Journal of Nursing Education

Syllabus Selections: Innovative Learning Activities Free

Improving Advance Care Planning Readiness Among Nursing Students

Kathleen Tilton, DNP, RN, CDCES, CNE; Lorena Paul, DNP, RN

The Institute for Healthcare Improvement (2015) encourages health care providers to accomplish their own advance care planning (ACP) and advance directives (ADs) prior to assisting clients. Personal experiences empower abilities to facilitate clients' accomplishment of ADs. The normalization of ACP and AD planning optimally begins during prelicensure programs. Without comprehensive preparation, nurses may not be prepared to advocate for client-centered care.

Learning Activities Informed by Theory, Laws, and Evidence

Baccalaureate nursing faculty designed an ACP and AD learning module within the context of a core nursing course focused on care of older adults and care coordination. Learning activities were developed with consideration for Bloom's (1956) taxonomy, federal and state laws, state-approved AD documentation templates, and evidence-based facilitation methods.

The goal was to increase students' ACP and AD readiness as evidenced by progressions in stages of change in accordance with the transtheoretical model (Prochaska & Velicer, 1997). Corresponding learning objectives included:

  • Discuss legal and ethical issues associated with ACP and AD.
  • Develop a problem statement related to the absence of AD.
  • Apply an evidence-based strategy to facilitate ACP and AD.
  • Evaluate preparedness to accomplish one's own AD.

Method and Materials

Prior to class, students accomplished assigned readings and watched a video about fictitious characters' experiences with AD. During the class, the students were divided into small groups. They completed an ACP and AD readiness presurvey, reviewed a brief synopsis of a landmark legal case, and facilitated short presentations about ACP and AD barriers and facilitators. The instructor and students reviewed the state-approved AD forms and role-played a scripted ACP discussion. Finally, the students repeated the readiness survey and documented their reflections.

Evaluation Method and Results

The evaluation method included analysis of 39 students' reflections and comparisons of the pre- and postsurvey results using the t test. Reflection themes included the importance of promoting clients' autonomy, increased understanding of ACP processes, and improved abilities to complete the AD forms. The pre- and postsurvey results indicate increased awareness of medical treatment goals and preferences (p < .001), as well as preparedness to discuss this information with others (p < .001). Moreover, the majority of students plan to discuss medical treatment goals and preferences with a health care provider (p < .002), seek more information about AD (p < .001), and document their own AD within the next 30 days (p < .001).


A combination of application, analysis, synthesis, and evaluation ACP and AD specific learning activities significantly increased nursing students' preparedness to accomplish their own ACP and ADs. Pre- and postsurvey results and reflections suggested increased readiness to advocate for patient-centered care within the interprofessional team. Recommendations include offering clinical practicum experiences to further enhance ACP and AD facilitation competencies. Optimally, all prelicensure nursing programs will utilize evidence-based methods and materials for the purposes of preparing students to accomplish ACP processes and to document their own ADs prior to assisting clients, as recommended by the Institute for Healthcare Improvement (2015).

Kathleen Tilton, DNP, RN, CDCES, CNE

Lorena Paul, DNP, RN
University of the Incarnate Word
School of Nursing and Health Professions


  • Bloom, B. S. (1956). Taxonomy of educational objectives: Book 1 cognitive domain. Longman.
  • Institute for Healthcare Improvement. (2015). “Conversation ready”: A framework for improving end-of-life care.
  • Prochaska, J. O. & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48 doi:10.4278/0890-1171-12.1.38 [CrossRef] PMID:10170434

The authors have disclosed no potential conflicts of interest, financial or otherwise.


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