Presentation on using High Fidelity mannikin based simulation for curricula addressing death and dying in the health sciences. Presented at HPSN 2009 3/2009 in Tampa FL.

1. To Die or Not to Die?
That is the Question!
Eric Bauman, PhD, RN, Paramedic
Kim Leighton, PhD, RN, CNE

2. “. . . nurses are privileged to
have the unique and special
opportunity to be present at the
most remembered events
during one’s life—both birth and
death.
How you handle these
situations will always be
remembered.”
(Walsh & Hogan, 2003, p. 890)

3. Disclosure
 Eric is an education consultant for
the Town of Madison Fire
Department, Vernon Memorial
Healthcare, and a Pfizer stockholder
 Kim is adjunct faculty for METI,
receiving honorarium for training
and consultation

4. Objectives
 Examine perceptions of simulated
death experiences
 Explore faculty concerns related to
teaching students about death and
dying
 Identify the benefits of integrating
simulated patient death experiences
into clinical curricula

5. What is the Problem?
 Should the simulator die?
 Very controversial
 Beneficial or harmful?
 What should be considered when
deciding whether to allow the
simulator to die?

6. What Are YOUR Thoughts?

7. What Others Have Said. . .
 Won’t see correct outcome of SCE
 Takes too long to restart simulator
 Don’t have enough time to re-run
SCE
 Might affect students’ feelings about
learning with simulation
 Won’t like coming to simulation lab

8. Additional Concerns
 Feel like they killed the simulator
 Might think they didn’t provide
correct care
 Educator not comfortable talking
about death
 Might hurt students psychologically,
bring out buried feelings

9. Simulated Death
Experiences
 Expected
 End-of-Life
 Unexpected
 Acute Respiratory Distress Syndrome
(ARDS), Herniation Syndrome
 Result of Action or Inaction
 Blood Transfusion, ACS, Medication
Error, Failure to act - provide treatment

10. We Need TWO Volunteers!

11. What Does the Research Say About Student
Nurses and Patient Death?
 Anxiety stems from feelings of personal
inadequacy and limited clinical experience
caring for dying patients (Beck, 1997; Van Rooyen, Laing, &
Kotzk, 2005)
 Preconceived ideas/not prepared for reality, self-
doubt leading to fear and anxiety, feel could
have done more/did something wrong leading
to guilt (Van Rooyen, Laing, & Kotzk, 2005)
 Anxiety R/T shock over physical deterioration,
feeling inadequate, not knowing how to
communicate, making mistakes; Sudden death
more distressing than expected (Cooper & Barnett, 2005)

12. What Do Practicing Nurses Say
About Their EOL Education?
 75% of Australian nurses received
neither adequate nor appropriate training
to enable them to deal with death and
dying (Mooney, 2002)
 Survey 352 nurses, 66% rated
knowledge of EOL care fair or poor (Meraviglia,
McGuire, & Chesley, 2003)
 Survey 2300 oncology and generalist
nurses, 62% rated EOL education as
inadequate (Ferrell, Virani, Grant, Coyne, & Uman, 2000)

13. Medical Education Literature
In a study of Internal Medicine Residents(8)
 49.3% felt inadequately trained to lead a
cardiac arrest
 50.3% felt that standard ACLS training did not
provide necessary team leadership skills related
to resuscitation
 40% indicated they received no additional
training related to resuscitation beyond a
standard ACLS course
 52.15 felt prepared to lead a cardiac
resuscitation - 55.3 worried they made errors
 Residents felt unsupervised - No backup
 Post event debriefing/feedback was lacking
(Hayes, Rhee, Detsky, LeBlanc, & Wax, 2007)

14. How Do We Prepare Them?
 2% of nursing textbook content related to EOL
care (Ferrell, Virani, & Grant, 1999)
 Review of 50 top medical, surgical, psychiatry
texts for 13 EOL content areas found helpful
EOL info in < 25%, minimal coverage in 20%,
and no content in over 50% (Rabow, McPhee, Fair, & Hardie,
1999)
 In the UK, average 12.2 hours of EOL education
in degree programs and 7.8 in diploma
programs (Lloyd-Williams & Field, 2002)
 Clinical experiences
 Medical Students lack educational experience
related to delivering death notification and legal
aspects of death investigation

15. How Do YOU Think
Simulation Can Help?

16. How Can Simulation Help?
 Experience death in a safe environment
 Pattern recognition for expected or
adverse outcomes
 See consequences of actions or inactions
 Improve communication skills
 Increase comfort in caring for patient at
EOL
 Do everything right; sometimes patients
still die “Bad Pathology is Bad Pathology”
 Opportunity to talk about current or
suppressed feelings
(Squire, 2006; Gee 2003)

17. Psychological Safety
 Debriefing is vital: support, reassurance,
guidance, knowledge (Allchin, 2006; Walsh & Hogan, 2003;
Thiagarajan, 1992)
 Qualitative study found personal
reflections of loss, death, dying, and grief
helped students deal with patient death
and helped them deal with their own
losses (Allchin, 2006)
 Chaplain/Religious practitioner
 Psychiatric nurse practitioner
 Backup for the instructor
 Counseling opportunities

18. Psychological Safety:Take Home Message
Have a psychological safety
plan in place prior to
death and dying training

19. More Volunteers Please!!

20. NOW What Do You Think?
 Should the simulator die?
 What are the benefits?
 How do we prevent potential harm?
 What will YOU do?

21. Responses to End-of-Life
Simulated Clinical Experience
 “I learned valuable ways of caring for dying patients.”
 “Students need more exposure to these situations.”
 “Made me realize I need more time to practice providing
cares to the dying and their families.”
 “More realistic than just talking about it (and role playing).”
 “Demonstrated a real life-like event and the emotions and
feelings that one might experience.”
 “We need to know if we can handle patients dying before our
first day taking call”
 “Gaining experience with death and dying earlier in medical
school might have influenced my choices related to residency
training”

22. Questions?
Dr. Eric Bauman, Faculty Associate
Department of Anesthesiology
University of Wisconsin School of Medicine and Public Health
Madison, WI
ebauman@wisc.edu
608-263-5911
Dr. Kim Leighton, Dean of Educational Technology
BryanLGH College of Health Sciences
Lincoln, NE
kim.leighton@bryanlgh.org
402-481-8713

23. REFERENCES
Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of
Hospice and Palliative Nursing, 8(2), 112-117.
Beck, C. T. (1997). Nursing students’ experiences caring for dying patients. Journal
of Nursing Education, 36(9), 408-415.
Cooper, J., & Barnett, M. (2005). Aspects of caring for dying patients which cause
anxiety to first year student nurses. International Journal of Palliative
Nursing, 11(8), 423-430.
Ferrell, B., Virani, R., & Grant, M. (1999). Analysis of end-of-life content in nursing
textbooks. Oncology Nursing Forum, 26(5), 869-876.
Ferrell, B., Virani, R., Grant, M., Coyne, P., & Uman, G. (2000). Beyond the
supreme court decision: Nursing perspectives on end-of-life care. Oncology
Nursing Forum, 27(3), 445-455.
Gee, J. P. (2003). What video games have to teach us about learning literacy. New
York: Palgrave MacMillian.
Hayes, H.W., Rhee, A., Detsky, E., LeBlanc, V.R., and Wax, R.S. (2007). Residents
feel unprepared and unsupervised as leaders of cardiac arrest teams in
teaching hospitals: A survey of internal medicine residents. Critical Care
Medicine 35(7), 1668-1672.
Lloyd-Williams, M., & Field, D. (2002). Are undergraduate nurses taught palliative
care during their training? Nursing Education Today, 22(7), 589-592.

24. REFERENCES (cont)
Meraviglia, M. G., McGuire, C., & Chesley, D. A. (2003). Nurses’ needs for
education on cancer and end-of-life care. Journal of Continuing Education in
Nursing, 34(3), 122-127.
Mooney, D. C. (2002). Nurses and post-mortem care: A study of stress and the
ways of coping [doctoral dissertation]. Griffith University, Southport,
Queensland, AU.
Rabow, M. W., McPhee, S. J., Fair, J. M., & Hardie, G. E. (1999). A failing grade for
end-of-life content in textbooks: What is to be done. Journal of Palliative
Medicine, 2(2), 153-156.
Squire, K. (2006). From content to context: Videogames as designed experience.
Educational Researcher. 35(8), 19-29.
Thiagarajan, S. (1992). Using games for debriefing. Simulation and Gaming, 23(2),
161-173.
Van Rooyen, D., Laing, R., & Kotzk, W. J. (2005). Accompaniment needs of nursing
students related to the dying patient. Curationis, 28(4), 31-39.
Walsh, S., & Hogan, N. (2003). Oncology nursing education: Nursing students’
commitment of ‘presence’ with the dying patient and the family. Nursing
Education Perspectives, 2A, 866-890.