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Providing high quality care for dying patients and their families has been highlighted as a na-tional priority in the United Kingdom (UK)1 with national guidelines and policies existing to provide direction specific to the provision of end-of-life care (EOLC).
Providing high quality care for dying patients and their families has been highlighted as a national priority in the United Kingdom (UK)1 with national guidelines and policies existing to provide direction specific to the provision of end-of-life care (EOLC). These include National Institute for Health and Care Excellence ‘Guidance for end-of-life care in adults’.2 and ‘Endof-life Care Strategy: Promoting high quality care for adults at the end of their life’ from the Department of Health.3 The challenges faced by dying patients are substantial and potentially overwhelming4 and those near the end-of-life may experience perhaps extreme symptoms that include physical, spiritual and psychosocial suffering.5 It is recognised that quality EOLC can only be delivered when the needs of both patients and their support network, such as families, are addressed; taking into account their priorities, preferences and wishes.6
Despite the inevitability of death, patients and families may not always receive the quality EOLC they desire. Patients and their families have reported sub-optimal EOLC with unmet needs in areas such as communication and information giving,7 and symptom control and emotional support.8 This can be exemplified in the case of the care of patients with cancer cachexia at end-of-life, where research uncovered a lack of communication and information giving from healthcare professionals about the causes and impact of cachexia in advanced cancer.9 They reported that this left patients and their families feeling apprehensive and distressed at an already emotive time, weakening their confidence in the ability of the staff to provide
revealed that a lack of understanding of this complex symptom at end-of-life contributed to a culture of avoidance, as staff struggled to recognise cachexia or understand how to manage it appropriately. Participants reported that an absence of professional
This lack of preparation appears as a common thread throughout the literature, including at undergraduate level with evidence suggesting that end-of-life education is poorly delivered within undergraduate nursing and medical curricula.
Medical students have reported feeling unprepared to deal with end-of-life issues14 and nursing students and newly qualified nurses report feeling ill-equipped to provide quality EOLC to 1,15 patients and their families.1,15 It is a recognised area of concern for undergraduate students, with many reporting concerns about communication (such as talking about death and dying), how they will react to death and practical matters such as symptom 16,17 management. This lack of preparation appears to have an impact in clinical practice. A recent independent investigation into the utilisation of the Liverpool Care Pathway18 highlighted a number of concerns about the competence of nursing and medical staff to care for the dying and bereaved. Too often there were variations and failings in the delivery of EOLC, causing unnecessary distress to people who were dying and those close to them.19
From the evidence presented above it is imperative that EOLC must have a predominant place in the curricula of undergraduate healthcare professionals, particularly in the disciplines of nursing and medicine, with effective teaching strategies tailored to the needs of the undergraduate learner.
Teaching strategies must provide meaningful connections between the student, course content, practical experience, and the dying patient.20 Literature on preferred teaching strategies for EOLC have been reported over the years, such as the preference for experiential approaches for teaching about death and dying.21 Experiential learning can aid the discovery of possibilities which may not be evident solely from direct experience.22 Experiential learning opportunities are necessary to allow students to spend time with dying patients and their families.23 For example, research has found that newly qualified doctors’ competence and confidence in delivering care to patients at the end-of-life increased in tandem with accumulated exposure to EOLC.24
It has been argued that technological advances in healthcare have obscured the need for human compassion for those at the end-of-life and their families. Not surprisingly, public demand for a more holistic, integrated approach toward health, illness, death and dying has been increasing.25 The literature has reported on a number of different teaching strategies used to deliver EOLC, including:
‘Traditional’ classroom-based methods: EOLC education using ‘traditional’ teaching methods, such as didactic lectures, audiovisual aids and small group discussions in the classroom have been found to have had a positive impact on students’ personal and professional development regarding care of the dying.26 Other ‘traditional’ classroom activity, such as seminars on EOLC, can help students to learn about communication skills, holistic
Artistic strategies: Whilst ‘traditional’ teaching methods have had some previous positive evaluations as described, the use of theatre (a performance of Wit) has been reported as a more 12,13 preferable teaching method of EOLC in comparison to didactic lectures and reading journal papers.28 A method known as ‘storyboarding’—sharing stories through written words and pictures—is another artistic learning strategy and has been reported as a helpful way to learn how to identify cultural aspects and feelings related dying patients and valued by students as a way of sharing their experiences.29
Low and high fidelity simulation: Low fidelity simulation, using role-playing and low fidelity manikins, has been reported as useful by undergraduate nurses for developing communication skills for EOLC.30 High fidelity simulation using more sophisticated technology (such as computer controlled simulator manikins) has been reported as an effective way to change attitudes toward EOLC in undergraduate nursing and medical students.31
Online learning resources: Online EOLC education can include online courses. The use of an online learning course on death and dying found that students appreciated the ability to reflect on their experiences in a non-judgmental setting and online education increased their confident in EOLC.32 Other online resources include the use of virtual patient cases, which has been found to increase students’ comfort and knowledge regarding EOLC.33
Clinical or voluntary placements: Aside from mandatory clinical practice placements forming part of students’ healthcare programmes, (voluntary) placements specific to EOLC have been employed as a teaching strategy for EOLC education, such as visits to hospices. Such experiences can improve students’ attitudes towards EOLC and students have reported improvements in self-perceived competence to care for dying patients follow- 22 34 ing EOLC education placements.34
Standardised patients: Standardised patients (actors) have been used as a strategy to deliver EOLC education, and their use has been found to improve students’ confidence and knowledge of 24 35 EOLC.35 This strategy had also been reported to be a valuable way to practice conversations relating to death and dying before encountering patients at the end-of-life in clinical practice.36
Multimodal methods: Multimodal (or multidimensional) methods incorporate more than one type of teaching strategy into an EOLC curriculum or EOLC course. For example, ‘traditional’ methods such as didactic lectures partnered with experiential methods such as high fidelity simulation have been found to improve students’ attitudes towards EOLC.37
Although, these studies have demonstrated the effectiveness of some of these teaching methods to deliver EOLC, there are a number of limitations within the published literature, which includes small-scale pilot studies with small samples sizes, potential bias, and the use of non-validated measurement tools for data analysis. Many of these studies were carried out
sample (such as nursing students only), or recruited students from a number of healthcare courses but the study did not focus on their learning in an interprofessional education (IPE) context.
A literature review by Gillan et al found that studies suggest end-of-life simulation to be a viable learning approach and have a positive impact on knowledge acquisition, communication skills, self-confidence, student satisfaction and level of engagement in learning.38 Simulation using high fidelity manikins is being increasingly used by educators in EOLC education, due to the lack of practice placements in this area due to increasing student numbers.31 Research conducted in the UK quantitatively evaluated the use of high fidelity simulation in EOLC education.31 This was a quasi-experimental, pre-test-post-test pilot study which recruited undergraduate students from nursing (n=15) and medicine (n=4). The intervention involved two independent simulation scenarios, intended to reflect the challenges of providing EOLC to dying patients and their families. A highfidelity simulation manikin was used as the patient and an actor played the role of the patient’s relative. Using the Frommelt Attitudes Towards Care of the Dying (FATCOD) Form B-scale, results showed that students’ attitudes towards EOLC were more positive after taking part in the simulation intervention in comparison with pre-intervention scores. This study noted that whilst high fidelity simulation is a viable method for teaching EOLC, the use of high fidelity simulators to teach EOLC in both undergraduate nursing and medical education in an interprofessional context is scarce. IPE, “…occurs when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes”.39 After almost fifty years of enquiry, evidence sufficiently indicates that effective IPE enables effective collaborative practice, with the implementation of IPE into healthcare profession programmes gaining support from the worldwide governments and universities.
A systematic review of the literature is being conducted to identify empirical evidence regarding teaching strategies which are effective for delivering EOLC education in undergraduate healthcare programmes. As there is a lack of evidence concerning the use of high fidelity simulation for teaching EOLC to undergraduate students for IPE, a study is currently being conducted as a part of the lead author’s doctoral research training to address this gap in the literature. The study is currently recruiting undergraduate nursing and medical students to take part in high fidelity simulation scenarios (adaptations of those used in previous research). The study will employ a three-phase mixed-methods research design. Symbolic interactionism was the chosen theoretical framework for this study as it provides a meaningful framework by which to interpret and understand human behaviour and social interaction. This is relevant as the study is focusing specifically on IPE.
EOLC is an internationally applicable area of healthcare. The research team has recognised this and has therefore made tentative links with a higher academic institution in Canada that is highly involved with undergraduate EOLC education with an IPE presence within the university. It is then hoped to develop a research agenda related to EOLC education that is globally applicable.
The authors declare that they have no conflicts of interest.