Use of Simulations in

Preparing Nurses for End of

Life Care
Sara Dietrich
Melina Miller
Elle Pavelonis NURS 470
Taylor Romero University of Arizona
Brianna Roth College of Nursing
Melia Skinner
Krystal Sotis
Laura Worcester
Introduction
Nurses feel uncomfortable with end of life care and the lack of
continued education on improvement of the process (Gelinas, Fillion,
Robitaille, & Truchon, 2012).

Communication:
Communication between physician and family often lacking
Familys confused about situation (Efstathiou & Walker, 2014)
Communication between healthcare team
Poor communication can make process more difficult (Efstathiou &
Walker, 2014)
Introduction

Barriers between patient and family

Families become disconnected from patient due to ICU
environment
Nurses spend time to reconnect family to the patient
(Efstathiou & Walker, 2014)
Emotionality
Nurses are often the first or only person that families confide in
Obligation felt to be constant presence at bedside of patients with
no visitors (Efstathiou & Walker, 2014)
Significance to Nursing

Nurses are most direct contact to patient

Additional responsibilities presented to nurses in end of life
care and withdrawal of care (Wagner & Hardin-Pierce, 2014)
Can cause
Nurses to feel overwhelmed
Nurse burnout
Compassion Fatigue
(Wagner & Hardin-Pierce, 2014)
 PICOT Question
- Population: High Acuity Nurses
- Intervention: Interprofessional workshops
simulating withdrawal of life support
- Comparison: No previous training
- Outcome: To improve the satisfaction for families
- Time: annually
Current Nursing Practice for End of Life Care

Specific guidelines can be found in policy and procedures

handbook of facility

Nurses responsibility to provide

Pain relief
Symptom management
Clarification of process of withdrawal of care
Promotion of familial reconnection with the patient
Informational and emotional familial support
Synopsis of the Research
What are the main areas affecting quality end-of-life care?
Insufficient:
Education and training
Identified as one of the largest barriers to providing optimal EOL care
(Shifrin, 2016)
A study by Shifrin demonstrated that educational intervention resulted in
increased knowledge on EOL care in ICUs (2016)
Knowledge of death
Contribute to nurses discomfort with EOL care (Fernandes & Komessu,
2013)
 Ineffective:
Communication between healthcare providers
Overall, nurses perceived the lack of or conflicting communication
negatively impacted care (Coombs, Addington-Hall & Long-Sutehall,
2012)
Nurses believed they should be able to contribute in the decision making
process (Kisorio & Langley, 2016)
Communication between nurses and patients and families
Nurses felt unprepared to discusses EOL care (Gutierrez, 2013)
Felt that it is acquired through experience alone (Fernandes & Komessu,
2013)
Synopsis of the Research
Ambiguity during transition
EOL trajectory provides a framework that enhances understanding of role and
decision making (Coombs et at., 2012)
Psychological and emotional stress
Nurses felt a lack of emotional support in dealing with patient and family
suffering (Gelinas, Fillion, Robitaille & Truchon, 2012)
Fear of death
New nurses felt their fear of death impacted the quality of care they were able to
provide (Efstathiou & Walker, 2014)
 Strengths and Limitations
Strengths
Applicability of research conclusions to issue at hand (Gelinas,
Fillion, Robitaille, & Truchon, 2012)
Outlines of how trustworthiness was maintained and biases
addressed during research (Kisorio & Langley, 2015)
Inclusion/exclusion criteria used
Steps taken to ensure transcription accuracy and study credibility
using member checks (Kisorio & Langley, 2015)
Themes or theories congruent with the quotes and portrayals given
by participants (Gutierrez, 2012)
Results consistent with previous research (Shifrin, 2016)
Published in peer-reviewed journals
 Strengths and Limitations
Limitations
Most studies were done at 1-3 hospital ICUs (Efstathiou & Walker,
2014)
Homogeneity of the samples (Gutierrez, 2012)
All studies used convenience sampling methods
Data collected from a few small ICU groups or individuals so
findings cannot be generalized to a larger population (Efstathiou &
Walker, 2014)
 Evidence Based Recommendations

Education
Practice guidelines (Aslakson et al., 2012)
Transition from curative intervention to end of life care
(Coombs, Addington-Hall, & Long-Sutehall, 2012)
Training
Simulations (Ballangrud et al., 2013)
 Evidence Based Recommendations
Communication
Improvement within the ICU
Good communication between caregivers & families
(Efstathiou & Walker, 2014)
More experienced nurses need to have open discussions
with less experienced nurses (Fernandes & Komessu, 2013)
Nurse and Family Support
Families experience nursing presence as a comforting
support system
Support programs (Gelinas et al., 2012)
Implementations
Implementation to the unit/facility
All charges nurses of MICU educated
Place flyers throughout unit and in break room
Have the charge nurse explain the simulation purpose, guidelines, and
requirements to staff
Charge nurse will hand information out to staff and provide a sign up
sheet
Send mass email to nurses with email reminders
Timeline
Implementation to the unit/facility will begin two months prior to the scenario
month (ex. June)
Every Friday in the month of June a simulation will take place at the CON
Every nurse will be required to attend one scenario at an available date and
time of their choice within available dates in June
After the scenario month is over, nursing surveys and evaluation of simulated
training will be analyzed and planning will begin to create new scenarios for
the following year
Cost Analysis
A one-hour training would include:
Booking a room in the hospital: Free

ICU Nurse: $33.17/hr x 100/unit= $3,317

Attending: $163.96/hr x 6/unit= $983.76

Resident: $34.72/hr x 18/unit= $624.96

Nurse Assistant: $14.25/hr x 20/unit= $285

Respiratory Therapist: $21/hr x 10/unit= $210

Salary of simulation staff: $12/hr x 24hr x 6/day= $1728

TOTAL: $7,148.72

(Banner Health, 2017)

Cost Analysis
Hospitals lose money each year due to:

Negligence lawsuits which total in the millions - Confidential settlements,

common in medical malpractice lawsuits, prevent the public from knowing
important details, including admissions of wrongdoing (cite AZ Daily Star
Article?)
Poor patient reviews which lead to potential patients choosing facilities with
better reviews
Empty beds- At Banner, a 5 day stay in the ICU costs around $160,000 (Banner Health, 2017)
Loss of ratings and thus funding to the hospital
Risk/ Benefit
Risks
Patient ?
Nurse
competing schedules and calendars
Workload
Less available nurses on the floor
Stereotypes and hierarchies
Hospital
Lack of meeting space
Financial loss for hospital if proven ineffective

Risk/ Benefit
Benefits
Patient
Interprofessional communication- patients benefit from having their care providers
communicate effectively with each other
Nurse
Interprofessional education
Simulation
Values and Ethics
Roles, Responsibilities and teamwork
Hospital
score higher in patient satisfaction surveys if successful
Provide more cost- effective care to patients
Prefered hospital for satisfied patients and families
Evaluation

Surveys will be taken by patient families that will allow

healthcare organizations to measure patient family
satisfaction before and after the simulations take place.

Begin surveying 10 families 1 year before simulations, and

continue surveying another 10 families 1 year after
simulations

Comparison of survey scores

Family Survey
Numeric scale questions:

1 - strongly disagree; 2 - disagree; 3 - neutral/not sure; 4 - agree; 5 - strongly agree

1) I felt involved in my relatives care.

2) I felt that my informational needs were met by the healthcare team throughout the end of life process.
3) I felt that my spiritual needs were met by the healthcare team throughout the end of life process.
4) I felt that my emotional needs were met by the healthcare team throughout the end of life process.
5) I felt confident in the healthcare teams ability to make decisions regarding my relatives care.
6) I felt that there was effective and clear communication amongst the members of the healthcare team.

Free response questions:

1) What could we, as healthcare professionals, improve on to create a more therapeutic and nurturing environment for
the end of life patient and their family?
2) Was there anything that we did that especially helped and/or comforted you throughout the end of life process?
Simulation Evaluation
Participating ICU nurses will be asked to take a survey 1
week before the simulation and 1 week after the simulation

Provide feedback on the effectiveness of the simulation tool

Provide an outlet to improve simulations for future years

Comparison of scores
Nursing Feedback
Numeric scale questions:

1 - strongly disagree; 2 - disagree; 3 - neutral/not sure; 4 - agree; 5 - strongly agree

1) I feel competent providing end of life care.

2) I feel knowledgeable and able to share information with families regarding their relatives condition.
3) I feel that I have the ability and resources to provide spiritual and emotional needs to families during end of life care.
4) I feel that the healthcare team effectively communicates to provide continuity of care and accurate information that
can be conveyed to family members.
5) I feel that this simulation was beneficial in fostering effective teamwork and communication amongst the healthcare
team during end of life care.

Free response questions:

1) Do you feel that this simulation was helpful?

2) Do you have any ideas on how we could improve the simulation?
Outcomes
The average patient family survey score one year after the end of life simulations
take place will be at least 5 points higher compared to the average survey score
one year before the end of life simulations.

The average nursing feedback score one week after the end of life simulations
take place will be at least 5 points higher compared to the average feedback score
one week before the end of life simulations.
Summary
Nurses are on the front lines during end of life care.
There are several perceived barriers between providing quality care
This includes, lack of education and training, poor interprofessional
communication, ambiguity of protocols, stress on the nurses and personal
fears and insecurities.
Education and training has been shown to result in increased knowledge,
quality and competency of care as well as seamless teamwork among
interprofessionals.
 Simulation training will be implemented to improve communication and
knowledge of hospital protocols.
The cost of the suggested implementation costs $153,061.28 less than the
loss of one patient due to poor hospital reviews.
The benefits far outweigh the risks of implementing an educational simulation
program