Kristen Jones-Bonofiglio BScN, RN, MPH(N), PhD(c) and Katherine Kortes-Miller, HBMT, MSW, PhD(c)
Dying with Grace: A pilot project exploring the use of high-fidelity simulation in interprofessional palliative care education.

Introduction

This pilot project combined the use of high-fidelity simulation technology with the pedagological approaches of interprofessional education. The overarching goal of this project was to explore an innovative opportunity for teaching and learning in interprofessional palliative care education. We were interested in learning if an experienced team of palliative care providers would find  high-fidelity simulation an effective tool for interprofessional education. Simulation in the context of healthcare education “refers broadly to any device or set of conditions that attempts to present patient problems authentically” (Issenberg & Scalese, 2008, p. 33). Healthcare simulations attempt to imitate real patient situations, anatomic regions, clinical tasks or real-life scenarios in which healthcare practice is conducted. Simulation can be defined as “an educational technique that allows interactive, and at times immersive activity by recreating all or part of a clinical experience without exposing patients to the associated risks” (Maran & Glavin, 2003, p. 22). 

 Simulation has been in use for a number of years now for educating students and professionals in allied health care professions (Baerheim & Malterud, 1995; Finlay et al., 1995; Kameg et al., 2010; Rosenzweig et al., 2008; Palmer et al., 2008; Solnick & Weiss, 2007; Sperlazza & Cangelosi, 2009; Leighton & Dubas, 2009; Jeffries, 2005). However the use of simulation for palliative care education is a relatively new area for exploration (Freer & Zinnerstrom, 2001; Faulkner, 1994; Finlay et al., 1995; Reilly & Ring, 2004). Although palliative care has adopted an interprofessional approach to care, very little research has actually been conducted about interprofessional education (IPE) in palliative care (MacLeod & Egan, 2007). Illingworth and Chelvanayagam (2007) support the idea that IPE is beneficial not only for the patient and their family but also the care providers, students, and educational institutions. IPE is being proposed as one of the potential solutions to help stabilize and sustain the Canadian healthcare system because it has been shown to improve patient outcomes (Zwarenstein, 2006). Situating IPE in the context of a high-fidelity simulation environment allows for the best of both worlds- for both learners and facilitators. It is an innovative opportunity to combine the strengths of an interprofessional team approach to learning with the safety of a simulated teaching environment.

 The term high-fidelity simulation (HFS) is often used to refer to a number of very different concepts which may include computerized manikins, virtual reality environments (avatars), or actors role-playing a patient and predetermined health concern. Our use of HFS involves the use of manikins which are driven by computer software and compressors. The manikin is located in a simulation lab environment that closely resembles a patient’s hospital room. With the help of a trained simulation technologist, the manikin is capable of speaking and hearing conversations in real time and has vital signs (i.e. pulse, blood pressure, respirations, bowel sounds, heart beat) which are adjustable. The fidelity of this environment is further enhanced by our use of props (i.e. items on the bedside table such as photographs, rosary, prayer book, half-written obituary, candies, Kleenex, etc).

Purpose

The goal of this pilot project was to introduce the use of high-fidelity simulation (HFS) technologies (computer software driven manikins) as an opportunity for continuing interprofessional palliative care education for our local hospice team. Also, we hoped to determine, even if only in a preliminary way, whether HFS might have promise as an effective palliative care teaching tool in an IPE setting. We were particularly interested in exploring the use of HFS technologies with a high functioning and seasoned group of interprofessional hospice staff members as this was in contrast to work we have done previously with undergraduate students and novice health care professionals.
 
Participants

Lakehead University School of Nursing (Thunder Bay, Ontario) hosted a pilot project utilizing HFS.  This IPE initiative brought together 10 interprofessional healthcare practitioners from our local hospice team (St Joseph's Care Group Thunder Bay) and a hospice volunteer (Hospice Northwest) to share current information, facilitate knowledge transfer, and participate in team building.  This pilot was funded by the Northern Ontario School of Medicine (NOSM). Members of the hospice team participating in this IPE initiative came from the fields of nursing, social work, spiritual care, occupational therapy, physiotherapy, and speech-language pathology.

What we did

Setting the stage for ‘real’ learning


On a cold day in February, 10 brave members of the hospice team gathered in the nursing  simulation lab for a unique experience called “Dying with Grace”: An IPE Experience using High-Fidelity Simulation.  During the three hour lab the team members were introduced to “Grace”, a high-fidelity simulation manikin, with the capacity to respond physically and verbally to the team's actions, and even die!

Bedside teaching and learning

At the bedside, team members worked with the patient, Grace, individually or in pairs on areas specific to their discipline; asking questions and doing assessments. This provided opportunities for team members to demonstrate an integration of theory with practice.  After a team meeting, focused on planning care and honouring patient choice, the team conducted a family meeting at the beside with Grace and her brother Alex (a role played by a volunteer). This added another layer of realism to the experience, and the focus expanded to include family needs and conflict resolution. 
Debriefing the HFS experience
An essential component of any simulation experience is the debrief session which allows learners to begin to synthesize the experience.  Some areas explored during the debriefing included:

  • issues of pain and suffering, and client’s frame of mind
  • communication
  • exploring the patient and family expectations around death and dying
  • challenges around advanced planning
  • interprofessional care and team work

Evaluation of the overall experience

As this was an educational pilot project, formal evaluation of the experience was not sought. The team members’ anecdotal experiences were explored in light of their perceptions about the value of using HFS and IPE in palliative care learning experiences, and their perceptions about other potential uses for HFS in IPE in palliative care (i.e. orientation training, professional development, team building, etc). Overall, the experiences as reported were very positive and well received by the hospice team.  Comments made by the team included:

“It [the simulation lab] is much like what we presently do.”

“This experience makes me realize some further uses of a simulation for staff in hospital.”


 “Will make my experience more meaningful when I am visiting clients.”

 “I will have even more respect for my teammates.”

“I feel I learned some good ways to answer client/family questions from watching what other team members do/say… More awareness of others roles…Awareness of when to refer increased.”

“Reinforces the importance of good communication in the interprofessional care team.”

Conclusion

There is much work to be done to advance interprofessional palliative care education.  Patient and family care at the end of life will only be improved when interdisciplinary palliative care  education is enhanced and supported by evaluation and research within undergraduate, graduate and continuing education  (Ferrell & Coyle, 2010). 

 The experiences of the members of the hospice team in this pilot project show strong support for further exploration and use of HFS in interprofessional palliative care education. 

The clear benefits of using HFS include:

  •  patient safety
  •  a safe, interactive, and immersive learning environment
  •  potential for capacity building and positive interactions between academic and community partners 

 This pilot project demonstrates the potential for HFS in the development of increased effective pedagogical strategies for interdisciplinary palliative education resulting in better care for individuals who are dying and their families through improved knowledge, skills and attitudes of those providing care and lays the foundation for future research in this area.

Thank you to our community partners: Linda Pisco (CERAH, Lakehead University), Marianne Larson (Manager, Hospice Unit, St. Joseph’s Care Group),  Dr. Geoff Davis (Medical Director for Palliative Care, St. Joseph’s Care Group), Karen Poole (School of Nursing, Lakehead University), Kathryn Hildebrandt (Nursing Simulation Lab Coordinator, Lakehead University), Audrey Drebit (School of Nursing), and Hospice Northwest.

Acknowledging funding for this pilot project: Northern Ontario School of Medicine (NOSM)
 



References

Baerheim, A., & Malterud, K. (1995). Simulated patients for the practical examination of medical students: Intentions, procedures and experiences. Medical Education, 29,  410-413.

Faulkner, A. (1994). Using simulators to aid in the teaching of communication skills in cancer and palliative care. Patient education and counselling, 23, 125-129.

Ferrell, B. & Coyle, N. (2010).   Oxford Textbook of Palliative Nursing.  Oxford, England:  Oxford University Press. 

Finlay, I., Stott, N., & Kinnersley, P. (1995). The assessment of communication skills in palliative medicine: A comparison of the scores of examiners and simulated patients. Medical Education, 29, 424-429.

Freer, J. & Zinnerstrom, K. (2001). The palliative medicine extended standardized patient scenario: A preliminary report. Journal of Palliative Medicine, 4(1), 49-57.

Illingworth, P., & Chelvanayagum, S. (2007).  Benefits of interprofessional education in
  health care.  British Journal of Nursing, 16, 121-124.

Issenberg, B., McGaghie, W., Petrusa, E., Gordon, D., & Scalese, R. (2005). Features and uses of high fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27(1), 10-28.

Jeffries, P. (2005). A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nursing Education Perspectives, 26(2), 96-104.

Kameg, K., Howard, V., Clochesy, J., Mitchell, A. & Suresky, J. (2010). The impact of high fidelity human simulation on self-efficacy of communication skills. Issues in Mental Health Nursing, 31, 315-323.

Leighton, K., & Dubas, J. (2009). Simulated death: An innovative approach to teaching end-of life care. Clinical Simulation in Nursing, 5(6), 223-230.

MacLeod, R., & Egan, T. (2007).  Interprofessional Education. In B. Wee and N. Hughes, (Eds.),   Education in  Palliative Care; Building a culture of learning, pp. 235-249, Oxford,  England:  Oxford University Press.

Maran, N. & Glavin, R. (2003). Low-to high-fidelity simulation – A continuum of medical education? Medical Education, 37(1), 22-8.

Palmer, M., Kowlowitz, V., Campbell, J., Carr, C., Dillon, R., Durham, C., Gainer, L., Jenkins, J., Page, J., & Rasin, J. (2008). Using clinical simulations in geriatric nursing continuing education. Nursing Outlook, 56, 159-166.

Reilly, J. & Ring, J. (2004). An end-of-life curriculum: Empowering the resident, patient, and family. Journal of Palliative Medicine, 7(1), 55-63.

Rosenzweig, M., Hravnak, M., Magdic, K., Beach, M., Clifton, M., & Arnold, R. (2008). Patient communication simulation laboratory for students in an acute care nurse practitioner program. American Journal of Critical Care, 17(4), 364-272.

Solnick, A., & Weiss, S. (2007). High fidelity simulation in nursing education: A review of the literature, 3, 41-45.

Sperlazza, E., & Cangelosi, P. (2009). The power of pretend: Using simulation to teach end-of life care. Nurse Educator, 34(6), 276-280.

Zwarenstein, M., Reeves, S., & Perrier, L. (2005).  Effectiveness of pre-licensure
 interdisciplinary education and post-licensure collaborative interventions.  Journal of  Interprofessional Care, 19 (Suppl. 1), 148 – 165.