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Care of the Dying.. a Positive Nursing Student Experience

Care of the Dying.. a Positive Nursing Student Experience

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MEDSURG Nursing—August 2006—Vol. 15/No. 4
Judy L. MalloryCharles L. Allen
Care of the Dying: A PositiveNursing Student Experience
Judy L. Mallory, EdD, RN, CHPN,
is anAssistant Professor of Nursing,Western Carolina University, Cullowhee,NC.
Charles L. Allen, BSN, RN,
is a StaffNurse, Harris Regional Hospital, Sylva,NC.
 How a staff nurse should determine the appropriateend-of-life care experience for a nursing student, including what course work the student should have prior to the expe- rience as well as what knowl- edge and support the staff nurse and student should expect from the clinical instructor, is discussed. Trans- formative learning theory isused as the basis for enhanc- ing the student’s learning and can facilitate a positive end- of-life care experience.
istorically, nurses have not received extensive education on how tocare for dying patients and their families (Allchin, 2006; Ferrell, Virani,Grant, Coyne, & Uman, 2000). This lack of education has been reflected inthe level and quality of end-of-life (EOL) care provided to patients. NursingEOL curricula have been lacking both in didactic education and clinicalexperiences. Students who by chance cared for a dying patient wereunprepared and in some cases had little support from staff nurses or theirclinical instructors. With the funding of the End of Life Nurse EducationConsortium (ELNEC), this trend began to change (Matzo, Sherman,Sheehan, Ferrell, & Penn, 2003).
The History of Nursing Education in Relation to End-of-Life Care
Many nurses and nursing students have difficulty dealing with death(Brockopp, King, & Hamilton, 1991; Cooper & Barnett, 2005; Payne, Dean,& Kalus, 1998; Servaty, Krejci, & Hayslip, 1996; Thompson, 1985; Waltman& Zimmerman, 1992). In contrast, the International Council of Nurses(1997) stated that nurses have a unique and primary responsibility forensuring that individuals at the EOL experience a peaceful death. Thenursing role in EOL care has expanded in the last decade to includeadvanced directives, do-not-resuscitate (DNR) decisions, and palliativecare discussions (Haisfield-Wolfe, 1996).The authors have noted that, because many nurses struggle withnegative personal issues concerning death and dying, they are thereforeuncomfortable providing care to dying patients. Examples include arecent experience with a nurse caring for a dying patient. The nurseasked one author, who was in the role of nursing instructor with hospiceexperience, to talk to the family about the approaching death of apatient. In another experience, the authors witnessed staff nurses avoid-ing an approaching death conversation with family members of a dyingpatient because they wanted the hospice nurse to ask for a DNR order.The nurses openly admitted discomfort in dealing with death and dying.A recent unpublished study (Connell, 2006) found that several schoolsof nursing do not provide effective education for nursing students onEOL care options. In another study (Ferrell et al., 2000), the majority ofnurse respondents (89.5%) felt that EOL content was important to basicnursing education. However, 71% of respondents said their EOL painmanagement education was inadequate, 62% rated their overall contenton EOL care as inadequate, and 59% rated management of other symp-toms education as inadequate. The study also found that less than 35%of nurses rated their grief/bereavement support and spiritual support topatients at the EOL as effective.
MEDSURG Nursing—August 2006—Vol. 15/No. 4
The increase in EOL aware-ness in the United States andother countries has promptednursing programs to evaluatetheir curricula and begin to addEOL material. Studies on EOLcare have included semester-longcourses, 2-day seminars, andclasses that last only a few hours.Education does have a positiveeffect on nurses’ attitudes towardcare of the dying, at least in theshort term (within a year of thecourse) (Brent, Speece, Gates,Mood, & Kaul, 19991; Degner,1985; Durlak & Reisenberg, 1991;Frommelt, 1991; Kaye, Gracely, & Loscalzo, 1994; Lev, 1986;Mallory, 2003). Many of thesestudies also show that previousexperience with death and a classabout death and dying seem relat-ed to nurses’ and nursing stu-dents’ attitudes toward death andcare of the dying. Specifically, stu-dents who have had previouslypositive experiences with deathand dying, or a course aboutdeath and dying, have more posi-tive attitudes.Kaye and colleagues (1994)found that participants in a deatheducation course showed a cleardecline in negative attitudes ascompared with the control group.Lev’s (1986) study indicated thatan elective course in hospicenursing was effective in decreas-ing subjects’ negative attitudestoward death and dying andavoidance behaviors. Frommelt(1991) stated “the only demo-graphic variable which proved tohave a significant effect on thenurses’ attitudes toward caringfor the terminally ill was havingtaken a specific course on deathand dying previously (Fprob=0.04)” (p. 41). Mallory(2003) noted that nursing stu-dents’ attitudes toward care ofthe dying improved with coursework and clinical experience incare of the dying.Yeaworth, Kapp, and Winget(1974) assessed nursing students’attitudes toward death and dying.Comparing freshman nursing stu-dents to senior nursing students,they found that senior nursingstudents had greater feelings ofacceptance, more open communi-cation, and were less likely tostereotype attitudes. They alsofound that freshman nursing stu-dents were more likely to rely onreligious beliefs to cope withdeath anxiety. Others found thatindividuals with more death edu-cation and death experience havemore positive attitudes towarddeath and dying (Gesser, Wong, & Reker, 1987).Thompson (1985) noted thatmore experience leads to lessanxiety about dying and positiveattitudes toward caring. Ex-perienced nurses were more will-ing to share feelings and atti-tudes, and view the dying patientas a patient first and as a dyingperson second. Franke andDurlak (1990) found death of asignificant other to be the highestlife experience to affect attitudestoward death; religion was thenext highest, with near-deathexperience as third. Individualswith strong intrinsic religiousbeliefs tend to report less deathanxiety according to Waltmanand Zimmerman (1992), whofound that nurses who had expe-rienced the death of a close fami-ly member in the previous 2 yearswere significantly more likely toprovide continuing care forbereaved family members thanthose who had not. Alvarado,Templer, Bresler, and Thomas-Dobson (1995) found that strongreligious convictions and a beliefin an afterlife were associatedwith less death anxiety. Davis-Berman(1998) looked at atti-tudes toward aging and death.Contrary to her expectation, shefound that after a course onaging, students’ attitudes towarddeath did not improve.Allchin(2006) found that students asso-ciated caring for the dying withdiscomfort, anxiety, and sadness;however, they felt the course wasbeneficial overall and necessaryto become a nurse.
Theoretical Framework
Research has indicated thatnursing students’ exposure to apositive death experience in asupportive atmosphere wouldallow improved attitudes towarddeath and dying. These guide-lines are based upon Trans-formative Learning Theory, whichinvolves the transformation of anindividual’s beliefs, ideas, andviews. Nursing faculty and staffcan create an atmosphere inwhich learners are encouraged toevaluate their beliefs and viewsthrough self-reflection. Changeoccurs as learners incorporatetheir new learning into theirbelief system and transform orreject their old beliefs. Nursingfaculty and staff can facilitatetransformative learning throughuse of a variety of educationexperiences and teachablemoments. Care of dying patientsand their families lends itselfreadily to Transformative Learn-ing Theory. Allchin (2006) foundthat when nursing studentsreflected on their experienceswith dying patients they com-bined their own personal experi-ences with grief, loss, and death,with their clinical experiencesand found the clinical experienceto be of value.Palliative care at the end oflife is an example of a subjectthrough which an adult learnercould have a transformativelearning experience. As the edu-cator and learner explore pallia-tive care issues for EOL care,strongly held views may be reaf-firmed or challenged. New infor-mation is learned and, afterreflection, previously held beliefsmay be challenged or changed.Transformative learning bringsabout change within persons thatis significant to their beliefs andthought processes. Habermas(1971) discussed three domainsof knowledge in relation to trans-formative learning.
Technical knowledge
is related to cause andeffect,
 practical knowledge
per-tains to understanding what oth-ers mean, and
emancipatory knowledge
involves critical self-reflection. Cranton (1994) notedthat emancipatory knowledge is aprocess of removing constraintsand being free of forces that limitoptions and control lives.Transformative learning is pri-marily emancipatory knowledge“gained through critical selfreflection, as distinct from theknowledge gained from our ‘tech-nical’ interest in the objectiveworld or our ‘practical’ interest in
MEDSURG Nursing—August 2006—Vol. 15/No. 4
social relationships” (Mezirow,1991, p. 87). Cranton (1994)expressed the importance ofemancipatory knowledge whenshe stated, “If we view educationas the means by which individu-als and societies are shaped andchanged, fostering emancipatorylearning is the central goal ofadult education” (p. 19).The suggestions in this arti-cle are based upon the few stud-ies related to the topic as well asthe experiences of the authors inworking with nursing studentsand staff nurses to provide posi-tive clinical experiences in thecare of dying patients. The goal isto encourage staff nurses tochoose clinical experiences fornursing students that allow themto apply their knowledge of EOLcare and to foster critical self-reflection and personal growth intheir attitudes toward care of thedying.
Staff Nurses’ Role inAssigning Care of DyingPatients
A staff nurse can facilitate apositive experience for a nursingstudent in caring for a dyingpatient by being friendly, showinginterest in the student, and mak-ing himself or herself available toanswer questions (Jackson & Mannix, 2001). The uniqueness ofcaring for a dying patient requiresthat the staff nurse assess theknowledge and experience ofboth the faculty and nursing stu-dent who will be involved in thepatient’s care (see Table 1). Thestaff nurse must recognize thatthe student may feel tentativeand even fearful of caring for adying patient. The staff nurseshould show understanding ofthese feelings and be available tothe student (Jackson & Mannix,2001). Allchin (2006) reportedthat students who cared for dyingpatients found that “a significantbenefit of the experience of pro-viding care for a dying personwas the support and presence ofthe clinical instructor and thestaff nurse” (p. 115). Part of show-ing interest in working with anursing student caring for a dyingpatient is to give the student adegree of responsibility with thepatient in accordance to his orher own knowledge and experi-ence. If the student is a first-semester student with little clini-cal experience, he or she mayonly help turn the patient, pro-vide personal care, and sit withthe family at the bedside.Students with more advancedexperience and communicationskills may administer analgesics,provide alternative comfort mea-sures, discuss approaching deathwith the family, and possiblyadvocate to the physician for pal-liative measures.Explaining is also an impor-tant staff nurse behavior(Jackson & Mannix, 2001). Thenurse should ensure that the stu-dent understands the needs ofthe patient and the reasons forprescribed care and treatment.Explaining also will foster trans-formative learning. As the stu-dent gains new knowledge andexperiences the challenges andrewards of caring for dyingpatients, attitudes will bechanged and he or she will havethe opportunity for emancipa-tion. Policies regarding palliativecare and postmortem care shouldbe explained. Explaining empow-ers the student to locate informa-tion independently after explana-tion and thus develop a level ofindependence.The authors found that stu-dents feel degraded and fearful ofcaring for dying patients afterhaving a negative clinical experi-ence. Behaviors that can causethe student to have a negativeclinical experience with EOL careinclude working with a nurse whoignores him or her, treats the stu-dent with contempt, or as thoughit is not the nurse’s responsibilityto help educate or socialize him
Encourage and support the student.Provide a detailed report to student at the beginning of the shift. Thisshould be accomplished before the student enters the patient’s roomand should include:DiagnosisProgression of illnessPalliative needs and treatmentsPsychosocial needsSpiritual needsInclude family members and who is present in the roomWhat the student will encounterThe patient’s general appearance and mental statusAny unpleasant symptomsAny unusual or potentially uncomfortable family dynamicsAny invasive treatmentsOther patient care team members if applicableCNAChaplainPTOTSpeechDietarySocial workerIntroduce student and faculty member to patient and family, and explainstudent’s role in caring for patient.Provide student with suggestions of ways to interact with patient andfamily.Suggest palliative measures which student can initiate.Emphasize the importance of the role of “nurturing presence” in nurs-ing.Provide opportunity to role play difficult conversations.Encourage student to identify any additional patient needs and suggestfurther interventions or consults if applicable.Provide follow-up de-briefing, and give feedback to student and facultymember about clinical experience.
Table 1.The Role of the Staff Nurse

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