April 5, 2011 — Discussions about end-of-life issues are hard for patients and families – and for health care professionals. Nurses and doctors are challenged by the complex topic, although they may routinely witness the pain, suffering and ethical issues at life's end.
To help medical and nursing students learn to address these issues with compassion and understanding, the University of Virginia's schools of Nursing and Medicine are working together to provide inter-professional programs that will foster teamwork between these future health care providers in delivering effective end-of-life clinical care and responding to patients' needs.
This year, two educational initiatives are addressing these issues: "Witnessing Suffering," organized by the School of Medicine, and "Difficult Discussions," a program that began in the School of Medicine and since 2009 is a collaborative initiative with the School of Nursing. The programs are aimed at third-year nursing and medical students who are immersed in the clinical portion of their educations.
In February, the medical and nursing students participated in the daylong workshop, "Witnessing Suffering." The project centered on dramatic readings of Sophocles' drama "Women of Trachis," which deals with human suffering and compassionate presence.
"Focusing on plays, rather than patients, empowers participants equally, momentarily suspending workplace hierarchies," said Marcia Day Childress, associate professor of medical education and director of programs in humanities in U.Va's Center for Biomedical Ethics and Humanities. Childress and colleagues developed the program based on "End of Life," a dramatic presentation developed by classicist and theater director Bryan Doerries, founder of the New York-based Theater of War Productions.
The "Witnessing Suffering" program participants included 230 nursing and medical students, chaplain residents, 15 nursing professors, 10 medical professors, eight chaplains, a lawyer, and a bereavement counselor. It was a required curriculum initiative. Doerries came from New York to moderate "End of Life," which featured local actors who had been rehearsed by College of Arts & Sciences' drama professor Betsy Tucker.
"'Witnessing Suffering' was an opportunity to develop an innovative, interdisciplinary approach to something that is not well-covered in the curriculum, and U.Va. is the first school to use ‘'End of Life' in a required course," Childress said.
First the participants worked in mixed groups of medical and nursing students sharing stories from their own clinical experiences about being a witness to suffering.
"It was useful to hear the perspectives of the nursing students and get an idea of how to use the different roles in the health care team to our advantage when approaching end-of-life conversations," medical student Diana Newsom said.
They then observed the "End of Life" dramatic presentation, followed by a discussion. Their small groups then reconvened to respond to questions related to the dramatic readings. The responses were shared with the larger group in a chorus-like presentation similar to what might be found in Greek tragedy.
"The use of Greek drama to portray suffering is brilliant," medical student Michelle Maust said. "It lends a greater sense of responsibility to the medical student not only as a caregiver, but also as a companion in suffering. It creates a connection, a sharing of humanity, between modern and ancient professionals."
Through drama, the participants learned to listen and process information in ways different from their usual classroom experiences. "The intense imaginative engagement of theater helps make health care professionals more aware of how they respond – cognitively, but also affectively, sometimes viscerally – when someone is telling them how they feel," Childress said.
For medical professionals, the focus is often on "what we can fix," Childress said. "Traditionally, the medical curriculum does not offer strategies for addressing what we call suffering, which may include emotional and spiritual distress as well as physical pain. In 'Witnessing Suffering,' we focused both on being a witness to someone's suffering and on helping students identify practical strategies for being compassionately present with suffering persons."
Maust declared the collaborative nature of the day a success. "One of the best aspects of this day was its inter-professional nature. Opportunities for medical and nursing students to discuss and learn together fosters much-needed respect and mutual appreciation," she said.
Nursing student Jamie Clair shared the sentiment. "We are expected to work together fluidly on the floor, but unfortunately, that has often been our first encounter with each other. Learning how each profession approaches a situation is invaluable and I enjoyed having the opportunity to get to know my future colleagues."
The second program, "Difficult Discussions," is a yearlong initiative that began in January and is funded by a $10,000 grant from the Oncology Nursing Society. This monthly interactive workshop for students also focuses on end-of-life issues and inter-professional collaboration with an emphasis on developing communication skills.
The program is led by an interdisciplinary team from the Nursing and Medical schools. The team includes Jeanne Erickson and Lucy Goeke, oncology nurses from the Nursing School, and Leslie Blackhall and Virginia Boothe, palliative care physicians from the School of Medicine.
At the beginning of the workshop, nursing and medical students are presented with a similar end-of-life scenario but receive differing sets of details about the situation before they are expected to interact.
"We give them two perspectives about the scenario hoping they'll realize that they have information that they need to share with each other," Erickson said.
Students volunteer to role-play the scenario. Timeouts may be called at critical points in the discussion by faculty to address a specific issue about communication, by the role players when they want some help or guidance, or by the observers when they have constructive input to share. Students rotate during the role-playing activity.
"Collaborative care is one of the most important facets of the health care system," nursing student Casey Holmes said. "Doctors and nurses are responsible for giving patients the best possible care while in the hospital, but they have to be on the same page to do so. 'Difficult Discussions' helped us to figure out our roles in palliative care discussions."
The give-and-take aspect of the workshop provides an opportunity to learn on many levels.
"Sometimes people get up and do a wonderful job, which is a reflection of their already well-developed interpersonal skills," Erickson said. "And sometimes people get in there and don't feel at all comfortable discussing a patient's declining health status or offering information to make difficult end-of-life decisions. Some students don't need content and didactic instruction; they are already compassionate and empathetic. They just need to practice those skills.
"Also, decisions are not easy to plan for and can change over the course of an illness."
Holmes said she was able to bring firsthand knowledge about the importance of good, unified communication with health care providers. "The workshop struck close to home because I have been a family member on the other side of the discussion. Seeing both sides of the conversation will definitely affect my future interactions with patients," she said.
A $49,000 grant from the Academy of Distinguished Educators, a Medical School initiative, is funding Blackhall and Erickson to hold a series of focus groups with practicing physicians and nurses in oncology and critical care. From the focus group work, they hope to develop a tool to evaluate whether the students are putting to use the communication and collaboration skills they are learning.
The observational assessment will seek to measure awareness of what collaboration looks like and how it is practiced. Questions will focus on information sharing between physicians and nurses, Erickson said: Do they each have the information the other needs to make the best plan of care, and do they share a common outcome they hope to achieve before speaking with the patient and family?
After the tool is developed, it will be refined and then used in later "Difficult Discussions" workshops. The 140 medical students and 90 nursing students in their third years and the 30 students in the clinical nurse leader program – registered nurses preparing to become leaders in nursing and health care – are required to attend one workshop during their third year.