Many patients struggling with a serious or advanced illness want to talk with clinicians about spirituality.1 Healthcare providers often are reluctant to engage in such discussions, however, because of lack of time, lack of training, or simple discomfort with the subject matter.
“Interdisciplinary end-of-life education remains sparse among nursing and medical schools,” observes Dana Hansen, PhD, APRN, ACHPN, FPCN, an associate professor and co-director of the PhD program at Kent State University’s College of Nursing.
As a result, new graduates are unsure of what to say to patients and families when they start practicing. This leads to stressed clinicians and dissatisfied families. “Despite varied attempts at improving communication, talking to dying patients and their families, especially about spirituality, remains difficult for the healthcare team,” says Hansen.
Many people in a health crisis are confronted with existential questions, such as ‘Why is this happening to me?’” says Pam Stephenson, PhD, RN, an associate professor at Kent State University’s College of Nursing. If healthcare providers are not confident that they can respond to a question like this, they likely avoid interacting with the patient. As a result, the patient does not receive the spiritual support they need.
The Catalyzing Relationships at the End of Life program provides interdisciplinary end-of-life education and has been part of the curriculum for the past two years at Kent State University College of Nursing and Northeast Ohio Medical University.2 The program features an online cognitive component and a live forum theater simulation. The online component includes three modules with voiced-over PowerPoint presentations on developing resilience through interprofessional teamwork, family relationships at the end of life, and relational communication (called “final conversations”). Students are asked to complete journal entries reflecting on their own relationships and views on death and dying.3
Students also watch videos depicting end-of-life communication. The first video depicts poor end-of-life communication. In it, a physician dismisses a patient’s comments about seeing her deceased husband as delirium. Then, in response to the patient’s son becoming upset, the physician curtly replies that medication will address the delirium. The scenario is an example of a clinician’s failure to meet the family’s spiritual and emotional needs. The students are asked to reflect on what occurred in the video.
Next, students are shown a video with the same scenario, but depicting quality end-of-life communication. The physician sits down next to the patient and asks her how the vision of her deceased husband made her feel, and the patient shares more details. The physician then turns to the son and says, “This is something that I hear about often from my dying patients. It seems to provide your mom with comfort, so it is not harmful to her. I encourage you to talk to her about what she saw.” The son talks with his mom and ends up receiving important messages about his parent’s love for him.
Lastly, students participate in a live forum theater simulation. Undergraduate theater students play the roles of patients, family, and healthcare providers. First, the actors demonstrate poor end-of-life communication. Faculty leaders guide students in a discussion on how it could be improved. Students make decisions on what should happen with the care of the patient and family, and faculty leaders instruct the actors to make those changes. “The students are driving the next scene, to improve the care of the patient and family. The use of forum theater is a powerful way to create behavior change,” says Stephenson.
Stephenson, Hansen, and colleagues collected data from the journals of 156 nursing and medical students who participated in the initiative.4 The researchers focused on student reflections on these questions: What would be most important if you learned you were dying? What would be hardest to give up? What would you want loved ones to know before your death?
Students were not asked directly about spirituality. “However, spiritual themes organically emerged from the student responses and were prevalent,” reports Stephenson. Students’ responses revealed two misconceptions. Students assumed that there would be time to plan their death, and also romanticized death by envisioning a prolonged dying period during which they would be the center of attention. The analysis demonstrated that student reflections are a powerful learning technique. Students came to understand that forgiveness and discussing end-of-life preferences were important tasks to accomplish before death, for example.
Overall, the study’s findings suggest that healthcare providers’ lack of comfort with spiritual conversations begins before they enter clinical practice. “The wall created by reluctant providers can start early, while they are in school, if their own personal losses are unresolved or insufficient to provide context,” concludes Stephenson.
- Fitch MI, Bartlett R. Patient perspectives about spirituality and spiritual care. Asia Pac J Oncol Nurs 2019;6:111-121.
- Hansen DM, Motter T, Keeley MP, et al. Interdisciplinary simulation for nursing and medical students about final conversations: Catalyzing relationships at the end of life (CAREol). Palliat Support Care 2023;21:798-804.
- Hansen DM, Stephenson P, Lalani N, Shanholtzer J. Reflective journaling as preparation for spiritual care of patients. J Hosp Palliat Nurs 2023;25:45-50.
- Stephenson P, Hansen D, Lalani N, Biggs J. Nursing and medical students’ responses about end-of-life communication reveal educational opportunities for spiritual care. J Nurs Educ 2023;62:601-605.
