Too often, families are thrust into critical medical situations that necessitate making decisions concerning a loved one without knowing the individual's desires. It is imperative that patients and families clearly communicate their treatment wishes to each other and to their health care providers before a crisis occurs. Unfortunately, dying in hospitals is not uncommon, despite research that shows most Americans prefer to die in their own homes (Hall, Levant, & DeFrances, 2013). Knowing that 25 percent of Americans have given little or no thought to expressing their end-of-life (EOL) wishes may contribute to this misalignment (Institute of Medicine, 2015).
Nurse educators are ideally suited to encourage future nurses to have conversations about EOL care wishes with patients before the patients experience a crisis. While a growing body of literature describes EOL care education, including simulation, among nursing undergraduates (e.g., Gillan, Parmenter, van der Riet, & Jeong, 2013) and, to a lesser degree, nursing graduate students (e.g., Northam, Hercelinskyj, Grealish, & Mak, 2015), most describe educating students about caring for dying patients, not about having EOL discussions well in advance of death. Therefore, the focus of this article is an innovative curriculum to educate graduate nursing students about EOL communication piloted at two nursing schools in the Northeast.
THE CONVERSATION PROJECT
The Conversation Project (TCP) is a national campaign to assist individuals in having conversations about their EOL care wishes (https://theconversationproject.org). TCP developed extensive free resources to help educate the public. The current project, a six-hour training program using TCP resources, educated 26 registered nurses in a graduate nursing program.
The program focused on a broad range of communication surrounding EOL care options and how to encourage conversations around this topic. The session format included a brief discussion of facts versus myths, role-play activities, film clips, written reflections, and focused small-group discussions. Based on a review of the literature, no other nursing schools have integrated TCP resources into their curricula. The project was approved by the institution's institutional review board, and students completed informed consent documents.
The study used an interdisciplinary approach with a research team that included nurse faculty from two different institutions, as well as a communication faculty colleague, who is also a physician assistant. A goal of the TCP team and the curriculum was to ensure that participation resulted in more than a six-hour experience. Thus, a participation grade was linked to two assignments designed to encourage students to actively apply what they had learned. The focus of the assignments was on students' abilities to disseminate TCP information and on self-reflections related to EOL communication. Reflections were written before and after the course.
Kolb's (2015) experiential learning theory was utilized to support this course enhancement. Kolb's model provides a framework for linking education, work, and personal development. "It offers a system of competencies for describing job demands and corresponding educational objectives, and it emphasizes the critical linkages that can be developed between the classroom and the real world with experiential learning methods" (pp. 3-4). Because students were able to connect with the topic, experiential learning theory provided the ideal structure for this innovative education. Utilizing the cutting-edge curriculum, relevant and meaningful links between the classroom and the students' work lives became apparent. Requiring reflective essays before and after the program demonstrated student assimilation and distillation of the information, "from which implications for action can be drawn" (Kolb & Kolb, 2005, p. 194).
SELF-REFLECTION
Self-reflection is commonly used to evaluate student learning during or following an event or clinical rotation. The current study assessed the expectations of students and practicing RNs about TCP before and after program participation. Thus, before students read any assigned materials related to TCP, their first assignment was to complete a reflection in Week 1 of the class. Course objectives included only broad references to populations and did not specify content related to EOL/palliative care. These reflections included a written description of students' expectations regarding their learning during the session and its relationship to their clinical efforts.
A service-learning approach was used for the second assignment during the second week. Within 48 hours following the program, students conducted a community outreach to assigned agencies. Students first role-played, explaining TCP to each other using a script; they then made phone calls to agencies, offering university-sponsored community-based TCP sessions. They answered questions and documented which agencies agreed to host a session. After sessions were conducted by the TCP team, students completed another reflection, focusing on what they had learned in the TCP program. Both sets of reflections were submitted electronically; a third party removed student names, paired the reflections, and coded them anonymously. Two researchers, a nursing and a social science faculty member who were not teaching the course, independently assessed the reflections.
OUTCOMES
The benefits of using this innovative approach were multifaceted. The nature of the assignments mandated that students focus on talking about EOL conversations. They role-played and reinforced their skills by talking with community agencies. Furthermore, their calls disseminated TCP in a time-effective manner by contacting multiple agencies concurrently. In one hour, seven student groups successfully recruited five agencies; 54 community members attended and participated in TCP sessions.
The students' first assignment was to complete a reflection before reading assigned materials related to TCP. To minimize bias, course objectives included only broad references to populations and did not specify content related to EOL/palliative care. In these reflections, the 26 students identified five major topic areas they expected to learn via the TCP program. Nearly all of the students described their desires to become more effective in EOL communication (88 percent) and/or to enhance their health communication skills (73 percent). Nearly half (46 percent) wanted clarity related to ideal contexts for EOL conversations (e.g., office, hospital room) and hoped to reduce their anxieties related to such interactions (42 percent). More than one third (38 percent) expected to learn about patient education in the course.
The second set of reflections focused on perceived course outcomes. Nearly half of the students (46 percent) documented new intentions to have EOL conversations with their families; 42 percent reported enhanced health communication skills; 38 percent reported feeling less anxious about having EOL conversations with patients/families, possessed enhanced readiness to initiate such discussions, and had greater awareness of their own EOL care values.
DISCUSSION AND LESSONS LEARNED
A number of important and unexpected implications were identified based on the reflections. It was not surprising that the students' personal values would be such a major focus of their learning outcomes; the affirmation that communication skills were enhanced and anxiety decreased were positive self-reported results. The students were also very clear about their desire to have "the conversation" with their families as soon as possible. It was extremely reaffirming that students felt better prepared to initiate EOL conversations, had less anxiety (communication apprehension) about doing so, and had more confidence in their communication skills. These results were similar to the findings of Lum, Dukes, Church, Abbott, and Youngwerth (2017), who used the Conversation Starter Kit with medical students. Findings from their study demonstrated a positive learning experience (professionally and personally) about advance care planning conversations.
Based on students' reflections, the benefits of TCP in a graduate nursing course seem clear. Students reported, in classroom interactions as well as in their self-reflections, feelings of enhanced communication, readiness, and intent to have EOL conversations, with less anxiety and more self-awareness of their own wishes. Kubler-Ross (1997) wrote: "The most important [answer] is our [the provider's] own attitude and ability to face terminal illness and death. If this is a big problem in our own life, and death is viewed as a frightening, horrible, taboo topic, we will never be able to face it calmly and helpfully with a patient" (p. 44).
As a result of this interactive and interpersonal curriculum, the 26 students reported key learning outcomes that not only met the course objectives and goals but surpassed them in terms of students' assessments of their own EOL care decisions, as well as recognition of the importance of discussing EOL care with their families as soon as possible. Based on student feedback, future sessions will be decreased from six to three hours. Given that graduate students already have basic communication skills, they require less time to master certain aspects of the program (e.g., ice breakers). Faculty will continue to utilize TCP in future courses. To further extend student community reach, students will do the TCP presentations at requesting agencies. This will facilitate a service-learning relationship where community and academics collaborate as a benefit to all.
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