Does EOL and palliative care training increase clinicians’ self-perceived knowledge and/or confidence with EOL care and communication?
Findings from a Systematic Review
Hayley Nusser
Senior Honors Thesis
UNC Chapel Hill – School of Nursing March 23, 2020
Approved:
Abstract
Nurses care for patients approaching the end of life (EOL) regularly and are often looked towards by the patient and family members to be a source of comfort and support. Without proper EOL care and communication training, nurses may feel uncomfortable in communicating about EOL. This systematic review analyzed the effects of EOL educational intervention in nursing students, nurses, and advance practice registered nurses (APRNs). An online search of PubMed, CINAHL, and Google Scholar was conducted with the following search terms, end-of-life care, training, education, communication, skills training, nurse, nursing students, and
palliative care. Inclusion criteria consisted of articles written in English, published within the
last 5 years (2015-2020), studies involving nursing students, nurses, or APRNs as participants, and studies that included some form of educational intervention that measured knowledge, attitude, or confidence in regards to palliative care or EOL care. Thirty-three articles were screened for eligibility, and 7 articles were included in the final sample. With educational interventions such as group discussions, lectures, role-play, film discussions, and online training, nurses have opportunities to improve their confidence when communicating about EOL to better provide care for patients and family members. Further research in measuring actual EOL
communication change is needed to demonstrate complete evidence on the necessity for this training.
Introduction Personal Interest
I have never considered myself to be exceptional when it comes to comforting others who are confronting heavy life situations; it has always been something that seemed a bit
problem during my first clinical rotation that happened to be on UNC’s 4 Oncology, an adult medical oncology unit. The patient I was assisting the RN with that day was near the end of life and had made the choice to begin hospice care and services. I wanted to be as helpful as I could to the patient and the patient’s wife, but I felt at a loss for my complete inability to be able to comfort them, as I had been able to comfort patients and families who had been in less
devastating situations. After leaving clinical, and feeling as if there was something more I could have done, I began to wonder what kind of training programs were in place for nursing students and nurses, in order for them to better communicate with patients as they approached the EOL.
As I began my summer oncology fellowship in Summer 2019 with three weeks on UNC’s Bone Marrow Transplant Unit and three weeks on UNC’s 4 Oncology Unit, I had even more experiences in caring for patients who were approaching the EOL. I began asking around the units for some advice on how to handle these situations with compassion and caring, and I was grateful for the recommendations I received from the nurses who had years of experience in dealing with death and dying. I asked the nurses if they had ever received specified training for how to communicate with patients at the EOL, and all replied that they had not, but thought that that would be beneficial not just for the newer nurses, but for the more experienced nurses as well, because it is never too late to learn new skills or ideas. From my personal experiences in working with patients at the EOL, and in speaking to oncology nurses, I became interested in reviewing literature in EOL communication training for nurses and the benefits that may result from this type of training.
Background
thus the importance of education of nurses on this topic is paramount. However, the quality of EOL care in hospitals has been found to be variable, and of lower quality compared to outside hospital settings, prompting the discussion of the significance of EOL training for nursing students, nurses, and nurse faculty (Scammell, 2018).
The End-of-Life Nursing Education Consortium (ELNEC) is mentioned frequently as a method for educating nurses on EOL care throughout this paper and throughout the literature. ELNEC began in 2000 after being funded by a grant from the Robert Wood Johnson Foundation, and to date, over 24,600 nurses and healthcare professionals have received ELNEC training (“End-of-Life-Care (ELNEC)”). Additionally, over 380 nursing schools have utilized the
ELNEC-Undergraduate curriculum, helping educate over 33,500 nursing students (“End-of-Life-Care (ELNEC)”). ELNEC began as a generalized training course for nurses, but has now
developed various subspecialties, including ELNEC Geriatric, ELNEC Pediatric Palliative Care, ELNEC Critical Care, ELNEC APRN, ELNEC Communication, ELNEC Oncology APRN, ELNEC International, and ELNEC for Veterans (“End-of-Life-Care (ELNEC)”). The general ELNEC curriculum consists of 8 modules including: Introduction to Palliative Nursing, Pain Management, Symptom Management, Communication, Ethical and Legal Issues, Cultural Considerations, Loss/Grief/Bereavement, and Final Hours (“End-of-Life-Care (ELNEC)”). Teaching methods include role-play, case study reviews, and lectures (“End-of-Life-Care (ELNEC)”). Although not every study in this paper utilized ELNEC specifically, many of the studies did utilize teaching methods and curriculum based on ELNEC.
aspect of ELNEC is that once a participant has completed the course, they will then go on to train other nurses in their workplace to extend the reach of the curriculum (Ferrell et al., 2015).
The purpose of this literature review is to examine the question, “In clinicians (including nursing students, nurses, and faculty) who are receiving EOL/palliative care training and/or communication training compared to those with no training, what is the clinicians’ self-perceived knowledge and/or confidence with EOL care and communication?”
Methods
The following words and combinations were used to conduct searched using the databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar: end-of-life care, training, education, communication, skills training, nurse, nursing students, and palliative care. Inclusion criteria consisted of articles written in English,
published within the last 5 years (2015-2020), studies involving nurses, advanced practice registered nurses (APRNs), or nursing students as participants, and studies that included some form of educational intervention that measured knowledge, attitude, or confidence in regards to palliative care or EOL care. One international study was included as it met the inclusion criteria. Articles that were excluded from the literature review included those that were systematic reviews, literature reviews, case reports, expert opinions, guidelines, dissertations, abstracts, editorials, and those that discussed pediatric EOL or palliative care. Seven articles met the inclusion criteria and were selected for review (see Table 1). See Figure 1 for the article selection process.
Results:
participants, and in 2019, there were 95 participants. The 2018 study had the most participants with 1,700 nursing students from greater than 100 nursing schools across the United States completing the ELNEC-Undergraduate curriculum. Participants of the studies included undergraduate nursing students, inpatient nurses, and APRNs. Six out of seven of the studies were conducted in the United States, but one of the studies was conducted in Korea. The
intervention approach consisted of online modules (n=1), in-person training sessions (n=5), and a multi-modal approach of online modules versus in-person meeting and online modules (n=1). Study length varied from semester-long courses for undergraduate students to 1- or 2-day
training courses. Courses for undergraduate students involved lecture, group and film discussion, reading, and essay writing. Training sessions included watching educational videos, small group discussion, and role-play. Common delivery methods were some form of educational teaching, either via lecture or video. Four of the seven studies were explicitly a part of or modeled from ELNEC curriculum.
Registered Nurses Survey to assess nurses’ perceptions of palliative care before and after completing the ELNEC Core curriculum. Banerjee et al. (2017) involved self-reports using a 5-point Likert scale and pre- and post-standardized patient assessments to assess skill. Robinson & Epps (2017) assessed attitudes towards EOL care using the Frommelt Attitude Toward Care of the Dying Scale and assessed knowledge using the Palliative Care Quiz for Nursing. Therefore, a variety of scales were utilized to assess a wide range of aspects including attitude towards death, communication skills, confidence levels in EOL discussions, and knowledge. A common tool for measurement was a 4- or 5-point Likert scale for measuring self-reports of attitude, confidence, or whether the curriculum increased their knowledge.
A strength of the review is that there were a variety of participants assessed, including nursing students, registered nurses, and APRNs, all of whom will at one point utilize palliative or EOL nursing care. Another strength is that while there is a focus of EOL care in the United States, there was also one study conducted in Korea, thus it’s plausible that further studies in other countries will be conducted in upcoming years. An additional strength was the variety of educational interventions used to cater towards different learning styles of participants. One common limitation of the studies were that findings could not be generalized due to either being carried out at one specific location, using a convenience sample, or using a small sample size without randomization. Another limitation of the studies was that self-rated ability does not necessarily correlate with objective measures of performance. An additional limitation was that the nurses, nursing students, or APRNs who agreed to participate in these studies most likely had an interest in palliative care, possibly biasing the sample.
If I could design my own study, I would want to complete a series of three studies with each of the three groups: nursing students, registered nurses, and APRNs. I think it would be interesting to see if one group would see the interventions as more beneficial than another. I would include many of the educational interventions utilized in these 7 articles, including role-play, lectures, group discussions, and potentially include a former caregiver panel, which was not included in the seven studies I selected for my review, but I did see in one of the articles I read throughout the screening process. Former caregivers could offer the perspective of the entire EOL process through death.
Prior to any of the educational interventions being utilized, I would provide participants with a survey to rank their confidence with different aspects of EOL, including communicating with the family, communicating with the patient, and for RNs and APRNs, ask them to estimate their perceived amount of experience with EOL by guessing the number of hours spent
communicating about EOL with patients and family members. Then, after the study is over, I would have the participants once again rank their confidence with communicating about different aspects of EOL to see if there has been an increase in overall confidence from pre-test to post-test, and whether the potential increase is higher in one group compared to another.
In order to assess potential longevity of the interventions, I would want to send out a survey at 6 months and 12 months for RN and APRN participants to rank their perceived usage of communication skills taught since the course had ended from 1-5 with 1 signifying “not so much” and 5 indicating “very much.” The survey would also have a comments section for participants to elaborate on how they selected that number, and any other general comments that they would like to note.
Overall, these 7 studies do highlight the significance of educational intervention for nursing students, nurses, and APRNs to become more confident in communicating with patients and families about EOL. However, the difficulty with these studies is that they only measure perceived change, rather than actual change. It is important that future studies on this topic develop a way to measure the actual change in EOL care and communication. If actual change were to be measured, these educational interventions would have stronger evidence for their ability to invoke positive change, and it is possible that more nursing schools and hospitals would be inclined to adopt and utilize these programs.
Feasibility
The interventions utilized in these studies are highly feasible and require minimal resources. The resources needed would include, nurse experts on the subject of EOL hired to conduct lectures, lead role-play and group discussions, a large enough space to provide the educational interventions, handouts and resources for participants, and incentives for former caregivers who participate. These resources do require having a decent amount of money, but hospitals and nursing schools could be required to pay a fee to help offset this cost.
Conclusion:
Lessons Learned from the Review
Throughout my career, I am going to encounter death and dying, and I will have to support both patients and families through this process. Thus, it is important for me to remain knowledgeable about the best methods to do so. From this review, I have learned of the
nursing program has not currently adopted ELNEC into the curriculum, but I do think this educational program would prove beneficial for students to better care for patients approaching EOL.
References
Banerjee, S. C., Manna, R., Coyle, N., Penn, S., Gallegos, T. E., Zaider, T., Krueger, C. A., et al. (2017). The implementation and evaluation of a communication skills training program for oncology nurses. Translational behavioral medicine, 7(3), 615–623.
Bishop, C. T., Mazanec, P., Bullington, J., Craven, H., Dunkerley, M., Pritchett, J., & Coyne, P. J. (2019). Online End-of-Life Nursing Education Consortium Core Curriculum for Staff Nurses: An Education Strategy to Improve Clinical Practice. Journal of hospice and palliative nursing : JHPN : the official journal of the Hospice and Palliative Nurses
Association, 21(6), 531–539.
Coyle, N., Manna, R., Shen, M., Banerjee, S. C., Penn, S., Pehrson, C., Krueger, C. A., et al. (2015). Discussing Death, Dying, and End-of-Life Goals of Care: A Communication Skills Training Module for Oncology Nurses. Clinical Journal of Oncology Nursing, 19(6), 697–702.
Dahlin, C. M., Coyne, P. J., Paice, J., Malloy, P., Thaxton, C. A., & Haskamp, A. (2017). ELNEC-APRN. Journal of Hospice & Palliative Nursing, 19(3), 261–265.
“End-of-Life-Care (ELNEC).” American Association of Colleges of Nursing: The Voice of Academic Nursing, www.aacnnursing.org/ELNEC.
Ferrell, B., Malloy, P., & Virani, R. (2015). The end of life nursing education nursing consortium project. Annals Of Palliative Medicine, 4(2), 61-69. Retrieved from
http://apm.amegroups.com/article/view/6342.
Jo, K.-H., & An, G.-J. (2015). Effect of end-of-life care education using humanistic approach in Korea. Collegian (Royal College of Nursing, Australia), 22(1), 91–97.
Robinson, E., & Epps, F. (2017). Impact of a Palliative Care Elective Course on Nursing Students’ Knowledge and Attitudes Toward End-of-Life Care. Nurse educator, 42(3), 155–158.
Scammell, J. (2018). Improving end-of-life care. British Journal of Nursing, 27(21), 1269. https://doi.org/10.12968/bjon.2018.27.21.1269
Table 1
Summary of Articles Included in Literature Review (n=7)
Author, Year Sample, Setting Educational Intervention Measurement/Data Points Data Analysis/Results
Outcome Major Findings
Jo, K.-H., & An, G.-J. (2015) 39 nursing students, two universities in Korea Experimental: A humanistic EOL care course 2 hours/week for 16 weeks with content adopted from ELNEC. The course included lecture, group discussion, reading, research on the cultural diversity of death, film
discussion, and essay writing. Control: Traditional
learning method of only lectures, held 2 hours per week for 16 weeks.
Participants rated 20 items that assessed their attitudes towards death on a 5-point Likert scale, death anxiety was measured using a modified Death Anxiety Scale, and communication skills were measured using the
Communication Assessment Tool.
Prior to the course, there were no significant
difference between the groups for attitude toward death, death anxiety, and communication skills. After the course, students in the experimental group showed significant increases in attitudes towards death and
communication skills, while death anxiety didn't significantly differ.
The results of the study suggest that the course utilizing a humanistic approach was sufficient for helping nursing students develop a positive attitude toward death because of the cumulative effect of these repeated humanistic expressions.
A humanistic EOL care course is effective for improving nursing students’ attitudes toward death and enhancing their communication skills. Replication studies with larger samples are vital to provide more generalizability.
Coyle, N., Manna, R., Shen, M., Banerjee, S. C., Penn, S., Pehrson, C., 247 inpatient oncology nurses EOL care communication skills training module consisting of a 45-minute didactic, exemplary
Using a five-point Likert-type sale, the participants
completed pre and post workshop surveys rating their
Prior to the workshop, the nurses' confidence was on average a 3.09, and after the workshop, the
The majority of nurses agreed that the skills training module helped them think more about their
This skills training showed feasibility, acceptability, and potential benefit at improving
Krueger, C. A., et al. (2015)
video and 90 minutes of small group interaction and experiential role-play with a simulated patient.
confidence in discussing death, dying, and EOL goals of care with patients.
average confidence score was 4.07.
communication with patients and improved their ability to
communicate with patients.
having EOL care discussions. Dahlin, C.
M., Coyne, P. J., Paice, J., Malloy, P., Thaxton, C. A., & Haskamp, A. (2017)
944 APRNs ELNEC APRN curriculum consisting of a 2-day course on clinical issues and program
development in palliative care pertinent to APRN practice
Knowledge and attitude surveys were completed precourse and postcourse at 6 and 12 months. Participants were asked in these surveys to rate their
confidence level in various aspects of advanced practice palliative nursing.
More than 90% of the participants reported that they felt moderately to very confident in all aspects of EOL care, including pain assessment, pain management, and communication.
APRNs have found the course to enhance their clinical practice and ability to develop and lead palliative care programs. Participants indicated the lack of palliative care education for both nurses and
physicians as a barrier.
The ELNEC-APRN is an excellent educational program dedicated to support the APRN who sees diverse patients along the health/illness continuum and across the lifespan.
Ferrell, B., Mazanec, P., Malloy, P., & Virani, R. (2018) >100 nursing programs have accessed the curriculum, there have been 1700 total curriculum completions, and all students have achieved ELNEC-Undergraduate Curriculum for nursing students composed of six 1-hour online modules. Each module includes case studies, testimonials from national palliative nursing leaders,
At the end of each module, students are asked to respond to 13 evaluation questions. The students evaluate the modules based on items such as how relevant the content was to their
progression and if the activities and
interaction in the
In the first 6 months, combined responses of strongly agree and agree for each question averaged 99% when asked about how relevant the content was to their profession and if the modules enhanced the
Evaluations and communication with faculty have indicated that the students are grateful to have this important nursing content and are feeling more prepared to care for patients and families, especially
The new online
mastery, with an average score of 90.13% for all modules.
brief videos demonstrating palliative nursing skills, and 2-3 nursing licensure examination-style questions woven throughout.
modules enhanced the effectiveness of their education.
effectiveness of
their education. at the EOL. Bishop, C. T., Mazanec, P., Bullington, J., Craven, H., Dunkerley, M., Pritchett, J., & Coyne, P. J. (2019)
95 nurses from a large
southern academic university medical center divided into 2 groups
Group 1: Received online education only Group 2: Received online education plus a 3-hour in-person training session. The online
education consisted of 8 didactic modules. The in-person sessions focused on communication, pain, and symptom management, and included case study discussions, handouts, and worksheets.
The Palliative Care Practices of
Registered Nurses Survey was adapted and used to explore nurses' perceptions before and after completing the ELNEC Core
program. The survey was administered before, after, and 3 months after educational intervention. There was statistically significant improvement between the pre-education and post education for almost all
competencies. Of the respondents who completed the education, 80% reported that they'd change their
practice as a result of the training.
At 3 months postcourse, there was a significant increase in practice change between the 2 groups, with more participants in Group 2 reporting practice change. 72% of the participants who completed the 3-month follow up survey reported they had changed their practice by improving their communication, symptom
management, and understanding the roles and benefits of palliative care.
The results of this study demonstrate that online
education can be utilized effectively to provide
palliative care education to nurses and that this improved competence can translate into clinical practice. Banerjee, S. C., Manna, 342 inpatient oncology A 1-day communication Participants completed course
The majority of participants (>80%)
The study demonstrated a
R., Coyle, N., Penn, S., Gallegos, T. E., Zaider, T., Krueger, C. A., et al. (2017).
nurses at MSKCC
skills training program that focused on three teaching modules: responding
empathically to patients; discussing death, dying, and EOL goals of care; and responding to challenging interactions with families. Training included didactic and experiential small group role-plays.
evaluations, self-reports, and pre- and post-standardized patient assessments.
rated each
individual module as aiding in learning. Overall, nurses' self-efficacy significantly
improved from pre- to post-training. In particular, nurses' self-efficacy in responding empathically to patients significantly increased. There was an increase in overall skill use from pre- to post-training. The biggest gain was observed in empathic skills. successful implementation of a communication skills training program for nurses, as evidenced through favorable program
evaluation,
significant gains in self-efficacy regarding communicating with patients in various contexts, and significant improvements in several empathic skills, as well as clarifying skills.
Robinson, E., & Epps, F. (2017)
83 senior-level nursing students
Elective palliative care course that modeled ELNEC. Delivered via face-to-face meetings that occurred every other week for 2 hours. Faculty- and student-led
discussions and guest speakers were the primary teaching methods.
Group 1: Completed the palliative care course and then took a post-test to assess their knowledge and attitudes towards EOL care. Group 2:
Received the post-test only. The two
instruments used were: Palliative Care Quiz for Nursing (PCQN) and Frommelt Attitude Toward Care of the Dying (FATCOD) Scale.
There was a significant difference in the scores for the FATCOD Scale, measuring their attitudes toward EOL care, between the 2 groups. A significant relationship was also found between students' attitudes toward and knowledge about EOL care. Findings revealed that those participants, who took the course, achieved higher scores on the PCQN than
students who didn't receive the
instruction. Student knowledge about EOL care increased after completing the course.
Significant
differences existed in the attitudes toward EOL care between students who were enrolled in the course and students who were not. Findings from the study support the importance of an ELNEC-based course to increase students'
knowledge about EOL
(ELNEC).: End-of-Life Nursing Education Consortium (APRN).: Advanced Practice Registered Nurse
Figure 1
Article Selection Process
Articles Excluded: Pediatrics
Non-Intervention studies Studies that
included participants outside of nursing (n=26) Articles Excluded:
Obvious irrelevance Duplication Literature
reviews, systematic reviews, case reports, expert opinions, guidelines Non-English
language (n=3701)
7 articles include in literature review Articles screened for eligibility
(n=33)
Articles identified via search of PubMed, CINAHL, and Google Scholar
