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The interactions and observations of residents speaking with patients and family members about end-of-life decisions indicated a need for more empathy. Nursing and medical students have been called to learn and work together so they can work more effectively. A review of the evidence on interdisciplinary education of residents concerning end-of-life care and communicating with patients and their family members was the inspiration for this study. This article applies evidence related to interdisciplinary education in critical care settings. This pilot project was a collaboration of medical education between a critical care service in a public hospital and baccalaureate nursing students assisting family members in making end-of-life decisions. As nursing students, we were able to effectively present content on end-of-life decision making to medical residents.
As leadership/management nursing students were precepted on the intensive care unit (ICU), it was recognized that residents and medical students often require additional or supplementary training on communication with patients who have a poor prognosis and require end-of-life (EOL) care. Therefore, this pilot project was created to gather evidence on current attitudes and confidence levels related to EOL interactions with patients and their family members, as well as current therapeutic communication methods currently used by medical professionals, and effective training programs that have been used. The objective of the pilot project (intervention) was to teach medical residents how to talk to patients and their family members about EOL decisions in a critical care setting while in a community hospital.
Seven articles were identified as particularly relevant to this project (Table). One article was entitled SPIKES-a 6-step protocol for delivering bad news to a patient with cancer.4 SPIKES provided a framework for the presentation and discussion created for the residents and other medical professionals. SPIKES is an acronym for (1) setting up time with the patient and family, (2) assessing the patient's perception, (3) obtaining the patient's invitation to discuss prognosis and options, (4) giving knowledge and information to patient and family, (5) addressing patient's emotions with empathetic responses; and (6) strategizing and summarizing of care plan.4
Eskildsen and Flacker2 identified a variety of modes of learning that assisted medical students and residents in their approach to palliative care. The education of EOL care is presented in interactive methods, which facilitate straightforward learning. These methods included (1) PowerPoint presentation, (2) lectures, (3) case scenarios, (4) scripted role play, and (6) collaborative small-group discussions.2
A qualitative study conducted by Jackson and colleagues6 discussed the benefits and barriers of the patient-physician relationship and communication. The article noted how doctors with a solely biomedical approach to their practice would report more distant relationships with patients and the patient's family, and these doctors may have a sense of failure at helping their patients cope with their disease process. Alternately, physicians who approached their practice with both psychosocial and biomedical methods had more satisfaction and felt more competent in their practice.6
Alternately, physicians who approach their practice with both psychosocial and biomedical approaches have more satisfaction and feel more competent in this practice.
A study conducted by Schroder and colleagues1 compiled data from 5 Canadian universities presenting the attitudes and perceptions of medical residents.1 The results showed that residents lacked supervision and feedback. Residents also felt that their knowledge was only average in 50% of the EOL competencies.1
Schwartz and colleagues5 conducted a study in a large urban teaching hospital. The residents reported feeling that they did not have adequate palliative care training or supervision. This, in turn, reduced their skills in the clinical setting.5 Specifically, the residents stated that they did not know how to deliver bad news, collaborate with patients in treatment planning, or provide optimal care because of large inpatient case loads.5
A study by Smith and Hough3 identified inadequate training in EOL care for internal medicine intern. Monthly learning sessions were created in the ICU setting to identify and address their emotional conflicts in accordance with a patient's death.3 Participation in these sessions showed a trend in decreased anxiety in EOL discussions with patients and increased comfort with communication at end of life.3
The body of research we reviewed continued to indicate that not all medical students felt equipped emotionally and professionally to handle EOL communication with patients. As soon-to-be RNs of the medical community, we felt a sense of duty and obligation to address these needs.
A convenience sample of residents participated during their lunch hour. These residents were from various departments of a public hospital on the West coast.
After obtaining institutional review board approval and approval from the organization that developed the Talking It Over Curriculum,7 a workshop was designed. The workshop started with an explanation of the study and potential benefits. The benefits in participating in the workshop would include, but were not limited to the following: (1) successful communication encounters, (2) positive feedback, (3) viewing self as a therapeutic agent, (4) building relationships with patients/patient's families, and (5) increased job satisfaction.
After a presentation and assessment on their EOL concerns, a student-prepared video was presented. The video presented 2 extreme scenarios concerning EOL care conversations between physicians, patients, and family members. In order to encourage participation and assist in learning, humor was used. The first scenario was of a resident who spoke to the patient and her daughter while displaying improper behavior and ineffective communication skills. The second scenario was of a resident who implemented effective communication techniques and displayed empathy and professionalism. The discussion was facilitated by predetermined questions aimed at evaluating residents and their perception of themselves in their practice concerning these types of situations.
The preworkshop and postworkshop was used to evaluate the presentation. The Concerns About Dying Scale was developed by Mazor and colleagues8 and used in this pilot project. This is a 13-item survey developed for members of the health care occupations. The postworkshop survey had an additional question concerning how each resident could change his/her own personal practice based on the curriculum presented.
The overall goal of this presentation was to increase the resident's knowledge and confidence in providing EOL care and techniques. In the course of talking to the residents during the postworkshop survey, they verbalized confidence in their own knowledge and ability to practice these techniques. The postworkshop also shed light on some areas that residents may need further instruction on EOL caregiving. The self-reflective question on the postworkshop survey helped to evaluate the objective of encouraging the residents to consider making changes to their practice based on the information presented.
Our experiences in critical care reflect how difficult it is for anyone to talk about EOL care. Most patients have not thought about their wishes ahead of time. Nurses and physicians face a lot of challenges when it is time to make difficult decisions. As nursing and medical students, we face even more challenges to develop communication skills to help these family members. Being nursing students, the process of teaching residents on how to effectively and empathically communicate had a few challenges. The residents were adamant that they knew much of the information because they have had "a class" on it. However, being educated in a classroom environment does not equal to being able to apply the knowledge usefully in a clinical setting. As nursing students, we have observed this in the clinical setting. The need continues to exist that residents rely on delegating responsibilities to the palliative care team in order to speak to the patient about EOL decisions. In reality, the resident must be able to work with the palliative care team and seek opportunities to provide attention to their patients once the patient is in need of EOL decision options.
Nurses and physicians face a lot of challenges when it is time to make difficult decisions.
From the data collected using the preworkshop and postworkshop surveys, it was found that the percentage of neutral responses decreased, and the percentage of disagree responses increased. The decrease in neutral responses to the survey indicates that the participants are engaged in thoughtful reflection of their own skills after viewing the video. There was a slight increase in agreement to 2 of the questions, although there was a more defined increase in disagreement. These data show that the instruction provided to the residents was effective in accomplishing its goals. Subjectively, the residents were actively engaged in the presentation. This shows further support that the educational session was thought-provoking and productive in refreshing and consolidating the teaching that residents have received concerning EOL care discussions with patients and families.
The research suggested that nursing students and medical residents are not adequately trained in the area of EOL communication and care, especially in initiating these discussions. Nursing students working with community partners, such as a palliative care team, can be utilized to supplement other instruction. By implementing an interdisciplinary curriculum, such as Talking It Over,6 other types of health care occupation students may be more prepared to discuss EOL care. In addition, this education may be of benefit to experienced nurses and physicians as well as utilized as a refresher course for seasoned health care professionals.
Nursing students working with community partners, such as a palliative care team, can be utilized to supplement other instruction.
Too often we saw that the palliative care team was not used as a resource, but as a crutch, further inhibiting the learning opportunities that residents may have in developing their skills as professionals concerning EOL care. The more exposure the residents have to patients in end of life, the more comfortable they will become when caring for them.
This experience was illuminating for nursing students such as ourselves. Teaching residents EOL communication can be daunting as well as rewarding. The daunting part consisted of how easily the medical "hierarchy" can write off lowly nursing students as not knowing much of anything, much less try to teach dozens of residents and medical students a curriculum. The curriculum we used was helpful in educating the residents, but more importantly was that it helped to facilitate critical thinking and thoughtful self-reflection. This is a good step forward for the residents in evaluating their personal practice. We witnessed a lot of verbal interaction between the palliative care team representatives (coordinator, chaplain, nurses) and the residents. Off the floor, they may not be able to discuss key issues as straightforwardly as in this forum. It was obvious that some points of discussion elicited more feedback than others. For the residents to hear their peers speaking candidly about personal thoughts on end of life and relating that to their approach to EOL care, it was a major breakthrough in observing residents who usually keep more intimate details away from their peers. The vulnerability that was present would help educators fill in the gaps where residents need support. Overall, we felt that this workshop was a success, and our hope is that the residents learned from the education and absorbed it into their practice when applicable. We hope, too, that with our aimed efforts, nursing students and nurses can make a lasting difference in the quality of EOL care and communication.
The authors thank Dr Marilyn Stoner, their clinical instructor, and Fran Dyckman, coordinator for palliative care, for their assistance with this project and for their vision and inspiration. They also thank the hardworking nurses at the medical ICU and the surgical ICU at the hospital in which they precepted during their last quarter of nursing school.
1. Schroder C, Heyland D, Jiang X, Rocker G, Dodek P. Educating medical residents in end-of-life care: insights from a multicenter survey. J Palliat Med. 2009; 12 (5): 459-470. [Context Link]
2. Eskildsen M, Flacker J. A multimodal aging and dying course for first-year medical students improves knowledge and attitudes. J Am Geriatr Soc. 2009; 57 (8): 1492-1497. [Context Link]
3. Smith L, Hough C. Using death rounds to improve end-of-life education for internal medicine residents. J Palliat Med. 2011; 14 (1): 55-58. [Context Link]
4. Baile W, Buckman R, Lenzi R, Glober G, Beale E, Kudelka A. SPIKES-a six-step protocol for delivering bad news: application to the patient with cancer. Oncologist. 2000; 5 (4): 302-311. [Context Link]
5. Schwartz C, Goulet J, Gorski V, Selwyn P. Medical residents' perceptions of end-of-life care training in a large urban teaching hospital. J Palliat Med. 2003; 6 (1): 37-44. [Context Link]
6. Jackson V, Mack J, Matsuyama R, et al.. A qualitative study of oncologists' approaches to end-of-life care. J Palliat Med. 2008; 11 (6): 893-906. [Context Link]
7. California Coalition for Compassionate Care. Talking It Over: A Guide for Group Discussions on End-of-Life Decisions. Center for Health Care Decisions; September 1999. http://www.chcd.org/docs/TIO.pdf. Accessed September 26, 2011. [Context Link]
8. Mazor K, Schwartz C, Rogers H. Development and testing of a new instrument for measuring concerns about dying in health care providers. Assessment. 2004; (11): 230-237. [Context Link]
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