In the past decade, innovative use of simulation has been transforming nursing education. Although simulation using human patient simulation (HPS) is a highly effective teaching strategy, gaps remain between the experiences that nursing education and simulation offer and what students and graduates encounter in the clinical environment. Nurse educators conducting research in simulation identified student-reported lack of preparation for end-of-life (EOL) care and patient deaths (Fluharty et al., 2012; Hamilton, 2010; Leighton, 2009; Leighton & Dubas, 2009; Robinson, 2004). A brief review of the recent simulation literature reveals multiple studies and reports of simulations in which the HPS dies in palliative care or hospice care, or scenarios in which the death is expected. The focus of these simulations is on assessment of the dying patient, comfort care, and therapeutic communication with the patient and family members. Leighton (2009) indicated that students express feelings of anxiety and lack of communication skills surrounding the death of a patient. Kopp and Hanson (2012) reported that students express a lack of preparation by the nursing curriculum for EOL care and a lack of opportunities in the clinical setting to increase their comfort in giving care to dying patients. Hamilton (2010) suggested that students need opportunities to increase coping strategies to decrease fear and anxiety when confronted with death and dying. Little information exists regarding EOL issues specific to unexpected death, the bearing of bad news, and postmortem care. Leighton and Dubas (2009) posited that nursing literature indicates a lack of education related to death and dying, resulting in unprepared students who will be called on to care for patients at the end of life sometime in their careers.
This EOL simulation was specifically developed for Competencies II, a front-loaded, skills-based course with both laboratory (1 credit) and clinical (1 credit) components. Competencies II is offered during the first semester of the junior year in a 4-year traditional baccalaureate nursing program and runs concurrent with students’ first medical–surgical practicum. Students participate in three simulations over the course of the semester: (a) a medication administration simulation in week 2, (b) a blood transfusion reaction simulation mid-semester, (c) and this EOL simulation in the last week of the course. This simulation addresses the following main objectives that are reflective of accreditation guidelines (American Association of Colleges of Nursing, n.d.) to (a) demonstrate principles of caring; (b) demonstrate effective communication with patients, family, and interprofessional team members; (c) perform key assessments and evidenced-based interventions for myocardial infarction and lethal dysrhythmias; (d) explore personal and professional attitudes and feelings regarding death; (e) facilitate coping with loss and bereavement for self, team members, and family; (f) engage in the care of the patient who has died and of his or her family; and (g) participate in postmortem care.
To facilitate achievement of the desired outcomes, students receive a preparation sheet 1 week prior to the simulation with the patient history and status, common emergency drugs, and specific cardiopulmonary resuscitation (CPR) skills they should review. Readings assigned from course textbooks cover: (a) cultural and spiritual nursing care; (b) grief, loss, and palliative care; (c) cardiac arrest, CPR, and defibrillation (Assessment Technologies Institute, 2010); (d) administering emergency measures to the hospitalized client; (e) EOL care (Berman & Synder, 2012); and (f) and the End-of-Life Nursing Education Consortium (ELNEC) fact sheet (American Association of Colleges of Nursing, 2012). On simulation day, students are introduced to the basic expectations of a nurse during a code and view a YouTube example of a megacode. This is followed by a 30-minute introduction to the simulation environment, which includes examination of the manikin, code cart, drugs, defibrillator, monitor, and other equipment in the room. Student code teams, composed of 4 or 5 students, meet for an additional 30 minutes to determine roles and devise a general plan for the scheduled megacode simulation. Due to the nature of the course, a faculty member acts as the physician, facilitating the completion of tasks, providing direct orders, and coaching technique. American Heart Association (AHA, 2011) algorithms, although not expressly taught, are followed. The Table provides an example rotation schedule for five students.
End-of-Life Simulation Rotation Schedule
Students are greeted at the door by a nurse who tells them she “has to run,” but that the report she sent them is accurate and that the patient is expecting them. Two students enter the room to find the monitored patient unresponsive and in ventricular fibrillation. These first responders must press the code button and begin CPR to trigger the entry of the rest of the peer group with the code cart and defibrillator. Placement of the backboard under the patient cues the arrival of the faculty “physician.” Under the direction of the faculty physician, students perform the 2-minute shock–drug–CPR sequence several times. Upon learning the patient’s history from students, the faculty physician requests a cardiology consult and asks someone to notify the patient’s wife. After 10 minutes, the monitor shows asystole. After approximately 18 minutes, with no return of spontaneous circulation, the code is called and the scenario ends. Students are told that despite their best efforts, the code was unsuccessful and the patient is pronounced dead.
The megacode simulation is conducted using an HPS with the Laerdal SimMan 3G™ scenario, titled Trey Anderson; diagnosis: ventricular fibrillation. This is an auto-mode case where the patient is found in ventricular fibrillation and requires defibrillation, intravenous medication, and CPR. The scenario has been reconfigured to keep the patient in ventricular fibrillation and ultimately progress to asystole. Students are aware that the code is recorded, using a webcam positioned at the head of the bed. Due to the relatively limited clinical experience of the students in this course, the focus is on the roles typically performed by the nurse: airway management, compressions, documenting, defibrillation, and drug preparation and administration. In addition to functioning as the team leader, the faculty physician rotates students through the nursing roles so that each student will perform compressions for at least one 2-minute cycle and experience three roles.
Debriefing. Prior to leaving the simulation room, faculty answer any questions about the megacode equipment. Formal debriefing is conducted in an adjacent, private room utilizing the Laerdal debriefing log and a standardized structured debriefing guide designed to facilitate participant discussion. Typically, students openly reflect on their individual and collective psychomotor performances. Most students are critical of themselves, highlighting their slowing compression rates or dexterity issues. Positive comments revolve around their calm demeanors, their communication within the team, and their ability to take direction from the faculty leader. Although faculty permit the students to drive the debriefing, students are encouraged to express their feelings, which typically range from an adrenaline-induced excitement through distress at having lost their patient. Key points emphasized include (a) when and why the person performing chest compression must be relieved; (b) basic medication preparation techniques and the difficulty of performing those skills under emotional strain; and (c) expectations of a real code, including interprofessional roles, family presence, and algorithm knowledge.
Hand-Off. After 20 minutes of reviewing the megacode video and the associated debriefing, the faculty member shows a 5-minute, in-house–produced video that depicts a physician notifying the wife of her husband’s death. This video prompts conversation regarding roles and impressions of verbal and non-verbal communication and bridges students to the after-care rotation. Students are reminded that the megacode in which they just participated involved primarily nursing equipment and interventions. Students are told that the next simulation station includes the full breadth of equipment and materials that may have been used by the entire interprofessional team, and therefore depicts a realistic post-code picture.
Students enter the hospital room in the medical–surgical simulation suite and witness the immediate aftermath of a code: the patient is naked, multiple intravenous lines are in place, the patient is intubated and has a Foley catheter, the patient is covered in stool and blood, and the room is strewn with package wrappers. Students are reminded that the patient does not require an autopsy, which, according to policy (available at the bedside), allows for removal of all invasive lines. Under the supervision and guidance of a faculty member, students perform personal care for the patient and clean the room in preparation for a family visit. The faculty member provides words of encouragement, models talking to the deceased patient, and demonstrates the use of touch. After the patient is ready, a student is asked to retrieve the wife (a paid actor unknown to the students) and chaplain (portrayed by an actual hospital chaplain) from chairs outside the simulation room. The students greet and interact with the wife as they would in a real situation. The actress follows a script written by the faculty, which provides continuity from scenario to scenario. About 10 minutes into the interaction with the wife, the script prompts the wife to ask the students to allow her a few minutes alone with her husband. Leaving the wife at the bedside, the faculty member spends a few minutes with the students providing any coaching needed in therapeutic communication. Students must be coached how to use communication that is easily understood by family members and not steeped in medical jargon. Faculty often use the analogy of speaking German among the medical team but having to speak French when communicating with the patient’s wife. The students reenter the room and finish their interaction with the wife, frequently incorporating phrases and comments described in the coaching session. To end this scenario, the chaplain offers a prayer with the group gathered around the patient’s bed. The wife thanks the students and is escorted to the door by one or two students.
Part two of the scenario is conducted utilizing the Laerdal Vital-Sim® manikin with no program running, but this could also be done with a static manikin. The actress’s script directs her to cry and display raw emotions of grief sufficient to elicit a response from students. Students admit to grappling with their own feelings as they attempt to provide comfort to the wife. Student groups that contain a member who displays obvious difficulty in managing the depth of emotion experienced tend to emote more, frequently rallying around their peers, using increased touch and crying. The faculty member assigned to the station provides emotional support to all students, with clinical simulation center faculty available as needed.
Postmortem Care. The students and faculty member are now alone in the room with the patient who has died. Faculty coach students through the postmortem care policy, highlighting preparation of the body. Students place the patient in the body bag, attach the appropriate tags, and move the patient to a gurney, which is transported across the room to simulate taking the patient to the morgue. Students leave the bedside and proceed to a second formal 20-minute debriefing conducted in a debriefing suite.
Debriefing. Because it is an interactive teaching simulation, a formal debriefing was not originally included after the postmortem care rotation. Based on faculty assessment, despite the additional time required, a second formal debriefing was added in the second semester this simulation was conducted. The chaplain is invited to attend and engage in this debriefing. Chaplains who engage in the simulation are frequently provided the opportunity to observe one of the earlier megacode rotations, which enhances their ability to appreciate the experience of the students and support them appropriately. Debriefing at this stage allows students to articulate their feelings in a safe environment and attain some closure. At the completion of the debriefing, students are asked to find a quiet place to consider this entire experience using the adapted Nielson, Stragnell, and Jester (2007) guide for reflection that is used throughout the curriculum.
At the end of the day, the course and clinical simulation center faculty provide a panel discussion. Faculty tell stories about their personal and professional experiences with death and dying, highlighting key points, including the role of the nurse, scripting, displays of emotion, connections, and caring. Storytelling provides a means of conveying the range of emotions elicited by EOL experiences. Although the stories vary each session, several mainstay stories are shared: (a) the case that provided the impetus for the after-care rotation—an unwitting family friend of a faculty member who rushed to the emergency department to be sent into a room where, alone, she faced her dead, naked father, surrounded by the bloody aftermath of a code; (b) a story that depicts the impact nurses can have—as a new intensive care unit nurse, one faculty member referred family to the monitor with the paced electrocardiogram rhythm instead of assessing the patient (who had just died) and being present with the family; (c) a case that highlights the differences between expected and unexpected death—one faculty member musters the courage to talk about caring for her dying husband and the positive impact that touch, presence, and acknowledging the loss of control can have on patients and their families; and (d) the story that displays how a nurse can make a difference—the patient died while the faculty member was alone with him, but when the mother returned, she was certain she saw her son take his last breath and expressed how very grateful she was that she was there with him when he died. Although we have considered videotaping this panel discussion, faculty enjoy the connection with students and tailor their stories to each group. Students are encouraged to ask questions or comment, but they rarely do. Many students cry during the discussion, and some approach faculty later for a personal discussion.
This simulation could be replicated by nurse educators from other institutions. The full-circle experience is unique to simulation and is facilitated by the collaborative clinical simulation center and faculty relationships, the simulation center facilities, and the dedication of the faculty involved. The rotation schedule developed to guide students is detailed and structured.
Emotion plays an important part in the simulation as a whole. Students experience the adrenalin rush common during a code situation, the anxiety inherent in having to perform new skills quickly, and the fear of the unknown. The students work on practicing loving kindness as they delve within themselves to empathize with the wife. They admit feeling uncertainty as they attempt to offer comfort and support, and they avoid saying the wrong thing. Students cry with the faculty as faculty share their stories, their voices often thick with emotion. We do not often take the time to show our students that we feel. We erect the personal–professional wall and invoke a set of boundaries. Yet, how are students to know when it is okay to cry, when to reach out and touch, and how to harness and control their very human emotions? By taking the time to share the real impact that individual patients and their families have on us as nurses and as people, faculty give their students permission to embrace and share in the dying process with their patients.
- American Association of Colleges of Nursing. (n.d.). Peaceful death: Recommended competencies and curricular guidelines for end-of-life nursing care. Retrieved from http://www.aacn.nche.edu/elnec/publications/peaceful-death
- American Association of Colleges of Nursing. (2012). End-of-life nursing education consortium (ELNEC) fact sheet. Retrieved from http://www.aacn.nche.edu/elnec/about.htm
- American Heart Association. (2011). Advance cardiovascular life support (ACLS) provider manual. Dallas, TX: Author.
- Assessment Technologies Institute. (2010). Skills modules [Interactive videos]. Retrieved from http://www.atitesting.com
- Berman, A. & Snyder, S. (2012). Skills in clinical nursing (7th ed.). Upper Saddle River, NJ: Prentice-Hall.
- Billings, D.M. & Halstead, J.A. (2011). Teaching in nursing a guide for faculty (4th ed.). St. Louis, MO: Saunders.
- Fluharty, L., Hayes, A.S., Milgrom, L., Malarney, K., Smith, D., Reklau, M.A. & McNelis, A. (2012). A multisite, multi-academic track evaluation of end-of-life simulation for nursing education. Clinical Simulation in Nursing, 8, e135–e143. doi:10.1016/j.ecns.2010.08.003 [CrossRef]
- Hamilton, C.A. (2010). The simulation imperative of end-of-life education. Clinical Simulation in Nursing, 6, e131–e138. doi:10.1016/j.ecns.2009.08.002 [CrossRef]
- Kopp, W. & Hanson, M. (2012). High-fidelity and gaming simulations enhance nursing education in end-of-life care. Clinical Simulation in Nursing, 8, e97–e102. doi:10.1016/j.ecns.2010.07.005 [CrossRef]
- Leighton, K. (2009). Death of a simulator. Clinical Simulation in Nursing, 5, e59–e62. doi:10.1016/j.ecns.2009.01.001 [CrossRef]
- Leighton, K. & Dubas, J. (2009). Simulated death: An innovative approach to teaching end-of-life care. Clinical Simulation in Nursing, 5, e223–e230. doi:10.1016/j.ecns.2009.04.093 [CrossRef]
- Nielson, A., Stragnell, S. & Jester, P. (2007). Guide for reflection using the clinical judgment model. Journal of Nursing Education, 46, 513–516.
- Robinson, S. (2004). Simulation: The practice of model development and use. West Sussex, England: Wiley.
End-of-Life Simulation Rotation Schedule
|Student||Megacode Simulation Experience||Debrief||Hand-Off||After-Care Rotation||Debrief||Reflection||Panel Discussion|
|1 to 5||0830–0850||0850–0910||0910–0925||0925–1005||1005–1025||1025–1100||1100–1145|