Simulation sessions improve the comfort level of nurses in initiating and maintaining palliative sedation for clients who are at home at end of life
The Edmonton Zone of Alberta Health Services (AHS) covers a large geographic area of 11,800 km2 and has 1.3 million residents (Alberta Health Services, 2015). Palliative and end-of-life care is provided in private residences, long-term care and supportive living sites, hospice and acute care. Clients living at home at the end of life are supported by the Edmonton Zone home care program.
Palliative sedation in the home is an infrequent occurrence. However, although the circumstances surrounding it are somewhat difficult to predict, an order for palliative sedation requires swift and confident coordination. This includes confirming and clarifying the orders, calling the pharmacy to confirm delivery of the medication, obtaining the infusion pump, gathering supplies, faxing documents to the call centre for independent double check and confirming that the patient and family are ready for the sedation.
With a large staff complement spread over an extensive geographic area, home care nursing staff, educators and managers were finding it challenging to establish or sustain the complex, specialized skills required: communicating with prescribers, starting the infusion, assessing the level of sedation, providing caregiver support, troubleshooting and documenting. Some of the registered nurses and other health-care practitioners involved in providing palliative sedation reported finding the process anxiety producing. They were requesting support through more information and training.
Providing simulation to practise skills used during highly stressful health-care situations is more common than ever as a way to connect theoretical learning with practical application. The benefits of using simulation to improve skill sets in end-of-life care are widely supported (Kopp & Hanson, 2012; Leighton & Dubas, 2009).
The clinical nurse specialist (CNS) for palliative home care contacted the AHS eSIM program to discuss the opportunity to collaborate. This program provides oversight and assistance with simulation events to any patient care service requesting its help. It was determined that simulation would be an ideal way to focus on palliative sedation skills.
The CNS attended an eSIM workshop intended to introduce educators to simulation techniques and prepare them to design and run sessions and facilitate debriefs. Next, she collaborated with clinical nurse educators (CNEs) in home care to develop an implementation strategy and a realistic scenario. She obtained support from managers to allow nursing staff to participate in one-hour simulation sessions.
The simulation consultant responsible for the home care program helped with scenario development. She also booked an actor to play the part of a client, mentored the home care simulation leaders, played the part of the client’s daughter and offered advice when needed. Having an actor present would provide staff with the opportunity to identify and practise the appropriate communication skills with the client and family member.
In preparation for the simulation sessions, the CNS and the CNEs conducted an hour-long general overview of palliative sedation for nursing staff at all 10 home care offices in the Edmonton Zone. Guidelines for practice, relevant policy and procedures, and tips and troubleshooting techniques were reviewed.
To create as realistic an environment as possible , private homes, a lab in the central eSIM simulation centre (furnished to look somewhat home like) and, as a last resort, conference rooms were used for the simulation sessions.
The CNS facilitated the first few sessions, receiving feedback from the simulation consultant on her technique of pre-briefing and debriefing the staff. It is important participants understand that these are non-evaluative learning and practice sessions meant to increase their confidence and that facilitators are not part of the scenario. The CNEs observed the first sessions to prepare them for facilitating independently, with feedback from the consultant and the CNS.
At the start of the session, participants were given the following scenario: the client is an elderly woman in the late stages of lung cancer who is experiencing refractory pain and delirium. She has discussed her goals of care with family, including the desire for palliative sedation if her symptoms became unbearable. Her family physician has visited and provided the orders. The nurse on the previous shift has obtained the equipment required and started a new subcutaneous site.
Participants were reminded to focus on supporting the client and the family member while preparing and initiating the infusion and titrating to the desired effect. In addition to observing the participants in action, CNEs facilitate the debrief immediately following the session to review the experience, address specific issues and elicit suggestions for improving practice.
Between October 2015 and June 2016, we conducted 60 simulation sessions for 117 staff from home care offices across the zone. Although this was a huge undertaking in terms of coordination, the CNS and CNEs believed that all the nursing staff should have an opportunity to participate in this training.
The sessions were well received by the attendees, nearly all of whom were registered nurses, licensed practical nurses or nurse practitioners. Many wanted to see similar sessions offered yearly and asked that the various resources needed when palliative sedation is ordered (i.e., guidelines and procedures for palliative sedation, home care documentation guidelines, equipment and medical supplies) be more accessible and centralized. We received good feedback about having an actor play the part of the client, and the general comments from participants were positive, especially about the benefit of practising the skills in a safe environment.
Before and after their session, nursing participants were asked to provide a ranking ( from 0 to 10) of how comfortable they would be in initiating palliative sedation in a client’s home; 106 provided these rankings. The CNS performed a paired t-test of the pre (mean 2.73) and post (mean 6.74) event scores, using Stata 14. Overall, there was a significant improvement ( mean difference 4.00, 95% CI 3.58-4.44) in the nurses’ comfort level, indicating they found their session helpful.
Refinements were made as the sessions proceeded to ensure the scenario flowed as close as possible to a real-life situation. For example, to challenge more confident participants, we instructed the client’s daughter to ask specific questions about the medication and asked the client to portray more severe delirium symptoms. Participants with little experience in palliative sedation were reminded to continue to support the daughter after her mother had died by explaining what to do next. As well, greater emphasis on documentation was added to the debrief.
Overall, palliative sedation simulation has been an excellent learning experience for all involved. The simulation sessions will continue as part of the annual education for nursing staff in home care. All sessions are now facilitated by CNEs and are conducted in a lab in the eSIM centre — a setting that allows them to observe participants from outside the lab. New scenarios are being developed to challenge and engage staff who have attended previous sessions. Registration of participants has been switched to the electronic method used for annual education activities. Participation at each session is limited to two nurses to ensure they have opportunities to practise both psychomotor and communication skills.
Alberta Health Services. Alberta Health Services annual report 2014-15. Edmonton, Alberta: AHS.
Kopp, W., & Hanson, M. A. (2012). High-fidelity and gaming simulations enhance nursing education in end-of-life care. Clinical Simulation in Nursing, 8(3). doi:10.1016/j.ecns.2010.07.005
Leighton, K., & Dubas, J. (2009). Simulated death: An innovative approach to teaching end-of-life care. Clinical Simulation in Nursing, 5(6). doi:10.1016/j.ecns.2009.04.093