Evidence Based Strategies for Nursing Students and Advance Directive Preparedness

Advance directives (ADs), sometimes known as advance healthcare directives (ACHDs), are legal documents that allow individuals to communicate and document their choices regarding medical care and treatment in the event they are unable to communicate their decisions. The most common types of advance directives are the living will, durable power of attorney for health care (DPOA) and do-not-resuscitate (DNR) orders. A living will allow an individual to outline treatment preferences The most common types of advance directives are the living will, durable power of attorney for health care (DPOA) and do-not-resuscitate (DNR) orders.such as mechanical ventilation or artificial nutrition. A DPOA is a person appointed to make decisions about medical care and treatment in the event an individual is unable to communicate. The person appointed is expected to carry out the individual’s medical care and treatment decisions. A DNR order means an individual does not want cardiopulmonary resuscitation in the event their heart stops or they stop breathing (Weiss, 2024). These concepts are all part of the larger process of advance care planning (ACP).

The Patient Self Determination Act of 1990 ([PSDA], Congress.gov, H.R., 4449, 1989-1990) mandated that hospitals, skilled nursing facilities, hospice organizations, home health agencies, and health maintenance organizations receiving Medicare or Medicaid funding uphold and promote patient autonomy in medical decision making. Patients must be informed of their right to be an active participant in decisions about their medical treatment, including the choice to complete ADs. Patients must be asked if they have ADs and their preferences about the acceptance or refusal of medical interventions must be documented in the medical record. Patients must be given the option to complete an AD if they do not have one. ADs must be implemented where they are legally valid and consistent with relevant state laws (Teoli & Ghassemzadeh, 2023). Patients must be given the option to complete an AD if they do not have one.

Role of the Nurse with Advance Directives

The American Nurses Association ([ANA], 2025) Code of Ethics with Interpretive Statements, Provision 1.4 The Right to Self-Determination states that nurses must respect human dignity, which includes the right to self-determination. Nurses are responsible for educating, discussing, and answering patient questions about ADs so that they can make informed decisions. It is the nurse’s duty to advocate for patients’ ADs when they lack their own decision making capacity.

Nurses are often the most consistent point of contact for patients, positioning them to initiate and sustain meaningful conversations about ADs. This close access enables them to assess individual values, cultural beliefs, and psychosocial factors  It is the nurse’s duty to advocate for patients’ ADs when they lack their own decision making capacity.that influence patient decision-making. In cases where patients are unable to make decisions, nurses must support surrogate decision-makers and ensure that care aligns with the patient’s previously expressed ADs. By upholding the right to self-determination and encouraging the use of ADs, nurses support the ethical underpinning of patient centered care and contribute to the integrity of clinical practice (ANA, 2025). Because nurses are held to the provisions of the ANA Code, it is important they are knowledgeable about ADs and can assist patients with its completion.

Nursing Students’ Knowledge of Advance Directives

Knowledge and understanding of ADs offers a critical foundation for nursing students as they build the skills to support and assist patients to complete AD documents. Research about preparation of nursing students with experiences and knowledge related to ADs remains limited. Most studies have focused on nursing students’ preparation with other aspects of end- of-life care (physical needs, pain and symptom management). Some studies specifically about nursing students and ADs were conducted in international settings. This section provides a brief overview of the most recent findings. ...nurses must support surrogate decision-makers and ensure that care aligns with the patient’s previously expressed ADs.

U.S. Based Research About AD
George et al. (2018) surveyed 166 baccalaureate nursing students in their first through fourth semesters about knowledge, experiences and attitudes regarding ADs at a public, rural university in the southeastern United States (U.S.). The results showed that while AD knowledge increased across academic semesters, students experienced knowledge decline during academic breaks. Demographic factors influenced attitudes, with older and Caucasian students demonstrating stronger support for patient autonomy and nurse involvement in ADs. Pagano et al. (2020) conducted a study involving 26 graduate nursing students from two northeastern U.S. nursing schools utilizing The Conversation Project (TCP), which aims to improve communication about advance care planning and end-of-life decision making. Students reported increased engagement, confidence and reduced anxiety when discussing advance directives and end-of-life care after completing assignments, reflection activities, participation in active learning strategies, and a community service-learning project. Knowledge and understanding of ADs offers a critical foundation for nursing students as they build the skills to support and assist patients to complete AD documents.

Enhancing curricula to emphasize legal and ethical frameworks is essential for preparing students to facilitate decision making and understand their role and responsibilities as a nurse. Doan & Brennan (2025) conducted a qualitative study at a public university in San Francisco, CA that analyzed the impact of assignments involving the Advance Health Care Directive, and the Five Wishes (Aging with Dignity, 2021) document. The results showed these assignments promoted personal insight, a better understanding of patient advocacy and professional awareness among baccalaureate and entry-level master nursing students. Students reported increased confidence in engaging in end-of-life (EOL) conversations, and increased understanding about EOL decision making. Barriers reported were discomfort and uneasiness initiating EOL conversations with patients, uncertainty when and how to introduce the Advance Health Care Directive or Five Wishes documents and lack of knowledge about legal responsibilities and the nurse’s role in the process. To address these barriers, the authors recommended clinical practice exposure to build confidence and EOL communication skills. Another recommendation was for nurse educators to incorporate active learning strategies such as role playing and case study discussions to increase student confidence and decrease discomfort and uneasiness when initiating discussions about ADs. Enhancing curricula to emphasize legal and ethical frameworks is essential for preparing students to facilitate decision making and understand their role...

Students may enter clinical practice unprepared to advocate for patients and their ADs (Tilton & Paul, 2020). In their study conducted in a baccalaureate program in Texas, Tilton & Paul (2020) developed a module about ACP including ADs for students to complete, which led to increased knowledge about ACP, the process for completing an AD, and increased confidence to discuss ACP and AD information. They also noted the willingness of students to discuss personal medical care preferences with their healthcare provider.

International Research about AD
International studies have shown similar findings. Shi et al. (2020) surveyed 261 nursing students in China. They reported overall positive attitudes toward ACP, but some concerns about the process. For example, students reported that discussing ACP could cause discomfort for patients and families. In addition, uncertainty about whether the ADs would be implemented presented barriers for nursing students to begin a discussion of ADs. Additional factors affecting the likelihood of students engaging in ACP included academic performance, religious beliefs, family relationships and previous discussions about death. Students may enter clinical practice unprepared to advocate for patients and their ADs.

Lopane et al. (2025) conducted a pre-post study in Italy. Results suggested that utilizing an oncology palliative care module can enhance nursing students’ knowledge and attitudes toward advance directives. Students reported an increased preference by patients to refuse non-beneficial treatments, indicating a better understanding of patient decision-making in end-of-life care. Internationally, Shi et al. (2020) recommended integrating structured end-of-life education and ACP training into nursing curricula to address knowledge gaps and improve implementation. Ng & Wong (2021) found that only 11.6% of Hong Kong nursing students felt adequately educated on ACP, even though they support its principles. These results demonstrate the need for culturally responsive and clearly outlined educational strategies. ...uncertainty about whether the ADs would be implemented presented barriers for nursing students to begin a discussion of ADs.

Overall, nursing students recognize the importance of ADs yet often face barriers to engaging in meaningful ACP conversations. Barriers that were identified included limited knowledge, discomfort initiating conversations, anxiety, lack of confidence with discussing ADs, and uncertainty about legal responsibilities (Lopane et al., 2025). In sum, studies across various nursing educational settings in the United States and internationally consistently showed targeted educational interventions that involved experiential learning, reflective assignments, and active learning strategies improved students’ preparation. Specific improvements were noted in the areas of knowledge, confidence, understanding, and willingness to advocate for patient autonomy (Doan & Brennan, 2025; George et al., 2018; Lopane et al., 2025; Pagano et al., 2020; Shi et al., 2020).

Evidence Based Strategies for Nursing Education about Advance Directives

Strengthening nursing curricula to address gaps about ADs is critical for preparing students to advocate for patients’ wishes and provide competent and compassionate care. Over the past 10 years, some evidence that supports active learning Overall, nursing students recognize the importance of ADs yet often face barriers to engaging in meaningful ACP conversations.strategies has shown effectiveness in preparing nursing students for AD discussions. Researchers (Brohard et al., 2021; Doan & Brennan, 2025; & Hall & Grant, 2014) have stressed the importance of embedding AD content into nursing curricula through active learning strategies. In their study, students completed the Honoring Choices Minnesota, which is a version of an AD, and had a discussion with their appointed healthcare proxy outlined in the document or someone they felt comfortable talking with about their end-of-life care choices. They then completed a reflection. Students reported increased confidence after completing their own AD and were more likely to encourage others to complete an AD and also to share AD documents with them.

Doan & Brennan (2025) further demonstrated the value of experiential learning by having baccalaureate nursing students enrolled in a three-unit Chronic Care and End-of-Life Theory course complete AHCDs or the Five Wishes assignment at a public university in San Francisco, CA. The assignment allowed students to engage in EOL conversations, gain insight into personal values, foster empathy and increase confidence with having EOL conversations. Pagano et al. (2020) integrated The Conversation Project (TCP) into graduate nursing curricula with the goal of preparing students to initiate and engage in AD conversations before a health crisis occurs. Using TCP resources, graduate students completed assignments, reflection activities, and role-play exercises focused on educating others about ADs. Students also participated in a community service-learning project, applying their knowledge in collaboration with community agencies to provide education about ADs. In the reflections, students reported decreased anxiety and improved communication skills related to ADs. Strategies to prepare ... nursing students to engage in AD conversations with confidence include utilizing simulations, reflective assignments, role-playing, and community-based projects.

Tilton & Paul (2020) emphasized the importance of integrating advance care planning (ACP) and advance directives (ADs) into baccalaureate curricula to better prepare students for clinical practice. Their study in Texas involved the development of a module that embedded ACP and AD concepts into a core nursing course when discussing caring for and care coordination of the older adult. Students engaged in experiential learning that included assigned readings, a video about ADs, pre- and post-surveys assessing readiness for ACP and ADs, the creation and presentation of ACP and AD content in class, completion of an AD, and role-playing using an ACP script. Post-survey results demonstrated increased student understanding of ACP processes, increased comfort with patient advocacy, improved ability to complete AD documents, increased knowledge of medical preferences and treatment choices, and improved comfort discussing their own healthcare preferences with their healthcare providers. Tilton & Paul (2020) recommended including clinical practice experiences to allow students to apply classroom knowledge in real-world settings, thus increasing their ability to advocate and support the completion of ADs. 

Brohard et al. (2021) implemented an AD simulation at a university in the Southwest United States. The simulation incorporated the American Association of Colleges of Nursing ([AACN], 2022) primary palliative care competencies and recommendations for educating nursing students to care for seriously ill patients and their families. The process immersed second degree baccalaureate students in a scenario where they were caring for a terminally ill patient transitioning to hospice care. The content included educating the patient and family about ADs. Post-simulation, students reported increased knowledge about hospice care and decision making related to ADs and end-of-life care. In addition, students reported growth in confidence, collaborative practice, and communication skills. Faculty help to shape nursing students’ readiness to engage with ADs.

Collectively, these studies (Brohard et al., 2021; Doan & Brennan, 2025; Hall & Grant, 2014; Pagano et al., 2020; Tilton & Paul, 2020) support the evidence base by demonstrating the clear effectiveness of active and experiential learning. Strategies to prepare undergraduate and graduate nursing students to engage in AD conversations with confidence include utilizing simulations, reflective assignments, role-playing, and community-based projects. These strategies have consistently led to improved communication skills, increased knowledge, decreased anxiety, and increased confidence with discussions about ADs. 

Impact of Nursing Faculty on Student Experiences with Advance Directives

Faculty help to shape nursing students’ readiness to engage with ADs. Hall & Grant (2014) and George et al. (2018) emphasized faculty-led instruction, such as incorporating didactic content about ADs each semester and providing clinical experiences that allow students to apply classroom learning to real world settings. Incorporating AD documents, such as including the Five Wishes, in learning activities fosters student empathy, knowledge, and confidence with ADs (Doan & Brennan, 2025). The Conversation Project provides resources that can be embedded throughout curricula to prepare students to engage and initiate in AD conversations before a health crisis occurs.

As part of their nursing programs, students can partner with local agencies to provide education about ADs. Doing so has reduced student anxiety, enhanced their understanding of ACP, increased comfort in discussing ACP with family and others, and even facilitated awareness of their own personal wishes (Pagano et al., 2020). Incorporating high-fidelity simulations that focus on ADs help faculty better prepare students to discuss ACP with patients and families in a safe environment, which can lead to an increase in student knowledge, confidence, and comfort (Brohard et al., 2021). Carvalho et al. (2020) emphasized the role of faculty to guide reflective journaling after an end-of-life simulation to help students process emotional responses, knowledge about end-of-life care, and the importance of honoring patient documented wishes. Incorporating high-fidelity simulations that focus on ADs help faculty better prepare students to discuss ACP with patients and families in a safe environment...

Internationally, Ng & Wong (2021) found gaps in Hong Kong’s nursing curricula and healthcare guidelines, in relation to vague role definitions which may hinder nursing students’ understanding of their role and responsibilities in ACP. They recommended that faculty develop clear definitions of healthcare team members roles and responsibilities and the development of team care models that define these roles and responsibilities with ACP. Students also had a lack of knowledge about ACP documents and policies. They suggested adopting clearer models, and recommended the United States-based End-of-Life Nursing Education Consortium (ELNEC) program (AACN, n.d.) to improve faculty-led ACP education.

In sum, faculty play an important role in developing nursing students’ knowledge, competence and confidence in AD education. Although research specific to student knowledge and ADs is limited, what we do know clearly supports faculty-led instruction utilizing didactic content, experiential learning, simulation, active learning and community engagement. These strategies have strong evidence to support improvement of students’ understanding of ADs, reduced anxiety, increased confidence and increased advocacy for patient wishes (Brohard et al., 2021; Doan & Brennan, 2025; Hall & Grant, 2014; Pagano et al., 2020; Tilton & Paul, 2020). In short, incorporating tools like the Five Wishes and The Conversation Project with reflective practices and clinical application enables students to translate classroom knowledge into real world patient-centered care. These findings also emphasize the need for nurse educators to integrate AD education throughout the curriculum to prepare students for professional responsibilities with ACP and ADs. These strategies have strong evidence to support improvement of students’ understanding of ADs...

Use of ELNEC in Undergraduate Nursing Curricula

The End-of-Life Nursing Education Consortium
ELNEC (AACN, n.d.) is a partnership between the City of Hope, a cancer center in California and the AACN. This consortium created online educational modules about palliative care across the lifespan (Cross et al. 2024; Davis et al., 2020; Gould, 2020). The six educational modules are available online and include case studies, videos on palliative care skills and quiz questions in the format of the National Council Licensure Examination ([NCLEX]; Cross et al., 2024; Davis et al., 2020). The ELNEC palliative care modules can be accessed in several ways including individual student purchase. Institutional partnerships allow nursing programs to offer the curricula through their bookstore, whereby students can use financial aid. Schools may also purchase access on behalf of students at a discounted volume rate.

Benefits of ELNEC Undergraduate Modules. Benefits of using the ELNEC modules include delivery through a user-friendly platform compatible with a variety of devices. Module content can be delivered in person, online, or integrated into existing courses. Students like the flexibility of completing modules based on their schedules and the variety of learning strategies that help reinforce important concepts (Davis et al., 2020). Other benefits are that the content in each module was developed by subject matter experts in palliative care, ease of use for faculty who are not experts in palliative care, and their use in a stand-alone palliative care course or integration throughout curricula. Each module contains an NCLEX style question quiz, and students can receive a certificate after successful completion (Cross et al., 2024; Davis, et al., 2020). Module content can be delivered in person, online, or integrated into existing courses.

Barriers of ELNEC Undergraduate Modules. Barriers of using the ELNEC modules include faculty reluctance to incorporate palliative care content into an already crowded curriculum, not knowing where to best place palliative care competencies into curricula, lack of faculty knowledge regarding the importance of palliative care to prepare for the generalist role, lack of faculty awareness about palliative care (i.e., some faculty may view palliative care as a specialty), and cost of the ELNEC curriculum (Cross et al., 2024; Davis et al., 2020). Strategies to address these barriers are to provide faculty with education about palliative care and specifically the importance of including it in curricula to prepare students for the generalist role. It can be helpful to discuss the importance of palliative care education with curriculum committees and administration, and to seek grant funding or (if necessary) charge a course fee to cover the expense (Davis et al., 2020).

Best Practices for Integrating the ELNEC Undergraduate Modules
Davis et al. (2020) recommend faculty champions that can provide education to colleagues about palliative care and the need for preparation of students about this topic to ease their transition into the generalist role. Commitment of nursing programs to provide ELNEC training for all faculty teaching in undergraduate programs is an important best practice. Options may include utilizing the ELNEC modules in a stand-alone palliative care course or integrating modules into already established coursework to align with course and program level learning outcomes. Davis et al. (2020) have suggested integrating modules throughout curricula to incorporate the communication, pain, and symptom management modules in early courses; utilizing clinical post conference as a time to debrief on module content; and incorporating the module concepts into simulation experiences. Cross et al. (2024) recommend integrating the pain management module into a pharmacology course. Commitment of nursing programs to provide ELNEC training for all faculty teaching in undergraduate programs is an important best practice

The incorporation of ELNEC modules into undergraduate nursing curricula provides preparation to deliver end-of-life and palliative care to patients across the life span while also supporting families. Modules may be integrated into current nursing curricula or utilized in a stand-alone palliative care course. Resources, guides, and topic specific materials are provided to faculty to assist with classroom and clinical applications. Although AD content is not a separate module, it is integrated within the communication module of the ELNEC curriculum.

To prepare nursing students to make the transition to the generalist role, which includes responsibilities related to ADs, nursing programs using the ELNEC modules should consider developing a stand-alone module on ADs. Such a module could include content about state laws, pertinent legislation including the Patient Self-Determination Act (Congress.gov, H.R., 4449, 1989-1990), and guidelines about effective communication strategies that include teaching patients about ADs. The content should also include education about the types of ADs, the driving principles providing support for ADs (e.g., the ANA 2025 Code of Ethics, especially Provision 1.4 The Right to Self-Determination), and the nurse’s role related to ADs. Covering these important concepts would prepare students for practice with the knowledge and skills needed to engage in advance directive conversations and support patients in making informed end-of-life decisions.

Implications for Employers of Recent Graduate Nurses

Lacking sufficient attention to ACP and ADs in nursing program curricula using any of the strategies discussed above, employers of recent baccalaureate graduates will likely have to address their lack of knowledge. Strategies to address this gap could include jurisdictional-specific information offered at in-service orientation. At minimum this should include legal requirements and specific forms for ADs. Using actual documents in real life scenarios may help familiarize nurse graduates with ACP and AD documents. A final recommendation for employers of recent nurse graduates is to encourage nurses to begin their own EOL and ACP, including completion of the AD forms for their jurisdiction. This has been demonstrated to normalize these conversations about dying as well as help nurse graduates feel more confident in initiating the discussion and filling out AD documents. Using actual documents in real life scenarios may help familiarize nurse graduates with ACP and AD documents.

Conclusion

Barriers to providing education about ADs frequently originate from perceived taboos about discussion death in personal terms. Normalizing the conversation about death and dying could help facilitate patient and family discussions about EOL and AD options. Other issues that often prevent educating nursing students about ADs may include lack of instructor knowledge about this process and even the perception that ADs are a nursing specialty and not an integral part of the generalist nurse role. An additional challenge can include facilitating widespread training in EOL care, and specifically ADs, for all nurse faculty who teach at the undergraduate level. Faculty who have received specific education in these important areas may be more likely to embrace use of the ELNEC modules. Other barriers relate to the difficulty teaching about legal aspects of ADs. For example, faculty may be concerned about their liability while teaching a part of nursing skills and knowledge with a potential lasting financial impact on patients and families; differing statutes that regulate ADs; changing regulations; and the role ambiguity regarding the nurses’ role in the AD process. Normalizing the conversation about death and dying could help facilitate patient and family discussions about EOL and AD options.

A review of the current research regarding Advance Directives (ADs) and nursing students clearly supports the need for education about this important topic at the undergraduate and graduate levels, and the effectiveness of current strategies. Experiential learning, including simulation of real-world scenarios; incorporation of readily available, well-established resources, such as the ELNEC modules; and partnering with local agencies for community-based clinical experiences are evidence-based approaches to consider as nurse faculty work to address these barriers and facilitate advanced directive preparedness.

Authors

Blanca Miller, PhD, RN
Email: bmiller@methodistcol.edu

Blanca Miller is Dean of Nursing at Methodist College, where she leads advance directive curriculum development. Drawing on her clinical experience as a critical care nurse and commitment to advancing education on advance directives within nursing academia, she is well equipped to address the complexities of teaching this critical topic. Her background provides both practical insight and academic perspective essential for meaningful curriculum integration.

Erin Reitz, PhD, MS, MBA, BS, RN, NEA-BC
Email: oreitz2@ilstu.edu

O. Erin Reitz has a BS (1982), and MS (1985) in social sciences, an MBA (1989) from Illinois State University, a BSN from Mennonite College of Nursing (1994) and a PhD from University of Illinois at Chicago (2009) in Nursing Science. She is a Board-Certified Nurse Executive (NEA-BC) and currently an Associate Professor of Nursing at Mennonite College of Nursing. She has practiced in a multitude of settings including pediatrics, long term care, acute care and home health and been a peer reviewer for Geriatric Nursing.