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Nursing Student Perceptions of End-of-Life Communication Competence A Qualitative Descriptive Study

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Stephanie Jeffers, PhD, RN ¦ Megan P. Lippe, PhD, RN ¦ Amanda Justice, BSN, RN ¦ Dawn Ferry, APRN, CHSE ¦ Kara Borowik, BSN, RN ¦ Cera Connelly, BSN, RN

Effective communication skills are required when nurses care for patients and their families navigating life-limiting illness and the end of life. Educators have made great strides in integrating end-of-life content into prelicensure curricula. It is critical to evaluate nursing students' perceptions of their communication skills to empirically guide the development and implementation of future education interventions. The purpose of this qualitative descriptive study was to explore nursing students' perceptions of their verbal and nonverbal communication competence when providing end-of-life care. Students participated in an established high-fidelity simulation focused on difficult end-of-life conversations. Students explored their perceptions during postsimulation debriefing sessions. Colaizzi's method guided thematic analysis of the audio-recorded debriefings. One major theme emerged from the data: delivering bad news is difficult. Four subthemes further described this theme and its components: (1) reflecting on communication at end of life, (2) feeling uncomfortable, (3) calling for more exposure to end-of-life communication, and (4) fostering a supportive environment for patients and families. Results indicate that nursing students had anxiety and discomfort when engaging in end-of-life conversations.

nie Jeffers, PhD, RN, is associate professor, Widener University of Nursing, Chester, PA.

P. Lippe, PhD, RN, is associate professor, University of Texas Science Center San Antonio School of Nursing.

da Justice BSN, RN, University of Alabama Capstone College of , Tuscaloosa, AL.

Ferry, APRN, CHSE, is adjunct nursing professor, Widener Univer- ool of Nursing, Chester, PA.

orowik, BSN, RN,Widener University School of Nursing, Chester, PA.

onnelly, BSN, RN,Widener University School of Nursing, Chester, PA.

s correspondence toMegan Pfitzinger Lippe, PhD, RN, University of ealth Science Center San Antonio School of Nursing, San Antonio, 29 ([email protected]).

thors have no conflicts of interest to disclose.

rk was supported by Widener University and the Eta Beta chapter a Theta Tau International Honor Society of Nursing.

ght © 2022 by The Hospice and Palliative Nurses Association. All eserved.

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al of Hospice & Palliative Nursing

These findings support increased investments in additional training interventions to facilitate the development of student competence in end-of-life communication prior to entering the professional workforce.

KEY WORDS communication, competency, end-of-life education, nursing education, nursing student, palliative nursing, simulation

E ffective communication skills are an important com- ponent of palliative and end-of-life nursing care.1,2

Nurses have integral roles in interdisciplinary teams that care for patients with serious illness and their families. Specifically, nurses need to be competent in imparting and gathering information, listening, and eliciting sensitive as- pects of care related to holistic patient and family care, in- cluding culture, religion, and ethics.1 Educators have an obligation to prepare nursing students to communicate ef- fectively with patients throughout the disease trajectory, including at the end of life.3 Students and nurses cannot develop competence or confidence in communication skills without formal education and training.

Nurses with more years of experience in the workforce report having greater confidence about and positive atti- tudes toward communicating with and caring for seriously ill patients and their families.4,5 More years of experience undeniably is an important aspect of competence. How- ever, the strategic incorporation of more education fo- cused on communicating with seriously ill patients within formal nursing curricula may help reduce the competence gap between nursing students and experienced nurses.

Over the past fewdecades, the provision of communication- focused education interventions, frequently simulation, has con- sistently led to enhanced knowledge, attitudes, and abilities.6-9

However, some of the most difficult aspects of communi- cating with patients with serious illness continue to be con- ducting difficult conversations, or “breaking bad news,” and managing conflict.4,10-12 Given the importance of

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effective, transparent, and honest communication in pallia- tive and end-of-life care, nursesmust be adequately prepared to conduct all types of conversations, including difficult ones.

The mandate for education about and experience with conducting difficult conversations has never been as great as with the publication of new accreditation requirements for nursing programs from the American Association of Colleges of Nursing (AACN) in 2021.3 Historically, AACN's accreditation guidelines have emphasized acute care; however, the new standards require that students receive adequate education across 4 spheres of care, one of which is hospice/palliative/supportive care, including end-of-life care. Furthermore, AACN cites communication as a core component of effective nursing care, specifically stating that by graduation prelicensure nursing students must “demonstrate the ability to conduct sensitive or difficult conversations.”3(p30) Never before has it been more imper- ative that nursing programs evaluate the current status of student competence in conducting difficult conversations. Exploration is required to identify the specific elements of communication that require greater attention within ac- ademic nursing programs. The purpose of this qualitative study was to explore nursing student perceptions of their verbal and nonverbal communication competence when engaging in complex or difficult end-of-life conversations.

LITERATURE REVIEW

Simulation Within the field of palliative care, simulations have been a staple of educational interventions to promote knowledge acquisition, attitude modification, and competence devel- opment. Simulation is consistently identified as an effective strategy to teach palliative and end-of-life care to nursing students.7,13,14 End-of-life simulations offer nursing students the chance to practice palliative care skills in a safe, low- stakes environment. Previous studies have shown that sim- ulation can improve student's confidence and attitudes in providing end-of-life care.9,15-17 Although both classroom and simulation settings help students learn about end-of- life care, simulation has been shown to be more effective in teaching students to apply palliative care skills and pre- pare for the emotional aspects of caring for dying patients.18

Communication-focused simulations are effective edu- cational interventions for students, nurses, and interdisci- plinary teams. A systematic review of the literature reports that simulations have been utilized to teach nursing stu- dents or practicing nurses about multiple aspects of pallia- tive care communication, such as end-of-life conversa- tions, family support, bereavement, and interdisciplinary collaboration.7 Gellis et al19 developed an interprofes- sional communication simulation for students in nursing, pharmacy, medicine, social work, occupational and phys- ical therapy, and chaplaincy. Focused on a geriatric patient

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requiring palliative care, the simulation improved multiple variables of interprofessional team dynamics, such as com- munication and collaboration. Perceived competence also improved through multiple 4-hour interdisciplinary simulation-based workshops focused on palliative care communication skills.6

Communication Training In addition to simulation, multiple different methods have been utilized to teach communication skills to diverse health care populations. The End-of-Life Nursing Educa- tion Consortium (ELNEC) is a primary source for palliative care communication education for nurses, with offerings beginning in the early 2000s.20 ELNEC developed com- munication curricula for nurses and interdisciplinary teams that were implemented via train-the-trainer for- mats.21,22 The curricula have been adapted into multiple formats and provided in conjunction with other ELNEC trainings.21 The ELNEC Undergraduate/New Graduate curriculum has devoted 1 of the 6 onlinemodules to teach- ing prelicensure nursing students and new-graduate nurses palliative care communication.23-25 Similarly, the ELNEC Graduate online curriculum has a dedicated mod- ule for palliative care communication tailored to the educa- tional needs of master's degree and doctor of nursing practice students.26,27

Another frequently cited intervention is the COMFORT curriculum, which stands for “C—Communication, O— Orientation and options, M—Mindful communication, F —Family, O—Openings, R—Relating, T—Team.”28(p2)

Comprising 7 palliative care communication modules, the COMFORT curriculum positively impacts attitudes and perceived competence in communicating with patients with serious illness, including for oncology nurses,29,30

and licensed practical nurses.31

Several other communication-focused educational in- terventions have been cited in the extant literature. An ed- ucational intervention for nurses that incorporated multi- ple strategies (slide presentations, a toolkit, and a conver- sation guide) positively improved their comfort and confidence with advance care planning conversations.32

The End-of-Life Essentials project includes 6 modules for interdisciplinary health care providers focused on ele- ments of end-of-life care, including “patient-centered com- munication and shared decision-making… goals of care… and responding to concerns.”33(p2) Analysis of qualitative data revealed many elements of communication that were impacted by the intervention.

METHODS

This qualitative descriptive study was approved by the Widener University institutional review board.

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THEORETICAL FRAMEWORK

Bandura's Social Cognitive Theory (SCT) served as the the- oretical framework for this study.34 Two key constructs within SCT are self-regulation and self-efficacy. Self- regulation involves learners' critical self-appraisal of their performance and identification of necessary revisions. Based on feedback received, self-regulation takes place such that learners modify their understanding of the be- havior, change their goals, or modify their strategy for learning or performing the behavior.34 Self-efficacy is the learner's perceived ability to correctly perform the behavior. Learners make determinations about their self-efficacy based on their actual performance of a behavior, observance of peers' performance of a behavior, verbal and social persua- sion, and their current physiological state.34 The focus of this study was student perceptions of their communication competence in complex end-of-life conversations. The re- search team considered self-regulation and self-efficacy to be possible influences on how students appraised and dis- cussed their communication skill competence.

The primary purpose of the theory within the studywas to support the use of simulation as a mechanism for students to reflect upon their communication skill competence. In addi- tion, the SCT informed the adaptation of the simulation to maximize student self-appraisal and reflection regarding their communication skillset. Finally, the researchers bracketed the constructs of SCT from initial data analysis to adhere to the tenets of descriptive phenomenology. In the final stages of analysis, the researchers considered possible alignment of SCT constructs with the themes that had emerged.

TABLE 1 Simulation Semistructured Interview Guide

1. Tell me how you felt in that simulation. 2. Tell me your general thoughts on the simulation. 3. What were some positive communication techniques

that were used? a. Exploration of verbal and non-verbal communication techniques

4. What were some interventions that were not helpful in the communication process?

5. How did you feel while you were talking with the patient's family about the prognosis?

6. How did you feel during the interactions? a. Discomfort? b. Feel differently in various parts of the simulation?

7. What do you think could be improved in the end-of-life simulation? What would you change if you could?

8. What could have prepared you better to communication with the family or the health care team?

9. How did you approach the first part of the simulation? 10. How did you approach the second part of the simulation? 11. What is one key lesson that you will take from this

simulation?

Difficult Conversations Simulation The study utilized a high-fidelity simulation as a mecha- nism for students to participate in and subsequently reflect upon their communication skills. The simulation was adapted from an existing end-of-life simulation,15 with em- phasis placed on engaging in difficult conversations and conflict management with a dying patient, his family, and the health care team. The simulation scenario centered on a patient who had a long-standing history of multiple end-stage comorbidities (congestive heart failure and chronic obstructive pulmonary disease). Actors portrayed a physician and 2 family members throughout the sce- nario, whereas a high-fidelity manikin was the patient and was remotely operated by a simulation facilitator.

Students participated in the simulation within groups of 8 students. The simulation began with a prebriefing in which students were oriented to the scenario and the ex- pectations for their engagement. Throughout each part of the simulation, 2 to 3 nursing students actively engaged in the scenario while the remainder having observed the interactions remotely via teleconferencing software. Nursing students engaged in 2 types of difficult conversations with

Journal of Hospice & Palliative Nursing

the patient's family during the simulation. The first difficult conversation required students, in partnershipwith the physi- cian, to discuss patient prognosis following an emergent intu- bation. Students were expected to support the patient's fam- ily member when she received information about the patient's poor prognosis. The second difficult conversation required students to engage in conflict management be- tween 2 familymembers arguing about whether to continue with life-sustaining interventions or to allow a natural death. Students were expected to de-escalate the argument and redirect the family's focus to the patient's goals of care. Af- ter the scenario, all students participated in debriefing. The Plus-Delta framework was used at the beginning of the debriefing to promote student discussion about what went well and what students would do differently in the fu- ture.35 Within this framework, students identify what went well within the scenario and what they would change about their practice in the future. A semistructured inter- view guide assessed nursing student perspectives of their communication within the simulation (Table 1).

Researcher Characteristics and Reflexivity The primary investigators for this study are experienced educators in baccalaureate nursing programs and have ex- pertise in palliative nursing care. The investigators utilized this expertise to adapt the simulation and develop the semi- structured interview guide. One investigator is an expert in qualitative methodology and provided oversight through- out the data collection and analysis process. Each imple- mentation of the simulation and debriefing (including data collection) was conducted by the simulation laboratory

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director, not the primary investigators. The laboratory direc- tor has prior clinical practice experience in hospice nursing and therefore was able to ask meaningful questions as ap- propriate. Furthermore, the laboratory director is not con- nected with the academic course in which the students were enrolled, supporting student openness in discussion.

Sample Students were recruited from one, large, private nursing school in the northeastern United States. The baccalaure- ate nursing curricula do not have a dedicated health com- munication course; principles of effective, therapeutic communication are threaded throughout nursing courses. All students were enrolled in a senior-level medical-surgical nursing course. The simulationwas a required course activity. Information about the study was presented by one primary investigator, who taught in the course, during an in-person class session. Participation in the study did not have any impact on student academic performance in the course. Students who wished to participate provided consent for the debriefing to be audio-recorded for analysis.

Data Collection Groups for which all students provided consent were in- cluded in data collection and analysis. Any group for which a single student did not consent would not be in- cluded; however, this was not an issue as all students provided consent.

Following completion of the end-of-life scenario, teams of students participated in guided debriefings to explore their perceptions of their communication skills. All debriefingswere conducted by the same individual (simula- tion laboratory director) who used a semistructured inter- view guide. Questions explored students' perceptions of their communication with the family members and the health care team during the difficult conversations.

Data Analysis Transcriptions of the simulation debriefing sessions were analyzed in accordance with Colaizzi's36 method of the- matic analysis. Audio-recorded debriefing sessions were transcribed by a third-party service. All transcripts were re- viewed by the research team to verify accuracy. Transcripts were deidentified prior to analysis to mask student identity as one investigator was a course instructor. During data analysis, the research team stayed close to the statements made by participants, without substantial interpretation or extrapolation. Three undergraduate research assistants were trained by the primary investigators in thematic anal- ysis. One primary investigator partnered with 2 students to conduct initial data analysis by hand as a team. Key phrases were identified, and themes emerged. Similar analysis of the data and themes was conducted by the sec- ond primary investigator and the third student in order to

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determine consensus of key phrases and themes. Results were shared with the simulation laboratory director, who led the debriefing sessions for confirmation and clarifica- tion and to build consensus.

RESULTS

The convenience sample consisted of 117 nursing stu- dents. The mean age of these students was 22 years. The majority of the sample consisted of White female students, with a minority of African American and male students.

One major theme emerged from the data: delivering bad news is difficult. A range of emotions were expressed by students, which included fear, sadness, stress, feeling awkward, and a general lack of self-confidence in commu- nicating bad news. Students were aware that communica- tion was essential; however, their ability to convey verbal information to the family members was hindered by their anxiety surrounding the impending death of the patient. The concept of communication was weaved throughout the 4 subthemes, which included (1) reflecting on commu- nication at end of life, (2) feeling uncomfortable, (3) calling for more exposure to end-of-life communication, and (4) fostering a supportive environment for patients and family.

Subtheme 1: Reflecting on Communication at End of Life The students identified both positive and negative commu- nication strategies. Participants were aware of the influ- ence of nonverbal cues, such as body posture, eye contact, and presence. One student reported, “When I looked down… I was like ‘OK, I need to be more inviting’ and I opened my arms up.” Students also reported asking family about their feelings and providing education and support. They did not want to rush out the door, but rather waited until all questions were answered to the satisfaction of the family members. One student said, “[I was] using terminol- ogy the family understood. I tried to break it down and be as simple and clear and straight to the point as possible.”

Students reported ineffective communication techniques, including repeating themselves, being unable to manage their own emotions, and not feeling confident with com- munication skills, evidenced by this student quote: “…it's like you don't know what to say to comfort them.”

Subtheme 2: Feeling Uncomfortable In this subtheme, students discussed the uncomfortable nature of having difficult discussions surrounding end-of- life decisions. The emotional aspects of communication that were identified included anxiety, sadness, and overall apprehension, particularly with saying the words “death” or “dying.” Students reported being aware that having a conversation to address the needs of the dying patient was important and necessary; however, they had difficulty

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sharing bad news. One student stated, “We don't want to say the ‘D’ word.” Another student expressed apprehen- sion saying, “I felt it [dying] on the tip of my tongue and I just couldn't get through it.”

Subtheme 3: Calling for More Exposure to End- of-Life Communication Despite feeling overwhelmed, anxious, and uncomfort- able with communication, students shared that education and clinical exposure with patients receiving palliative or end-of-life care are needed prior to graduation. One student stated, “We've been taught death and dying so many times that we know the information… we don't have the experi- ence of delivering the information.” Recommendations to enhance their learning and practice of therapeutic commu- nication at the end of life included having a mandatory course in the curriculum about end-of-life care and focused clinical experiences such as caring for patients in a hospice setting or participating in palliative care discussions with patients, their families, and the interdisciplinary team.

Subtheme 4: Fostering a Supportive Environment for Patients and Families Students participating in the simulation reported feeling they fostered a supportive environment for the patient and the family at the bedside by remaining present, an- swering questions from the family members, and deliver- ing information in an empathetic manner. Reflecting on the simulation allowed students to become aware of their nonverbal communication skills as well as the verbal infor- mation and emotional support they were providing the pa- tient and family. One student stated, “All the stuff when it comes to death and dying, it's never going to be cut and dry. It is just one of those things where you have to take the situation for what it is and just meet people where they are.”

DISCUSSION

This study explored nursing student perceptions of their communication skills in difficult end-of-life conversations. Students reported feeling confident with some elements of communication, such as assessments and pain manage- ment. These types of communications were associated with more concrete tasks that typically have objective pro- cedures guiding implementation. However, they reported greater feelings of anxiety and apprehension throughout the difficult conversations. Students reported anxiety sur- rounding the word “dying” and identified it was nearly im- possible to say theword aloud. This anxiety is reported fre- quently in the literature among both registered nurses and nursing students.37,38 Within the context of SCT, this anxi- ety can adversely affect self-efficacy to engage in difficult conversations. The consistent identification of anxiety with

Journal of Hospice & Palliative Nursing

regard to difficult conversations highlights that education in complex communication continues to be insufficient. Nursing education programs need to provide more oppor- tunities for students to engage in difficult conversations as one mechanism to reduce their anxiety.

Despite feeling uncomfortable with addressing end-of- life issues, students provided meaningful end-of-life care and active presence to support the patient's family during a difficult time. Being present and being silent are critical, highly effective communication skills when caring for seri- ously ill patients and their families.1 The literature similarly describes this behavior of nurses and nursing students as effective and supports the positive influence of a peaceful environment on patients' and families' end-of-life experi- ences.39,40 Nursing student perceptions of greater compe- tence with these types of communication skills can en- hance self-regulation and performance in future situations requiring presence.

In this study, students reported feeling underprepared to communicate effectively during difficult conversations at the end of life. The literature shows that nursing students report a lack of education specifically on communication skills and would like to have this education integrated into their curriculum.41,42 Integration of communication, pallia- tive care, and end-of-life care content into nursing curricula is evenmore imperativewith the recent publication of new accreditation guidelines emphasizing palliative and hos- pice care as 1 of 4 key content areas for nursing education.3

Prelicensure nursing programs need to bemore intentional about integrating didactic elements of communicationwith their curricula, such as through the ELNEC.43

Communication skills within difficult conversations re- quire deliberate practice and reflection. Therefore, educa- tion alone is not enough. Students must have multiple, practice-based experiences (simulated or real) to develop their communication skills. Traditionally, educators may feel compelled to reduce students' opportunities to engage in or witness difficult conversations within clinical settings out of a desire to respect/protect the patients and families. While respecting the wishes of patients and families is im- perative, without opportunities to observe real patient– family–health care team conversations, students will con- tinue to enter practice with deficient self-efficacy and skills with end-of-life communication. More opportunities to ob- serve (in a respectful, protective manner) and, more im- portantly, participate in difficult conversations will allow students to engage in self-regulation behaviors and in- crease their self-efficacy with their communication skills.

The findings of this study have important implications for clinical practice settings. As mentioned, students continue to struggle with engaging in difficult conversations, even to- ward the conclusion of their formal nursing education. Clini- cal agencies need to be prepared to offer new nurses oppor- tunities to develop and refine their communication skills, as

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these opportunities may not have been provided in their prior education. Ensuring nurses are competent with en- gaging in difficult conversations can improve the quality of patient care provided; protect against nurse anxiety and other adverse mental health outcomes, such as burn- out; and facilitate improved identification of patients who require specialty palliative care services by being able to elicit important information in the serious illness setting. Furthermore, agency leadership should engage in conver- sations with their interdisciplinary health care teams and the leadership at collaborating academic institutions to de- termine how opportunities to engage in difficult conversa- tions can be provided to nursing and other health care stu- dents conducting clinical experiences in their facilities. These conversations could facilitate identification of mutu- ally agreed upon mechanisms to provide these experi- ences to students while ensuring patients and families re- ceive the best possible care.

Limitations This study was conducted with a convenience sample of students at a nursing program within the United States. Therefore, the results may not generalize to other regions. However, the large sample size and the consistency with other literature support that nursing student anxiety with end-of-life communication persists and requires change within nursing curricula. One primary researcher was a faculty member in the medical surgical course in which the simulation was implemented. While steps were taken to protect against coercion and power imbalances, some students may not have shared as much information as they would have otherwise.

Conclusion It is imperative that prelicensure nursing programs deliver end-of-life content, which includes communication and participating in difficult conversations. Clinical or simula- tion experiences are needed with greater frequency to in- crease competence with regard to end-of-life communica- tion.3 However, before any new educational interventions are implemented, current students' experience and per- ceived competence should be considered to help identify gaps that need to be addressed. Better communication skills can translate to better patient and family experiences, including at the end of life.

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