AN INTERNATIONAL SURVEY OF DEATH EDUCATION TRENDS IN FACULTIES OF NURSING AND MEDICINE oocodcoooooryooooocodcloyoooycococ@xo)ooyoocococucoocueroooo BARBARA DOWNE-WAMBOLDT DEBORAH TAMLYN hool of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada The purpose of this study was to identify and describe the availa bility of dea issues being addressed, and the background and expertise of the facu hy me bers involved in teaching death and dying content. A question n aire wt as develop based on the current literature and sent to 80 facu lties of nursing and 36 fac u lties of m edicine in Canada and the United kingdoM. The m ajority of nu an in tegrated approach, th rough all years of their program s. Despite recent criti- isms ofKubler-Ross's model of grieving, the m ajority of programs reported using her theory ost regu en tly. The findings identify the current stafus of death ed u ation for health professionals in Canada and the United kingdom, and im pli- cations for curricu lu m changes are discussed Death education emerged as a topic for discussion, research, and education in the late 196os and has continued to be an educa tional challenge in the 1990s. Health professionals require appro priate educational experiences to acquire the necessary knowl edge, attitudes, and skills to meet the physical, psychological, and spiritual needs of the dying and their family members death education for health professions in the United States has been described, there is a paucity of such information for similar programs in Canada and the United Kingdom o. Address correspondence to Barbara Downe- boldt, Dalhousie iversity, School of Nursing, Halifax, Nova Scotia, B3H 3J5, Canada Death Studies, 21: 177-188. 1997 177 Copyright o 1997 Taylor Francis 0748-1187/97$1200+.00
¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥ AN INTERNATIO NAL SURVEY O F DEATH EDUCATIO N TREN DS IN FACULTIES OF NURSING AN D MEDICINE ¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥¥ BARBARA DO WNE-WAMBO LDT DEBORAH TAMLYN Sch o o l o f Nu rsin g , Dalh o u sie Un ive rsity, H alifax , No va Sco tia, Can ad a T h e p u rpose of t h is stu d y w a s to i d en tify a n d d escribe t h e a v a ila bility of d e a th e d u ca tio n , in clu d in g te a c h in g a n d ev a lu a tio n m et h o d s, specific co n ten t a re a s, issu es bein g a d d resse d , a n d t h e b a ckgrou n d a n d exper tise of th e fa c u lty m em bers in volve d in te a c h in g d e a t h a n d d yin g co n ten t. A q u estio n n a ire w a s d evelope d b a se d o n t h e c u r ren t liter a tu re a n d sen t to 8 0 fa c u lties of n u rsin g a n d 3 6 fa c - u lties of m e d icin e in C a n a d a a n d t h e U n ite d K in g d om . T h e m a jority of n u rs - in g a n d m e d ic a l sch ools t h a t respo n d e d to t h e su rvey in clu d ed d e a th e d u c a tion , a n in tegr a te d a ppro a ch , th ro u g h a ll ye a rs of t h eir progr am s. D espite recen t criti - cism s of K u bler-R oss’s m o d el of grievin g, t h e m a jority of progr am s repor te d u sin g h er t h eor y m ost freq u en tly. T h e ®n d in gs id en tify t h e cu r ren t sta tu s of d e a t h e d u - c a tion for h e a lth professio n a ls in C a n a d a a n d t h e U n ite d K in g d om , a n d im plic a tion s for cu r ricu lu m ch a n ges a re d iscu ssed . De ath e du catio n e m e rg ed as a to pic fo r d iscu ssion , re se arch , an d e d u c atio n in th e late 1960s an d h as co n tin u e d to b e an e d u c atio n al ch alle n g e in th e 1990s. H ealth pro fe ssion als re quire ap p ro- p riate e d u c atio n al e x p e rie n c e s to acq u ire th e n e ce ssar y k n o wl- e d g e , attitu de s, an d sk ills to m e e t th e p h ysical, p sych o log ical, an d sp iritu al n e e d s o f th e d yin g an d th e ir fam ily m e m be rs. Alth o ug h d e ath e d u c atio n fo r h e alth p r o f e ssio n s in th e Un ite d State s h as be e n d e scribe d , th ere is a pau city of su ch in form atio n fo r sim ilar p ro g ram s in Can ada an d th e Un ite d Kin gdo m . Ad d re ss co rr e sp o n d e n c e to Barb ar a Down e -Wam b o ld t, Dalh o u sie Un ive rsity, Sch o o l o f Nu rsin g, Halifax , No va Sco tia, B3H 3J5 , Can ad a. Death Studies, 21: 177±188, 1997 Copyright q 1997 Taylor & Francis 0748-1187/97 $12.00 ` .00 177
B, Dow boldt and D. Tamlyn Death education surveys of health-related faculties conducted in the United States over the last decade(Dickinson, Sumner, Durand, 1987; Dickinson, Sumner, Frederick, 1992)and in Canada( Caty Downe-Wamboldt, 1983)have found that the majority of professional schools provide students with some expo sure to content related to death and dying within required courses. Full courses on death and dying are generally electives taken by less than 25% of the health professions students in the United States(Dickinson et al, 1992). A multidisciplinary approach is frequently used; however, most schools tend to use pri marily professionals from their own academic disciplines to teach death and dying content. Dickinson et al.(1987)found that American nursing schools did not generally use physicians or pharmacists as instructors; but 19% of medical schools and 11% of harmacy colleges used nurses to teach death education classe Lectures and discussion formats were the most popular teaching approaches, and seminars were the least popular Candy and Sexton(1985), in a survey of health education departments in the United States, compared institutional and expert opinions regarding topics that were considered to be essen tial to death education courses. Both groups identified 12 essential topics, including cultural aspects, the dying process, euthanasia funerals/burials, the grief process, hospice, le gislation, gender dif ferences, preparation for death, suicide, terminal illness, and wills There was no consensus concerning the topics of death history, religion and death, out of body experiences, or ethnic group per ceptions In the United Kingdom, despite the existence of death edu ation content in many programs, medical and nursing stud have reported that their preparation to provide terminal care was inadequate(Doyle, 1987). Hospice staff have also noted that there was inadequate professional training in palliative care for all health professionals working with the dying (Doyle, 1987) The present in vestigation was designed to address the gap in the literature on the nature of formal death education within nursing and medical schools in Canada and the United Kingdom The purpose of this descriptive, exploratory study was to identify and describe the current availability of death education, including
De ath ed u catio n sur ve ys o f h e alth -re late d facultie s co n d ucte d in th e Un ite d State s o ve r th e last d e c ad e ( Dic k in so n , Su m n e r, & Du r an d , 1987; Dic k in so n , Su m n e r, & Fr e d e ric k , 1992) an d in Can ad a ( Caty & Down e -Wam b o ld t, 1983) h ave f o u n d th at th e m ajority o f pro fe ssion al sch o ols p ro vide stud e n ts with so m e exp osu re to co n te n t re late d to d e ath an d d yin g with in re q u ire d co u rse s. Fu ll co u rse s o n d e ath an d d yin g ar e g e n e rally e le c tive s tak e n by le ss th an 25% o f th e h e alth p ro fe ssio n s stu d e n ts in th e Un ite d State s ( Dic k in so n e t a l., 1992) . A m u ltid is c ip lin ar y ap proach is fre que n tly use d; h owe ver, m ost sch o ols ten d to u se prim arily p rofe ssion als fro m th e ir own acade m ic d iscip lin e s to te ach d e ath an d d yin g co n te n t. Dic k in so n e t al. ( 1987) f o u n d th at Am e ric an n u rsin g s ch o o ls d id n o t g e n e rally u se p h ysic ian s o r p h arm acists as in str uctors; bu t 19% of m e dical sch oo ls an d 11% o f p h arm acy co lle g e s u se d n u rse s to te ach d e ath e d u c atio n classe s. Le c ture s an d discussio n fo rm ats we re th e m o st p o p u lar te ach in g ap p roach e s, an d se m in ars we re th e le ast p op u lar. Tan d y an d Se x to n ( 1985) , in a su r ve y o f h e alth e d u c atio n d e p artm e n ts in th e Un ite d State s, co m p are d in stitu tio n al an d e xpe rt op in io n s re g ardin g top ics th at were co n side re d to be e ssen - tial to de ath e ducation cou rse s. Both g ro ups id en ti® e d 12 esse n tial to p ics, in c lu d in g cu ltu ral asp e c ts, th e d yin g p ro ce ss, e u th an asia, fun erals/ bu rials, th e g rie f pro cess, h o spice , le g islatio n , g en de r diffe re n ce s, pre paratio n for de ath , suicid e, term in al illn e ss, an d wills. Th e re was n o co n se n su s co n c e r n in g th e to p ic s o f d e ath h isto r y, re lig io n an d de ath , o ut of bo d y exp e rie n ce s, o r e th n ic g ro up pe rc ep tion s. In th e Un ite d Kin g d o m , d e sp ite th e e xiste n c e o f d e ath e d uc atio n co n te n t in m an y p ro g ram s, m e d ical an d n u rsin g stu d e n ts h ave re po rted th at th e ir pre p aration to p ro vide te rm in al care was in ad e qu ate ( Doyle , 1987) . Ho spice staff h ave also n oted th at th e re was in ad e q u ate p ro f e ssio n a l tr ain in g in p alliative c are fo r all h e alth profe ssion als wo rk in g with th e d yin g ( Do yle , 1987) . Th e pre se n t in ve stig atio n was d e sign e d to ad d re ss th e g ap in th e lite r atu r e o n th e n atu re o f f o rm al d e ath e d u c atio n with in n u rsin g an d m e d ical sch oo ls in Can ada an d th e Un ite d Kin gdo m . Th e p u rp o se o f th is de scrip tive , e xplo rator y stud y was to id e n tify an d d e scribe th e curren t availability of de ath e du catio n , in clud in g 178 B . D o w n e-W am bold t a n d D . Ta m lyn
In ational Study 179 teaching and evaluation methods, specific content areas, and the professional background of faculty members in volved in teachin death and dying content in university programs of nursing, medi- cine, and social work in Canada and the United Kingdom, and to identify priorities for future education plannin Method A listing of university based programs for nursing, social work and medicine was obtained from the respective professio national academic associations. Questionnaires were mailed to all of the programs listed in the association rosters, including 80 uni- versity nursing programs, 65 university social work programs, and 6 university medical programs in Canada and the United Kingdom. The seven-page questionnaire was developed by the authors based on the relevant literature and was assessed for con- tent validity and clarity by a panel of four local hospice nurses and faculty members with expertise in the content area A total of 50(63%)questionnaires were received from nursin programs, 17(26%)from social work programs, and 15(42%) from medical programs. Because of the low response rate from the social work programs, these data were deleted from further analy sis. The response rate from Canadian programs was 93% and 38% for nursing and medical programs, resp ectively; for the United Kingdom the response rate was 45% for both nursing and medical programs. Responses from nursing programs were received from all regions of Canada; for medicine, responses were received from all regions except Atlantic Canada. United Kingdom responses were received from nursing programs in England, Northern Ireland, Scotland, and wales, and from medical programs in England and Scotland
te ach in g an d e valu ation m e th o ds, spe c i® c co n te n t are as, an d th e p ro fessio n al backg ro u n d o f facu lty m em bers in vo lved in te ach in g d e ath an d d yin g co n te n t in u n ive rsity pro g ram s of n ursin g , m e d ic in e , an d so cial wo rk in Can ad a an d th e Un ite d Kin gd o m , an d to id e n tify prio ritie s for fu tu re e du cation plan n in g . Method A listin g of un ive rsity-base d p ro g ram s fo r n u rsin g , social work , an d m e d ic in e was o btain e d fro m th e re sp e c tive p ro fe ssio n al o r n atio n al acad em ic asso ciatio n s. Qu e stio n n aire s we re m aile d to all o f th e pro g ram s liste d in th e asso ciatio n ro ste rs, in clu din g 80 un ive rsity n ursin g p ro g ram s, 65 u n iversity social wo rk p rog ram s, an d 36 u n ive rsity m e d ic a l p ro g ram s in Can ad a an d th e Un ite d Kin g d o m . Th e s e ve n -p ag e q u e stio n n a ire was d e ve lo p e d by th e au th o rs base d o n th e re levan t lite ratu re an d was asse sse d fo r co n - te n t valid ity an d c larity b y a p an e l o f f o u r lo c al h o sp ic e n u rs e s an d facu lty m e m be rs with e xp e rtise in th e co n te n t are a. Sample A to tal o f 50 ( 63%) que stion n aires we re re ce ived fro m n ursin g p ro g ram s, 17 ( 26% ) fr o m so c ial wo rk p r o g ram s, an d 15 ( 42% ) from m e dical pro gram s. Because of th e low re sp on se rate fro m th e so cial wo rk p rog ram s, th e se d ata we re d e le te d fro m furth e r an alysis. Th e re spo n se rate fro m Can adian p ro gram s was 93% an d 38% f o r n u rsin g an d m e d ic al p ro g ram s, re sp e c tive ly; fo r th e Un ite d Kin gdo m th e re spo n se rate was 45% fo r both n ursin g an d m e dical p ro g ram s. Re spo n se s fro m n ursin g p ro g ram s we re re ce ived fro m all re gio n s o f Can ada; fo r m e d icin e , re spo n se s we re re ce ived fro m all re g io n s e xc e p t Atlan tic Can ad a. Un ite d Kin g d o m re sp o n se s we re r e c e ive d fro m n u rsin g p ro g ram s in En g lan d , No rth e r n Ire lan d , Sco tlan d , an d Wale s, an d fro m m e d ic al p r o g r am s in En g lan d an d Sco tlan d. In ter n a tio n a l Stu d y 179
B, Dow boldt and D. Tamlyn TABLE 1 Curriculum approaches to death education(n= 65) Medicine Canada ntegrated throughout curriculum 16 lective courses 33 United Kingdom ntegrated throughout curriculum lective courses 2217 11 Required worksho Curriculu a broach Death education content was included in all of the respondin g Canadian nursing programs and 96% of the U.K. nursing pro grams. All of the Canadian medical programs and 89% of the medical programs in the United Kingdom that responded eported including death and dying content in their curricula The frequ ency with which death education was addressed by inte grating it throughout the curriculu m and/or using elective or rkshops is described in Table 1. Nursing programs reported allocating a greater number of hours for both lassroom teaching and clinical practice than medical programs TABLE 2 Average number of hours for death education Nursing Medicine Count Canada 50 6.60 5.50 United Kingdom C= Classroom instruction; CP= Clinical practice
Findings C u r ric u lu m A ppro a c h De ath e d u c atio n co n te n t was in c lu d e d in all o f th e re sp o n d in g Can ad ian n u rsin g p ro g ram s an d 96% o f th e U.K. n u rsin g p ro - g r am s. All o f th e Can ad ian m e d ic al p ro g ram s an d 89% o f th e m e d ic al p ro g r am s in th e Un ite d Kin g d o m th a t re sp o n d e d r e p o rte d in c lu d in g d e ath an d d yin g co n te n t in th e ir cu rricu la. Th e frequ e n cy with wh ich de ath e du cation was add re sse d by in te- g r atin g it th ro u g h o u t th e cu rricu lu m an d / o r u sin g e le c tive o r re q u ire d co u rs e s o r wo rk sh o p s is d e sc rib e d in Table 1. Nu rsin g p ro g ram s re po rted allo catin g a g reate r n um be r o f h ou rs fo r both c lassro o m te ach in g an d c lin ical p ractice th an m e d ical p ro g ram s ( Table 2) . 180 B . D o w n e-W am bold t a n d D . Ta m lyn
In tern ational Study TABlE 3 Teaching strategies for death education (n= 65) Medicine Canada Kingdom Strateg %n% % 7745 Case studies 96662 04661 65916704665 6 Audiovisual aids Self-directed activities Role playing 83011481170 Clinical experience 519730233222 Journal writing 4000 The death education teaching strategies reported by the nursing and medical programs in Canada and the United Kingdom are described in table 3. self-directed activities were used more than twice as often in U. K nursing programs as in Canadian pro grams. Lectures, case studies, and small-group discussion were used most frequently in Canadian medical programs, whereas medical programs in the United Kingdom preferred lectures and small-group discussion. The majority of Canadian(66% and U.K.(57%)nursing programs reported that most or several students had the opportunity to work with dying patients Opportunities to work with dying patien ts were also made avail- able for many Canadian (50%)and United Kingdom (55%) medical students Program Content Table 4 provides a summary of the content areas most frequently addressed in nursing and medical programs. Nursing programs in Canada and the United Kingdom covered very similar content areas, including grief and bereavement, communication, pain and symptom control, legal/ethical issues, and family needs. Howeve
Te a c h in g Str a tegies Th e d e ath e d u c atio n te ach in g strate g ie s re p o rte d by th e n u rsin g an d m e d ic al p ro g r am s in Can ad a an d th e Un ite d Kin g d o m are d e scribe d in Table 3. Se lf-d ire c te d ac tivitie s we re u se d m o re th an twic e a s o fte n in U.K. n u rsin g p r o g r am s as in Can ad i an p r o - g r am s. Le c tu r e s, c as e stu d ie s, an d sm a ll-g ro u p d iscu ssio n we r e u s e d m o st fre q u e n tly in Can ad ian m e d ic a l p ro g r am s, wh e r e as m e d i c a l p r o g r am s in th e Un ite d Kin g d o m p r e f e r r e d le c tu re s an d sm a ll-g r o u p d is c u ssio n . Th e m a jo rit y o f Can ad ian ( 6 6% ) an d U.K. ( 57%) n u rsin g p ro g ram s re p o rte d th at m o st o r se ve ral stu d e n ts h ad th e o p p o rt u n ity to wo r k with d yin g p atie n ts. O p p o rtu n itie s to wo rk with d yin g p atie n ts we re also m ad e avail- ab l e f o r m an y Can ad ian ( 50% ) an d U n it e d Kin g d o m ( 55 % ) m e d ic al stu d e n ts. P rogra m C o n te n t Table 4 p ro vid e s a sum m ar y o f th e con te n t are as m o st fre qu e n tly ad d re sse d in n u rsin g an d m ed ical pro g ram s. Nu rsin g pro g ram s in Can ad a an d th e Un ite d Kin g d o m co ve re d ve r y sim ilar co n te n t are as, in clu din g g rief an d be reavem en t, co m m u n ication , pain an d sym pto m co n tro l, le g al/e th ical issu e s, an d fam ily n e e d s. H owe ve r, In ter n a tio n a l Stu d y 181