WK 4 DIS DATA

Clinical Simulation in Nursing ( 2023 ) 77 , 1- 5

Enhancing Palliative Communication in the

Intensive Care Unit Through Simulation: A Quality

Improvement Project

Adrienne Markiewicz, DNP, RN, AGACNP-BC, CHSE

a , c , ∗, Ronald L. Hickman, PhD, RN, ACNP-BC, FAAN

b , Natalie S. McAndrew, PhD, RN, ACNS-BC, CCRN-K

c , d , Andrew Reimer, PhD, RN

b

a Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA

b Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44106, USA

c University of Wisconsin-Milwaukee College of Nursing, Milwaukee, WI 53211, USA

d Department of Nursing Research, Froedtert & the Medical College of Wisconsin Froedtert Hospital, Milwaukee, WI 53226, USA

KEYWORDS simulation ; palliative communication ; critical care nurse ; intensive care unit ; end-of-life

Abstract Background: Palliative communication is a vital aspect of patient and family-centered end-of-life care in the intensive care unit. Despite this, specialty-specific training and education in palliative communication are generally limited for critical care nurses. The purpose of this quality improvement project was to assess the effect of adding a simulation-based learning experience to the existing End of Life Nursing Education Consortium adult critical care course on critical care nurse comfort with palliative communication as a component of end-of-life care. Method: Using a pretest/post-test design, 11 critical care nurse participants completed a measure of comfort related to end-of-life communication prior to the course and immediately following the simulation experience. Result: A paired-samples t-test showed a statistically increase in comfort with palliative communica- tion from the pretest (M = 56.36, SE = 2.40) to post-test (M = 48.27, SE = 2.97), t (10) = 2.54, p = .30 (two-tailed), The mean decrease in scores was 8.09, 95% CI (0.98, 15.91). Qualitative sur- vey responses indicated that the simulation provided valuable practice of palliative communication techniques. Conclusion: A simulation-based learning experience incorporated into an existing palliative care ed- ucation course is feasible to implement and increased critical care nurse comfort with palliative com- munication at end-of-life.

Cite this article: Markiewicz, A., Hickman, R.L., McAndrew, N.S. & Reimer, A. (2023, Month). Enhancing Palliative Com- munication in the Intensive Care Unit Through Simulation: A Quality Improvement Project. Clinical Simulation in Nursing , 77, 1-5. https://doi.org/10.1016/j.ecns.2023.01.007 .

∗ Corresponding author. [email protected] (A. Markiewicz).

1876-1399/© 2023 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ecns.2023.01.007

Clinical Simulation in Nursing 2

© 2023 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Introduction

An estimated 1.4 million adult patients die in the inten- sive care unit (ICU) each year ( Halpern, 2021 ). As pa- tients experience an episode of critical illness, their fami- lies struggle to provide support and navigate the burden of end-of-life (EOL) decisions.

Palliative communication (PC) is recognized by leading nursing organizations as an essential competency for nurses providing EOL care. PC as a component of EOL care is an essential skill in the delivery of effective symptom man- agement and psychosocial support ( American Nurses As- sociation, 2017 ). Though EOL care is a multidisciplinary endeavor, as the primary clinician at the bedside, regis- tered nurses are uniquely positioned to manage symptoms and provide immediate supportive interventions to dying patients and their families. Colleges/schools of nursing are increasingly strained to meet the demands of prelicensure education given curriculum timing and progression issues as well as limitations in clinical sites. The onus has there- fore been placed largely on health care organizations to provide postlicensure training to bedside nursing staff in EOL and PC competencies. In general, postlicensure train- ing in EOL competencies is lacking and this can lead to increased anxiety, moral distress, and attrition among new nursing staff ( Shaw & Abbott, 2017 ).

Background

The need for postlicensure training in PC and EOL care is particularly evident in critical care environments, where nursing staff provide primary palliative care to patients dying of sepsis, multiple organ failure, advanced cancer, and many other conditions. Specialty-specific challenges exist in providing EOL care in the ICU which span sev- eral domains of learning and include terminal removal of mechanical ventilation and other organ supportive thera- pies, heavy patient symptom burden, highly technologi- cal environment, time constraints, other patient care, chal- lenging family dynamics and ethical conflict. Critical care nurses therefore require additional training beyond core EOL competencies to achieve fluency in the delivery of high quality EOL care in the ICU ( Ferrell et al., 2007 ; Ferrell et al., 2019 ). Simulation-based learning experiences (SBLEs) have been used for some time in health care and other fields to provide practice experience in a particular skill set or competency prior to implementation in clinical practice. SBLEs have been approved by major accredita- tion bodies as high-quality learning experiences. Evidence-

based theory ( Jeffries, 2005 ; Jeffries, 2016 ) and frame- works ( Salifu et al., 2022 ) exist for simulation develop- ment and the International Nursing Association of Clinical and Simulation Learning and the Society for Simulation in Healthcare, have established evidence-based best practice standards for simulation development and implementation in nursing ( Watts et al., 2021 ). The purpose of this project was to integrate a SBLE within the End-of-Life Nursing Education Consortium (ELNEC) adult critical care course to assess the effect on nurse comfort with palliative com- munication.

Sample

Project participants included a convenience sample of four- teen adult ICU nurses taking the ELNEC critical care course offered by the partner institution. Eleven nurses completed both pre-and posttest surveys (n = 11).

Methods

Design

A quality improvement project was conducted to ascertain the impact of the SBLE within the ELNEC critical care course on the comfort of critical care nurses with palliative communication at end-of-life. The project was formally submitted to the project site Institutional Review Board and received a quality improvement project designation.

Potential participants learned about the project by the investigator prior to the start of the first day of the EL- NEC critical care course. On the first day of the ELNEC course, numbered paper surveys were passed out and eligi- ble nurses were given the chance to opt out by not taking the survey at the start of the course with no consequences related to their participation in the ELNEC course. Nurse participants could also discontinue participation at any time by not completing both surveys.

Setting

The partner institution for this project was a 689-bed tertiary academic medical center containing five special- ized ICUs and employing approximately 500 critical care nurses. The ELNEC adult critical care course is given twice per year over two, eight-hour days at this facility. The eight core ELNEC modules include: nursing care at the end-of-life, pain management, symptom management, ethical and legal issues, cultural and spiritual consider-

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Clinical Simulation in Nursing 3

Table 1 Demographic Data

Baseline Characteristic Critical Care Nurses

n %

Gender Female 11 100

Years Nursing Experience Less Than Five Years 7 63.6 Five to Ten Years 2 18.2 Ten Years or More 2 18.2

Years of Critical Care Experience Less Than Five Years 7 63.6 Five to Ten Years 3 27.3 Ten Years or More 1 9.1

Level of Education BSN 9 81.8 MSN 2 18.2 Racial Identity White/Caucasian 11 100

Prior Experience with Death a

Yes 11 100 ICU Specialty

Medical ICU 5 45.5 Surgical ICU 3 27.3

Transplant ICU 1 9.1 Neurological ICU 1 9.1 Cardiovascular ICU 1 9.1

Note. N = 11. Participants were on average 29 years old (SD = 5.93) and participant age did not differ by condition. a Reflects the number and per- centage of participants answering “yes” to this question.

ations, communication, loss, grief, bereavement, and fi- nal hours/days are presented, with special consideration to ICU-specific learning needs.

Description of the Simulation-based Learning

Experience

The Jeffries Nursing Education Simulation Framework guided the SBLE development the scenario was created for the course, reviewed and approved by three ELNEC course faculty and subject matter experts. The scenario was designed to allow nurse participants the opportunity to practice PC skills with the daughter of a dying pa- tient who has been recently removed from organ support- ive therapy while also providing acute symptom manage- ment for the patient as she progressed through the dying process. The confederate acting as the patient’s daughter was a trained simulation facilitator by the partner institu- tion and Certified Healthcare Simulation Educator through the Society for Simulation in Healthcare. A SimMan Es- sentials (Laerdal Medical) simulator was used to repre- sent the dying patient and physiologic changes consis- tent with the dying process were made in real time by a trained simulation facilitator. Two cohorts of seven nurse participants rotated through the SBLE. Two nurses from each cohort entered the simulation together, with the other nurses participating as active observers. Each cohort be- gan with a safety orientation and pre-briefing conducted by an ELNEC course faculty member and a member of the partner facility’s simulation center staff. Nurses were provided a brief safety orientation as well as orientation to the simulation room functions and limitations. The simu- lation lasted approximately 20 minutes and was followed immediately by a structured debriefing session led by the ELNEC course faculty facilitator. Debriefing allowed for faculty-student interaction, peer to peer feedback and self- reflection. All participants were asked targeted debriefing questions designed to engage critical thinking surrounding PC concepts and their application in EOL care. Debriefing lasted approximately 45 minutes for both groups.

Instruments

Comfort with palliative communication was measured utilizing the Comfort with Communication in Palliative and End-of Life-Care (C-COPE). C-COPE is a 28-item tool measuring nurse comfort with palliative and end- of-life care communication. Five factors are assessed: cultural/spiritual considerations, team considerations, ad- dressing decision-making, addressing symptomatology, and deliberate awareness. Each item is rated on a Likert scale (1- Not difficult, 5- very difficult) and internal consistency reliability by coefficient was 0.90 for the tool as a whole and above 0.75 for each of its five factors. Test-retest reliability showed an intraclass correlation co- efficient of 0.87 (CI 95%, 0.82-0.91) ( Minton et al, 2020 ).

Demographic data was collected for the sample using an investigator-generated tool.

Results

Descriptive Statistics

All participants (n = 11) self-identified as white females. The mean age of the participants was 29 years. All partic- ipants held bachelor’s degree in nursing; two of the par- ticipants held a Master of Science in Nursing. A clear majority of the sample (n = 7) had less than five years of total nursing experience and all but one had less than ten years of critical care experience (n = 10). All participants reported at least one prior experience with death. The sam- ple was nearly equivalent in nurses who reported working in Medical ICUs (n = 5) versus Surgical ICUs (n = 6). Table 1 further describes the sample demographics.

Comfort With Palliative Communication

A paired-samples t-test was conducted using an alpha level of 0.05. There was a statistically significant decrease in C-COPE scores from the pretest (M = 56.36, SE = 2.40) to posttest (M = 48.27, SE = 2.97), t (10) = 2.54, p = .03

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Table 2 Item-based Paired Samples T-Test

Paired Differences Significance

Item Mean Standard Deviation

Standard Error

t df p

Talking with patients when they’ve received difficult news 0.82 1.40 0.42 1.94 10 .82 Talking with patients about spiritual and/or religious concerns

0.73 0.79 0.24 3.07 10 .12

Talking with patients about spiritual and/or religious concerns that are different from my own

0.18 1.33 0.40 0.45 10 .66

Remaining silent while listening to the expression of feelings from patients

–0.91 0.54 0.16 –0.56 10 .59

Talking to patients about end-of-life decisions 0.82 1.25 0.38 2.17 10 .55 Talking with patients from cultures other than my own –0.18 1.17 0.35 –0.52 10 .62 Talking with patients about physical symptoms –0.18 1.08 0.33 –0.56 10 .59 Talking with patients about psychosocial symptoms 0.36 1.03 0.31 1.17 10 .27 Talking with patients without using medical jargon –0.91 0.94 0.29 –0.32 10 .76 Talking with families once they have received difficult news 0.73 1.42 0.43 1.70 10 .12 Talking with families about spiritual and/or religious concerns

0.18 1.08 0.33 0.60 10 .59

Talking with families about spiritual and/or religious concerns that are different from my beliefs

0.55 1.13 0.34 1.60 10 .14

Discussing decisions to be made when a family member is the patient’s proxy

1.09 1.04 0.32 3.46 10 .06

Remaining silent while listening to the expression of feelings from families

–0.36 0.81 0.24 –1.49 10 .17

Talking to families about end-of-life decisions 1.18 1.47 0.44 2.67 10 .02 Talking with families from cultures other than my own 0.73 1.00 0.30 2.39 10 .04 Talking with families about the patient’s physical symptoms 0.64 1.57 0.47 1.35 10 .21 Talking with families about the patient’s psychosocial symptoms

0.73 1.10 0.33 2.19 10 .05

Talking with families without using medical jargon 0.91 1.04 0.32 0.29 10 .78 Talking with physicians about palliative care issues 0.18 1.40 0.42 0.43 10 .68 Talking with nurses about palliative care issues 0.00 0.78 0.23 0.00 10 1.00 Talking with physicians about end-of-life issues 0.36 1.03 0.31 1.17 10 .27 Talking with nurses about end-of-life issues –0.18 1.47 0.44 –0.41 10 .70 Talking with other members of the healthcare team about palliative care and/or end-of-life issues

–0.27 1.56 0.47 –0.58 10 .57

Note. p is two-sided.

(two-tailed), indicating an increase in comfort with pallia- tive communication postsimulation. The mean decrease in C-COPE scores was 8.09, 95% CI (0.98, 15.91). The effect size was medium (d = 0.765). The largest difference in C-COPE scores was seen in the domain of family commu- nication. Specific items were: “Talking to families about end-of-life decisions” (p = .02), “talking with families from cultures other than my own” ( p = .04) , and “talking with families about the patient’s psychosocial symptoms” ( p = .05). Table 2 provides further details of the paired t-test data for the 24 Likert items in the C-COPE tool.

Qualitative Findings

Participants were given the opportunity to answer two open-ended questions about their experiences with the SBLE on the post-test survey. Eight nurses responded to

at least one of the questions. All comments were positive and are included below.

The responses highlighted the value of SBLEs as an op- portunity for peer feedback on communication techniques learned in the course and for skill application. “It put all of the pieces we were taught together.”, “This simulation helped us utilize the communication strategies we were taught in the morning session.”, and “Very hands-on, real- life experience.”

Nurses expressed increased empowerment in the initia- tion of end-of life discussions and the opportunity for less experienced nurse learners to gain new insights for practice from more experienced staff. A nurse wrote,

“I feel more empowered to initiate palliative and end of life conversations with patients and families. I loved learning new tools and hearing about how more expe- rienced nurses approach this.” Another commented,

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“Nice to hear other perspectives and learn what re- sources are available for the patients and families.”

One nurse participant highlighted the value of the sim- ulation facilitator playing the role of the patient’s fam- ily member participating in the formal scenario debriefing. This participant shared,

“Hearing from the actor’s perspective was also valuable to know family concerns.”

Several participants shared new palliative communica- tion techniques they would use in their future practice be- cause of the SBLE experience. These specific comments included:

“Taking time for silence and allowing family to use the nurse as a sounding board.”, and “This [SBLE] helped me think of new ways to handle things like therapeutic touch, silence, reassurance, and chaplain presence.”

Limitations

The findings of this project have several limitations. The project design does not include a control group. As this was a pilot project, it was single center, with a small sam- ple size that is homogeneous in demographics, giving se- rious limitation to generalizability of the findings beyond local scope and raising the possibility of bias. Larger stud- ies of this SBLE with more rigorous study designs and inclusion of a control group are recommended.

Conclusion

The results of this quality improvement project indicate a statistically significant difference in mean C-COPE scores pre and postsimulation among critical care nurses exposed to a SBLE for improving the quality of palliative commu- nication at EOL. Based on our data, we concluded that the ELNEC course and SBLE were effective in increasing nurse comfort with palliative communication at end of life. Qualitative responses expressed that the simulation was valuable to apply skills and obtain peer and facilitator feedback. Several nurses reported specific examples of techniques they would bring to their future practice be- cause of the course and SBLE. The scenario was feasible to implement and was well-received by both participants and facilitators. Avenues of future study include assess- ment of longitudinal effects of simulation of the PC skills of critical care nurses and effect on critical care nurse

moral distress, burnout, and retention. The optimal timing and dose of further SBLE to maintain nurse competence and affect these outcomes could also be explored.

Declaration of Competing Interest

Dr. McAndrew is a 2021 Cambia Health Foundation So- journs Palliative Leader Scholar. The other authors declare no conflicts of interest.

Funding

This project did not receive any specific grant from fund- ing agencies in the public, commercial, or not-for-profit sectors.

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