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Nurse Education Today

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Interprofessional simulation-based training in gynecologic oncology palliative care for students in the healthcare profession: A comparative randomized controlled trial Fatma Uslu-Sahana,⁎, Fusun Terzioglub a Department of Obstetrics and Gynecologic Nursing, Faculty of Nursing, Hacettepe University, Ankara, Turkey b Faculty of Health Science, Atilim University, Ankara, Turkey

A R T I C L E I N F O

Keywords: Cancer Gynecology Healthcare team Palliative care Randomized controlled trial Simulation training Students

A B S T R A C T

Background: Preprofessional palliative care education may be inadequate, leaving a gap in health professional students' knowledge and understanding of managing patients with gynecologic cancer and their families. Interprofessional simulation-based training may be useful in helping health professional students gain the ne- cessary skills required for palliative care. Objective: This study aimed to determine the effectiveness of different simulation methods used for inter- professional training on gynecologic oncology palliative care knowledge, interdisciplinary education percep- tions, and teamwork attitudes of health professional students and to compare these methods. Design: A comparative randomized controlled trial was conducted with a pre-test and two post-tests. Settings: This study was conducted at a university in Ankara, Turkey, in 2016–2017. Participants: A convenience sample of 84 interprofessional students (nursing, medical, nutrition-dietician, and social work) was used in the study. Methods: Students were stratified by their profession and randomized by four blocks into high-fidelity simulation, hybrid simulation, and a control group. Data were collected using a semi-structured questionnaire form, palliative care knowledge test, interdisciplinary education perception scale, and teamwork attitudes questionnaire. Results: The high-fidelity simulation and hybrid simulation groups improved their palliative care knowledge, interdisciplinary education perception, and teamwork attitudes from pre-test to first and second post-tests compared to the control group. Conclusion: The introduction of high-fidelity simulation and hybrid simulation or hybrid simulation-based in- terprofessional training in undergraduate education can increase students' palliative care knowledge, inter- disciplinary education perception, and teamwork attitudes. Training programs that are used together with high- fidelity simulation and hybrid simulation applications in interdisciplinary training should be integrated into the undergraduate curricula of future cooperating health professions.

1. Introduction

Gynecologic cancers constitute an important part of cancer load in developing countries in particular and may be a significant cause of mortality and morbidity in these countries (International Agency for Research on Cancer, 2012). The diagnosis and treatment procedures in gynecologic cancers remain insufficient, and disorders related to the symptoms may impair the quality of life of women and their families (Landrum et al., 2015; Uslu Sahan and Terzioglu, 2017). In this respect, there is presently increasing interest in palliative care in gynecologic cancer cases (Mullen et al., 2019; Uslu Sahan and Terzioglu, 2017).

The National Consensus Project Clinical Practice Guidelines for Quality Palliative Care emphasizes that palliative care should be pro- vided for patients and their families by an educated and interprofes- sional team and highlights the importance of interprofessional co- operation (National Consensus Project, 2013). Meeting the needs of patients and their families who need palliative care requires an inter- professional team approach that develops a common philosophy and can share the responsibility of care as a team (Landrum et al., 2015; Mullen et al., 2019; National Consensus Project, 2013; Saylor et al., 2016). In the literature, however, the lack of palliative care knowledge and skills of healthcare professionals included in interprofessional

https://doi.org/10.1016/j.nedt.2020.104588 Received 19 June 2019; Received in revised form 16 July 2020; Accepted 25 August 2020

⁎ Corresponding author at: Department of Obstetrics and Gynecologic Nursing, Faculty of Nursing, Hacettepe University, 06100 Samanpazari, Ankara, Turkey. E-mail address: [email protected] (F. Uslu-Sahan).

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palliative care teams has been emphasized (Mullen et al., 2019; Turgay and Kav, 2012; Uslu Sahan and Terzioglu, 2017), and it has been stated that this impairs the quality of care (Mullen et al., 2019).

The interprofessional palliative care training programs are vital to gain competencies in palliative caregiving (Efstathiou and Walker, 2014; Pastor et al., 2016). In interprofessional training, many competencies, such as problem solving, successful communication, teaching and im- proving knowledge and skills, patient-centered practice, and team co- operation (Birk, 2017; Gough et al., 2012; Randall et al., 2018; Sicat et al., 2014) may be developed using simulation, which is a new and technological method used in training (Gough et al., 2012; Lefebvre et al., 2015; Randall et al., 2018). Interprofessional simulation-based training is beginning to be used more regularly in undergraduate edu- cation programs of healthcare professionals (Birk, 2017; Costello et al., 2017; Randall et al., 2018). Simulation provides health professional students a safe environment for the development of practice-based skills in addition to their academic skills (Costello et al., 2017; Gough et al., 2012; Pastor et al., 2016; Saylor et al., 2016). Interprofessional simula- tion-based training allows students to understand and practice their roles on their teams better and improve their skills individually and as a team (Costello et al., 2017; Efstathiou and Walker, 2014; Gough et al., 2012; Randall et al., 2018; Saylor et al., 2016). The literature indicates that different simulation methods, such as high-fidelity simulation (HFS) (Lefebvre et al., 2015; Liaw et al., 2014; Sharder et al., 2013) and standardized patient simulation (Liaw et al., 2014), are used in inter- professional training. It has also been observed that acute clinic scenarios are often used (Costello et al., 2017; Lefebvre et al., 2015; Sharder et al., 2013). There are a limited number of studies in the palliative care field, and different simulation methods are not included in these studies (Efstathiou and Walker, 2014; Gough et al., 2012; Pastor et al., 2016; Saylor et al., 2016). Interprofessional simulation-based training may be useful in helping health professional students gain the necessary skills for palliative care (Efstathiou and Walker, 2014; Pastor et al., 2016; Prelock et al., 2017; Randall et al., 2018; Saylor et al., 2016).

Palliative care is accepted as one of the most significant elements in cancer control programs in Turkey (Turkish Ministry of Health, 2010; Uslu Sahan and Terzioglu, 2017). However, healthcare professionals included in the palliative care team are not trained as team members who can work together and do not receive palliative care training that includes an interprofessional learning experience during their under- graduate education. There are some significant obstacles in maintaining high-quality palliative care services and improving their effect (Uslu Sahan and Terzioglu, 2017). Education of students and healthcare professionals in palliative care is organized by different institutions and organizations. However, this is limited to theoretical training without practice. In this study, simulation applications in interprofessional gy- necologic oncology palliative care training, and interventions that in- clude both theoretical and applied training were used. However, to the best of our knowledge, no study was found in Turkey and in the recent literature on the use of HFS and hybrid simulation (HS) methods in interprofessional palliative care training and on determining which si- mulation method/methods would be more effective. This study aimed to determine the effectiveness of different simulation methods used for interprofessional training on gynecologic oncology palliative care

knowledge, interdisciplinary education perceptions, and teamwork at- titudes of health professional students, and to compare these methods.

The following hypotheses were tested in this study:

H1. There are differences between HFS and/or HS groups and the control group in health professional students' gynecologic oncology palliative care knowledge.

H2. There are differences between HFS and/or HS groups and the control group in health professional students' interdisciplinary training perception.

H3. There are differences between HFS and/or HS groups and the control group in health professional students' teamwork attitudes.

2. Methods

2.1. Design

This study was a comparative randomized controlled trial with a pre-test and two post-tests. The randomized sampling method was used, and a 22 factorial test level was used to form the four different groups. The groups and their interventions are shown in Table 1. Only inter- professional gynecologic oncology palliative care training (IP Gyn-Onc PCT) was applied to the control group, and different simulation methods (HFS, HS, and HFS + HS) were applied to the experimental groups together in this training.

2.2. Sample/participants

This study was conducted at a university in Ankara, Turkey, in the 2016–2017 academic year. Convenience sampling was used to obtain a sample of health professional students. The sample in this study was composed of third-year students in the departments of nursing, nutrition- dietician, and social work and fourth-year medical students. The sample inclusion criteria were determined as those who had successfully com- pleted courses on gynecologic oncology and/or oncology, had no verbal or written communication problems, and had volunteered to participate. The sample comprised 96 students (24 nursing, 24 medical, 24 nutrition- dietician, and 24 social work) who met the inclusion criteria. The stu- dents were stratified by profession and randomized by four blocks into experimental or control groups. Fig. 1 shows the process from sample- eligibility verification to data analysis and the changes in sample size. Two nursing, seven medical, one nutrition-dietician, and two social work students were excluded from the study because they did not participate in IP Gyn-Onc PCT. This study was completed with a total of 84 students (22 nursing, 17 medical, 23 nutrition-dietician, and 22 social work). The sample size of 84 students can reveal the inter-group difference with the power of 90.4%, margin of error of 5%, and the effect size value of 25%.

2.3. Data collection

Data were collected using a semi-structured questionnaire, pallia- tive care knowledge test (PCKT), interdisciplinary education perception scale (IEPS), and teamwork attitudes questionnaire (TAQ) between

Table 1 The study design.

Groups Before (T1) Intervention After simulation (T2) 3 months later (T3)

Control Pre-test IP Gyn-Onc PCT First post-test Second post-test HFS Pre-test IP Gyn-Onc PCT + HFS First post-test Second post-test HS Pre-test IP Gyn-Onc PCT + HS First post-test Second post-test HFS + HS Pre-test IP Gyn-Onc PCT + HFS + HS First post-test Second post-test

IP Gyn-Onc PCT: interprofessional gynecologic oncology palliative care training; HFS: high-fidelity simulation; HS: hybrid simulation; pre-test: semi-structured questionnaire form, Palliative Care Knowledge Test (PCKT), Interdisciplinary Education Perception Scale (IEPS), Teamwork Attitudes Questionnaire (TAQ); first post- test: PCKT, IEPS, and TAQ; second post-test: PCKT, IEPS, and TAQ.

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March and July 2017. All students were asked to fill out a semi-struc- tured questionnaire before IP Gyn-Onc PCT. PKCT, IEPS, and TAQ were collected from all of the students before IP Gyn-Onc PCT, after simu- lation interventions (one week after IP Gyn-Onc PCT for the control group), and three months after the simulation interventions (Table 1).

2.4. Intervention

All students in the control and experimental groups participated in IP Gyn-Onc PCT, which lasted for 16 h (two days). The content of IP Gyn- Onc PCT was prepared using the related literature. The opinions of three experts on gynecologic oncology and palliative care were considered for the content validity of the training program content, necessary revisions were made, and IP Gyn-Onc PCT was finalized. Table 2 illustrates in- formation on the training provided to the study groups. In the last stage of the training program, the case discussion included planning the treatment and care of a woman with cervical cancer using an inter- professional approach. The experimental groups, including three simu- lation groups in each experimental group, participated in the simulation, including one medical student, two nursing students, two social work students, and two dietitian students. The simulations were performed in the Interprofessional Training and Simulation Center at the institution where the study was conducted and lasted for two weeks. To prevent interactions between the students in the simulation groups, the group simulations were planned at different times.

The scenario template suggested by the University of Alabama at Birmingham's Interprofessional Training and Simulation Center was used to prepare the simulation scenario (https://www.uab.edu/ simulation/images/Scenario_Template_GUIDE_COA_logo_ver_01.02_ Sept192014.pdf). The opinions of three experts on gynecologic on- cology and palliative care were considered for the content validity, necessary revisions were made, and the simulation scenario was

finalized (Table 3). All scenarios were composed of 10-minute pre- briefing, 30-minute simulation, and 45- to 60-minute debriefing stages.

For the experimental groups' HFS and HS applications, a palpable mass that was 10 cm × 5 cm in size was placed in the abdomen of the simu- lation mannequin/standardized patient, and the abdomen was covered by abdominal skin. Bruising formed on the mannequin/standardized patient's arm and hand and urine catheterization was applied (the catheter tip was fixed on the standardized patient's leg). A catheter was inserted into the mannequin for IV infusion but applied on the standardized patient's skin. A marker (showing +2 degrees of edema) was added to the ankles, and a 15-cm-long scar tissue formed on the abdomen with moulage technique and was covered with dressing materials. For the role of the patient's daughter, a second standardized patient was included in the simulation. The standardized patients were trained according to the scenarios. Hybrid simulation was conducted in group 4 after the high-fidelity simulation. After completing both simulations, debriefing sessions were held.

2.5. Instruments

The study data were collected using a semi-structured ques- tionnaire, PCKT, IEPS, and TAQ.

The semi-structured questionnaire consisted of questions de- termining the age, gender, students' faculties/departments, level of in- formation received on palliative care, status of ever having participated in simulation-based training before, and status of ever having partici- pated in interprofessional training before.

The students' level of palliative care knowledge was assessed using a multiple-choice PCKT with 28 questions prepared to determine the cognitive competencies in accordance with the objectives of the Gyn- Onc PCT. This test was designed based on the relevant literature. The opinions of three experts on gynecologic oncology and palliative care were considered for content validity, necessary adjustments were made,

Fig. 1. Flowchart showing the process from sample eligibility verification to data analysis. IP Gyn-Onc PCT: interprofessional gynecologic oncology palliative care training; HFS: high-fidelity simulation; HS: hybrid simulation; pre-test: semi-structured questionnaire form, Palliative Care Knowledge Test (PCKT), Interdisciplinary Education Perception Scale (IEPS), Teamwork Attitudes Questionnaire (TAQ); first post- test: PCKT, IEPS, and TAQ; second post-test: PCKT, IEPS, and TAQ.

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and the PCKT was finalized. The students received one point for each correct answer and zero point for each incorrect answer. Higher scores indicated greater knowledge of palliative care. Cronbach's alpha based on the measurement times was 0.56 before the training, 0.60 just after the simulation, and 0.81 three months after the simulation.

The students' level of interdisciplinary education perception was assessed using the 17-item IEPS developed by Luecht et al. (1990) and adapted for use in Turkey by Terzioğlu et al. (2019). The scale is a six- point Likert scale. An increase in the scale's mean scores signifies that the interdisciplinary training perception increased (Luecht et al., 1990; Terzioğlu et al., 2019). Cronbach's alpha was 0.87 in the original study (Luecht et al., 1990) and 0.93 in the Turkish version (Terzioğlu et al., 2019). Cronbach's alpha based on the measurement times was 0.90 before the training, 0.93 just after the simulation, and 0.93 three months after the simulation.

The students' level of teamwork attitude was assessed using the 26- item TAQ developed by Baker et al. (2010) and adapted for use in Turkey by Yardımcı et al. (2012). The scale is a five-point Likert scale.

An increase in the scale's mean scores signifies that the teamwork at- titude increased (Baker et al., 2010; Yardımcı et al., 2012). Cronbach's alpha was 0.87 in the original study (Baker et al., 2010) and 0.82 in the Turkish version (Yardımcı et al., 2012). In this study, Cronbach's alpha based on the measurement times was 0.91 before the training, 0.92 just after the simulation, and 0.96 three months after the simulation.

2.6. Ethical considerations

The necessary permissions were obtained from the institutions and the university's Non-Interventional Clinical Research Ethics Board (16969557/793). The students were given a detailed explanation of the study and informed that no academic credit would be given for parti- cipating. The students allocated to the control group who wanted to experience the HFS and/or HS practices were offered the same program after the data collection was complete. Written informed consent was obtained from all participants.

2.7. Statistical analyses

The data were analyzed using SPSS 20 (SPSS Inc., Chicago IL, USA). The appropriateness of the data for normal distribution was tested using the Kolmogorov-Smirnov test. By considering this information, chi- squared test was used to determine whether there was a correlation between two independent categorical variables. The one-way ANOVA test was used to determine whether there was a difference between the groups, and the Bonferroni post-hoc test was used to decide which group was different. Repeated ANOVA measures were used to de- termine whether there was a difference in terms of the measurement times, and the Bonferroni post-hoc test was used to decide which group was different. In the analysis of the repeated ANOVA measures, Pillai's trace values were used based on the results of the sphericity test. Statistical significance was defined as p < 0.05.

Table 2 Interprofessional gynecologic oncology palliative care training in the control and experimental groups.

Item Control group Experimental groups

Title HFS HS HFS + HS

Content • Objectives, objectives of palliative care, and obstacles in palliative care application • Status of palliative care in the world and Turkey • Why is palliative care important? • The roles and responsibilities of the interdisciplinary palliative care team (nurse, doctor, dietitian, and social worker) • Spiritual care • Communication with patient and family in palliative care • Evidence-based practices in symptom management (pain, dyspnea, acid, fatigue, nausea-vomiting, constipation, delirium, depression, anxiety, and problems with sexual life)

• Patient care during and after death • Family care in grieving process • Ethical and legal issues in palliative care • Teamwork in interpersonal palliative care (case discussions) – High-fidelity simulation scenario-

based teaching Hybrid simulation scenario- based teaching

High-fidelity and hybrid simulation scenario-based teaching

Teaching strategies 1. Lecture 2. Power Point presentation 3. Case discussions 4. Group discussion, reflection, and feedback

1. Lecture 2. Power Point presentation 3. Case discussions 4. Group discussion, reflection, and feedback 5. High-fidelity simulation practice

5. Hybrid simulation practice 5. High-fidelity and hybrid simulation practice

IP Gyn-Onc PCT Sessions March 4 and 5, 2017 16 h

Simulation time – 2 h per session 2 h per session 4 h per session Simulation Participants In each simulation group consist

of: 1 medical students 2 nursing students 2 social work students 2 dietician students

Three simulation groups in each experimental group

Table 3 The scenario.

Mrs. Ayşe, 66, was diagnosed with stage 3 ovarian cancer two years ago. She presented at the emergency department one week ago. An emergency room exam found a high amount of acid. She had visual analog scale pain score of 8. The patient wants to be discharged from the hospital now. The scenario is composed of three parts.

✔ First part: Nurse interview and a team meeting with the patient and her relative (10 min). In this part, the nurses perform patient handover; first the nurse and then the team evaluates the patient and her daughter and perform the required palliative care interventions. This part ends after the evaluations and interventions are complete.

✔ Second part: Team meeting: The patient's general condition is evaluated in the team meeting room and the team decides to discharge her from the hospital.

✔ Third part: Sharing the discharge decision with the patient and her daughter: The discharge decision is shared and discussed with the patient and her daughter.

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3. Results

3.1. Demographic characteristics

The average age of the students was 22.06 ± 2.56. The majority of the students were female (73.8%), did not have knowledge about pal- liative care (75.0%), and had not received simulation training before (66.7%) (Table 4). All students stated that they had not received any prior interprofessional training. There was no difference between the demographic characteristics of the study groups (p > 0.05; Table 4).

3.2. The outcomes of palliative care knowledge

There was no difference between the students' PCKT pre-test mean scores (p > 0.05). The control group's first post-test mean score was higher than its pre-test mean score (p < 0.001). The first post-test and second post-test mean scores of the HFS (p < 0.001), HS (p < 0.001), and HFS + HS (p < 0.001) groups were higher than their pre-test mean scores. The HFS + HS group had the highest PCKT mean scores on the first post-test (p < 0.001) and second post-test (p < 0.001) (Table 5; Fig. 2). The interprofessional simulation-based training using HFS + HS increased the students' PCKT mean scores, and the H1 hy- pothesis was accepted.

3.3. The outcomes of the interdisciplinary education perception

No significant difference was determined between the students' IEPS pre-test mean scores (p = 0.977). No significant difference was de- termined between the control and HFS groups' pre-test, first post-test (p = 0.723), and second post-test (p = 0.205) mean scores. The HS group's first post-test mean score was higher than its pre-test mean score, but the difference between them was insignificant (p = 0.309). The HFS + HS group's first post-test and second post-test mean scores were higher than its pre-test mean score (p = 0.001). The HFS + HS group's first post-test (p = 0.056) and second post-test (p = 0.174) mean scores were the highest (Table 5; Fig. 3.), and the H2 hypothesis was accepted.

3.4. The outcomes of the teamwork attitudes

No significant difference was determined between the students' TAQ pre-test mean scores (p = 0.972). There was no difference between the control and HFS groups' pre-test, first post-test (p = 0.907), and second post-test (p = 0.268) mean scores. The HS group's first post-test mean score was higher than its pre-test mean score (p = 0.007). The HFS + HS group's first post-test mean score was higher than its pre-test mean score (p = 0.012), and the H3 hypothesis was accepted. The HFS + HS group had the highest first post-test mean score (p = 0.198) and second post-test mean score (p = 0.494), and the difference be- tween them was not statistically significant (Table 5; Fig. 4).

4. Discussion and conclusion

Together with the aging population and increasing chronic diseases, palliative care and end-of-life care needs have increased, and it is im- portant for healthcare professionals to receive training on this subject (National Consensus Project, 2013; Prelock et al., 2017). In our study, 75% of the students had not received training on palliative care. In a study by Uslu Sahan and Terzioglu (2017), 52.3% of nurses had no knowledge of palliative care. Similar results were shown in a study by Turgay and Kav (2012) in which 64.2% of healthcare professionals had no such knowl- edge. Studies in the literature indicate that palliative care education is lacking in undergraduate curricula, and this is one of the most important obstacles for the development of effective palliative caregiving (Mullen et al., 2019; Randall et al., 2018; Turgay and Kav, 2012; Uslu Sahan and Terzioglu, 2017). Accepted as one of the most essential components of any cancer control program (Turkish Ministry of Health, 2010), palliative care has been better understood only recently. This may be associated with the lack of palliative care training in undergraduate education programs, which often adhere to traditional teaching and learning methods.

In the education of healthcare professionals, changes that will im- prove health systems and decrease medical errors are necessary (Costello et al., 2017; Sicat et al., 2014). Interprofessional training may be used to bring about these changes (Costello et al., 2017). In our study, it was determined that none of the students had participated in an interprofes- sional training program before, and 66.7% had not participated in any

Table 4 Demographic characteristics.

Variable Control (n = 23)

HFS (n = 21)

HS (n = 21)

HFS + HS (n = 19)

Total (n = 84)

Age Mean ± SD 22 ± 0.95 21.62 ± 1.24 22.71 ± 4.08 21.89 ± 2.85 22.06 ± 2.56

n % n % n % n % n % Gender Female 16 69.6 12 57.1 16 76.2 18 94.7 62 73.8 Male 7 30.4 9 42.9 5 23.8 1 5.3 22 26.2 χ2** = 7.598 p = 0.055

Program of enrollment Nursing 4 17.4 6 28.6 6 28.6 6 31.6 22 26.2 Medical 8 34.8 3 14.3 3 14.3 3 15.8 17 20.2 Dietician 5 21.7 6 28.6 6 28.6 6 31.6 23 27.4 Social worker 6 26.1 6 28.6 6 28.6 4 21.1 22 26.2 χ2** = 5.001 p = 0.834

Knowledge about palliative care Yes 6 26.1 4 19.0 5 23.8 7 36.8 21 25.0 No 17 73.9 1 81.0 1 76.2 12 63.42 63 75.0 χ2** = 0.866 p = 0.834

Previous simulation experience Yes 8 34.8 6 28.6 6 28.6 8 42.1 28 33.3 No 15 65.2 15 71.4 15 71.4 11 57.9 56 66.7 χ2** = 1.108 p = 0.775

HFS: high-fidelity simulation, HS: hybrid simulation. *One-way ANOVA test. **Pearson's chi-squared test.

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prior simulation education. Lefebvre et al. (2015) determined that 35.9% of students had not participated in an interprofessional training program, and Costello et al. (2017) found that 98% of students had never partici- pated in a simulation-based interprofessional training program. In a sys- tematic review conducted by Lapkin et al. (2013), it was stated that the interprofessional cooperation attitudes and perceptions of students and their clinical decision-making skills may be improved by interprofessional training. In the literature, the importance of healthcare professionals undergoing interprofessional training programs before starting their professional careers has been emphasized (Birk, 2017; Chambers et al.,

2018; Costello et al., 2017; Gough et al., 2012; Liaw et al., 2014; Sicat et al., 2014). This result may be associated with the fact that simulation education in Turkey, especially in nursing and medical education, has increased in recent years. The institution where this study was conducted is one of the leaders in providing simulation education in Turkey; how- ever, the concept of interprofessional training is quite new in Turkey. The results of this study revealed an important deficiency in the under- graduate curricula of healthcare education programs in Turkey.

The fact that the knowledge and skills in palliative care services are improving to deliver and maintain these services effectively is an

Table 5 RM ANOVA and one-way ANOVA on the outcomes of mean palliative care knowledge and total mean interdisciplinary education perception, teamwork attitudes scores, between the control and experimental groups.

Dependent variable T1 T2 T3 Repeated measures ANOVA

Mean ± SD Mean ± SD Mean ± SD F p Bonferroni post-hoc test

Palliative care knowledge Control (n = 23) 14.13 ± 3.38 16.91 ± 2.73 14.13 ± 5.71 11.476 0.001 T1 < T2 HFS (n = 21) 14.86 ± 2.50 19.14 ± 2.50 19.19 ± 3.66 16.390 0.001 T1 < T2,T3 HS (n = 21) 14.76 ± 3.30 20.29 ± 3.12 20.05 ± 3.06 23.153 0.001 T1 < T2,T3 HFS + HS (n = 19) 15.32 ± 4.87 23.32 ± 2.31 22.42 ± 2.73 46.083 0.001 T1 < T2,T3 One-way ANOVA F 0.396 20.293 16.063

p 0.756 0.001 0.001 Bonferroni post-hoc test Control < HFS, HS, HFS + HS

HFS + HS > HFS, HS Control < HFS, HS, HFS + HS HFS + HS > HFS

Interdisciplinary education perception Control(n = 23) 4.23 ± 0.78 4.36 ± 0.83 4.29 ± 0.91 0.327 0.723 – HFS (n = 21) 4.15 ± 0.73 4.40 ± 1.21 4.60 ± 0.95 1.650 0.205 – HS (n = 21) 4.13 ± 0.82 4.64 ± 1.02 4.67 ± 0.77 3.536 0.039 T1 < T3 HFS + HS (n = 19) 4.20 ± 1.04 5.10 ± 0.46 4.86 ± 0.66 9.952 0.001 T1 < T2,T3 One-way ANOVA F 0.068 2.634 1.697

p 0.977 0.056 0.174 Bonferroni post-hoc test – – –

Teamwork attitudes Control (n = 23) 4.37 ± 0.35 4.41 ± 0.49 4.37 ± 0.75 0.098 0.907 – HFS (n = 21) 4.38 ± 0.31 4.54 ± 0.49 4.51 ± 0.54 1.360 0.268 – HS (n = 21) 4.35 ± 0.36 4.59 ± 0.30 4.56 ± 0.40 5.593 0.007 T1 < T2,T3 HFS + HS (n = 19) 4.37 ± 0.55 4.67 ± 0.20 4.61 ± 0.28 5.868 0.012 T1 < T2 One-way ANOVA F 0.033 1.589 0.807

p 0.992 0.198 0.494 Bonferroni post-hoc test – – –

T1: pre-test; T2: first post-test; T3: second post-test. HFS: high-fidelity simulation, HS: hybrid simulation.

Fig. 2. PCKT scores in the control and experimental groups. T1: pre-test; T2: first post-test; T3: second post-test. HFS: high-fidelity simulation, HS: hybrid simulation.

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important feature of modern healthcare service policy and practice (Efstathiou and Walker, 2014; Landrum et al., 2015). In our study, the experimental groups' palliative care knowledge mean scores increased after the simulations, and the HFS + HS group had the highest increase. No statistically significant difference was found in the control group's palliative care knowledge mean score in the second post-test mea- surements. This indicated that the effects of the interprofessional si- mulation-based training persisted three months after the intervention. The literature has emphasized that simulation-based interprofessional training in palliative care increases knowledge levels and competencies of students in related subjects (Efstathiou and Walker, 2014; Randall et al., 2018; Saylor et al., 2016). In research conducted on simulation- based interprofessional training, no study has been found in which the efficiency of different simulation techniques was assessed. However, it has been emphasized that using standardized patients to practice pal- liative caregiving increases students' knowledge levels on communica- tion in end-of-life care (Efstathiou and Walker, 2014) and their quali- fications and professional competencies in palliative care (Saylor et al.,

2016). In our study, different simulation interventions for interprofes- sional palliative care training in gynecologic oncology were used as a training strategy to increase the students' knowledge levels on this subject. It has been observed that training interventions without si- mulations have a limited effect.

One of the most important factors in assessing the efficiency of in- terprofessional training is assessing the perceptions and attitudes of students on the interprofessional experience (Costello et al., 2017; Lefebvre et al., 2015). In this study, while there was no difference be- tween the groups' interdisciplinary education perceptions before the training, the HS and YGS + HS groups' interdisciplinary education perceptions increased after the simulations. Although no study com- paring different simulation methods was found in the literature, it has been stated that using standardized patients (Liaw et al., 2014) and high-fidelity simulations (Lefebvre et al., 2015; Liaw et al., 2014; Sharder et al., 2013) in interprofessional training increases the inter- disciplinary training perceptions of students. In a study by Sicat et al. (2014), it was determined that online interprofessional training without

Fig. 3. IEPS scores in the control and experimental groups. T1: pre-test; T2: first post-test; T3: second post-test. HFS: high-fidelity simulation, HS: hybrid simulation.

Fig. 4. TAQ scores in the control and experimental groups. T1: pre-test; T2: first post-test; T3: second post-test. HFS: high-fidelity simulation, HS: hybrid simulation.

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simulations resulted in no change in students' interdisciplinary educa- tion perceptions. In our study, the simulation experience may have caused positive changes in the interdisciplinary education perceptions because the students in the intervention group had knowledge of their professions and the roles of other healthcare professionals on the team.

One of the most important goals that students should achieve in interprofessional training is to practice using teamwork (Birk, 2017; Costello et al., 2017; Lefebvre et al., 2015; Liaw et al., 2014). In our study, while there was no difference between the groups' teamwork attitudes before the training, the HS and YGS + HS groups' teamwork attitudes increased after the simulation. In the literature, while no study comparing different simulation methods was found, it has been stated that interprofessional simulations significantly increase students' teamwork attitudes (Costello et al., 2017; George and Quatrara, 2018; Lefebvre et al., 2015; Liaw et al., 2014; Sharder et al., 2013). Costello et al. (2017) and Liaw et al. (2014) reported that simulation-based interprofessional training may be used as a training strategy to increase students' teamwork attitudes. Sharder et al. (2013) determined that students' teamwork skills improved, and these skills had a 54% effect on their clinical simulation skills. Thus, YGS + HS and HS applications may be recommended to improve teamwork skills and increase team- work attitudes.

4.1. Study limitations

This study has some limitations. The one-time training intervention performed in this study may not be enough to cause significant beha- vioral changes in the research subjects. The researchers observed in the sample identification stage that there is no well-established inter- professional training education in Turkey, and students often resist this kind of training. Additionally, the researchers had difficulty in con- ducting the study due to the students' intense program and in obtaining permission from the related institutions to conduct the study with students from several disciplines.

5. Conclusion

The results of this study revealed that the HFS + HS application in interprofessional simulation-based training effectively increased the students gynecologic ontological palliative care knowledge, inter- disciplinary education perception, and teamwork attitude. The HS ap- plication on its own also increased the students' palliative care knowl- edge, interdisciplinary education perception, and teamwork attitudes. As the results of this study clearly demonstrate, palliative care training should be integrated with other health professions during under- graduate education and reinforced using simulations.

The university where this study was conducted accepts students with the highest university exam scores in Turkey for education in many healthcare professions. For this reason, the training techniques conducted in this study will play an important role in developing not only the nursing profession but other occupational groups. As there is lack of comprehensive simulation applications in the literature, these training techniques will be useful throughout Turkey and set an ex- ample for other countries to follow.

Funding

This study is a doctor of philosophy thesis. This study (Project No: 117S900) was supported by the Scientific and Technological Research Council of Turkey (TUBITAK).

Declaration of competing interest

None.

Acknowledgements

The authors grateful to all the students who participated in this study and to the TUBITAK which supports by the research fund.

Credit author statement

All authors have contributed significantly to this article to design of the work; analysis, or interpretation of data for the work and all authors are in agreement with the content of the manuscript. FUS and FT were responsible for research conception and design. FUS collected the data. FUS and FT conducted data analysis. FUS and FT drafted and revised the manuscript.

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