Conversations Had at Trying Times (CHATT): Development & Testing of an Advance Care Planning Simulation

Purpose/Introduction: The process of advance care planning (ACP) aims to ensure the articulation and documentation of a patient’s health care goals. ACP works toward aligning patient’s wishes and preferences with health treatment options. All patients benefit from early conversations in ACP, but particularly those with serious illness. These conversations lead to earlier utilization of palliative and hospice services, improved quality of life, decreased use of unwanted medical interventions and hospitalizations, and reduced stress, anxiety and depression among family members. ACP conversations between patients, families, and healthcare providers allow the opportunity to clarify individual goals of care and symptom management preferences, identify decision-makers, complete advance directives, and manage changes along the disease trajectory. Although these patient-centered conversations should occur early and longitudinally in the context of an existing patient-provider relationship ACP conversations are often not done or not done iteratively. Many clinicians struggle with having ACP conversations due to a lack of training, time, and comfort, which can result in low self-efficacy.

Simulation in Communication and Nursing

Standardized simulation provides structure for practical skill development for learners and observers. It also addresses competencies, improvements in care quality and patient safety, and promotes readiness for clinical practice. The literature on ACP, simulation, and RNs is sparse. Many studies that do exist focus on the actively dying patient but not on the ACP communication.

Aim

This study intends to examine the development and feasibility of an ACP simulation, Conversations Had At Trying Time (CHATT), exploring changes in knowledge, attitudes, and self-efficacy.

Theoretical Framework

Using the National League of Nursing (NLN) Jeffries Simulation Theory (2015) and Albert Bandura’s Self-Efficacy Theory (1977), a theoretical framework was designed. This framework depicts increased self-efficacy of nurses through a simulation of ACP communication. Designing the simulation, which is Stage one of the study, consists of establishing goals and specific expectations, and creating specific learning objectives through the Background and Design. Stage two consists of administering the simulation to a population. The simulation experience is characterized by an environment that is collaborative, interactive, experiential, and learner-centered, which promotes trust between the facilitator and participant. Within the simulation experience, a dynamic interaction occurs between facilitator and participant. The facilitator responds to the emerging participant’s needs by adjusting education strategies. The participants’ attributes may also affect the experience based on age, gender, level of anxiety, and self-confidence, as well as modifiable elements such as preparedness for the simulation. Outcomes are separated into three areas: participant, patient (or care recipient), and systems outcomes. The focus of this study is on participant outcomes including, reaction and learning. Specifically, this study will look at knowledge, attitudes and self-efficacy outcomes. Using Bandura’s theory, after a nurse participates in the ACP simulation, the nurse will become more comfortable with ACP communication, resulting in a decrease in defensive behaviors, thereby increasing self-efficacy.

Method

Design: The study is a two-phase study: (1) simulation development and (2) simulation testing. Construct and content validity will guide the development of a simulation using DeVellis’s (2017) scale development guidelines and the INACSL Standards of Best Practice: SimulationSM Design. The seven steps in simulation development include performing a needs assessment, determining clearly what to measure, generating a scenario for simulation, determining a simulation format, iterative review by experts, establishing inclusion of scenario items, and administering the simulation to a sample of subjects. Simulation testing will consist of a one-group pre/post-test design.

Sample: Enrollment will include approximately 40-50 registered nurses who work in a health system.

Analysis: Instruments to measure outcomes include the Caring Efficacy Scale(CES) and the Knowledge, Attitudes, and Practice Behaviors Scale (ACPKAP). The Simulation Design Scale and The Student Satisfaction and Self Confidence in Learning Scale will be used to evaluate the simulation. Statistical analysis of mean change from the pre-to-post simulation will be performed.

Results

A template from the National League of Nursing, curriculum from the Center to Advance Palliative Care, and case studies from the study site’s palliative care team was used to develop the simulation scenario. The simulation has been approved by content experts and is now in phase 2 of simulation testing among RNs. Recruitment and testing of the simulation will occur from Sept-November 2019.

Conclusion & Significance

The study aligns with the Palliative Nursing Summit in transforming the nurse’s role in communication, the NINR’s mission to enhance end-of-life and palliative care, and the Hospice and Palliative Nursing Association position statement that nurses take the leading role in ACP. Nurses must be educated in ACP and trained to facilitate difficult but crucial conversations.