End-of-Life Care Course for Pre-Licensure Nursing Students

Nurses in a hospital setting spend more time with patients than any other healthcare professionals providing treatment and caring for the dying. The increased burden for chronic diseases and the aging population means that thousands of patients die daily at the hands of nurses. It is common for undergraduate students to encounter situations in which they are faced with caring for a dying patient, but this experience leaves most students traumatized due to inadequate preparation. Caring for a dying patient is a multifactorial process that is dependent on individual skills, knowledge, attitude, and support from colleagues (Griffiths, 2019). Limited exposure and instruction of nursing students can lead to ineffective delivery of end-of-life (EOL) care to patients and the provision of necessary support to the family.

Table of Contents

Being knowledgeable about EOL care can help nurses overcome barriers in managing terminally ill patients. End-of-life care represents the support and medical care given to patients during the time surrounding death (Smothers et al., 2019). This care usually involves four domains including physical comfort, mental and emotional needs, spiritual care, and practical tasks. It is crucial to note that EOL care encompasses activities done during palliative care, hospice care, and supportive care that most patients receive at home (Griffiths, 2019). While these care delivery models can be used interchangeably, the environment surrounding the care and actual components of care differ. For instance, palliative care involves improving the quality of life and quality of care for patients with life-threatening conditions and their families by reducing suffering, alleviating pain, and managing other distressing symptoms (Costa et al., 2016). On the other hand, hospice care involves activities during the final weeks and months of care when attempts to slow disease progression have failed.

Nursing curricula must teach students about EOL care and other important care domains like palliative care that are always in every nurse’s career path. Nursing students are traditionally provided knowledge about chronic diseases with a focus on curative care and promotion of healing. However, some diseases are not curable and death is always inevitable in the healthcare environment. This proposal introduces the course of EOL care to the nursing curriculum to adequately prepare students for better care delivery to patients with terminal illnesses and medical care delivery during the time surrounding death.

Academic Setting

The academic setting observed during my clinical practice experience (CPE) involved undergraduate nursing students from Western University. The institution’s nursing school is ranked among the best in the country and provides prelicensure, master’s, and doctor of nursing practice programs. Of particular interest for this proposal are undergraduate nursing students seeking education to provide care to diverse patient populations upon completion of the course. This student population represents individuals that currently do not hold a nursing license and have no prior nursing education and experience. The end-of-life care course is available under the “Nursing Concepts IV: Complex Patient Centered Care “ course that is taught during the third year, second semester. The placement of this course in the senior years means that students experience difficulties to care for patients without knowledge on end-of-life care. The student population in this course are from diverse ethnic backgrounds with the 2021 class having enrolled 80% Whites, 8% Asians, 7% Hispanic, and 5% Blacks. Regarding gender, the majority of the students are female with only 9% representing males. The school of nursing faculty comprises 49 members that are specialized in various fields including nursing management and nursing education. The curriculum committee comprises all faculty members that schedule curriculum review meetings monthly.

Curriculum Gap

During my clinical practice experience, I observed undergraduate nursing students as they provided care to diverse patient populations. One issue that I noticed was a lack of preparedness to care for dying patients including their families. To understand more about the root cause of the problem, I reviewed the nursing curriculum to determine gaps in nursing education that could be a contributing factor. I was able to identify a gap in the ‘Complex Patient-Centered Care’ course that educates students on caring for terminally ill and dying patients. This course lacked adequate information about palliative care, hospice care, and essential components of nursing care during the period surrounding the patient’s death. Additionally, the course failed to address the concept of family-centered care especially after the loss of their loved ones leaving students with little knowledge on how to handle such situations. Apart from the above gaps, I noticed that learning strategies minimally involved active learning activities that could expose the student to end-of-life care during education before actual exposure in the clinical area.

Proposed Course

The recognition of life’s final stage can be difficult, but extremely necessary for nurses to prepare care for patients and support for the family. Nursing students should be well prepared to provide EOL care because lack of knowledge is a big obstacle to achieving the goals of palliative care (Costa et al., 2016). Additionally, the attitude of nurses towards EOL care should be set right to avoid trauma and emotional problems after caring for the dying. Students must be able to address the physical, emotional, and spiritual needs of families including proper guidance throughout the bereavement process. To address the identified challenges, this proposal focuses on implementing a formal end-of-life care course that will also tackle palliative care to prepare and support the students as they strive to care for dying patients. The introduction of the course will ensure students acquire effective communication skills and improved attitudes towards EOL care (Smothers et al., 2019). This preparation will also ensure that students have knowledge and skills to address the physical, emotional, and psychological needs of patients and families during the time surrounding death.

Theoretical Framework

The theoretical framework that supports this proposal is the constructivist learning theory. Constructivism is an approach to learning whereby people actively make their own knowledge and reality is determined by the experiences of the learner (Fernando & Marikar, 2017). This theory mainly emphasizes the need to experience the phenomenon in order to influence decisions. The meanings generated during learning are influenced by the interaction of prior knowledge and new events. Additionally, the constructivist theory holds that learning is an active mental process rather than passive reception of thinking. As individuals get exposed to new knowledge, they construct meaning that aids in subsequent care delivery during practical works (Fernando & Marikar, 2017). The proposed course aligns with the constructivist learning theory because it aims at introducing new knowledge to students and the utilization of past experiences to change their practice.

The constructivist learning theory is based on various principles that demonstrate how knowledge is constructed, gained, and utilized. The first principle states that knowledge is constructed, rather than innate or passively absorbed (Fernando & Marikar, 2017). The foundation of previous learning determines the construction of new knowledge. Secondly, learning is viewed as an active process where active engagement leads to the construction of new knowledge. The use of active learning strategies at this point ensures that the learner makes connections between previous and newly learned behaviors. The theory views learning as a social activity whereby doing things together leads to the construction of meaning. Another key principle of this theory describes knowledge as personal (Fernando & Marikar, 2017). Each individual will have a distinctive point of view upon learning and this explains different understanding observed among students.

The constructivist theory posits that learning exists in the mind and is not determined or matched by word reality. Learners will always try to develop their own model of understanding based on the knowledge gained. The application of learned knowledge in different situations explains this principle. When using this theory, the instructor understands that active and collaborative learning is crucial to the construction of knowledge. The teacher acts as a facilitator of learning rather than an instructor to enable understanding (Fernando & Marikar, 2017). Involving active learning strategies like simulation-based learning, group discussions, and the utilization of the online environment promotes constructivist learning. When compared to the traditional classrooms, constructivist classrooms value the pursuit of the student’s questions, involve interactive learning, promote collaborative learning, and allows dialogue to help students construct their own knowledge (Fernando & Marikar, 2017). This curriculum proposal will involve the use of strategies that are based on constructivism to enable student’s gaining of knowledge and improvement of attitudes towards end-of-life care.

Purpose of Proposal and Overview

The demand for nursing expertise in end-of-life care is growing as more people are living with chronic-life-limiting illnesses. There have been a lot of advances in nursing education to incorporate curricula that could adequately prepare students to take care of dying patients both in hospitals and home care facilities. However, gaps exist in the way nursing education is delivered and the content given to students leading to inadequate preparation. The purpose of this proposal is to recommend revision of the current nursing curriculum in Western University to incorporate the end-of-life care course that will adequately address identified gaps. This course will align with the American Association of Colleges of Nursing (AACN) CARES end-of-life competencies that explain what is required of students in the subject area upon graduation. Incorporation of this course will ensure that students are able to address the emotional, physical, and spiritual needs of dying patients. Most importantly, the course will encourage self-determination among students and aid in decision making during times surround the patient’s death.

To fully address the challenge of EOL care among nursing students, a literature review was conducted to identify support for the proposal and ways to solve the challenge. Ten peer-reviewed sources are provided in the proposal to demonstrate support for the subject area. Secondly, the ADDIE (analysis, design, development, implementation, and evaluation) model of instruction was utilized to design a course that will be incorporated into the current nursing curriculum. The last part of the paper addresses the key points of the developed course to summarize the proposal.

Literature Review

Refer to Table 1: Literature Review Summary Table

Curriculum Gap and Potential Causes

The challenge of EOL care to patients by nursing students can be described in the context of constructivism. Constructivism theory stipulates that learners construct knowledge rather than just passively taking in information. The learner assimilates information and uses the gained knowledge to inform other decisions or care delivery like in EOL care. The curriculum gap observed in Western University is inadequate preparation of students with skills, knowledge, and expertise to effectively manage dying patients. The complex patient care module in the current nursing curriculum fails to address key aspects of EOL care like effective communication, patient and family-centered care, and support for the healthcare provider. Despite equipping the nursing students with knowledge about diseases and their management, the curriculum fails practically expose students to end-of-life care through active learning leading to low self-confidence. The introduction of the EOL care course will help assist students to gain skills, knowledge, and confidence to face the dying patient while providing appropriate support to the family.

There are various reasons why the gap in providing EOL care exists among undergraduate nursing students. Nursing faculty cannot teach what they do not know, and their students cannot practice what they do not know. The nursing fraternity has been in the dark regarding EOL care for many years with key interventions focusing on promoting a peaceful death and alleviating suffering. Because of the increasing acuity and complexity of patient care, more research has focused on how well EOL care can be provided to patients and families. It was until the development of the End-of-Life Nursing Education Consortium (ELNEC) recently that institutions started to focus on EOL care. Lack of adequate knowledge by faculty and qualified nurses about EOL care is among the reasons why students find it challenging to care for dying patients. For instance, about 40,000 nurses have completed national or international ELNEC training in the US (Ferrell et al., 2016). This leaves a huge gap in institutions and faculty making it difficult for student preparation during education and training.

The second potential reason why EOL care is a challenge for nursing students is the lack of adequate active learning. Taking care of patients and making decisions is are practices that require experience and exposure. Reflecting on the constructivist learning theory, active learning enables the acquisition of knowledge and construction of meaning. Additionally, the use of collaborative approaches to learning helps students discover more leading to the acquisition of skills and improvement of self-confidence. According to the information gathered, most lecturers in the institution prefer the traditional classroom method that provides limited exposure to active learning. The learning activities included in the complex patient-centered care module minimally involve student interaction and the use of active learning strategies like simulation. Failure of the current curriculum to effectively approach EOL care during teaching leads to inadequate preparation of students.

Curriculum instruction and design is a complex process, especially in nursing due to the busy nature of faculty programs. Sometimes the faculty members might lack adequate time to review the curriculum and propose changes. The current problem may be attributed to this challenge. For instance, the BSN curriculum is already overstretched and some units lack adequate time for instruction. Lack of adequate time may be the reason why necessary changes have not been made to address the observed issue. Challenges in decision making due to competing priorities among faculty members may also contribute to curriculum change failure. Members have been unwilling to openly communicate changes due to mixed interests leading to the observed curriculum gap. More importantly, the current curriculum fails to address the key concepts of EOL care. This proposal provides a solution to the above challenges and ways that faculty members can work to ensure the curriculum gap is filled.

The theory selected for this discussion is the constructivist learning theory. This theory addresses the curriculum gap in the aspect of active student learning to promote understanding of palliative care. As explained earlier, the current curriculum minimally involves students in active learning through the use of strategies like group discussions, simulations, and case studies. The constructivist theory holds that learning is an active mental process rather than passive reception of thinking. Without the incorporation of constructivism in the new curriculum, students will not be able to adequately address end-of-life care concerns for the patients. This theory will help students to generate new meaning from what is learned and be able to think critically during end-of-life care.

Research Findings and Support of Proposal

Attitudes Towards End-of-Life Care

It is common for undergraduate students who start their careers in acute care settings to encounter situations in which they are faced with the care of dying patients. Effective delivery of care to such patients depends on the knowledge and skills obtained during learning alongside other support systems in clinical areas (Lippe & Carter, 2015). Most students face the situation of caring for dying patients when they already have little or no knowledge about the required care. For instance, many institutions introduce nursing students to palliative and EOL care during their third or final year. This means that nursing students will only use their knowledge of diseases to care for the patient in the early years of practice (Smothers et al., 2019). Because of this gap in nursing education, the attitude towards the end of life care is greatly affected leaving many students with psychological problems upon caring for the dying.

Palliative care aims at improving the quality of life of patients with serious illnesses and life-limiting conditions. Nursing students providing this care exhibit mixed attitudes due to the quality of training given. Gelegjamts et al. (2020) explains that despite an increased need for the inclusion of PC in undergraduate nursing curricula, nursing programs often fail to provide adequate theoretical and clinical experience to prepare nurses to care for dying patients and their families. Inadequate preparation of students can impact how they feel towards caring for the dying because of lack of skills. For instance, communication with the patient and families during end-of-life care is a skill that determines the quality of care given. Most students fail to understand what to tell the patient or the family that is frequently asking about the condition of their patient (Robinson & Epps, 2017). Lack of these basic skills leads to the creation of negative attitudes towards caring for dying patients.

Teaching Strategies

In order to provide appropriate end-of-life care, prelicensure nursing students need adequate education prior to entering professional nursing practice. Research establishes current nursing education lacks adequate content to fully prepare students on the aspects of palliative, hospice, and end-of-life care (Smith et al., 2018). Apart from the content delivered, the use of effective teaching strategies hinders the quality of EOL care teaching provided to students. The use of active learning strategies like simulations is among the proposed methods that adequately prepare students to face dying patients (Cantrell et al., 2017). The key concept in the simulations is fidelity whereby the simulated experience approaches reality to expose the student to what will be faced in clinical areas. This strategy is observed to improve important aspects of palliative care like communication, decision making, and the involvement of families (Smith et al., 2018). Apart from improving on these skills, simulations make it possible for the utilization of technology that further improves patient outcomes.

End-of-Life Care Delivery Challenges

Providing end-of-life care is both an integral and ethical obligation of nurses. By focusing on patient-centered holistic care, nurses are able to determine the type of death and conditions surround the patient during their end times. Nursing students face challenges with determining what type of care the patient and the family need during the time of death. For example, many would require being around familiar environments, being close with family members, or being treated as an individual with dignity and respect (Griffiths, 2019). Nursing students may find it difficult to determine these needs because they have little knowledge and skills to offer end-of-life care. The need to train nurses within the classroom and not in the hospital has emerged to ensure that little pressure is put on students, otherwise leading to negative attitudes towards the practice (Westwood & Brown, 2019). Nurses, even at the point of initial clinical rotations should be confident in caring for the dying and this can be achieved through proper education.

Lack of exposure to end-of-life care is a challenge that is observed not only in nursing students but also in senior nurses. The level of confidence during the care of the patient reduces the anxiety that might lead to errors or panic. Self-efficacy refers to the confidence that individuals have in their ability to perform a specific behavior or skill. Zhou et al. (2021) explain that nurses believe they can provide the required level of care when they have higher self-efficacy. With limited education and exposure to the scenarios, self-efficacy is hindered leading to poor quality care. Additionally, insufficient knowledge may make the nurse feel unprepared and stressed regarding palliative care that perhaps contributes to the observed negative attitudes (Costa et al., 2016). Additionally, the concept of culturally competent care and family involvement is a challenge to nurses during EOL care delivery. Nursing students should be more educated on these areas to strengthen their end-of-life care skills.

In summary, end-of-life care refers to the comfort and medical care given to the patient who is dying. The goal of this practice is to relieve pain and suffering as much as possible and to improve the quality of life while respecting the dying patient’s wishes. The above evidence demonstrates that students may find it difficult to provide end-of-life care to patients if they are inadequately prepared. To effectively prepare students, various teaching strategies can be used by instructors to improve their understanding and application of learned concepts. Active learning strategies like simulations, case studies, and flipped classrooms can help to prepare students.

Application of the ADDIE Model

The ADDIE instructional development model comprises five phases: Analysis, design, development, implementation, and evaluation. This framework is used by many instructional designers and training developers to develop courses (Kim et al., 2020). The ADDIE model was utilized in developing the EOL care course using the five steps. The first part of this discussion highlights the components of each of the five phases in preparation for their use in designing the EOL course.

Analysis Phase

The analysis is the first phase of the model and the most important because it guides the development of a blueprint for the designing of the new course. The educators focus on the target audience to ensure the development of a course that is proportionate to the intelligence and level of knowledge of the learner. The main aspect of the analysis is to clarify instructional problems and objectives (Kim et al., 2020). Several questions could be asked during the needs analysis to clearly identify the curriculum gap and what changes are required to address the gap. Additionally, an analysis of forces for and forces against the development of the new curriculum is done to gauge organizational preparedness for the new course.

Design Phase

The design phase deals with learning objectives, instruments for assessment, exercises for learners, content, and lesson planning. It is a systematic process that identifies strategies that could be used to meet the identified goals. The designed objectives should be student-centered and incorporate both the cognitive, affective, and psychomotor domains of learning. Upon designing and refining the course objectives and learning strategies, pilot testing can be planned to ascertain the workability of the plan.

Development Phase

The development phase involves refining and further developing the learning resources and content. Multiple meetings are held to review the objectives, technologies, and other programs that could be critical in achieving the set goals. The curriculum development team reviews and develops the curriculum according to the feedback from the learners and pilot testing procedures. The most important part of the development phase is the involvement of stakeholders to ensure the new curriculum is fully supported by the organization (Kim et al., 2020). Formative and summative assessments are also part of the key aspects of the development phase during curriculum design.

Implementation Phase

This phase involves continuous modification of the newly developed course to suit the learners’ needs. The training facilitators cover the course curriculum, learning outcomes, delivery methods, and testing procedures. Any training that is required prior to instruction is carried out at the initial stages of this phase. The implementation phase takes into account the feedback from the stakeholders during the development phase.

Evaluation Phase

This phase consists of the formative and summative evaluation plans. The formative evaluation is available in each stage of the ADDIE model while the summative evaluation is available upon full completion of instruction. Irrespective of the approach used, the purpose of the evaluation is to assess the effectiveness of learning resources and how well they met the objectives and learning outcomes (Kim et al., 2020). Completion of the process involves the establishment of new goals to improve instruction and the incorporation of new learning resources to improve student outcomes.

Proposal Analysis Phase

Academic Setting Description

Program level. The academic setting observed during my clinical practice experience was Western University with a focus on the school of nursing. Of particular interest were the prelicensure nursing students who were observed during their clinical rotations to identify gaps in patient care. The nursing curriculum in this institution is evaluated yearly where new goals are set including the introduction of new programs. The curriculum committee is made up of all nursing faculty members and discussions are held monthly to address any issues of concern.

Knowledge and skills. The typical learners under this program are new to the nursing field and have little clinical experience. Having done a few clinical rotations, the observed learners are able to communicate and provide basic nursing care to patients. Regarding end-of-life care to patients, the learners lack adequate knowledge and skills to provide the most appropriate care to the patient including their families.

Learning environment and instructional delivery method. Western University follows the traditional weekday classroom format. Both the classroom and online learning environments are utilized during instruction. The main methods of instruction delivery involve lecturing and discussions. Students mostly read through the use of textbooks with a few courses encouraging the use of online materials.

Needs Assessment and Gap Analysis Creation Procedures

Needs assessment is a methodical and organized process used to determine the needs of learners and improve ways. The methodical process used during the design of the EOL care course involved observation of students, critical evaluation of the current curriculum, survey, and involvement of key stakeholders. The first step involved the review of the current curriculum in the institution to determine gaps in nursing education that led to the observed challenge in EOL care delivery to patients by nursing students. Upon determining the gap, a comprehensive literature review was conducted to gather more information about the challenge and ways to address it. Apart from these approaches, it was crucial to involve faculty members to learn more about the instruction methods and organizational factors that could be contributing to the curriculum gap. Lastly, a survey was conducted to assess the student’s knowledge, attitude, and perceptions towards EOL care. The survey allowed the students to point out areas of difficulty and how the current curriculum contributed to the observed challenge.

Refer to table 2. Curriculum Need-Gap Analysis Table

Stakeholders

Faculty members. The nursing school faculty members were crucial to the design of the EOL care curriculum because they are directly involved in the implementation of new changes in the organization. Most of the faculty members are nurse educators with masters and doctor of nursing degrees. The nurse educators were involved due to their expertise in designing curriculum and implementing new changes. Apart from the nurse educators, other faculty members were administrators in charge of the whole nursing department. It was important to involve the administration because of their interest in growth and performance improvement in the organization.

Academic practice partners. Nursing education involves a partnership with the local community and organizations to adequately prepare students and create supportive environments for practice. Western University partners with local hospitals to ensure students get adequate experience as they prepare for their future roles. The gap analysis process involved consultation with the clinical instructors at the local hospital to ascertain the areas that students performed poorly regarding EOL care delivery. As part of the teaching environment, it was important to partner with these institutions to ensure the developed course aligned with the organizational standards. Other partners were external stakeholders from other institutions that had well-developed EOL care courses that provided more insight to nursing educators on effective teaching strategies for the newly developed course.

Executive management. The executive managers are responsible for developing the vision and strategic plan for curriculum changes in learning institutions. These individuals have knowledge and expertise on practice changes to improve the quality of nursing education. The executive manager will oversee the curriculum change process, advise where necessary, and organize financial resources that will be required for the exercise. The manager will also be tasked with analyzing the causes of the observed gap, any performance issues contributing to the gap, and propose solutions to the identified challenges.

Current and Desired Curriculum

Refer to Diagram 1. Affinity Analysis Diagram

The current curriculum addresses the issue of palliative and end-of-life care under the complex patient-centered care course. The course is currently allocated a minimum of 35 hours with the main method of instruction being lectures. Apart from the lectures, the course encourages the use of small group discussions to promote student engagement, especially during class hours. Based on the course content, there is a gap in addressing the key domains of EOL care including the psychological, spiritual, and emotional needs of the patient. Additionally, there is limited information on how students should involve and care for the patient’s family during death. Due to the inadequate preparation, nursing students experience anxiety, fear, and sadness including decreases self-efficacy when caring for patients.

The involvement of the academic nurse educators in the analysis of the course revealed their support for the curriculum change. These individuals noted that the complex care course should be included in the junior years to allow students take care of patients during their clinical rotations. The stakeholders also acknowledged that the new course should use simulation-based approaches to educate students for proper acquisition of required skills. Based on the observed gap, the stakeholders noted that the desired curriculum should address both the physical, emotional, and spiritual needs of patients during the time surrounding death. The new curriculum should prepare students to engage the family and identify their needs during death and the grieving period. The new curriculum should involve active learning strategies like simulations, online board discussions, and video learning to strengthen their skills in EOL care. The new curriculum should focus on educating students on communication strategies, the use of empathy, and seeking support during EOL care.

Curriculum Changes

Refer to Diagram 1. Affinity Analysis Diagram

Several changes are made to the new curriculum to enable students to gain adequate knowledge and skills to take care of dying patients. The curriculum changes are made in consideration of the fact that dying patients do not only require physical care and alleviation of pain, but also emotional and spiritual support. The curriculum changes also recognize patient-centered care as a key feature during end-of-life care and it encompasses the patient’s family. To begin with, the new curriculum should be implemented early in prelicensure nursing education to prepare students for what is expected in their clinical areas. For instance, students should be introduced to EOL care during their first year before beginning their clinical rotations. This change will help reduce the fear and anxiety that is observed in many students that hinder effective care delivery to dying patients.

Today’s healthcare environment is faced with challenges that require the utilization of critical and creative thinking. The development of these skills is dependent on how learning happens especially the use of active learning strategies. The theory of constructivism should be applied during teaching to ensure that active learning strategies are incorporated into nursing curricula to promote critical and creative thinking. The new curriculum will utilize active learning strategies like simulation-based learning to expose the student to what will be faced in their clinical areas. Evidence indicates that simulation-based learning helps in improving communication skills between the nurses and the patients or their families during care delivery (Smith et al., 2018). This approach typically involves mimicking the real-world scenarios to provide learners with pertinent experiences under controlled or practice conditions.

The rapid increase in technology use in the nursing world has also impacted nursing education. The use of technology is another crucial change that will be observed in the new curriculum to facilitate faster access of information by students. The current curriculum relies mostly on the traditional lecture method that only presents students with facts about what EOL care entails. However, the curriculum does not offer much exposure to students about actual scenarios and how decisions can be made based on the patient’s needs. Based on the need gap analysis in collaboration with stakeholders, it was determined that students must learn to make decisions in a safe and controlled environment. The stakeholder interview recommendations emphasized the need to include palliative care education that could promote well-being, caring, empathy, and care for patients with genuine presence. Additionally, the stakeholders discussed the need to close the gap between classroom learning and clinical practice to allow students understand issues experienced in end-of-life care.

The proposed curriculum will allow students to use online platforms to access videos and other media that can increase their confidence in taking care of dying patients. The students will also be able to access online resources like journals and articles that provide detailed information about EOL care. Lastly, the observed changes mean that more time will be required to educate and prepare students adequately. The proposed EOL care course will require a minimum of 45 hours to effectively teach students and achieve the set learning outcomes.

Organizational Strengths and Weaknesses

Please refer to Diagram 2: Organizational Readiness for Curriculum Proposal

Among the initial steps of establishing the essence of the new curriculum in the institution involve a force field analysis to determine forces for and those against the new change. To begin with, the organization strongly values the use of evidence-based practices to inform changes that can improve student’s performance and patient care.Integrating necessary EBP knowledge and skills systematically into the formal curriculum allows students to obtain better learning experience and outcomes (Kim et al., 2020)The introduction of the EOL care course will be well-supported in the institution due to the need to implement evidence-based practices. Secondly, the nursing department is striving to formulate a standardized and streamlined curriculum that addresses all the crucial aspects of student learning and nursing practice. Evidence suggests that standardization is not a threat to academic freedom; rather, it is an approach to elevate the educational process and provide better outcomes for patients (Gardenier et al., 2018). The stakeholders noted that students can apply their decision-making skills and emphatic communication techniques in simulation environments. As the faculty members look for ways to standardize the nursing curriculum, the introduction of the EOL care course will be supported as it serves to improve students’ knowledge and skills. Lastly, the organizational leadership’s support for change and the utilization of technology supports the introduction of the EOL curriculum. Western University is a nationally ranked institution that strives to maintain its reputation through quality education.

The organizational weaknesses and situational factors that can limit the adoption of the new curriculum may include a lack of adequate time and faculty preparations for the new change. For instance, the nursing curriculum is already overstretched and some courses even lack enough credit hours to effectively prepare students. In some situations, nurses and nurse educators are feeling stressed, overstretched, and unable to assist students with their needs (Griffiths, 2019). The academic nurse educators explained that the anticipated workload may discourage buy-in from the faculty members, especially those with more lenient expectation for outcome standards. Introducing the EOL care course means faculty will have to adjust their time to give the course more hours. Secondly, the new curriculum will require discussions, refining, testing, and monitoring of implementation. The faculty staff members may be too busy to create adequate time for the curriculum implementation. Another limiting factor is the presence of faculty members that may perceive the new change negatively. Occurring concomitantly with the growing nursing shortage is the impending retirement of nurse educators leaving behind inexperienced nursing faculty (Costa et al., 2016). For example, many nurse educators have previously instructed students using traditional methods. The introduction of new strategies like simulation-based learning and online classrooms may seem inappropriate for the aged staff who will otherwise require extra computer training to cope. It may be difficult to achieve effective collaboration due to the presence of these factors.

The organizational strengths can be leveraged to my advantage during the design of the EOL care course through the formation of strong links with faculty members and effective collaboration. The readiness of the organization to improve nursing education means that faculty members will be ready to cooperate and implement the new strategy. Any financial resources required for the proposal will be provided by the administration in an attempt to support evidence-based practices in nursing education. The negative impacts of the weaknesses observed can be mitigated through seeking support from stakeholders. Support from the administration and nurse educators will ensure that time is created to review the proposed curriculum. Additionally, comprehensive education and training of faculty members will serve to improve knowledge and understanding of the relevance of the new curriculum to students and the organization.

Proposal Design Phase

Syllabus Creation Procedures

In cultivating the end-of-life care course to be added into the nursing curriculum, both independent and collaborative approaches were used. Independently, I reflected on my philosophy of teaching and the importance of the new course to students. I was able to conduct a literature review to further develop knowledge on teaching and learning strategies that could benefit the students. Using Bloom’s taxonomy verbs, I was able to identify the course objectives that could best help the students gain appropriate knowledge and skills. Collaboratively, I involved key stakeholders like the academic nurse educators, students, and the information technology team to design the syllabus. For instance, collaborative approaches with the nurse educators ensured the development of the course objectives, student learning outcomes, and assessments. Communication through emails and regular meetings ensured refining of the new course and how learners could benefit.

Course Description

Refer to Appendix A: Course Syllabus – Course Description

The course description provided in the syllabus orients students on the rationale for implementing the EOL care course, an overview of key concepts, and what the learner will achieve upon completion. A new student reading the course description will understand that the purpose of the course is to equip students with knowledge and skills to care for dying patients. The learner will understand that the course uses different learning strategies to achieve the set goals while demonstrating what the learner will be able to do upon completion of the course. Lastly, a new student reading the course description will be able to understand how the course benefits the learner. Apart from providing care to the patient, the learner understands that the course will help them prioritize care and utilize effective communication strategies to promote good relationships with patients and families.

Course Objective

Refer to Appendix A: Course Syllabus – Course Objectives

Using Bloom’s taxonomy of measurable verbs, five course objectives were developed to help students describe and classify observable knowledge, skills, attitudes, behaviors, and abilities. Each of the course objectives provided utilizes action verbs that are higher cognitive levels of Bloom’s taxonomy. For example, action verbs like analyze and design are used in the course objectives. These verbs demonstrate that the learner applies knowledge gained to inform decisions during care delivery. The course objectives align with the proposed EOL care course because they are measurable and focus on the student’s ability to analyze information and apply it during patient care. The first course objective requires students to analyze the role of nurses in collaborating and coordinating care with interprofessional teams during EOL care. This objective will be measured through student’s explanation of their roles and interprofessional teams they can collaborate with during EOL care. The second objective deals with development of a plan of care for dying patients. This objective will be measured through the student’s ability design a nursing care plan that incorporates all aspects of care during EOL care.

Teaching Strategies, Instructional Delivery Methods, and Learning Materials

Refer to Appendix A: Course Syllabus: Teaching strategies, Learning Materials

Teaching strategies. The teaching strategies proposed in this course are based on the general idea of constructivism. The constructivist theory establishes that learners construct new knowledge based on past experiences or previously learned information (Fernando & Marikar, 2017). Additionally, the theory encourages collaborative learning that engages students allowing the application of knowledge. This course will use teaching strategies like role play, simulations, and group discussions to promote active learning. These strategies focus less on memorization while encouraging self-efficacy.

Instructional delivery methods. The instructional delivery methods utilized in the course involve both online and traditional classroom teaching. During the face-to-face learning, the content will be delivered through lecturing to allow students to ask questions and seek clarification where they do not understand well. The instructor will utilize this opportunity to engage students in small group discussions to enhance teamwork that improves knowledge acquisition. The students will then have an opportunity to utilize the online environment where videos, real-life case scenarios, and online discussion boards will be utilized. These methods will ensure that technology is utilized while maximizing the acquisition of knowledge for those students that learn best through different environments. The instructional delivery methods used are consistent with constructivist learning because student engagement is involved (Fernando & Marikar, 2017). Learning is observed to be inherently social as the students and teachers work together during discussions and group activities.

Learning Materials. The learning materials involved in this course are textbooks and web-based journal articles. The textbooks utilized in the course contain detailed information about end-of-life care including specific care for patients suffering from chronic illnesses. The books highlight the symptomatic management of patients during EOL care and the critical aspects of spiritual and emotional care. On the other hand, the journal articles provide evidence-based interventions to patient care that can be used by students to improve their care delivery. For instance, the ‘AACN CARES’ journal provides students with insight on the core competencies of palliative care ad how to achieve them (Ferell et al., 2016). The utilization of these materials provides students with diverse knowledge on how to care for patients during the time surrounding death. The incorporation of diverse learning materials demonstrates constructivism because students are exposed to new learning experiences (Fernando & Marikar, 2017). For instance, journal articles will provide students with evidence-based interventions to EOL care delivery. Additionally, there is creation of cognitive dissonance through the use of materials that challenge students to think critically.

Student Learning Outcome Analysis

Refer to Appendix A: Course Syllabus – Student Learning Outcome

One of the student learning outcomes states that upon completion of the course, the student should be able to “Apply the nursing process in identifying and prioritizing the patient’s needs during EOL care.” Bloom’s cognitive level of the SLO is the level of ‘application’ where students use acquired knowledge to solve new problems. The expected student’s performance level of the SLO is the use of the nursing process (assessment, diagnosis, planning, implementation, evaluation) to prioritize care for patients during the time surrounding death. To effectively measure this SLO, the scenario-based learning activity will provide the student with an opportunity to prioritize cases based on assessment results. The SLO aligns with course objective number two that requires students to ‘Develop a plan of care for dying patients including care for the patient’s family.’ This objective is created at the application level of Bloom’s taxonomy to encourage learners to create something by combining parts of a unique problem. This SLO will be measured using both the formative and summative assessments. Multiple choice questions in the summative objective assessment will test the student’s ability to prioritize care during EOL care. The summative performance assessment will focus on the aspect of communication that is crucial during application of the nursing process.

Course and Grading Policies

Refer to Appendix A: Course Syllabus – Grading Criteria and Scale and Course Policies

The course policies and grading procedures are available to guide the learning process and achievement of the course objectives. The policies focus on the areas of student participation, professionalism, and preparedness to take the course including special considerations for special groups. The first policy requires the student to attend all classes and submit assignments on time. The second policy talks about academic honesty during tests and assignments to promote independence. The other course policy provides procedures for any withdrawal from the course while the last objective focuses on students with disabilities and how they can complete the course. These policies support the course objectives because they all support the acquisition of knowledge that can be used to improve patient care. Regarding the grading procedures, learners will be graded on both formative and summative assessments. Successful completion will demonstrate competency in the areas like cultural patient care, collaborative care, and legal/ethical nursing that are addressed in the course objectives.

Proposal Development Phase

Course Material Creation Procedures

Independent procedures. Based on the need gap analysis and literature review, I reflected on the course materials including the course content, assessments, and learning resources that could be included to adequately prepare students. I reviewed the AACN CARES competencies for BSN students to determine what was required upon completion of the course to adequately enable care for dying patients. During the literature review process, I focused more on the use of strategies that could engage students during learning. Eventually, I was able to come up with active learning strategies, assessment methods, and some resources that could be included in the EOL care course.

Collaborative Procedures. During the independent review of materials for the course, I understood that collaborative approaches were necessary to develop a course that could comprehensively address the observed gap. To begin with, I presented my general idea of the course content, learning materials, and assessments to the curriculum design team. Using emails, zoom meetings, and face-to-face discussions, I was able to present the materials for discussion and the addition of changes from the instructors. The collaborative approaches proved effective because more learning materials were suggested and included I the course. Additionally, the academic educators reviewed the assessments and corrected several aspects, especially the multiple-choice questions according to the student’s level of understanding. The last part of the collaborative procedures involved drafting of the course materials and presentation to the faculty administration for approval.

Learning Resources and Learning Activity

Refer to Appendix A: Course Syllabus – Required Resources

The learning resources utilized in this course include two textbooks and two journal articles. The textbooks contain detailed information about end-of-life care and specific care for patients with chronic conditions. The inclusion of these materials will ensure that students get extra information on patient care to improve on their knowledge learned in class.

The first textbook titled ‘Medical-Surgical Nursing Patient-Centered Collaborative (7^th ed.)’ by Ignatavicius and Workman (2013), focuses on chronic conditions, their management during end-of-life. The book contains information about concepts of hospice and palliative care including interventions during end-of life. The second book titled ‘Pathways through care at the end of life: A guide to person-centred care (13^th ed.) by Hayes (2014), covers assessment of needs and planning care, coordinating care between different agencies, and ensuring quality in different settings, such as at home, in a hospice, or in hospital. The book provides a guide to effective communication during patient care and discusses several case studies to encourage reflective practice.

The first journal article titled ‘CARES: AACN’s New Competencies and Recommendations for Educating Undergraduate Nursing Students to Improve Palliative Care’ by Ferell et al. (2016) outlines the core competencies for undergraduate students regarding end-of-life care. This article discusses 17 competencies that all nursing students should achieve by the time of graduation and guidance on how to achieve them. The other article titled ‘ Cultural Considerations at the End- of- Life’ by Saccomano and Abbatiello (2014) discusses the ability and capacity to provide culturally competent care during end-of-life. As an essential component of patient care, students will understand more about cultural competence and models of home and hospice care.

The scenario-based activity present in the assessment part serves to improve self-confidence and communication skills among learners when caring for patients and families. The activity will involve a description of how communication can be achieved during end-of-life care. The students will then discuss effective communication strategies that can be used to convey information to patients and families by turning in a one-page paper. This activity will help students practice communication techniques, nursing skills, and interventions to help patients and families discuss difficult topics in palliative care and at the end of life. These materials promote reflective practice because they involve practical approaches to patient care. Engagement in role-play activities during the simulations will enable the student to reflect on areas that were performed better and those that can be improved with practice. The students will be able to utilize a variety of learning resources that will ensure acquisition of more knowledge and reflective practices. The inclusion of case studies in the learning textbooks will allow students to reflect nursing approaches and interventions during end-of-life care.

Formative Assessment

Refer to Appendix C. Formative Assessment

Formative assessments are used to gauge the effectiveness of learning and learning materials including designs of content presentation to students. The assessment helps the instructor to understand areas that can be improved to better improve the student’s performance. The formative assessment chosen for this course will utilize a five-item quiz given at the end of week 1. The assessment will measure the student’s concentration, listening abilities, and reading practices to help prepare them throughout the course. How learners perform on the formative assessment will provide insight into areas of strength, and areas where learners have room for improvement and remediation of material. Learners will all be provided feedback for their performance on the formative assessment so that the will know what content areas they have mastered, and what areas they will need to revisit and focus on in order to master the content

Looking at the results, the instructor will be able to verify if the students understood the questions and and the course content. The instructor will use the results to advise those that perform poorly or go through difficult questions to educate them on how they can provide correct answers in subsequent tests. Apart from the general discussions, the instructor will schedule appointments with students who need more help to discuss individually how their performance can be improved. Additionally, the assessment will help the learner to set personal goals like utilization of textbooks or reading regularly to ensure mastery of content. Setting goals like mastering the course objectives and SLO will help the students have deeper understanding of the content leading to better performance. Learners will set personal learning goals for themselves with this formative assessment by utilizing their performance evaluations to their advantage and by focusing on the topics that they missed or did not clearly understand.

Summative Objective Assessment

Refer to Appendix C. Summative Objective Assessment

The summative objective assessment designed for this course is a 10-multiple choice question test. The test will be completed at the end of the instruction period and unlike the formative assessment, the objective assessment will account for the final grade of the student. The results from the objective assessment will be used to improve teaching strategies and redesigning learning outcomes in the future. For instance, the item difficulty index will be used to gauge questions that were difficult to answer and guide the instructor in restructuring the questions in subsequent courses. The assessment will provide the instructor with information on areas that excelled and those that were more difficult for learners. Using items like the discrimination index, the instructor will understand the difference in scores between high and low performers including ways to reduce the gap in future classes.

Low pass rates. Pass rates are used to measure the preparation of students and understanding of the course content. The quality of the assessment should align with the course objectives to ensure students pass the test. The instructor must set the examination following what was taught and use a language that students can easily understand. Revising the test and including more than one instructor during the revision of the questions can have a huge impact on the pass rates.

Item difficulty. Each test question can be evaluated based on the item difficulty index, which is the percentage of students who answered a test item correctly. The p-value which ranges from 0.0 to 1.0 is used to assess how well students passed a certain question (Kocdar et al., 2016). The instructor will assess questions with P-values less than 0.3 to determine why they were too difficult for students and those with values over 0.7 to determine why they were easy for students. Analysis of each item by calculating difficulty and discrimination indices provides feedback on what the learners have learned and enables instructors to determine and correct the faulty items (Kocdar et al., 2016). Adjustments for the assessments may include restructuring the questions or using a more simple language that all students can understand.

Item discrimination. The discrimination index can be applied to the summative assessment to distinguish between the learners who scored high, versus the learners who scored low on the assessment, and determines the overall quality of the exam. The point-biserial index (PBI) looks at the relationship between each student’s performance on a given item (right or wrong) and the student’s score on the overall test while differentiating between those who have low and high scores (Kocdar et al., 2016). This item is crucial in identifying students who are knowledgeable from those who are not. Poor items should be revised to ensure all students understand the questions. A negative discrimination index may indicate that the item is measuring something other than what the rest of the test is measuring and this may require revision of the item.

Reliability. It refers to the extent to which the test is likely to produce consistent scores. The validity and reliability of the assessment systems is one of the prerequisites for quality assurance and accreditation of institutions (Kocdar et al., 2016). Reliability of the test will be based on previous scores from other students who took a similar test. Poor performance will indicate revision of the questions and the curriculum will be required. Additionally, the instructor can review the course objectives and learning materials to ensure students have access to all information required to pass the test.

Summative Performance Assessment

Refer to Appendix C. Summative Performance Assessment

To assess the achievement of the course objectives and student learning outcomes, a scenario-based assessment will be used in this part. This assessment aims at introducing the student to real-life scenarios in clinical areas where end-of-life care and decision making will be necessary. It will gauge the student’s ability to communicate and prioritize care during the time surrounding the patient’s death. This assessment addresses the course objective of developing care plans for patients and involving the family in making decisions during death. The chosen assessment is authentic because it challenges students to think critically and make decisions based on individual patient’s needs. The assessment encourages the student to collaborate with colleagues and other professionals to meet the required demands. This performance-based assessment demonstrates authenticity as it challenges students to use their critical thinking skills and judgments to complete tasks that represent the duties they will have as professional nurses. Performance-based assessments expect students to engage in activities that require them to use research practices, collaboration, and presentation skills to meet course objectives and student learning outcomes.

References

Cantrell, M. A., Franklin, A., Leighton, K., & Carlson, A. (2017). The evidence in simulation-based learning experiences in nursing education and practice: An umbrella review. Clinical Simulation in Nursing, 13(12), 634-667. https://doi.org/10.1016/j.ecns.2017.08.004

Costa, Á. P., Poles, K., & Silva, A. E. (2016). Palliative care training: Experience of medical and nursing students. Interface-Comunicação, Saúde, Educação, 20(59), 1041-1052. https://doi.org/10.1590/1807-57622015.0774

Fernando, S. Y. J. N., & Marikar, F. M. M. T. (2017). Constructivist teaching/learning theory and participatory teaching methods. Journal of Curriculum and Teaching, 6(1), 110–122. https://doi.org/10.5430/jct.v6n1p110

Ferrell, B., Malloy, P., Mazanec, P., & Virani, R. (2016). CARES: AACN’s new competencies and recommendations for educating undergraduate nursing students to improve palliative care. Journal of Professional Nursing, 32(5), 327-333. https://www.sciencedirect.com/science/article/pii/S8755722316300850

Gardenier, D., Roberts, L., & Swanson, W. M. (2018). Should the NP curriculum be standardized?. The Journal for Nurse Practitioners, 14(3), 140-141. https://www.npjournal.org/article/S1555-4155(17)30818-8/pdf

Gelegjamts, D., Yong Yoo, J., Kim, J., & Sun Kim, J. (2020). Undergraduate nursing students’ palliative care knowledge and attitudes towards end-of-life care: A cross-sectional descriptive study. Contemporary Nurse, 56(5-6), 477–490. https://doi.org/10.1080/10376178.2021.1890165

Griffiths, I. (2019). What are the challenges for nurses when providing end-of-life care in intensive care units?. British Journal of Nursing, 28(16), 1047-1052. https://doi.org/10.12968/bjon.2019.28.16.1047

Hayes, A. C. (2014). Pathways through care at the end of life: A guide to person-centred care (13^th ed.). London: Jessica Kingsley Publisher.

Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing patient-centered collaborative care (7th ed.). St. Louis: Elsevier.

Kim, S., Choi, S., Seo, M., Kim, D. R., & Lee, K. (2020). Designing a clinical ethics education program for nurses based on the ADDIE model. Research and Theory for Nursing Practice, 34(3), 205–222. https://doi.org/10.1891/RTNP-D-19-00135

Kocdar, S., Karadag, N., & Sahin, M. D. (2016). Analysis of the difficulty and discrimination indices of multiple-choice questions according to cognitive levels in an open and distance learning context. The Turkish Online Journal of Educational Technology, 15(4), 16-24. http://www.tojet.net/volumes/v15i4.pdf

Lippe, M. P., & Carter, P. (2015). End-of-life care teaching strategies in prelicensure nursing education: An integrative review. Journal of Hospice & Palliative Nursing, 17(1), 31-39. https://doi.org/10.1097/NJH.0000000000000118

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. https://doi.org/10.1097/NNE.0000000000000342

Saccomano, S. J., & Abbatiello, G. A. (2014). Cultural considerations at the end of life. The Nurse Practitioner, 39(2), 24–32. https://doi.org/10.1097/01.NPR.0000441908.16901.2e

Smith, M. B., Macieira, T., Bumbach, M. D., Garbutt, S. J., Citty, S. W., Stephen, A., Ansell, M., Glover, T. L., & Keenan, G. (2018). The use of simulation to teach nursing students and clinicians palliative care and end-of-life communication: A systematic review. American Journal of Hospice & Palliative Medicine, 35(8), 1140–1154. https://doi.org/10.1177/1049909118761386

Smothers, A., Young, S., & Dai, Z. (2019). Prelicensure nursing students’ attitudes and perceptions of end-of-life care. Nurse Educator, 44(4), 222–225. https://doi.org/10.1097/NNE.0000000000000606

Westwood, S., & Brown, M. (2019). Preparing students to care for patients at the end of life. Nursing Times, 115(10), 43-46. https://derby.openrepository.com/handle/10545/624314

Zhou, Y., Li, Q., & Zhang, W. (2021). Undergraduate nursing students’ knowledge, attitudes and self‐efficacy regarding palliative care in China: A descriptive correlational study. Nursing Open, 8(1), 343-353. https://doi.org/10.1002/nop2.635

Table 1.
Literature Review Summary Table
First Author (Pub Year)	Title	Purpose	Context	Findings	Relevance	Strength of Evidence
Smothers, 2019	Prelicensure nursing students’ attitudes and perceptions of end-of-life care	The purpose of the research was to measure nursing students’ attitudes towards the delivery of end-of-life care to patients upon implementation of ELNEC curriculum.	The population of interest was nursing students where 80 sophomores were assessed initially and later 40 selected upon reaching the senior level.	Students demonstrated improved comfort with certain key aspects of end-of-life care. Students had improved attitudes towards providing care for both the patient and the family.	This article demonstrates that including end-of-life care education in the nursing curriculum can improve the student’s knowledge and attitude towards providing care to a dying patient.	Level III, Quasi-experimental Strengths: The study keenly followed results over time for 80 nursing students leading to the observed outcomes. Weaknesses: The fact that only one nursing school was involved in the study is a limiting factor to the applicability of the findings.
Griffiths, 2019	What are the challenges for nurses when providing end-of-life care in intensive care units?	The literature review aimed at exploring qualitative studies in which nurses discussed the challenges faced during end-of-life care in ICUs.	The population of interest was ICU nurses. Literature search utilized various databases including British Nursing Index, EBSCOhost/Psychology and Behavioral Science, Inter-nurse, Ovid/MEDLINE and Wiley Online.	Upon evaluation of different studies, it was observed that there was lack of nurse involvement in end-of-life care decision making, lack of adequate knowledge in providing the care and dilemma in prioritizing care between the patient and the family.	This research identifies common areas that pose challenges during the delivery of end-of-life care to patients. My research focuses on addressing the challenges above.	Level I, Literature Review. Strengths: The study comprehensively describes the challenges of providing end-of-life care to patients using evidence from qualitative studies only. Weaknesses: The author failed to identify the study weaknesses including areas that might require future research. Secondly, only six qualitative studies have been included in the study.
Smith, 2018	The use of simulation to teach nursing students and clinicians palliative care and end-of-life communication	The purpose of the study was to present literature findings on the use of simulation-based learning experiences (SBLEs) to teach communication skills to nursing students and clinicians who provide palliative and end-of-life care to patients and their families.	The population of focus for the identified studies was on students and clinicians. Literature was obtained from different databases including PubMed, CINAHL, ERIC, Web of Science, and PsycINFO.	It was observed that simulation-based strategies are widely used to teach end-of-life care to nursing students and clinicians. Additionally, lack of standardization, poor evaluation methods, and limited exposure to the entire interprofessional team makes it difficult to provide required care.	The study is relevant to my research because it demonstrates how teaching strategies like SBLEs can be effective in improving communication skills during end-of-life and palliative care to patients.	Level I, Systematic Review Strengths: Numerous articles (30) were included in the study. Also, the researchers utilized statistical methods to determine the effectiveness of the studies and included a summary of each study. Weaknesses: Most of the studies included did not provide or include validated information on improved communication upon the use of SBLEs.
Cantrell, 2017	The evidence in simulation-based learning experiences in nursing education and practice	The purpose of the study was to present findings on the use of simulation-based learning experiences in nursing education and practice.	The central focus of the study was nursing education especially the nursing students. Eight electronic databases were utilized in the study.	The study identified common themes during the use of SBLEs including its use in specific learner areas and to elicit specific learner skills and outcomes.	This article is relevant to my research because it addresses the teaching strategies that can be used to improve knowledge on end-of-life care among nursing students.	Level I, Umbrella review Strengths: The research provided evidence from numerous systematic reviews. Weaknesses: The provided evidence relied too much on self-reported outcomes.
Gelegjamts, 2020	Undergraduate nursing students’ palliative care knowledge and attitudes towards end-of-life care	The aim of the study was to identify nursing students’ palliative care knowledge and attitudes towards end-of-life care, as well as related factors.	The study population included 163 undergraduate nursing students from Mongolia. A self-reported questionnaire was used to collect data from participants that met the inclusion criteria.	The mean palliative care quiz for the nursing score was 7.15 out of 20 while the mean attitude score of students towards end-of-life care was 64.2 out of 100. Additionally, factors like age, gender, and higher satisfaction with nursing school determined the type of care provided.	This study is relevant to my research because it highlights the importance of assessing attitudes of students towards end-of-life care. It also identifies important factors that are observed to affect successful care delivery to dying patients.	Level IV, Cross-sectional descriptive study Strengths: The study collected data from four different undergraduate schools and utilized a large study population (163 students). Weaknesses: The study was conducted in a city capital using convenience sampling that translates to selection bias.
Robinson, 2017	Impact of a palliative care elective course on nursing students’ knowledge and attitudes toward end-of-life care	The study aimed at examining the influence of a palliative care elective course on nursing students’ knowledge and attitude toward providing end-of-life care.	The population of study involved 74 senior nursing students from an institution in Southeast Louisiana. The study group had 23 students while the control group had 51 students.	The findings demonstrated that students who received end-of-life care education had increased knowledge and attitude toward caring for dying patients.	This research is relevant to my study because it shows how educating nursing students about end-of-life care improves their knowledge and attitude towards caring for dying patients.	Level IV, Cohort Comparison Strengths: The selection of participants and researchers was random eliminating any bias that could have altered the results. Weaknesses: A small study population (74) was utilized from one institution. The results cannot be used for generalization.
Lipe, 2015	End-of-life care teaching strategies in prelicensure nursing education	The focus of the study was to critically evaluate teaching strategies found effective for improving student learning outcomes associated with providing care to patients at the end of life.	The literature search focused on studies comprising pre-licensure nursing students that utilized qualitative, quantitative and mixed approaches. Search engines utilized in the research included CINAHL, EBSCOhost, ERIC, MEDLINE, and PsycINFO.	The findings from the integrative review showed that in-class activities were the most implemented teaching strategies. The lecture/didactic strategies were often used and yielded positive attitudes, self-confidence, and awareness among nursing students towards end-of life care.	The study is relevant to my proposal because it informs on the various educational strategies that can be used to improve the delivery of end-of-life care to patients by students.	Level I, Integrative review Strengths: The study included articles that utilized qualitative, quantitative, and mixed methods study designs that presented strong evidence. Weaknesses: Most of the reviewed studies failed to adequately describe the teaching strategies including the course content used at deriving conclusions.
Costa, 2016	Palliative care training: experience of medical and nursing students	The study aimed at investigating the experience of medicine and nursing students in the assistance provided for patients in palliative care to understand necessary education required for this type of care.	The population of focus was nursing and medicine students in southeastern Brazil.	Five aspects that make up the students’ experience were identified including change in the perception about palliative care, identification with the patients and their family, rationalization and awareness process, palliative care training and practice learning and multidisciplinary work.	This study is relevant to my proposal because it supports the use of palliative care training and practice learning to improve care for dying patients.	Level VI, Qualitative study Strengths: The study collected opinions from numerous students and thematically organized findings into cluster groups. Weaknesses: It is possible that data collection was biased because no criterion was used to select students for interviews.
Zhou, 2021	Undergraduate nursing students’ knowledge, attitudes and self‐efficacy regarding palliative care in China	The purpose of the study was to describe nursing students’ knowledge, attitudes, and self-efficacy about palliative care and to examine the associations between these variables in China.	The population of focus was undergraduate nursing students from a university in China. 187 participants were involved where they provided data on palliative care quiz for nursing.	The findings demonstrated that most nursing students had a low level of knowledge and self-efficacy regarding palliative care and care for the dying patient.	This study is relevant to my proposal because it supports my argument for the need to implement a course that would improve knowledge and attitudes of nursing students towards end-of-life care.	Level IV, Descriptive Correlational study. Strengths: The study provided a thorough analysis of findings using tables, figures, and other statistical methods to clearly demonstrate the gap in nursing education. Weaknesses: The study only involves one university and this limits generalization of findings to all nursing students across China.
Westwood, 2019	Preparing students to care for patients at the end of life	The study focused on discussing current guidance on end-of-life care and how this area can be improved among pre-registration nursing students.	The population of focus was prelicensure nursing students from the University of Derby. 59 first-year students who had completed their first placement were evaluated for their preparedness to take care of dying patients.	The study found out that generally, students lacked training, support, and confidence to provide effective care for dying patients.	This study is relevant to my proposal because it demonstrates the gap available among many students regarding end-of-life care.	Level IV, Cohort study Strengths: The study provides a thorough literature analysis of the topic and groups the findings into common themes that demonstrate the gaps for end-of-life care among nursing students. Weaknesses: Only 59 students from a single university were used in the study and this limits generalization of findings among all nursing students in the US.

Table 2.

Curriculum Need-Gap Analysis Table

Instructional Objectives

Current Curriculum

Desired Curriculum

Need-gap

Action Steps to Meet the Need-gap

1. Analyze the role of nurses in collaborating and coordinating care with interprofessional teams during EOL care.

2. Develop a plan of care for dying patients including care for the patient’s family.

u The curriculum inadequately addresses key concepts of palliative, hospice, and end-of-life care.

u Traditional classroom teaching method is the primary means of instruction.

u Learning strategies include the use of textbooks, small group discussions, and assignments.

u Lacks adequate active learning strategies utilization e.g simulations, case studies, and online discussions.

l A curriculum that focuses on EOL care including strategies to involve and care for families (patient and family-centered care).

l A curriculum that utilizes active learning strategies to enable critical thinking and decision making during EOL care.

l A curriculum that introduces EOL care course to prelicensure nursing students early in their practice to increase confidence during their clinical rotations.

v The gap identified was inadequate preparation of nursing students to manage patients during the time surrounding their death.

v The course content failed to provide adequate information EOL care especially the aspect of patient and family-centered care.

v The constructivist learning theory provided insight on how active learning strategies like simulations and group discussions could improve student’s knowledge on EOL care.

i. Design a module proposal to address the challenge of EOL care among prelicensure nursing students.

ii. Form task force and identify key stakeholders to serve on the task force.

iii. Collaborate with key stakeholders to redesign the current curriculum to meet the students’ needs.

iv. Brainstorm ideas to include in the new module and train instructors to effectively deliver information.

v. Assess organizational readiness for change.

Diagram 1

Affinity Diagram

Complex Patient-Centered Care

Diagram 2.

Organizational Readiness for Curriculum Proposal

Forces FOR Curriculum Proposal	Curriculum Proposal	Forces AGAINST Curriculum Proposal
Organizational readiness to support evidence-based nursing education changes.	The introduction of end-of-life (EOL) care course into the current curriculum for BSN students.	Time barrier for curriculum development as a result of the busy nursing education schedule.
The need for a standardized nursing education curriculum that adequately prepares students		Overstretched prelicensure nursing curriculum that leaves less room for more expansion.
Strong nursing leadership that values quality education.		Challenges with faculty collaboration due to mixed interests and opinions about the proposed changes.
The need to align with the professional standards of EOL care.		Costs associated with curriculum change including implementation of new technologies.
Western University’s reputation regarding quality nursing education and the need to maintain that reputation.		Organizational culture of student instruction and training procedures.

Appendix A

Course Syllabus

Course Number:

Course Title: End-of-Life Care

Credits: 45 classroom hours (3 credits)

Delivery Method: Classroom

Faculty: Nursing

Instructor Information:

Name: (Please utilize email for all communication purposes)

Office Location: (Please utilize email for all communication purposes)

Contact: (Please utilize email for all communication purposes)

Course Description:

This course is designed to provide learners with an opportunity to explore nursing care during end-of-life (EOL) care delivery using evidence-based practices. Focusing on complex patient care, the course introduces students to palliative and home-based care that form nursing care environments for dying patients. Students will learn about communication strategies that can be used to effectively deliver information to patients and families during the time surrounding death. The course will help students prioritize care for dying patients including aspects of physical, emotional, and spiritual support. The EOL care course also demonstrates the student support services available for those that find EOL care delivery challenging to promote mental health. Generally, the goal of this course is to equip nursing students with the skills needed to deliver quality and multifaceted patient- and family-centered care at the end of life.

Course Objectives:

Upon completion of this course, the student should be able to:

Analyze the role of nurses in collaborating and coordinating care with interprofessional teams during EOL care.
Develop a plan of care for dying patients including care for the patient’s family.

Student Learning Outcomes

Upon successful completion of the module, learners will be able to:

Distinguish between palliative and hospice care as used in end-of-life care.
Illustrate the role of the nurse in providing patient and family-centered care during EOL care.
Apply patient-centered approaches while working with multidisciplinary teams during EOL care.
Apply the nursing process in identifying and prioritizing the patient’s needs during EOL care.

Teaching Strategies/Delivery Methods

The EOL care course will be taught using the traditional classroom and online learning environments. During teaching and learning, the following methods of instruction will be utilized.

Lecture
Online discussion boards
Small group discussions
Simulation-based learning/Role-play simulations

Materials/Required Resources

Textbooks

Hayes, A. C. (2014). Pathways through care at the end of life: A guide to person-centred care (13^th ed.). London: Jessica Kingsley Publisher.

Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing patient-centered collaborative care (7th ed.). St. Louis: Elsevier.

Additional Resources

Saccomano, S. J., & Abbatiello, G. A. (2014). Cultural considerations at the end of life. The Nurse Practitioner, 39(2), 24–32. https://doi.org/10.1097/01.NPR.0000441908.16901.2e

Methods of Evaluation

The final grading will consist of:

Final examination = 60%
Summative performance assessment = 20%
Summative objective assessment =10%
Online discussion boards = 10%

Grading Scale

90 – 100 = A
83 – 89 = B
75 – 82 = C
Below 75 = F

Course Policies

Attendance is expected for all classes and absence will definitely affect the final grade. Late submission of assignments is discouraged and the learner will lose 10% of the score for each late assignment submitted.
Academic honesty is highly encouraged. Aspects of cheating and plagiarism are discouraged because they can lead to serious consequences like discontinuation.
Withdrawal from the course should follow the right procedures including filling the appropriate withdrawal form and informing faculty about the same. Failure to communicate will result to an ‘F’ grade in the course.
Any student with documented disabilities and may require special attention like accommodation should contact the specialized support services.

Appendix B

Course Materials

Course Module/Unit Overview

This module will examine the principles and philosophy of end-of-life care that can be applied in healthcare to improve the quality of nursing care for patients across the illness trajectory. Students will learn about the management of complex and chronic diseases during EOL care and how interprofessional collaborative practices could promote better care delivery. Students will examine the symptoms of EOL and the role of nurses in promoting peaceful death. Students will gain insight into the legal issues that often arise during palliative and EOL care delivery. Overall, the goal of this module is to equip nursing students with the skills needed to deliver quality and multifaceted patient- and family-centered care at the end of life.

Course Content Outline

The course content to be covered in this course include the topics of :

Chronic and complex disease management
Patient-centered collaborative care
Introduction to palliative care
End-of-life symptom management and the role of nurses
Physical, emotional, and spiritual support during EOL care
Cultural issues surrounding EOL care
Legal considerations in EOL care

Learning Resources

Textbooks:

Hayes, A. C. (2014). Pathways through care at the end of life: A guide to person-centred care (13^th ed.). London: Jessica Kingsley Publisher.

Ignatavicius, D., & Workman, M. (2013). Medical-surgical nursing patient-centered collaborative care (7th ed.). St. Louis: Elsevier.

Journal Articles:

Ferrell, B., Malloy, P., Mazanec, P., & Virani, R. (2016). CARES: AACN’s new competencies and recommendations for educating undergraduate nursing students to improve palliative

care. Journal of Professional Nursing, 32(5), 327-333. https://www.sciencedirect.com/science/article/pii/S8755722316300850

Saccomano, S. J., & Abbatiello, G. A. (2014). Cultural considerations at the end of life. The Nurse Practitioner, 39(2), 24–32. https://doi.org/10.1097/01.NPR.0000441908.16901.2e

Scenario Based Learning Activity #1

Overview: This activity is about a Latino family confronting end-of-life care decisions. The scenario-based learning activity will facilitate the understanding of culturally sensitive care and empathic communication to patients and families. Additionally, this activity will help students identify ethical practices during end-of-life care and how to discuss difficult choices during palliative and end-of-life care. The instructions about the assignment will be discussed at the beginning of the course and a hard copy with further directions will be given to the students. Students will discuss the first part in groups and present their answers in class. An individual written activity will be completed and turned in after participating in the discussions.

Scenario: Gabriela Peterson is an 80-year-old woman from Puerto Rico who lives in New York. Gabriela has long suffered from high blood pressure, which she controls with medication. She also has type II diabetes and she tries to take her medications whenever she remembers. Gabriela’s youngest son, Marco, who now lives with his mother was recently diagnosed with diabetes at the age of 45 years. Marco is a heavy drinker and his fear of needles makes it difficult to self-medicate or obtain regular blood tests. He explains that he will learn to live with his symptoms, which are still relatively mild. Lately, Gabriela has had a persistent cough, shortness of breath, headache, and dizziness that prompted hospitalization.

Gabriela’s initial workups reveal a diagnosis of COPD and bilateral pneumonia. Blood test results indicate that her diabetes is out of control and her kidneys are functioning less than the normal capacity. Dr. Watson informs Marco and Gabriela that on top of COPD and pneumonia, she is suffering from kidney failure secondary to her diabetes. Translation services are available at this time because not much can be expressed by the doctor in Spanish. Gabriela is admitted to the ICU for initiation of treatment and consultation on how to manage her kidney failure. At this time, Dr. Watson begins to discuss the option of a DNR but soon realizes that the patient is not in a position to make a sound decision. The doctor approaches Marco on the matter, but he vehemently forbids the DNR and insists it should not be an option.

The following morning, Dr. Watson consults with the nephrologist and it is determined that Gabriela is not a good candidate for a kidney transplant because of her medical problems. As they try to explain other available options like hospice care, Gabriela simply looks at the floor while Marco bursts angrily that her mother will not die. Marco cries to God not to let such a saint woman die and insists that doctors have no right to talk about hospice care. He insists that dialysis be initiated immediately and that kidney transplant be pursued.

Questions: (Questions 1-3 should be addressed in your respective groups. The last part should be answered individually).

What are some communication techniques that helped during this situation? Are there things that could have been said differently?
What interventions demonstrate culturally sensitive and compassionate care?
Explain ethical principles observed in the scenario or principles that should guide the final decision about care for Gabriela.

Individual activity: In a one-page paper, discuss the concept of patient and family-centered care and how it may apply to end-of-life care. Can the involvement of other family members in making decisions impact the responses observed in the case? Support your arguments using two pieces of evidence from scholarly sources.

Scenario Based Learning Activity #2

Overview: Learners will be assigned to three different case studies available via the provided online resources. The student will work independently on the assigned case study and upon completion, they will be placed in groups according to the assigned case study. Group discussions will follow to allow students share their insight on what they learned, the approach taken to solve the case and also to allow reflective practices.

Directions: Learners will be assigned one of the following scenarios (Available in the online student’s portal).

Medical-surgical nurse addressing the needs of a dying patient case study.
Family involvement in EOL care case study.
Ethical-legal issues during EOL care case study.

Online discussion board. Upon completion of the case study, students should share by discussing the following questions.

How does end-of-life care differ from normal patient care by nurses?
Discuss your newly gained insight, knowledge, and skills concerning end-of-life care?

Reply to at least 2 of your fellow classmates’ responses. Make sure to discuss how they may have broadened your knowledge or perception about EOL care.

Appendix C

Assessments

Formative assessment
Summative performance assessment
Summative objective assessment
Formative Assessment

Instructions: This assessment contains five questions to test your understanding of the introduction to end-of-life care. The test will be marked and given back to the students in the next lecture. A maximum of 15 minutes is allowed for this test.

Questions:

Define end-of-life care (2 Mks)
Explain your understanding of a ‘serious illness’ (2 Mks)
State any two goals of palliative care (2 Mks)
Explain ONE of the four domains of end-of-life care (2Mks)
State one common ethical dilemma at the end of life and how it can be overcome (2Mks)

Answer key

Q1. Refers to the support and medical care given during the time surrounding death.

Q2. A health condition that carries a high risk of mortality and either negatively impacts a person’s daily function or quality of life, or excessively strains the care giver.

Q3. – To improve the patient’s quality of life and positively influence the course of illness.

– To provide relief from pain and other distressing symptoms.

– To address goals of care and ensure all care provided is aligned with patient wishes.

– To offer a support system to help the patient and family cope during serious illness

Q4. – Physical comfort

-Mental and emotional needs

– Spiritual issues

– Practical tasks

Q5. – Withdrawing or withholding medical interventions. A competent patient has the right to decline medical intervention, even when the decision is expected to lead to death. Withdrawing care is accepted when an intervention is no longer helpful in achieving the patient’s goals for care or desired quality of life.

– Medical aid in dying. Involves assisting or administering certain medications to bring about peaceful death.

– Moral distress in nursing. The ANA compels nurses to make every effort possible to ensure aggressive symptom management at the EOL; the code of ethics also denotes that it is never ethically permissible for a nurse to act by omission or administer a medication with the intention of ending a patient’s life.

Summative Objective Assessment

Instructions: This objective assessment has a total of 10 items including multiple-choice questions and select all that apply. Students must score at least 75% to pass the test. Only students with approved absence will be allowed a make-up test.

Time: 30 minutes

Questions:

End-of-life and palliative care focus on managing symptoms and providing comfort to patients. Which statement below best defines palliative care?
Ongoing care that is provided by the family during illness.
Care that can be given in any stage of a serious illness.
Care to patients that have six months or less to live.
Care to patients that are in the end stage of a serious illness.
End-of- life care involves four main domain. Select an option that correctly identifies all the domains.
Providing physical comfort, family involvement, managing mental and emotional needs, performing practical tasks.
Managing mental and physical needs, performing practical tasks, pain management, patient-centered care.
Family involvement, patient-centered care, managing mental and emotional needs, providing physical comfort.
Performing practical tasks, managing mental and emotional needs, pain management, family involvement.
Culturally sensitive end-of-life care includes?
Asking a bilingual patient if they will require interpreter services during discussions with providers.
Involving the family in decisions during end-of-life care
Offering Catholic priest to pray with the patient and the family
Giving the family information about the terminal condition of the patient
The most common end-of-life symptom that can give the patient distress is?
Lethargy
Loss of energy
Increased energy
Pain
One of the main determinants of family satisfaction with end-of-life care is?
Where the death happens
The level of care the patient receives
The level of pain the patient is in
Whether the patient died alone
During your clinical rotations, one of your colleagues asks the nurse to explain more about brain death. The nurse explains that following brain death:( Select all that apply)
The brain will not recover function
The individual’s body can be supported for days or even weeks
Independent respiration is absent
With time, the brain can recover function
The nurse is taking care of a newly admitted 80 year-old male patient observed to be in her last moments of life. While preparing, the patient’s wife states out loud, “he will not want this.’ To prevent legal/ethical issues, which of the following document containing the patient’s wishes applies?
A healthcare power-of-attorney
Do not resuscitate (DNR)
Healthy proxy
Organ donor card
What type of care is administered to prevent and relieve suffering of patients whether they have terminal illness or not?
Holistic
Hospice
Palliative
Facility
Which emotional response is constant throughout the stages of dying according to Kubbler-Ross?
Denial
Anger
Depression
Hope
Henderson is a patient with terminal illness and both the patient and family are aware that nothing can be done. While the family is at the bedside to say their goodbyes, culturally sensitive and compassionate care include? Select all that apply
Ask the family for any beliefs or practices they would like to honor on the patient’s behalf
Allow family to spend time and sit quietly with the patient
Play soft music and keep the room bright
Keep the patient uncovered to minimize sweating
Use moist swabs to keep the mouth of the patient moist.

Answer Key

1) B	2) A
3) A	4) D
5) A	6) A, B, C
7) B	8) C
9) D	10) A, B, E

Summative Performance Assessment

Type: Group Role-Play Activity

Directions: The instructions for this summative performance assessment will be available to students at the beginning of the course. Detailed instructions about this activity will be posted electronically in the online classroom portal, and a hard copy will be provided to students at the beginning of the course. A minimum score of 75% will be required for students to pass this test. Students will be required to present a 10-minutes role-play video in class concerning the case scenario provided. Your imagination and creativity will be highly required in the presentation. Secondly, students will be required to upload the video online for access by peers and on-board discussions. Lastly, a formal one-page narrative paper will be submitted based on the instructions that will be provided.

Scenario: For the past few days, you have been working in the intensive care unit as a nurse. Today afternoon, you are in a room with Kerry, a 31-year-old female patient admitted two weeks ago with stage IV breast cancer. The patient’s family is at the bedside waiting for results from the lab that will determine the course of her treatment. The attending doctor comes to the patient’s room and starts discussing the results. After a brief discussion, the doctor informs you that not much can be done as the cancer is far beyond any form of treatment. The patient and younger siblings at the bedside are observed to be in tears as the mother tries to comfort them.

Questions: Assuming the role of the nurse and the doctor in the provided scenario:

Demonstrate how the doctor could have communicated the information differently. What communication techniques could have made a difference? Provide at least three techniques. As a nurse, how will you calm the patient and the family while communicating the same information that their patient has got little time to live? In a one-page paper, discuss the stages of grief by Kubler-Ross and how they might apply in Kerry’s case. Support your arguments using two pieces of evidence from scholarly sources.

Summative Performance Assessment Rubric

Criteria	Not Evident 0 points	Approaching Competence 1 point	Competent 2 points
Role play activity	The student demonstrates little or no effort in the role activity. There is minimal interest in role-play and the student is unknowledgeable about the topic.	Generally minimal quality of participation in the role play activity. The student shows some degree of enthusiasm and interest during role-play.	Generally high quality of role play with the demonstration of high a degree of enthusiasm. The student is exceedingly knowledgeable about the topic.
Communication Techniques	The communication techniques applied in the scenario-based activity are inappropriate and do not yield expected results. The communication techniques are not discussed in the role activity.	One to two communication techniques are evident in the case scenario role play activity. One or more of the discussed techniques are vague or do not apply in the provided case.	Three communication techniques are evident in the case scenario activity. A comprehensive discussion of the techniques is done during the group activity.
Nursing Interventions	The role play activity does not demonstrate nursing interventions to improve communication and understanding about end-of-life care for the patent.	Less than two interventions are evident to improve communication about end-of-life care. One or more of the interventions minimally address the patient and family needs.	More than two nursing interventions are evident to improve communication about end-of-life care. All the interventions comprehensively address the patient and family needs.
Stages of Dying	The submission fails to discuss the stages of grief and the application of these stages to the completed group activity.	The submission does not fully discuss the five stages of grief and how they apply to the completed group activity.	The submission provides an adequate discussion of the five stages of grief and how they apply to the completed group activity.
Scholarly Sources	The submission is not supported by an appropriate scholarly source.	Only one scholarly source is used to support arguments and is correctly cited using the current APA format (APA 7^th Ed).	Two scholarly sources are used to support arguments and are correctly cited using the current APA format (APA 7^th Ed).

End-of-Life Care Course for Pre-Licensure Nursing Students

Academic Setting

Curriculum Gap

Proposed Course

Theoretical Framework

Purpose of Proposal and Overview

Literature Review

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