A Perspective of End-of-Life Care Education in Undergraduate Medical and Nursing Students in Buenos Aires,Argentina

Abstract

Background:

The goals of this study were to evaluate: (1) the experiences and attitudes after exposure to dying patients in undergraduate medicine and nursing students with lack of training in end-of-life care issues; (2) whether or not exposure to terminally ill patients (TIPs) influences attitudes in students who had no training in end-of-life care; (3) students wishes regarding their future care of TIPs; and (4) if medicine and nursing students are indeed interested in receiving training in end-of-life care.

Materials and methods:

A survey was administered to students in the first and last year in schools of medicine and nursing, comprising seven universities in the city of Buenos Aires, Argentina, and surrounding areas. Data were collected during the 2005 to 2010 time period. Data from 730 students were analyzed.

Discussion and conclusion:

We found that nursing and medical undergraduate students at nursing and medicine schools in the city of Buenos Aires and surrounding areas: (a) come in direct contact with TIPs and perceive their suffering; and (b) have a highly positive attitude toward these patients, even though some of them referred to that relationship as arduous and in some cases they tended to avoid emotional involvement because they did not feel well trained. We also found that (c) this wish for avoidance was increased in final-year medical and nursing students who had been exposed to a higher number of TIPs; and (d) students unanimously manifested the opinion that the teaching about caring of TIPs should be included in the curricula and they would be well disposed to receive it. For all these reasons, we consider that the teaching of caregiving to TIPs in the academic degree programs of nursing and medicine should not be presented as a marginal issue.

Introduction

This study was carried out to analyze undergraduate medical and nursing students' experiences, attitudes, and training in end-of-life issues at schools of medicine and nursing in Buenos Aires, Argentina. Our purpose was to obtain enough information to enable local education authorities to adopt the necessary strategies that would assure end-of-life caring competences in medical and nursing graduates.

Many physicians, nurses, and medicine and nursing students express difficulties in dealing with death and report feeling anxious and unprepared to be with patients who are dying. Also, they consider their basic education to be inadequate for end-of-life care.^1–9 In fact, there is extensive research documenting the serious deficiencies in undergraduate medical and nursing education and in knowledge and attitudes related to end-of-life care.^2,6,10–15

The frail condition of dying patients leaves little margin to rectify errors, reinforcing the importance of improving the quality of care when dealing with such patients.¹⁶ However, other aspects, such as compassion, communication skills, experience, and thoughtful reflection on the meaning of that experience, are also very important. These aspects not only improve quality of life and relieve suffering of terminally ill patients (TIPs) and their families, but are useful in every other health setting.¹⁷

Helping TIPs to come to terms with the imminence of death is highly demanding, often stressful, and may result in disengagement from or avoidance of the patient. Dissatisfaction in health care workers has also been reported and may lead to the disregard of some details of care with failure in the quality of assistance.^10,18

Because of this, it has been emphasized that changes in basic medicine and nursing education and more continuing education are key strategies to improve end-of-life care.^9,10 This could lead to a reduced death anxiety and improvement in the attitude of physicians and nurses toward the dying.^3,10,19,20

Although it has been recommended that end-of-life care education should begin at the undergraduate level,^21,22 in Argentina, education on palliative care has not been made part of the curriculum for medicine or for nursing students.^23–25 In fact, so far, only one school of medicine has incorporated these topics, in the undergraduate curriculum, as an elective subject. Apart from our previous studies^23,26,27 there are no publications regarding these topics in medical and nursing schools in Argentina.

The goals of this study were to evaluate: (1) the experiences and attitudes of undergraduate medicine and nursing students after exposure to dying patients; (2) whether or not exposure to TIPs influences attitudes in students who had no training in end-of-life care; (3) students wishes regarding their future care of TIPs; and (4) if medicine and nursing students are indeed interested in receiving training in end-of-life care.

Material and Methods

A survey was administered to students in the first and last year in schools of medicine and nursing, comprising seven universities in the city of Buenos Aires and surrounding areas. Data were collected during the 2005 to 2010 time period. Incomplete responses (more than 30% of missing items) were excluded.

An incidental sample of the first and the last course of medical and nursing students was made. All students present at the day of survey were included, with the exception of those who declined to participate. We took the survey during single classes of a given subject in first and last year courses.

Students were presented with a self-administered anonymous questionnaire that usually took between 15 and 25 minutes to answer. A previously described 24-item questionnaire^23,26,27 was used. Domains included age, sex, and course data. Internal consistency of the variables expressed as Likert scales was assessed using Cronbach's α for students of each career: the coefficient was 0.773 for medical students and 0.770 for nursing students.

Exposure to TIPs was evaluated using the variables: presence of any exposure (yes/no), kind of TIPs involved (relative or patient, both), estimated number of TIPs seen, and feelings toward the relationship with those TIPs, using a Likert scale ranging from 0 (felt uneasy) to 10 (felt at ease).

Students were asked about any education received on the meaning of suffering and death, and on understanding and helping TIPs. Answers were analyzed using a Likert scale ranging from 0 (none at all) to 10 (a lot). Also, students were asked to identify those subjects in which they received that training.

Students' attitudes were evaluated with a set of statements, using a Likert scale with values ranging from 0 (strongly disagree) to 10 (strongly agree). The kind of relationship with TIPs that the student would prefer was also explored, and they were encouraged to express the reason in their own words.

Students' wishes and interest regarding their future involvement in end-of-life care were explored with open questions.

Additionally, students were asked whether or not death and preparation for a dignified death should be included in the contents of the courses. In the case of positive answers the preference to have this topic covered throughout the whole career, or as an elective or mandatory course was explored.

The study and survey questionnaire were approved by the Institutional Review Board of the School of Medicine at Austral University. Procedures followed the principles of the Declaration of Helsinki.

Categorical data were summarized using percentages, whereas for continuous data the mean and the standard deviation (SD) were used. For central tendency and Likert scale the median and mode were calculated. Significance was assessed using the χ² test, and p values<0.05 were considered significant. The SPSS version 17 software package was used for analysis (SPSS, Inc., Chicago, IL).

Results

Participants

Data from 730 students were analyzed. They comprised: (a) 483 from nursing schools (first year 289 [59.8%] and last year 194 [40.2%]), and (b) 247 from medical schools (first year 100 [40.5 %] and last year 147 [59.5%]). In both careers the number of women was significantly higher. Regarding age, the numbers were more homogeneous; however, medical students were slightly younger than nursing students (Table 1).

Table 1.

Descriptive Statistic of Demographic Variables

	Nursing students		Medicine students
	First year	Last year	First year	Last year
N	289	194	100	147
Gender
Female (%)	247 (85.5)	166 (85.6)	65 (65)	90 (61.2)
Male (%)	41 (14.2)	28 (14.4)	35 (35)	57 (38.8)
Missing (%)	1 (0.3)	–	–	–
Age
N (%)	280 (96.9)	193 (99.5)	100 (100)	146 (100)
Range	[17–53]	[20–54]	[17–30]	[22–35]
Mean	24.91	32.20	19.71	25.13
Median	23	30	19	25
Mode	20	25	19; 20	23
Standard deviation	6.63	7.99	1.8	2.19
Coefficient of variation	26.61%	24.81%	9.13%	8.71%

Exposure to terminally ill patients

Seventy-three percent of nursing students had had direct exposure to TIPs; 94.8% of these had had contact with TIPs during the practice years in nursing school or when working as nursing auxiliaries, and the rest (5.2%) had had this experience with relatives. The average ratio for each nursing student that had had a direct exposure to TIPs was 5.95±7.31 for first year students and 14.3±23.37 for those in the last year. Thirty-eight percent of first year students and 9.8% of last year students had not had any direct exposure to TIPs (Table 2).

Table 2.

Experience of Direct Contact with Terminally Ill Patients at the End of Life

	Nursing students		Medicine students
	First year	Last year	First year	Last year
Contact with terminally ill patients
N	289	194	100	147
Yes (%)	176 (60.9)	175 (90.2)	17 (17)	143 (97.3)
No (%)	111 (38.4)	19 (9.8)	83 (83)	4 (2.7)
Did not answer (%)	2 (0.7)	–	–	–
Relationship with
N	176	175	17	143
Patients (%)	143 (81.2)	138 (78.9)	2 (11.8)	99 (69.2)
Relatives (%)	16 (0.9)	2 (1.1)	15 (88.2)	2 (1.4)
Both (%)	13 (7.4)	35 (20)	–	42 (29.4)
Did not answer	4 (2.3)	–	–
Number of patients
N	156	159	16	131
Range	[1–50]	[1–220]	[0–2]	[1–50]
Mean	5.95	14.3	1.19	9.76
Median	3	6	1	6
Mode	1	10	1	5
Standard deviation	7.31	23.37	0.54	8.48
Did not answer	20	16	1	12

Sixty-five percent of medicine students did have direct exposure to TIPs; 89.4% of these had had experiences during their clerkship years and the rest (10.6%) with relatives. The average ratio for each medicine student who had had a direct exposure to TIPs was 5.95±7.31 for first year students, and 14.3±23.37 for those in the last year. Eighty-three percent of first year students and 2.7% of last year students did not have any direct exposure to TIPs (Table 2).

To establish a relation between courses (first and last year) and the experience of direct exposure to TIPs, both in medicine and nursing, contingency tables were used. The χ² value for nursing was 48.96 with p<0.0001; for medicine the value was χ²=168.104 and p<0.0001.

For the question, “How did you feel during that experience with patients at the end of life?,” the median and the mode for both careers during the first and last years was 5, using a Likert scale ranging from 0 (felt uneasy) to 10 (felt at ease).

Attitude with respect to terminally ill patients

Students' attitudes toward the suffering patient who is close to death, illustrated by the values of the median and the mode using a Likert scale, was positive, of interest, and with a feeling of empathy for the patient. This was observed in both medical and nursing students in the first and last years (Table 3).

Table 3.

Comparison of First and Last Year Students' Agreement with Key Statements Regarding End-of-life Care

	Nursing students						Medicine students
	First year (n=289)		Last year (n=194)				First year (n=100)		Last year (n=147)
Statements	Median ^a	Mode ^a	Median ^a	Mode ^a	X ²	P value	Median ^a	Mode ^a	Median ^a	Mode ^a	X ²	P value
Treating terminally ill patients may be gratifying for a nurse/doctor.	7	10	6	10	25.309	0.005	7	5	8	10	10.154	NS
I would feel at ease listening to terminally ill patients.	9	10	8	10	20.451	0.025	8	8	8	10	7.894	NS
Nurses/Doctors should be available to listen to patients.	10	10	10	10	14.973	NS	10	10	10	10	9.762	NS
Patients should be told the truth when they ask whether or not they will die.	8	10	8	10	15.796	NS	9	10	9	10	7.898	NS
Nurses/Doctors should discuss death in detail with terminally ill patients.	10	10	10	10	13.461	NS	10	10	10	10	12.597	NS
Nurses/Doctors should discuss death in detail with the family of the dying patient.	10	10	10	10	9.097	NS	10	10	10	10	9.116	NS
The time devoted to be prepared to die may have meaning.	7	10	8	10	19.475	0.035	7	10	9	10	22.386	0.013
I consider that a dying patient could accept death with serenity.	6	10	7	10	13.682	NS	6	5;10	8	10	25.786	0.004
I am interested in terminally ill patients' care, death, and the dying process.	10	10	10	10	10.437	NS	9	10	9	10	10.750	NS

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

NS, nonsignificant; X², Chi square.

A high percentage of all students (80%) indicated, with values above 5 (in a 10-point Likert scale), that a dying patient could accept death with serenity (75%) and that the process caused by a terminal disease and the time devoted to be prepared to die, may have meaning in a person's life (83%). In fact, 92.6% of nursing students and 95.06% of medical students considered that these issues may help patients to value certain assets (their life, health, family, friends) and may change the priorities that rule their lives or may tighten affective ties with their loved ones.

In their approaches to interacting with TIPs in the future, students were asked if they would prefer to have a “short-lasting or a prolonged” relationship with the patients. Fifty-five percent of first year nursing students opted for prolonged relationship, whereas 33% preferred a short-lasting one. The ratio short-lasting/prolonged relationship was reversed in last year nursing students, where 49% preferred a short-lasting one and 45.4% a prolonged relationship with TIPs. In the case of first year medical students a high percentage (63%) opted for a prolonged relationship, whereas 34% opted for a short-lasting relationship with TIPs. In last year medical students, 45% opted for a short-lasting relationship and 50.6% opted for a prolonged one.

Students who opted for a short relationship with TIPs argued that they wanted to avoid over-commitment and emotional involvement, as well as to get around the possibility of not feeling capable of handling the situation. One percent of medical students and 9.3% of nursing students did not answer this question.

Also, 51.3% of nursing students and 57% of medical students expressed the 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 peaceful death). For many students, those encounters would be professionally challenging and personally rewarding, although they would require technical training.

First and last year students of both careers expressed the same wishes and gave similar reasons when asked about their relationship with TIPs (Table 4). They described in short and expressive phrases the emotional impact of meeting and speaking with patients who are near the end of life. They expressed feelings of sadness, vulnerability, and helplessness, as well as sympathy for the patients. No significant differences were observed when comparing first and last year students, except for nurses where a higher number in the last year wished to avoid affective involvement with patients (Table 4).

Table 4.

Wishes and Reasons Expressed by the Students Regarding Their Relationship with Terminally Ill Patients (Main Statements)

	Nursing students (n: first 205 – fifth 164)			Medicine students (n: first 62 – sixth 81)
Main statements expressed by students	First year N (%)	Last year N (%)	P value	First year N (%)	Last year N (%)	P value
Wish to prepare to offer a better care for the benefit of terminally ill patients, i.e.:
“to offer them a better care,” “to accompany the patient in those moments,” “get to know them,” “listen to them,” “to understand him/her,” “to offer moral and psychological support to the patient,” “prepare them to die”	111 (54.1)	72 (43.9)	0.051	35 (56.5)	46 (58.6)	0.968
Wish to avoid affective involvement and a painful personal experience for the nurse, i.e.:
“to avoid affective involvement,” “it is very hard for 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”	64 (31.2)	74 (45.1)	0.006	21 (33.9)	28 (34.6)	0.931
Wish for personal enrichment and the opportunity for personal growth, i.e.:
“it is an enriching experience for the nurse,” “it is inspirational for the nurse,” “I want to learn from the patient”	26 (12.7)	15 (9.1)	0.283	6 (9.7)	7 (8.6)	0.831

P value: asymptotic significance level, according to Pearson's X² (Chi square).

Students' interest in end-of-life care education

In medicine as well as in nursing, it was confirmed there was a lack of technical training in understanding and caring for patients near the end of life. However, students of both careers referred to having discussion on the meaning of suffering and death. This took place, in most cases, in subjects with humanistic orientation, for example,bioethics, ethics, anthropology, theology, philosophy, or psychology. The significance that students assigned to this topic was explored by asking whether they thought death and how to help patients to die should be included in their curricula.

Ninety-six percent of nursing students and 100% of medical students believed that these topics ought to be part of the curricula. Many of them suggested that they are cross-cutting topics and should be present in several subjects. Some students indicated that these topics could be present in a mandatory course or as an extracurricular subject.

Ninety-eight percent of nursing students (median=10; mode=10) and 99.6% of medical students (median=10; mode=10) expressed their interest in the topics of TIPs caregiving, death, and the process of dying. No significant differences were observed between the opinions of first and last year students.

Discussion

Our main findings were thatMedical and nursing students had had experience of direct contact with patients near the end of life, in the process of dying, and at death itself.

During first year the number of students with that experience was higher in nursing than in medicine. This was due to the structure of the nursing study programs, which foster from the very beginning a higher degree of relationship with the patient. Another reason was that some students had already worked as nursing auxiliaries.

During their last year, 94% of students (91.2% nursing; 97.3% medicine) had contact with this kind of patients. The average number of patients treated by last year students, in both careers, was significantly higher than first year students.

According to previous works,²⁸⁽²⁸⁾ and considering nursing students' experience, we were inclined to think that their attitudes toward TIPs would be more positive than those of medicine students. However, our data did not support this view. Interestingly, the number of students who preferred to shorten their relationship with TIPs, when comparing first and last year, was higher in nursing than in medicine. This observation was coincident with the fact that a significant number of fifth year nursing students did not agree with the statement that considered treating TIPs gratifying (Table 3). This was not the case of medicine students, where no significant difference was achieved between those of first and last year. Our results also indicate that students who are more likely to withdraw from the care of the dying tend to limit the relationship to the strictly necessary matters.

These data suggest that students with more experience in dealing with TIPs, without a proper training, try to protect themselves in order to avoid emotional involvement derived from the relationship with these patients, as has already been published.^2,13,18,20

It is important to underscore that both medicine and nursing students from different years and schools expressed in similar terms their expectations regarding their future professional relationship with TIPs (Table 4).

On the contrary, first year students, with less interaction and experience with TIPs, showed a better disposition to engage in a relationship that would allow them to devote all the time that the patients demanded, in order to accompany, listen, understand, and prepare them for a peaceful death. It should be thought that these students may not be aware of how highly demanding and often stressful is the care of patients for whom imminence of death is a fact. In fact, this also explains the decrease of the disposition to engage with TIPs in more senior students.

Further studies will be necessary to demonstrate whether or not training in end-of-life care could improve the attitudes of students toward TIPs. In students with proper training, the needs of the patients should be a priority over their will to protect themselves.

The indication made by all students that during their studies more emphasis has been put into the meaning of suffering and death than into the technical aspects of the caring of TIPs (to sympathize and to help), was reflected also by the fact that the subjects more referred to by the students were those with more humanistic contents. Additionally, almost all of the students pointed out that training on how to care for dying patients should be taught as a topic within mandatory clinical subjects, organically, as part of the program's curriculum.

As previously stated, terminal disease and death are moving life experiences, and caring for patients at the end of life requires that health care professionals receive special training.^26,29,30 These results indicate that occasional contact of nursing and medical 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.

Conclusion

As a result of the findings of this work we conclude that nursing and medical undergraduate students at nursing and medicine schools in the city of Buenos Aires and surrounding areas: (a) come in direct contact with TIPs and perceive their suffering; (b) have a highly positive attitude toward these patients, even though some of them referred to that relationship as arduous and in some cases they tended to avoid emotional involvement because they did not feel well trained; (c) this wish for avoidance was increased in last year medical and nursing students who had been exposed to higher number of TIPs; and (d) unanimously manifested the opinion that teaching about caring of TIPs should be included in the curricula and they would be well disposed to receive it.

For all these reasons, we consider that the teaching of caregiving to TIPs in the degree programs of nursing and medicine should not be presented as a marginal issue.

It seems appropriate to include, as soon as possible, undergraduate, specific training that would allow future physicians and nurses to provide the best possible quality of life to these frail patients. This new content in medical and nursing curricula should address and provide training that helps health care professionals avoid the emotional exhaustion that can result from the complex professional relationships dying patients demand.

We suggest that these issues should be incorporated into the required standards for the accreditation of medical and nursing degree programs. The addition of an optional subject, in the short term, covering end-of-life care, should be encouraged in all academic centers. Subsequently, these issues should be presented as an organic and transversal part of all subjects across study programs, mainly in those with more clinical content, and should not relegated to the humanistic ones only.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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