Nurse Education Today 34 (2014) e1–e6

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A qualitative exploratory study of nursing students' assessment of the contribution of palliative care learning Montserrat Ballesteros a,b, Carlos Centeno a,c, Maria Arantzamendi a,d,⁎ a

University of Navarra, Institute for Culture and Society (ICS), ATLANTES Research Program, Pamplona, Spain Nursing Department of the University of Valladolid, Spain University of Navarra, Clínica Universidad de Navarra, Department of Palliative Medicine and Symptom Management, Pamplona, Spain d Faculty of Nursing, Pamplona, Spain b c

a r t i c l e

i n f o

Article history: Accepted 26 December 2013 Keywords: Palliative care Nursing education Qualitative research Undergraduate Student experience

s u m m a r y Objective: We explored the contribution of optional palliative care (PC) learning to the training of undergraduate nursing students. Design: This is a qualitative, exploratory study. Participants: PC students from two universities (n = 236) responded to the open question: What was the contribution of the PC course to your training? Methods: A thematic analysis of the respondents' answers was performed with investigator triangulation. Findings: Four themes were identified. Firstly, the PC course provided a comprehensive view of the nursing discipline. Secondly, the course helped the students to know how to interact with, communicate with and better understand patients. Thirdly, the contribution of the course to the students' personal growth prompted them to reflect personally on death, thus promoting self-awareness. Finally, the students considered the PC course to be of great importance in the nursing curriculum. Conclusion: Nursing students believed that a PC course was an essential component in their training, which contributed favourably to their personal and professional development. © 2014 Elsevier Ltd. All rights reserved.

Introduction Learning about palliative care (PC) should form part of the basic training of all healthcare professionals, and the core competencies that have been identified can provide guidance for all professionals undertaking education in palliative care (Gamondi et al., 2013). However, the nurse is the professional who spends the most time with patients; therefore, it is particularly important that all nurses receive basic training in PC as part of their university courses (Barrere et al., 2008). Palliative or end-of-life care education provided to nursing students has rarely been studied (Wilson et al., 2011). Fifteen years ago, in countries where PC had been introduced, the attention given to PC in nursing schools was insufficient: few programmes and only a small number of hours were devoted to this subject, little attention was paid to healthcare services and the teaching staff often lacked specialised qualifications (Lloyd-Williams and Field, 2002). Nonetheless, this situation has undergone rapid transformation. By 2006, all UK nursing schools had some provision for palliative and end-of-life care, and more than

⁎ Corresponding author at: University of Navarra, Institute for Culture and Society (ICS), ATLANTES Research Program, Edificio de Bibliotecas, 31009 Pamplona. Spain. Tel.: + 34 948425600x80 3421; fax: + 34 948425636. E-mail addresses: [email protected] (M. Ballesteros), [email protected] (C. Centeno), [email protected] (M. Arantzamendi). 0260-6917/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.12.010

95% of students participated in these courses (Dickinson et al., 2008). Recent data from other countries have confirmed that in the USA (Dickinson, 2007) and Canada (Wilson et al., 2011), PC education has gradually been incorporated as part of the basic training programme. In Spain, PC teaching has now been included in the undergraduate curriculum in almost all schools of nursing as a mandatory subject in 46%, an optional subject in 14% or a specific module within other subjects in 37% (Valles and García, 2013). In Spain, the average number of European Credit Transfer System (ECTS) for a PC course is 4.5. Teaching PC has certain special characteristics because providing PC means ‘caring for people at the end of their lives in terms of the whole person’. That is, PC offers a model of whole-person care (Mount, 2013) because all-around care is provided to the ill person and his/her family. This provision requires professional care but also quality personal presence as, particularly at the end of life, the professional is the ‘most frequently used drug’ (Balint, 1957). A recent review article showed how end-of-life care education has been delivered to undergraduate nursing students, focusing on the modes of delivery and teaching strategies (Gillan et al., 2013). One consequence of the special characteristics of PC education that this review noted was that lecturers often apply innovative methods when they teach the subject as a specific course. These methods include highfidelity simulation scenarios (Moreland et al., 2012); companion programmes (Kwekkeboom et al., 2005); courses based on literature,

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art and the humanities; and interdisciplinary courses (Ellman et al., 2012). As holistic principles actually have a bearing on any type of care, some universities prefer to integrate these contents throughout the nursing curriculum (Wallace et al., 2009; Ramjan et al., 2010). In basic PC education, it is also surprising how well this type of instruction has been received: nursing students enjoy learning about this topic and have requested that it be made a mandatory topic in their curriculum (Mutto et al., 2012). Evaluating PC presents a challenge because it requires taking the special characteristics of this subject matter into account. However, until now, most studies have assessed the learning experience using closed questions and quantitative methods, while in addition, they have focused on exploring particular knowledge (Tishelman et al., 2008), skills (Arantzamendi et al., 2012a; Bush and Shahwan-Akl, 2013) or attitudes (Barrere et al., 2008; Mutto et al., 2010). As Gillan stated, the lack of qualitative research into teaching strategies for endof-life care has prompted the question of how to assess learning strategies effectively in terms of depth of the learning experiences in end-oflife care education (Gillan et al., 2013). One problem is that when such methodologies are used, it is possible that more profound personal experiences might remain unexplored. More open qualitative methodologies would be appropriate if we aim to determine the potential personal impact and special meaning that courses on PC have for future nurses (Brajtman et al., 2009). Study Objective The objective of the study was to conduct an exploratory study that would allow students to voice unexpected or surprising aspects that have arisen by inviting the students to reflect directly on what they feel PC learning has contributed to their training. Materials and Methods Because qualitative methods are useful in disclosing the visions, experiences and perspectives of participants, we decided that a qualitative methodology would be appropriate in this case (Arantzamendi et al., 2012b; Green and Thorogood, 2009). Participants The study participants were undergraduate nursing students who had taken a course entitled Palliative Care (n = 306) at the Nursing School of the University of Navarra and the Nursing School of the University of Valladolid in Soria. The first school is a private university, while the second is a public university. From a total of 306 students enrolled in PC courses, we obtained responses from 236 students, all of whom were approximately 20–21 years of age and 94% of whom were female. Characteristics of the Palliative Care Course In both schools, the PC course was offered as an optional course, and it did not include any clinical practice. In the Nursing School at the University of Navarra, the course was offered to 2nd and 3rd year nursing students with 45 teaching hours (using formal lectures, small group discussions and audio-visual aids), while in the University of Valladolid, it was only offered to 3rd year students and consisted of 60 teaching hours (formal lectures, small group discussions and audio-visual aids). At the Nursing School of the University of Valladolid, a nurse-professor from the school mainly taught the syllabus and enlisted individual collaborations from other PC professionals. In Navarra, the course was taught mainly by nurses (faculty and hospital), with the collaboration of other professionals (clinicians, psychologists) who worked mainly in terminal patient care. The contents of the subject included PC principles and their evolution, team work in PC, patient needs assessment, control

of pain and other symptoms, psychological and social support and spiritual needs. Data Collection Data were collected at the School of Nursing of the University of Navarra over a 4-year period (from 2006 to 2010) and at the School of Nursing of the University of Valladolid over a 6-year period (from 2005 to 2011). On the last day of each course, the students were asked to respond to a written, open-ended question regarding the PC course: “What was the contribution of the PC course to your training?” The responses were submitted anonymously. This data collection method enabled us to obtain information from a majority of the students, using a very open approach that encouraged students to express themselves in their own words. In this manner, we focused not only on knowledge or attitudes but on anything that the students wanted to mention. Analysis and Rigour A thematic analysis of the students' comments was performed to determine the key elements of the respondents' accounts (Green and Thorogood, 2009). An inductive process, whereby there were no predefined categories, was used. Initially, the main author and the coauthors performed independent analyses of 10 students' assessment documents each, and they then met to compare which categories were emerging. This process was undertaken until the main author, who was inexperienced in qualitative analysis, became familiar with the analytical process. Subsequently, two authors continued to analyse the findings independently and to collate the emerging categories. Then, all of the authors held periodic meetings, at which the categories and the data included in each response were checked, and the answers' coherence was tested. For occasional cases in which there were discrepancies or nuances, each author explained his or her category, and then all of the authors returned to the original data to review the text and agree on the category that represented the data most faithfully. The assessments from each school of nursing were analysed separately, and the findings from each population were later compared to identify a common core and some subtleties (using Na as an abbreviation for the Nursing School of the University of Navarra and So for the Nursing School of the University of Valladolid). The full study was approved by the Research Ethics Committee of the University of Navarra, and the committee's approval was communicated to the Nursing School of the University of Valladolid. Findings Four themes were identified as being the primary contributions of the PC course. Firstly, the course provided a comprehensive view of the nursing discipline. Secondly, it helped students to know how to act, communicate with and better understand patients. Thirdly, the contribution of the course to the students' personal growth prompted them to reflect personally on death, thereby promoting self-awareness. Finally, the students commented on the importance of the PC course in the nursing curriculum. The Palliative Care Course Provides a Comprehensive View of the Nursing Discipline The students indicated that the course was of great value to them because it provided them with a more comprehensive view of the nursing discipline (Table 1). They said that nursing care had a different meaning for them since they took the PC course, along with other objectives. The students stated that the course helped them to realise that ‘taking care of people is the essence of the profession’. The students felt that the subject helped them to become more sensitive to the

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Table 1 Theme 1: The palliative care course provides a comprehensive view of the nursing discipline. Theme

Category

The palliative care course provides a comprehensive view of the nursing discipline.

Taking care of people is the essence of the profession. It highlights the human side of the profession.

needs of patients and to understand that the patient must be at the centre of all nursing actions. “To learn that not only is the art of curing people important, but so is taking care of them” (NUR-So 88).

them to deal appropriately with difficult situations. They indicated that there were situations that they had been unable to resolve and that they had previously viewed people's suffering from a different perspective. However, they now had other support tools and attitudes necessary to alleviate patients' suffering.

“Everything is interrelated in the nursing profession, and everything revolves around the patient” (NUR-Na 1).

“To know how to deal with situations in which I was previously paralysed” (NUR-Na 32).

The interrelationship of topics is considered part of the principles of nursing (Royal College of Nursing, 2010). Nurses provide and promote care that puts the patient at the centre (Manley et al., 2011). However, it seems that the students became particularly aware of this principle when they faced the vulnerability of terminally ill patients, perhaps because in these circumstances, the importance of techniques is relegated to the background and caring becomes important. This finding coincides with the idea that palliative care is a model of whole-person care (Mount, 2013). The students understood that all activities performed in the nursing profession are interrelated and that there are no isolated areas that are unrelated to others. Nursing is not only about technical procedures, but patients also need to feel accompanied and cared for as a whole person. In addition, the students specified that the PC course ‘highlights the human side of the profession’.

“One needs strength, patience and courage and, above all, to do everything with warmth to be able to transmit this warmth to the patients” (NUR-So 51)

“I think it is particularly useful because of the emphasis placed on the issue of humane and friendly care, stressing that nursing is not all about technical procedures” (NUR-Na 27). This statement is in agreement with the widespread vision of PC. Cicely Saunders clearly defended the need to combine science and humanity, which is the essence of PC (Saunders, 2001). According to the students, the PC course humanised nursing practice and made it easier to understand terminally ill patients. However, above all, the course made the students aware that nursing is more than applying techniques or procedures and that patients need to feel that they are being accompanied. This idea coincides with the concept of PC as a model to humanise health care, as it is based on person-centred care with a holistic perspective (Román, 2013). “To become more humane myself and, from now on, to understand better the needs and demands of terminally ill patients when accompanying them during the last days of their lives” (NUR-So 38).

Palliative care training assists nursing students in caring for terminally ill patients The second theme that emerged as a feature of the PC course was that ‘it helps them to feel more confident when caring for terminally ill patients’ (Table 2). The students believed that not only had they gained knowledge but also that ‘the course “trained” them in how to care for the terminally ill’. Their training involved not only acquiring knowledge but also being able to apply it and act accordingly. The students referred to being capable of acting, communicating, understanding the different situations the patient experienced and addressing the patient's emotional needs. The students indicated that the course ‘assists them in overcoming difficult situations’. Some of the students stated that the subject trained

It was as if the students discovered the effect of simply being with the person as a therapeutic intervention (Halifax and Byock, 2008), an aspect not mentioned in previous studies of PC education. However, there were also nuances about the training provided by the subjects: some students felt assured that the PC course had qualified them to provide end-of-life care. “To provide care for a person who is living his last days” (NUR-So 29). “I have learned what a terminally ill patient goes through in the final moments and how we should care for them and their families” (NUR-So 83). This outcome seems logical. However, it is known that sometimes, when the end of a person's life is closer, the attention that he or she receives decreases, as some health professionals tend to distance themselves from these situations (Wakefield, 1999). In the current study, the students specified the importance of caring until the end. One possible explanation for this finding might be the emphasis placed on caring until the end in the PC course. Another explanation could be that the students became aware of the importance of caring for the person as a whole from the beginning of his or her life to the end, as the person has a value independent of his or her status. Other students specified that when they had to put their training into practice, they became aware that the PC course had taught them to be understanding and to empathise with patients. “I have learned to put myself in other people's shoes, more so than from a simply physical or pathological perspective” (NUR-So 127). “To know how to behave with a terminally ill person and try to understand” (NUR-So123). In addition, other students indicated that the PC course trained them to ‘communicate better’. They understood that communication is essential when caring for terminally ill patients, and some of the students indicated that the course helped them to communicate better with patients and their families. “…to maintain a good relationship-communication with them and thus to know how they feel” (NUR-Na 4). “It has taught me to value emotional and communication aspects and to respect patients and their families” (NUR-Na 3). “It has helped me to understand that communication and listening are the most important elements” (NUR-So 2).

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Table 2 Theme 2: Palliative care training assists nursing students in caring for terminally ill patients. Theme

Category

Sub-category

Palliative care training assists nursing students in caring for terminally ill patients.

It helps them to feel more confident when caring for terminally ill patients.

• • • • • • •

It trains them to communicate better.

It assists them in overcoming difficult situations. It assists them in providing end-of-life care. It teaches them to be understanding. It teaches them to empathise. It improves communication with patients. It improves communication with families. It emphasises the importance of communication.

It helps the students to understand the patients' situations.

This achievement is important because studies conducted with nursing students have shown that they feel insecure when communicating with this group of patients and their families (Yildiz and Akansel, 2011). Nurse–patient communication has been an area of concern in nursing because one of the most basic goals for nurses is that their patients and the patients' families should experience effective communication (Casey and Wallis, 2011). It would be interesting to explore whether students perceived differences between communicating with terminally ill patients and their families and communicating with other types of patients. In addition, it would be interesting to assess whether the PC course really improved the way that students act. This focus has been suggested in previous studies (Bush, 2012; Moreland et al., 2012), although little evidence has been available to determine whether it is true in clinical practice (Gillan et al., 2013). Finally, some students stated that the course helped them to understand the patients' situation, considering their emotional and behavioural determinants. “To get closer to patients' feelings, whatever their disease” (NUR-So144).

Other students thought that ‘the PC course is important for life’, and they found it so interesting and important for life that they believed that it should be a mandatory subject for all students, independent of what they were studying. “I found the subject very interesting and important for life, and I think that it should be a compulsory subject in all degree courses” (NUR-So 8). As it will be explained below, some studies reported that medical and nursing students believed that PC education should be compulsory for all students of health care professions (Mutto et al., 2012). However, in the current study, the students went one step further, suggesting that it should be compulsory for all students, not only for future health professionals. It is a new idea: PC education could benefit all students, irrespective of their future professions. It is not clear why they had this belief, but it might be because of the influence on a personal level that they attributed to the PC education that they received. Another aspect mentioned by the students regarding this theme was related to spirituality and how PC helped them to think about it. “To help me to believe that it does not all end after death and to be more confident in what awaits us after we die” (NUR-So 29).

The Palliative Care Course Enhances Personal Development The students considered the PC course to have enhanced their personal development (Table 3). That is, having completed the course, they believed that it helped them to grow in personal skills or in issues such as maturity. “Because it has made me a more understanding person and a little more mature, growing both as a human being and as a nurse” (NUR-So 56). “I have gained many practical and theoretical skills that I can put to use in both my personal and professional lives” (NUR-Na 45). The effect of PC education on a personal level has not been discussed in previous studies. This lack of discussion might be due to previous studies having focused more on measuring attitudes (Barrere et al., 2008; Mallory, 2003; Mutto et al., 2010) or knowledge (Pimple et al., 2003; Moreland et al., 2012). However, it could be argued that if PC involves a holistic approach, the whole person is needed to care for the terminally ill.

It can be argued that with the nearness of death, spirituality gains greater relevance. The students' comments can be understood on this basis. However, it should be noted that previous studies have tended to highlight aspects related to death and dying, attitudes toward death (Dickinson et al., 2008; Gillan et al., 2013) and aspects that the students in the current study also mentioned, as will be mentioned below. However, to our knowledge, this study is the first time that spirituality has been mentioned when assessing the influence of a PC course. Other students acknowledged that ‘the PC course made it possible for them to cope with their own grief’. They argued that after completing the course, they were able to understand situations that they had experienced and were more capable of coping with their grief. “It helped me to deal with my personal problems because I realised that grief is something that it is necessary” (NUR-So 68). “To better understand situations experienced in the past” (NUR-Na 29).

Table 3 Theme 3: PC training enhances personal development. Theme

Category

Sub-category

The palliative care course enhances personal development.

It helps you grow as a person.

• • • •

It helps you reflect on the end of life. It promotes better self-understanding. It helps one to overcome fears.

It promotes individual development. The PC course is important for life. It helps you to enhance your spirituality. It makes it possible to cope with one's own grief.

• It helps to overcome one's fear of death. • It prepares you for death.

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Dealing with students' possible grief was not an objective of this study. However, it should be recognised that teaching about PC involves addressing death and dying issues as natural parts of life rather than as taboos. This directness could facilitate accepting death, the grief that it entails, and reflecting on the end of life. “It has helped me to realise how important it is to have a good end to your life, to accept what happens in our lives and to live actively” (NUR-So 3) Some students stated that ‘the PC course helped them overcome their fears’, stating that ‘it removes the fear of death’ and also that ‘it prepares you for death’. “To overcome the fear of death by talking naturally about it” (NUR-So 120). “Because sooner or later it will be our turn, and we have to begin to deal with it and also teach people how to deal with death as a natural event” (NUR-So 19). This coping with death is one of the few positive aspects of dealing with terminally ill patients, which has rarely been mentioned in the literature (Rittman et al., 1997; Arantzamendi, 2009). Finally, other students added that it ‘promotes better selfunderstanding’, showing a help for self-knowledge.

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stated that the PC course should be ‘mandatory’, due to the value they attributed to it. “I believe it is a very important subject, which should be included as a compulsory subject to at least learn the basic principles, because as we have seen, it is a type of care we must provide to all types of patients” (NUR-Na 51). “It should be a compulsory subject because all patients have the right to receive special care at the time of their death” (NUR-So 111). This idea is in line with the European Association for Palliative Care (EAPC) recommendations for nursing education. In these recommendations, the EAPC proposed different levels of training in PC, depending on the nurse's area of work, but recommended a minimum for any nurse (De Vlieger et al., 2004). Thus far, studies have focused on assessing the professional influence of this subject on healthcare professionals, as it is believed that all health care professionals should receive PC education (Gamondi et al., 2013). Considering the general recommendation and also the students' suggestions based on their own experiences, the introduction of PC education in all nursing curricula should be seriously considered. The students believed that this subject helped them ‘to understand other subjects’ in terms of the procedures and observed that everything was interrelated. “It helped me to better understand some of the topics covered within the Medical-Surgical II subject (another course in the programme)” (NUR-Na 50).

“In short, to know my limitations” (NUR-So 43).

Palliative Care is a Course of Great Importance in the Nursing Curriculum The students believed that the PC course contributed positively on both professional and personal levels, so it is not surprising that the students considered the course important in the nursing curriculum (Table 4). The students reported that ‘the PC course has its own identity as a subject’. The students believed that the PC course provided them with ‘new knowledge’, teaching them different aspects about nursing and how to improve end-of-life patient care. However, they went further, admitting that it was in the field of pain management that they learned the most. They discovered they could alleviate pain not only with drugs but also through caring, through their own interventions as nurses. “[It has been useful to me] to learn different aspects of nursing and to understand how to improve end-of-life care for patients” (NUR-Na 5). “The biggest contribution for me was in pain management because I learned that not only is it possible to alleviate pain pharmacologically but also using nursing techniques” (NUR-So 88). Arber also showed improvements in students' knowledge of pain control and opioid use (Arber, 2001). In the current study, the students specifically mentioned that they discovered other nursing interventions that were not pharmacological but helped them to manage pain. Some students recognised the subject as ‘different from others’, it was not simply another subject that provided more knowledge, and

“Because it is related to other subjects, and it is easier to understand the practical part” (NUR-So 40). Similarly, some students thought that the PC course ‘brings together the knowledge acquired in other subjects’. It helped them to understand and to relate issues addressed in other subjects. In addition, it helped them not only to better understand specific topics or procedures, as indicated above, but also to gain a better overview of nursing practice, thus reinforcing their learning. “The content has been of great value to me when studying other courses such as Nursing Care (nursing techniques and procedures), or the composition or the names of the common medications. It has helped me to see that everything is interrelated and to have a good overview of all the subjects” (NUR-Na 49) “It has reinforced the concepts dealt with in other subjects” (NUR-So 40) In addition, they also stated that the course ‘complements other subjects’. Some students added that they thought ‘the PC course completed their training as professional nurses’. Limitations and Further Research This study was conducted in only two schools of nursing, so questions regarding the generalisation of findings could be raised. However,

Table 4 Theme 4: The PC course is of great importance in the nursing curriculum. Theme

Category

Sub-category

Palliative care is a course of great importance in the nursing curriculum.

It has its own identity as a subject.

• • • • • •

It complements other courses.

It contributes new knowledge. It is different from other courses. It should be mandatory. It helps one to understand other subjects. It brings together the knowledge acquired in other subjects. It complements other subjects.

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when rigorous research has been conducted and detailed information about the process has been provided, there is a strong likelihood that the findings will be transferable to other contexts, such as other schools of nursing, at least in Spain. The PC course was an optional subject. Motivation is always a factor in education, and the motivations of the students that chose the PC course versus the students that had the course as a compulsory subject might have differed. This limitation is common to previous studies because, to date, PC education has only been offered as an optional course. Now that PC is becoming a compulsory subject, further research can be conducted. Our use of documentary sources also imposes certain limitations. This data collection method was used because the study was exploratory, and an emphasis was placed on uncovering the students' assessments with minimum guidance. The use of other complementary data collection methods, such as interviews or focus groups, would enrich future studies. Future studies should develop a different and more complete method for evaluating PC education, considering different spheres apart from knowledge and attitudes. Aspects of the manner in which courses affect students personally should be considered when assessing the contributions of PC education. Conclusion In this study, the students provided an additional point of view on the contribution of the PC course, complementing the views reported thus far in the literature, which have focused mainly on the acquisition of new knowledge. This group of nursing students attributed contributions on both the professional and personal levels. On the professional level, they said that the course gave them a more comprehensive vision of the nursing discipline. They learned to place the person at the centre of care, as should be the case. The course prepared them to care for terminally ill patients to the end, to deal with difficult situations and to discover their own capacity as professionals and humans to relieve suffering. Although the students reported having learned a considerable amount, the way their learning impacted clinical practice must be investigated further. A noteworthy contribution of this study was the manner in which the students reported that the PC course made an impact on them on a personal level. The course helped them to know themselves better and to develop as people, thereby overcoming their fear of death. This area was not mentioned in previous studies, likely due to the more specific objectives that were assessed. The students in this study clearly noted that PC education helped them as individuals and that it should be a subject open to any student, regardless of his or her future profession. Our findings clearly indicate areas for further research into the impact of PC courses. References Arantzamendi, M., 2009. A mixed methods study of the experiences of Spanish hospital nurses caring for terminally ill patients. Doctoral thesis King's College London (Florence Nightingale School of Nursing &Midwifery). Arantzamendi, M., Addington-Hall, J., Saracibar, M., Richardson, A., 2012a. Spanish nurses' preparedness to care for hospitalized terminally ill patients and their daily approach to caring. Int. J. Palliat. Nurs. 18 (12), 597–605. Arantzamendi, M., López-Dicastillo, O., Vivar, C.G., 2012b. Qualitative Research: Handbook for Beginners. Eunate, España. Arber, A., 2001. Student nurses' knowledge of palliative care: evaluating an education module. Int. J. Palliat. Nurs. 7 (12), 597–603. Balint, M., 1957. The Doctor, His Patient and the Illness. International Universities Press, Oxford, Oxford, England.

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