DISCUSSION
These preliminary data suggest that participating in the Palliative Care Companion program improves students' knowledge and attitudes toward palliative care and reduces concerns about caring for dying patients. While both groups of students learned some content related to end-of-life care and improved their knowledge during a one-semester period, the Palliative Care Companions experienced greater increases in knowledge and also improvements in attitude and reductions in concerns. This program provides one potential remedy to the problem of inadequate preparation for providing end-of-life care noted by other authors (Ellerton & Curran-Smith, 2000; Marra, 2000). In talking with dying patients and their families, students receive the additional preparation that practicing nurses report wishing they had had (Georges & Grypdonck, 2002; White et al., 2001).
These findings are consistent with those of Frömmelt (1991), who reported improved attitudes toward care of dying patients after didactic and role play education; and those of Arber (2001) and Kenny (2001), who reported increased knowledge after didactic education and a palliative care clinical experience. These results demonstrated that improvements in knowledge and attitudes could be made with less didactic training (2 to 4 hours versus the 50-hour and 13-week sessions tested in previous studies) and with less direct clinical supervision and evaluation.
Students' evaluations of the program provided positive comments, reflecting more confidence and less apprehension in working with dying patients. For example, one student wrote:
It gave me confidence in dealing and talking about death with patients. I think when I encounter patients who may have a terminal illness, I will be able to give them the type of care they need.
Another stated:
I really enjoyed talking with the families and the patients.... I learned that you don't have to speak all the time and that a person's support is sometimes the only thing needed.
A student who expected to be nervous wrote:
I thought I wouldn't know what to do or say, but every experience was really enjoyable. It was nice when they [the patients] would ask me to come back and visit again.
Experiential learning theory was useful in this program, helping students learn in a flexible way, based on their individual needs and abilities. Students were allowed to learn at their own pace, with patients or families they selected, and without the stress of performance evaluation inherent in a clinical practicum. However, we did not have the opportunity to compare outcomes from our Palliative Care Companion group to students receiving a more traditional, structured clinical in palliative care. This would be an interesting and important comparison to pursue in future work.
LIMITATIONS
Several limitations of our assessment of knowledge and attitudes and of the Palliative Care Companion program, in general, should be noted. We have data from only small numbers of students at this point, and changes based on participant feedback were made to the program during this period. Students self-select into the program, while their peers in the control group did not choose to participate in the end-of-life experience. However, the data appear to indicate that these groups were similar at baseline in terms of demographic characteristics and knowledge and attitudes scores.
The program itself requires professional commitment and time, particularly on the part of the Palliative Care Coordinator. In our program, this individual is central in orientation sessions, including the one-on-one shadowing experience; maintains communication on a daily basis throughout the semester; and is key in determining the success of the program. The experience also requires a time commitment from students, many of whom may have other responsibilities, including jobs and families. However, we have found that those students who were truly interested in working with dying patients were willing to make necessary sacrifices to participate in the program.
A one-semester experience is somewhat limited, and students often end the program wanting to continue providing companionship. These students could be directed to the hospital's traditional volunteer program or provide volunteer services to a local hospice organization.
Finally, the volunteer model may be viewed as out of step when schools of nursing are expanding end-of-life content and expecting palliative care content on the NCLEX-RN® to increase. Many schools of nursing are attempting to incorporate end-of-life content in existing didactic courses; however, there is no mandate to provide a specific clinical practicum. In programs that simply do not have the time or faculty to provide this specialty clinical experience to all students, a volunteer collaborative program, such as the one described in this article, could provide the experience for those students who desire it, without significantly increasing faculty workload. Our program grew, in part, out of suggestion by students who had a desire to learn about this population and to help those who were alone or lonely during the last days or weeks of life.