Nursing Education: The Experience,Attitudes,and Impact of Caring for Dying Patients by Undergraduate Argentinian Nursing Students

Abstract

Background:

There is extensive research documenting serious deficiencies in undergraduate nursing education related to end-of-life care. Many nurses and nursing students have difficulties in dealing with death and report feeling anxious and unprepared to be with patients who are dying. In Argentina, education on palliative care, death, and dying has not been made part of the undergraduate nursing curriculum.

Methods:

We performed a multicenter survey on undergraduate nursing education regarding the care of dying patients at eight schools of nursing in Buenos Aires, Argentina. We enrolled 680 students from first to fifth year.

Results:

Students acknowledged interacting directly with dying patients. Attitudes toward dying patients were highly positive. Students of the fifth year expressed a less satisfying relationship with their patients than those from the first year; considered it as a less gratifying occupation, and also showed a greater preference for avoiding emotional involvement with those patients.

Discussion:

Many of them described in short and very expressive phrases the emotional impact of their encounters with patients facing a life-threatening illness. Students perceived that this issue received more attention in humanistic rather than clinical subjects. Ninety-eight percent of students spontaneously demanded more training in end-of-life care. The interest and desire of undergraduate students to enhance their knowledge and experience in palliative care, demands more specific teaching contents.

Conclusion:

This suggests that in Argentina, improvements in undergraduate nursing training are urgently needed and would be well received by the students. It could be very useful to consider this topic as part of accreditation standards for nursing programs.

Introduction

This article refers to a multicenter study on undergraduate nursing education regarding the care of terminally ill patients at schools of nursing in Buenos Aires, Argentina.

Although it is well recognized that teaching end-of-life care should begin in the undergraduate level,^1,2 in Argentina, education on palliative care has not been made part of the undergraduate curriculum either for medicine or for nursing students.^3–5 In fact, only a few medicine and nursing schools are considering incorporating systematic end-of-life care education, with planned assignment, throughout their curricula. However, there are no studies analyzing the general situation regarding this topic in nursing schools in Argentina.

Good care at the end-of-life depends on interdisciplinary health teams with strong interpersonal skills, clinical knowledge, technical proficiency, and respect for individuals; and it should be informed by scientific evidence, values, and personal and professional experience. Clinical excellence is important because the frail condition of dying patients leaves little margin to rectify errors. However, other aspects, such as compassion, communication skills, experience, and thoughtful reflection on the meaning of that experience are also very important.⁶

Among the members of the interdisciplinary health team, nurses are the frontline caregivers for those nearing the end of life. They are in the most immediate position to provide care, comfort and counsel for patients and families. The success of nurses in palliative care relies on their relationship with each patient and it is related to her/his interest and willingness to care for people at the end-of-life.^7,8

Many nurses and nursing students have difficulties in dealing with death and report feeling anxious and unprepared to be with patients who are dying.^7,9–16 In fact, they consider their basic nursing education to be inadequate for end-of-life care. Also, they need to struggle with negative personal issues concerning death and dying, and therefore are uncomfortable providing care at the end-of-life. Furthermore, nurses' strong emotional reactions to patient suffering may result in their disengagement from or avoidance of the patient and his/her family or in dissatisfaction with work, and may also fail to attend some details of care.^17,18 Because of this, it was emphasized that changes in basic nursing education and more continuing education are keys to improving end-of-life care.^16,18

Many nurses who work with dying patients realize how important it is to cherish each encounter. Thus, it is crucial that nurses do not consider death as a failure.¹⁷ Many nurse encounters with patients gave them satisfaction through the process of caring, and they felt enriched in those interactions motivated by the way they transcended their suffering.¹⁹ Being able to communicate effectively with patients facing life-threatening illness and with their families is a significant role that nurses need to fulfill. But helping terminally ill patients to come to terms with the imminence of death is highly demanding and often stressful.¹⁹

It has been shown that nurses with greater exposure to dying patients, more years in practice, more experience and more hours of palliative care education, tend to have more positive attitudes toward death and caring for dying patients ^{(15, 20, 21)} than those with less exposure.^10,20 On the contrary, when nurses are exposed to care of the dying without receiving a systematic death education, they suffer a higher incidence of death anxiety and develop negative attitudes toward care of the dying. Also, they limit their involvement in death-related situations, and are more likely to withdraw from the care of the dying.^9,22 These observations indicate that death anxiety and personal attitudes related to end-of-life issues are shaped during students' initial educational programs, which may be associated with reduced death anxiety and an improved attitude with regard to caring for the dying.^10,18,20,22

There is extensive research documenting the serious deficiencies in undergraduate nursing education and in nursing knowledge and attitudes related to end-of-life care.^{9–13,18,23–27}

The goals of the study were to establish: (1) undergraduate nursing students' experience and attitude toward dying patients and training in end-of-life issues, (2) students wishes regarding care of terminally ill patients and their future caring approaches in the relationships with them, and (3) the opinion about the quantity and content of end-of-life care in the curriculum.

Materials and Methods

During 2008 and 2009 eight university schools of nursing from Buenos Aires City were invited to take part in this survey. These schools share some common features such as a similar curricula of 5 years, divided in two cycles. The first cycle has a duration of 3 years and provides an intermediate degree that allows the students to work as professional nurses. The second cycle has 2 additional years and provides a bachelor's degree. In Argentina, education on palliative care, death, and dying has not been formally made part of the undergraduate nursing curriculum. Therefore, in these schools there are no clinical subjects specifically related to end-of-life care, and the topic is not integrated in other subjects. During their training, students have direct contact with patients mainly from the hospital wards in which they practice. Exposure to terminally ill patients is occasional and takes place at the hospital inpatients services. The population included all students from the second semester of the first to the last (fifth) course of the career of nursing.

We used a semistructured, anonymous, and voluntary 24-question survey. In some cases, answers were rated using a Likert scale ranging from 0 (strongly disagree) to 10 (strongly agree). We also used yes/no questions and left blank spaces for open answers. The questionnaire was developed based partly on Lloyd-Williams and Dogra,²⁸ and advice received from physicians and nurses specializing in end-of-life-care in Buenos Aires. Also our previous experience with medical students was considered.^3,29 The questionnaire was administered ad random among students from the eight universities participating in the study. The questions were self-explanatory and no further information was given to the students.

For statistical analysis, the one-way analysis of variance (ANOVA) test was applied. Results were expressed as the mean ± standard error of the mean (SEM). Statistical significance was set at a p value of <0.05. The mean was considered the cutoff point value to interpret the results. Calculations were done using the SPSS 15 package (SPSS Inc., Chicago, IL).

Results

Participants

Data for 680 students from eight schools of nursing were analyzed. They comprised: first year, 289 (42.5%); second year, 55 (8%); third year, 142 (20.9%); fourth year, 14 (2.1%); and fifth year, 180 (26.5%). The mean age of the students was 28 years (range, 17–56). Eighty-six percent were female and 14% male. The response rate was very high (680 complete questionnaires) and only 1.5% of the students delivered incomplete questionnaires, which were discarded.

Experience, attitudes, and wishes regarding death and the care of terminally ill patients

The majority of the students (528, 78%) had had experience of direct contact with terminally ill patients. The average number of terminally ill patients per student were: 9.46 (first year: 6; second year: 7; third year: 8.5; fourth and fifth years: 10). However, 55% (289) of the students had contact with less than 5 terminally ill patients; 22% (150) did not have contact with terminally ill patients, and 74% (111) of them were first-year students.

Table 1 is based on 680 students' statements toward end-of-life care. They felt at ease when in contact with terminally ill patients (74.4%); treating terminally ill patients may be gratifying for a nurse (81.6%), and 92.3% would feel at ease listening to terminally ill patients. Also, they considered that nurses should be available to listen to his/her patients (97.8%), and should discuss death in detail with terminally ill patients (93.6%). Regarding dying patients' last wishes, 86% considered that when being asked, the nurse, should discuss the issue with the patient.

Table 1.

Students' Agreement with Key Statements Regarding End-of–Life Care

Statements	Students % (n = 680)	Mean of ratings ^a
I felt at ease when in contact with a terminally ill patient	74.4	5.53
Treating terminally ill patients may be gratifying for a nurse	81.6	6.85
I would feel at ease listening to terminally ill patients	92.3	7.81
Nurses should be available to listen to his/her patients	97.8	9.05
Patients should be told the truth when they ask whether or not they will die	87.3	7.27
Nurses should discuss death in detail with terminally ill patients	93.6	8.53
Nurses should discuss death in detail with the family of the dying patient	92.4	8.41
Nurses should discuss last wishes with the patient	86	^b
The time devoted to be prepared to die may have a positive sense in a person's life	81.3	7.04
I consider that a dying patient could accept death with serenity	75	6.11
The issue of how to help patients to die should be part of nursing training	97	^b
I am interested in terminally ill patients' care, death, and the dying process	94.3	8.44

Likert scale range: 0 = strongly disagree to 10 = strongly agree.

Yes–No question.

Likewise, 81.3% of the students believed that the process caused by a terminal disease and the time devoted to be prepared to die, may have a positive sense in a person's life. In fact, they considered that these issues may help patients to value certain assets (their life, health, family, friends) and change the priority of their values that rule their lives or tighten affective ties with their beloved (85%). Also, 75% stated that a dying patient could accept death with serenity.

Nursing students also, were asked to express what they wished to obtain from the nursing–patient relationship using their own words. We grouped these expressions in three groups. Examples and results are shown in Table 2.

Table 2.

Attitudes and Wishes Expressed by Students Regarding Relationships with Terminally Ill Patients (n = 205 Statements from First Year and 164 from Fifth Year)

Main statements expressed by students	1st year n (%)	5th year n (%)
Wish to prepare to offer a better care and benefit of terminally ill patients, i.e.,	111 (54.1)	72 (43.9)
“To offer them a better care,” “To accompany the patient in those moments,” “Get to know them,” “Listen to them,” “To under stand him/her,” “To offer moral and psychological support to the patient,” “Prepare them to die”
Wish to avoid affective involvement and a painful personal experience for the nurse, i.e.,	64 (31.2)	74 (45.1)
“To avoid affective involvement,” “It is very hard on the nurse,” “It scares me,” “I feel so sad,” “I feel uneasy,” “The more you interact, the more affection you feel,” “It would affect me greatly,” “It should not affect my personal life,” “It creates anxiety,” “It is depressing,” “I feel there is nothing I can do,” “I am not up to it”
Wish for personal enrichment and the opportunity for personal growth, i.e.,	26 (12.6)	15 (9.1)
“It is an enriching experience for the nurse,” “It is inspirational for the nurse,” “I want to learn from the patient”

The main ideas have been highlighted.

In their approaches to care of terminally ill patients in the future, and referring to the type of relationship they would prefer to have, 49.9% expressed their wish to engage in a relationship that would allow the caregiver to adapt to the needs of the patients (i.e., to devote all the time that the patients demand, in order to accompany, listen, understand, and prepare them for a pleasant death). Besides, for many students, those encounters were personally rewarding and professionally challenging. On the other hand, 39.9% stated their wish to maintain a short-lasting relationship with terminally ill patients (“the shorter the better”). The main reason for this, they argued, was trying to avoid overcommitment and emotional compromise, as well as to get around the possibility of not feeling capable of handling the situation. Ten percent did not answer this question.

First- and fifth-year students expressed the same wishes and used similar expressions. However, we found statistically significant differences between first and fifth years with respect to their wish to avoid emotional involvement and a painful personal experience for the nurse p < 0.008 (Table 2).

Fifth-year students, who were older (mean: 32.9 years) and had more experience with terminally ill patients, expressed a less satisfying relationship with their patients (mean: 5.2/10 in the scale) than those from the first year (mean: 24.9 years and mean: 5.6/10 in the scale), and considered it as a less gratifying occupation (p < 0,003; Table 3). Additionally, they also showed a greater preference for avoiding emotional involvement with those patients, because they did not feel adequately prepared (p < 0.008; Table 2), and also, tried to limit the relationship to the strictly necessary matters (p < 0,0001).

Table 3.

Comparison of First and Fifth Year Students Agreement with Key Statements Regarding End-of–Life Care

	Mean of ratings ^a
Statements	1st year (n = 289)	SEM	5th year (n = 180)	SEM	p value^b
I felt at ease when in contact with a terminally ill patients	5.6	0.16	5.2	0.19	NS
Treating terminally ill patients may be gratifying for a nurse	7.1	0.16	6.2	0.26	<0.003
I would feel at ease listening to terminally ill patients	8.1	0.15	7.4	0.22	<0.016
Nurses should be available to listen to his/her patients	8.9	0.11	9.2	0.10	<0.035
Patients should be told the truth when they ask whether or not they will die	6.8	0.20	7.6	0.21	<0.008
Nurses should discuss death in detail with terminally ill patients	8.4	0.15	8.7	0.17	NS
Nurses should discuss death in detail with the family of the dying patient	8.3	0.15	8.5	0.19	NS
The time devoted to be prepared to die may have a positive sense in a person's life	6.5	0.20	7.5	0.23	<0.001
I am interested in terminally ill patients' care, death, and the dying process	8.6	0.12	8.3	0.19	NS

Likert Scale range: 0 = strongly disagree to 10 = strongly agree.

NS, non significant.

SEM, standard error of the mean.

Students opinion about the quantity and content of end-of-life care in the curriculum

There were no significant differences in the specific training given to students from first and fifth years in order to take care of terminally ill patients. During the time they were in school that education was limited. Forty-seven percent of first-year students thought that they did receive training about matters related with death, the meaning of death and the caring of terminally ill patients, while among students of the fifth year only 30% had a similar opinion. Only 3% of the students pointed out they had taken part in palliative care seminars. At the moment of the survey, none of the participant schools included the subject of palliative care in their curricula, neither as a mandatory subject nor as an optional one.

From the students' perspective, the subjects where these topics were approached were mostly those with broader humanistic contents (54%; i.e., anthropology, bioethics and ethics, theology and philosophy, psychology). These topics were referenced fewer times in “nursing care of elder” subjects (46%). Ninety-seven percent of students considered that death and care of dying patients should be part of their professional training; and 94% stated a high personal interest on the care of terminally ill patients, death and dying process (Table 1).

Discussion

In this study we examined the experiences, attitudes, and training that nursing students from eight different schools in Buenos Aires received regarding end-of-life care. Our main findings were that although in Argentina, education on palliative care, death, and dying has not been formally made part of the undergraduate nursing curriculum, 78% of the students acknowledged having interacted with terminally ill patients. This was because along their training, students have direct contact with patients from the hospital wards in which they practice. Therefore, exposure to terminally ill patients is sporadic. In addition, in several cases, students had contact with terminally ill patients in their clinical practice, as a result of their work as auxiliary nurses in parallel to their undergraduate studies.

As shown in Table 2, most of the students have a positive attitude toward end-of-life issues and would like to receive more training on these themes. They stated that they would feel comfortable listening to a dying patient, and almost all of them expressed a high personal interest in assisting dying patients, death and the end-of-life process. Nurses' attitudes toward caring for the dying patients are influenced by their personal feelings about death and contact with dying patients¹⁴ and can increase nurse awareness of their own losses and vulnerabilities and heighten their fear of death, thereby raising anxiety and stress levels.

Many of the students described in short and very expressive phrases the emotional impact of meeting and talking with patients who are near their end-of-life. They expressed feelings of sadness, vulnerability, helplessness as well as sympathy for the patients. Ten percent of the students did not include any personal observation about this topic. A possible reason may be that they felt it inappropriate for such writing to be read by others.

Interestingly, fifth-year students, who have more experience in dealing with terminally ill patients, expressed they were less at ease when in contact with these patients; and also considered less gratifying their care when compared to first-year students. However, these same fifth-year students perceived that their education regarding terminally ill patients and end-of-life care was lower than that perceived by first-year students.

These results confirm, as shown by other studies,^9,17,22,25 that students with more experience in the dealing with terminally ill patients, without however a proper training, try to protect themselves in order to avoid emotional involvement due to the relationship with these patients. Our results indicate that these students are more likely to withdraw from the care of the dying and tend to limit the relationship to the strictly necessary matters. Some of them even try to avoid any contact at all with these patients.

On the contrary, first-year students, with less interaction and experience with terminally ill patients, showed a better disposition to engage in a relationship that would allow them to devote all the time that the patients demand, in order to accompany, listen, understand and prepare them for a pleasant death. It is possible that the lack of a deeper experience of these students, may not affect their motivation to offer terminally ill patients all the time they require. It should be considered that these students may not be aware of how highly demanding and often stressful is the care for patients where imminence of death is a fact. This could also explain the decrease of the disposition to engage with terminally ill patients in more senior students.

It is interesting to note that 38% (111) of first-year students had not been in contact with terminally ill patients, and that 19% of them expressed their wish to avoid affective involvement.

In many cases, students spontaneously declared they felt unprepared to care for dying patients. They also perceived that this issue received more attention in the humanistic rather than in the clinical subjects, and pointed out that training to deal with the care of dying patients should be taught as a topic within mandatory clinical subjects, organically, as part of the program's curriculum.

As previously stated, death and terminal disease are moving life experiences which require a special training and handling.^29–31 These results indicate that the occasional contact of nursing students with dying patients did not change the fear for personal involvement and suffering, indicating that a more reliable and specific training is still needed.

This is the first study comparing the attitudes toward end-of-life care and terminally ill patients of undergraduate students at schools of nursing in Buenos Aires city. The questionnaire was easily understood across populations and was enriched by students' free opinions. Also the response rate was very high.

Conclusions

Our study shows that students have a highly positive attitude toward contact with dying patients and end-of-life care, and also emphasize the fact that the relationship with terminally ill patients and death is an emotionally tough experience for nursing students.

The interest and desire of undergraduate students to enhance their knowledge and experience in palliative care, demands more specific teaching content. This suggests that, in Argentina, improvements in undergraduate nursing training are urgently needed and would be well received by the students.

In order to overcome this deficiency a significant step would be to formally include the teaching of palliative care by skillful and adequately trained faculty in a similar way as has been done in many schools of Great Britain and United States. At an initial stage the addition of optional subjects introducing the basis of end-of-life care education could be organized. However, the first task we should undertake is the training of experts on those countries with a well-developed expertise in end-of-life-care.

Also, it could be very useful to consider this topic as part of accreditation standards for nursing programs.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

References

MacLeod

, Parkin

, Pullon

, Robertson

. Early clinical exposure to people who are dying: Learning to care at the end of life. Med Educ, 2003; 37:51–58.

Gibbins

, McCoubrie

, Maher

, Forbes

. Incorporating palliative care into undergraduate curricula: Lessons for curriculum development. Med Educ, 2009; 43:776–783.

Mutto

, Primogerio

, Villar

. Teaching care of terminally ill patients at public and private Medical Schools in Argentina. Revista Argentina de Educación Médica, 2007; 1:23–30.

Field

, Wee

. Preparation for palliative care: Teaching about death, dying and bereavement in UK medical schools 2000–2001. Med Educ, 2002; 36:561–567.

Paz

, Clark

. Palliative care in Argentina: Barriers, opportunities and recomendations for future developments. International Observatory on End of Life Care, Institute for Health Research, Lancaster University. Prog Palliat Care, 2004; 12:303–311.

Field

, Cassel

. Approaching Death: Improving Care at the End of Life. Washington, D.C.: National Academy Press, 1997.

White

, Coyne

, Patel

. Are nurses adequately prepared for end-of-life care? J Nurs Scholarsh, 2001; 33:147–151.

Olthuis

, Dekkers

, Leget

, Vogelaar

. The caring relationship in hospice care: An analysis based on the ethics of the caring conversation. Nurs Ethics, 2006; 13:29–40.

Mallory

. The Impact of a palliative care educational component on attitudes toward care of the dying in undergraduate nursing students. J Prof Nurs, 2003; 19:305–312.

10.

Dickinson

, Clark

, Sque

. Palliative care and end of life issues in UK preregistration, undergraduate nursing programmes. Nurse Educ Today, 2008; 28:163–170.

11.

Wallace

, Grossman

, Campbell

, Robert

, Lange

, Shea

. Integration of End-of-life care content in undergraduate nursing curricula: Student knowledge and perception. J Prof Nurs, 2009; 25:50–56.

12.

Brien

, Legault

, Tremblay

. Affective learning in end-of-life care education: The experience of nurse educators and students. Int J Palliat Nurs, 2008; 14:610–614.

13.

Iranmanesh

, Dargahi

, Abbaszadeh

. Attitudes of Iranian nurses toward caring for dying patients. Palliat Support Care, 2008; 6:363–369.

14.

Meraviglia

, McGuire

, Chesley

. Nurses' needs for education on cancer and end-of-life care. J Contin Educ Nurs, 2003; 34:122–127.

15.

Lange

, Thom

, Kline

. Assessing nurses' attitudes toward death and caring for dying patients in a comprehensive cancer center. Oncol Nurs Forum, 2008; 35:955–959.

16.

Ferrell

, Virani

, Grant

, Coyne

, Uman

. Dignity in dying. Nurs Manage, 2000; 31:52–57.

17.

Witt

. Nurses' stress & burnout. How to care for yourself when caring for patients and their families experiencing life-threatening illness. Am J Nurs, 2004; 104:48–56.

18.

Wass

. A Perspective on the current state of death education. Death Stud, 2004; 28:289–308.

19.

Mok

, Chiu

. Nurse–patient relationships in palliative care. J Adv Nurs, 2004; 48:475–483.

20.

Kurz

, Hayes

. End of life issues action: impact of education. Int J Nurs Educ Scholarsh, 2006; 3:1–13.

21.

Dunn

, Otten

, Stephens

. Nursing experience and the care of dying patients. Oncol Nurs Forum, 2005; 32:97–104.

22.

Degner

, Gow

. Preparing nurses for care of the dying. A longitudinal study. Cancer Nurs, 1988; 11:160–169.

23.

Sullivan

, Lakoma

, Block

. The status of medical education in the end of life care: A national report. J Gen Intern Med, 2003; 18:685–695.

24.

Degner

, Gow

. Evaluations of death education in nursing. Cancer Nurs, 1988; 11:151–159.

25.

Hurtig

, Stewin

. The effect of death education and experience on nursing students' attitude towards death. J Adv Nurs, 1990; 15:29–34.

26.

Lloyd-Williams

, Field

. Are undergraduate nurses taught palliative care during their training? Nurse Educ Today, 2002; 22:589–592.

27.

Ferrell

, Virani

, Grant

, Rhome

, Malloy

, Bednash

, Grimm

. Evaluation of the End-of-Life Nursing Education Consortium undergraduate faculty training program. J Palliat Med, 2005; 8:107–14.

28.

Lloyd-Williams

, Dogra

. Caring for dying patients—What are the attitudes of medical students? Support Care Cancer, 2003; 11:696–699.

29.

Mutto

, Cavazzoli

, Ballbé

, Vittoradolfo

, Centeno

, Villar

. Teaching dying patient care in three universities in Argentina, Spain, and Italy. J Palliat Med, 2009; 12:603–607.

30.

Wear

. “Face-to-face with it”: Medical students' narratives about their end-of-life education. Acad Med, 2002; 77:271–277.

31.

Rhodes-Kropft

, Carmody

, Seltzer

, Block

. “This is just too awful:I just can't believe I experienced that … ”: Medical students' reactions to their “most memorable” patient death. Acad Med, 2005; 80:634–640.