Page 248 - EJMO-9-3

Eurasian Journal of
Medicine and Oncology Nursing students’ views on advance directives

1. Introduction inclusion of specific modules within university curricula
that incorporate active learning methodologies, simulation,
The progressive aging of the population and the increasing and ethical reflection. 20,21
incidence of chronic and degenerative diseases are reshaping
global health-care priorities. In 2021, the World Health Building on these premises, it is worth exploring how
Organization estimated that by 2050, the proportion of targeted educational interventions can bridge existing gaps
individuals over the age of 60 will double, reaching 22% of in nursing students’ knowledge and attitudes concerning
1
the total population. In Europe, more than 70% of deaths end-of-life care. Accordingly, the present study seeks to
are attributable to non-communicable chronic diseases, address the following research question: “To what extent
such as cancer, cardiovascular, and respiratory conditions, can a structured educational module on AHDs influence
2
many of which require advance care planning. Studies nursing students’ attitudes, knowledge, and ethical
conducted in Europe highlight that a substantial number orientation toward end-of-life decision-making?”
of patients die without receiving adequate palliative care The primary objective is to evaluate the impact of a
despite having complex needs. In Italy, the Higher Institute targeted educational intervention on students’ knowledge
3
of Health reports that approximately 30% of dying patients regarding therapeutic self-determination by examining
require palliative care, but only a minority receives it. changes in awareness, preferences, and ethical sensitivity
4
According to data from the 2022 Italian National Institute before and after the training. Ultimately, this study
of Statistics, fewer than 10% of citizens have signed an aims to contribute to the development of more effective
Advance Treatment Directive (Disposizioni Anticipate di educational strategies that promote ethical competence,
Trattamento [DAT]), indicating limited cultural familiarity relational awareness, and empathy in supporting patients
and dissemination of this tool, even among health-care during the final stage of life.
professionals. 5
The promotion of patient autonomy in clinical settings 2. Materials and methods
has been legally recognized in many countries. In the 2.1. Study design
United States, the Patient Self-Determination Act of 1990
introduced the requirement for health-care institutions A pre–post observational study design was employed
to inform patients about their right to express advance to evaluate the impact of an educational intervention on
health-care directives (AHDs). In Europe, regulation is nursing students’ understanding and attitudes toward
6
not uniform—some countries, such as Germany and Spain, AHDs. This exploratory study involved a single cohort
legally recognize advance directives, whereas others, such of nursing students recruited through convenience
as the Netherlands and Belgium, also allow euthanasia or sampling. The sample size was determined by the number
medically assisted suicide. 7-9 of eligible participants who enrolled in the module. This
study adhered to the Strengthening the Reporting of
In Italy, Law No. 219/2017 introduced the DAT, Observational Studies in Epidemiology guidelines for
22
officially recognizing citizens’ rights to express their reporting observational research.
wishes concerning medical treatment in the event of future
incapacity, including the option to designate a health- 2.2. Setting and participants
care proxy. In addition to codifying the principle of The study was conducted during the second semester of
10
informed consent, the law aims to enhance the therapeutic the 2024/2025 academic year at Humanitas University,
relationship and communication among patients, families, Italy, within the Bachelor’s Degree in Nursing program.
and healthcare professionals. However, the implementation The target population consisted of 3 -year students
rd
of DAT in clinical practice remains limited, hindered by enrolled in the palliative care module. Inclusion criteria
cultural resistance, lack of information, and operational required attendance at a minimum of 75% of the total
uncertainty among health-care providers. 11,12 module hours and mandatory participation in the final
Nurses play a crucial role in supporting patients at the two lessons. Exclusion criteria included failure to meet
end of life, assisting them in articulating their individual attendance requirements or being absent during the final
values and preferences. 13,14 Nevertheless, several studies sessions. A total of 39 students met the inclusion criteria
report a lack of preparation among nursing students and completed all study phases.
regarding the ethical-legal aspects of end-of-life decision-
making. 15,16 Barriers such as insecurity, fear of addressing 2.3. Educational intervention
sensitive topics, and limited knowledge of the legislation The educational module comprised 75 h of instruction on
restrict their ability to support patients in advance care palliative care and integrated lectures, case discussions,
planning. 17-19 Therefore, several studies advocate for the and active learning methodologies. A dedicated session

Volume 9 Issue 3 (2025) 240 doi: 10.36922/EJMO025250263