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Review Article American Journal of Hospice & Palliative Medicine® The Use of Simulation to Teach Nursing 2018, Vol. 35(8) 1140-1154
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  Review Article The Use of Simulation to Teach NursingStudents and Clinicians Palliative Careand End-of-Life Communication:A Systematic Review Madison B. Smith, RN, BSN 1 , Tamara G. R. Macieira, BSN 1 ,Michael D. Bumbach, PhD, FNP-BC 2 , Susan J. Garbutt, DNP, RN, CIC, CNE, CHSE 3 ,Sandra W. Citty, PhD, ARNP-BC, CNE 2 , Anita Stephen, MSN, RN, CNL 4 ,Margaret Ansell 5 , Toni L. Glover, PhD, GNP-BC, ACHPN 4 ,and Gail Keenan, PhD, RN, FAAN 2 AbstractObjectives:  To present the findings of a systematic review on the use of simulation-based learning experiences (SBLEs) to teachcommunication skills to nursing students and clinicians who provide palliative and end-of-life care to patients and their families. Background:  Palliative care communication skills are fundamental to providing holistic patient care. Since nurses have thegreatest amount of direct exposure to patients, building such communication competencies is essential. However, exposure topatients and families receiving palliative and end-of-life care is often limited, resulting in few opportunities to learn these skills inthe clinical setting. Simulation-based learning experiences can be used to supplement didactic teaching and clinical experiences tobuild the requisite communication skills.  Methods:  Searches of CINAHL, MEDLINE, PsychINFO, ERIC, and Web of Scienceelectronic databases and Grey Literature returned 442 unique records. Thirty articles met the established criteria, including theSBLE must contain a nursing role.  Results:  Simulation-based learning experience are being used to teach palliative and end-of-lifecommunication skills to nursing students and clinicians. Lack of standardization, poor evaluation methods, and limited exposure tothe entire interprofessional team makes it difficult to identify and disseminate validated best practices.  Conclusion:  While theneed for further research is acknowledged, we recommend this evidence be augmented by training programs that utilize SBLEsthrough (1) applying standards, (2) clearly specifying goals and objectives, (3) integrating externally validated scenarios, and (4)employing rigorous evaluation methods and measures that link the SBLE to the training objectives and desired clinician practicebehaviors and patient outcomes. Keywords simulation, communication, end of life, palliative care, nursing education, interprofessional 1 College of Nursing, University of Florida, Gainesville, FL, USA 2 College of Nursing, Family, Community, and Health System Science, University of Florida, Gainesville, FL, USA 3 Assessment Technologies Institute, Leawood, KS, USA 4 College of Nursing, Biobehavioral Nursing Science, University of Florida, Gainesville, FL, USA 5 Health Science Center Libraries, University of Florida, Gainesville, FL, USA Corresponding Authors: Madison B. Smith, RN, BSN, College of Nursing, University of Florida, 1225 Center Drive, HPNP Room 3229, PO Box 100197, Gainesville, FL 32610, USA.Email: mbrick16@ufl.eduGail Keenan, PhD, RN, FAAN, College of Nursing Family, Community, and Health System Science, University of Florida, 1225 Center Drive, HPNP Room 2206,PO Box 100197, Gainesville, FL 32610, USA.Email: gkeenan@ufl.edu American Journal of Hospice& Palliative Medicine ® 2018, Vol. 35(8) 1140-1154 ª The Author(s) 2018Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/1049909118761386 journals.sagepub.com/home/ajh  Introduction Effective communication among members of the interprofes-sional team and with the patient is essential to achievingdesired patient outcomes. Curricula for members of thehealth-care team are replete with objectives focused on devel-oping communication skills; however, curricula that outlinespecific communication skills needed in palliative and end-of-life (EOL) care remain deficient. Recent national reportshave emphasized the need to improve primary palliative care,including patient-centered communication, which focuses onfostering healing relationships, exchanging information, and responding to emotions, for both students and clinicians. 1-3 As a result, educators are increasingly using simulation-based learning activities to help build critical communication skills inthe clinical setting. 4 As frontline providers of care, nurses arekey members of the interprofessional team. The purpose of thisarticle is to report the findings of a systematic review designed to identify how simulation is being used to teach communica-tion skills to nursing students and clinicians who care for  patients and families receiving palliative and EOL care.Palliative care communication skills are essential to provid-ingpatients with effective symptommanagement, psychosocialand spiritual support, and advance care planning. 5 For nurses,the ability to develop skills in caring for dying patients and their families is a significant professional rite of passage—onethat they remember for the remainder of their careers. 6,7 Asnurses develop skills in caring for dying patients, they gainmore confidence in the care they provide. 8 Students who par-ticipate in palliative care immersion experiences that allowthem to hone their communication skills report they feel better  prepared to care for dying patients in their first year of profes-sional practice. 9 Time constraints and limited availability of clinical settingsin nursing education may not allow direct experience in pallia-tive and EOL care for large cohorts of nursing students. There-fore, most new nurses must develop communicationcompetencies in palliative and EOL care on the job, which isnot ideal and can be unnecessarily anxiety-provoking. 10 Furthermore, nurse clinicians—who are accustomed to advo-cating for their patients’ needs—cite a need for more educationon palliative and EOL care. 11-13 The use of simulation-based learning may enable educators to reach greater numbers of nursing students and clinicians to foster the development of these important communications skills. 14 Simulation-based learning experiences (SBLEs) offer anopportunity to enhance students’ and clinicians’ communica-tion skills. Simulation typically involves mimicking the real-world scenarios to provide learners with pertinent experiencesunder controlled or practice conditions. 15,16 The SBLEsinvolve a variety of simulated learning methods, includingmanikin-based, standardized/simulated patients or computer- based programs, virtual reality, or hybrid simulation to achieverealistic environments representative of the learner’s profes-sional responsibilities. 17 An important concept in SBLEs isfidelity, defined as “the degree to which a simulated learningexperience approaches reality.” 18 Fidelity goes beyond themanikin itself and includes environmental fidelity, conceptualfidelity, and psychological fidelity. Fidelity allows the SBLE toreplicate the practice environment, typically the hospital, asclosely as possible and allows learners to practice their skillsin a safe environment.In the following sections, we report the methods and find-ings of a systemic review of the literature for SBLE exemplarsfocused on palliative care and EOL communication thatinclude the nursing role. For this article, SBLE is defined asa method of accomplishing learning goals through interactingwith people, simulators, computers, or task trainers that insome way mimic or represent the real-world experiences and responsibilities, adapted from Agency for Healthcare Researchand Quality’s definition. 17 The communication component of the SBLE is defined as the exchange of thoughts, messages, or information related to palliative care or EOL care throughspeech and behavior using actors or artifacts to represent patients, families, caregivers, or members of health-care teams. MethodsData Sources The sponsoring institution’s nursing librarian, with the other coauthors of the article, performed a comprehensive systema-tic literature search on February 15, 2017, of the PubMed,CINAHL, ERIC, Web of Science, and PsycINFO databases.Searches of the grey literature resources—ProQuest Disserta-tions & Theses Global, Worldcat Dissertations and Theses,and NLM Gateway—were also performed. All search strate-gies included terms related to the concepts of simulation, palliative care, EOL, and nursing. The complete strategy isavailable upon request. No date, study, or subject filters wereapplied. Comprehensive details of the protocol for this sys-tematic review were registered on PROSPERO at http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID ¼ CRD42017058046. 19 Inclusion and Exclusion Criteria Explicit inclusion and exclusion criteria were established toensure a uniform selection of articles amongst reviewers. Theinclusion criteria were articles that (1) described a simulated learning experience that (a) involved technology (b) was deliv-ered to nursing students or practicing nurses (c) and focused on palliative care or EOL communication and (2) included anevaluative component. The exclusion criteria were letters,commentaries, news items, and articles not published in Eng-lish. In addition, we excluded articles that did not provide adescription of the sample, lacked evaluation results, or had insufficient details about the learning scenarios. These criteriaexcluded articles that did not provide sufficient details to deter-mine whether an SBLE involving communication was per-formed and evaluated. A list of articles excluded during thefull-text review phase and the rationale for exclusions are Smith et al   1141  available upon request. Our final list of 30 articles includes allinstances of SBLEs in which other health disciplines wereeither included in the scenarios or participated in the training.The list, however, does not include interprofessional SBLEsthat took place without direct involvement from the nursing profession (an inclusion criteria). Review Process The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram 20 (Figure 1) lists thenumber of articles included during each phase of the systematicreview (identification, screening, eligibility, included). Thedatabase and grey literature search identified 442 studies,excluding duplicates. During the screening phase, 2 reviewers(M.S. and T.M.) independently reviewed all abstracts for inclu-sion and exclusion criteria. Disagreements between reviewerswere resolved through discussion and consensus (M.S., T.M.,G.K.). All articles that met the inclusion criteria and none of theexclusions or had abstracts with insufficient information avail-able to determine whether they met inclusion status weremoved to the eligibility (full text) review phase. Two reviewersseparately (M.S. and T.M.) evaluated 53 full-text articles dur-ing the eligibility review phase to confirm those that met all of the inclusion and none of the exclusion criteria. All discrepan-cies between the 2 reviewers in this phase were resolved by athird reviewer (G.K.). In total, 30 articles matched the eligibil-ity criteria. Kirkpatrick’s Level of Evaluation The Kirkpatrick Model 21,22 was used to differentiate the levelof evaluation assessment completed for the training reported ineach of the articles reviewed. The model consists of 4 levels:(1) participants responses—REACTION—to training (eg,satisfaction); (2) extent of knowledge, attitude, or skillsgained—LEARNING; (3) extent to which desired behaviorsare being used on the job—BEHAVIOR; and (4) extent towhich desired behaviors are producing the desired outcomesin practice—RESULTS— (eg, achieving desired patient out-comes). The level of evaluation for each article is reported inthe last column of Table 1. Results In the 30 articles that met the eligibility criteria, the researchteam focused on identifying the use of SBLEs to educate nur-sing students and clinicians (practicing nurses) about palliativecare or EOL communication. A word cloud of the review arti-cles was generated from summaries of each article’s synthesisto provide a visual of the themes and strengths that character-ized the simulation exercises described (Figure 2). The topthemes included family, care, patient, EOL, symptoms, man-agement, grief, conflict, palliative, and support. The following paragraphs summarize information from the articles that helpcontextualize the communication component of the SBLEsreported in the articles (Table 1). # of records identified through database searchingCore Databases(n=462)# of additional records identified through other sourcesGrey Literature(n=140)# of records afterduplicates removed (n=442)# of records screened (n=442)# of records excluded (n=389)# of full-text articles assessed for eligibility(n=53)# of studies included in systematic review(n=30) # of full-text articles excluded for reasons that include; not tested, no evaluation, no use of technology, lack of simulation description/communication training(n=23)       I    n    c      l    u      d    e      d    n    o      i      t    a    c      i      f      i      t    n    e      d      I    g    n      i    n    e    e    r    c      S    y      t      i      l      i      b      i    g      i      l      E Figure 1.  PRISMA flow diagram illustrating the selection process of articles. 1142  American Journal of Hospice & Palliative Medicine ® 35(8)

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