Palliative Care Simulations in Undergraduate Nursing Education: An Integrative Review

Clinical Simulation in Nursing (2017) 13, 414-431

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Review Article

Palliative Care Simulations in Undergraduate Nursing Education: An Integrative Review Amanda J. Kirkpatrick, MSN, RN-BCa,*, Mary Ann Cantrell, PhD, RN, CNE, FAANb, Suzanne C. Smeltzer, EdD, RN, ANEF, FAANc a

Assistant Professor, Creighton University, College of Nursing, Omaha, NE 68178, USA Professor and PhD Program Director, Villanova University, College of Nursing, Villanova, PA 19085, USA c Professor and Director, Center for Nursing Research, Villanova University, College of Nursing, Villanova, PA 19085, USA b

KEYWORDS palliative care; end of life; nursing; simulation; education; competence; research; review; death; dying; undergraduate; student

Abstract: This integrative review summarized the findings from 19 studies about the known effects of simulation on nursing students’ preparation for delivery of palliative care (PC), identified gaps in the literature, and provided directions for future research. Three mixed method studies, 10 quantitative studies, and 6 qualitative studies were reviewed. The outcomes support PC simulation in developing nursing student competence by providing meaning and context to the care they deliver to seriously ill patients. Future investigations examining the relationships between PC simulation, students’ role in simulation, and effects on student knowledge, self-awareness, and clinical performance in providing PC are warranted. Cite this article: Kirkpatrick, A. J., Cantrell, M. A., & Smeltzer, S. C. (2017, September). Palliative care simulations in undergraduate nursing education: An integrative review. Clinical Simulation in Nursing, 13(9), 414431. http://dx.doi.org/10.1016/j.ecns.2017.04.009. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

The American Association of Colleges of Nursing (AACN, 2016) released 17 new palliative care (PC) competencies and recommendations for educating undergraduate nursing students. According to the AACN (2008), nursing faculty must prepare students to deliver high-quality PC to seriously ill and dying patients. Several reports by the Institute of Medicine (IOM, 2000, 2001, 2011) call for

innovative and evidence-based solutions, such as simulation-based learning experiences (SBLEs), to be implemented for the delivery of safe and high-quality nursing care, especially in the face of the current shortage of nurses and nursing faculty.

Problem Identification Conflicts of interest: none. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. * Corresponding author: [email protected] (A. J. Kirkpatrick).

A literature review conducted by Gillan, van der Riet, and Jeong (2014a) revealed that undergraduate nursing students are inadequately prepared to deliver PC, especially to dying patients, and many view end-of-life (EOL) care as an

1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.ecns.2017.04.009

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unpleasant task and source of stress. Gillan et al. (2014a) cited lack of content in nursing textbooks and undergraduate curricula as issues that contribute to inadequate preparation of these students. Although some nursing programs provide didactic PC content, lecture format does not often provide the opportunity for students to reflect on their Key Points own emotions and experi
This integrative reences in caring for the dying view includes (a) a patient (Gillan et al., 2014a; synthesis of evidence Smith-Stoner, 2009). Experegarding the benefits riential teaching strategies, of and special considspecifically SBLE, are recerations for impleommended in the delivery menting palliative of palliative and EOL concare (PC) nursing tent because they allow opsimulations in nursing portunities for student programs, (b) identifiengagement and learning in cation of limitations all three domains of of current studies, learning: cognitive, affecand (c) directions for tive, and psychomotor future research. (Gillan et al., 2014a;
Among other findLeighton & Dubas, 2009). ings, quantitative and SBLE enable students to qualitative studies communicate and provide indicate that PC simuquality care for simulated lation results in posipatients and their families tive student outcomes at the EOL without fear of including improved doing or saying the ‘‘wrong confidence, commuthing.’’ When followed by nication, reassurance, debriefing, SBLE allow stuemotional prepareddents the opportunity to ness, and understandexamine their own feelings ing of PC principles. and reactions to the experi
The most significant ence (Gillan, Parmenter, gaps in study findings van der Riet, & Jeong, include establishing 2013; Gillan et al., 2014a; correlations among Leighton & Dubas, 2009). (a) the controlled efDespite these known advanfects of PC simulation tages, a limited body of alone, (b) the sturesearch on EOL simulation dent’s role in PC exists. In a review of pubsimulation, (c) clinlished literature from 2009 ical performance of to 2013 by Gillan, van der PC behaviors, and Riet, and Jeong (2014b), (d) self-awareness in only 16 articles on EOL the provision of PC simulation used in underand end-of-life care. graduate nursing education were identified. Nine of these primary research articles are in this integrative review. The purpose of this integrative review was to summarize the known effects of SBLE on nursing students’ preparation for delivery of PC, identify gaps in the literature, and provide directions for future research.

Methods Search Strategies A systematic literature search was conducted using library databases and ancestry searches of articles’ reference lists. Use of search term variations included ‘‘Hospice Nursing,’’ ‘‘Palliative Care,’’ and ‘‘Terminally Ill’’ resulting in 42,155 articles from the Web of Science, Medline/PubMed, ERIC, Google Scholar, EBSCOhost, and CINAHL databases. The terms ‘‘Simulations,’’ ‘‘Patient Simulation,’’ ‘‘Computerized Clinical Simulation,’’ and ‘‘Vignettes’’ resulted in 15,430 articles from these databases. The terms ‘‘Students, Nursing’’ and ‘‘Education, Nursing’’ resulted in 52,457 articles. The combination of these terms narrowed the results to only 41 articles. No limitations were set for publication date, but a limiter was set for English-only language. The identification and selection of research studies for this review are detailed in the PRISMA flow diagram in Figure. Exclusions included poster abstracts, simulation studies involving implementation of life-saving measures such as cardiopulmonary resuscitation, and interprofessional PC simulation studies in which nursing student sample size and outcomes were not easily discerned. Nineteen articles (from 2011 to 2016) met the inclusion criteria for this integrative review: three mixed method studies, ten quantitative studies, and six qualitative studies. The qualitative methods included one phenomenological study, one phenomenographic comparative study, and six studies classified as qualitative descriptive designs. The quantitative methods included quasi-experimental pre/posttest research design (six single-group, one multisite study, and two multigroup studies), one true experimental study, and three descriptive studies. Sample sizes ranged from 12 to 128 students, with one multisite study with 336 students. Table 1 and Table 2 describe the aims, study design, instrumentation, and major findings of the quantitative and qualitative studies, respectively.

Literature Synthesis Simulation Design: High-fidelity Manikins Versus Standardized Persons Table 3 describes the SBLE used in the studies. Although high-fidelity manikins were used alone in most studies, use of live actors and role play were shown to be effective in increasing student knowledge and self-efficacy in the delivery of PC (Fink, Linnard-Palmer, Ganley, Catolico, & Phillips, 2014; Saylor, Vernoony, Sekelman, & Cowperthwait, 2016; Tuxbury, McCauley, & Lement, 2012; Wyrostok, Hoffart, Kelly, & Ryba, 2014). Students reported higher engagement and satisfaction with high-fidelity simulators and/or use of real actors for the patient and family members versus stationary manikins (Eaton, Floyd, & Brooks, 2012; Gillan et al., 2013; Leighton & Dubas,

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Figure

PRISMA diagram representing search methodology for integrative review.

2009; Wyrostok et al., 2014). Students sometimes have a difficult time taking the SBLE seriously and responding to a manikin and are more engaged in the SBLE when a person enacts the patient role (Swenty & Eggleston, 2011). According to the International Nursing Association for Clinical Simulation and Learning (INACSL), use of a standardized patient for educational and therapeutic conversations promotes psychological fidelity (Lioce et al., 2015). Researchers confirmed that use of actors not known to students is preferred over high-fidelity manikins to portray sensitive issues that involve psychosocial responses (Fink et al., 2014; Swenty & Eggleston, 2011; Wyrostok et al., 2014). It is also often difficult to simulate critical EOL signs with use of a manikin and low-fidelity simulators (Gillan, van der Riet, & Jeong, 2016). Students indicated that the ability to observe and recognize pain, breathing difficulty, and agitation in the patient is important to their learning and can be made more realistic with standardized patients (Leighton & Dubas, 2009; Wyrostok et al., 2014). Presence of family members and varied family dynamics enhance the realism of an EOL simulation, by providing students with an opportunity to support family in coping with the death of a loved one and emphasizing the

importance of holistic care (Eaton et al., 2012; Gillan et al., 2016; Leighton & Dubas, 2009). The presence of multicultural and spiritual traits of EOL care was also found to enhance student learning and confidence for future care (Eaton et al., 2012; Wyrostok et al., 2014). Observer Role Eight of the 19 studies included a student observer role, where an EOL simulation was enacted in front of nursing students to demonstrate the uniqueness, complexity, and holistic approach of quality palliative nursing care (Eaton et al., 2012; Fink et al., 2014; Fluharty et al., 2012; Gillan et al., 2013; Kunkel, Kopp, & Hanson, 2016; Ladd, Grimley, Hickman, & Touhy, 2013; Tuxbury et al., 2012; Wyrostok et al., 2014). Although the student observers were not actively involved in these SBLE, they participated in a postsimulation debriefing that included discussion of SBLE aspects and communication that could have been modified or improved. Sixty-two percent of students in one descriptive pilot study strongly agreed that they learned as much from observing their peers as they would if actively involved in caring for the simulated patient (Tuxbury et al., 2012). One faculty member in the Wyrostok et al. (2014) study suggested that involving

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Quantitative Study Methods Aim, Sample, Setting

Design

Carman et al. (2016), USA

Quasi-experimental Examine the combined effects of didactic single-group instruction and simulation on student pre/posttest attitudes toward EOL care. First semester (preclinical) accelerated BSN students (62 pretest, 28 posttest)

Fabro et al. (2014), USA

Provide example of high-fidelity EOL simulation used in elective BSN course. Twenty-five students in an elective BSN course

Fink et al. (2014), USA

Quantitative true Evaluate student knowledge, confidence, experimental and satisfaction in spiritual care after EOL pre/posttest simulation. Fifty-four junior-level BSN students in San Francisco Bay Area (30 treatment, 24 control)

Mixed method descriptive pilotd single-group posttest only

Fluharty, Evaluate the impact of EOL simulation on Quantitative multisite et al. (2012), student knowledge, self-confidence, and quasi-experimental USA communication. 336 senior-level BSN pre/posttest (traditional and accelerated) and upper level ADN students for their required medicalesurgical clinical course at four sites (one large public, research-intensive university, two smaller private universities, one community college)

Quantitative Instrumentation

Key Findings

1. Frommelt Attitudes on Care of the Dying Average student attitudes improved from pre- to postlearning bundle (p < .01 on Scale (30 family- and patient-focused all scales, including family-, patient items assessing student feelings, subscales). values, and expectations on 5-point Likert scale, internal consistency of 0.90) 1. NLN Educational Practices Questionnaire Mean scores for all items ranged between 4.3 and 4.7, indicating that students either (16 items about learning and collaboagreed or strongly agreed that active ration; 5-point Likert on level of learning, collaboration, satisfaction, and agreement and importance) self-confidence were present or improved 2. NLN Student Satisfaction and Selfby the SBLE. Researchers indicated these Confidence in Learning tool (13 items findings support EOL simulation as on 5-point Likert on level of agreement) effective in preparing students to care for dying patients. 1. Spiritual Care at the End-of-Life Results included statistically significant differences in the treatment group at Questionnaire (evaluates student posttest including higher perceptions of knowledge and confidence in delivering skill and knowledge (p ¼ .001, effect size spiritual care at EOL) of 0.98), confidence in delivering EOL care 2. Knowledge assessment (5 self-assess (p ¼ .001) and care to patients with a items of knowledge and skill on religion different from that of the student 5-point Likert scale, 15 religious custom (p ¼ .005). exam items) 3. Confidence (two VAS scales to rate confidence in caring for religious EOL patients; 0 mm ¼ no confidence to 100 mm ¼ very confident; expert validation; a ¼ 0.76 pretest, 0.79 posttest) 1. Knowledge Related to EOL Care instru- Statistical analysis revealed an increase in student knowledge regardless of ment (10 EOL symptom and intervensimulation role (p ¼ .017). Confidence, tion exam items with expert validation) communication, and satisfaction were 2. Self-Confidence in Caring for a Dying Paalso high. Knowledge and previous tient and in Nursing (modified version simulation experience had significant of Nurse Self-Concept Questionnaire; 30 correlation (p < .01). items on 8-point Likert scale from 1 [definitely false] to 8 [definitely true]; a ¼ 0.95) 3. EOL Communication Self-Assessment tool (4 items on 5-point Likert from 1 (continued on next page)

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Author

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Table 1

PC Simulations

Table 1 (continued ) Author

Aim, Sample, Setting

Design

Quantitative Instrumentation

4.

Grossman (2013), USA

Develop algorithm to assist students and ICU Quasi-experimental single-group nurses’ facilitate positive death for dying pre/posttest patients. Convenience sample of 50 students in a critical care course Descriptive correlational posttest only

To explore confidence and learning in 60 nursing students and 12 nurses immediately (24 juniors), 1 year (36 seniors), and 2 years (practicing nurses) after an EOL simulation at a private Midwestern BSN program

Lippe and Becker (2015), USA

Assess learning outcomes of a critical care Quasi-experimental multigroup simulation on withdrawing care. One pre/posttest hundred twenty-eight students recruited from 3 cohorts of students (1 critical care elective [10 traditional, 9 ANDeBSN], and 2 final semester adult health courses [53 and 56 traditional BSN students])

2. 1.

1.

2.

Moreland et al. (2012), USA

Mixed methods Evaluate knowledge and self-efficacy of quasi-experimental undergraduate nursing students in EOL pilot studydsinglecare via SBLE. Fifteen nursing student group pre/posttest volunteers from junior-level medical/ surgical class (combination of accelerated and traditional students) from midsize private institution in Northeast United States

1.

2.

Key Findings

Knowledge scores were significantly increased from pre- to posttest (p < .001) and average perceived level of comfort increased from 3 (first class) to 6 (end of course). No significant differences in responses between groups (juniors, seniors, and nurses) were found; 90.3% of respondents strongly or somewhat agreed with the confidence items and 86.1% strongly agreed or somewhat agreed with the learning items. Emotional readiness results not analyzed due to low instrument reliability (a ¼ 0.52 pretest, 0.62 posttest). Significant improvement in perceived competence was determined in 14 of 15 competencies post simulation (p < .001). Improvement was also identified in student attitudes in caring for dying patients (p < .01), but pre/posttest means were lower than reported by practicing nurses in other studies.

Statistical analysis revealed significant improvement in knowledge (p ¼ .003) and self-efficacy (p ¼ .05) between preand postsimulation scores.

(continued on next page)

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Kunkel et al. (2016)

1.

[poor] to 5 [excellent]; expert validation; a ¼ 0.7) Satisfaction with instructional method (5 item on 5-point Likert; a ¼ 0.88 and 0.92 previous, 0.95 this study) Revised ELNECdKnowledge Assessment Test (50-item multiple choice; a ¼ 0.84) PC With Critically Ill Survey (students rate level of comfort between 1 and 10) Simulation Effectiveness Tool (13 item instrument on 3-point Likert from Medical education Technologies, Inc. [METI] to assess overall learning and confidence levels; a ¼ 0.87 for 8-item learning subscale and a ¼ 0.84 for 5-item confidence subscale) Perceived Competence in Meeting ELNEC Standards (15 items on 5-point Likert; ELNEC competencies as content validity; internal consistency a ¼ 0.94) Concerns About Dying Scale (10 emotional readiness items in 3 domains: general, spiritual, patient; 5-point Likert; teste retest 0.83-0.89; internal consistency in previous studies of a ¼ 0.62-0.81) Frommelt Attitudes on Care of the Dying Scale (content validity ¼ 1.0; teste retest ¼ 0.90-0.94; interrater ¼ 0.98; internal consistency for this study a ¼ 0.84) Knowledge Assessment Instrument adapted from Symptoms in Normal Progression of Dying and Suggested Interventions (7 multiple choice exam items; is physiological process increased, decreased, or maintained in last 30 minutes before death; expert validation) Self-Efficacy Instrument (8 items related to professional care, emotional

Author

Saylor et al. (2016), USA

Aim, Sample, Setting

Design

Evaluate licensed and prelicensure nurse and Quasi-experimental pilot studyd physician self-efficacy and attitudes multigroup following a PC simulation. Eighteen junior pre/posttest and senior nursing students from large research intensive university and 19 thirdand fourth-year medical students from large medical school in urban location

Quantitative Instrumentation

1.

2.

3.

Analyze differences in student perceptions Quasi-experimental single-group of active learning and fidelity in four SBLE pre/posttest (one EOL). Seventy-nine junior-level BSN repeated measure students enrolled in the second of a series of three medicalesurgical classes (focus on hematology, oncology, and gastrointestinal system)

1.

2.

3.

4.

reaction, and physiological knowledge on 6-point Likert scale; a ¼ 0.77 with small sample size; expert validation) General Self-Efficacy Scale (items Overall means for self-efficacy increased significantly after the SBLE (p ¼ .001), regarding affective aspects of clinical with nursing students reporting greatest decision making on 4-point Likert scale improvement. Attitudes toward from 1 [not at all true] to 4 [exactly collaboration were also significantly true]; a ¼ 0.75-0.91) increased overall (p ¼ .008), but no Jefferson Scale of Attitudes Toward significance was found when analyzed by Physician-Nurse Collaboration (15 discipline. Medical students scored higher items measuring perception of physician (6.29) in objectively measured dominance, nurse autonomy, teamwork, interprofessional competency than and caring on 4-point Likert scale on nursing students (4.91). level of agreement; a ¼ 0.77) Team Objective Structured Clinical Examination (6 core interprofessional competencies: communication, collaboration, roles, patient/family-centered approach, conflict management, and team functioning on 9-point scale from 1-well below to 9-well above expected; interrater ¼ 0.92; internal a ¼ 0.730.87) Educational Practices in Simulation Active learning and fidelity were both Scale (10 items measuring perceived present and important to students. active learning presence and importance Students reported satisfaction and in simulation on 5-point Likert; improved self-confidence. The HIV EOL a ¼ 0.0.86 for presence, 0.91 for simulation had higher means on all importance) instruments compared with other SBLE. Simulation Design Scale (2 items Post hoc analysis showed that mean measuring perceived presence and scores for active learning, satisfaction, importance of fidelity in simulation on and self-confidence were significantly 5-point Likert; expert validation; higher (p < .05) for the HIV simulation. a ¼ 0.0.92 for presence, 0.96 for importance) Student Satisfaction with Learning Scale (5 items on 5-point Likert; expert validation; a ¼ 0.0.94) Self-Confidence in Learning Using Simulations Scale (3 items in knowledge (continued on next page)

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Swenty and Eggleston (2011), USA

Key Findings

PC Simulations

Table 1 (continued )

Author

Aim, Sample, Setting

Evaluate the use of forum theatre to teach Tuxbury EOL care to undergraduate nursing et al. (2012), students. Forty-five nursing students in USA second semester medicalesurgical course

Evaluate effect of EOL simulation experience Twigg and on nursing student clinical knowledge and Lynn (2012), emotional readiness. Sixteen final USA semester BSN student volunteers from large mid-Atlantic nursing school

Quantitative Instrumentation

Key Findings

confidence and skills acquired on 5-point Likert; expert validation; a ¼ 0.0.87) 1. Evaluation of the SBLE with quantitative Seventy-five percent of students rated all Descriptive pilot items with strongly agree or somewhat and qualitative components (13 stateprojectdsingleagree. Specific measurements were ments with 3-point Likert scale and group posttest reported for two items: 61% strongly space to provide original comments) only agreed to that they would be confident in recognizing changes in patient condition at EOL and 65% strongly agreed that the SBLE was a valuable learning tool. Students also anecdotally reported decreased anxiety about EOL care. 1. Concerns About Dying Scale (claimed as No differences were found between students Quasi-experimental with and without EOL experience in all valid/reliable) pilot studydsingledomains of emotional readiness. Higher 2. NCLEXdstyle exam to assess student group, pre/posttest anxiety in the ‘‘patient’’ domain was noted clinical knowledge (8 questions; stated following the SBLE, but not significant that testing validity established) (p ¼ .301). This may have been related to 3. Ranking of teaching strategies (discusthe conflict in the SBLE. No significant sion, video clips, SBLE, and debriefing) differences were found in knowledge or emotional readiness. Results included higher self-awareness after Mixed method quasiTwo instruments were developed for this observation of the SBLE, especially in experimental pilot study based on the Silver Hour Model: student understanding of the Silver Hour projectdsingle-group 1. Self-Awareness Inventory to evaluate Model. Self-efficacy was highest for items pre/posttest student self-awareness (perception of measuring alliance between the nurse, the effectiveness of teaching/learning patient, family, and providers. in improving understanding and awareness of EOL care during Silver Hour; 5 dimensions with 0-100 scale in increments of 10 to rate level of selfawareness) 2. Self-Efficacy Inventory to measure level of confidence in being able to fulfill role in EOL care delivery (20 items based on attributes of Smith-Stoner model; 4point Likert scale)

Note. ADN ¼ Associate’s Degree in Nursing; BSN ¼ Bachelor’s of Science in Nursing; ELNEC ¼ End-of-Life Nursing Education Consortium; EOL ¼ end of life; ICU ¼ intensive care unit; NLN ¼ National League for Nursing; PC ¼ palliative care; SBLE ¼ simulation-based learning experience; VAS ¼ Visual Analog Scale.

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Wyrostok Explore application of situated cognition as et al. (2014), a pedagogical approach for teaching Qatar nursing students about EOL care. Unreported number of BSN students in an adult health clinical course in the Middle East; included two visiting senior nursing students and an instructor from Canada

Design

PC Simulations

Table 1 (continued )

Qualitative Summary

Author

Design/Methods

Study Aim(s)

Results

Themes prevailed in both sets of survey responses Explore whether a home health and hospice simulation (immediate postsimulation and three to four weeks enhanced learning in 30 senior-level BSN students from later): a Large East Coast University 1. Experiential learning (regarding SimLab experience including opportunity for guidance, exposure, and reflection) 2. Affirmative outcomes (positive perceptions of safe environment, realism, critical thinking, and improved confidence) 3. Family as client (importance of including family with careful consideration for dynamics, culture, and therapeutic communication) Fabro et al. Mixed method descriptive qualitative Provide an example of a high-fidelity EOL simulation used Themes: in an elective BSN course 1. Feelings and thoughts experienced (awkward, ner(2014), USA Data analysis: analysis of student vous, sad, not knowing what to dodbut now ‘‘able perceptions in 18 reflective to see ways in which death can be good, natural, and journal submissions post simulation expected’’ p. 23) 2. Components of a good death (pain control, comfort measures, peaceful environment, spiritual needs, family presence, honest/clear communication, nursing presence) 3. Principles of PC (grasped meaning and intent of PC and that it does not end at patient’s last breath) 4. Lessons learned for future nursing (importance of spiritual care, presence, communication, and handling competing priorities) Five major themes: Evaluate an EOL simulation experience provided to 120 Gillan et al. Qualitative descriptive 1. Linking theory to practice (students were able to third-year nursing students at a rural Australian (2013), Australia Data analysis: thematic analysis apply knowledge from didactic instruction to a realUniversity of qualitative evaluation istic clinical situation) survey responses 2. Approaching families of dying patients (better understanding of how to respond to families in difficult situations) 3. An encounter with death (importance of observing EOL to increase confidence and decrease anxiety in care of the dying patient) 4. ‘‘Hands on’’ experience in a ‘‘protected environment’’ 5. Importance of postsimulation discussion and debriefing (ability to ask questions and learn from other students’ experiences) Eaton et al. (2012), USA

Phenomenological Data analysis: Colaizzi approach and coding with ethnograph to analyze results of two anonymous surveys

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(continued on next page)

PC Simulations

Table 2

Author

Design/Methods

Results

Explore the EOL simulation experiences of 18 undergraduate nursing students six to eight months after the SBLE

Ladd et al. (2013), USA

Descriptive qualitative Data analysis: content analysis with open coding of transcripts from two focus groups (semistructured group interviews)

Explore student experiences, attitudes, and concerns about caring for a person at EOL before and after a structured EOL simulation with 35 traditional and accelerated students from a Southeastern University

Leighton and Dubas (2009), USA

Descriptive qualitative Data analysis: compilation and analysis of results on five-question evaluation

Describe a high-fidelity EOL simulation used for application of theory during a nursing elective to 16 Midwestern University students

Plotlines: 1. The privilege of EOL care (students viewed delivery of empathetic/compassionate care and sharing of emotion with family as a privilege) 2. Witnessing death as surreal and beautiful (students described presence as death as spiritual, surreal, and beautiful) 3. The honor of providing after-death care (students acknowledge that postmortem care is personal and a way to honor the patient and family) Other findings:
The SBLE was educational, allowing realistic handson experience
Involving family in the SBLE increases realism and promotes holistic care
SBLE promotes preparation and positive EOL care experiences in clinical practice Themes: 1. Avoiding the subject 2. Witness of pain and suffering in the dying 3. Finding comfort in memories of ‘‘good deaths’’ (p. 49) Other findings:
Most students had encountered death either in clinical or their personal lives and were able to articulate caring behaviors that would be useful in EOL care
Presimulation concerns were mostly related to communication (appropriateness, what to say, handling conflict, and implementation of advance directives); relief postsurvey that active listening and caring behaviors are most reassuring to family
Question of chronology of EOL simulation: some students feel SBLE is best placed before hospice clinical to prepare, some after to tie together clinical experiences Themes: 1. Impact of family (positive learning effects, enhanced realism, practice opportunity to provide support, with some student distress) 2. Value of realism (fidelity) (better understanding of ‘‘whole picture,’’ application of material, enhanced (continued on next page)

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Study Aim(s)

Gillan et al. Qualitative descriptive (2016), Australia Data analysis: used ‘‘narrative inquiry’’, which involved repeated reading of participant interview transcripts to enter their lived experience

PC Simulations

Table 2 (continued )

Author

Design/Methods

Mixed method descriptive qualitative Data analysis: group content analysis of transcripts from audiorecorded debriefing

Venkatasalu et al. (2015), United Kingdom

Phenomenographic (comparative qualitative) Data analysis: analyzed 12 individual interview transcripts into themes and subthemes using matrix-based framework analysis with NVivo v. 10

Results

learning, ‘‘more realistic than role playing and discussion’’) 3. Self-efficacy (most not confident which indicates need for further practice in caring for dying) Evaluate knowledge and self-efficacy of 15 Northeastern Themes: University accelerated and traditional nursing students 1. Caring vs. curing (students had difficulty moving from task completion to ‘‘just being there’’ for the after an EOL care simulation involving patient with patient p. 11) lung cancer 2. Big picture (importance of PC in doing what the patient wants which may include the nurse ‘‘just doing nothing’’ p. 12) 3. Great expectations (‘‘Expectation conflicts encompassed role, performance, self-efficacy, and the global experience’’ p. 12; students expected positive outcome through tasks but realized physical and emotional presence were most important) Content analysis revealed that junior-level nursing students are task oriented and focused on demonstrating nursing skills; they, therefore, have difficulty in transitioning from curing to caring for patient Assess effectiveness of EOL simulation (n ¼ 7) compared Themes: 1. Recognizing death and dying (SBLE prepared stuwith classroom-based teaching (n ¼ 5) in preparing dents through knowledge development and first-year nursing students for first death experiences in confidence) clinical 2. Knowledge into practice (SBLE allowed students to perform skills in clinical practice) 3. Preparedness for clinical eventualities (SBLE reduced anxiety and mentally prepared students to ‘‘expect the unexpected’’) 4. Emotional preparedness (SBLE provided exposure that contributed to emotional readiness and decreased ‘‘shock’’ in caring for dying patients) Other findings:
Classroom-based teaching also benefited student knowledge, but students experienced more challenges in performing clinical skills of EOL care and did not feel academics could emotionally prepare them
Students acknowledged self-awareness as prerequisite of EOL care delivery (continued on next page)

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Moreland et al. (2012), USA

Study Aim(s)

PC Simulations

Table 2 (continued )

Author

Wyrostok et al. (2014), Qatar

Design/Methods

Mixed method descriptive qualitative Data analysis: analyzed unreported number of student perceptions related to the SBLE both immediately and oneweek post event

Study Aim(s)

Explore students’ feelings, expectations, values, and experiences surrounding EOL following a simulated clinical event using a situated cognition approach

Results

Note. BSN ¼ Bachelor’s of Science in Nursing; EOL ¼ end of life; PC ¼ palliative care; RQ ¼ research question; SBLE ¼ simulation-based learning experience.

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Younger 1st year students lacked life experience and preparation for EOL Immediately postsimulated clinical event:
Phase 1: ‘‘Reaction phase’’dreported emotions of anxiety, sadness, and anger that nothing more could be done for the patient
Phase 2: ‘‘Importance of holistic care’’dtransition from patient/family-centered care to familycentered care after death and importance of cultural sensitivity
Phase 3: ‘‘Views to improve simulation’’dstudents reported limitations such as actors known to them in SBLE was distracting, critical signs such as pain, breathing difficulty, and agitation need to be made more obvious/realistic, and death experience was ‘‘too positive’’ (need to show challenges such as family dispute); some students argued for taking an observer vs. active role in the SBLE One week post event: students were able to better articulate thoughts/feelings (‘‘shell shocked’’ and overwhelmed immediately postsimulation); commented on value of realism and SBLE in providing a clearer understanding of patient/family-centered care and complexity of the nurse’s role (cultural practices, communication, support); theoretical model supported learning and illustration of transitions from one phase of the Silver Hour to another (dying, death, dead)

PC Simulations

Table 2 (continued )

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students in the SBLE in more active roles would be more ‘‘immersive,’’ allowing students to gain clinical experience in delivering care (p. e220). Feedback from faculty and students about this issue was mixed. In Fluharty et al.’s (2012) multisite study, students in the observer role scored higher in knowledge post simulation than students in active SBLE roles. The researchers acknowledged that an observation checklist given to the observing students may have contributed to their higher scores (2012). However, higher scores are consistent with the findings of other studies regarding the observer role and learning outcomes. The opportunity to observe the SBLE increased student learning and satisfaction in multiple EOL qualitative studies (Eaton et al., 2012; Gillan et al., 2013; Ladd et al., 2013; Wyrostok et al., 2014). Jeffries (2007) and Kaplan, Abraham, and Gary (2012) also reported that students in the observer role benefited as much if not more than students in active roles in their non-EOL simulation studies. These researchers suggested that the observer role might produce less anxiety and greater engagement of students in the SBLE. Debriefing INACSL indicates that all simulations should be followed by debriefing sessions that promote reflective thinking and assimilation of new knowledge, skills, and attitudes (2013). Students in the qualitative studies reviewed reported that these sessions offered an opportunity for reflection and reinforced their learning by allowing an opportunity to ask questions and learn from others’ experiences (Eaton et al., 2012; Gillan et al., 2013; Ladd et al., 2013). Simulations in all studies reviewed were followed by structured debriefing sessions. Most debriefing sessions were conducted immediately post-EOL simulation and varied in length from 15 to 45 minutes. Wyrostok et al. (2014) conducted active reflection sessions before, immediately after, and one-week after the SBLE to allow students to assimilate the experience and more deeply reflect on the personal impact of the SBLE on their learning and emotions. Varied length and timing of simulation debriefing are addressed by INACSL: debriefing should be flexible and based on the learning objectives and needs of the students. Thus, longer debriefing sessions are needed for deeper reflection; therefore, debriefing may be delayed to allow a period of self-reflection post simulation (INACSL, 2013). Student Outcomes Students in the qualitative studies reported a number of positive outcomes from participation in the EOL simulations: increased confidence, improved communication skills, reassurance, understanding of the complexity and competing priorities of EOL care, and learning of PC principles (Table 2). Statistically significant differences were reported for a number of postsimulation student

outcomes in the quantitative studies as well, including higher self-efficacy, increased knowledge, improved attitudes, and increased student satisfaction (Table 1). Participating in the SBLE increased students’ confidence in their ability to utilize nursing presence to provide effective patient- and family-centered care during the EOL period (Eaton et al., 2012; Wyrostok et al., 2014). Students who reported increased self-efficacy also indicated feelings of decreased stress, anxiety, and concern about their personal emotional responses in EOL situations (Moreland, Lemieux, & Myers, 2012).

Qualitative Themes Qualitative studies offered an opportunity to explore and understand the lived experiences and perspectives of nursing students who participated in these simulations (Ladd et al., 2013). There were a number of common findings identified in the qualitative studies reviewed with two emerging themes: mixed emotions and care transitions. Mixed Emotions Students reported that although they recognized that the SBLE was not real, the emotions they experienced were very real. Some students reported feeling uncomfortable not knowing what to do or how to respond to family questions or helpless when the family was crying (Fabro, Schaffer, & Scharton, 2014; Leighton & Dubas, 2009). In addition to anxiety, the simulations generated feelings of sadness and anger on the part of the students when nothing more could be done to save the patient (Wyrostok et al., 2014). Despite students’ strong emotional reactions, they valued participation in the simulated experience, which allowed them to cry and discuss their fears, and challenged them to think critically (Ladd et al., 2013; Leighton & Dubas, 2009). Students in Venkatasalu, Kelleher, and Shao’s (2015) study stated that the SBLE helped to prepare them emotionally for what they would experience in clinical practice. Care Transitions Transitions from patient- to family-centered care and from a curing to a caring perspective were noted by students following the SBLE. Students indicated that when the SBLE continued after the patient’s final breath, it revealed that family support is a very large aspect of PC (Eaton et al., 2012; Fabro et al., 2014; Gillan et al., 2013, 2016; Wyrostok et al., 2014). In fact, students frequently identified presence of family and nursing presence as important in facilitating a ‘‘good death’’ (Fabro et al., 2014; Gillan et al., 2016). Students learned that rather than performing curing or life-saving functions, the role of the nurse in promoting a peaceful and comfortable death includes providing pain control and a peaceful environment and addressing cultural and spiritual needs (Eaton et al., 2012; Fabro et al., 2014; Wyrostok et al., 2014).

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SBLE Description and Student Outcomes HFM and SP SBLE

Author

HFM

Carman et al. (2016)

X

Eaton et al. (2012)

X

Fabro et al. (2014)

X

Fink et al. (2014)

SP

X

X

Gillan et al. (2013)

X

Gillan et al. (2016)

Patient fidelity not specified

Grossman (2013)

Patient fidelity not specified

Kunkel et al. (2016)

X

Ladd et al. (2013)

X

Leighton and Dubas (2009)

X

Students viewed an online lecture and had an in-class discussion prior to an EOL simulation involving a 58-y.o. patient with intracranial hemorrhage. Students viewed a recorded family conference, including a biracial family and interpersonal conflict. Groups of five to six students were assigned roles, including two nurses and three family members. Faculty-led postmortem care and debriefing ended the session. SBLE involving 82-y.o. male with stage IV metastatic lung cancer was used for home health/hospice practicum. Groups of four to five students were assigned roles of nurse, nursing assistant, social worker, and recorder. Faculty members enacted nurse practitioner, wife, and daughter roles, demonstrating a cultural/family conflict between the Muslim daughter and her stepmother. Fifteenminute simulations were filmed and watched back by students in groups of ten for reflection and debriefing. An EOL simulation involving a 78-y.o. patient with lung cancer and liver and bone metastasis was piloted with four students for feedback and revisions prior to course implementation. Groups of five to six students then performed in roles of nurse, family, and observer followed by a debriefing session. Three separate SBLE involving dying women with end-stage cancer and three different religious backgrounds (Catholic, Jewish, Islam) were utilized. SBLE were developed by religious experts, who then participated in the SBLE as visitor roles. A scripted disagreement about the advanced directive occurred among family members. Groups of six to eight students rotated through the SBLE, including prebriefing and debriefing sessions conducted by the experts. Groups of four to five students (two nurses, one family, one to two observers) participated in a 20-minute EOL simulation conducted in a mock hospice environment followed by a debriefing session. Scripts were provided to students performing in the role of nurse or family member. Observation checklists were given to observers for evaluation. Groups of 20 students were provided didactic content and tutorials prior to the SBLE and then asked to volunteer to perform roles (not specified) during the filmed simulation. All other students observed. SBLE involved a female patient with metastatic bowel cancer with family at the bedside. Debriefing post simulation included playback of the recordings. SBLE involved five clinical stations, with groups of three to four students rotating through each station and performing various roles (not specified). The five SBLE stations involved management of the following: 1. pain, 2. constipation, 3. nausea/vomiting, 4. EOL care to unconscious patient, and 5. death/dying phase. The SBLE ended with a debriefing session, including playback of the recorded death/dying station. Students completed the ELNEC Undergraduate Modules followed by three SBLE of critically ill dying patients (33-y.o. cystic fibrosis, 54-y.o lymphoma, 34-y.o. heart failure following arthritis treatment). Seven students participated, and all others observed. Final SBLE was repeated for all students to actively participate in delivery of bad news to the husband. An algorithm was used to debriefing post simulation. SBLE included a dying patient with cancer and her daughter (played by nursing faculty). Two oncology nurses assumed their natural work roles in the SBLE, utilizing a simulation script for consistent student experience. Students reviewed preparation materials prior to observing the SBLE and participated in a postsimulation debriefing. A four-part SBLE was included at the end of a full-day didactic (ELNEC) program. Groups of eight to nine students rotated through the SBLE in four minigroups of two to three, performing nursing roles in caring for a 67-y.o. female with stage IV ovarian cancer. ELNEC trainers performed roles of daughter and patient’s voice. Debriefing followed each of the four parts of the SBLE. SBLE was implemented as part of an elective course, which also included didactic, case studies, videos, and group discussion. Preparatory questions, patient history (middle-aged woman with metastatic ovarian cancer on hospice), and orders were provided one week prior. Students performed nursing role and faculty played the patient’s daughter. Group debriefing followed the SBLE. (continued on next page)

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Fluharty et al. (2012)

Description

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Table 3

HFM and SP SBLE Author

HFM

Lippe and Becker (2015)

Patient fidelity not specified

Moreland et al. (2012)

X

Saylor et al. (2016)

Swenty and Eggleston (2011)

X

X

Tuxbury et al. (2012)

X

X

X

Venkatasalu et al. (2015)

X

X

Description Utilized a three-part unanticipated EOL simulation involving an adult male with exacerbation of congestive heart failure requiring intubation and progressing to unanticipated EOL care. During the prebriefing, students watched a recorded goals of care conference where a disagreement occurred between family members about the care plan. A night shift report was also provided. Groups of six to ten students participated as either active observers or were assigned tasks in the SBLE. Debriefing followed. Following an EOL lecture, students listened to prerecorded shift report and worked in pairs during an EOL simulation involving a terminally ill patient with lung cancer. Students participated in a debriefing immediately after simulation and viewed recordings of their performance. Each nursing student was partnered with a medical student to participate in a 15-minute PC simulation (not involving EOL) followed by a debriefing session. Pairs discussed treatment options and elicited goals of care determination from the patient (22-y.o. college athlete with a progressive osteogenic sarcoma reoccurrence) and patient’s parents. Four SBLE (one EOL) were conducted in four-hour blocks and coincided with classroom topics (perioperative care, gastroenterology, hematology, and oncology). A written assignment was completed by students to prepare for each experience. Groups of four to five students were assigned roles as nurses, family members, and observer (took notes and shared during debriefing). Collaboration between the theatre and nursing departments offered ‘‘mutual learning’’ (theatre professor acted as patient and theatre students as patient’s daughters thus building skills in improvisation). Nursing student observers discussed and offered alternative solutions for important moments in an EOL simulation involving a 54-y.o. Jewish woman with metastatic cancer. These moments were then reenacted with different outcomes. Debriefing was utilized to address emotions/responses to the SBLE. Students received an overview of EOL nursing to establish baseline understanding of EOL care due to varied student exposure. Students were split in two groups (participants and observers) and switched for a second SBLE. Scripts were provided for roles: primary nurse, new graduate nurse, PC nurse, social worker, and clergy. The SBLE involved the rapid deterioration of a patient with colon cancer and bone metastasis. Faculty performed family roles and demonstrated a conflict between family members. Debriefing followed. Groups of 24 students were divided into 2 SBLE (care of dying person and care of deceased person) as either active participants (n ¼ 6) or observers (n ¼ 6). Each SBLE involved a 15-minute prebriefing, 20-minute simulation, and 40-minute debrief session. Student roles and elements of the SBLE (such as patient history, family dynamics, etc.) are unclear. One week after their EOL lecture, students observed professional role modeling (faculty) in the delivery of EOL care to a Muslim patient using the Silver Hour Model (Smith-Stoner, 2009). Debriefing sessions included guided questions and offer of additional support.

Note. ELNEC ¼ End-of-Life Nursing Education Consortium; EOL ¼ end of life; HFM ¼ high-fidelity manikin; PC ¼ palliative care; SBLE ¼ simulation-based learning experience; SPs ¼ standardized persons; y.o. ¼ year old.

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Twigg and Lynn (2012)

Wyrostok et al. (2014)

SP

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Table 3 (continued )

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The transition from trying to cure the patient, to simply being present, was difficult for junior-level students who view their nursing role as primarily life saving (Moreland et al., 2012). Despite this, students recognized that this transition is essential in palliative EOL nursing care and that the nurse’s role is to advocate for what the patient wants, even if that means forgoing life-saving measures.

Study Limitations Major limitations of the studies reviewed primarily involved instrumentation, data analysis, and study design. Twenty-three instruments were used in the quantitative studies to measure ten outcomes (self-efficacy/confidence, knowledge, satisfaction, active learning, collaboration, emotional readiness, anxiety, attitude, simulation fidelity, and communication). Student anxiety was measured via a single item by Twigg and Lynn (2012). Self-efficacy was the most common outcome measured in the studies (n ¼ 11), followed by knowledge (n ¼ 8). Many of the studies utilized one or more newly developed or recently modified instruments without established reliability (Fabro et al., 2014; Fink et al., 2014; Fluharty et al., 2012; Grossman, 2013; Kunkel et al., 2016; Lippe & Becker, 2015; Moreland et al., 2012; Tuxbury et al., 2012; Twigg & Lynn, 2012; Wyrostok et al., 2014). Although acceptable alpha levels (0.70 or higher for new instruments) were reported in two of the pilot studies (Moreland et al., 2012; Swenty & Eggleston, 2011), repeated use of the new or modified instruments on larger sample sizes is necessary to establish psychometric rigor. Instrument validity was addressed in only five studies and with only 10 of the 23 instruments (Table 1). Lack of established reliability and validity for some of the instruments utilized in the studies reviewed may affect the quality and validity of the findings (Polit & Beck, 2012). Only six of the instruments allowed objective measurement of outcomes; five measured knowledge (Fink et al., 2014; Fluharty et al., 2012; Grossman, 2013; Moreland et al., 2012; Twigg & Lynn, 2012) and one measured collaboration (Saylor et al., 2016). Eleven other instruments relied on students’ perception of each outcome, typically students’ level of agreement. Objective measurements of nursing performance are more helpful and less biased in identifying areas for improvement than self-report about one’s own performance (Becker, 2000). Bias was also a concern in qualitative studies where researchers reported their roles as primary instructors in the course where the SBLE was conducted, which could introduce bias into data collection and analysis or influence student responses (Eaton et al., 2012; Gillan et al., 2013; Ladd et al., 2013). Despite this risk to the neutrality of the study findings, bracketing of biases was only reported by the researchers in one qualitative study (Eaton et al., 2012). Rigor of qualitative data analysis methods was also often difficult to ascertain. Although Eaton et al.

(2012) clearly described use of the Colaizzi approach for analysis, they did not state whether transcripts were read independently. Moreland et al. (2012) conducted content analysis as a group, which may have compromised the ability of other content reviewers to reach the same conclusion independently. Peer review to confirm interpretation of study findings was reported in only two studies (Gillan et al., 2013, 2016). Member checks, which help to increase the interpretive validity of the researchers’ findings by verifying themes and definitions with the study participants, were not reported in any of the studies. Threats to external validity threaten the generalizability of study findings across varied populations and settings. These threats are present in all studies due to single group nonrandomized convenience sampling and small sample sizes in most studies. Attrition of study participants contributed to small sample sizes in five studies (Fabro et al., 2014; Fink et al., 2014; Fluharty et al., 2012; Moreland et al., 2012; Saylor et al., 2016). Sample description with baseline demographic data (age, gender, religion) is also important in determining the generalizability and transferability of study findings. Reports of baseline demographic data were missing from two quantitative studies (Fabro et al., 2014; Wyrostok et al., 2014) and seven qualitative studies (Eaton et al., 2012; Fabro et al., 2014; Gillan et al., 2013, 2016; Leighton & Dubas, 2009; Venkatasalu et al., 2015; Wyrostok et al., 2014); in only two studies, participants’ previous experience with EOL care was assessed (Grossman, 2013; Twigg & Lynn, 2012); further, only one study asked participants about previous simulation experience (Fluharty et al., 2012). Personal factors such as previous experience and personal, religious, or cultural beliefs may influence students’ perceptions during the PC SBLE and, therefore, must be addressed (Kunkel et al., 2016). This information is important to identify relationships among variables and covariates to control as extraneous factors. History was a common threat to internal validity in studies that used posttest-only designs (Table 1). In these studies, lack of control for historical circumstances through baseline knowledge and confidence assessment make it impossible to determine if the outcomes reported were solely the result of the SBLE or something else. Campbell and Stanley (1966) described the findings of studies with these designs as uninterpretable, because changes in behavior, clinical knowledge, and confidence may be the result of baseline education provided (such as lecture or modules), scripts or checklists provided to the students, or previous clinical experience. These limitations could invalidate the results of the study by producing effects attributed in error solely to the SBLE. Whenever possible, experimental studies should include a comparison group with control for extraneous variables. Only one study reported comparison with a control group; however, randomized assignment was not used and this group was much less diverse and one semester ahead of the treatment

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group (Fink et al., 2014). When a control group is not possible, repeated measurements between interventions can assist in differentiating the effects of these possible external influences but may result in participant recall of previous questions and responses (Polit & Beck, 2012). Although the researchers in the reviewed studies did not specifically discuss compliance with the nine Standards of Best Practice for Simulation outlined by INACSL, most of the SBLE methods described were consistent with these standards (INACSL, 2013; Decker et al., 2015; Lioce et al., 2015). There were a few outliers. Confidentiality, anonymity, and consent of students, as required by Standard II, were not specifically addressed in two of the quantitative studies (Tuxbury et al., 2012; Wyrostok et al., 2014). Additionally, given the sensitive nature of PC and EOL care and the risk of emotional distress during or following the SBLE, researchers consistently offered follow-up support to participants, including counseling services. Discussion of facilitator training and experience in SBLE was not addressed in the reviewed studies (Standard V). Although most studies referenced preparatory review materials provided to students, specific discussion of a facilitated prebriefing (Standard VI) was included in only two of the studies reviewed (Fink et al., 2014; Lippe & Becker, 2015). Simulation Standards VIII and IX regarding enhanced interprofessional education and simulation design were added after most of the EOL simulations reviewed were published (Decker et al., 2015; Lioce et al., 2015). Only three SBLE offered opportunities for student collaboration and communication with multiple members of the interprofessional health care team (Saylor et al., 2016; Twigg & Lynn, 2012). Adoption and use of a theoretical framework to guide the simulation research design was effectively implemented in only 5 of the 19 studies (Gillan et al., 2016; Grossman, 2013; Ladd et al., 2013; Lippe & Becker, 2015; Wyrostok et al., 2014). Despite the lack of a cited theoretical framework in research design, the SBLE described did meet the student outcomes set forth by the AACN for BSN Practice (2008) and were consistent with the Clinical Practice Guidelines for Quality Palliative Care (Hospice & Palliative Nurses Association [HPNA], 2015). Several researchers also mentioned use of the End-of-Life Nursing Education Consortium curriculum materials to prepare students for the SBLE (Fluharty et al., 2012; Grossman, 2013; Lippe & Becker, 2015; Tuxbury et al., 2012).

Implications for Nursing Education Results of this integrative review support the inclusion of SBLE in PC education in undergraduate nursing curricula. However, study findings indicate that students’ maturity, experience, and academic level in the program should be considered when introducing EOL care concepts. Understanding these principles can be challenging for nursing

students, in the early courses of a program of study, when they are task oriented and focused on learning or demonstrating psychomotor nursing skills, making it difficult to transition from the mindset of curing to allowing a patient’s natural death (Lippe & Becker, 2015; Moreland et al., 2012; Venkatasalu et al., 2015). Having students care for a simulated dying patient can increase their confidence prior to caring for a dying patient in a practice setting and enhance their understanding of the complex care these patients require (Eaton et al., 2012; Fabro et al., 2014; Ladd et al., 2013; Venkatasalu et al., 2015; Wyrostok et al., 2014). Fidelity in these simulations and inclusion of specific SBLE elements, such as family conflict and multicultural aspects of PC, affected the impact of the experiences on student outcomes related to care of dying patients (Eaton et al., 2012; Fabro et al., 2014; Gillan et al., 2013, 2016; Leighton & Dubas, 2009; Wyrostok et al., 2014). The reported benefits of the observer role indicate that an increased number of students may benefit from a single SBLE allowing these experiences to be conducted with large groups of students, thus increasing efficiency and resource utilization in programs with limited faculty or no access to manikins (Eaton et al., 2012; Fluharty et al., 2012; Gillan et al., 2013; Ladd et al., 2013; Tuxbury et al., 2012; Wyrostok et al., 2014). A quality debriefing session may be even more important than the simulation itself (Gillan et al., 2013). Given the nature of EOL care and the emotional intensity associated with EOL simulations, one could argue that the importance of debriefing is intensified following the SBLE. Faculty must recognize the risk of emotional distress with EOL simulations and prepare students for the inevitability that the patient in the simulated experience will die to promote psychological safety of students (Gillan et al., 2014b). In postsimulation debriefing, students are able to then reflect on their emotions in an environment of peers who have similar emotions and with the support of faculty who can offer resources for those who are especially distressed.

Implications for Future Research Lack of theoretical frameworks for PC nursing was evident in studies of EOL simulations in undergraduate nursing education, which may be due to limited theory development in PC nursing. Evaluation of the relationships among student knowledge, self-awareness, selfefficacy, and their delivery of care to dying patients is necessary for theory development. Objective measurement of students’ performance in PC nursing has not yet been conducted (outside of addressing team behaviors in interprofessional simulations). Examining the impact of EOL simulation on patient outcomes and new graduate nurses’ practice is needed to address this known gap in the science (Gillan et al., 2014b).

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A comparison of postsimulation outcomes between students with and without real life PC and EOL care experience could assist in determining whether SBLE can achieve desired outcomes when actual clinical experience is not available (Grossman, 2013; Lippe & Becker, 2015). Comparing effects of active versus observer roles in undergraduate nursing EOL care simulations on student anxiety, self-awareness, and self-efficacy would also be advantageous (Carman, Sloane, Molloy, Flint, & Phillips, 2016; Swenty & Eggleston, 2011; Wyrostok et al., 2014). Controlling for the effects of lecture only, lecture and SBLE, or SBLE only would also add to our understanding of how SBLE alone affects student outcomes (Carman et al., 2016; Fluharty et al., 2012; Twigg & Lynn, 2012).

Conclusion Recent emphasis on the importance of nursing competence in PC has prompted an increase in PC and EOL simulations in undergraduate nursing education. The published literature included in this integrative review indicates great potential in the use of PC and EOL care SBLE in supporting the development of nursing student competence in the delivery of this specialized care. This literature has laid a foundation for future research to reinforce findings and fill knowledge gaps regarding the relationships among student outcomes and the effects of PC SBLE on their clinical performance.

Acknowledgment The authors would like to acknowledge Dr Helene Moriarty, Dr Bette Mariani, and Dr Jennifer Ross for their expertise and feedback during the process of preparing this manuscript.

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