Nurses play a pivotal role in palliative care for clients and their families. With the older-than-60-years population projected to rise to 1.4 billion worldwide by 2030 (United Nations, 2015), nurses will inevitably be responsible for the care of larger populations of clients with serious conditions and chronic debilitating illness. The National League for Nursing (2015) has challenged nurse educators to develop innovative curricula that meet the evolving learning needs of future nurses in rapidly changing care environments. In response to the growing need for palliative care education, the American Association of Colleges of Nursing (2016) released competencies and recommendations for educating undergraduate nursing students to care for the seriously ill and their families. The Institute of Medicine (2015) has also called for innovation and evidence-based solutions for the delivery of safe, high-quality palliative care. This article discusses the use of student-centered multimedia approaches and simulation within the context of palliative care in an end-of-life course.
BACKGROUND
Undergraduate education does not adequately prepare the graduate nurse to talk to clients and their families about advanced care planning and palliative services (Lippe et al., 2017). According to Kirkpatrick et al. (2017), students described feelings of anxiety about their inability to communicate with clients and families during the time of impending death. Students reported that their nursing program did not prepare them to provide appropriate palliative patient care. As clinical settings offer few opportunities to improve students' confidence in this area (Kirkpatrick et al., 2017), opportunities are needed that assist in the development of coping strategies to decrease anxiety and fear when confronted with death and dying. The ability to witness the consequence of one's actions and improve practice with remediation in a safe, controlled simulation environment may lead to recognition of patterns of expected or adverse patient outcomes (Kirkpatrick et al., 2017; Lippe & Becker, 2015; Lippe et al., 2017).
As nurses often face the challenge of educating patients, families, and/or significant others about life-changing events, they require proficient empathetic communication skills as well as technical nursing skills (Kirkpatrick et al., 2017). Scenarios employing patient actors provide opportunities for students to practice and improve their therapeutic communication skills.
END OF LIFE SPAN COURSE
Thirty-seven second-semester nursing students from an accelerated 16-month nursing baccalaureate program in the Northeastern region of the United States were enrolled in an End of Life Span course as a curricular requirement. This course used a holistic approach to examine cultural considerations/rituals, religious influences, loss, grief, socioeconomic challenges, and end-of-life physical concerns across the life span. In order to create a meaningful student-centered approach to learning, participants were surveyed and asked, "What do you most want to get out of this course?" The results were unanimous. Students wanted to learn how to communicate with clients and families suffering from chronic illness who were at or near the end of life. Because communicating with clients is a fundamental and essential nursing skill, a series of innovative learning strategies was used in the course to build on students' prior knowledge of therapeutic communication and death and dying.
An experiential constructivist theoretical design using Vygotsky's zone of proximal development was used as a framework in the development of this course. This framework provides an effective instructional strategy of cooperative learning that involves knowledge scaffolding using five essential tenets of cooperative learning: positive interdependence, face-to-face interaction, individual accountability, small-group interpersonal skills, and group self-evaluation (Doolittle, 1997). The learner moves from a level of knowledge to actual development facilitated by the nurse educator.
Dynamic interactive activities based on palliative care, ethical and legal considerations, and communication techniques were incorporated into the course. Students individually reviewed the National Consensus Project for Quality Palliative Care (2018) Clinical Practice Guidelines to increase their understanding of the scope of practice in palliative care. The importance of interdisciplinary communication, collaboration with the client and family, and ethical aspects of patient care were all part of course learning objectives. Students met in groups to discuss the practice guidelines, communication techniques, and the ethical behaviors as portrayed in documentaries and films involving the care and treatment of patients diagnosed with cancer who were nearing the end of life. They also viewed End of Life Nursing Education Consortium vignettes portraying palliative care situations and analyzed them with regard to communication, continuous presence, and patient advocacy.
These interactive educational strategies facilitated students' understanding of crucial conversations during serious illness (Ferrell et al., 2015). Following completion of learning activities and reflections, students participated in a simulated experience employing patient actors in the roles of a client with refractory heart failure and his daughter at the bedside.
SIMULATION DEVELOPMENT AND IMPLEMENTATION
The simulated experience was developed to address learning objectives related to therapeutic communication, quality of life, and advanced care planning. Two students interactively engaged in conversation with patient actors while four observed the interactions. Palliative care education, health concerns, and the importance of having an advanced directive were addressed.
The students were divided into groups of six for each simulation. A prebriefing addressed psychological safety, timing, case setting, and the learning objectives. Students viewed videos of patient actors discussing their health care challenges, which were linked to the scenario's objectives. Students decided who would take the role of the nurse or observer. The actual scenario lasted 10 to 15 minutes; it was followed by a debriefing session that lasted 20 to 25 minutes. Students were aware that patient actors would provide feedback after the scenario, prior to the faculty-facilitated debriefing. Although accommodations were developed for students who wished to opt out of the simulation, all students took part, either in the role of observer or nurse.
The case stated that Chuck Wilde, an 85-year-old man, had been admitted to the emergency department the previous evening complaining of shortness of breath resulting from chronic heart failure. The patient was adamant about maintaining his independence and had avoided prior conversations about advance care planning and palliative care services. During the debriefing, students were encouraged to talk about their emotional responses to the scenario. The patient actors also provided feedback related to the perceived empathy of the caregiver. Students in the role of bedside nurse reflected on the real-life nature of the scenario. Although students acknowledged discomfort in discussing topics of advance care planning and palliative care services, most described feeling a sense of relief at having this educational opportunity in a controlled environment. An evaluation form completed by the students after the debriefing focused on self-confidence in therapeutic communication skills, the patient actors' feedback, and the realism of the simulation scenario.
LESSONS LEARNED
Nursing programs are encouraged to integrate and build upon palliative care principles with the use of educational and simulation activities that scaffold learning from novice to advanced beginner. Innovative student-centered learning activities and simulated experiences provide students with valuable opportunities to develop important skills needed for giving competent and compassionate palliative nursing care. Because this activity involved an instructional strategy conducted in an educational setting, institutional review board exemption was granted.
The pedagogical strategy presented in this article can serve as an effective method to increase student confidence communicating with clients and families about advanced care planning. Students self-reported a 41-percent increase in confidence following participation in this simulation. Key points from students' comments include the importance of nonverbal communication in providing palliative care, the patient actors provided a real-world experience with constructive feedback, and students felt safe in the practice environment.
CONCLUSION
The use of student-centered learning strategies and simulation has been supported in the literature as an effective teaching method for palliative care. By incorporating practice guidelines and multimedia approaches, accelerated nursing students engaged in interactive learning opportunities, building on their life experiences and prior knowledge. Having patient actors in the simulation scenario provided students with saliency when caring for patients nearing the end of life. Requiring this course early in the accelerated nursing curricula provided a strong foundation for students, as concepts of palliative care and experiential learning opportunities are included in subsequent courses.
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