End-of-Life Simulation Lessons

According to the Current Populations Reports, issued in 2014, the aging population will double between the years of 2012 and 2050. As of 2012, it was estimated at 43.1 million people; by 2050 that is expected to grow to be 83.7 million 12. The number of individuals who receive hospice care has increased from 17% in 1995 to 45% in 2011, with a majority of all deaths in the U.S. related to chronic illnesses. However, hospice services are being underutilized with only 35% of patients receiving care for less than seven days due to a lack of referrals. 11.

A baccalaureate nursing student’s competence in the delivery of care to a dying patient can enhance dignity for both the patient and/or family during that sensitive time. In the case of the end of life, pre-licensure BSN students can integrate theory into practice in a simulated setting. Faculty who facilitate simulations can debrief which may enhance key interventions at the end of life. The purpose of this paper was to heighten awareness to the importance of educating pre-licensure nursing BSN students about the end of life care through simulation.

Review of the Literature
End-of-life care is the period in which the patient’s prognosis is limited or nearing death 8. Other relevant terms concerning the end of life care include; palliative and hospice care 10. The use of palliative and hospice care depended on the prognosis of the patient. Hospice care is used for patients with a life expectancy of 6 months or less. Whereas, palliative care can be provided to any patient during the disease process to promote quality of life, pain relief and support 10.

The American Academy of Hospice and Palliative Medicine Workforce Taskforce state there is a shortage of 6,000-18,000 palliative medicine specialists 11. According to the IOM report, “all clinicians across disciplines and specialties who care for people with advanced serious illness should be competent in basic palliative care, including communication skills, inter-professional collaboration, and symptom management “14. Palliative care trained clinicians, can promote dignity for the patient, increase the quality of life, and support for the family.

SEE ALSO: The Science Behind Spiritual Care

BSN Competency through Simulation
The frontline caregivers of patients with life-limiting diseases are nurses, more than any other health professional 13. A review of the literature, highlighted gaps in the curricula of undergraduate and graduate nursing education programs that include the end of life care. According to White & Coyne 14, it was found that 2% of nursing textbooks provide information addressing the end of life care. The hours spent on content focused on the end of life care in nursing programs was estimated at 15 hours for pre-licensure BSN programs 11. Some programs are faced with time constraints, such as accelerated baccalaureate of nursing programs, to provide sufficient didactic content focused on the care of patients at end-of-life including: the capacity of the patient, family members or tending to their self-cares 4.

The use of simulation can be a powerful teaching method for the pre-licensure BSN nursing student. Simulation can be defined as an activity that attempts to imitate a clinical experience, understand the rationale for learning in a safe, controlled environment 7. The use of simulation to prepare pre-licensure BSN nursing students for the delivery of end-of-life care can help decrease anxiety associated with death, improve self-efficacy and help the student increase their awareness of the patient and family’s needs. Simulation of end-of-life care can help the student gain valuable knowledge, skills and competency before transitioning into a professional role in the field. These skills include, understanding critical aspects of end-of-life care, understanding the different phases of a patient actively dying, how to provide effective pain management, and using therapeutic communication 5. Many students describe simulation as stressful, but a great opportunity to learn and master their skills in a low-risk environment 8.

A recent study by Fabro, et al. included a simulated scenario of two chronically ill patients with family members present. The students were asked to perform assessments to include, pain management, communicate and deliver care to the patient and family. Students were evaluated on their professional behavior of being on time, participating in the scenario and contributing to the debriefing component 5. A Likert-type scale was used to evaluate the students perception of the scenario and if they valued the experience or not. After the simulation was completed the students were able to discuss their feelings of death, learned how to answer questions truthfully to family members, understood the meaning of nursing presence, and learned the importance of spiritual care.

End of Life Education
One challenge in nursing education is linking theory and clinical components. A survey of more than 400 baccalaureate nursing programs throughout the country illustrated that several methods for teaching end of life care were being used. According to Flaherty, et al., these included lectures, small group discussions, clinical case discussions, video’s, visiting funeral homes and hospice facilities, role playing, simulation and speaking with someone with a terminal illness. The majority of baccalaureate programs included just the lecture component while a small percentage of programs reported using the simulation 6.

In 1998, the American Association of Colleges of Nursing (AACN) released its landmark publication Peaceful Death: Recommended Competencies and Curricular Guidelines for End- of- Life Care, which listed sixteen areas nurse educators should incorporate into nursing curricula. Many of these competencies involved the psychosocial aspect of end of life care such as how to assist the patient, their family, as well as fellow colleagues, to manage grief and loss, including how to communicate with patients and their families 2.

In response, the End-of-Life Nursing Education Consortium was established. The ELNEC provides end of life care training to many healthcare providers. This training is divided into eight modules incorporating the use of case studies, on-line courses and simulations . The ELNEC reported that as of January 2015, over 19,500 nurses and other health care professionals have participated in this training and are currently teaching this material to many in educational and clinical settings 1

The care of the patient during the end of life in their final hours, days, or weeks should be treated as a privilege to the healthcare provider. Being able to provide support and care to the patient and family should be held to the highest of standards and is truly a profound aspect of the nursing career 4. Therefore, when nurses are not adequately trained or prepared for end of life care, they may feel dejected or it may cause anxiety within the nurse, affecting the patient’s care as well as the nurse’s confidence as a professional 13.

Recommendations for Future Study
The integration of simulation to enhance the end of life education will support transition into the clinical environment where this is a required competency, and help alleviate discomforting situations. However, the use of simulations should never replace experience with a patient, but integrated appropriately into the nursing program 3. In a report by the IOM, 9, a need for increased palliative care in the curriculum content is needed. In response, the committee strongly suggested that, “state regulatory agencies to include education and training in palliative care in licensure requirements for physicians, nurses, chaplains, social workers, and others who provide health care to those nearing the end of life,” 14.

The ELNEC suggested that nurse educators be trained in the following modules: Nursing Care at the End of Life, Pain Management, Symptom Management, Ethical and Legal Issues, Cultural Considerations in End-of-Life Care, Communication, Loss, Grief, Bereavement and Preparation for and Care at the Time of Death. Subsequently, trained faculty could incorporate these modules into their respective baccalaureate nursing classes 1. Therefore, once faculty was trained in these areas, simulation of the end of life could be added to the curriculum course in adjunct to didactic theory.

The education of baccalaureate nursing student’s is paramount to the patient who is at the end of life. It is becoming more vital due to the increase in the population age and the existence of chronic health conditions in the United States 5. Every nurse is inevitably faced with the experience of caring for a patient and family at the end of life at some point during their career. Understanding how to make the change is imperative and providing simulation time for the end of life care in pre-licensure BSN nursing programs can be one avenue for doing so. The provision of end of life care is a critical aspect of nursing; one in which graduates need to be prepared.


1. American Association of Colleges of Nursing | ELNEC Fact Sheet. (2015, February). Retrieved from http://www.aacn.nche.edu/elnec/about/fact-sheet

2. American Association of Colleges of Nursing | Peaceful Death: Recommended Competencies and Curricular Guidelines for End-of-Life Nursing Care. (1998, February). Retrieved from http://www.aacn.nche.edu/elnec/publications/peaceful-death

3. Berragan, L. (2011). Simulation: An effective pedagogical approach for nursing? Nurse Education Today, 31, 660-663

4. Carman, M. J. (2014). Bundling the death and dying learning experience for pre-licensure nursing students. Nurse Educator39(3), 135-13

5. Fabro, K., Schaffer, M., & Scharton, J. (2014). The development, implementation, and evaluation of end of life simulation experience for baccalaureate nursing students. National Education Perspectives, 35(1), 19-25

6. Flaherty, L., Hayes, A. S., Milgrom, L., Malarney, K., Smith, D., Reklau, M. A., McNelis, A. M. (2012). A Multisite, Multi-Academic Track Evaluation of End-of-Life Simulation for Nursing Education. Clinical Simulation in Nursing8, 135-143. doi:10.1016/j.ecns.2010.08.003

7. Huston, C. (2014). Using simulation to teach nurses. Professional issues in nursing, challenges and opportunities (pp. 48-52). Baltimore: Lippincott Williams & Wilkins

8. Hamilton, C. A. (2010). The Simulation Imperative of End-of-Life Education. Clinical Simulation in Nursing6, 131-138. doi:10.1016/j.ecns.2009.08.002

9. Institute of Medicine (IOM), (2014). Dying in America: Improving quality and honoring individual preferences near the end of life. The National Academic Press

10Lewis, K. (2013). How nurses can help ease patient transitions to end of life care. Nursing Older People25(8), 22-26

11. Meghani, S., & Hinds, P. (2014). Policy brief: The Institute of Medicine report dying in America: Improving quality and honoring individual. Nurs Outlook, 63, 51-59

12. J., Velkoff, V., & Hogan, H. (2014). An aging nation: The older population in the United States. Retrieved from http://www.census.gov/prod/2014pubs/p25-1140.pdf

13. Pullis, B. (2013). Integration of End-of-Life Education into a Community Health Nursing Course. Public Health Nursing, 30(5), 463-467

14. White, K., & Coyne, P. (2011). Nurses’ perceptions of educational gaps in delivering end-of-life care. Oncology Nursing Forum, 38(6), 711-711. Retrieved from https://onf.ons.org/sites/default/files/B0QV85T157X13721_first.pdf

Derrith Foster and Jessica Rickard are graduates of MCPHS University, class of 2015. Tammy Gravel is interim assistant dean of curriculum at School of Nursing, MCPHS University, Worchester, Mass.

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