Quality end-of-life (EOL) care requires the utilization of special knowledge and skills by professional nurses. Pesut et al. (2014) have stated that "an aging population requires that nurses in all areas of practice be knowledgeable about high-quality palliative care" (p. 47). Because EOL events are not always readily available, nursing students often lack opportunities to learn the knowledge and skills necessary to provide palliative care.
High-fidelity simulation (HFS) is an appropriate teaching method for teaching EOL care to nursing students, as it provides students with the opportunity to respond, react, and increase their levels of self-confidence in a safe and supported environment. As supported by Smith-Stoner (2009), "Simulators provide an effective bridge between the unknown of caring for a dying person and developing the skills necessary to facilitate a meaningful death experience for patients and their families" (p. 115). However, researchers have identified the need for further research on the effects EOL education and HFS have on students' cognitive skills and confidence levels (Sanford, 2010; Sperlazza & Cangelosi, 2009).
The purpose of this study was to explore reports of confidence and overall learning immediately, at 1 year, and at 2 years following an EOL simulation. The population included a convenience sample of nursing students and recent graduate nurses.
METHOD
The simulation was designed to introduce first-semester junior nursing students to an EOL experience and allow them to observe the management of EOL care. The simulation setting was prepared to resemble an oncology patient's room. Two oncology nurses assumed their natural work roles, and one nursing instructor acted the role of the dying patient's daughter and sole family member. A high-fidelity simulator manufactured by Medical Education Technologies, Inc. (METI) was dressed to resemble a dying cancer patient and programmed to display appropriate physiological changes.
Each student sample group received the same preparation materials and experienced the same simulation script, software program, and structural environment. Debriefing was a vital component of the experience for all groups.
Following institutional review board approval, the researcher provided participants with written instructions. Protection of human rights was ensured, and informed consent was obtained; participation was voluntary and anonymous. Data collection took place at one private, single-purpose baccalaureate nursing program located in the Midwest or by mail. Participants completed a researcher-generated demographic survey and the 13-item Simulation Effectiveness Tool (SET), developed by METI to evaluate overall learning and confidence levels.
The learning subscale consisted of eight items with a Cronbach's alpha of .87; the confidence subscale consisted of five items with a Cronbach's alpha of .84 (Elfrink, Leighton, Ryan-Wendger, Doyle, & Ravert, 2012). A 3-point Likert-type scale provided participants with a range of responses (strongly disagree, somewhat agree, strongly agree, and not applicable).
Junior nursing students were administered the SET in a private room following their EOL HFS debriefing. Seniors were administered the SET in a private room and were instructed to evaluate their current perceptions of the EOL simulation experience that was implemented 1 year prior during their junior year. Nurses who had graduated from the program 6 months earlier were invited by mail to participate in the study; they were asked to evaluate their current perceptions of the EOL simulation experience that was implemented 2 years earlier during their junior year.
Descriptive data analyses were conducted using SPSS 17.0. Of the 100 eligible participants, 72 completed the study: 24 (33.33 percent) were junior nursing students, 36 (50 percent) were senior nursing students, and 12 (16.67 percent) were recent graduate nurses.
QUANTITATIVE RESULTS
Sixty-five of the pooled survey participants (90.3 percent) either strongly agreed or somewhat agreed with the confidence subscale survey statements supporting confidence in their abilities to manage an EOL event. Results indicated that 62 participants (86.1 percent) either strongly agreed or somewhat agreed with the overall learning statements.
A two-way chi-square analysis indicated no significant difference in the responses of junior, senior, or graduate respondents (p < .05). These results support the use of simulation as an effective EOL teaching modality; junior students rated the same level of confidence as senior students and practicing graduate nurses who had experienced the same simulation scenario 1 and 2 years prior, respectively.
OBSERVATIONAL ANALYSIS AND COMMENTS
Although the study was designed to gather quantitative data, observations were noted by the researcher. Informal observational analysis identified the EOL simulation to be an emotional experience; tears were shed by the simulation participants and student observers. One junior shared how her personal and cultural beliefs made the simulation difficult to observe; in her culture, it was considered disrespectful for a family member to say "goodbye" to a dying person.
A comments section located on the SET provided participants the opportunity to share unsolicited written feedback. Several juniors indicated that the simulation was an effective learning tool that enhanced their understanding of the nurse's role throughout the EOL process. Senior participants who had experienced the simulation a year earlier shared that the experience "felt very real." One senior wrote that "simulation is a wonderful way to learn!"
A graduate nurse participant who had experienced the simulation 2 years earlier shared how she "vividly remembered the EOL simulation." She indicated that, by providing the basics of EOL care, the simulation helped reduce her personal anxiety about providing care for a dying patient.
The debriefing period provided an opportunity for students and simulation participants to ask questions and share personal experiences. Several students mentioned experiences they had had with family members and with patients they had cared for in clinical settings. The importance of effective therapeutic communication was a common theme shared throughout the debriefing. One participant shared that the simulation helped her realize that involving the family of a dying patient is as important as caring for the patient.
Different types of EOL experiences, such as unexpected or traumatic death, were also discussed during the debriefing period. This allowed students to appreciate the uniqueness of each EOL experience. Further discussions surrounded the topics of medication administration, comfort measures, religious practices, organ donation, and, most importantly, effective communication between family members and members of the health care team.
DISCUSSION
This study was limited by the relatively small number of participants and the homogeneity of the sample, as well as the focus on care of a simulated oncology patient only. More participants with other EOL situations would add to the generalizability of the results. In addition, baseline measurements, including students' perceptions and prior experiences with EOL care, were not evaluated prior to the simulation experience. Literature reviews show that prebriefing, including informing students of the nature of the simulation and that the simulator may or will die, will help promote psychological safety for students (Gillan, Jeong, & van der Riet, 2014). Having experienced prior EOL events, coupled with personal, religious, or cultural beliefs, may have influenced student perceptions during the simulation event.
This simulation provided students with the opportunity to observe an expected EOL event, but EOL events are not always expected. Had the scenario focused on trauma or other medical conditions, students may have reacted differently. Despite the limitations, the review of literature conducted by Gillan and colleagues (2014) found that "the reality of the simulation may have helped students recognize the inherent stress in caring for a dying person."
CONCLUSION
This study contributes to the body of nursing knowledge by providing quantitative and unsolicited participant comments to describe, evaluate, and support the outcome of confidence and overall learning among nursing students and new nursing graduates following an EOL simulation event. The data obtained from this study validate the use of HFS as an effective and sustainable tool for teaching entry-level nursing students the special knowledge and skills necessary to provide EOL care.
Continued evaluation of student outcomes and confidence levels following an EOL simulation can significantly add to the nursing education knowledge base. Research should explore the effects of EOL simulation events on student confidence levels, particularly in the areas of communication, clinical reasoning, and prioritization of care. Prior experience with EOL care and the extent of the experience should be explored as it would provide a solid comparative baseline. Unsolicited qualitative data from this study support the need to explore personal and cultural beliefs surrounding EOL care.
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