Welcome to this episode of the NLN podcast Nursing EDge Unscripted. I'm your host, Dr. Steven Palazzo, a member of the NLN editorial board for the Nursing Education Perspectives journal. In this episode we will discuss the impact of an end-of-life simulation on graduate students anxiety and self-confidence. The article we will be discussing is titled "Implementation and Evaluation of an End-of-Life Standardized Participant Simulation in Adult Gerontology Acute
Care Nursing Practitioner Program." The article can be found in the May-June issue of Nursing Education Perspectives. The authors of the article are joining us for today's discussion. Dr. Shannon Daly, associate professor of nursing at Middle Georgia State University. Dr. Sterling Roberts, associate professor nursing and director of the Simulation and Translational Research Center at Georgia College at State University. Dr. Lawanda Greene, director nursing at the Fort Valley State
University. Welcome all of you. Thank you. Well let's, you're welcome. Let's get right into the article. So tell us a little bit about what got you interested in this topic and how it led to your study. So I have always had a passion for end-of-life and palliative care as it relates to patients and family members and I'm also aware that as a nurse I was aware of my lack of comfort when handling situations that related to terminal illness and communicating to patients
about that. And so my goal was to work with an institution that would allow me to incorporate those concepts into the into their curriculum and so Dr. Lawanda Greene, who at the time was the program chair of an adult gerontology acute care nurse practitioner program. She recognized that there was a gap in the graduate curriculum in her program and there was also a need to meet that accreditation requirement. And so from there we just began to fill that gap that we
identified in the curriculum. And that's what led us to implementing that end-of-life simulation program into the adult gerontology acute care nurse practitioner program. That's great. Tell us a little bit about the study specifics. Okay. So a little overview. Yeah or the methodology. So what we did was we actually the study was actually conducted at a university in the southeast here in Georgia and we identified that
there was a need. And so our steps were to one, implement an end of life simulation into the program and we wanted to use standardized patients. This was my doctoral project and so I could have paid for actors but instead I recruited undergraduate nursing students because that was also going to be an opportunity for them to learn.
Oh that's great. And so we recruited undergraduate nursing students to be those standardized actors and we put them through a standardized participant training for them to be prepared for that process. And so we prepared our standardized patients which were the undergraduate nursing students and we had our students actually participate in one group, they participated in a pre-test and post-test study that evaluated their comfort levels when incorporating or when participating
in that simulation. That's great, thank you. Can you guys discuss why you chose the end-of-life nursing education consortium curriculum as the intervention and the nursing anxiety and self-confidence with clinical decision-making scale to measure impact? Okay, We're trying to explore using psychometrics and tools more too so I thought this was a great opportunity, this article, to kind of discuss that. All
right, sure. So I was Dr. Daly's chair and when she brought this idea that her and Dr. Greene had, we wanted to do it off of a program that was already well established, well-founded.
So ELNEC answered that call. You know, it's been around since 2000 Dr. Betty Ferrell and her colleagues with the City of Hope originally developed this for the health care professionals that are already out there practicing but however it formulated over time and expanded into academia and supporting the educational efforts of nursing students at various degree levels. So that is where we started out with okay ELNAC, this is going to really fit what we're
trying to establish here. It's a six module program. It touches on all those things that Dr. Daly has talked about that are really hard to deal with when you have a patient that's dying with palliative care. The symptom management, the ethical-legal dilemmas that come along, cultural considerations that vary between patients and communicating and dealing with the grief process not only the patient but their
significant others as well. So it was a very robust program training program and Dr. Daly was very committed to it and she went through the program herself and became the train the trainer so she was in the perfect position to pass this education on to her students. That's wonderful. And the tool to measure? So the nursing anxiety and self-confidence with clinical decision-making tool I did discover, well, I will say that when you think about your project you ask yourself,
what what do I want to get out of this? Snd I did want to see if that ELNEC portion of communication, if that portion of didactic would be effective and what an impact learning about communication would have as it relates to anxiety
and self-confidence. And so Dr. Krista White, who actually she developed this tool from Georgetown University's School of Nursing and Health Sciences and I did get her permission to use it but it was the perfect tool to utilize when trying to determine, hey, are students comfortable when communicating with patients about terminal illness? Do they have the self-confidence and will it change and
make an impact in their anxiety levels? So it was the perfect tool to measure what we were trying to discover. And you didn't find any changes in anxiety levels or correlation between years of experience and self-confidence. Do you have any explanation for why you didn't see that or why that may be? I thought it was curious. Yeah.
Well I will say that what the study identified was I think what we all kind of understood that there is a certain level of anxiety that one may experience when they're discussing terminal illness and end of life to patients. So to not have a change in their anxiety levels, it made sense to us. We understood that finding. We also were able to identify that this just goes along with our purpose here that there needs to
be more training. And not just graduate programs, undergraduate programs and even when they become nurses to continue that training because regardless of the amount of years of experience that you have there is a level of discomfort that you may have if you are not comfortable or trained to communicate effectively
with those family members and patients. Yeah, I enjoyed that statistic, thinking that with more experience perhaps maybe there was more comfort or less anxiety and when you're dealing with something like end of life it seems that there's still some discomfort there even those who may be seasoned or experienced in this area. And is it the nature of the environment they're working in or is it because they still maybe this training
that you were talking about would be helpful. I would say when we looked at the participants and where they worked a lot of them were emergency room nurses or ICU nurses and still they felt a sense of anxiety and they felt a sense of discomfort. And so that again shows that that environment is known to have an increased possible level of ... they experience terminal illness or death a little bit more frequently than someone who may work in a different setting. And they
too still were uncomfortable with the topic. What are your next steps? So actually and Dr. Greene can talk more on this, although this study was done with graduate nurse practitioner students, Dr. Greene and I have actually been working with her undergraduate nursing students at Fort Valley implementing end of life standardized participant
simulations into her curriculum. And I think that when we first started talking about this I knew that this was a big deal because we were looking at the competencies for adult gerontology care nurse practitioners who primarily work in the acute care setting, critical care, and they see a
lot of death and dying. But that like Dr. Daly was saying, the comfort with talking to people about end of life care and who should do it - should it be a chaplain talking to the family, should it be the nurse, should it be the physician, the nurse practitioner? And these students need that type, like we would saying, that type of training. I feel like it needs to start at the undergraduate
level. When we did an initial run with this a couple months ago with our BSN students we had one students say, well, we usually have a nurse to do this. I'm like, that's the role you're stepping into! Yes. And whether you like it or not, you're gonna see a lot of death and dying with all these different disease processes that are going on in the light of Covid it's ... you're going to see it and it's just a matter of time when you see
it. so being prepared to talk to families and to just they say more than I understand because you really don't. You don't understand. You may can sympathize with them if you've been through similar situations but you don't understand where they're coming from. so that listening, being empathetic, and knowing what not to say that may trigger somebody to go into a tail spin is a big deal. starting early and getting them on board with this would be great. I think that's
wonderful. I think all undergraduate programs should have some simulation built in that's about end of life or palliative care. I think it's very helpful for the students. We used to do it at a university I worked at previously and I know we're talking about doing something like that in our new undergraduate curriculum that's beginning
this fall. So go ahead. I was just gonna say also I'm doing a interdisciplinary collaboration project with the respiratory therapy program and we're going to actually try, we are going to actually implement terminal weaning with our respiratory students and incorporating the role that nurses have and getting them comfortable with collaborating during that end of life process and so I'm excited about that as well. It just shows the passion that we all have when it comes to end
of life. Dr. Roberts and her simulation experience giving us the guidance to follow the simulation guidelines accurately to make sure we meet our outcomes. We definitely have a desire to implement this in our own individual programs and let it be something that's continuous. As Dr. Greene stated, it has to start with our undergraduate students, making sure that they're comfortable and they we start with simulation because that's a safe environment for them to begin with such a
difficult situation and difficult conversation. So is it accurate to say we should be expecting some new research data to come out from your team? It's accurate to say you'll see one our names, each of our names on some form of research related to either end of life simulation or palliative care. That is true. Great. I'm looking forward to that. What's your takeaway messages you want to leave the audience with?
I definitely will highly encourage all nursing institutions, nursing schools to implement end of life and palliative care into their curriculum somehow. ELNEC was the perfect way to do that. It covers six domains related to end of life nursing education consortium and I just highly recommend all programs to find a way to implement end of life into the curriculum and add simulation to give that real world safe experience on how to effectively communicate during those difficult
times. And another component to that is looking at spirituality and how that plays a role into this as well because a lot of people depend on their spirituality. I don't like to use religion because religion is just a set of principles that a group of people follow, but everybody has some type of spirituality so that needs to be incorporated as well and how it plays a role into end of life care, advanced care planning, palliative care, so that's what
I'm working on right now. So hopefully that will be something that will be up and coming and that we're going to incorporate in this curriculum here at Fort Valley State as well. We have in the life one two and three so we're going from med-surg one to med-surg three with some component of end of life. Oh that's really good.
And might I add diversity and inclusion because in our study we actually had the standardized participants, which were our undergraduate students, we based on how many participants we had and with their permission the participants were either a male and female or female male and female and so that diversity and inclusion to give them comfort about end of life and dealing with different family dynamics that was really a good
aspect of the study as well. Simulation is so rich in enabling us to all offer multiple perspectives and be very dynamic in you know our scenarios which is just great. Well I want to thank you all for joining us for this really interesting and very important I think conversation. I appreciate your time and your expertise in helping us better understand your research
and this topic. And to our listeners, if you have not had the opportunity, please look for this article in the May-June issue of Nursing Education Perspectives, "Implementation and Evaluation of an End-of-Life Standardized Participant Simulation in an Adult Gerontology Acute Care Nursing Practitioner Program." I got it out almost in one breath. And again, I want to thank you all for joining us. Very much appreciated. Thank you. Thank you. Thank you. [Music]