. To complete the CNS degree, students are required to complete 17 quarter units, or 580 clinical hours, per student. Student bereavement care experiences occurred within these quarter units, with most students averaging from 36 to 150 clinical hours specific to bereavement care. Students received academic credit for the clinical practicum based on satisfactory final evaluations.
Evaluation and Student Reflections
Although not formally assessed, instructors sought student feedback on the preclass assignments at the beginning of the first class session. Students verbalized comfort levels with both the content and the amount of work involved, and that they were helpful in preparing for the classroom learning activities.
A majority of students provided feedback on the spiritually based bereavement care content of the course through course evaluations. Students responded positively and consistently strongly agreed with the importance and clarity of the material. One student, writing about the overall course experience, stated:
This course was very powerful in creating a new vision for the diverse roles an APN can play in the inevitable and necessary journey we all find ourselves on, in our personal and professional lives.
The lectures, articles, videos and class interactions and activities were like a packaged learning to me. It made me [feel] in touch with the often morbid/evaded issue of loss [and] grieving in such a positive way.
Students also provided feedback on practicum experiences. Overall, a consensus of students reported the value of this experience. Allowing students the opportunity to experience the practical application of spiritually based bereavement care concepts enhanced their growth as APNs.
Conclusion, Implications, and Follow-Up Plan
Through this innovation, the authors found that a variety of learning activities addressing spiritual needs during the bereavement process was highly satisfactory to APN nursing students. The new spiritual bereavement care modules and the optional clinical practicum experiences allowed students to apply theory to practice and use evidence-based interventions when caring for individuals experiencing the need for spiritual bereavement care. The initial plan to integrate spiritual bereavement care into the advanced practice curriculum seemed formidable. Challenges faced in adding new modules to the curriculum included the need for a comprehensive review of the three-quarter course sequence, resulting in a reprioritizing of content. Faculty also obtained appropriate administrative approval. Lessons learned include the need to explore the length of time necessary to plan the entire process better before curriculum implementation. For example, implementation of the new format was designed to begin the year before it did. Appropriate planning to consider all aspects of development before implementation would allow for smoother classroom application and faculty acceptance. Including spiritual bereavement skills into the APN curriculum supported students' ability to provide holistic care to patients in a variety of settings.
- Bensing, K. (2013). Spirituality in nursing: Part 1—Enhancing the journey. Retrieved from http//www.advanceweb.com/Article/Spirituality-in-Nursing-Part1-Enhancing-the-Journey-2.aspx
- Bognar, S. & Reichert, J. (2006). A lion in the house: Discussion guide. New York, NY: Independent Television Service Publishing.
- Burkhart, L. & Hogan, N. (2008). An experiential theory of spiritual care in nursing practice. Qualitative Health Research, 18, 928–938. doi:10.1177/1049732308318027 [CrossRef]
- Chrash, M., Mulich, B. & Patton, C.M. (2011). The APN role in holistic assessment and integration of spiritual assessment for advance care planning. Journal of the American Academy of Nurse Practitioners, 23, 530–536. doi:10.1111/j.1745-7599.2011.00644.x [CrossRef]
- Coyne, P.J. (2003). The evolution of the advanced practice nurse within palliative care. Journal of Palliative Medicine, 6, 769–770. doi:10.1089/109662103322515275 [CrossRef]
- Dosser, I. & Nicol, J.S. (2014). Difficult conversations in bereavement. Nursing and Residential Care, 16, 693–697. http://dx.doi.org/10.12968/nrec.2014.16.12.693 doi:10.12968/nrec.2014.16.12.693 [CrossRef]
- Draper, P., Holloway, M. & Adamson, S. (2013). A qualitative study of recently bereaved people's beliefs about death: Implications for bereavement care. Journal of Clinical Nursing, 23, 1300–1308. doi:10.1111/jocn.12326 [CrossRef]
- Educational Broadcasting Corporation. (2004). Concept to classroom: Constructivism as a paradigm for teaching and learning. Retrieved from http://www.thirteen.org/edonline/concept2class/about.html
- Egan, K. & Arnold, R. (2003). Grief and bereavement care. American Journal of Nursing, 103(3), 42–52. doi:10.1097/00000446-200309000-00015 [CrossRef]
- End-of-Life Nursing Education Consortium, Super Core Curriculum. (1999). Module 7: Loss, grief, & bereavement. Retrieved from http://homecareinformation.net/handouts/hen/823_Presentation_Handout.pdf
- Feldstein, B.D., Grudzen, M., Johnson, A. & LeBaron, S. (2008). Integrating spirituality and culture with end-of-life care in medical education. Clinical Gerontologist, 31, 71–82. doi:10.1080/07317110801947185 [CrossRef]
- Glass, B.C. (1993). The role of the nurse in advanced practice in bereavement care. Clinical Nurse Specialist, 7, 62–66. doi:10.1097/00002800-199303000-00005 [CrossRef]
- Hardy-Bougere, M. (2008). Cultural manifestations of grief and bereavement: A clinical Perspective. Journal of Cultural Diversity, 15, 66–69.
- Hungelmann, J., Kenkel-Rossi, E., Klassen, L. & Stollenwerk, R. (1996). Focus on spiritual well-being: Harmonious interconnectedness of mind-body-spirit-use of the JAREL spiritual well-being scale. Geriatric Nursing, 17, 262–266. doi:10.1016/S0197-4572(96)80238-2 [CrossRef]
- Johnson, A. (2015). Analyzing the role played by district and community nurses in bereavement support. British Journal of Community Nursing, 20, 272–277. doi:10.12968/bjcn.2015.20.6.272 [CrossRef]
- Lomas, D., Timmins, J., Harley, B. & Mates, A. (2004). The use of pastoral and spiritual support in bereavement care. Nursing Times, 100(31), 34–35.
- Matzo, M., Sherman, D., Lo, K., Egan, K., Grant, M. & Rhome, A. (2003). Strategies for teaching loss, grief, and bereavement. Nurse Educator, 28, 71–76. doi:10.1097/00006223-200303000-00009 [CrossRef]
- Meier, D.E. & Beresford, L. (2006). Advanced practice nurses in palliative care: A pivotal role and perspective. Journal of Palliative Medicine, 9, 624–627. doi:10.1089/jpm.2006.9.624 [CrossRef]
- National Association of Clinical Nurse Specialists. (2013). Impact of the clinical nurse specialist role on the costs and quality of healthcare. Retrieved from http://www.nacns.org/wp-content/uploads/2017/01/CNSOutcomes131204.pdf
- Paice, J., Ferrell, B., Virani, R., Grant, M., Malloy, P. & Rhomme, A. (2006). Graduate nursing education regarding end-of-life care. Nursing Outlook, 54, 46–52. doi:10.1016/j.outlook.2005.04.003 [CrossRef]
- Shea, J., Grossman, S., Wallace, M. & Lange, J. (2010). Assessment of advanced practice palliative care nursing competencies in nurse practitioner students: Implications for the integration of ELNEC curricular modules. Journal of Nursing Education, 49, 183–189. doi:10.3928/01484834-20090915-05 [CrossRef]
- Wright, P. (2011). Innovations in bereavement education. Journal of Nursing Education, 50, 476–478. doi:10.3928/01484834-20110415-02 [CrossRef]