Impact of an Advance Care Planning Simulation on the Communication Skills of Nurse Practitioner Students

Effective communication is the cornerstone of a therapeutic patient-clinician relationship, especially when dealing with serious, life threatening illness. Although difficult at times, advance care planning (ACP) conversations surrounding care wishes and options are foundational in the provision of quality palliative care. While the literature highlights the benefit of ACP discussions for patients and families (Heylan, Barwick, Pichora, Dodek, Lamontage, You…Simon, 2013; Houben, Spruit, Groenen, Wouters, & Janssen, 2014), providers often avoid these conversations. This avoidance, in return, contributes to the low rate of advance directive completion within the United States (Rao, Anderson, Lin, & Laux, 2014). Clinicians cite a variety of reasons to explain their lack of engagement in the ACP process, including inadequate communication skills training (Keating, Landrum, Rogers, Baum, Virnig, Huskamp, Earle, & Kahn, 2010). The recent report from the Institute of Medicine (IOM, 2014) titled, “Dying in America: Improving Quality and Honoring Individual Preferences near the End of Life” acknowledges the importance of effective communication for quality care and the need for all clinicians to possess the skills necessary to engage in difficult conversations with patients and families. To this end, attainment of quality communication skills has been identified as a core competency for the Advanced Practice Registered Nurse (APRN) in palliative care (Grant, 2013). Care decisions based upon a patient and family’s wishes, goals and values needs to occur over time, guided by clinicians equipped to engage in these complex conversations. Since APRNs provide care throughout the continuum of illness, they are often the most appropriate team member to conduct these critical ACP and goals of care discussions (You et al., 2015).

Simulation has a long-standing history as an effective pedagogy for procedural and technical skills training in healthcare education (Jeffries, 2012). More recently, simulation utilizing a standardized patient model has been employed for communication skills training in medical and nursing education. Current literature surrounding the use of simulation for teaching communication skills in palliative care has involved physicians and nurses, medical resident or fellows, with a few studies focused in the APRN student population. These graduate nursing studies are mostly descriptive in nature, with limitations to their generalizability due to small sample sizes or variations in the evaluation methodologies (Bays, Engelberg, Back, Ford, Downey, Shannon…Curtis, 2014; Rosenzweig, Hravnak, Magdic, Beach, Clifton & Arnold, 2008; Rutherford-Hemming & Jennrich, 2013; Shawler, 2011). In 2013, Curtis and colleagues published the first randomized controlled clinical trial evaluating the impact of simulation on the quality of nurse practitioner student communication with patients who had life threatening illness.  The results were quite disappointing, with no improvement in communication quality or patient/family quality of life scores. These outcomes further support the prioritization of simulation research in nursing education by the National League of Nursing (NLN). The following pilot study sought to address this NLN directive and fill the current gap in the nursing literature surrounding simulation and its effectiveness for communication skills training in the palliative care nurse practitioner student population. 

A prospective, quantitative study using a one-group pretest-posttest design was implemented using a convenience sample (N=19) of students enrolled in the palliative care nurse practitioner track at a metropolitan college of nursing. The participants were assigned to groups of three or four with a designated faculty member. They engaged in a standardized patient simulation based on an ACP discussion with a newly diagnosed cancer patient. Once all of the group members completed the exercise, the participants received feedback based on the SPIKES protocol (Baile, Buckman, Lenzi, Beale & Kudelka, 2000) from their fellow students, the faculty member and the standardized patient. The participants engaged in the same simulation scenario seven weeks later, using the same format. Both simulations were videotaped, excluding the feedback portion of the exercise. Data collection included a demographics tool, a self-confidence survey based on the work of Clayton and colleagues (2012) which the participants completed prior to the first and after the second simulation and a scored checklist based upon the SPIKES protocol. These checklists were completed by an independent faculty member who viewed the simulation encounter videotapes. The planned statistical analysis will include evaluation of the study's variables (participant communication skills and feelings of self-efficacy) using paired t test measurements.