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
am boldt and D. Tamlyn TABLE 4 Content included in death education (n = 65) Nursing Medicine United United Canada Kingdom Content % % Family needs %4647 23851878350444 821878 228218785834 Pain/symptom control Role health professional 21 78 17 74 4 Spiritual issues 17817741172 7415655836 Ethical issues 197019836100556 Hospice movement 17631983466 Cultural diversity 17631 Death anx 17631774466556 Dying with AIDs 165915653502 22 gal issues 15561774583556 Gender issues 114112520 there was a greater emphasis on the hospice movement and the topic of body image in U.K. programs. Medical programs in both countries addressed similar content, with Canadian programs placing greater emphasis on the topics of loss and grief, ethical issues, and the role of the health professional. Gender issues were reported as a content area only in the United Kingdom The specific theorists most frequ ently cited as being used by Canadian nursing programs were Kubler-Ross(52%), Aries (19%), Saunders(15%), and Engel(11%). Stress adaptation and coping theories were also identified as being used by several pro grams (15%). Can adian medical programs most frequently reported using the work of Kubler-Ross(33%). In the United Kingdom, nursing programs most often reported using the theo- retical approaches of Kubler-Ross(57%), Parkes(44%),Worden (22%), and Saunders(13%). Only one medical program in the
th e re was a g re ate r e m p h asis o n th e h o sp ic e m o vem e n t an d th e to pic of bo dy im ag e in U.K. prog ram s. Me d ical p ro gram s in both c o u n trie s ad d r e ss e d sim ilar c o n te n t, with Can ad ian p ro g ram s p lac in g g re ate r e m p h asis o n th e to p ic s o f lo ss an d g rie f, e th ic al issu e s, an d th e ro le of th e h e alth p rofe ssion al. Ge n d e r issu e s were re po rte d as a co n te n t are a o n ly in th e Un ite d Kin gdo m . Th e sp e cific th e o rists m o st fre qu e n tly c ite d as be in g u se d by Can ad ian n u rsin g p ro g ram s we r e Ku b le r-Ro ss ( 52% ) , Arie s ( 19% ) , Saun de rs ( 15%) , an d En g e l ( 11% ) . Stre ss adap tatio n an d cop in g th e orie s we re also id e n ti® e d as be in g u se d by se ve ral pro- g r am s ( 15% ) . Can ad ian m e d ic al p ro g r am s m o st fre q u e n tly r e p o rte d u sin g th e wo r k o f Ku b le r-Ro ss ( 33% ) . In th e Un ite d Kin gd o m , n ursin g p ro g ram s m o st ofte n re p o rte d u sin g th e th e ore tical ap p ro ach e s o f Ku ble r-Ro ss ( 57% ) , Park e s ( 44% ) , Wo rd e n ( 22% ) , an d Sau n d e rs ( 13% ) . O n ly o n e m e d ic al p ro g ram in th e 182 B . D o w n e-W am bold t a n d D . Ta m lyn
In tern ational Study TABLE 5 Methods for evaluating students'knowledge and attitudes(n=65) Nursing Medicine United Canada Kingdom Canada Kingdom 6) Method n % Tests 20746263500 Papers 186713572330 9%008 Clincal practice 17631252l173 Discussions 228217743501 333 Attitude measurement Death anxiety measurement 6 22 2 9 00 0 1300 U nited Kingdom reported using any specific theorists or theory; that response identified the work of Parker, Kubler-Ross, Glaser and strauss. Foucault, and elias Ethical and legal Issues The ethical and legal issues addressed in both nursing and med ical programs were strikingly similar in Canada and the United Kingdom. Euthanasia, living wills, assisted suicide, abortion, and reproductive technolo gy were issues that the majority of programs consistently included in their programs. Most respondents stated that these issues were addressed in a required or elective ethics course. Se minars, tu trials, small-group discussions, case studies, role playing, and, less often, lectures were formats that many of the programs used to discuss these ethical and legal issues Eval ation Method Table 5 provides a su mmary of the methods used for evaluating students'knowledge and attitudes. For Canadian nursing and
Un ite d Kin gd o m re p o rte d u sin g an y sp e cific th e o rists o r th e o r y; th at re sp o n s e id e n tifie d th e wo rk o f Park e r, Ku ble r-Ro ss, Glase r an d Strau ss, Fo u cault, an d Elias. E th ic a l a n d L eg a l Iss u es Th e e th ical an d le g al issu e s ad d re sse d in bo th n u rsin g an d m e dic al p ro g ram s we re strik in g ly sim ilar in Can ad a an d th e Un ite d Kin gd o m . Eu th an asia, livin g wills, assiste d suicid e , abo rtio n , an d re pro d uctive te ch n olo g y we re issue s th at th e m ajo rity o f pro gram s con siste n tly in clu d e d in th e ir p ro g ram s. Mo st re spo n de n ts state d th at th e s e issu e s we re ad d re ss e d in a re qu ire d o r e le c tive e th ic s co urse . Se m in ars, tu to rials, sm all-g ro u p d iscu ssio n s, c ase stud ie s, ro le p layin g , an d , le ss o fte n , le ctu re s we re fo rm ats th at m an y o f th e p ro g ram s use d to discuss th e se e th ical an d le g al issu e s. E v a lu a tio n M eth o d s Table 5 p ro vid e s a su m m ar y o f th e m e th o d s u se d f o r e valu atin g stu d e n ts’ k n o wle d g e an d attitu d e s. Fo r Can ad ian n u rsin g an d In ter n a tio n a l Stu d y 183
B, Dow boldt and D. Tamlyn medical programs, written tests and papers, clinical practice, and case studies were frequently used to evaluate the cognitive domain of learning. In the United Kingdom, only nursing programs used written tests or papers and cases studies, with medical programs reporting relying exclusively on clinical practice to evaluate cog ve learn ing. Methods to evaluate the affective domain of learn in nursing programs frequently included discussion and obser vation during clinical practice, and less often attitude and death anxiety measurement For medical programs, only discussion and clinical practice were reported to be used to evaluate student learning in the affective area Consistent with earlier findings from Dickin son et al. (1992) many programs used professionals from their own discipline to teach classes. Eighty-nine percent of nursing programs in Canada and 83% of nursing programs in the United Kingd om most fr quently used nursing faculty members to teach death and dying content. Similarly, 100% of the respondents from medical pro grams in Canada and the United Kingdom used medical staff most frequently Sixty-five percent of nursing schools in the U nited Kingdo and 83% of medical schools in Canada stated that they used interdisciplinary approach to death education; con versely, only 33% of Canadian nursing programs and U.K. medical programs indicated that an interdisciplinary approach was used espondents identified the benefits of an interdisciplinary approach to death education as including enhanced opportuni ties for interprofessional communication and problem solving the develop ment of broader persp ectives around theoretical and philosophical issues, the promotion of team work and collab ora ive practice, and demonstration of a holistic model of care Limitations of an interdisciplinary approach included a loss of depth and contin-uity of content, role confusion, and organiza tional and financial problems associated with using team members from diverse backgrounds
m e d ic al p ro gram s, writte n te sts an d p ape rs, c lin ical p ractice , an d case stud ie s we re fre qu e n tly use d to e valuate th e cogn itive do m ain o f le arn in g . In th e Un ite d Kin gdo m , o n ly n u rsin g p ro gram s u se d writte n te sts o r p ap e rs an d case s stu d ie s, with m e d ic al p ro g ram s re p o rtin g re lyin g e xclu sive ly o n clin ic al p ractic e to e valu ate co g - n itive le ar n in g. Me th od s to e valu ate th e affe ctive d o m ain o f le arn - in g in n ursin g p rog ram s fre qu en tly in clude d discussion an d o bser- vatio n d u rin g c lin ic al p ractice , an d le ss o fte n attitu d e an d d e ath an xie ty m e asure m e n t. For m e dical p ro gram s, o n ly discu ssio n an d c lin ic al p r ac tic e we re re p o rte d to b e u s e d to e valu ate stu d e n t le ar n in g in th e affe ctive area. P rofessio n a l B a ckgro u n d of F a cu lty Co n siste n t with e a rlie r fin d in g s fro m Dic k in so n e t al. ( 1992) , m an y p ro g ram s u se d p ro fe ssio n als fro m th e ir o wn d is c ip lin e to te ach c lasse s. Eigh ty-n in e p e rce n t o f n ursin g prog ram s in Can ad a an d 83% o f n u rsin g p ro g ram s in th e Un ite d Kin gd o m m o st fre - q u e n tly u se d n u rsin g facu lty m e m b e rs to te ach d e ath an d d yin g c o n te n t. Sim ilarly, 100% o f th e re sp o n d e n ts fro m m e d ic al p ro - g ram s in Can ad a an d th e Un ited Kin gd om use d m ed ical staff m o st fre que n tly. Sixty-five p e r c e n t o f n u rsin g sch o o ls in th e Un ite d Kin gd o m an d 83% o f m e d ic al sch o o ls in Can ad a state d th at th e y u s e d an in te rd is cip lin ar y ap p ro ach to d e ath e d u c atio n ; co n ve rs e ly, o n ly 33% o f Can ad ian n u rsin g p ro g ram s an d U.K. m e d ical p ro g ram s in d ic ate d th at an in te rd is c ip lin ar y ap p ro ach was u s e d . Re sp o n d e n ts id e n tifie d th e b e n e fits o f an in te rd is c ip lin ar y ap p ro ach to d e ath e d u catio n as in c lu d in g e n h an c e d o p p o rtu n itie s f o r in te rp ro fe ssio n al co m m u n ic atio n an d p r o b le m so lvin g , th e d e ve lop m e n t o f bro ad e r pe rsp e ctive s aro u n d th e o re tical an d p h ilo so p h ical issu e s, th e p ro m o tio n o f te am wo rk an d co llab o rative p r ac tic e , an d d e m o n str atio n o f a h o listic m o d e l o f c are . Lim itatio n s o f an in te rd isc ip lin ar y ap p r o ach in c lu d e d a lo ss o f d e p th an d co n tin -u ity o f co n te n t, ro le co n fu sio n , an d o rg an ization al an d ® n an cial problem s associate d with usin g te am m e m bers fro m d ive rse back g ro un ds. 184 B . D o w n e-W am bold t a n d D . Ta m lyn
In ational Study Future Curriculum Planning Priority areas for future curriculum planning for nursing pro Canada, 41%; United Kingdom, 43%); provision of focused clla grams were similar, as follo ws: affective /emotional issu ical experiences( Canada, 26%; U nited Kingdom, 17 %); addition or refocusing of theoretical approaches(Canada, 22%;United Kingdom, 26%); inclusion of palliative and hospice care Canada, 15%; U nited Kingdom, 17%); issues of cultural diversity Canada, 11%; United Kingdom, 9%); use of an interdiscipli nary approach( Canada, 4%; U nited Kingdom, 4%); and more formalized approach to death education( Canada, 4%;United Kingdom, 4%). Medical programs identified very few priority areas, as follo ws: affective/emotional issues(Canada, 0%; United Kingdom, 33%); focu sed clinical experience( Canada,17% United Kingdom, 0%); interdisciplin ary and more formalized approach to death education( Canada, 17%; United Kin gdom 0%); and communication skills( Canada, 0%; U nited Kin gdom, 11%) Discussion and Conclusions Most nursing and medical schools in Canada and the united Kingdom that responded to this survey included death education content in an integrated fashion throughout all years of their pro grams, and most frequently programs used professio nals from their o wn disciplines to teach death and dying content. These findings are consistent with those reported in a survey of health profession schools in the United States(Dickin son et al. 1992) Elective death education courses were more common in Canadian medical and nursing programs than in U. K programs As was found for American programs(Dickin son et al., 1992) required death education courses were rarely reported Consistent with Dickinson et al. 's (1992)findings for American programs, lectures were the most common teaching strategy reported by both medical and nursing programs in both Canada and the United Kingdom. Despite research(Hutchison Scherman, 1992; Tamlyn Caty, 1984) that poin ts to the supe
F u tu re C u r ric u lu m P la n n in g Prio rity ar e as f o r fu tu r e cu rric u lu m p lan n in g f o r n u rsin g p r o - g ram s we r e sim ilar, as f o ll o ws: af f e c tive / e m o tio n al issu e s ( Can ad a, 41% ; Un ite d Kin gd om , 43% ) ; p ro visio n o f focuse d c lin - ic al e xp e rie n c e s ( Can ad a, 26%; Un ite d Kin gd o m , 17%) ; ad d itio n o r re f o cu sin g o f th e o re tic al ap p ro ach e s ( Can ad a, 22% ; Un ite d Kin g d o m , 26 % ) ; in c lu sio n o f p all iative an d h o sp ic e c ar e ( Can ada, 15%; Un ite d Kin gd o m , 17% ) ; issu e s o f cultu ral dive rsity ( Can ad a, 11 % ; Un ite d Kin g d o m , 9% ) ; u s e o f an in te r d is c ip li- n ar y ap p ro ach ( Can ad a, 4% ; Un ite d Kin g d o m , 4% ) ; an d m o re f o rm alize d ap p r o ach to d e a th e d u c atio n ( Can ad a, 4% ; Un ite d Kin g d o m , 4% ) . Me d ic a l p r o g r am s id e n tifie d ve r y f ew p rio rity are as, as fo llows: affe ctive /e m o tio n al issu e s ( Can ada, 0%; Un ite d Kin g d o m , 33% ) ; f o c u s e d c lin ic al e x p e rie n c e ( Can ad a , 17% ; Un ite d Kin g d o m , 0% ) ; in te r d is c ip lin ar y an d m o re f o rm alize d ap p r o ach to d e ath e d u c atio n ( Can ad a, 17% ; Un ite d Kin g d o m , 0% ) ; an d co m m u n ic atio n sk ills ( Can ad a, 0%; Un ite d Kin gd o m , 11%) . Discussion and Conclusions Mo st n u rsin g an d m e d ic al sc h o o ls in Can ad a an d th e Un ite d Kin gdo m th at re sp o n d e d to th is sur ve y in clu de d d e ath e du catio n con te n t in an in te grate d fash io n th ro u gh o ut all ye ars o f th e ir p ro- g r am s, an d m o st fre q u e n tly p ro g r am s u s e d p ro fe ssio n als fro m th e ir o wn d is c ip lin e s to te ac h d e a th an d d yin g c o n te n t. Th e s e fin d in g s are co n siste n t with th o se re p o rte d in a su r ve y o f h e alth p ro f e ssio n s ch o o ls in th e Un ite d State s ( Dic k in so n e t al. 1992) . Ele c tive d e ath e d u c atio n co u rs e s we re m o re c o m m o n in Can adian m e d ical an d n u rsin g p ro g ram s th an in U.K. pro g ram s. As was f o u n d f o r Am e ric an p ro g ram s ( Dic k in so n e t a l., 1992) , re qu ire d d e ath e du catio n cou rse s we re rare ly re po rte d . Co n siste n t with Di c k in so n e t a l.’ s ( 1 992 ) fin d in g s f o r Am e ric an p ro g ram s, le c tu re s we re th e m o st co m m o n te ac h in g strate g y re p o rte d by bo th m e d ical an d n u rsin g p ro g ram s in bo th Can ad a an d th e Un ite d Kin gd o m . De sp ite re se arch ( H u tch iso n & Sch e rm an , 1992; Tam lyn & Caty, 1984) th at p o in ts to th e su p eIn ter n a tio n a l Stu d y 185
B, Dow boldt and D, Tamlyn riority of experien tially based learning to didactic approaches, here was less emphasis on role playing, journal writing, and clinical experience. Self -directed activities were more commonly reported by nursing programs, especially in the United Kingdom, where they were used by all of the programs that responded Sixteen or more topics were reported as being addressed many of which were similar to those identified as being im por tant for health education studen ts in an american study by tandy and Sexton (1985). Despite recent criticisms of the Kubler-Ross stage model of grieving, her theoretical model was identified as being used by the majority of programs. Theory-based instruc tion was not strongly evident in U.K. medical programs. Some authors have indicated that health profession programs do not incorporate theory as a foundation for the design of death edu cation programs, and th is has been identified as a significant prob lem (Durlak Riesenberg, 1991) Evaluation of cognitive learning was generally achieved through tests, Papers, discussion of clinical practice, and case stud ies, Affective ch assessed through class discu ssions and observations in the clinical area. Only selected nursing programs attempted to measure changes in attitude toward death and dying or death anxiety The findings identified eight priority for futur lu m planning that provide direction for curriculum de velopment Affective issues such as attitudes to ward death and dying and death anxiety were seen as the greatest priority for nursing pro grams. Canadian nursing programs ranked as their second prior ity the provision of focused clinical experiences. This finding i consistent with the finding that a structured clinical experience with dying individuals and their family members was provided in few programs. The addition or refocusing of theoretical approaches was the third priority identified by Canadian nursing programs and the second priority for U. K nursing programs Medical programs gave limited responses to this question, mak ing it difficult to provide any meaningful interpretation of these data here are several conclusions that can be drawn from this sur- vey of Canadian and U.K. nursing and medical programs. Many
rio rity o f e x p e rie n tially bas e d le ar n in g to d id ac tic ap p ro ach e s, th e r e was le ss e m p h asis o n r o l e p la yin g , jo u r n al writin g , an d c lin ical e xp e rie n ce . Se lf-d ire cte d ac tivitie s we re m o re co m m o n ly r e p o rte d b y n u rsin g p r o g r am s, e sp e c ia ll y in th e Un it e d Kin g d o m , wh e r e th e y we r e u s e d b y al l o f th e p r o g r am s th a t re sp o n d e d . Six te e n o r m o re to p ic s we re r e p o rte d a s b e in g ad d re ss e d , m an y o f wh ich we r e sim ilar to th o se id e n tifie d as be in g im p o rtan t fo r h e alth e du catio n stu de n ts in an Am e rican stud y by Tan dy an d Se xto n ( 1985) . De sp ite re ce n t criticism s o f th e Ku ble r-Ro ss stag e m o d e l o f g rie vin g , h e r th e o re tic al m o d e l was id e n tifie d as b e in g u se d b y th e m ajo rity o f p ro g ram s. Th e o r y-b as e d in str u c - tio n was n o t stro n g ly e vid e n t in U.K. m e d ic a l p ro g r am s. So m e au th o rs h ave in d ic ate d th at h e alth p ro fe ssio n p r o g ram s d o n o t in co rp o rate th e o r y as a fo u n d atio n fo r th e d e sign o f d e ath e d u - cation pro gram s, an d th is h as be e n ide n ti® ed as a sign i® can t p roble m ( Durlak & Rie se n be rg , 1991) . Eva lu a tio n o f c o g n itive le ar n in g was g e n e rally ach ie ve d th ro ugh te sts, p ap e rs, d iscussion of clin ical practice , an d case studie s. Affec tive ch an ge s we re asse sse d th ro ugh class d iscu ssio n s an d o bse r vatio n s in th e clin ical are a. On ly se le cte d n u rsin g p rog ram s atte m p te d to m e asure ch an g e s in attitu d e toward de ath an d d yin g o r d e ath an xie ty. Th e ® n d in g s id e n ti® e d e igh t prio rity are as for fu ture cu rriculu m p lan n in g th at p rovide d ire ctio n fo r cu rriculu m d e ve lo pm en t. Af f e c tive issu e s su ch as attitu d e s to ward d e ath an d d yin g an d d e ath an xie ty we re se e n as th e g re ate st p rio rity fo r n u rsin g p ro - g ram s. Can ad ian n ursin g p ro g ram s ran k e d as th e ir se co n d p rio rity th e p ro visio n o f f o cu s e d c lin ic al e x p e rie n c e s. Th is fin d in g is co n siste n t with th e fin d in g th at a stru ctu re d clin ical e x p e rie n c e with d yin g in d ividu als an d th e ir fam ily m e m be rs was p ro vide d in f ew p ro g ram s. Th e ad d itio n o r re f o cu sin g o f th e o re tic al app ro ach e s was th e th ird priority id e n ti® e d by Can ad ian n ursin g p r o g r am s an d th e se co n d p rio rity f o r U.K. n u rsin g p ro g ram s. Me d ic al p ro g ram s g ave lim ite d re sp o n se s to th is q u e stio n , m ak - in g it d ifficu lt to p ro vid e an y m e an in g fu l in te rp re tatio n o f th e se d ata.Th e re are seve ral con clusion s th at can be drawn fro m th is sur- ve y o f Can ad ian an d U.K. n u rsin g an d m e d ic al p ro g ram s. Man y 186 B . D o w n e-W am bold t a n d D . Ta m lyn
