Care Of The Dying.. A Positive Nursing Student Experience

Judy L. Mallory Charles L. Allen

Care of the Dying: A Positive Nursing Student Experience How a staff nurse should determine the appropriate end-of-life care experience for a nursing student, including what course work the student should have prior to the experience as well as what knowledge and support the staff nurse and student should expect from the clinical instructor, is discussed. Transformative learning theory is used as the basis for enhancing the student’s learning and can facilitate a positive endof-life care experience.

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istorically, nurses have not received extensive education on how to care for dying patients and their families (Allchin, 2006; Ferrell, Virani, Grant, Coyne, & Uman, 2000). This lack of education has been reflected in the level and quality of end-of-life (EOL) care provided to patients. Nursing EOL curricula have been lacking both in didactic education and clinical experiences. Students who by chance cared for a dying patient were unprepared and in some cases had little support from staff nurses or their clinical instructors. With the funding of the End of Life Nurse Education Consortium (ELNEC), this trend began to change (Matzo, Sherman, Sheehan, Ferrell, & Penn, 2003).

The History of Nursing Education in Relation to End-of-Life Care

Charles L. Allen, BSN, RN, is a Staff Nurse, Harris Regional Hospital, Sylva, NC.

Many nurses and nursing students have difficulty dealing with death (Brockopp, King, & Hamilton, 1991; Cooper & Barnett, 2005; Payne, Dean, & Kalus, 1998; Servaty, Krejci, & Hayslip, 1996; Thompson, 1985; Waltman & Zimmerman, 1992). In contrast, the International Council of Nurses (1997) stated that nurses have a unique and primary responsibility for ensuring that individuals at the EOL experience a peaceful death. The nursing role in EOL care has expanded in the last decade to include advanced directives, do-not-resuscitate (DNR) decisions, and palliative care discussions (Haisfield-Wolfe, 1996). The authors have noted that, because many nurses struggle with negative personal issues concerning death and dying, they are therefore uncomfortable providing care to dying patients. Examples include a recent experience with a nurse caring for a dying patient. The nurse asked one author, who was in the role of nursing instructor with hospice experience, to talk to the family about the approaching death of a patient. In another experience, the authors witnessed staff nurses avoiding an approaching death conversation with family members of a dying patient because they wanted the hospice nurse to ask for a DNR order. The nurses openly admitted discomfort in dealing with death and dying. A recent unpublished study (Connell, 2006) found that several schools of nursing do not provide effective education for nursing students on EOL care options. In another study (Ferrell et al., 2000), the majority of nurse respondents (89.5%) felt that EOL content was important to basic nursing education. However, 71% of respondents said their EOL pain management education was inadequate, 62% rated their overall content on EOL care as inadequate, and 59% rated management of other symptoms education as inadequate. The study also found that less than 35% of nurses rated their grief/bereavement support and spiritual support to patients at the EOL as effective.

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Judy L. Mallory, EdD, RN, CHPN, is an Assistant Professor of Nursing, Western Carolina University, Cullowhee, NC.

The increase in EOL awareness in the United States and other countries has prompted nursing programs to evaluate their curricula and begin to add EOL material. Studies on EOL care have included semester-long courses, 2-day seminars, and classes that last only a few hours. Education does have a positive effect on nurses’ attitudes toward care of the dying, at least in the short term (within a year of the course) (Brent, Speece, Gates, Mood, & Kaul, 19991; Degner, 1985; Durlak & Reisenberg, 1991; Frommelt, 1991; Kaye, Gracely, & Loscalzo, 1994; Lev, 1986; Mallory, 2003). Many of these studies also show that previous experience with death and a class about death and dying seem related to nurses’ and nursing students’ attitudes toward death and care of the dying. Specifically, students who have had previously positive experiences with death and dying, or a course about death and dying, have more positive attitudes. Kaye and colleagues (1994) found that participants in a death education course showed a clear decline in negative attitudes as compared with the control group. Lev’s (1986) study indicated that an elective course in hospice nursing was effective in decreasing subjects’ negative attitudes toward death and dying and avoidance behaviors. Frommelt (1991) stated “the only demographic variable which proved to have a significant effect on the nurses’ attitudes toward caring for the terminally ill was having taken a specific course on death and dying previously (F prob=0.04)” (p. 41). Mallory (2003) noted that nursing students’ attitudes toward care of the dying improved with course work and clinical experience in care of the dying. Yeaworth, Kapp, and Winget (1974) assessed nursing students’ attitudes toward death and dying. Comparing freshman nursing students to senior nursing students, they found that senior nursing students had greater feelings of acceptance, more open communication, and were less likely to

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stereotype attitudes. They also found that freshman nursing students were more likely to rely on religious beliefs to cope with death anxiety. Others found that individuals with more death education and death experience have more positive attitudes toward death and dying (Gesser, Wong, & Reker, 1987). Thompson (1985) noted that more experience leads to less anxiety about dying and positive attitudes toward caring. Experienced nurses were more willing to share feelings and attitudes, and view the dying patient as a patient first and as a dying person second. Franke and Durlak (1990) found death of a significant other to be the highest life experience to affect attitudes toward death; religion was the next highest, with near-death experience as third. Individuals with strong intrinsic religious beliefs tend to report less death anxiety according to Waltman and Zimmerman (1992), who found that nurses who had experienced the death of a close family member in the previous 2 years were significantly more likely to provide continuing care for bereaved family members than those who had not. Alvarado, Templer, Bresler, and ThomasDobson (1995) found that strong religious convictions and a belief in an afterlife were associated with less death anxiety. DavisBerman (1998) looked at attitudes toward aging and death. Contrary to her expectation, she found that after a course on aging, students’ attitudes toward death did not improve. Allchin (2006) found that students associated caring for the dying with discomfort, anxiety, and sadness; however, they felt the course was beneficial overall and necessary to become a nurse.

Theoretical Framework Research has indicated that nursing students’ exposure to a positive death experience in a supportive atmosphere would allow improved attitudes toward death and dying. These guidelines are based upon Transformative Learning Theory, which

involves the transformation of an individual’s beliefs, ideas, and views. Nursing faculty and staff can create an atmosphere in which learners are encouraged to evaluate their beliefs and views through self-reflection. Change occurs as learners incorporate their new learning into their belief system and transform or reject their old beliefs. Nursing faculty and staff can facilitate transformative learning through use of a variety of education experiences and teachable moments. Care of dying patients and their families lends itself readily to Transformative Learning Theory. Allchin (2006) found that when nursing students reflected on their experiences with dying patients they combined their own personal experiences with grief, loss, and death, with their clinical experiences and found the clinical experience to be of value. Palliative care at the end of life is an example of a subject through which an adult learner could have a transformative learning experience. As the educator and learner explore palliative care issues for EOL care, strongly held views may be reaffirmed or challenged. New information is learned and, after reflection, previously held beliefs may be challenged or changed. Transformative learning brings about change within persons that is significant to their beliefs and thought processes. Habermas (1971) discussed three domains of knowledge in relation to transformative learning. Technical knowledge is related to cause and effect, practical knowledge pertains to understanding what others mean, and emancipatory knowledge involves critical selfreflection. Cranton (1994) noted that emancipatory knowledge is a process of removing constraints and being free of forces that limit options and control lives. Transformative learning is primarily emancipatory knowledge “gained through critical self reflection, as distinct from the knowledge gained from our ‘technical’ interest in the objective world or our ‘practical’ interest in

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social relationships” (Mezirow, 1991, p. 87). Cranton (1994) expressed the importance of emancipatory knowledge when she stated, “If we view education as the means by which individuals and societies are shaped and changed, fostering emancipatory learning is the central goal of adult education” (p. 19). The suggestions in this article are based upon the few studies related to the topic as well as the experiences of the authors in working with nursing students and staff nurses to provide positive clinical experiences in the care of dying patients. The goal is to encourage staff nurses to choose clinical experiences for nursing students that allow them to apply their knowledge of EOL care and to foster critical selfreflection and personal growth in their attitudes toward care of the dying.

Staff Nurses’ Role in Assigning Care of Dying Patients A staff nurse can facilitate a positive experience for a nursing student in caring for a dying patient by being friendly, showing interest in the student, and making himself or herself available to answer questions (Jackson & Mannix, 2001). The uniqueness of caring for a dying patient requires that the staff nurse assess the knowledge and experience of both the faculty and nursing student who will be involved in the patient’s care (see Table 1). The staff nurse must recognize that the student may feel tentative and even fearful of caring for a dying patient. The staff nurse should show understanding of these feelings and be available to the student (Jackson & Mannix, 2001). Allchin (2006) reported that students who cared for dying patients found that “a significant benefit of the experience of providing care for a dying person was the support and presence of the clinical instructor and the staff nurse” (p. 115). Part of showing interest in working with a nursing student caring for a dying patient is to give the student a degree of responsibility with the

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Table 1. The Role of the Staff Nurse • Encourage and support the student. • Provide a detailed report to student at the beginning of the shift. This should be accomplished before the student enters the patient’s room and should include: • Diagnosis • Progression of illness • Palliative needs and treatments • Psychosocial needs • Spiritual needs • Include family members and who is present in the room • What the student will encounter • The patient’s general appearance and mental status • Any unpleasant symptoms • Any unusual or potentially uncomfortable family dynamics • Any invasive treatments • Other patient care team members if applicable • CNA • Chaplain • PT • OT • Speech • Dietary • Social worker • Introduce student and faculty member to patient and family, and explain student’s role in caring for patient. • Provide student with suggestions of ways to interact with patient and family. • Suggest palliative measures which student can initiate. • Emphasize the importance of the role of “nurturing presence” in nursing. • Provide opportunity to role play difficult conversations. • Encourage student to identify any additional patient needs and suggest further interventions or consults if applicable. • Provide follow-up de-briefing, and give feedback to student and faculty member about clinical experience.

patient in accordance to his or her own knowledge and experience. If the student is a firstsemester student with little clinical experience, he or she may only help turn the patient, provide personal care, and sit with the family at the bedside. Students with more advanced experience and communication skills may administer analgesics, provide alternative comfort measures, discuss approaching death with the family, and possibly advocate to the physician for palliative measures. Explaining is also an important staff nurse behavior (Jackson & Mannix, 2001). The nurse should ensure that the student understands the needs of the patient and the reasons for prescribed care and treatment. Explaining also will foster transformative learning. As the stu-

dent gains new knowledge and experiences the challenges and rewards of caring for dying patients, attitudes will be changed and he or she will have the opportunity for emancipation. Policies regarding palliative care and postmortem care should be explained. Explaining empowers the student to locate information independently after explanation and thus develop a level of independence. The authors found that students feel degraded and fearful of caring for dying patients after having a negative clinical experience. Behaviors that can cause the student to have a negative clinical experience with EOL care include working with a nurse who ignores him or her, treats the student with contempt, or as though it is not the nurse’s responsibility to help educate or socialize him

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or her in the care of the dying patient. The student should not be sent into a dying patient’s room alone for the first time, but should be accompanied by the staff nurse or the clinical instructor. As part of the assessment, signs of approaching death should be noted for later discussion and as a baseline for progression toward death. Staff nurses and faculty should serve as role models in the care of the dying patient and the patient’s family. The authors believe ensuring that the patient is comfortable and dying in the manner in which he or she wishes to die should be preeminent in their care. Nursing staff and faculty should initiate an analytical discussion with the student on patients’ choices regarding dying (Schirm & Sheehan, 2005). This discussion should include advance directives, heroic measures, comfort measures, and patient autonomy. Research has revealed critical nursing behaviors in the care of the dying (de Araujo, da Silva, & Francisco, 2004; Degner, Gow, & Thompson, 1991): • Responding during the death scene • Providing comfort • Responding to anger • Enhancing personal growth • Responding to colleagues • Enhancing the quality of life during dying • Responding to the family. These behaviors were based upon the knowledge of 10 palliative care nurses and 10 nurse educators who described situations in which nurses displayed positive or negative attitudes in care for the dying. DeAraujo et al. (2004) found similar results in their qualitative study about essential elements in care of the dying. Staff nurses and faculty should emphasize these critical behaviors and model them for the student. During the time the student is caring for a dying patient and his or her family, the staff nurse and faculty should allow opportunities for the student to talk about the experience in order to offer

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self-reflection. Also the student should be given the opportunity for role-play before entering the room to allow him or her to experience a difficult conversation in the safe environment of a roleplay situation (Marchand & Kushner, 2004).

The Staff Nurse Role in Working with Clinical Faculty Members The staff nurse should be familiar with the faculty member’s experiences and knowledge of caring for dying patients and their families. The faculty member should discuss the experiences and education of the student in regard to death and dying and communicating with patients and families. Faculty members should have a background or special training in end-of-life care. Faculty from many nursing programs in the United States have had an opportunity to learn how to teach an EOL curriculum through the ELNEC (Ferrell et al., 2005). Faculty should have special knowledge in communication, symptom management, ethics, pharmacology, approaching death, and bereavement care. Prior to taking nursing students into the clinical setting, the faculty member should have spent time dealing with personal feelings related to death and dying. The staff nurse should assess the level of support the faculty member will be able to give the student during the clinical experience. A student nurse providing one-on-one care to a dying patient and family can be an incredible asset to the staff nurse. In the authors’ experience, a nursing student who is comfortable with the dying experience can spend extra time with the dying patient and family. Authors have encouraged students to model for the family touching the patient and talking to the patient. When appropriate, the student can initiate a conversation of reminiscing about the patient (Cappeliez, O’Rourke, & Chaudhury, 2005). This is not a time for the student to talk about himself or herself; the student also should take cues from family members as to

whether they would like to talk or be silent. Both silence and the student’s presence are very powerful. If the student is not prepared or the faculty member is not supportive, the student nurse may create a burden in an already challenging situation. A time of processing is important for the nursing student who has cared for a dying patient. Both listening and providing guided reflection on the thoughts and feelings of the experience, along with any personal experience that may be associated, are important to the process (Allchin, 2006). The faculty member should be available for days to weeks after the experience to discuss and follow up. For some students, the process may take a long time and experiences may build upon each other. Allchin (2006) suggests having a weekly “open house” set aside for students to review clinical experiences and to read. The role of the staff nurse is of key importance to a positive experience for both the dying patient and the student. The staff nurse should be sensitive to and understand both the needs of the dying patient and the potential experience of the student. As the staff nurse allows nursing students to care for a dying patient, the nurse will affect the attitudes of the next generation of practitioners regarding care of the dying.

Case Study Jennalee is a 20-year-old firstsemester student in a nursing program that makes end-of-life education a priority. Jennalee expresses apprehension at the thought of death in general and caring for a dying patient in particular. As part of the nursing curriculum, students go to a funeral home and investigate services and costs. They also spend a day at a hospice, observing the care of dying patients and the role of the hospice nurse. Students also must go to the cadaver lab. Classroom lectures include “Communication,” “Approaching Death,” “Grief,” “Culture,” “Palliative

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Care,” and “Death and Postmortem Care.” Nursing faculty work closely with the nursing staff at the local hospital to build rapport and establish knowledge and expertise in EOL care. All the nursing staff who work with nursing students are educated in palliative care. Nurses who enjoy working with nursing students are chosen to work with students in caring for dying patients. Jennalee is assigned to care for Bessie Baldwin, an 89-year-old patient with end-stage congestive heart failure and a systemic blood infection. Bessie has supportive family members who are eager to ensure that Bessie gets the best care possible. When Jennalee comes to preplan her care for Bessie, she meets with Charles, a palliative care nurse who regularly cares for dying patients, who gives her a report on Bessie’s current status including diagnosis, prognosis, progression of illness, palliative needs and treatments, psychosocial needs, and spiritual needs. He prepares Jennalee to see Bessie in her premorbid state. She is breathing very shallowly, with intermittent apnea, and has a coarse rattle. She is pale and unresponsive to stimuli. Her extremities are cold and her nail beds are blue. Charles briefs Jennalee on her role as caregiver to Bessie and her family, emphasizing the importance of comfort measures and providing care for the family. Prior to entering the patient’s room, Charles discusses the opportunity to model care of the dying patient to the family. He encourages Jennalee to do such things as touch Bessie, talk directly to her, and avoid talking over her to others in the room. Jennalee expresses concern to Charles that the family might ask her questions that she can’t answer: How much longer does Bessie have to live? Why is God allowing this to take so long? Charles offers to spend a few minutes role playing these two scenarios with Jennalee. She plays the family member with questions and Charles plays the role of the nursing student. Charles and Jennalee discuss possible

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answers to the questions before Jennalee enters the patient’s room. When Jennalee enters the room, she notes that Bessie’s great-granddaughter is sitting next to the patient, holding her hand and crying. Bessie’s son asks Jennalee if she agrees that Bessie should not be getting fluids. He accuses the medical staff of starving his mother; he raises his voice, then is quieted quickly by his wife who apologizes to Jennalee for his behavior. Jennalee does not respond to the son’s anger, but rather initiates a discussion with the granddaughter about her grandmother.

Jennalee asks the granddaughter to tell her something special about her grandmother, and they talk for a few minutes. Jennalee monitors Bessie’s pulse and respirations, notifying Charles that respirations have decreased to 6 per minute and they are very shallow. Bessie is mottled to her thighs and is not responding to any stimuli. Charles lets Jennalee know that she is doing a good job and encourages her to continue being present with the family. Jennalee is with them when Bessie dies. Bessie takes one long, deep breath, then does not breathe again. Jennalee is able to

Students Share Education and Experiences Two nursing students who were part of a nursing education program based upon the ELNEC initiative expressed the following about their education and experiences. “I feel like it is an honor to be in the presence of a dying person, especially when it was my parent. Because of the death and dying focus in my nursing school curriculum, the support of my professor, and the service hospice offers, it made caring for my dying parents a reality. The time I was able to spend with them was and is so valuable. Being able to be present and attentive to their needs at this very special time in life was therapeutic for me. I see people in the hospital visiting their loved ones with such despair in their eyes because they just don’t know what to do, how they can help this person that they’ve been helping for so many years. People feel so helpless in the foreign environment of a hospital and forget that it’s the small things, talking to the person, holding their hand, praying with them, or swabbing their mouth, that makes all the difference. The information and experiences I gained during nursing school along with my parents’ request to be at home when they died empowered me to make decisions that challenged me to care for my parents at home. I can’t say that caring for a dying parent is easy, but I can say that having this experience facilitates the healing process. I had time to laugh with, read to, sit quietly with, lay with, cry with, and pray with my mom and dad in the privacy of our home. The smells of the home, the sounds of the piano, children playing in another room, adults talking or soft music from the radio were all familiar and comforting to both the dying and the caretaker. Ours were sweet and perfect passings, and for that we are thankful. Since my brother and I have both been with, cared for, and prayed with our dying parents, I have become more attentive as a nurse to make suggestions to family members when they visit their loved ones. I try to help them become more comfortable touching their loved one who often looks to be locked away in a bed with rails too high for comfort. Recently I engaged a wife in the process of cleaning her husband’s burnt face. She had the most tender touches and was patient with progress, but it seemed she took the task almost gratefully after having spent a week or more feeling helpless. Needless to say, care for a loved one certainly assisted in the emotional healing of the husband.” A second student said, “Without your lectures, my grandmother would have died in the hospital last September after being diagnosed and reaching death in only 1 month of ovarian cancer. My mom and her sister didn’t want to deal with my grandmom dying at home despite that she said she wanted to die at home. She lived independently in Hanover, New Hampshire, at the age of 85 and was a real strong woman. I flew up during my weekends (I happened to be in my oncology rotation) to NH and was able to get my mom and aunts to meet with the hospice folks and social workers, and she was able to go home. My mom lived the closest in Connecticut, but no one wanted to deal with this home death and without your lecture on hospice, I would not have known how to help my grandmother die with dignity.”

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comfort the family and confirm with Charles that Bessie is in fact dead. After the family has said their goodbyes, Jennalee provides postmortem care for Bessie. Charles and the faculty member take time to allow Jennalee to discuss her thoughts and feelings about the experience. They encourage self-reflection. Questions 1. What critical nursing behaviors in the care of the dying did Jennalee provide? 2. How did Charles ensure that Jennalee and Bessie had a positive death experience? 3. In what ways did Charles and the nursing faculty members facilitate Transformative Learning Theory? ■ References Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice and Palliative Nursing, 8(2), 112-117. Alvarado, K.A., Templer, D.I., Bresler, C., & Thomas-Dobson, S. (1995). The relationship of religious variables to death depression and death anxiety. Journal of Clinical Psychology, 51, 202-204 Brent, S.B., Speece, M.W., Gates, M.F., Mood, D., & Kaul, M. (1991). The contribution of death-related experiences to health care providers’ attitudes toward dying patients: I. Graduate and undergraduate nursing students. OMEGA, 23(4), 249-278. Brockopp, D.Y., King, D.B., & Hamilton, J.E. (1991). The dying patient: A comparative study of nurse caregiver characteristics. Death Studies, 15, 245-258. Cappeliez, P., O’Rourke, N., & Chaudhury, H. (2005). Function of reminiscence and mental health later in life. Aging and Mental Health, 9(4), 295-301. Connell, B. (2006). Advance directives: Curriculum content and preparation of nursing students. Unpublished research project. Cooper, J., & Barnett, M. (2005). Aspects of caring for dying patients which cause anxiety to first year student nurses. International Journal of Palliative Nursing, 11(8), 423-430. Cranton, P. (1994). Understanding and promoting transformative learning: A guide for educators of adults. San Francisco: Jossey-Bass. Davis-Berman, J. (1998). Attitudes toward aging and death anxiety: Aging and death class. OMEGA, 38(1), 59-64. deAraujo, M.M.T., Da Silva, M.J.P., & Francisco, M.C.B. (2004). Nursing the dying: Essential elements in the care of terminally ill patients. International Council of Nurses, International Nursing Review, 51, 149-158. Degner, L.F., Gow, C.M., & Thompson, L.A. (1991). Critical nursing behaviors in

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care for the dying. Cancer Nursing, 14(5), 246-253. Degner, L.F. (1985). The effect of an undergraduate nursing course in palliative care on death anxiety and attitudes to care of the dying nursing students. (Doctoral dissertation, University of Michigan, 1985). Dissertation Abstracts International, 46, 11B Durlak, J.A., & Reisenberg, L.A. (1991). The impact of death education. Death Studies, 15, 39-58. Ferrell, B., Virani, R., Grant, M., Coyne, P., & Uman, G. (2000). Dignity in dying. Nursing Management, 31(9), 52-57. Ferrell, B.R., Virani, R., Grant, M., Rhome, A., Malloy, P., Bednash, G., et al. (2005). Evaluation of the end-of-life Nursing Education Consortium undergraduate faculty training program. Journal of Palliative Medicine, 8(1), 107-114. Franke, K.J., & Durlak, J.A. (1990). Impact of life factors upon attitudes toward death. OMEGA, 21(1), 41-49. Frommelt, K.H.M. (1991). The effects of death education on nurses’ attitudes toward caring for terminally ill persons and their families. The American Journal of Hospice and Palliative Care, 8(5), 37-43. Gesser, G., Wong, P.T.P., & Reker, G.T. (1987). Death attitudes across the life span: The development and validation of the death attitude profile (DAP). OMEGA, 18(2), 113-128. Habermas, J. (1971). Knowledge and human interests. Boston: Beacon Press. Haisfield-Wolfe, M.E. (1996). End-of-life care: Evolution of the nurse’s role. Oncology Nursing Forum, 23(6), 931935. International Council of Nurses. (1997). Basic principles of nursing care. Washington, DC: American Nurses Publishing. Jackson, D., & Mannix, J. (2001). Clinical nurses as teachers: Insights from students of nursing in their first semester of study. Journal of Clinical Nursing, 10(2), 270-277. Kaye, J., Gracely, E., & Loscalzo, G. (1994). Changes in students’ attitudes following a course on death and dying: A controlled comparison. Journal of Cancer Education, 9, 77-81. Lev, E.L. (1986). An elective course in hospice nursing. Oncology Nursing Forum, 8(1), 151-154. Lockard, B.E. (1989). Immediate, residual, and long-term effects of death education instructional unit on the death anxiety level of nursing students. Death Studies, 13, 137-159. Mallory, J.L. (2003). Assessing undergraduate nursing student’s attitudes toward care of the dying. Journal of Professional Nursing, 19, 305-312. Marchand, L., & Kushner, K. (2004). Death pronouncements: Using the teachable moment in end-of-life care residency training. Journal of Palliative Medicine, 7(1), 80-84. Matzo, M.L., Sherman, D.W., Sheehan, D.C., Ferrell, B.R., & Penn, B. (2003). Teaching strategies from the ELNEC

curriculum. Nursing Education Perspectives, 24(4), 177-183. Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco: Jossey-Bass. Payne, S.A., Dean, S.J., & Kalus, C. (1998). A comparative study of death anxiety in hospice and emergency nurses. Journal of Advanced Nursing, 28(4), 700-706. Schirm, V., & Sheehan, D.K. (2005). Conversations about choices for endof-life care: Knowing and understanding preferences. Journal of Hospice and Palliative Nursing, 7(2), 91-97. Servaty, H.L., Krejci, M.J., & Hayslip, B., Jr. (1996). Relationships among death anxiety, communication apprehension with the dying, and empathy in those seeking occupations as nurses and physicians. Death Studies. 20, 149161. Thompson, E.H., Jr. (1985). Palliative and curative care nurses’ attitudes toward dying and death in the hospital setting. OMEGA, 16(3), 233-242. Waltman, N.L., & Zimmerman, L. (1992). Variations among nurses in behavioral intentions toward the dying, The Hospice Journal, 7(4), 37-49. Yeaworth, R.C., Kapp, R.T., & Winget, C. (1974). Attitudes of nursing students toward the dying patient. Nursing Research, 23(1), 20-24.

Nursing Pharmacology continued from page 246 Sharp, L.K., & Lipsky, M.S. (2002). Screening for depression across the lifespan: A review of measures for use in primary care settings. American Family Physician, 66(6), 1001-1008. Shelton, R.C., Simon, G.E., Stahl, S.M., Treisman, G.J., & Williams, J.W. (1999, August 15). Fine-tuning the treatment of depression. Patient Care, 181-197. Sondergard, L., Kvist, K., Andersen, P.K., & Kessing, L.V. (in press). Do antidepressants precipitate youth suicide? A nationwide pharmacoepidemiological study. European Child-Adolescent Psychiatry. Stong, C. (2005). Celebrities join campaign trail against depression. Retrieved April 21, 2006, from http://www.neuropsychiatry reviews.com/jun05/celebritydepression. html Wagner, K.D. (1998). Childhood depression: Its time has come. Psychiatric Times, 17(12), 54. Whooley, M.A., & Simon, G.E. (2000). Managing depression in medical outpatients. New England Journal of Medicine, 343(26), 1942-1950. Wysowski, D.K., Beitz, J., Jick, S.S., & Vasilakis-Scaramozza, C. (2001). Methodological limitations of the study Isotretinoin use and risk of depression, psychotic symptoms, suicide, and attempted suicide. Archives of Dermatology, 137, 1102-1103.

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