Nursing schools to teach new ways to cope with death ==================================================== * Lauren Vogel The Canadian Association of Schools of Nursing will test new ways to include more palliative care training in undergraduate nursing programs, after a survey of 91 nursing schools revealed many inadequately prepare graduates to deal with death and dying. Funded by Health Canada, the two-year project will pilot models for integrating a spate of new palliative care competencies into existing curriculum and accreditation standards in a bid to improve graduate readiness to deal with both the physical and emotional demands of terminally ill or dying patients. The competencies — which cover practical skills, such as pain and symptom management, and “soft” skills, such as “knowing how to be with suffering” — were developed after a survey conducted by the association in 2007 found existing programs offered “limited” instruction and hands-on training in end-of-life care, if any, says executive director Cynthia Baker. “Programs cover bits and pieces of things related to palliative care, but most of the time it depends on the knowledge and willingness of the instructor to talk about that connection as they’re going through the module,” says Darcee Bidgood, president of the Canadian Hospice and Palliative Care Nurses Group, a partner in the project. “Often, because the instructor lacks the resources or confidence to tackle death and dying, they just gloss over it.” Although most nurses will confront death while performing their daily duties, few workplaces other than palliative care settings provide additional training and support to help nurses cope with caring for dying patients, says Bidgood. “Some young nurses are lucky enough to find mentors to walk them through a situation and give them the space and guidance to process it emotionally, but in most nonpalliative settings it’s a case of sink or swim.” Those who sink often experience “terrifying” moral distress and burnout, Bidgood says. “Particularly in acute care settings, the focus is to fix the person up and send them home, so when things start to go badly, it splinters people. When death isn’t part of the plan, it’s hard not to feel incredible failure and personal responsibility.” ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/183/4/418/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/183/4/418/F1) Under the new competencies, nursing students will be asked to demonstrate self-care, communication and the ability to “recognize and attend to meaning in suffering,” in addition to providing more practical care to the patient. Image courtesy of © 2011 Jupiterimages Corp. Inadequate palliative care education among nurses caring for a terminally ill or dying patient has also been associated with inappropriate communication, lack of compassion and avoidance of the patient, as well as increased patient and family anxiety, says Baker. “If people are flippant or rushed or get caught up in the task at hand, and fail to acknowledge the patient or their family, that can have long-lasting repercussions,” says Bidgood. “The task-oriented culture in which nurses have to look busy in order to be seen as doing their jobs properly may partly be to blame, because it values changing a dressing or distributing medicines over chatting with a patient when they seem distressed.” Other nurses “harden” towards their patients as a kind of coping mechanism, she adds. “They flip into this survival mode, but at what cost?” Under the new competencies, nursing students will be asked to demonstrate self-care, communication and the ability to “recognize and attend to meaning in suffering,” in addition to providing more practical care to the patient. “It’s about giving them space around the whole death and dying issue, so they can reflect, look after themselves and in some cases grieve,” says Bidgood. However, a national consultation on the competencies revealed some nurses felt such “soft” skills were better left to other members of the interprofessional team. According to one anonymous respondent, the competencies “suggest that the nurse can function in the role of a SW[social worker]/counselor … Maybe we do, but it can lead to role confusion and role conflict” ([www.casn.ca/vm/newvisual/attachments/856/Media/FinalReporttoHealthCanada.pdf](http://www.casn.ca/vm/newvisual/attachments/856/Media/FinalReporttoHealthCanada.pdf)). Others have questioned how institutions will find time to teach the new competencies without lengthening training, Baker says. Although the association is still developing ways to integrate the competencies into programs, Bidgood says the goal is to work with existing curricula and pedagogical approaches. “We’re not proposing the development of stand-alone courses because a lot of the competencies could fit under existing modules on thing like pain or communication.” To close remaining gaps, the association will build a national repository of teaching and learning resources on palliative and end-of-life competencies. The association will also hold a forum in March to see where new tools or resources are needed.