Pediatric End-of-Life Simulation Workshop to Clinical Care: Lasting Implications on Clinical Practice

Introduction

Simulation is a well-established method for teaching and learning communication skills, including for end-of-life (EOL) care education.^1–10 Most findings report increased learner efficacy immediately following simulation sessions,^1,9–18 yet fewer studies explore the learning efficacy weeks to months following participation. The purpose of this study is to understand pediatric subspecialty fellows' participants' perceptions about influences of a simulation-based workshop on pediatric end-of-life care skills (PECS) provided at the bedside several months following participation.

Simulation education seeks to create safe learning spaces where health care professionals can practice and refine a broad range of skills. ¹ Participants can gain experience with challenging situations not encountered regularly in clinical practice or too high stakes to practice clinically without prior education. ²

As noted by the American Academy of Pediatrics, pediatric death is a rare part of pediatric practice, ³ and simulation can effectively address these situations for pediatric trainees who lack significant exposure to EOL care during medical training. ⁴ Pediatric residents have reported improved perceptions of their communication skills at EOL following an educational intervention involving simulation focused on providing EOL care. ⁴ One study found mentor observation and personal experience to be the most valuable tools in helping clinicians care for a child at the EOL. ⁵ This takes time, experience, and a quality mentor-mentee relationship, however, plus the situations must spontaneously arise when mentor and mentee are both in the clinical learning environment.

Many groups have implemented palliative care simulation workshops and courses to enhance provider and interprofessional team members' abilities at all levels, from students to practicing clinicians.^6–10 Compared to didactic courses alone, learning sessions that include simulation are an effective method for improving learner comfort in providing palliative and EOL care. ⁶ One group showed that participants' simulation sessions improved their knowledge and self-awareness on post-session tests and quality performance, as measured by direct observation with a competency evaluation. ⁷

Focused PECS education can teach EOL communication skills, ⁸ and new clinicians report increased knowledge about available supports, as well as improved listening skills, support for families, and provision of medications at EOL. ⁹ Pediatric critical care fellows reported an increase in both preparedness for difficult conversations and confidence in communication surrounding EOL care with simulation-based training specific to EOL communication. ¹⁰ Their group recommended EOL care teaching as a standard part of pediatric critical care training. ¹⁰ Overall, participants at multiple levels perceive an improvement in their comfort and skills following simulation participation and intentional PECS education.

Many of the studies published provide survey data from before, during, and after participation in an EOL simulation, and participants generally perceive training as beneficial.^1,9–18 Some studies elicited detailed feedback on the perceived benefits of the simulation experience in the form of focus groups^9,13 or guided reflections with the participants. ⁸ Other studies focused primarily on giving participants feedback on their performance.^19,20 While all of these outcomes are important toward program evaluation, there is a paucity of reporting on higher level outcomes, including participant behaviors and any clinical impact outside the workshop, as conceptualized by Kirkpatrick. ⁷ Overall, there is an educational gap in understanding participant perceptions about ongoing practice implications following pediatric EOL workshops.

Our group conducts annual workshops in PECS for subspecialty fellows across several subspecialties (neonatal-perinatal medicine, pediatric critical care, hematology oncology, cardiology, pulmonology, blood and marrow transplant, nephrology, and hospital medicine). Fellows are required to attend a half-day workshop once or twice during their training. Workshops were developed with a deliberate practice model and include the following:

- didactic content;

Immediate formative feedback and debriefing with interprofessional facilitators are emphasized across all portions. The workshop is feasible and effective as assessed by a survey of participant self-efficacy immediately following the workshop. ¹⁶ For this study, we aimed to understand pediatric subspecialty fellows' perceptions about influences of the PECS simulation-based workshop on PECS provided at the bedside several months following participation through focus groups.

Methods

This study was conducted and reported according to the Standards for Reporting Qualitative Research. ²¹ Researchers and expert practice educators at a Midwest academic hospital implemented a workshop in 2018 for pediatric subspecialty fellows with a goal to improve competence in care at EOL for pediatric patients and their families. Researchers are doctorally prepared and have conducted numerous qualitative studies. Expert practice educators have been serving in academic and clinical medicine for over eight years. In this half-day workshop, participants learned and practiced PECS through a combination of didactic instruction and immersive simulation. ¹⁶

To address our study aim, we used focus group methodology to stimulate participant interactions, explore transfer of PECS workshop knowledge, skills, and attitudes, and draw out self-awareness perceptions of practice performance at the bedside at the EOL in experiences with pediatric patients and their families.^7,22 A purposive, convenience sample was recruited from the original groups of EOL workshop participants.

We intentionally invited neonatal-perinatal medicine, pediatric hematology and oncology, and critical care fellows who had participated in one of the workshops (n = 16) with the goal of obtaining a sample of at least two participants from each subspecialty and two from each year of training. We did not attempt to reach sampling saturation; instead, we intentionally sought participant experiences across groups. Participation was voluntary, and the institutional review board deemed the study exempt from full review. In the spring of 2019, 16 pediatric fellows were invited to participate in one of three 90-minute focus groups.

We utilized focus groups instead of a survey or interviews to capitalize on perceptions shared within conversations and interactions between participants. ²³ An interview guide for the focus group was developed to access emotive dialog, explore practice examples, and derive meaningful responses (Table 1). ²² Approximately six months following participation in the workshop, and in the week before meeting together, researchers sent an introductory letter through email, including the five guiding focus group questions (Table 1). Facilitators (H.K. and J.M.S.) led focus groups during regularly scheduled 90-minute subspecialty educational sessions. Sessions were recorded for accuracy and transcribed for analysis. Data were de-identified and analyzed through content analysis methods. ²⁴

Researchers (N.G., H.K., S.M., and J.M.S.) individually read each transcript to get a sense of the whole. Using an asynchronous, modified scissor and sort technique, the data were broken up into meaning units and condensed to address the study objective. A code list of themes and subthemes was formed from the condensed meaning units, ²⁵ and all transcripts were re-read according to the themes and subthemes. Conflicts in coding were resolved through consensus at a synchronous group meeting. Researchers addressed study trustworthiness by creating a memoing trail of thoughts throughout the analysis, recording detailed descriptions of data as it evolved, maintaining an initial and final list of themes and subthemes, and tracking how the evolving themes and subthemes addressed the study objective for the purpose of interpretation and conclusions. ²⁶ Actual quotes from fellows are used to enhance the credibility of data (Table 2).

Results

Ten fellows participated in one of the three focus groups. All programs invited (neonatal-perinatal medicine, pediatric hematology and oncology, and critical care) and years (post-graduate years one through three) were represented.

Researchers identified three major themes of pediatric fellow perceptions of the influence of the EOL workshop experience on subsequent EOL care for dying children and their families: the burden of EOL care, safe practice space, and self-efficacy. Subthemes and supporting exemplar quotations detail perceptions that emerged and include the following:

Table 2 contains all sub-themes and their exemplar quotations.

In all focus groups, fellows described translating specific skills gained from the EOL workshop to the bedside with patients and families. Real-world practice implications that pediatric fellows identified stemming from their workshop participation are further described in Table 3. These skills included increased confidence as a leader, improved anticipatory guidance, and incorporation of skills specifically learned and practiced during the workshop.

Discussion

We aimed to understand the pediatric subspecialty fellows' perceptions about influences of a simulation-based workshop on PECS provided at the bedside several months following participation. Our findings demonstrate that subspecialty pediatric fellows perceive the EOL workshop to be a safe space to practice EOL communication and skills. Across the six months following deliberate practice in the simulation-based PECS workshops, fellows reported incorporating learnings into active clinical practice. Our findings suggest perceptions of long-lasting skill development translated to real-world practice changes during the six months after the workshop. These findings begin to fill the gap in the literature regarding potential long-term outcomes following simulation-based EOL education.

Participants reported implementation of several strategies learned in the PECS workshop in distressing clinical scenarios. Strategies included using direct language, using preferred phrases, and knowing how to structure a difficult conversation. Participants also reported perceptions of freedom in conducting difficult EOL conversations after learning that there are multiple reasonable and correct ways to do so. Fellows reported an increase in confidence in having conversations with families regarding EOL, despite having to do so while experiencing continued emotional distress.

Our study has some limitations. First, our study relied on trainee self-report; there was no direct observation by supervisors or interprofessional team members on how they incorporated skills nor their competency in this area. Findings are limited to outcomes for participants at a single institution that provided one method of simulation-based PECS education. Finally, findings are limited to a single time period and are not longitudinal.

In our study, self-report by these participants provided important themes, subthemes, and practice implications. We demonstrate lasting clinical implications following this simulation-based educational intervention for these participants. Future work should consider how to gather data on even longer-term practice influence of PECS education and to reach data saturation. Focus groups with participants from additional workshops and specialties, as well as a longitudinal approach might be considered.

Finally, subspecialty fellows provide care for patients and families along with multiple interprofessional team members. As the local workshop expands to include other health care team members, it will be imperative to collect their perceptions on lasting clinical practice implications of the workshop. It will also be important to consider direct observation of PECS competence by supervisors, interprofessional team members, and bereaved parents.

In conclusion, targeted, deliberate simulation-based practice of PECS can help close the gap from learning to practice, contributing to provider self-efficacy and potentially improving clinical care for pediatric patients and families at EOL.