Author: Anna Boneberg, MSN, PNP-BC, CNE
Title: Clinical Assistant Professor and Doctoral Student
Institution: D’Youville College and Teacher’s College, Columbia University
Skills or Simulation Laboratories
1. Demonstrates professionalism in behaviors while caring for dying patient (knowledge, skills, attitude)
2. Utilize therapeutic communication techniques (ex. SBAR when speaking to provider) (skills)
3. Assess spiritual and cultural needs of patient and family during dying (knowledge, skills)
4. Provide patient and family-centered approach to care with sensitivity and respect for diversity (knowledge, skills)
5. Evaluate personal beliefs and values that influence ability to provide care to the dying (attitude)
End-of-life care is a topic in nursing education that is challenging to teach as it is a sensitive topic and clinical practice experiences are limited. Both the American Association of Colleges of Nursing (AACN) and the Institute of Medicine (IOM) have called for nursing education to prepare students to deliver safe and quality-nursing care to dying patients (Kirkpatrick, Cantrell, & Smeltzer, 2017). Many nursing programs provide this information in the didactic component of courses, using lecture only does not allow students to reflect on their emotions and experience in caring for dying patients (Kirkpatrick, Cantrell, & Smeltzer, 2017). Integration of high-fidelity patient simulation into the curriculum allows nursing students to care for the dying patient. Simulation research studies have shown that students have an increase in self-confidence, increase in communication skills, and improvement in clinical judgment after participating in simulation experiences (Cole & Foito, 2019). This scenario regarding pediatric end-of-life care will provide nursing educators with a teaching tool to assist in bridging the theory-practice gap by allowing nursing students to practice in an environment that is safe.
High-fidelity patient simulation allows nursing students to participate in a clinical scenario that is realistic in nature without having to worry about harm to a real patient. Nursing students are able to transfer the knowledge and skills gained in simulation into clinical practice improving patient care. Simulation has been greatly influenced by Malcom Knowles’ theory of adult learning (Clapper, 2010). Adult learners have different characteristics than younger learners, including: (a) self-directed, (b) previous experiences that serve as a knowledge resource during the learning process, (c) internal motivation, and (d) readiness to learn and improve social roles (Clapper, 2010). During simulation, the instructor serves as a facilitator of learning allowing the student to become actively engaged in the learning process. Students are also able to promote understanding through doing allowing the merger of theory with practice when participating in simulation (Clapper, 2010).
End-of-life care tends to cause anxiety for nursing students as this time is an emotional experience for all involved. During this time in a patient’s life, nurses spend more time with them than any other health professional (Cole & Fioto, 2019). Utilizing effective communication with patients and members of the health care team is essential to achieving positive patient outcomes (Smith et al., 2018). One of the learning theories that were utilized in scenario development was constructivism. Using the active learning technique of simulation with an end-of-life scenario allows learners to develop ideas or concepts upon using their current or past knowledge (Brandon & All, 2010). Students will develop principles and skills on their own while performing the end-of-life scenario and instructors serve as facilitator and coach. During the debriefing session, instructors encourage the students to assess the activity’s ability to assist in gaining. Understanding (Brandon & All, 2010).
The second learning theory utilized was Bandura’s social learning theory. Bandura emphasizes the importance of observational learning and modelling (Bahn, 2000). Students not actively participating in the scenario will be observing the experience and completing a simulation observer checklist. Social learning theory states that observation allows for a safe way of acquiring complex patterns of behavior as opposed to trial and error (Bahn, 2000). These observations will be reinforced further during the debriefing session as students reflect on the scenario and actions taken during completion by those performing nursing tasks. This type of vicarious learning that occurs in nursing education is linked with socialization (Bahn, 2000).
Description of Scenario
Being assigned a patient at the end-of-life can be emotional and anxiety provoking, imagine being a new graduate who has never cared for a patient at that time and the only preparation was through didactic material. Simulation can bridge the gap between theory and practice through the use of end-of-life simulation scenarios. Teaching students to care for the dying child and family including utilization of therapeutic communication and appreciation for the individualized response of the family (Cole & Fioto, 2019). Simulation experiences can provide nursing students with valuable opportunities to practice how to respond to challenging situations especially when unintended actions can lead to further family distress (Cole & Fioto, 2019). Effective communication skills are essential to providing the patient and family with psychosocial and spiritual support during one of the most difficult times they will face (Smith et al., 2018). This scenario allows nursing students to practice communication skills with parents during end-of-life experiences. It takes place during the shift of a planned withdrawal of support. The 3-year-old child has been declared brain dead after a drowning incident. Nursing students will be given report from the night nurse and be expected to care for the patient/family throughout the dying process. Students participating in simulation experiences have reported improvement in their communication skills allowing for better preparation to care for dying patients in clinical practice (Smith et al., 2018).
End-of-life situations are unpleasant and stressful regardless of experience level. Undergraduate nursing students may not encounter end-of-life experiences during their clinical rotations leaving them without any experience when entering clinical practice. Nursing students require the ability to communicate with the patient and patient’s family while providing quality care to the dying patient. Emotional reflection by the student nurse is also necessary during end-of-life experiences as one’s personal beliefs may not match those of the patient/patient’s family. End-of-life simulation experiences can assist nursing students in meeting the following QSEN competencies: (a) patient centered care, (b) teamwork and collaboration, and (c) safety.
The simulation would take place in a simulation lab located within a school of nursing or simulation center. The simulation manakin would be a high-fidelity pediatric manakin with moulage to look like a 3-year-old female. The patient room would be decorated similar to a pediatric hospital room. In the room would be the following: (a) patient bed, (b) IV poles and pumps with drips outlined on the NLN scenario template attached, (c) ventilator or tubing from patient leading to assumed ventilator, (d) chairs for visitors, (e) bedside stand, (f) over the bed table, and (g) suction and oxygen outlets. There would be a separate debriefing room where students and faculty could watch the scenario unfold via AV equipment. Attached is the NLN Simulation Scenario Template (NLN, 2018) with further detail regarding the setting (Appendix A).
Debriefing has been used in many situations to analyze what occurred and develop strategies to improve future experiences (Nehring & Lashley, 2010). Using debriefing after simulation allows the participants to reflect on actions during the exercise allowing for learning to occur. Learners should feel safe during debriefing being able to share their thoughts and feelings about mistakes without being criticized or ridiculed in order to promote reflective thinking to promote improved patient care outcomes (Nehring & Lashley, 2010). Debriefing of the scenario will take place in a private room away from the simulation room. During the scenario, students in observation role will be given a plus/delta worksheet while watching the active participants. They will have two columns to complete on the worksheet: plus (behaviors that were performed well) and delta (behaviors that need improvements along with suggestions to do this).
Debriefing will then take place in verbal format with the facilitator and clinical faculty leading students in reflection. Open-ended questions will be asked in order to allow students to reflect on what occurred during the simulation. The facilitator should be aware of their voice tone, nonverbal actions, and words utilized in order to foster effective learning (Nehring & Lashley, 2010). The NLN Simulation Scenario Template (NLN, 2018) provides a list of general opened questions to assist in guiding facilitators during the debriefing session (Appendix A). The facilitator should also add the following questions that are specific to the end-of-life scenario:
1. What was your first reaction to the sign-out you received?
2. What do you feel went well during the simulation?
3. What difficulty did you have in caring for a child who was being withdrawn from support?
4. Which communication skills did you use when interacting with the family?
5. How did this experience differ from your thoughts about patient death in pediatrics?
6. How did you feel at the end of the scenario regarding the care you provided?
Script for orientation to the simulation lab and scenario.
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Nursing students will be evaluated by the facilitator on their clinical nursing skills and use of therapeutic communication. The evaluation will be formative as it is designed to focus on the teaching-learning process (Nehring & Lashley, 2010). The facilitator will use a checklist to evaluate the nursing students as they perform their roles during simulation allowing for feedback to be provided to the students upon completion (Appendix C).
Nursing students will have one week after the scenario to complete a reflective journal. Instructions for the reflective journal will be clearly written so that students are able to evaluate their use of therapeutic communication techniques (Appendix D).