Abstract
Advances in the management of life-limiting diseases coupled with an aging population mean there is an increasing prevalence of people with palliative and end of life care needs in most healthcare settings. Junior doctors and nurses are at the frontline of patient care, so it is essential they have the knowledge, skills, and attitudes required to provide safe, effective and compassionate care for people with palliative and end of life care needs. However, this area has traditionally been overlooked and under-represented in undergraduate medical and nursing education, which fails to prepare students for the realities of clinical practice. Ultimately, such deficiencies compromise the quality of life and the quality of death for patients and their family/whānau[1] and increase graduates’ distress if they do not feel well prepared for this part of their work.
The aims of this research are to investigate how undergraduate medical and nursing students in Aotearoa New Zealand learn about palliative and end of life care and their self-efficacy and attitudes towards doing so. This three-phase mixed methods doctoral research project is underpinned by Albert Bandura’s theory of self-efficacy, which is situated within social cognitive theory.
Key results from this research indicate that palliative and end of life care (PEOLC) is vertically integrated throughout undergraduate medical and nursing education, but to varying degrees. In medicine, this teaching is well established and guided by a national undergraduate medicine palliative and end of life care curriculum and implementation framework. PEOLC is identified as a requirement in the competencies set down by the Australian and New Zealand Medical Councils and more than 40 hours of formal PEOLC teaching is provided at 75% of the four main teaching campuses (RR=100%). In nursing, this teaching is under-developed with only 1-10 hours of formal PEOLC teaching provided at 85% of the nursing schools that responded (RR=72%). PEOLC is not included in the competencies for Registered Nurse Scope of Practice set down by the Nursing Council of New Zealand.
Medical and nursing schools share similar challenges. Gaps in content, minimal formal assessment, lack of teaching time, lack of suitably qualified and experienced teaching staff, and limited contact with specialist palliative care services are the main barriers to further curriculum development.
Overall, participants showed low to medium self-efficacy and positively oriented attitudes towards caring for people with PEOLC needs, although a notable group of registered nurse participants showed greater discomfort. Clinical learning experiences provided important opportunities to apply learning in the clinical context and to learn from clinicians who were competent in the palliative care approach. These role models were highly valued as a critical source of support as participants adjusted to their responsibilities as junior doctors and nurses.
Key results showed that self-efficacy and thanatophobia were positively associated with increased frequency of exposure to PEOLC activities in the clinical setting. While self-efficacy was more affected by education, attitudes were more influenced by family and cultural values and beliefs and prior personal experience of caring for a loved one who died. Being of Māori ethnicity and younger than 46 years of age was also positively associated with self-efficacy and attitudes. Participants identified that gaps in formal teaching and clinical learning experiences undermined their self-efficacy and left them feeling unprepared for clinical practice. Meanwhile, challenges in the workplace environment, including demand-resource imbalance and negative attitudes towards palliative care, caused frustration and distress, which was compounded by the emotional labour involved in providing PEOLC for patients and family/whānau. Despite these issues, many participants provided examples of exemplary patient care, especially if they had relevant prior personal or professional experience.
In conclusion, further curriculum development, using the results from this research, is urgently required, especially in nursing education, to ensure graduates are as well-prepared as possible to care for people with PEOLC needs. This work must be prioritised by government, education and healthcare providers to improve workforce capacity to meet the healthcare needs of the population into the future.
[1] Māori word for family, including extended family who may not have kinship ties to other members.