Nursing students' first experiences with patient death has a substantial influence on future practice, with attitudes toward death and dying firmly established by the time nurses gain licensure (Gillan, Jeong, & van der Riet, 2014; Kirkpatrick, Cantrell, & Smeltzer, 2017). Debriefing after a patient death can assist students in understanding their thoughts and feelings regarding death. There is a small but growing body of literature demonstrating the effectiveness of using simulation to educate nursing students in palliative care (Kirkpatrick, Cantrell, & Smeltzer, 2019; Lin, Supiano, Madden, & McLeskey, 2018; Lippe & Becker, 2015).
The inclusion of simulation and debriefing in nursing education has grown as a pedagogy over the past decade. Debriefing as an essential component of simulation is an effective learning method to consolidate nursing knowledge and skills for students (Dreifuerst, 2012). Despite the recommendations through the literature that simulation must have a component of quality debriefing, there is minimal research regarding debriefing palliative simulations.
Difficulties remain in ensuring that nurses have the skills to process the feelings they experience while providing end-of-life care, both in the clinical and simulation environments. Further research suggests debriefing is a crucial aspect to simulation and can be argued as even more important in palliative simulation (Heise & Gilpin, 2016). Endorsing a culture of self-reflection about death, mortality, and practice is of utmost importance if students are to grow both professionally and personally.
A literature review was conducted searching the electronic databases CINAHL®, MEDLINE®, and EBSCOhost as primary sources. This literature review focused on research articles that were published in English between 1992 and 2019. The keyword searches and phrases debriefing, high fidelity simulation, debriefing clinical experience, debriefing simulations, end of life nursing, end of life simulation, emotional preparedness, palliative simulation preparation, palliative simulation, futility, palliative care, palliative nursing education, nursing education, and nursing simulation debriefing were used in the electronic databases. Articles were excluded if they focused on postgraduate nurses.
Of all health care professionals, it has been shown that nurses spend the most time with patients who are dying (Zheng, Lee, & Bloomer, 2018). Research suggests that increased experience with death and dying situations has a positive effect on nursing students' attitudes toward patients experiencing this course in their illness (Hamilton, 2010; Lin et al., 2018). In clinical situations, when a patient is dying, members of the health care team may be apprehensive regarding students' abilities to care for palliative patients and their families (Gordon, Wilkerson, Shaffer, & Armstrong, 2001; Rietze, Tschanz, & Richardson, 2018). Affording students with the opportunity to simulate these clinical scenarios allows them to experience an interactive, hands-on experience in a safe, risk-free environment (Hope, Garside & Prescott, 2011; Kurz & Hayes, 2006). In addition, the reflection component provided during debriefing gave students the opportunity to express their thoughts and feelings on the death and dying process (Dame & Hoebeke, 2016; Venkatasalu, Kelleher, & Shao, 2015).
Debriefing and Patient Death
Nursing is known to be a stressful profession, and one of the leading stressors is patient death (Wilson & Kirshbaum, 2011; Zheng et al., 2018). Nurses who identify experiences with death early in their careers as negative encounters can also experience feelings of inadequacy and helplessness, as well as use ineffective coping mechanisms such as suppression, isolation, and avoidance (Heise & Gilpin, 2016; Terry & Carroll, 2008). Recent studies demonstrate the need for grieving health care professionals to be offered emotional support and opportunities to make meaning of the events that transpired leading up to death (Smith et al., 2018).
Parallels are seen in studies regarding nursing students and their need to be supported in order to develop their capacity to care for palliative patients (King-Okoye & Arber, 2014). Nursing students struggle to cope with death and dying, and research has shown that their greatest concern is regarding not having control of their own reactions (Parry, 2011). When students are not given support in caring for dying patients throughout their education, they tend to avoid forming relationships with patients and focus on providing strictly basic care (Heise & Gilpin, 2016; Zheng et al., 2018). Having students work alongside a staff nurse in providing physical, emotional, and spiritual care to a palliative patient can strengthen the student experience (Ek et al., 2014). Ultimately, if nurse educators can increase student knowledge, understanding, and acceptance of caring for palliative individuals, it will translate into increased student comfort and confidence, which will in turn become improved nursing care of individuals and their families (Heise & Gilpin, 2016).
Given the nature of this study, two theoretical frameworks were chosen. As simulation involves a cycle of learning, Kolb's experiential learning theory was chosen as a basis to guide the debriefing and simulation. Kolb (1984) identified that students must be able to apply abstract classroom concepts to practical situations in order to augment cognitive development and focused on the thought that learning is a consequence of experience. The theory also provides a framework for the use of simulation and its connectivity to debriefing, in which learners are able to apply their nursing knowledge to the care of a simulated patient within a safe environment, leading to an improved attainment of knowledge.
In addition, the nature of the debriefing of a palliative simulation-based experience (SBE) required additional considerations that address the sensitive nature of this type of SBE. A trauma-informed care framework was also chosen to specifically guide the debriefing component of this study. Trauma-informed care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of traumatic events that emphasizes physical, psychological, and emotional safety for both providers and survivors and creates opportunities for provision of services that assists survivors in rebuilding a sense of control and empowerment (Harris & Fallot, 2001).
Study Purpose and Research Questions
The aim of this study was to explore the usefulness and effectiveness of debriefing to process any emotions or feelings that students experienced during a palliative SBE. The specific research questions that were used to guide this study were:
- What is the perceived value of the debriefing process in palliative SBE to process student emotions or feelings?
- How does the quality of the debriefing affect students' emotions or feelings following a palliative SBE?
Research Method and Procedure
For this study, a mixed-methods approach was selected, specifically a concurrent triangulation approach. Mixed-methods research is an approach to inquiry that combines both qualitative and quantitative approaches. It uses both approaches in conjunction so that the overall strength of the study is greater than either quantitative or qualitative (Creswell, 2009). The concurrent triangulation approach to a mixed-methods research design allows the researcher to collect both quantitative and qualitative research concurrently and then compares the two databases to determine if there is a convergence, differences, or a combination (Creswell, 2009). This traditional mixed-methods approach often yields well-validated and substantial findings (Creswell, 2009).
A mixed-methods approach to research has many features that makes it appropriate to investigate the usefulness of debriefing following a palliative SBE to process feelings experienced by nursing students. A mixed-methods design allowed the researchers to thoroughly investigate the usefulness of debriefing following a palliative simulation in undergraduate nursing students to process emotions and feelings experienced by collecting quantitative data that addressed the debriefer and the debriefing, as well as qualitative data that provided insight to these experiences. Data from both stages of the study were incorporated to expand the understanding of students' perspectives to provide the best possible data to answer the research question.
Upon receiving ethics approval and access approval from the College of Nursing, a convenience sample of baccalaureate nursing students from the University of Manitoba who met the inclusion criteria were recruited. Inclusion criteria included third-year nursing students who were currently in a clinical course and currently participating in palliative simulation.
At the beginning of the day of simulation, interested participants signed the consent form and proceeded to complete their simulation as usual. Upon completion of the simulation and as part of their normal coursework, students completed two surveys: The Debriefing Assessment for Simulation in Health-care (DASH) model and an adapted version of the Debriefing Experience Scale (DES). Students who consented to participate in the study also completed a demographics questionnaire. On the consent form, students could indicate their interest in taking part in the interview portion of the study.
Students were assigned to participate in SBEs as part of their clinical course. In preparation for simulation, students had pre-learning activities and prebriefing sessions prior to starting their SBE. Over the course of 2 days, each student group participated in a series of six 50- to 60-minute scenarios, with debriefing taking place immediately after each SBE. Two of these simulation sessions were based on palliative care and one of the sessions was the focus of this study. Given the nature of these scenarios and the potential for trauma, a safe word was provided to students, and they were encouraged to use it if they felt that the psychological or emotional stress was too intense. The nursing program also employs a clinical psychologist who is accessible to students should they require the support.
The simulation experiences were developed, facilitated, and debriefed by faculty who were experts in palliative care, as well as certified as simulation educators. The simulation program follows the INACSL Standards of Best Practice: SimulationSM. The debriefing lasted approximately 30 minutes and was conducted using the PEARLS reflection model of debriefing (Eppich & Cheng, 2015). This model follows traditional debriefing models used in simulation and includes four phases: reactions, description, analysis, and summary. In addition to the prompts from the PEARLS model, questions were asked regarding the use of therapeutic communication and the role of the nurse in end-of-life care.
The modality of simulation used for the SBEs was a hybrid simulation technique—more specifically, a ShadowBox technique (Harder & Turner, 2018) combined with role-play. The ShadowBox technique is a series of short videos with embedded decision-making points that are created by experts that allow students to see the world through the eyes of the expert without having the expert present (Hintze, 2008). This technique is based on cognitive transformation theory and was originally developed and validated by and for New York City Fire Department officers (Hintze, 2008). The purpose is to develop higher level cognitive skills by watching videos with decision-making points ranked by experts. The SBE began with the prebriefing, followed by an introductory video. From there, during decision-making points, the students engaged in role-play to determine their response to the situation. When the video was resumed, a second video depicting an expert response was viewed, followed by a debriefing that included comparisons between novice and expert responses. Following completion of the debriefing, students were asked to complete the surveys as part of their normal coursework and could consent to having their surveys used for data collection if they so choose.
A total of 120 nursing students were invited to participate. Ninety-eight consented to allow their quantitative data to be included in the study, and 11 of them agreed to participate in the one-to-one interviews.
The DASH model evaluates the strategies and techniques used to conduct debriefings by examining concrete behaviors (Simon, Raemer, & Rudolph, 2010). The DASH has been developed to identify a set of generally accepted best practices for effective and ineffective debriefing and in particular is designed to assess debriefing quality in a variety of simulation environments across health care disciplines and educational objectives. The DASH has demonstrated content validity and is reliable, with a strong Cronbach's coefficient alpha of .89.
The DES was developed to evaluate the nursing student experience during debriefing following simulation and is composed of 20 items that are divided into four subscales (Reed, 2009, 2012). Given the type of simulation being conducted and for the purpose of this research, two subscales—analyzing thoughts and feelings, and learning and making connections—were used. The subscale analyzing thoughts and feelings questions students about the emotional, psychological, behavioral, and environmental aspects of debriefing. The second subscale, learning and making connections, focuses on the learning that takes place during debriefing. The DES has undergone content validity and has a Cronbach's coefficient alpha of .80 for the analyzing thoughts and feelings subscale and 0.89 for the learning and making connections subscale (Reed, 2012).
A semistructured interview was conducted with students who agreed to participate. The interviews were digitally audio-recorded and transcribed, and verbatim transcripts were read to classify and index data according to preliminary categories or themes. Transcripts were reread in order to identify emerging or recurring themes. After the categories had been identified, transcripts were reread and coded for correspondence to the categories.
The sample consisted mainly of female students, age 19 to 25 years, whose highest level of education was high school or equivalent. More than half of the participants (69.4%) had previous experience with death and dying. Of those who had had previous experience with death and dying, that experience was mostly in a personal facet (46.9%). Details are provided in Table 1.
Demographic Characteristics of the Sample (N = 98)
The DASH consists of six items that are rated using a 7-point Likert scale. The mean scores for the questions ranged from 6.04 to 6.56, with question five—The instructor identified what I did well or poorly and why—having the lowest mean of 6.04 (SD = 0.865) and question two—The instructor maintained an engaging context for learning—having the highest mean of 6.56 (SD = 0.704). Table 2 summarizes these data.
Debriefing Assessment for Simulation in Healthcare (DASH) Results
Modified DES Results
In the modified DES, questions one through three were derived from the subscale analyzing thoughts and feelings, and questions four through seven were derived from the subscale learning and making connections. The mean scores for the questions ranged from 4.41 to 4.73, with question six—Debriefing was effective in helping me to cope with the feelings experienced in a palliative simulation—having the lowest mean of 4.41 (SD = 0.835) and question seven—Debriefing was beneficial to my learning in a palliative SBE—having the highest mean of 4.73 (SD = 0.566). Table 3 summarizes these data.
Debriefing Experience Scale (DES) Results
Qualitative Data Analysis
During the semistructured interviews, students (n = 11) discussed their feelings before, during, and after the palliative SBE. The individual interviews were audiorecorded and transcribed in order to look for themes among the participant responses. Two researchers individually coded the transcript and then met to look for congruence in coding. As the interviews progressed, one overarching theme, along with three categories and three subcategories, emerged from the data. The theme of Feeling Prepared, specifically emotionally prepared, and how this varied at different points during the SBE were identified. This was further elaborated when discussing the debriefing. The three categories were before the simulation, during the simulation, and after the simulation. The three subcategories that emerged were included under the category of after the SBE and included qualities of the debriefer, other participants in the room, and value of debriefing (Table 4).
Theme: Preparedness. The overarching theme that emerged was Preparedness, specifically emotional preparedness. As participants were discussing participating in a palliative SBE, they described how the simulation affected their emotional preparedness. Overwhelmingly, the participants indicated that the debriefing component of the SBE assisted them in processing their feelings and emotions and significantly contributed to their feelings of emotional preparedness. In addition to feeling that the simulation emotionally prepared them to care for patients in palliative care, several students said they would like additional resources and supports that they could bring with them into the practice setting.
Category One: Preparedness Before Simulation. The first category to support the theme of Preparedness was that although students were aware that would be participating in a palliative SBE, most students did not feel prepared for the emotional aspects of the SBE. In addition, students described their life stage as affecting their emotional preparedness in discussing death and dying with a potential patient. Students indicated that preparing for a palliative SBE was not as straightforward as reviewing diseases, medications, or psychomotor skills. Students appreciated being made aware that it was going to be a palliative simulation and stated that previous communication-based simulations contributed to a sense of preparedness for this SBE.
Category Two: Preparedness During Simulation. Feelings were the strongest during the active phase of the simulation and included feelings of sadness, empathy, compassion, anxiety, and fear. Due to the intensity of emotions during the SBE, students appreciated the type of modality of simulation. They felt that role-play was not real enough but working with a standardized patient would be too psychologically stressful. According to the students, the ShadowBox technique of simulation videos and decision-making points was a realistic representation of the emotional aspect of providing end-of-life care. Combined with the use of role-play, students indicated that this was an appropriate introduction into emotionally laden simulation.
Students discussed their need for support from their peers during simulation to feel comfortable with their feelings of sadness and uncertainty. They appreciated the normalization of feelings that occurred throughout debriefing conversations with peers. Students also stated that having their peers express feelings resonated with them and allowed them to explore their own feelings.
Category Three: Preparedness After Simulation (Debriefing). The third category that supported the theme of Preparedness emerged through analysis of the qualitative interviews was the post-SBE component. The data in this category further created three subcategories consisting of subcategory one: qualities of the debriefer, subcategory two: fellow participants in the debriefing room, and subcategory three: value of debriefing.
Subcategory one: Qualities of the debriefer. Students shared that the debriefer normalized feelings, along with guiding discussion and allowed participants to speak when they felt comfortable. Students made it clear that the debriefer and the qualities of the debriefer were a key component to ensuring a positive SBE. Students appreciated the fact that the debriefer had experience not only in simulation but in palliative care as well, as they felt that this added value to the SBE.
Subcategory two: Other participants in the debriefing room. Throughout the interviews, students consistently discussed the benefits of having group debriefing. As established earlier, students felt that sharing feelings with their peers was important and it helped to normalize the feelings they were experiencing. Students also commented on group size, stating that groups of 8 to 10 participants was appropriate, in that it was enough to hear other people's perspectives but not too many that it would deter individuals from sharing their own feelings.
Subcategory three: Value of debriefing. Students commented on the value of debriefing in relation to clinical practice. Some students believed that the type of debriefing that is done on simulation should be a formal part of their clinical education as well, especially when emotionally stressful situations arise. Two students described wanting a simulation and debriefing session structured around coping as a nurse, specifically as it relates to compassion fatigue.
In the literature, it has been well established that nursing students find it difficult to cope with their own personal emotions and feelings when caring for patients who are dying (Sadala & de Silva, 2009). However, nursing students have stated that they were better able to cope with their own feelings once they were given an opportunity to share their experience regarding patient death in simulation, and that having an open conversation was one of the things that they felt helped to normalize the death and allowed them to process their own thoughts about that death (Edo-Gual, Tomás-Sábado, Bardallo-Porras, & Monforte-Royo, 2014).
Perceived Value of the Debriefing Process
The overarching theme regarding the perceived value of debriefing is that it contributes to overall preparedness. Valuable components of the debriefing following the palliative SBE included normalization of feelings and feeling better prepared to cope with feelings that may be experienced during a palliative SBE or in the clinical setting. Hearing that they were experiencing similar feelings helped students both to identify and to normalize the feelings experienced in the palliative SBE. A study by Edo-Gual et al. (2014) mirrors the finding that students have an increased sense of security talking about their emotions and feelings after they hear other students' experiences. Students who reflect on palliative care in small groups have been shown to have an increased awareness of their own emotions, a deeper appreciation of the normality of their reactions, and healthier coping strategies (Yang et al., 2011). The evidence in this study and supporting literature indicates that students perceive a value of debriefing as the normalization of feelings experienced.
Students felt both prepared and unprepared for the palliative SBE. They indicated that they felt prepared to participate in a palliative SBE but initially felt unprepared to cope with emotions they anticipated experiencing. In being able to go through the experience with a supportive debriefer, students feel better prepared and less anxious about being asked to care for a palliative patient. Researchers have echoed this sentiment and have found that the use of simulation in end-of-life education has increased nursing students' confidence in caring for patients in a clinical setting and that the debriefing component augments students' personal feelings of emotional preparedness (Hope et al., 2011, Kurz & Hayes, 2006; Venkatasalu et al., 2015).
Quality of the Debriefing
In discussing the quality of the debriefing, students indicated that the quality of the debriefer was key in assisting them process their feelings and emotions. In this study, the debriefer was skilled in debriefing but was also a content expert in palliative care. In reviewing the results from the surveys, creating an engaging learning environment and provoking in-depth discussions positively affected the quality of the debriefing. This is supported by the literature and the INACSL: Standards of Best Practice: Simulation standard VI: the debriefing process (INACSL Standards Committee, 2016). In order to ensure a quality debrief, the debriefer must be competent in best practices in debriefing with regard to structuring the format of the debriefing and facilitating reflective discussion. They must also be knowledgeable about the topic and about simulation facilitation methods and be able to create a psychologically safe learning environment (Fanning & Gaba, 2007; Hjelmfors, Strömberg, Karlsson, Olsson, & Jaarsma, 2016; Neill & Wotton, 2011; Turner & Harder, 2018). In coping with emotionally stressful simulations, the debriefer must be skilled both as a debriefer, as well as be skilled at handling emotional stress.
The final result was that students indicated that they would like similar debriefing to take place in the clinical setting. It is common practice in most North American and Australian nursing schools for students to reflect on their experience in clinical with each other and their instructor, share information, and analyze situations that occurred during their day and reflect on their actions (Andersen, 2016). This debrief, or postconference, that occurs following clinical education tends to focus on describing clinical situations and patient cases that are often complex and difficult to solve, and conversation revolves around thinking of solutions to these issues (Andersen, 2016). Research specifically regarding clinical experiences in a palliative care setting (Allchin, 2006) has encouraged the use of group or individual debriefing sessions to provide support to students who have been exposed to the emotional challenges of caring for individuals who are dying and their families. Allchin (2006) further stated it is important to have an instructor constructively guide this debriefing session to allow for students to make sense of the thoughts and feelings they are experiencing, as well as to be available to discuss personal feelings of loss and grief.
Limitations of this study include the use of a convenience sample from a single institution with a fairly homogenous sample, which can limit generalizability. In addition, convenience sampling is highly vulnerable to selection bias (Polit & Beck, 2012). The interview responses may have been induced by extraneous variables such as previous experience (personal or professional) with death and dying, student course load, and other life stressors (Brown & Chronister, 2009; Kirkman, 2011). Replication of this study would require that researchers contact the authors to obtain the ShadowBox videos and simulation template to ensure that the intervention is similar in other studies. This is also a single-site study with a small sample size, and results cannot be generalized beyond those who participated in the study.
Recommendations for Practice
From the findings of this study, the following recommendations are made when conducting palliative SBEs:
- Emotionally charged simulations should center around discussing emotions, feelings, and coping strategies, rather than focusing on learning outcomes. Traditional debriefing frameworks may not be sufficient.
- Palliative simulation can be used as a bridge between theory and clinical for nursing students; however, the modality needs to be chosen carefully. The use of the ShadowBox technique (combination of video and role-play) is an appropriate modality.
- In addition to receiving formal training in debriefing, additional training should be provided to the debriefers to ensure they have the necessary skills and resources to discuss such sensitive matters with participants.
This study has noted that there is a gap in specific debriefing following an emotionally stressful simulation. Future research should include a debriefing model that focuses on participants' feelings and emotions and less on clinical performance. This future research may help to provide further development in debriefing to assist students in learning healthy ways to cope with stressful situations in simulation, which then can be translated to clinical and then their own professional nursing practice. Additional studies could include following these students after graduation to determine whether the simulation experiences had an effect on their response to death in the clinical environment. This could be compared with the data from students who have not participated in the simulation experience.
The need for quality palliative care begins with quality palliative nursing education. Research has indicated that palliative simulation is a beneficial bridge between the palliative theory and palliative clinical gap. In debriefing palliative SBE, the debriefer needs to be competent in both debriefing simulations and experienced in coping with strong feelings and emotions that are often experienced in palliative care. Future research should focus on optimal ways to debrief palliative simulation and how this reduces feelings of anxiety and apprehension in nursing students caring for palliative patients.
- Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice and Palliative Nursing, 8, 112–117. doi:10.1097/00129191-200603000-00015 [CrossRef]
- Andersen, E. (2016). Enhancing the clinical reflective capacities of nursing students. Nurse Education in Practice, 19, 31–35. doi:10.1016/j.nepr.2016.04.004 [CrossRef]27428689
- Brown, D. & Chronister, C. (2009). The effect of simulation learning on critical thinking and self-confidence when incorporated into an electrocardiogram nursing course. Clinical Simulation in Nursing, 5(1), e45–e52. doi:10.1016/j.ecns.2008.11.001 [CrossRef]
- Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches (3rd ed.). Thousand Oaks, CA: Sage.
- Dame, L. & Hoebeke, R. (2016). Effects of a simulation exercise on nursing students' end-of-life care attitudes. Journal of Nursing Education, 55, 701–705. doi:10.3928/01484834-20161114-07 [CrossRef]27893906
- Dreifuerst, K.T. (2012). Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. Journal of Nursing Education, 51, 326–333. doi:10.3928/01484834-20120409-02 [CrossRef]22495923
- Edo-Gual, M., Tomás-Sábado, J., Bardallo-Porras, D. & Monforte-Royo, C. (2014). The impact of death and dying on nursing students: An explanatory model. Journal of Clinical Nursing, 23, 3501–3512. doi:10.1111/jocn.12602 [CrossRef]24698364
- Ek, K., Westin, L., Prahl, C., Österlind, J., Strang, S., Bergh, I. & Hammarlund, K. (2014). Death and caring for dying patients: Exploring first-year nursing students' descriptive experiences. International Journal of Palliative Nursing, 20, 509–515. doi:10.12968/ijpn.2014.20.10.509 [CrossRef]25350217
- Eppich, W. & Cheng, A. (2015). Promoting excellence and reflective learning in simulation (PEARLS): Development and rationale for a blended approach to health care simulation debriefing. Simulation in Healthcare, 10, 106–115. doi:10.1097/SIH.0000000000000072 [CrossRef]25710312
- Fanning, R.M. & Gaba, D.M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2, 115–125. doi:10.1097/SIH.0b013e3180315539 [CrossRef]19088616
- Gillan, P.C., Jeong, S. & van der Riet, P.J. (2014). End-of-life care simulation: A review of the literature. Nurse Education Today, 34, 766–774. doi:10.1016/j.nedt.2013.10.005 [CrossRef]
- Gordon, J.A., Wilkerson, W.M., Shaffer, D.W. & Armstrong, E.G. (2001). “Practicing” medicine without risk: Students' and educators' responses to high-fidelity patient simulation. Academic Medicine, 76, 469–472. doi:10.1097/00001888-200105000-00019 [CrossRef]
- Hamilton, C.A. (2010). The simulation imperative of end-of-life education. Clinical Simulation in Nursing, 6(4), e131–e138. doi:10.1016/j.ecns.2009.08.002 [CrossRef]
- Harder, N. & Turner, S. (2018). Applying simulation design criteria to nonmanikin-based experiences: A modified ShadowBox technique. Nursing Education Perspectives. Advance online publication. doi:10.1097/01.NEP.0000000000000424 [CrossRef]
- Harris, M. & Fallot, R.D. (2001). Trauma-informed inpatient services. In New directions for mental health services: Using trauma theory to design service systems (pp. 33–46). San Francisco, CA: Jossey-Bass. doi:10.1002/yd.23320018905 [CrossRef]
- Heise, B.A. & Gilpin, L.C. (2016). Nursing students' clinical experience with death: A pilot study. Nursing Education Perspectives, 37, 104–106.27209870
- Hintze, N.R. (2008). First responder problem solving and decision making in today's asymmetrical environment (Unpublished master's thesis). Naval Postgraduate School, Monterey, California.
- Hjelmfors, L., Strömberg, A., Karlsson, K., Olsson, L. & Jaarsma, T. (2016). Simulation to teach nursing students about end-of-life care. Journal of Hospice & Palliative Nursing, 18, 512–518. doi:10.1097/NJH.0000000000000279 [CrossRef]
- Hope, A., Garside, J. & Prescott, S. (2011). Rethinking theory and practice: Pre-registration student nurses' experiences of simulation teaching and learning in the acquisition of clinical skills in preparation for practice. Nurse Education Today, 31, 711–715. doi:10.1016/j.nedt.2010.12.011 [CrossRef]
- INACSL Standards Committee. (2016). INACSL standards of best practice: SimulationSM debriefing [Supplemental material]. Clinical Simulation in Nursing, 12, S21–S25. doi:10.1016/j.ecns.2016.09.008 [CrossRef]
- King-Okoye, M. & Arber, A. (2014). ‘It stays with me’: The experiences of second- and third-year student nurses when caring for patients with cancer. European Journal of Cancer Care, 23, 441–449. doi:10.1111/ecc.12139 [CrossRef]
- Kirkman, T.R. (2011). The effectiveness of human patient simulation on baccalaureate nursing students' transfer of learning (Doctoral dissertation). Retrieved from http://acumen.lib.ua.edu/content/u0015/0000001/0000746/u0015_0000001_0000746.pdf
- Kirkpatrick, A.J., Cantrell, M.A. & Smeltzer, S.C. (2017). Palliative care simulations in undergraduate nursing education: An integrative review. Clinical Simulation in Nursing, 13, 414–431. doi:10.1016/j.ecns.2017.04.009 [CrossRef]
- Kirkpatrick, A.J., Cantrell, M.A. & Smeltzer, S.C. (2019). Relationships among nursing students palliative care knowledge, experience, self-awareness, and performance: An end-of-life simulation study. Nurse Education Today, 73, 23–30. doi:10.1016/j.nedt.2018.11.003 [CrossRef]
- Kolb, D.A. (1984). Experiential learning: Experience as the source of learning and development. Upper Saddle River, NJ: Prentice Hall.
- Kurz, J.M. & Hayes, E.R. (2006). End of life issues action: Impact of education. International Journal of Nursing Education Scholarship, 3, 18. doi:10.2202/1548-923X.1189 [CrossRef]
- Lewis, K. (2013). How nurses can help ease patients transitions to end of life care. Nursing Older People, 25(8), 22–26. doi:10.7748/nop2013.10.25.8.22.e479 [CrossRef]24067044
- Lin, J., Supiano, K., Madden, C. & McLeskey, N. (2018). The impact of the end-of-life nurse education consortium on attitudes of undergraduate nursing students toward care of dying patients. Journal of Hospice & Palliative Nursing, 20, 340–348. doi:10.1097/NJH.0000000000000445 [CrossRef]
- Lippe, M.P. & Becker, H. (2015). Improving attitudes and perceived competence in caring for dying patients: An end-of-life simulation. Nursing Education Perspectives, 36, 372–378. doi:10.5480/14-1540 [CrossRef]
- Neill, M.A. & Wotton, K. (2011). High-fidelity simulation debriefing in nursing education: A literature review. Clinical Simulation in Nursing, 7(5), e161–e168. doi:10.1016/j.ecns.2011.02.001 [CrossRef]
- Parry, M. (2011). Student nurses' experience of their first death in clinical practice. International Journal of Palliative Nursing, 17, 448–453. doi:10.12968/ijpn.2011.17.9.448 [CrossRef]
- Polit, D.F. & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Wolters Kluwer Health.
- Reed, S. (2009). Comparison of debriefing methods following simulation: Development of pilot instrument (Unpublished doctoral thesis). Case Western Reserve University, Cleveland, OH.
- Reed, S.J. (2012). Debriefing experience scale: Development of a tool to evaluate the student learning experience in debriefing. Clinical Simulation in Nursing, 8(6), e211–e217. doi:10.1016/j.ecns.2011.11.002 [CrossRef]
- Rietze, L.L., Tschanz, C.L. & Richardson, H.R.L. (2018). Evaluating an initiative to promote entry-level competence in palliative and end-of-life care for registered nurses in Canada. Journal of Hospice & Palliative Nursing, 20, 568–574. doi:10.1097/NJH.0000000000000502 [CrossRef]
- Sadala, M.L.A. & de Silva, F.M. (2009). Cuidando de pacientes em fase terminal: A perspectiva de alunos de enfermagem [Taking care of terminal patients: Nursing student's perspective]. Revista da Escola de Enfermagem da USP, 43, 287–294. doi:10.1590/S0080-62342009000200005 [CrossRef]
- Simon, R., Raemer, D.B. & Rudolph, J.W. (2010). Debriefing assessment for simulation in healthcare (DASH)© - Student version, long form. Center for Medical Simulation, Boston, Massachusetts. Retrieved from https://harvardmedsim.org/wp-content/uploads/2017/01/DASH.SV.Long.2010.Final.pdf
- Smith, M.B., Macieira, T.G.R., Bumbach, M.D., Garbutt, S.J., Citty, S.W., Stephen, A. & Keenan, G. (2018). The use of simulation to teach nursing students and clinicians palliative care and end-of-life communication: A systematic review. American Journal of Hospice & Palliative Medicine, 35, 1140–1154. doi:10.1177/1049909118761386 [CrossRef]
- Terry, L.M. & Carroll, J. (2008). Dealing with death: First encounters for first-year nursing students. British Journal of Nursing, 17, 760–765. doi:10.12968/bjon.2008.17.12.30298 [CrossRef]18825851
- Turner, S. & Harder, N. (2018). Psychological safe environment: A concept analysis. Clinical Simulation in Nursing, 18, 47–55. doi:10.1016/j.ecns.2018.02.004 [CrossRef]
- Wilson, J. & Kirshbaum, M. (2011). Effects of patient death on nursing staff: A literature review. British Journal of Nursing, 20, 559–563. doi:10.12968/bjon.2011.20.9.559 [CrossRef]21647017
- Venkatasalu, M.R., Kelleher, M. & Shao, C.H. (2015). Reported clinical outcomes of high-fidelity simulation versus classroom-based end-of-life care education. International Journal of Palliative Nursing, 21, 179–186. doi:10.12968/ijpn.2015.21.4.179 [CrossRef]25901590
- Yang, C.P., Leung, J., Hunt, E.A., Serwint, J., Norvell, M., Keene, E.A. & Romer, L.H. (2011). Pediatric residents do not feel prepared for the most unsettling situations they face in the pediatric intensive care unit. Journal of Palliative Medicine, 14, 25–30. doi:10.1089/jpm.2010.0314 [CrossRef]
- Zheng, R., Lee, S. & Bloomer, M.J. (2018). How nurses cope with patient death: A systematic review and qualitative meta-synthesis. Journal of Clinical Nursing, 27, e39–e49. doi:10.1111/jocn.13975 [CrossRef]
Demographic Characteristics of the Sample (N = 98)
|Level of education|
| High school or equivalent||81||82.7|
| Bachelor's degree||13||13.3|
| Master's degree||1||1|
| Other certificate or diploma||3||3.1|
|Experience with death and dying|
|If yes to death and dying||46||46.9|
| Personal and professional||3||3.1|
Debriefing Assessment for Simulation in Healthcare (DASH) Results
|DASH 1: The instructor set the stage for an engaging learning experience.||98||1||7||6.27||1.011|
|DASH 2: The instructor maintained an engaging context for learning.||98||4||7||6.56||0.704|
|DASH 3: The instructor structured the debriefing in an organized way.||98||4||7||6.53||0.661|
|DASH 4: The instructor provoked in-depth discussions that led me to reflect on my performance.||98||5||7||6.51||0.677|
|DASH 5: The instructor identified what I did well or poorly and why.||97||4||7||6.04||0.865|
|DASH 6: The instructor helped me see how to improve or how to sustain good performance.||98||4||7||6.43||0.746|
Debriefing Experience Scale (DES) Results
|DES 1: Debriefing helped me to analyze my thoughts about the palliative simulation.||98||1||5||4.68||0.585|
|DES 2: Uncomfortable feelings experienced in the palliative simulation-based experience (SBE) were addressed by debriefing.||95||1||5||4.52||0.650|
|DES 3: Debriefing assisted me in identifying my feelings and emotions experienced during the SBE.||97||1||5||4.61||0.622|
|DES 4: Debriefing assisted me in reflecting on my feelings and emotions experienced during the SBE.||98||1||5||4.61||0.636|
|DES 5: Debriefing assisted me in processing my feelings and emotions experienced during the SBE.||97||1||5||4.55||0.736|
|DES 6: Debriefing was effective in helping me to cope with the feelings experienced in a palliative simulation.||98||1||5||4.41||0.835|
|DES 7: Debriefing was beneficial to my learning in a palliative SBE.||98||1||5||4.73||0.566|
|After simulation||Qualities of the debriefer|
|Value of debriefing|