Use of Simulations in Preparing High

Acuity Nurses for End of Life Care

NURS 470, University of Arizona, College of Nursing

SARA DIETRICH, MELINA MILLER, ELLE PAVELONIS, TAYLOR ROMERO,

BRIANNA ROTH, MELIA SKINNER, KRYSTAL SOTIS, LAURA WORCESTER
 Introduction
Nurses feel uncomfortable with end of life care and the lack of
continued education on improvement of the process. (Gelinas, Fillion,
Robitaille, & Truchon, 2012).

Communication:
Communication between physician and family often lacking
Familys confused about situation (Efstathiou & Walker, 2014)
Communication between healthcare team
Poor communication can make process more difficult (Efstathiou & Walker, 2014)
 Introduction (continued)
Barriers between patient and family
Families become disconnected from patient due to ICU environment
Nurses spend time to reconnect family to the patient (Efstathiou & Walker, 2014)
Emotionality
Nurses are often the first or only person that families confide in
Obligation felt to be constant presence at bedside of patients with no
visitors (Efstathiou & Walker, 2014)
 Significance to Nursing
Nurses are most direct contact to patient
Additional responsibilities presented to nurses in end of life care
and withdrawal of care (Wagner & Hardin-Pierce, 2014)
Can cause
Nurses to feel overwhelmed
Nurse burnout
Compassion Fatigue
(Wagner & Hardin-Pierce, 2014)
 PICOT Question
Should it be required for high acuity nurses (P) to
participate in annual (T) interprofessional workshops
simulating withdrawal of life support (I), compared to
having no previous training (C), in order to improve the
satisfaction for families (O) on ICU units following the
withdrawal of life support of their loved ones?
 Current Nursing Practices: National

No established National protocol for withdrawal of care

Required to follow institution protocol and state laws
Follow Nursing Code of Ethics and Hippocratic Oath
 Current Nursing Practices: Arizona/Banner

No Current Education for nurses

Lack of Communication from physicians leading up to withdrawal of care
Care Conference
Nurse, physician, social worker, chaplain, case manager, MPOA
Doctors explain in detail prognosis
Family asks questions to doctors and discuses with eachother
Time frame established
Doctor writes orders for taking patient off of life support
(Banner Health Staff, personal communication, 2017)
 Current Nursing Practices: Arizona/Banner

Bereavement Packet
Paperwork
Donor Network Information
Items for family
Shroud
Call Medical Examiner if suspicious death

(Banner Health Staff, personal communication, 2017)

 Nurses responsibility to provide
Pain relief
Symptom management
Clarification of process of withdrawal of care
Promotion of familial reconnection with the
patient
Informational and emotional familial support
(Wagner & Hardin-Pierce, 2014)
 Synopsis of the Research
What are the main areas affecting quality end-of-life care?
Insufficient:
Education and training
Identified as one of the largest barriers to providing optimal EOL care (Shifrin, 2016)
A study by Shifrin demonstrated that educational intervention resulted in increased
knowledge on EOL care in ICUs (2016)
Knowledge of death
Contribute to nurses discomfort with EOL care (Fernandes & Komessu, 2013)
 Synopsis of the Research (continued)
Ineffective:
Communication between healthcare providers
Overall, nurses perceived the lack of or conflicting communication negatively impacted
care (Coombs, Addington-Hall & Long-Sutehall, 2012)
Nurses believed they should be able to contribute in the decision making process (Kisorio
& Langley, 2016)

Communication between nurses and patients and families

Nurses felt unprepared to discusses EOL care (Gutierrez, 2013)
Felt that it is acquired through experience alone (Fernandes & Komessu, 2013)
 Synopsis of the Research (continued)
Ambiguity during transition
EOL trajectory provides a framework that enhances understanding of role and decision
making (Coombs et at., 2012)
Psychological and emotional stress
Nurses felt a lack of emotional support in dealing with patient and family suffering (Gelinas,
Fillion, Robitaille & Truchon, 2012)

Fear of death
New nurses felt their fear of death impacted the quality of care they were able to provide
(Efstathiou & Walker, 2014)
 Applicability of research conclusions to issue
at hand (Gelinas, Fillion, Robitaille, & Truchon, 2012)
Outlines of how trustworthiness was
Strengths maintained and biases addressed during
research (Kisorio & Langley, 2015)
Inclusion/exclusion criteria used
Steps taken to ensure transcription accuracy
and study credibility using member checks
(Kisorio & Langley, 2015)

Themes or theories congruent with the quotes

and portrayals given by participants (Gutierrez,
2012)

Results consistent with previous research (Shifrin,

2016)

Published in peer-reviewed journals

 Most studies were done at 1-3 hospital
ICUs (Efstathiou & Walker, 2014)
Limitations Homogeneity of the samples (Gutierrez, 2012)
All studies used convenience sampling
methods
Data collected from a few small ICU
groups or individuals so findings cannot
be generalized to a larger population
(Efstathiou & Walker, 2014)
 Evidence Based Recommendations

Education
Practice guidelines (Aslakson et al., 2012)
Transition from curative intervention to end
of life care (Coombs, Addington-Hall, & Long-Sutehall, 2012)
Training
Simulations (Ballangrud et al., 2013)
 Evidence Based Recommendations
(continued)
Communication
Improvement within the ICU
Good communication between caregivers & families (Efstathiou & Walker, 2014)
More experienced nurses need to have open discussions with less experienced
nurses (Fernandes & Komessu, 2013)
Nurse and Family Support
Families experience nursing presence as a comforting support system
Development of practice guidelines (Gelinas et al., 2012)
 Our Recommendations
Trial at Banner Tucson Medical Intensive Care Unit
Interprofessional simulation including nurses, doctors, nursing
assistants
Simulation staff will be educated by Banners palliative care nurses
Simulation staff will mediate and act out roles of patient and family
members
MICU staff will be required to attend one hour long simulation
 Implementations
Implementation to the unit/facility
All charges nurses of MICU educated
Place flyers throughout unit and in break room
Have the charge nurse explain the simulation purpose, guidelines, and
requirements to staff
Charge nurse will hand information out to staff and provide sign up
sheet
Send mass email to nurses with email reminders
 Timeline
Implementation and simulation staff education will begin two months prior
to the simulation
Every Friday in the month of June a simulation will take place
Every nurse will be required to attend one simulation within available dates
in June
After the simulation month is over, nursing surveys and evaluations will be
analyzed and planning will begin to create new simulations for the following
year
 Cost Analysis
A one-hour training would include:
Booking a room in the hospital: Free
ICU Nurse: $33.17/hr x 100/unit= $3,317
Attending: $163.96/hr x 6/unit= $983.76
Resident: $34.72/hr x 18/unit= $624.96
Nurse Assistant: $14.25/hr x 20/unit= $285
Salary of simulation staff: $12/hr x 24hr x 6/day= $1728
Palliative Care Nurse: $33/hr x 3 x 8hrs = $1,254
TOTAL: $8,182.72
(Banner Health, 2017)
 Cost Analysis (continued)

Hospitals lose money each year due to:

Negligence lawsuits
Poor patient reviews which lead to potential patients choosing
facilities with better reviews
Empty beds- At Banner, a 5 day stay in the ICU costs around $160,000
(Banner Health, 2017)

Loss of ratings and thus funding to the hospital

 Risks
Patient/Family Hospital
Margin of error Lack of meeting
space
Nurse Financial loss for
Competing schedules and hospital if
calendars proven
ineffective
Workload
Less available nurses on the floor
Stereotypes and hierarchies
 Benefits
Patient/Family Hospital
Interprofessional communication- Score higher in patient satisfaction
patients benefit from having their care surveys if successful
providers communicate effectively with
each other Provide more cost- effective care to
patients
Nurse Preferred hospital for satisfied patients
Interprofessional education and families
Simulation
Values and Ethics
Roles, Responsibilities and teamwork
 Evaluation
Surveys will be taken by patient families that will allow healthcare
organizations to measure patient family satisfaction before and
after the simulations take place.
Begin surveying 10 families 1 year before simulations, and
continue surveying another 10 families 1 year after simulations
Comparison of survey scores
 Family Survey
Numeric scale questions:
1 - strongly disagree; 2 - disagree; 3 - neutral/not sure; 4 - agree; 5 - strongly agree
I felt involved in my relatives care.
I felt that my informational needs were met by the healthcare team throughout the end of
life process.
I felt that my spiritual needs were met by the healthcare team throughout the end of life
process.
I felt that my emotional needs were met by the healthcare team throughout the end of life
process.
I felt confident in the healthcare teams ability to make decisions regarding my relatives care.
I felt that there was effective and clear communication amongst the members of the
healthcare team.
 Family Survey (continued)
Free response questions:
What could we, as healthcare professionals, improve on to create a more
therapeutic and nurturing environment for the end of life patient and
their family?

Was there anything that we did that especially helped and/or comforted
you throughout the end of life process?
 Simulation Evaluation

Participating ICU nurses will be asked to take a survey 1 week

before the simulation and 1 week after the simulation
Provide feedback on the effectiveness of the simulation tool
Provide an outlet to improve simulations for future years
Comparison of scores
 Nursing Feedback
Numeric scale questions:
1 - strongly disagree; 2 - disagree; 3 - neutral/not sure; 4 - agree; 5 - strongly agree
I feel competent providing end of life care.
I feel knowledgeable and able to share information with families regarding their relatives
condition.
I feel that I have the ability and resources to provide spiritual and emotional needs to
families during end of life care.
I feel that the healthcare team effectively communicates to provide continuity of care and
accurate information that can be conveyed to family members.
I feel that this simulation was beneficial in fostering effective teamwork and communication
amongst the healthcare team during end of life care.
 Nursing Feedback (continued)

Free response questions:

Do you feel that this simulation was helpful?

Do you have any ideas on how we could improve the

simulation?
 Outcomes
The average patient family survey score one year after the end of life
simulations take place will be at least 5 points higher compared to the
average survey score one year before the end of life simulations.

The average nursing feedback score one week after the end of life
simulations take place will be at least 5 points higher compared to the
average feedback score one week before the end of life simulations.
 Summary
Nurses are on the front lines during end of life care.
There are several perceived barriers between providing quality care
This includes, lack of education and training, poor interprofessional
communication, ambiguity of protocols, stress on the nurses and
personal fears and insecurities.
Education and training has been shown to result in increased
knowledge, quality and competency of care as well as seamless
teamwork among interprofessionals.
 Simulation training will be implemented to improve
communication and knowledge of hospital protocols.
The cost of the suggested implementation costs $153,061.28 less
than the loss of one patient due to poor hospital reviews.
The benefits far outweigh the risks of implementing an
educational simulation program
Questions?!?
 References
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