The COVID-19 pandemic created a number of challenges for the delivery of health care. Similarly, national guidelines and recommendations for social distancing, school closures, and stay-at-home orders uprooted both classroom and clinical education. These changes occurred rapidly and forced faculty, students, and clinicians to be flexible and innovative to continue effective teaching and learning. Providers and educators trained in palliative care (PC) were primed to support students in the rapidly changing educational and social environment. PC faculty are trained in breaking bad news and managing social and emotional distress (World Health Organization [WHO], 2020). These faculty were able to immediately apply their clinical training to their interactions with students in efforts to diffuse volatile and stress-provoking situations while facilitating a positive learning environment.
Different from compassionate teaching, which encourages faculty kindness and humanistic responses to circumstances (White & Ruth-Sahd, 2020), the application of PC concepts to the classroom has the potential to decrease overall stress, help students see the big picture, and provide anticipatory guidance in a rapidly changing environment. Clinically, PC is defined as an approach that focuses on improving quality of life (WHO, 2020). This is accomplished by early identification of stressful situations and the integration of the psychological and social aspects of one's life into an action plan. Unlike a mental health assessment, which is focused on an individual with the intent of gathering information or making a diagnosis, the application of PC concepts in a student population aims to decrease distress, provide context and understanding, and identify desirable goals and outcomes (National Consensus Project for Quality Palliative Care [NCPQPC], 2018). PC concepts can be applied to the individual, small groups, and the classroom as a whole, allowing for focused mental health intervention on an individual basis as needed.
To date, there has been no research or discussion of the use of PC concepts within classroom or clinical settings with students in crisis. Several organizations have called for the broad application of PC at a population level rather than an individual level in response to crisis (Wynne et al., 2020). Although this has the potential to benefit patients and improve outcomes, the health care arena changes continually, thus underscoring the need for graduates equipped with PC skills. PC providers have historically recommended integration of PC concepts into curricula; however, there has been no formal guidance on the palliation of students. This article describes the organic and immediate interactions that took place between four faculty trained in PC and their baccalaureate and graduate students (master's and doctor of nursing practice) at the onset of the pandemic. The palliative philosophy of breaking bad news is discussed, and examples that non-PC trained faculty can apply in interactions with students are provided. Just as in classroom participation, students elected when they would participate and share in discussions. Interactions with the students took place in the physical classroom, clinical areas, through personal contact (e.g., emails and phone calls), and over video-conferencing platforms.
COMMUNICATION USING SPIKES
Providers trained in PC are experts in communication and breaking bad news (NCPQPC, 2018). Using clear communication with simple words and avoiding jargon is one way that PC providers attempt to enhance understanding of difficult concepts. The rapidly changing environment brought about by the global pandemic resulted in chaotic and unplanned changes to the middle of the semester, providing faculty with the perfect opportunity to use the SPIKES tool to start conversations about the impact of the pandemic on both didactic and clinical education. SPIKES is a mnemonic for steps to guide communication and facilitate the breaking of bad news to patients (Baile et al., 2000). With some informal and impromptu adaptation of the SPIKES tool, faculty were able to assess students' perceptions of the circumstances, ask what they would like to know about the situation, provide knowledge, respond with empathy, and develop a strategy moving forward (see Supplemental Content for Table 1, which outlines how SPIKES was adapted for students, available at http://links.lww.com/NEP/A370).
DEALING WITH LOSS AND GRIEF
Graduate and undergraduate learners experienced distinct aspects of loss both in the classroom and in clinical settings during the pandemic. Graduate clinical learners were in the unique position of dealing with suffering, loss, and grief in their jobs as RNs and in the disruption to their formal education (Perry et al., 2020). These circumstances led to feelings of distress; students often felt confused, unsure of their next steps, and fearful of delays in classes and graduation. Undergraduates experienced the stress of being pulled from their clinical settings at the onset of the pandemic, only to return to complete coursework in the late summer wearing personal protective equipment (Carolan et al., 2020). The experience of being rapidly streamlined into the next level of their education in the fall semester caused some students to feel they lacked proficiency and competence. Graduates and undergraduates alike were concerned they might need to leave the clinical setting suddenly again should the pandemic worsen (Carolan et al., 2020; Perry et al., 2020).
These clinical challenges, coupled with unanticipated virtual didactic classroom delivery, left most students feeling disconnected and isolated from faculty and peers. Faculty trained in PC were able to respond to these feelings. Commonplace in clinical PC, faculty identified the emotion, described their observations, and sought clarity from students (Carolan et al., 2020; Perry et al., 2020; WHO, 2020). Students did not recognize the use of palliative communication but informed their faculty that they felt supported and valued, that they felt safe approaching faculty with concerns or questions, and that there was limited impact on learning. On a formal course evaluation, students described faculty as approachable during the time of crisis and indicated they felt supported, included, and valued in class (4.7/5 on a Likert scale). Students felt that faculty facilitated constructive interactions (4.8/5) and provided assistance despite the rapid change (4.9/5).
ADVANCE PLANNING
Advance care planning is one of the cornerstones of clinical PC, often involving identification of personal goals, anticipatory guidance about the different paths available in the future, and helping people make sense of clinical data and social-emotional feelings (NCPQPC, 2018). When advance care planning was applied to students during the pandemic, faculty were able to provide them with a clear roadmap of what the future might hold while also encouraging flexibility within a rapidly changing scenario. Assisting students in looking at the circumstances in a "big picture" or macrolevel resulted in some ease in feelings of distress because of smaller, microlevel changes.
SELF-CARE
The overarching philosophy of PC is to help patients live as well as they can for as long as they can (NCPQPC, 2018; WHO, 2020). This often involves providing patients with permission to discontinue disease-focused therapies or to disengage from clinical management that may cause distress or discomfort, encourages patients to utilize available resources within their communities, and reminds them to be kind to themselves and participate in activities that they enjoy (NCPQPC, 2018). During the global pandemic, faculty were able to organize online meetings and informal support groups, offer ideas for self-care during quarantine or lockdown, and remind students of the importance of self-care and mental health (Price, 2020). The university as a whole created avenues to connect students with mental health resources and designed virtual or socially distanced outlets for health and wellness (e.g., virtual meetups, distanced outdoor physical activity). The university even offered alternative grading options for courses that had been significantly disrupted, for example, changing from a letter grade to pass/fail or to no grade at all.
CONCLUSION
Although there is no physical disease or diagnosis, the emotional response to a global pandemic or crisis, the subsequent chaos, and continued uncertainty resemble that of a life-limiting illness. Thus, the application of PC concepts to students in crisis offers a potential solution to decrease feelings of stress and anxiety associated with this unprecedented time. Assisting students with seeing the big picture, providing knowledge of the situation with clear language, assessing and addressing emotion with an empathetic response, and encouraging student self-care are methods that can provide a level of comfort for all students. As the future of this pandemic remains unclear, it is up to faculty to attempt to create an encouraging environment for learning, despite uncertain steps forward and ongoing stress. The application of the philosophy of PC and its concepts can assist faculty to create a positive learning environment while also making students feel heard and supported.
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