Author: David Foley, PhD, MSN, RN-BC, CNE, MPA
Title: Assistant Professor and Director of Faculty Development
Institution: Case Western Reserve University Frances Payne Bolton School of Nursing
Evidence-Based Practice, Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration
Pre-Licensure ADN/Diploma, Pre-Licensure BSN
Through participation in this End-of-Life Simulation Exercise, the student will individually and collectively:
• Identify QSEN competencies observed during discussions of end-of-life care between team member (i.e. nurse, advanced practice nurse, physician, and chaplain), patients, and family members.
• Identify opportunities to promote a meaningful end-of-life experience for patients as framed within the QSEN Competencies of patient-centered care, evidence-based practice, safety, and quality improvement.
• In particular, highlight the importance of teamwork and collaboration as an effective means to affect positively patients and their families as they face end-of-life care planning.
Strategy Overview: End-of-life decision making can present patient-care scenarios highlighted by anxiety, spiritual distress, and complex family dynamics. Patients may discuss end-of-life planning with their bedside nurse, advanced practice nurse, physician, social worker, or chaplain as part of planned discussions or spontaneous interaction. As the nurse can often be the guiding force for these conversations and thus initiate referrals to other team members, opportunities are evident to frame these potentially difficult decisions within the QSEN competencies of patient-centered care, teamwork/collaboration, evidence-based practice, and safety. Given their highly sensitive nature, such conversations between patients, families, and other members of the team may understandably exclude students, thus excluding them from valuable opportunities for observational or interactive learning.
In response, a didactic nursing instructor developed a classroom-based simulation utilizing acting students as well as an actual hospital chaplain to re-create such a conversation on end-of-life planning between a nurse-actor, patient-actor, family members-actors, and licensed chaplain. After introductory comments by the instructor, a nurse-actor greeted the patient-actor, who conveyed much conflict between his spiritual beliefs and his desire for end-of-life planning and in turn expressed concern about how his decisions may be perceived by his family. During the discussion, the nurse-actor explored options for patient-centered care from the perspectives of choice, autonomy, and locus of control.
With no resolution for the patient-actor’s perceived conflict, the nurse-actor further recognized the opportunity engage in teamwork/collaboration by involving a practicing chaplain (also referred to as spiritual care in many institutions) as he discussed his wishes with family members. The chaplain, recruited from a nearby hospital, afforded students the chance to observe spiritually-based techniques designed to allay concern, provide comfort, and support patient choice. At the end of the scenario, the didactic instructor asked students to present questions to the actors as they remained in character, allowing them to engage in their art of improvisation.
Students further explored the patient-actor’s perspective on end-of-life planning, recognized opportunities to education, explored complex family dynamics, and perhaps identified further opportunities for additional interdisciplinary referrals (Social Work or the Physician). At the end of the improvisational session, faculty provided concluding comments and reviewed basic course concepts that were highlighted during the simulation—and perhaps identified concepts that needed further exploration. As with the clinical post-conference, a simulation debrief in the didactic classroom allowed students to convey thoughts and emotions in a safe, affirming environment as they benefitted from the faculty’s clinical expertise.
Follow-Up Reflective Journal: As a follow-up assignment, the didactic instructor asked the students to author a brief, one page reflective journal on how effectively the QSEN Competencies were explored during the exercise on end-of-life care. Such reflection is encouraged so students will engage the QSEN Competencies through the affective as well as the cognitive domains. The reflective journal presented three basic questions:
1. Which QSEN Competencies were engaged during today’s end-of-life simulation experience? Provide specific examples of each.
2. Comment on the application of QSEN Competencies to complex and often ethically laden scenarios such as end-of-life planning.
3. Describe how you may apply the QSEN Competencies like end-of-life care or other sensitive patient-care situations in your future nursing practice.
Alignment of QSEN Competencies with Didactic Course Objectives:
• As with any planned course activity, the QSEN End-of-Life Simulation is planned in accordance with course objectives and thus affirms curricular alignment:
o Students are requested to participate fully during the classroom-based simulation as they would during any patient care interaction in the clinical setting.
o As the clinical expert in the classroom, the didactic instructor’s pre-and post-simulation comments highlight course content as well as carefully frame the scenarios within the QSEN Competencies
o Faculty read the students’ reflective journals and provide formative constructive feedback on the application of course content and effective therapeutic communication as they engage the patient, family members, and chaplain in conversation that promotes patient-center care, safety and teamwork-collaboration, all supported by evidence-based practice.
With much careful planning, a complex clinical scenario involving end-of-life care and can highlight the need for effective teamwork and collaboration even as patients and their families face sensitive and potentially ethically laden decisions involving end-of-life care planning. The QSEN competencies can be an effective framework to maximize students’ opportunities to individually and collectively identify opportunities to enhance patient care as well as clarify their own thoughts and feelings. Classroom group discussions, faculty debriefing, and introspection through reflective journaling can all be effective mans to exploring the QSEN competencies’ efficacy, even during end-of-life planning.
Lindemulder, L, Gowens, S., & Stefo, K. (2018). Using QSEN competencies to nursing student end-of-life care during simulation. Nursing 48(4), 60-65.
Fabro K, Schaffer M, Scharton J. The development, implementation, and evaluation of an end-of-life simulation experience for baccalaureate nursing students. Nurs Educ Perspect. 2014;35(1):19–25.
Siles-Gonzales & Solano-Ruiz (2016). Self-assessment, reflection on practice, and critical thinking in nursing students. Nurse Education Today, 45, 132-137.
1. Suggested outline of end-of-life classroom simulation
2. Critical Reflection Journal Template
1). Critical Reflection Journal faculty feedback
2). Informal feedback from students and actors
3). Comments made by students on course evaluations