Interdisciplinary Education in End-of-Life Care: Creating New Opportunities for Social Work, Nursing, and Clinical Pastoral Education Students

Abstract

This article describes an interdisciplinary, interuniversity program that prepares social work, nursing, and chaplaincy students for competent practice when working with individuals and families facing end-of-life circumstances. Built upon a teaching format that provides knowledge-to-skill-building opportunities, the program immerses students in a range of related content. To maximize integration, the program relies on interdisciplinary team teaching (building knowledge) followed by practice sessions (building skill), in which volunteer actors play the roles of care recipients. With year 3 completed, program administrators have important indicators of the program's effectiveness in offering content specific to end-of-life care using a combination of discipline-specific and interdisciplinary learning strategies. This process has provided valuable lessons related to the nature of interdisciplinary education in end-of-life care.

KEYWORDS:

• clinical pastoral education
• end-of-life
• interdisciplinary
• interuniversity
• knowledge-to-skill-building
• nursing
• seminars
• social work

Contemporary changes in the demographics of our population, changes in medical technology, and subsequent health and social service provision needs are resulting in increasing complexities for families facing life-limiting circumstances or terminal illness. Frontline professional caregivers have a particular need for fluency and greater competence in dealing effectively with complex issues such as loss and grief, family dynamics, and difficult or confusing treatment options. This competence requires knowledge and skills tied to one's own professional role, as well as skills in maximizing the roles and resources of other disciplines involved in care.

Many traditional educational strategies for social work, nursing, medical, and clinical pastoral educational (CPE) programs have tended to operate in a silo-type manner. Disciplines educate their own, but do not embrace the critical function of interdisciplinary learning as a pathway for developing a strong knowledge and skill base. This approach to professional education tends to further entrench the current health care culture and consequences of professionals' limited understanding of the benefits of interdisciplinary health care and skills needed to function effectively within a team model of health care (Pietroni, 1994, as cited in Cooper, Carlisle, Gibbs, & Watkins, 2001). Even when acknowledging the need for change in academic preparation, educators find that the search for effective educational strategies within the hierarchical nature of education and health care provision is a challenging path. In light of these changing needs in health care and existing norms in higher education, those responsible for the preparation of future professionals who will be caring for people facing end-of-life matters are confronted with a daunting task: to create educational strategies that meet the knowledge and skill needs within existing academic structures and curricula norms.

What follows is a brief review of the situation of care and educational preparation among primary health care professions. Accompanying this is an examination of how one interdisciplinary, interuniversity educational approach developed and implemented in South Carolina, is working to make a difference in the academic preparation of social work, nursing, and CPE students in end-of-life care education within an interdisciplinary learning environment.

THE SITUATION

A series of studies and reports during the 1990s brought to the forefront the critical need for social work, nursing, physician, and CPE programs to develop and implement specific knowledge and skill-building strategies in end-of-life care. Four studies in particular shattered the illusion that existing educational and practice norms/strategies were meeting the needs of those facing life-limiting and terminal illness. The 1995 Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), considered a landmark study of care of the dying in America, brought to light alarming deficiencies in the way people have been cared for as they are dying. This longitudinal study revealed the challenges of attempting to train health care practitioners for greater competence in communication care strategies. Significant to this study was the strong take-home message related to the absence of educational content and need for greater curricular focus on knowledge and skill development in order to prepare future practitioners to provide care (SUPPORT, 1995).

In 1997, the Institute of Medicine (IOM) released Approaching Death: Improving Care at the End-of-Life. This report further revealed the alarming conditions of care nationwide. Descriptions of practice deficiencies were accompanied by an examination of educational preparation related to end-of-life care among medical, nursing, and social work schools. This report echoed the concerns identified in SUPPORT related to the lack of educational and field preparation needed to prepare these future practitioners to responsibly address the end-of-life and palliative care needs of their dying patients (Gelband, 2001).

In 1997, Last Acts, a national advocacy and educational organization, created a task force on palliative care. Discoveries that had been revealed in previous studies formed the foundation of the task force's work. The result was the development of the “gold standards” of palliative care. The document, A Vision for Better Care at the End-of-life: Five Principles of Palliative Care, emphasized the need for comprehensive, person-centered care, appropriate response to caregiver concerns, development of systems of care that create sustainable mechanisms of support, and strong interdisciplinary teams of care. Following the creation of this document, Last Acts followed with a study in 2002 of existing health care situations across the United States using a report card format along eight critical care provision areas. This report, Means to a Better End, set off yet another alarm related to the need for educational preparation for health care providers in order to better address pain and symptom management, psychosocial, and informed consent issues related to care options (Last Acts, 2002).

Disciplines Respond

Mounting evidence of the discrepancy between need and preparation has facilitated increasing levels of responsibility and ownership among professionals. With the help and support of national end-of-life care and discipline-specific organizations, several comprehensive professional development curriculum programs have been developed. Most notable are the large-scale professional development efforts such as the Education for Physicians in End-of-Life Care Program (EPEC), that originated in 1999; the End of Life Nursing Education Consortium (ELNEC), that originated in 2001; and the launching in 2004 of the National Association of Social Workers web-based course, titled, “End of Life Care: The Social Worker's Role.” The Project on Death in America created mechanisms for physician, nursing, and social work professionals and educators to develop specialized expertise in end-of-life matters in order to positively influence a culture change in care across the continuum. For example, the Social Work Development Leadership Award Program targeted activities related to creating innovative training projects based in partnerships between academia and community service providers (Aulino & Foley, 2001).

Progress has been made, yet the effort to bring this content focus into academic environments across disciplines remains a struggle. In a study looking at interdisciplinary education and teamwork in health care, Hall and Weaver (2001) noted that while there is an abundance of literature on this topic, certain contemporary realities significantly influence the transition from recognized need to development and implementation of suitable programs within academic environments. Essentially they remind us that given the context of current preparation environments, most of which emphasize specialization, the process of attracting administrative and student investment in interdisciplinary learning environments remain extremely difficult.

A Closer Look at Current Educational Situations

Schools of medicine, social work, nursing, and CPE programs have engaged in research into the status of their respective discipline's academic preparation-readiness. For example, from 1997 to 2000, the City of Hope National Medical Center in New York City conducted a program titled, Strengthening Nursing Education to Improve End-of-life Care. This program revealed major deficiencies among nursing education programs, including lack of content in nursing texts related to end-of-life care, limited course content, and inadequacy of nursing faculty knowledge related to end-of-life content (American Association of Colleges of Nursing, 2000).

Education within CPE programs has a rich history of embracing collaborative care strategies, yet with mixed results in terms of interdisciplinary practice skills. Wittenberg-Lyles, Parker-Oliver, Demiris, Baldwin, and Regehr (2008) examined the role of chaplains in interdisciplinary team collaboration. This study supported previous findings that the professional role of the chaplain was not clearly understood within settings involving multiple professional disciplines. Chaplains reported confusion and blurring of role identities with other disciplines, a problem that chaplains thought was compounded by their own limited educational exposure to skill development in interdisciplinary care strategies.

Social work also has struggled to de educational preparation related to end-of-life care. Studies by Kovacs and Bronstein (1999) and Christ and Sormanti (1999) highlighted the perceived level of educational preparedness and practice competence in end-of-life care among social work practitioners. In these studies, social workers expressed concern that the lack of or limited educational focus on practice knowledge and skills contributed to their limited competence in providing care to individuals and families facing the end of life. Christ and Sormanti also surveyed 35 faculty members from 30 schools of social work about end-of-life content and research in their own course teaching, and within their particular academic programs. Consistently, faculty reported that content specific to end-of-life matters was limited to one or two lectures in HBSE (human behavior in the social environment), policy, and practice courses. Only one fourth of the survey participants believed their schools adequately prepared students for practice in this area of care. More recently, the difficulties of shifting educational norms in social work education to support infusion of relevant material were highlighted in a study by Kramer, Pacourek, and Hovland-Scafe (2003), in which content related to end-of-life care was examined in 50 social work textbooks. Ten areas considered essential for competent social work practice in end-of-life care were used for the content and quantitative data analyses. The results revealed that content on end-of-life care comprised 3.35% of the total text, or 651 out of 19,377 total pages.

As unsettling as this picture may seem, there is a growing energy around the possibilities of creating reasonable next steps that allow for interdisciplinary learning strategies in end-of-life care within existing educational systems. Schools of medicine, nursing, and social work, and CPE programs are paying attention and responding with heightened content focus and course electives specific to the end of life. Along with this heightened energy, there is also a growing awareness related to the inherent pitfalls of such endeavors. Cooper and colleagues (2001) examined literature on existing interdisciplinary learning among undergraduate health care programs and found that while there are notable efforts being made in various disciplines, there remains a wide range of interpretation of suitable content and delivery of educational strategies. Predominant concerns are associated with discipline turf issues, traditional discipline-specific priorities, hierarchy-based influences, the timing of exposure to content, inconsistencies in content focus, and faculty preparation for providing such educational content (Hall & Weaver, 2001). So the question remains, what is the most reasonable next step to promote competence among the multiple disciplines involved in the provision of end-of-life care?

POINT OF ENTRY IN THE CAROLINAS

In the 2002 Last Acts report, Means to a Better End, South and North Carolina (the Carolinas) were ranked as poorly prepared in the area of training and preparation of health care professionals in palliative and end-of-life care (Last Acts, 2002). In response to this report, The Carolinas Center for Hospice and End-of-Life Care (Carolinas Center)—a two-state trade organization for hospice and palliative care providers—partnered with The Center for Child and Family Studies, College of Social Work, at the University of South Carolina to discuss and develop a strategy for action. Those early discussions led to two broad questions: (a) What currently existed in terms of educational and professional development strategies specific to knowledge and skill development in interdisciplinary strategies for end-of-life care; and (b) Where was the most beneficial starting point in addressing any identified gaps? Operating from the premise of starting where the client is, it became immediately apparent that any strategies must be developed through a collaborative effort among educators and practitioners within the two-state area. Given this, a two-phase strategy was developed.

NEEDS ASSESSMENT

In an effort to pursue answers to those two questions, and to begin the process of gaining support for any development of response efforts, a needs assessment was conducted in 2005 with health care disciplines across the Carolinas. Sixty social work, nursing, CPE, and physician educators and practitioners were asked about their knowledge of and experiences with existing educational and professional development opportunities within their disciplines specific to end-of-life and interdisciplinary care. Responses were overwhelmingly consistent with previously mentioned larger scale national studies. Across disciplines, respondents identified the lack of proper educational preparation as the key contributor in their struggles to develop and manage responsive biopsychosocial care provision. There was also speculation among respondents that this lack of educational preparation (and subsequent job frustrations) serves as a key factor in job retention struggles and in early job burnout (Carolinas Center, 2005). Specifically, faculty involved with schools of medicine in the Carolinas reported that academic curricula exposure in this arena is limited by the prescriptive nature of medical education and the profession's philosophical mindset. There was an awareness of the discrepancies in preparation and need. Yet, a sense also existed of resignation to the existing educational structure and its limitations.

A consensus among nurses and nursing faculty respondents was revealed regarding the limited academic content related to end-of-life and interdisciplinary care significantly that may then negatively influence practice competence within health care systems across the Carolinas (Carolinas Center, 2005). When asked about implications of the limited attention to relevant content, nursing respondents clearly identified poor retention of nurses in practice settings that had a high degree of exposure to critical care situations as a significant and damaging consequence.

CPE programs across the Carolinas revealed a similar pattern of fragmented exposure to interdisciplinary knowledge and skill building opportunities related to end-of-life care. According to respondents, turf struggles are often seen, especially between chaplains and social workers. The concerns expressed related to the frequent expectation among other disciplines that the chaplain's role is either limited to prayer or is too undefined and blurred to be of much benefit (Carolinas Center, 2005).

While faculty members in master's level social work programs in the Carolinas often apologetically reported no better effectiveness in bringing exposure to end-of-life care into course work, they also expressed a sense of urgency for social work education to take an active role in managing change efforts, and a sense of frustration that it has not occurred. Social work practitioners were the most vocal among the respondents in their dissatisfaction with social work educators not taking initiative in creating mechanisms for better academic exposure.

Among the most pointed themes that surfaced during this needs assessment was the overwhelming sense of frustration reported by many faculty respondents across disciplines related to the limited avenues for inclusion of adequate content. Primary reasons for the disconnect between awareness and response included the reality that core curricula demands much and leaves little room for infusion of suitable content. As several faculty members shared, “Tell us what to take out of existing required curricula, so we can add suitable end-of-life content…we know it is important, but we have to live within the boundaries of what is mandated by our accrediting bodies and the finite amount of time and space we have to meet those core requirements” (Carolinas Center, 2005). In the midst of their frustration was the recognition of responsibility. The consensus among respondents was that focusing on end-of-life care during academic preparation is integral to building the level of care-giving expertise necessary to meet the end-of-life care needs of Carolinians.

Based on the recommendations generated through the needs assessment, a multiyear program was developed and launched in South Carolina. The overarching intention was to increase the level of preparedness of a number of key professionals in the health care system, specifically nurses, social workers, and clergy, to provide competent and skilled care to individuals and families facing end-of-life matters.

THE INTERDISCIPLINARY EDUCATIONAL SPECIALIZATION IN END-OF-LIFE CARE

Concerns related to the administrative complexities of designing interdisciplinary education in end-of-life care and the reality that any effort would live in a fish bowl for all to critique, led to considerable discussion about the importance of maximizing the potential for success of our program. A decision was made to limit the program initially to South Carolina; with long-range plans to implement it in North Carolina. With the geographic starting point established, the next critical consideration was determining a suitable “academic home” for such a complex endeavor. The decision to house within an MSW program was based on the assumption that because of the profession's philosophical base and biopsychosocial practice focus, social work education is uniquely suited to be in the forefront of developing and managing interdisciplinary and interuniversity academic programs focusing on end-of-life care.

With 2-year initial funding from The Fullerton Foundation and continued funding from The Duke Endowment, the Interdisciplinary Educational Specialization in End-of-life Care (the Specialization) has introduced a unique and unprecedented opportunity for a partnership between academia and health care providers. With start-up partnerships among Clemson University School of Nursing, the University of South Carolina College of Social Work, and AnMed Health Clinical Pastoral Education program in Anderson, South Carolina, the ultimate goal of improving the quality of health care throughout the Carolinas became a possible reality. The intention was clear: provide future nurses, social workers, and clergy (as frontline practitioners) with academic preparation specific to end-of-life care within an interdisciplinary learning environment. Although schools of medicine have not been able to formally participate because of the structural complexities of the discipline's academic curricula, it must be noted that they have been supportive of this program and upon occasion, serve as guest lecturers and informal consultants.

Student Recruitment

In light of the program intent and structure, student recruitment and selection is a primary concern in order to ensure a good fit between students and the program's objectives. Following completion of an application, prospective student participants are interviewed and selected by an interdisciplinary team that includes faculty representatives and generally one agency professional of another discipline. For example, for the social work student interviews, a hospice nurse from a local partnering agency participates in the interview process. Faculty members from each university/program are actively involved in the recruitment process within their academic home community. Up to 16 students are selected for each academic year's cohort. The selected students represent master's level social work students from Winthrop University and the University of South Carolina, nursing students from Clemson University and Presbyterian School of Nursing at Queens University, and clergy in the Association for Clinical Pastoral Education Southeast Region program (AnMed Health). As part of the program design, each student receives a small stipend during the year in exchange for pursuing and holding employment in an end-of-life care setting in North or South Carolina for 1 year following graduation.

Development Activities

The program infrastructure was developed through an interdisciplinary advisory team representing social work, nursing, and chaplaincy educators and practitioners representing each discipline. A professional external program evaluator and two health care program administrators were also involved from conceptualization through development. This interdisciplinary development team created the parameters for the work, including interuniversity connections, program goals and objectives, strategies, and content. Significant to the team's work was developing a knowledge-to-skill-building format, in which every learning strategy focused on the relationship of knowledge need to develop each skill. Four program objectives were created to provide the context for the program infrastructure and content/strategy development. They are as follows:

1. Design and deliver an appropriate, relevant educational curriculum that:

   		is competency based (end-of-life oriented)
   		has an interdisciplinary focus
   		uses teaching strategies that build competencies

   In its first year, the program partners focused on developing professional competencies and associated curricula. The 30 competencies fall under three broad categories: (a) Knowledge Competencies, (b) Skills Competencies, and (c) Professional Identity Competencies. These competencies are shown in Tables 1 and 2. The teaching approaches are anchored by two strategies: interdisciplinary academic opportunities, and community partnerships. These two strategies work together to facilitate optimal educational avenues for integrating and synthesizing knowledge and skill development in end-of-life care, while enhancing the development of the individual student's professional identity. A learning environment has been created in which students benefit from a rich exchange of ideas and opportunities resulting in cross-pollination in learning. The philosophy of the program's work is the belief that all learning opportunities should be built with a knowledge-to-skill-building emphasis. Broad content areas for all project strategies involve knowledge and skill development using four primary modules: (a) Communication—Having Difficult Conversations; (b) Advance Care Planning; (c) Futile Treatment; and (d) Interdisciplinary Care Provision. In order to best accomplish this, learning strategies include interactive small group work, didactic instruction, case simulations, role plays, cross-discipline course exposure, and field experiences. Two distinct components support the program's work: the seminar and the out-of-department elective.

   TABLE 1 Confidence in Knowledge Competencies (1–5 Scale): N = 13 Self-Evaluation

   Your knowledge of…	Pre-program average N = 13	Post-program average N = 13	t-test statistic
   Distinctions and similarities of contemporary models of health care systems in this country (palliative medicine, hospice, and traditional medical model).	2.54	4.31	t(12) = −4.90, p < .01
   National and state health care-related policies and how they trickle down to form systems and norms of care.	2.00	3.77	t(12) = −5.17, p < .01
   Ethical concerns related to contemporary values of care around informed choice and consent; futile care; right to self-determination; and terminal sedation.	2.62	4.46	t(12) = −4.95, p < .01
   Legal mandates regarding physician-assisted suicide, euthanasia, terminal sedation, informed consent, advance directives.	2.23	4.23	t(12) = −6.68, p < .01
   Benefits and limitations of distinct models of care: interdisciplinary, multidisciplinary, and trans-disciplinary.	2.54	4.62	t(12) = −7.85, p < .01
   Major contemporary theories of grief; strengths and limitations.	2.08	4.00	t(12) = −4.19, p < .01
   The influence of developmental norms (across the life-cycle) associated with grieving/coping.	2.31	4.15	t(12) = −4.95, p < .01
   The effects of diversity on individual and familial experiences with illness, dying, death (cultural, religion, gender, socioeconomic status, spirituality, sexual orientation, age, and race).	2.62	4.38	t(12) = −4.31, p < .01
   The effects of societal norms on provision of care to diverse populations based on cultural, religious, gender, age, sexual orientation, socioeconomic status, spirituality, and racial differences.	2.85	4.08	t(12) = −3.00, p < .05
   Medical management tools for pain and other symptoms, including pharmacological and non-pharmacological therapies.	2.31	3.85	t(12) = −5.28, p < .01
   Changing dimensions of suffering and its relationship to biopsychosocial management of illness progression.	2.00	3.77	t(12) = −8.80, p < .01
   Best practice (based on research) intervention strategies based on your professional discipline.	2.54	4.08	t(12) = −6.33, p < .01
   Core team responsibilities for disciplines of social work, chaplaincy, nursing, counseling, and health education.	3.15	4.85	t(12) = −5.92, p < .01
   Advance care planning; benefits/limitations.	3.08	4.46	t(12) = −4.19, p < .01
   Various theoretical frameworks and trajectories explaining the progression of illness, dying, and death.	1.80	4.00	t(12) = −4.49, p < .05

   TABLE 2 Confidence in Skill Competencies (1–5 Scale): N = 13 Self-Evaluation

   Your ability to…	Pre-program average (N = 13 unless indicated otherwise)	Post-program average (N = 13 unless indicated otherwise)	t-test statistic
   Establish effective communication and psycho-educational strategies when working with individuals/families/other professionals.	3.38	4.31	t(12) = −4.40, p < .01
   Effectively communicate difficult news with individuals and families.	2.31	4.15	t(12) = −1.07, p < .01
   Assess and manage appropriate (grounded in recognition of individual diversities) interventions necessary for effective management of symptoms, pain, and suffering.	2.54	4.23	t(12) = −1.07, p < .01
   Provide care to individuals and families as part of an interdisciplinary team.	2.77	4.69	t(12) = −1.46, p < .01
   Conduct a biopsychological assessment.	2.69	4.62	t(12) = −1.21, p < .01
   Develop an integrated interdisciplinary care plan.	2.08	4.23	t(11) = −1.32, p < .01
   	N = 12	N = 12
   Conduct advance care planning sessions and directly assist in the creation of advance directives.	2.00	4.23	t(11) = −1.36, p < .01
   	N = 12	N = 12
   Advocate by organizing community response strategies related to increasing awareness/education of end-of-life issues.	1.69	4.08	t(12) = −1.62, p < .01
   Develop and implement discipline-specific process and outcome evaluations of the effectiveness of interventions provided by the team.	1.62	4.23	t(12) = −1.74, p < .01
   Intervene appropriately during a crisis.	2.54	4.23	t(12) = −.86, p < .01
   Define and perform duties of a team member.	3.42	4.85	t(11) = −.85, p < .01
   	N = 12	N = 12
   Educate the individual and family members regarding grief, the dying process, caregiving, and other related goals.	2.38	4.54	t(12) = −1.42, p < .01
   Work with the individual, family members, and other professionals to resolve ethical dilemmas including futile care, request for physician-assisted suicide, palliative sedation, etc.	2.15	4.15	t(12) = −.93, p < .01
   Use loss and grief interventions to work with the family members following the death of their loved one.	2.08	4.08	t(12) = −1.26, p < .01
   Ensure self-care while working as a professional providing end-of-life care (establish appropriate boundaries, practice good self-care, etc.).	3.31	4.15	t(12) = −2.5, p < .01

   The Seminar: Students attend monthly seminars alternating between discipline-specific and interdisciplinary instruction. This translates into eight seminars over the course of the academic year: four bi-monthly discipline-specific and four bi-monthly interdisciplinary seminars. The discipline-specific seminars are typically 3 to 5 hours and are team-taught by the program coordinator (social worker) and each particular discipline's program faculty. This is considered the knowledge-building piece and is intended to provide universal content along with each discipline's philosophical and practice standards related to that content. The interdisciplinary seminars involve all program students plus program faculty representing each university and discipline. These day-long seminars are the skill-building piece and are related to the previous month's knowledge-building session. Through careful coordination with partnering university programs, the seminars are generally scheduled for field placement or clinical rotation days.

   For the interdisciplinary seminars, case simulations are used to provide skill-building opportunities related to the content module for that period. For example, the first module focuses on communication. In the discipline-specific seminar, students are exposed to content related to communication strategies/skills. The interdisciplinary seminar is built around a case situation involving the need for a “difficult” conversation to occur. Recruiting volunteers from local acting groups, agency, and other community partners, actors are trained regarding the purpose of the activity and their roles in the particular case. Students are separated into small interdisciplinary groups and spend the day interacting with the actors using a case simulation format. Actors and program faculty use a behavioral checklist to provide feedback to the students and to facilitate further discussion related to students' knowledge and skills demonstration.

   Out-of-Department Elective: Students are required to audit or take for credit one course outside their academic home department. The idea behind this requirement is two-fold. It gives students the opportunity to have exposure to the philosophical and practice values and beliefs of other disciplines. The second perceived benefit is that students are exposed to content that they might not typically encounter. For example, nursing students have taken courses in therapeutic massage, counseling, and religious studies. Social work and CPE students have taken courses in Spanish, medical terminology, and sign language.

2. Design and deliver effective field and clinical experiences that:

   		are competency based
   		teach end-of-life practice with an interdisciplinary focus
   		effectively integrate didactic content with practice skill-building opportunities

   The clinical and field experiences serve as an effective strategy to ground content for students as these experiences provide immediate opportunities to practice or see what they are learning in action. Social work students are required to complete a field placement experience in a setting that emphasizes end-of-life care. Placements typically include skilled nursing homes, children's oncology units, hospice programs, and hospital units. This has been a natural fit for the nursing and CPE students because hospitals, hospice organizations, and skilled nursing facilities are routine clinical sites in their academic/preparation programs. The program coordinator works with practice sites to incorporate relevant program competencies into students' learning contracts/goals. To remain visible within the practice community and to monitor inclusion of program competency-related opportunities into the field/clinical experiences, the program coordinator conducts a minimum of one site visit per semester, and generally maintains phone contact with field supervisors throughout the academic year.

3. Develop policies and procedures (infrastructure) that support an educationally based program specific to end-of-life care.

   The critical part of this objective is ensuring that existing university administrative systems are capable of handling the budgetary and overall administrative supports and that there is university support for the creation of needed administrative structures. The program is managed by an administrative/programmatic director, who is the grant P.I. and serves as a full-time faculty member at Winthrop University. The full-time program coordinator, also a Winthrop employee, holds a master's degree in social work. These personnel requirements necessitate departmental and university support for faculty involvement, including course release time for the program director to direct the program's work.

4. Develop college-university-agency mechanisms that support interdisciplinary educational opportunities in end-of-life care.

Recruiting program partners during the initial development stage created a sense of partnership and ownership from respective disciplines and programs. Current partners—Clemson University School of Nursing, the Winthrop University Department of Social Work, the University of South Carolina College of Social Work, AnMed Health Clinical Pastoral Education program, and Presbyterian School of Nursing at Queens University in Charlotte, North Carolina—have assisted in the development of the interface of interdisciplinary core content and clinical experiences and are ongoing program partners. Faculty in these partner institutions are considered program faculty, and as such, are actively involved in participants' learning through team-teaching during the interdisciplinary seminars. They also participate in the ongoing evaluation of program effectiveness primarily through a program faculty retreat held at the end of each academic year. During this retreat, evaluations are reviewed and any relevant modifications to the program are made.

Because agency and organizational investment is also considered critical to the program's work, practitioners across disciplines and agencies are sought out to serve as consultants during the interdisciplinary seminars. Engaging the community at large through use of volunteer actors is a way to cast the net of support beyond the borders of academia and agency support.

Short-Term Outcomes

There are five specific, anticipated short-range outcomes for program graduates. Measures 2 through 5 are obtained through the self-report surveys and telephone interviews of program graduates.

1. Program graduates will complete payback for the benefit of participation in this specialization through a ratio of 1 month of participation = 1⅓ months of employment in some area of end-of-life care in South or North Carolina (for a total of 12 months of related employment).

2. Program graduates will report increased levels of knowledge in competencies related to practice in end-of-life care.

3. Program graduates will report increased skills in competencies related to effectively assessing for biopsychosocial end-of-life concerns or needs.

4. Program graduates will report skills related to the professional use of self in practice through delivery of competent and ethically sound interdisciplinary strategies. Graduates will demonstrate skills related to recognizing and responding to ethical concerns and decisions and in serving as advocates for clients who are dealing with end-of-life matters.

5. Program graduates will report increased skill development related to recognizing and responding to ethical concerns and decisions, and those related to serving as advocates.

EVALUATION

The evaluation seeks to provide program leadership and partners with feedback regarding the effectiveness of program components. It includes self-reports of student gains in knowledge and skill development, student satisfaction with the program content and management, including indicators of relevance and usefulness of strategies used in students' learning experiences, immediate outcomes and longer range evidence of the effects on practice behaviors of program graduates. In an effort to increase the validity of the evaluation measures and findings, an external evaluator is used for data collection and initial analysis.

With this in mind, the following broad questions guide the evaluation process:

1. Are the competencies relevant to the students' area of practice?

2. How are graduates using the knowledge/skills gained through the program in their current employment?

3. Is there a change in student perceptions of relevance prior to the program and their perceptions of relevance after completion of the program?

4. Does participation in the program increase students' perception of confidence and competence in their knowledge or skill base related to end-of-life and interdisciplinary strategies of care?

5. How satisfied are students with the program components and learning strategies? What program components and strategies are most effective in enhancing student learning? Which could be improved?

6. How has the program influenced the graduated participants' sense of work performance confidence and competence? Are they more inclined to be employed in end-of-life care settings than if they had not been involved in the program? Data is collected from five evaluation measures over a 27-month period. Both qualitative and quantitative techniques are used.

   1. Self-administered pre-program assessment

      This measure is administered during the orientation seminar held at the beginning of academic year. It provides a snapshot of where each student perceives her/himself in two areas:

      1. confidence in knowledge of and ability to perform the competencies

      2. relevance of each competency to the student's discipline (social work, nursing, CPE)

   2. Post-seminar self-administered surveys

      Following each interdisciplinary seminar, students receive an online questionnaire that is intended to evaluate the effectiveness of the knowledge-to-skill-building aspect of the seminar sequence.

   3. Focus groups

      There are two points during the academic year the external evaluator conducts focus groups with program students. These occur at the end of the first semester and at the end of the second semester (end of the program). The focus groups are intended to capture the students' perceptions of individual and collective progress and to gain feedback on their overall experiences in the program. The focus groups are audio-recorded and later transcribed with all identifiers removed. The data is reviewed to identify strengths and concerns that students expressed about the program.

   4. Self-administered, post-program assessment

      The same self-assessment that is given before the start of the program is again administered at the end of the students' involvement in the program in order to measure their perceptions of change in the same two areas of confidence and relevance of competencies.

   The pre/post program and post-seminar evaluation measure are analyzed using paired samples t-test and descriptive statistics including means, standard deviations, and frequencies.

   • e. Post-completion evaluation

Telephone interviews are conducted at 6 months and 18 months after the program has been completed with all graduates. These are designed to gain a sense of the perceived usefulness of what was learned and able to be applied in their professional practice. This provides program administrators with critical information related to integration and synthesis of content into practice behaviors. At this point, graduates are engaged in a quasi-advisory discussion with the evaluator about the ongoing relevance of and recommendations for modification of program content and structure based on their practice experiences. The interviews are transcribed and examined for areas of strength and concern as they progress through completion of the program.

FINDINGS

In order to verify payback for participation (Outcome 1), 6-month follow-up phone interviews have been completed for both cohorts 1 and 2. At the time of follow-up, 10 graduates of cohort 1 were working in South Carolina or neighboring states. Two were still completing their education.

All cohort 2 participants were in located in South Carolina, North Carolina, or Georgia, except one who was participating in a post-MSW interdisciplinary palliative care fellowship in New York. This student has since completed the fellowship and is working as a palliative care social worker for a large hospital system in South Carolina. Of cohorts 1 and 2, over 70% have reported working directly in end-of-life care. The remaining 30% are involved in post-degree programs, general medical/health care settings, or involved in congregation-based work.

In relationship to Outcome 2, increased levels of knowledge in competencies, cohorts 1 and 3 showed significant improvement in ratings (.05 level) on all knowledge competencies from pre- to post-test. Cohort 2 did not complete a post-test due to unforeseen administrative changes; therefore, post-test data are only available for cohorts 1 and 3.

For Outcome 3, increased skills in competencies related to effectively assessing for end-of-life concerns, cohort 1 showed significant improvement in ratings (.05 level) in two of the three related skill competencies. The third related competency focused on the ability to conduct a biopsychosocial assessment. Several students reported not having enough opportunity to apply this skill in their field or clinical settings in order to gain competence. At baseline, the participants' ratings on this competency ranged from 1 to 4 on a 5-point scale with an average rating of 3.0. At the end-of-the-year survey, the average score was 3.8 with a range from 1 to 5 on a 5-point scale. For cohort 3, significant improvement in ratings (.05 level) was achieved on all three skills competencies related to this area.

Outcome 4 focused on increased skill in professional use of self as related to competent and ethical interdisciplinary strategies or using clear boundaries around professional responsibilities and personal beliefs. Ten of the skill competencies were related to providing competent and ethical interdisciplinary strategies with clients. Significant improvement in ratings (.05 level) was achieved on all 10 skills competencies for both cohorts 1 and 3.

Outcome 5 focused on skill development related to recognizing and responding to ethical concerns and decisions and serving as advocates. Two of the skills competencies were related to recognizing and responding to ethical concerns and decisions and serving as advocates. Significant improvement in ratings (.05 level) was found for both skill competencies related to this area for cohorts 1 and 3.

Students were asked to provide a confidence rating for each competency in terms of any changes in this rating as a result of participation in the program. The confidence ratings increased for all knowledge and skill competencies for cohorts 1 and 3. A paired samples t test was performed to determine if the differences between pre- and post-survey confidence ratings were significant. The differences between the ratings were significant for all the knowledge competencies and the skills competencies. Tables 1 and 2 show the results for the confidence ratings.

Finally, students were asked about their level of satisfaction with the program components. On the end-of-program survey, students were also asked to rank their level of agreement (with 1 being totally disagree and 5 being totally agree) to eight programmatic questions. Responses strongly indicated that they believed the program components fit with the program competencies, and that their learning expectations were consistently met. Results are shown in Table 3.

TABLE 3 Level of Satisfaction With Program Components (1–5 Scale): N = 13 Self-Evaluation

The field or clinical experience requirements helped to prepare me for working with people who are dealing with end-of-life care issues.	4.92
The number of program requirements was manageable.	4.69
The program requirements were accurately described to me prior to admission.	4.15
The recruitment and application process gave me enough information to make an informed decision about accepting the traineeship.	4.62
I think this program should continue.	5.00
I am glad that I decided to participate in this program.	5.00
The Interdisciplinary Educational Specialization in End-of-Life Care program met my expectations.	4.85
How would you rate your overall experience with the Interdisciplinary Educational Specialization in End-of-Life Care program?	4.77

Focus Groups

For all cohorts, the first focus group has been held in December—the midpoint of the program year. The end-of-year focus group has been conducted at the final interdisciplinary seminar in April. Students were asked to discuss the knowledge and skills they had gained through the program related to end-of-life and interdisciplinary care.

IDENTIFIED STRENGTHS

It appeared that all of the students participating in this program have found it to be extremely valuable. They especially liked the interaction with colleagues from other disciplines. One member of the cohort 2 focus group summarized it well, stating:

We have developed an understanding of just how complex interdisciplinary care can be, and we have developed an understanding of the roles and values of other disciplines, and we have developed skills in working as part of an interdisciplinary team on end-of-life care.

Students were asked how their participation in the Specialization influenced their career plans. There was agreement among participants that the program had an impact on their future career plans. Many students stated that their career plans were altered, and they planned to look for a job in end-of-life care. Program graduates' comments included sentiments such as:

	If I can find work in a palliative care unit or hospice, I will be more aggressive about getting that job—where before, that would be the last thing on my agenda.
	I thought I would dabble in it, but now it is the only thing I want to work in, hospice or dialysis clinics. I definitely want to do end-of-life care.
	…it has become much more of a major focus of where I want to be….

Cohort 3 students generally were already interested in working in end-of-life care so the program did not necessarily change those plans, but they reported that their experiences in the program gave them the skills and confidence necessary to actually work effectively in this arena.

Students were asked how their exposure to the interdisciplinary team approach influenced their opinion of this model of care and their ability to be an effective member of an interdisciplinary team. They were also asked how they planned to promote this approach in their job. Most of the participants were glad to have been exposed to the interdisciplinary approach, but were frustrated with the lack of cooperation among disciplines and on teams that they witnessed and experienced in field placements or clinical settings. Students felt that being involved in this program made them more effective as team players, more empowered as team members to speak up, and better able to provide necessary care to their patients or clients:

	Just about every instance that we have had in our role plays [case simulations] I've seen play out in my organization setting…and I have really been able to draw on what we have learned here, and I think with that comes a lot of growth.
	My confidence has definitely grown. I have always been a follower…doing role plays and group projects helped me step out and take risks. I think I can advocate now.

Students discussed the coordination among the universities and institutions and recognized that the program modeled the strategy it promoted by bringing together different institutions for collaborative work—much like interdisciplinary work in end-of-life care. Students were enthusiastic about the team-teaching approach and working with the other disciplines to learn, and they enjoyed alternating the locations of the interdisciplinary seminars:

	I appreciate so much this program because personally I have become more comfortable with interdisciplinary relationships.
	This has been sort of a laboratory…when I do my real work in the hospital…this has helped me to feel more confident: personally and professionally.

Students were asked to identify the most valuable experience they had in the program. Consistently across all three cohorts, the majority of students valued the interdisciplinary case simulation exercises. The set-up of the role plays, with volunteers brought in to act out the case and having a professional mentor (practitioner) observe and provide feedback, allowed the students to fully engage in the experience, resulting in optimal learning. Students emphasized the importance of role plays—getting to practice the skills they were learning. They believed that this form of experiential learning significantly helped them interact more effectively in their actual field and clinical settings.

IDENTIFIED CONCERNS

During the focus groups, students also expressed concern with three issues. Cohort 1 specifically stated that the work expectation was greater than anticipated. They acknowledged that while they received an explanation of the program ingredients, they would have benefited from a more thorough examination of program requirements.

Cohorts 1 and 3 identified the timing of the interdisciplinary seminars as creating additional stress for them because of the sequence of the seminar with their academic exam schedules. They recommended holding the interdisciplinary seminars on Saturdays in an effort to reduce the weekday stress associated with juggling class and program seminar requirements.

Cohorts 1 and 3 also discussed the difficulty of fulfilling the out-of-class requirement. Some found it difficult to find an appropriate elective. Primary concerns were related to having access to acceptable courses within their home university, or in the case of the CPE students, having to seek out other local colleges or universities for acceptance into a single course. Cohort 3 students advocated for and were allowed to take a suitable online course to fulfill this requirement. Most students reported that they enjoyed the experience of taking the elective course outside their home discipline. They stated that they enjoyed being “outside of their box” while still learning something that they felt was relevant.

Follow-Up Telephone Interviews

Initial telephone interviews have been completed for the first two cohorts. The first contact at the 6-month interval has been difficult due to relocations and subsequent address/e-mail address/telephone number changes. This has resulted in some delays in getting the interviews completed, transcribed, and analyzed. For the first two cohorts, the following information has been gathered.

Cohort 1 graduates highlighted all three broad competency areas of the program as influencing their ability to do their jobs well. They specifically cited four areas of personal and professional growth:

	knowledge of end-of-life issues, including loss and grief and advance directives;
	skills of communication in addressing and advocating across disciplines;
	comfort in dealing with end-of-life issues in general;
	understanding the complexity of end-of-life care.

When asked how participation in the program influenced their job performance, one half of the respondents mentioned “teamwork” or the “interdisciplinary approach” as a primary skill they brought to their job.

Cohort 2 was also asked how they would describe the effects of their involvement in the Specialization on their job entry-level knowledge and skill base. Most responses centered on being able to work competently on an interdisciplinary team, being a better listener, and having knowledge of grief and loss. When asked for specific examples of ways program graduates are using the knowledge/skills developed through their involvement in the Specialization, respondents discussed the following areas:

1. They are skilled communicators. The respondents feel they are better listeners and are better able to effectively use silence. They emphasized that they understand the importance of open communication and involving family members.

2. They are better able to educate patients, families, and coworkers on various issues related to the end of life. They can help families make decisions by educating them and discussing options and benefits. One respondent has also educated coworkers on grief and loss.

3. They are effective in working with individuals from other disciplines. They appreciated learning the different roles and resources, and who to call on for different issues. One CPE student described particularly benefitting from understanding the “social work way” of handling issues.

Perhaps some of the most interesting evaluation findings come from the focus groups and the post-program follow-up interviews. Participants saw themselves as an important catalyst in their newfound mission. A unique and essential demonstration of the program's effectiveness is revealed as program graduates describe the importance of opportunities to model the interdisciplinary relationships they learned through involvement in the program. In fact, participants frequently express frustration at not seeing professionals in the field work across disciplines as often as they could. Essentially, the program seemed to provide opportunities for developing the confidence and skills to advocate for interdisciplinary work with current and future colleagues. Program participants consistently reported feeling a new sense of responsibility to spread the word about the benefits of interdisciplinary work in end-of-life care. One participant described how the program was making a difference beyond the students involved directly. She suggested that if each program participant could educate two others, who could then educate two others, and so on, then changes might occur more quickly! Additionally, while some students already felt a commitment to work in end-of-life care, many were still exploring their options as they entered the program. Upon completion of their involvement in the program, these students expressed a much greater investment in actively seeking employment in end-of-life care.

LIMITATIONS TO THE EVALUATION

There are several limitations to the evaluation design that should be noted. The evaluation design did not include a formative assessment, which might have provided more detailed development data that could aid others in replication. In addition, the difficulty of actually assessing directly the knowledge and skill development led to relying on self-report measures. Nevertheless, all participants that responded during the evaluation indicated that the program increased their knowledge of interdisciplinary work in end-of-life care. For all the skill competencies, participants indicated that they had greater confidence in performing these skills than prior to participating in the program. While actual measures to directly assess whether knowledge increased or skills were learned were not created outside of the behavioral feedback forms used in the case simulations, it is important to note that the participants did think their knowledge and skills increased. This internalization of the competencies and subsequent confidence and the recognition of the complexities of skill needed is an important aspect that needed to be further addressed.

IMPACT ON HEALTH CARE PROVISION IN THE CAROLINAS

The Interdisciplinary Educational Specialization in End-of-life Care shows promise in addressing the two major outcomes: workforce development and retention, and professional competency. These can have a significant impact on the quality of care for individuals and families who are dealing with end-of-life circumstances. Specifically regarding health care workforce development and retention, a number of encouraging indicators are occurring. The ultimate goal of the Specialization is to produce competent and confident professionals in the areas of social work, nursing, and pastoral care who will seek employment in health care systems in the Carolinas that focus on end-of-life care. It is expected that students will work in a variety of settings including nursing homes, hospitals, hospices, dialysis, and other outpatient clinics, as well as in other community service organizations. As of May 2009, 36 students have successfully completed the year-long academic specialization program. As of September 2009, 34 reported working in some area of practice addressing end-of-life care. One graduate was still seeking employment; another finished her PhD and was seeking a faculty position.

As the program becomes institutionalized at the partner academic institutions, it is expected that additional strategies will be launched to generate more resources in order to increase the capacity to accept more students. The outlook for retaining these graduates once they enter employment in end-of-life care settings is promising given that most program graduates described the program as a “career changing experience” and stated that they plan to work in end-of-life areas as a direct result of their participation in the program.

In examining the second outcome area, enhanced competency of front-line professionals, this program seems to be advancing the professionalization of interdisciplinary practice by combining relevant educational instruction with effective field education and clinical experiences in end-of-life care settings into a comprehensive learning environment. Evaluations of the three cohorts of program graduates note professional growth in targeted knowledge, skills, and professional identity-based competencies that include: theoretical foundations and biopsychosocial factors essential to effective practice; responsive and ethical services to persons and communities; and ethical practice of care as defined by one's professional code of ethics and that operate within larger contemporary bioethical standards. It is expected that the knowledge and skills gained in end-of-life care and interdisciplinary collaboration will ease beginning job tensions, which will help graduates manage their professional health and ultimately will lead to improved care outcomes.

DISCUSSION

The Interdisciplinary Educational Specialization in End-of-life Care demonstrates one creative strategy for successful introduction of concentrated interdisciplinary, interuniversity academic preparation into existing academic paradigms. Because we are limited to 16 students per academic year, and because students self-select for consideration of acceptance, there are obvious limitations in terms of the immediate reach of the program's intent. However, it is important to note the unintended outcomes of the work that have surfaced through the growing interest on the part of academic and practice colleagues. For example, at Winthrop University, each cohort of social work program students has presented information sessions to university-wide faculty/staff groups on advance care planning. The workshops have been well-attended and have resulted in increased attention to program activities while raising awareness of personal health care needs within the university community at large. At Clemson University, program nursing students have developed group projects that are demonstrated throughout their university's School of Nursing. CPE students at AnMed Health have been instrumental in assisting with organizational efforts to formally institutionalize advance care planning and palliative care efforts. For those who teach core curricula among social work and nursing faculty, there is growing interest in how to infuse more content on end-of-life related matters, and in developing interdisciplinary learning strategies. Practice communities are discovering the benefits of participating as learning partners and are beginning to informally solicit program graduates when employment vacancies occur. This certainly indicates that the net of influence within academia and the practice communities is actually being cast wider than may initially seem.

Challenges

The program faculty continues to learn with each academic year. Among the greatest challenges have been those related to logistics of the seminars. Coordinating the schedules for interdisciplinary seminars involving 16 students from five institutions, and five program faculty members from those same five institutions has been a tedious task! Other challenges that were particularly difficult early in the program involved recruiting and adequately training our volunteer actors. Yet, a snowball effect has occurred with volunteers. At this point, the vast majority of our volunteer actors are veterans to the program. New volunteer actors come to the program through recommendations of existing actors, creating richness beyond initial expectations. There is a growing sense of partnership in the process from the volunteer actors. As one actor recently stated during his introduction to students, “I am doing this for the third year because I want you to be better at taking care of the people I love than other providers have been. In doing this, I believe I am helping you learn to do a better job.”

The work of program faculty is labor-intensive. Key to the program's success has been the time invested in nurturing the involvement of other institutions in ways that have fostered excitement and created support for other discipline faculty members in their work on this effort.

With the enthusiasm and investment of academic and community partners and the promising short-term outcomes achieved, the program continues to breathe with a healthy life force.

Individuals and families facing end-of-life concerns are expected to receive more competent care from social workers, nurses, and chaplains who have been specifically trained in an interdisciplinary approach to provide biopsychosocial care. Although any long-range impact of this program is too early to assess, early indicators clearly demonstrate the relevance and usefulness of this format of educational preparation across disciplines in end-of-life care. It is expected that continued implementation and expansion of this initiative will foster a climate in which Carolinians will receive the highest quality care as they face end-of-life circumstances.

IMPLICATIONS FOR SOCIAL WORK EDUCATION AND PRACTICE

As the literature reveals, among the most challenging aspects of creating interdisciplinary learning opportunities within academia for health care related disciplines are those attached to the limited common language, discipline-driven turf issues, and the deeply entrenched norms around the hierarchy in health care provision. Yet, it is these very barriers that provide a sense of urgency in meeting the challenges through interdisciplinary higher education strategies. Reeves and colleagues (2008) remind us that interdisciplinary professional education—those strategies where different disciplines actually interact and learn together—carries the greatest potential for breaking down barriers and creating a new paradigm of interdisciplinary health care provision.

Paramount to any academically based interdisciplinary effort is the critical challenge of where best to house such a complex program. Social work's practice principle of “starting where the client is” becomes particularly relevant when exploring reasonable next steps. The foundational practice principles position social work to serve as an ideal conduit for developing and managing such complex learning and practice endeavors. According to Reese and Sontag (2001), it is social work's strong value of teamwork and the knowledge and skills in relationship building and communication that make social work's presence essential for facilitating true interdisciplinary approaches to care at the end of life. Based on this assertion that the profession's philosophical and practice base makes social work an ideal fit for interdisciplinary models of care, it is reasonable to assume that social work education is an ideal setting for the development and delivery of end-of-life-focused interdisciplinary, interuniversity educational strategies.

In facing the challenge of establishing itself as a leader in creating and managing responsive interdisciplinary educational strategies, social work educators cannot forget the contextual reality of existing educational and health care hierarchical norms. The success of this Specialization serves as an example of one academically-based strategy that is building positive steps in creating cross-discipline academic investment in concert with agency partnerships to facilitate more comprehensive preparation of those who will care for individuals and families facing the ending of life. While not truly a paradigm shift, this program has created a notable crack in the door of resistance among institutions of higher education in South Carolina and has facilitated the deepening of academic/community partnerships of learning. It has turned out to be a “win-win” situation for students and professional communities in the Carolinas.