Dying With Carolyn

Abstract

This article examines the development, implementation, and evaluation of a pilot project utilizing high-fidelity simulation (HFS) to improve frontline staff members’ confidence and skills to communicate about death and dying in long-term care homes. The target group was unregulated care providers who provide palliative care for residents and their families. Eighteen participants engaged in the educational intervention and evaluation. Results supported the effectiveness of HFS as an educational tool for unregulated health care providers. Quantitative data showed statistically significant improvements in participants’ self-efficacy scores related to communicating about death and dying and end-of-life care. Qualitative data indicated that the experience was a valuable learning opportunity and helped participants develop insights into their own values, beliefs, and fears providing end-of-life care. HFS is therefore recommended as an innovative training strategy to improve palliative care communication in long-term care homes.

Keywords

personal support workers unregulated care providers education palliative care death and dying end of life communication high-fidelity simulation long-term care homes

Background

This article explores how high-fidelity simulation (HFS) can enhance palliative care education and training for unregulated care providers working in long-term care (LTC) homes. The aim of simulation-enhanced, palliative care education is to provide learners with opportunities to integrate multiple dimensions of clinical knowledge and develop competency and increased confidence through reflective practice and hands-on experiential learning. The ultimate aim of the education is to improve palliative care for the resident and family at the end of life.

Unregulated care providers in LTC homes are given titles, such as health care aides, nurses’ aides, personal support workers, or nursing assistants, depending on the jurisdiction. For purposes of this article, the generic term unregulated provider will be used to describe this type of frontline worker. Unregulated providers offer personal care such as bathing and assist individuals to perform activities of daily living such as dressing or eating. They often develop strong personal attachments to the residents in their care that they describe as “family like bonds” (Sims-Gould et al., 2010). Furthermore, they report lack of confidence and skill talking about death and dying as an obstacle to caring for dying residents (Sims-Gould et al., 2010). In Ontario, Canada, unregulated providers account for 80% of the hands-on care given to chronically ill and frail elderly people when measured by the hours and nature of their work, thus providing services that form the backbone of both community and institutional services (Brookman, 2007; Ministry of Health and Long-Term Care (MOHLTC), 2007). Residents today have a high burden of chronic and terminal disease and high rates of Alzheimer’s disease or related dementias (Wowchuk, McClement, & Bond, 2006) that create care challenges due to communication, functional, and behavioral problems that arise.

As a group, unregulated providers are largely understudied and underrepresented in the literature (Baldwin, Roberts, Fitzpatrick, While, & Cowan, 2003; Brookman, 2007; Coffey, 2004; Lilly, 2008). Within the professional hierarchy of health care, they are positioned at the bottom rung relative to wages and status and often provided with little recognition, respect, or consideration for their substantial contribution to care of the elderly (Brookman, 2007; Lilly, 2008; Morris et al., 1999). There are also reports of a general expectation that unregulated providers will offer services beyond those outlined in their job descriptions and perform tasks for which they have received minimal or no formal training (Brookman, 2007; Morris et al., 1999). The unregulated providers’ scope of practice is not explicitly demarcated, because their duties do not extend beyond what their client or resident could do for themselves if they were physically/cognitively able (Personal Support Network of Ontario [PSNO], 2011).

The provision of palliative care for elderly people is an important issue that will become even more critical in all settings of care over the next decade (Carstairs, 2010), including in LTC homes. In Ontario, Canada, recent changes to the Long Term Care Homes Act stipulate that all staff who provide direct care to residents, as a condition of continuing to have contact with residents, receive training in palliative care (MOHLTC, 2007). This requirement includes unregulated providers; however, there is little research to inform providing their palliative care education. Thus, as a pilot project, we designed, implemented, and evaluated a high-fidelity palliative care simulation educational intervention targeted to unregulated providers.

HFS is increasingly being recognized as a pedagogical strategy for palliative and end-of-life care education (Foyle & Hostad, 2007; Gaba, 2004; Leighton & Dubas, 2009; Smith-Stoner, 2009; Sperlazza & Cangelosi, 2009). It is an appropriate teaching strategy for end-of-life care management (Leighton & Dubas, 2009) that enables experiential, learner-centered education in a safe environment (Cioffi, Purcal, & Arundell, 2005), and it can be used with novice and experienced practitioners from different disciplines (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005). This pedagogical strategy is an effective way to bridge theory and practice allowing for experiential training of skills, knowledge, and decision making, transferrable to real patient situations, while learners are able to remain in a safe, nonthreatening environment (Leighton & Dubas, 2009; Sleeper & Thompson, 2008; Solnick & Weiss, 2007). No research could be found that developed, implemented, and evaluated palliative care education for unregulated providers using HFS.

Objective

This article aims to describe the development, implementation, and evaluation of a pilot educational intervention utilizing HFS to improve unregulated care providers’ confidence and skills communicating about death and dying in LTC homes. This educational intervention was implemented as part of a larger program of research (2009-2013), which aimed to develop strategies, resources, and tools to implement palliative care programs in LTC homes (see www.palliativealliance.ca). The objective of this particular intervention was that unregulated providers would gain knowledge and skills in communicating with residents and their families about issues of death, dying, and palliative care, and increase their confidence to provide palliative care.

Ethics approval was received by two research ethics boards IRB 135-08-09. The pilot project included a variety of stages, including Learning Needs Assessment, Development of HFS Education, Participant Recruitment, Facilitation of the HFS Labs, and Evaluation (which used a mix of quantitative and qualitative methods). Each of these will now be outlined in detail.

Learning Needs Assessment

The first step in developing the HFS experience was to identify the specific learning needs of unregulated providers to establish appropriate learning objectives. This was done by conducting a secondary analysis of existing focus group data collected in 2009 as part of the larger program of research. Fifty unregulated providers from two study sites had participated in 14 focus groups that explored their perceptions about the provision of palliative care in LTC, their challenges, and learning needs. The verbatim transcripts were reviewed line-by-line by one researcher who identified and coded the participants’ learning needs as they emerged from the data, identified common themes, and ultimately grouped them into three categories: communicating with residents, communicating with family members of residents, and communicating with staff members of other disciplines. To validate the results, the analysis was reviewed by a second member of the research team, and all themes and categories were discussed to achieve consensus. These findings informed the learning objectives for the simulation experiences.

Development of the HFS Education

It was important that the HFS scenarios and content were tailored for the unique role unregulated providers have when communicating with residents (Rosenzweig et al., 2008). To develop realistic scenarios, two of the researchers met with the two unregulated providers recruited as collaborators in the larger participatory action research. Providers elaborated their role, common interactions with residents and their family members, and communication issues they encounter related to dementia and palliative care. This meeting provided valuable insights to guide development of the simulation lab scenarios and creation of the manikin “resident,” Carolyn, along with ideas for appropriate and meaningful props that could be incorporated into the simulation lab setting to increase the fidelity or realness of the experience for the participants. With the plethora of information that had now been collected, the researchers created Carolyn, a LTC home resident suffering from dementia in her late 80s. A detailed life history for Carolyn was also developed. As this educational experience focused on palliative and end-of-life care, it was decided that the manikin “resident” Carolyn would die during the simulation experiences. As such, it is important to note that provisions were made in advance to have a professional resource available should the participants feel the need for continued support.

Recruitment and Participants

Participants for this study were recruited from LTC homes that were study sites for the ongoing participatory action research through an email invitation and posters in the home. The two unregulated providers working as research collaborators also informed their peers of the simulation learning opportunity and promoted their perception of the benefits. Eighteen participants volunteered for the research and provided informed consent. All worked in 2 LTC homes that are private, nonprofit faith-based organizations with approximately 100 beds each. The majority of the participants were female (16 or 89%), and all participants were below the age of 55. Employment status was equally split between full- and part-time statuses. There was a wide range in the duration of LTC work experience, ranging from less than a year to 26 years. The average number of years that participants had worked in LTC was 7.7 years. It total, the participants represented 140 years of experience working in LTC. Sixty-one percent (11/18) had not previously received training in palliative care as defined as participating in a workshop or course.

The HFS Experience

A HFS educational experience was facilitated by two of the researchers on two separate occasions. Each experience was 3.5 hr in length, offering time for a meal, an introduction to the simulation lab, conducting the actual simulation experience, and a debriefing and evaluation afterward. Copies of the facilitator and participant manual can be accessed on the website (http://www.palliativealliance.ca/education).

To accommodate lab space and shift work schedules, researchers offered the educational sessions for two separate groups of nine unregulated providers. The sessions were offered at two different times of the day, one in the morning and one in the evening, allowing a greater opportunity for providers (who work shift work) to participate. All providers who volunteered for the study participated in the experience. Each of the participants completed the adapted Self-Efficacy in End-of-Life Care (SE in EOLC) survey prior to beginning the experience. The education session was videotaped with consent. The format for each simulation education experience was as follows:

Meeting the Resident—Carolyn McIntosh

Participants received a case study developed by the researchers that included demographic information and information about Carolyn’s family. There were purposeful gaps in information to stimulate the need for further dialogue with Carolyn. The case described the events leading to Carolyn’s move into the LTC home, her dementia diagnosis and other chronic health issues, and the fact that Carolyn had signed a Do Not Resuscitate (DNR) order during her admission assessment. The participants were then led through a series of three scenarios, each lasting for approximately 20 min. Each scenario began with a shift summary report read aloud by the facilitator, which indicated how Carolyn was doing that particular day.

The Three Scenarios

Scenario 1—Carolyn asks, “Am I dying?”

The simulation began with a 2-min relationship building exercise that allowed participants to get to know Carolyn. The first scenario then began. Carolyn cried out for help at 3 o’ clock in the morning and stated, in distress, that she needed to go home. Carolyn tells the participants that her pre-deceased husband, Stanley, woke her up and told her that he was going to drive her to heaven. Carolyn asks where her suitcase is and insists that she needs to pack so that she will be ready. Carolyn begins to ask questions of her caregivers about death and dying such as, “do you think I’m going to die soon?” The scenario lasted approximately 20 min. Participants and facilitators identified topics to be addressed in the debriefing.

Scenario 2—lunchtime with family (1 week later)

One week had passed since the providers last cared for Carolyn. After the report was provided, two to three participants were asked to begin the scenario at the bedside. Alex, Carolyn’s son, arrives to visit his mom after not seeing her for a couple of months; he has been on the road driving truck. He notices that his mother does not have a lunch tray and asks the participants about this. Carolyn begins to call Alex by her husband’s name, and it becomes evident that she is confused—she perceives Alex to still be a child. Upset, Alex leaves the room. After Alex is gone, Carolyn’s neighbor Ivy calls and starts to ask the participants questions about Carolyn’s personal health status. Again, this scenario lasted approximately 20 min. Participants and facilitators identified topics to be addressed in the debriefing.

Scenario 3—Carolyn dies (3 weeks later)

It was noted that 3 weeks had passed and Carolyn’s condition had changed significantly. The scenario begins with two to three participants providing care to Carolyn when her son arrives. He asks a few questions, and then Carolyn stops breathing. Alex comments about not knowing what to do now that his mother has died. Similar to the previous scenarios, the scenario was allowed to play out for approximately 20 min, after which the group was asked to highlight topics, ideas, or questions they wanted to discuss further in the debriefing.

In each of the scenarios, care was taken to enhance fidelity. For example, in this final scenario, the overhead lights were turned off in the lab with only the bedside lamp for lighting. Carolyn appeared with eyes closed and her labored breathing was audible. A rosary and prayer book were available on the bedside table. Personal care items were laid out for the participants to use (i.e., comb, face cloth). A male volunteer portrayed her son Alex and enters the room moments before she takes her final breath.

Evaluation of the HFS Education Intervention

The pilot project also included an evaluation component that aimed to explore the value of this intervention as a palliative care educational strategy for unregulated providers in LTC. The overarching evaluation question was as follows: Is HFS an effective teaching strategy for improving confidence and communication around death and dying for unregulated frontline care providers in LTC?

Method

The quantitative component of the evaluation study aimed to assess whether changes in participants’ perceptions of their self-efficacy in providing end-of-life care to residents and their family had occurred. A single group pretest–posttest design was used, and quantitative data were collected via pre and post-simulation surveys. One week prior to the education sessions, an email was sent to the participants, which included a link to an online pre-simulation evaluation survey and disclosed standard issues related to informed consent. In addition, participants were encouraged to spend time reviewing the information letter sent as an attachment to the email, which outlined important details regarding their potential participation in this research.

Because no appropriate measure could be located for use in this research, a SE in EOLC Survey for unregulated providers was created. It was adapted for use with unregulated staff from an instrument created and successfully used with registered nurses working in LTC homes (Brazil, Brink, Kaasalainen, Kelley, & McAiney, 2011). Both of these surveys were modeled on one designed by Barrington and Murrie (1999), which was shown to be a valid and reliable measure for examining perceived efficacy and outcome expectancies in palliative care (Mason & Ellershaw, 2004). The developed survey included a total of 18 items plus 7 demographic questions. The SE in EOLC instrument for unregulated providers we used included a communication subscale, a patient management subscale, and four additional items that were added to reflect the unregulated providers’ specific context and scope of practice; in addition, some of the original survey items were modified with appropriate language (e.g., the term resident rather than patient; see Appendix A for questions). The communication subscale included six items taken from the Barrington and Murray survey and adaptions of two others. The patient management subscale included two items taken from Barrington and Murray and adaptions of four others. The internal consistency of these scales was examined using Cronbach’s alpha.

Four new items specific to the role and challenges of unregulated frontline care providers around communication about death and dying in LTC were created and added to the survey. For each item, respondents rate their confidence in their abilities to engage in certain tasks on a 7-point scale. The anchors ranged from “cannot do at all” to “certain can do.”

The qualitative components of the evaluation aimed to explore participants’ experiences with the intervention. Qualitative data collected and analyzed included audio-recordings of the debriefing focus groups held in the simulation lab immediately after the HFS sessions, researcher field notes of observations during the HFS, video-recordings of the simulation lab education sessions, and follow-up individual telephone interviews with the participants 10 weeks after the educational intervention. Ten weeks was chosen because the purpose of the follow-up interviews was to gauge retention of knowledge and skills learned and whether or not participants were utilizing their new learning in their practice. A total of 16 of the 18 participants were able to be reached at follow-up and were asked three questions: What has been the most significant change in your practice since participating in the simulation lab? What new knowledge and skills have you gained as a result of participating in the simulation lab? How did participating in the simulation lab affect your confidence in working with dying residents?

Debriefing Focus Group

The debriefing focus group was held in an adjacent room to the lab 15 min following the simulation experience and audio-recorded with permission. The researchers used guiding questions (see Appendix B) to promote discussion in areas important to the palliative care learning experience, including a series of questions adapted from the Critical Incident Questionnaire (CIQ; Brookfield, 1995). The purpose was to discuss the simulation experience in detail and highlight specific issues and learning opportunities that emerged for participants. Participants related previous personal experiences and shared knowledge and stories related to palliative care. The facilitators ensured that each topic mentioned during the simulation experience was reviewed, offered new strategies for providing palliative care, and affirmed the work that the participants were already doing well on the frontline.

The debriefing focus groups were audiotaped and transcribed verbatim. Transcript data were imported into NVivo 8 to assist with the analysis. The overall approach to the line-by-line analysis was inductive, allowing for naturally emerging themes from the data in relation to the stated objective of the evaluation, which was to examine how the participants’ HFS experience affected their confidence and communication around death and dying. The analysis focused on the overall groups’ experience and learning and did not evaluate learning outcomes of each participants. Procedures for ensuring rigor included peer review of the analysis by a second researcher with discussion until consensus was reached and maintaining an audit trail of all analysis decisions.

Follow-Up Telephone Interviews

Telephone interviews were audio-recorded and then analyzed by the researcher who conducted the interviews. After listening to the tapes, data were summarized in notes using key words. Key words were grouped inductively into themes that related to the interview questions.

Results

Quantitative Findings

As depicted in Table 1, overall responses for each individual survey question indicated statistically significant (on a two-tailed test) improvement on ratings of self-efficacy for 12 of the 18 questions, each with 16 degrees of freedom.

Table 1.

Pretest–Posttest Survey Analysis by Question.

	Pre		Post
Survey questions	M	SD	M	SD
1. Discussing general issues related to dying and death.*	5.41	1.18	5.94	0.77
2. Discussing the potential course of end-of-life care with the resident.*	4.88	1.58	5.53	1.38
3. Discussing the potential course of end-of-life care with the resident’s family.*	4.24	1.25	5.06	1.48
4. Having a discussion with the resident regarding his or her concerns about dying and death.	5.24	1.20	5.65	1.27
5. Having a discussion with the family regarding their concerns about the resident’s dying and death.	5.06	1.14	5.41	1.12
6. Guiding the family to show them how they can participate in supporting the dying resident.*	4.82	1.19	5.59	1.23
7. Responding to the resident’s question: “How long have I got to live?”*	4.47	1.18	5.24	1.56
8. Responding to the resident’s question: “Will there be much suffering or pain?”*	4.18	1.33	5.65	1.17
9. Responding to the resident’s question: “Am I dying?”*	4.18	1.13	5.41	1.37
10. Providing support to a resident who is visibly upset and/or crying.	6.18	0.95	6.35	0.70
11. Providing emotional support to the resident at the end of life.	6.24	0.90	6.47	0.71
12. Providing emotional support to the family of the resident at the end of life.	5.82	1.33	6.00	1.00
13. Providing emotional support to the family after the resident’s death.	5.82	1.33	5.88	1.11
14. Describing the resident’s physical condition.*	5.00	1.06	5.88	0.99
15. Describing the resident’s emotional state.*	5.00	1.17	6.06	1.03
16. Describing the resident’s spiritual concerns.*	4.65	1.06	5.53	1.13
17. Describing the common indications that a resident is having pain.*	5.29	0.92	6.18	0.88
18. Describing common symptoms of a resident at the end of life.*	5.35	1.06	6.12	0.99

Statistically significant (when p ≤ .05).

Subscales

The Cronbach’s alpha values for the communication subscales (8 items) were .88 (pre-test) and .95 (post-test), indicating good reliability. The Cronbach’s alpha values for the patient management subscales (9 items) were .61 (pre-test) and .86 (post-test) indicating acceptable to good reliability.

Pre–post results indicated statistically significant change on both of the subscales: communication and patient management. Table 1 shows the average score on the communication subscale pre-test was 4.91 (SD = 0.94), and the overall average score on the communication subscale at post-test was 5.54 (SD = 1.1), t(16) = −.396, p = .001. The standardized effect size, d, was −.10, suggesting a large effect (Cohen, 1992). On the patient management subscale, the average pre-test score was 5.34 (SD = 0.64), and the average post-test score was 6.01 (SD = 0.75), t(16) = −4.17, p = .001. The standardized effect size, d, was −1.01, again suggesting a large effect (Cohen, 1992).

The questions added to the simulation evaluation survey were analyzed separately. Pre–post improvement was evident on all four of the added questions, with statistically significant results for three of the four questions. Item (J) showed no statistically significant improvement.

Based on the survey findings, it can be concluded that participants of the HFS educational initiative had increased self-efficacy in providing end-of-life care after attending the session.

Qualitative Findings

HFS debriefing focus group results

Three overarching themes emerged in relation to the research question: The simulation lab learning experience was effective, learning in the simulation lab was a positive experience, and participants believed that HFS is a valuable educational tool for palliative care training of unregulated providers working in LTC homes. Each theme is elaborated below with verbatim quotes from the participants to illustrate.

The simulation lab learning experience was effective

Overall, participants perceived HFS as an effective teaching tool for improving their confidence and communication skills around death and dying. Effectiveness related to the fidelity or realness of the simulation and the opportunity for mentorship in the lab. The fidelity or “realness” of the experience was enhanced by the use of a volunteer to portray the resident’s family member and his or her ability to communicate and interact with the manikin. For example, one participant commented on the sound of the manikin’s breathing at end of life: “Her breathing at the end that was, that was number one.” The stillness of the manikin’s chest when she took her last breath and how real the end-of-life experience felt were also identified as very realistic.

A key aspect of the HFS educational intervention that the participants appreciated and found beneficial was the opportunity to observe and learn from each other. This opportunity for sharing is not often available on the job due to high resident to provider ratios, which result in time pressures to get their work done. Participants with less experience expressed that, for them, the simulation experience was an opportunity for mentorship, and this was highly beneficial. The benefits of observing in the simulation lab are demonstrated in the following participant’s quote:

I think the best part for me was the fact that I don’t know very much about this. I haven’t had lots of palliative care training . . . . Just seeing all of my co-workers do what they know how to do, and just seeing the experience shown, because I’ve never seen that before. So, you guys really actually helped me a lot today.

Learning in the simulation lab was a positive experience

Participants described the simulation experience as affirming of the work that they do on a daily basis. They stated that the experience helped them to recognize the meaning and impact of their work. It was affirming to know that other providers were performing their roles similarly, were there for each other, and all doing their best. Because participants were employed in the same LTC homes and already knew one another, the opportunity for team building to occur during the simulation experience was enhanced. The importance of being validated by their peer group is illustrated in the following quote:

Because we work in this field, we understand, but when you hear from the other people, you know, it makes you feel better and you know you’re doing right thing, but then you know your co-workers that they’re there for you, and they’re doing the best they can.

HFS is a valuable educational tool for palliative care training of unregulated providers working in long-term care homes

Participants expressed that this type of simulation experience would be beneficial for palliative care training, both as a form of continuing education for unregulated care providers and especially for students undergoing their initial training. In addition, participants expressed that the simulation experience would enable students to receive an experiential type of training that may provide insights into their own values and beliefs about death and dying and their fears associated with caring for someone who is dying. Although not being viewed as a replacement for having a “real” death experience, participants believed that being involved in such training would better prepare unregulated providers for the realities of working in a LTC home where death and dying are frequent realities. In addition, the structure and layout of the scenarios were viewed as being able to provide an experience of the whole dying process, with the opportunity for learning new techniques and communication strategies throughout. This comment demonstrates a participant’s thinking of the impact of the experiential learning experience:

The course [a didactic college course for unregulated care providers] doesn’t do any justice to what actually, how it is, and I think that this really actually opened my eyes . . .

Follow-Up Telephone Interviews

In the 16 follow-up telephone interviews conducted, all participants indicated they benefited by participating in the simulation through increased awareness, confidence, or comfort. They illustrated how the simulation affected their work in a variety of ways. Some stated they had become more understanding, compassionate, and sensitive as a result of the simulation. Some specifically mentioned that their listening and communication skills had improved, and they gained new ideas of what to say and not to say during end-of-life conversations. Others felt more confident because their previous skills had been affirmed. As a result of being more comfortable talking about issues related to death and dying, several participants stated they no longer avoided these discussions with residents and their family members. End-of-life conversations were happening more frequently at work and on a deeper level. Some participants also learned that it is acceptable to show their emotions and attachment to residents and families.

Discussion

Using HFS for palliative care education is an innovative concept still in its infancy, and consequently, very little evaluation has been done. Despite this, the conclusions of this research that support the benefits of simulation education are strengthened by the fact that many findings of this study are consistent with existing literature. For example, Kameg, Howard, Clochesy, Mitchell, and Suresky (2010) examined the effects of HFS on nursing students’ self-efficacy related to communication skills. As was the case in this study, Kameg et al. (2010) found that the simulation experience improved students’ self-efficacy related to communication skills to a statistically significant level. Students in Kameg et al.’s (2010) study reported general satisfaction with the simulation experience, stating that simulation was a valuable learning experience that should be incorporated into the curriculum. Similarly, participants in this study expressed that HFS was a valuable educational tool that could help address the insufficient learning about palliative care currently offered during their initial course training. Students in Kameg et al.’s (2010) study expressed that although they believed that the knowledge gained from the simulation experience could be transferred to the clinical setting, they did not believe that simulation should replace clinical practice experiences. Participants in this study also expressed that although the simulation was useful, death is something that needs to be experienced in real life, not exclusively taught in a lab or classroom. Participants did believe, however, that simulation sessions focused on palliative care would be a good introduction for someone training for frontline work in LTC that has never experienced death. Results of this study are also consistent with literature focused specifically on the use of HFS for teaching palliative or end-of-life care. Studies with nursing students emphasized the importance of fidelity, including using actors to portray the patient’s family members, and identified the importance of debriefing and need to have support resources available (Leighton & Dubas, 2009; Smith-Stoner, 2009; Sperlazza & Cangelosi, 2009). The importance of all of these factors similarly emerged throughout the development, implementation, and evaluation of this study.

There were several limitations of this study. The sample size of this study was small and limited to two LTC homes due to the complexity of the intervention and requirement for access to simulation lab resources. A larger sample in the pre–post survey would have provided stronger results. The self-efficacy survey instrument created for this research has not been psychometrically evaluated. Finally, the evaluation design did not allow for measuring change in individual participant’s communication skills pre– and post simulation lab experience. It is also important to note that this study could also be conducted using lower fidelity simulators, and other LTC centers should not be discouraged from trying this kind of education because of the expense of a HFS.

Conclusion

The goal of this research was to explore the potential and feasibility of this innovative educational intervention. Our study indicated that HFS can successfully be used for improving confidence and skills in communicating about palliative care and death and dying for unregulated care providers working in LTC homes. It requires tailoring the simulation case study specifically to the learning needs and work of the unregulated provider and offering the education in a supportive and facilitated environment where providers can observe and learn from one another. Our research findings extend what we know about the effectiveness of using HFS for palliative care education of health care professionals by demonstrating that it can be used for improving communication skills of unregulated care providers. Lack of skills and lack of confidence having conversations about death and dying have been identified as significant barriers to improving palliative care in LTC. Future research should focus on evaluating this educational strategy in an increasingly rigorous manner to measure its effectiveness and determine whether learning objectives have, in fact, been achieved using this approach. The findings of this study have proven valuable to understanding and evaluating the benefits of utilizing HFS as a teaching tool and can be used to help guide future palliative care education for unregulated care providers in LTC. Based on the findings of this study, it can be concluded that HFS has the potential to be an effective pedagogical strategy for improving unregulated care providers’ confidence and communication around death and dying in LTC homes.

Footnotes

Appendix A

Appendix B

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Canadian Social Sciences and Humanities Research Council (SSHRC) through the Community University Research Alliance program and the Canadian Institutes of Health Research (CIHR FRN:112484).

Author Biographies

Katherine Kortes-Miller, MSW, PhD is a research fellow with Technology Evaluation in the Elderly Network (TVN) and a research affiliate with the Centre for Education and Research on Aging and Health (CERAH, Lakehead University). Her research interests include enhancing palliative and end-of-life care education, interprofessional education, high-fidelity simulation, and mentorship.

Kristen Jones-Bonofiglio, BScN, RN, MPH (N), PhD (candidate), is faculty at Lakehead University, School of Nursing, and a research affiliate with the CERAH in Thunder Bay, Ontario. She is a nurse researcher with broad interests in ethics, elder abuse, interprofessional education, mental health, palliative care, simulation, and quality and safety outcomes.

Stephanie Hendrickson, HBSW, MSW, RSW, is the lead palliative care education planner at the CERAH, Lakehead University. Prior to this role, she was a research assistant on two large projects: Quality Palliative Care in Long-Term Care and Improving End-of-Life Care in First Nations Communities, principal investigator, Dr. Mary Lou Kelley.

Mary Lou Kelley, MSW, PhD, is a professor in the School of Social Work, Lakehead University, Thunder Bay, Ontario, Canada. Her community-based participatory action research aims to improve access and quality of palliative care for people living in rural and First Nations communities, and nursing homes. Her capacity development approach includes developing interdisciplinary education and resources for health care providers.

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