Nursing students receive insufficient training in death, dying, and end-of-life care (Carmack & Kemery, 2018). Education in the acute or chronic care of patients is often related to end-of-life care. Students who experience a patient death often report on insufficient support from clinical instructors, leading to negative experiences (Heise et al., 2018). Prelicensure nursing students need positive experiences with patient death. Because of a decrease in nursing faculty and clinical placement availability, high-fidelity simulation presents the best opportunity for providing this type of experience (Hayden et al., 2014). There is a scarcity of research on the impact of experiencing patient death in simulation.

BACKGROUND

Simulation is a form of experiential learning popular in teaching health care professionals (Jeffries, 2020). Nursing faculty teach through high-fidelity simulation using high-technology simulators or standardized patients (Lavoie & Clarke, 2017). The simulation process follows the experiential learning cycle through the experience of a simulated scenario and debriefing. Studies have shown that the use of simulation can have a positive impact on learning, skill performance, learner satisfaction, critical thinking, and self-confidence (Shaw & Abbott, 2017). In relation to patient death, the use of experiential learning through simulation could be beneficial because it provides an opportunity for reflection (Jeffries, 2020). Learners are treated as unique individuals and thus are allowed to critically examine and discuss their own experiences with death and dying (Shaw & Abbott, 2017).

There are conflicting reports on the effectiveness of teaching about patient death in simulation (Smith et al., 2018). Positive aspects are that students want to learn about patient death, and simulation gives them the ability to experience death in a realistic but controlled environment. Experiential learning of a high-risk event in a controlled environment increases self-confidence and clinical decision-making. However, it is also believed that death of the patient during simulation could lead to emotional distress, as well as a decrease in self-confidence (Harder et al., 2020). Participating in debriefing following a simulation provides opportunities to develop coping skills to better handle patient death (Shaw & Abbott, 2017).

METHOD

A quasi-experimental study explored the use of high-fidelity simulation supported by the experiential learning theory to teach students about patient death. Two research questions were asked: Are there differences in emotional affect following simulation and following debriefing after a rescue or failure-to-rescue scenario? Are there differences in knowledge gain related to heart failure between students experiencing a rescue or failure-to-rescue heart failure patient scenario during a high-fidelity simulation experience?

Sample

The subjects included baccalaureate nursing students in their final year at a large public research institution in the northeastern United States. Traditional bachelor's and accelerated students who had participated in at least three previous simulations took part in the study. The simulation was a required activity in their clinical course. Students were assigned to a date with their clinical group, which negated pure random assignment. Within the assigned group, students were randomly assigned partners. The outcome of the scenario, rescue or failure-to-rescue, was decided randomly. Institutional review board approval for this study was granted by the university.

Three instruments were used to collect data: a demographic questionnaire, a knowledge assessment tool, and an emotional assessment tool. The Knowledge Assessment Tool is an eight-question multiple- choice test developed by the researcher using National Council Licensure Examination test bank questions about heart failure. It was reviewed by three expert medical-surgical nurses for content validity. The sum of correct answers is compared between time interval and students. Reliability of the scale was reported as a Cronbach's alpha of .671.

The Emotional Assessment Tool is an eight-item tool to assess the semantic structure of emotion (Feldman Barrett & Russell, 1998). Eight bipolar emotions (e.g., tense-calm, nervous-relaxed) are assessed on a 5-point Likert scale, with scores ranging from -2 to +2. Students self-reported their emotional affect by choosing the number best fitting their affect at that time. Mean subjective ratings of each emotion were compared between time interval and students. Internal consistency reliabilities for this scale range from a Cronbach's alpha of .79 to .91 (Watson & Vaidya, 2003).

Procedure and Analysis

The simulation scenario depicted a patient with chronic heart failure experiencing respiratory distress during assessment. Prior to the simulation, students received a prebriefing to the patient and simulation room; they did not receive information about the scenario topic. Education about the management of heart failure or patient death was provided during their didactic chronic care course prior to the simulation. Prior to the scenario, students were informed that the patient had a do-not-resuscitate order.

Within each session, students participated in simulation and debriefing with one other student. Rescue groups experienced a patient with heart failure who survived; failure-to-rescue groups experienced a patient with heart failure who died. Following the simulation, each group participated in debriefing led by a trained facilitator. The same facilitator observed and debriefed the simulations using the good judgment method; this allowed the facilitator to address performance in simulation considering the perspectives of the facilitator and participants, fostering deeper learning (Rudolph et al., 2006). Debriefing for both groups included review of the treatment and disease process of heart failure. Only the failure-to-rescue group received debriefing regarding the patient death, prior to discussion of heart failure.

The three main topics addressed regarding the patient death included caring for the patient following death, caring for the patient's family, and caring for oneself. For the treatment groups, discussion of heart failure followed discussion of patient death. The session was completed in a 90-minute time frame: 25 minutes for orientation, prebriefing, and presimulation surveys; 20 minutes for the simulation; and 45 minutes for postsimulation surveys, debriefing, and postdebriefing surveys.

Data were collected by self-report from the participants. Statistical analysis was conducted using Statistical Package for the Social Sciences Version 26. Descriptive statistics were run on all study instruments. Statistical evaluation of knowledge gain and emotion for the groups from the pre- and posttests was conducted using a two-way analysis of variance.

RESULTS

All 127 students who were enrolled in the course and eligible to participate took part in the study. Students were randomly assigned to a rescue (n = 63) or failure-to-rescue (n = 64) simulation. There was no significant difference between the two groups with respect to age, gender, academic program (traditional or accelerated), previous health care employment, or previous experience with death and dying.

Knowledge

The pretest scores of the rescue group (M = 4.71, SD = 1.11) were not significantly different than the failure-to-rescue group (M = 4.78, SD = 1.24). The posttest scores were not significantly different between the rescue group (M = 5.65, SD = 1.03) and the failure-to-rescue group (M = 5.59, SD = 1.09). The analysis demonstrated that the only difference in knowledge assessment scores was related to the time the instrument was administered. There was no significant interaction between the group assignment and the time of instrument administration.

A two-way analysis of variance was conducted on the influence of simulation outcome and time of instrument administration on knowledge gain. The main effect for simulation outcome yielded an F ratio of F(1, 125) = 0.001, p > .05, indicating no significant difference in gain on the knowledge scores between groups. The main effect for time yielded an F ratio of F(1, 125) = 64.747, p < .01, indicating that the effect for time of instrument administration was significant, with a significant increase from pretest to posttest. The interaction effect was not significant, F(1, 125) = 0.325, p > .05.

Emotion

Emotion was measured following simulation and following debriefing. A two-way analysis of variance was conducted on the influence of time the instrument was administered and simulation group on emotion. Analyses showed a significant difference in emotion over time, F(1, 118) = 91.060, p < .01, and between rescue and failure-to-rescue groups, F(1, 118) = 4.102, p < .05, as well as a significant interaction between the two, F(1, 118) = 19.875, p < .01.

Independent samples tests showed the following simulation emotion categories of nervous/relaxed (p = .003), stressed/serene (p = .007), upset/content (p < .001), sad/happy (p < .001), depressed/elated (p = .001), and bored/alert (p = .045). Scores were significantly different for the failure-to-rescue group when measured directly following the simulation, indicating that participants in the failure-to-rescue group were significantly more nervous, upset, sad, depressed, and alert. Following the debriefing, there was no significant difference in any categories for either group.

DISCUSSION

Results of the study support the idea that students who learned about heart failure through simulation had equally significant knowledge gain, regardless of the patient outcome. Students were given the opportunity to reflect on their own feelings and past experiences with death prior to discussing heart failure. Addressing the patient death allowed the students to learn about the process of handling death and gave them the opportunity to discuss and reflect on their experiences. Students were still able to retain new information about heart failure.

Students in the failure-to-rescue group had more negative emotions in multiple categories than the rescue group participants. Directly following the simulation, they were significantly more nervous, stressed, upset, sad, and depressed. Following the debriefing, students in both groups showed no significant difference in any emotional affect categories. After discussing the patient death and reflecting, their emotional states improved. This speaks to the power of debriefing. The opportunity for self-reflection during debriefing is a key aspect of experiential learning (Kolb, 1984).

Because of clinical site shortages and faculty shortages, students have decreased opportunities to experience patient death during their undergraduate education. The results of this study support inclusion of a patient death simulation with debriefing in the undergraduate nursing curriculum. Inclusion ensures that each student will have the opportunity to participate in a patient death scenario prior to graduation. In addition, the simulation experience takes place in a controlled setting followed by debriefing, including the opportunity for self-reflection and discussion of self-care. This study shows the importance of this discussion as seen by the significant changes in emotion following debriefing.

A limitation of this study was that it represented nursing students from one institution. Because the pre and post knowledge tests were developed by the researcher, only face validity was established prior to the study. Knowledge gain was tested directly following the debriefing; thus, knowledge retention over time cannot be assumed.

Future research on this topic could expand to multiple schools and geographical areas. A multisite study would increase the sample size and determine differences based on geographical location. Because death is something that is managed interprofessionally in the clinical setting, it would be beneficial to create an interprofessional simulation.

CONCLUSION

Findings from this study indicate that simulation can be effective in teaching nursing students about patient death. However, because not all nurses experience death frequently, continuing education is needed to reeducate practicing nurses. Nurse educators replicating this scenario should consider appropriate placement in the curriculum to allow for prior education on management of patient death. Faculty debriefers should be adequately trained in managing patient death scenarios. Because a negative emotional response is likely, a plan should be in place to handle potential traumatic reactions. The addition of education about death to the undergraduate nursing curriculum may improve future nurses' ability to handle patient death.

REFERENCES