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High-Fidelity and Gaming Simulations Enhance Nursing Education in End-of-Life Care

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Abstract

Existing research suggests that nursing education has not adequately prepared nurses to provide quality end-of-life care. As the population in the United States ages and chronic diseases increase, the number of dying patients will also increase. It is now more important than ever that nurses provide high-quality end-of-life care to those patients dying in hospitals or other inpatient facilities. Opportunities to care for dying patients are often unavailable to students in traditional clinical settings. This article describes the use of simulation as an innovative teaching strategy to prepare students in providing end-of-life care. The authors describe how an end-of-life scenario using high-fidelity simulation and an experiential gaming simulation, Seasons of Loss©, were used to enhance the curriculum on end-of-life care presented to nursing students.

Introduction

This article discusses how a baccalaureate nursing program enhanced its end-of-life (EOL) care experience by developing high-fidelity and gaming simulations using the simulation learning pyramid strategy. These strategies were incorporated into an existing Aging Adult Health five-credit theory and clinical course taken by first-semester junior nursing students.

In the United States, the majority of deaths occur in hospitals, medical centers, and long-term–care facilities. As a result, nurses are the professionals uniquely positioned to provide EOL care for these patients and their families; they are the ones at the bedside with these individuals at the end of life (Duke and Northam, 2009, Kelly et al., 2008, Robinson, 2004, Wallace et al., 2009.

By 2030, it is projected that 20% of the U.S. population will be older than 65 years of age. Because of the increase in the aging population, the increase in chronic diseases in this group, and the significant role nurses play in EOL care, it is imperative that nurses are adequately prepared to provide quality EOL care to meet the needs of dying patients and their families (Block, 2002, Easom et al., 2006, Mallory, 2003).

Providing quality EOL care is dependent on adequate knowledge and education. However, literature supports the fact that there is a serious deficit in formal EOL education in undergraduate nursing programs (Block, 2002, Kelly et al., 2008, Mallory, 2003, Robert Wood Johnson Foundation, 2010). To address this deficiency, many organizations across the United States have developed educational programs, position statements, policies, guidelines, and clinical resources with the goal of adequately preparing nurses to provide competent and compassionate care. Examples of the competencies and guidelines that some organizations have developed include the End-of-Life Nursing Education Consortium competencies and guidelines (see Table 1 at www.nursingsimulation.org). Funded by a grant from the Robert Wood Johnson Foundation, (RWJF) this is a national education program to improve EOL care by nurses. The End-of-Life Nursing Education Consortium has identified key elements and nine modules for nurses regarding EOL care: (a) nursing care at the end of life; (b) pain management; (c) symptom management; (d) ethical and legal issues; (e) cultural considerations in EOL care; (f) communication; (g) grief, loss, and bereavement; (h) achieving quality care at the end of life; and (i) preparation and care for the end of life. These elements can be used as a foundation for nursing education on EOL care (Robinson, 2004).

The American Association of Colleges of Nursing, supported by the RWJF, gathered a roundtable of expert nurses and other health care professionals and identified competencies regarding EOL care that every undergraduate nursing student should attain. The resulting Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care include promoting the provision of comfort care to the dying as an active, desirable, and important skill and an integral component of nursing care; communicating effectively and compassionately with the patient, family, and health care team members about EOL issues; recognizing one's own attitudes, feelings, values, and expectations about death and the individual, cultural, and spiritual diversity existing in these beliefs and customs; and assisting the patient, family, colleagues, and oneself to cope with suffering, grief, loss, and bereavement in EOL care. The complete list can be accessed at www.aacn.nche.edu/publications/deathfin.htm.

The National Council of State Boards of Nursing, the developer of the National Council Licensure Examination–Registered Nurse, has identified content in EOL care that is tested on the licensure exam. The National Council Licensure Examination Detailed Test Plan 2010 related to EOL care includes the following elements: Safe and Effective Care Environment; Management of Care (advanced directives)—providing and directing nursing care that enhances the care delivery setting to protect patients and health care personnel; Psychosocial Integrity (EOL care)—providing and directing nursing care that promotes and supports the emotional, mental, and social well-being of the patient experiencing stressful events, as well as patients with acute or chronic mental illness; and Physiological Integrity, including Basic Care and Comfort (nutrition and oral hydration and nonpharmacological comfort)—providing comfort and assistance in the performance of activities of daily living. The test blueprint can be accessed at www.ncsbn.org/2010_NCLEX_RN_Detailed_Test_Plan_Educator.pdf.

Clinical Practice Guidelines for Quality Palliative Care have been developed by the National Consensus Project for Quality Palliative Care, a group of five leading palliative care organizations in the United States. These guidelines form a national consensus on what the standard of good palliative care should be. They support eight domains of palliative care: structure and processes of care; physical aspects of care; psychosocial and psychiatric aspects of care; social aspects of care; spiritual, religious, and existential aspects of care; cultural aspects of care; care of the imminently dying patient; and ethical and legal aspects of care. The complete set of guidelines can be accessed at www.nationalconsensusproject.org/guideline.pdf.

Section snippets

Identifying the Need for Enhancement

Data from a program assessment of nursing students graduating from a baccalaureate nursing program revealed students either did not feel comfortable caring for a dying patient and the patient's family or did not have the opportunity available to them. This data, along with the research that demonstrates that nursing education lacks both didactic and clinical experiences in EOL curricula and the emergence of guidelines from professional organizations, has resulted in the need to enhance the

How Students Benefit From Simulation

High-fidelity patient simulation is gaining a well-respected place in nursing education. The advantages of using simulation are noted extensively in the nursing literature (Nehring & Lashley, 2010). Simulation is an excellent strategy for students to learn experientially. It can be guided by strategies emphasizing role modeling by expert nurses, self-discovery, analysis by students, and demonstration of the ways expert nurses think through a patient situation (Lambton, 2008). Simulation is goal

Simulation Learning Pyramid

Doerr and Murray's (2008) simulation learning pyramid contains four basic components (Figure 1). By incorporating these components, one can develop a successful simulation. The simulation plan involves defining the objectives, selecting a patient, and creating a scenario. The simulation involves setting the ground rules, orientating the students to what the simulator can do, and then performing the simulation. Debriefing is a valuable tool in which the group actively discusses the scenario,

Integrating Simulation Into EOL Care

In response to the identified need and using Doerr and Murray's (2008) simulation learning pyramid as a guide to integrate simulation into EOL content, we incorporated a high-fidelity simulation and a gaming simulation. These strategies, added to the aging adult health course for first-semester juniors, were incorporated to enhance the current methods, which included primarily didactic instruction using the nine modules created by the End-of-Life Nursing Education Consortium. Mallory (2003)

First Strategy

The first strategy involved a high-fidelity simulation using the Medical Education Technologies (METI) Emergency Care Simulator and EOL scenario. Using Doerr and Murray's simulation learning pyramid, we developed a simulation plan. The learning need was identified from program assessment data. From that learning need, the following objectives were developed: Prioritize nursing management of the dying patient, evaluate outcomes of nursing care and interventions, and modify care as needed for the

Conclusion

Because undergraduate education provides the foundation for nursing care, it is essential to provide appropriate EOL education in the nursing curriculum (Ferrell et al., 2000). Incorporating EOL care into simulation practice is essential if nursing education is to promote a quality experience for the dying patient and the patient's family.

Hurtig and Stewin (1990) and Rothgeb (2008) have found that a personal affective approach using experiential learning is more effective than simply providing

Future Needs

The use of high-fidelity and gaming simulations will be an integral part of the EOL content in the Aging Adult Health course. It would be valuable to design and conduct a research study using measurable outcomes to test these pedagogies. It may also be valuable to explore the student nurses' thoughts and feelings regarding the impact that these strategies have had on the transference of the information into the clinical arena and how it influenced their overall experience of caring for a dying

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