Simulation offers an opportunity for students to develop clinical skills and communication techniques in a setting that is realistic, nonthreatening, and allows students to reflect on their performance. High-fidelity mannequin which may blink, speak, create breath sounds, heart rates and blood pressures complement the patient backstories they accompany. However, it appears that palliative, hospice and end-of-life care are not often offered in undergraduate nursing curriculum in the United States. More so, apart from a few pilot studies, it appears even fewer programs offer pediatric end-of-life simulations. Death is often left to be an end note in traditional nursing lecture courses, if it is mentioned at all. Because of this, nursing students may feel they lack the ability to communicate effectively with those who suffer from life-limiting illnesses. While students may be able to address common symptoms including nausea, pain, and constipation they may be unable to address the patient’s psycho social concerns or goals.1 This report will address a variety of simulation topics including end-of-life care, pediatric end-of-life care, palliative care communications skills, and inter-professional palliative care, while also addressing gaps and recommendations in addressing pediatric palliative care and hospice simulation for undergraduate nursing students specifically.

Gotwals and Scholtz (2016) created one of the only existing pediatric end-of-life care simulations for nursing students. This simulation depended up students reviewing materials related to epidemiology, bone marrow transplantation, family responses, leukemia, and lymphoma prior to the simulation. Upon beginning, students were encouraged to discuss pediatric experiences, end of life experiences, pediatric cancer and pediatric end-of-life. The students then viewed a film that captured the “bio-psycho-social-spiritual aspects of healthcare.” This was done to provide a more immersive experience where students would be able to better understand and connect with the children receiving end-of-life care. The group then discussed and reflected on the film. Students were also encouraged to discuss, “family composition and socioeconomic status, aspects of growth and therapeutic communication and nontherapeutic communication, priority nursing diagnoses, interdisciplinary team coping/support, and unresolved issues after death leading to altered grieving processes.” Evaluations following this simulation indicated students were able to recognize stress and other emotions associated with end-of-life care and felt better prepared to provide EOL care.

Another simulation designed by Judith Lindsay (2010) was designed for baccalaureate level nursing students and included a mannequin SimBaby, nursing students, and student actors who portrayed physicians, respiratory therapists in addition to a chaplain. This scenario sought to portray an unexpected pediatric code and death. Prior to the simulation, students reviewed the responsibilities of the nurse in a code situation, including starting intravenous (IV) lines, cardiopulmonary resuscitation (CPR), medication administration and documentation. Students also reviewed the protocol for pediatric deaths and were reminded how important it is for families to understand how their child will appear after death and that they may wish to clean or hold their child’s body. An IV line was in placed prior to cut down on time. Throughout the scenario a cardiac monitor depicting heart rhythm changes was used. Students approached the room and were given the background that Billy, the SimBaby, had a seizure, stopped breathing, and was brought in by EMS to the ER where CPR began and was continuing. The student learners observed the parents speaking with the chaplain and physician as resuscitation efforts took place to discuss discontinuing resuscitation efforts. The cardiac monitor displayed asystole and the physician listened with a stethoscope to call the time of death. The student nurses then assisted in cleaning Billy and handing him to his parents and consoled them. Throughout the debrief for this scenario students discussed the support needed by the family, how nurses cope with unexpected loss, and what support is appropriate to provide the family.

Symptom management, communication, and family-centered care are integral to nursing care in end-of-life experiences, and this idea was used to create another simulation for nursing students. In this simulation, a mother asks for an update on their child who has had a sudden hypoxic-ischemic brain injury. She does not understand what has happened or why the child “…has all these tubes.” Students must then attempt to use therapeutic communication to comfort the mother and explore thoughts about resuscitation efforts. Simultaneously, the nurse must provide pharmacologic pain management. A de-briefing session then is held to allow students to express their difficulties in communicating with the mother. Many students expressed feeling saddened, uncomfortable, and afraid to say the wrong thing. This allowed the students to discuss how to tend to the child, realistically supporting the family, carefully choosing words and how to confront intense emotions.

While this next simulation does not involve a pediatric patient, the structure and background of the scenario may be incorporated into an older child’s script. Hjelmfors, Stromberg, Karlsson, Olsson, and Jaarsma (2016) developed this scenario for nursing students. The simulation included three scenarios, thee first of which is not too applicable to the pediatric population, which is why it is being left out. The second scenario involved a patient dying of cancer, who felt alone and tired. She had no appetite and felt worried about an upcoming family member’s birthday, as she would not have enough energy to participate. She continued to speak on her concerns for her family and asked what her final hours would be like. In the third scenario, the patient had died a few minutes prior. Her mother was outside the door and was asking what would happen to her body, who would tell the other family members of the death and who would call the time of death. Following the simulation, a tutor reviewed the student’s responses and suggested how they might respond differently.

The final simulation I’d like to discuss titled Dying with Grace, which was developed as a continuing education program for a local hospice team. The team was introduced to a high-fidelity mannequin, Grace, and then promoted to complete assessments, ask questions related to her care, address the patient’s pain, and explore the patient and family’s expectations about death and dying. This is a rare example of day-to-day care at an inpatient hospice.

Each of these simulations brings a unique perspective to how students may experience end-of-life care in a safe environment. However, to create a simulation that most benefits our undergraduate nursing students it may be useful to take the best aspects of each. The first scenario’s use of cinemeducation, or learning through the use of film, creates a more immersive situation allows students to more deeply understand the difficult lives of children undergoing life-threatening illness. This topic is after all more emotionally involved than other scenarios, so pre-screening a video clip prior to entering the simulation room may prove beneficial. The second scenario does well in demonstrating the role of the interdisciplinary team in caring for the child. Perhaps this could be in cooperated by having several actors including parents, a physician and/or chaplain with whom the students may interact with. The third scenario provided a rare opportunity for students to safely discuss the impending death of a child without causing any actual harm to a patient’s family members. Lectures reinforcing therapeutic communication techniques are valuable, but simply cannot compare to the opportunity to put those techniques into practice. The fourth scenario captures the emotional needs of patients and their loved ones. It also forces students to face difficult questions such as, “what will my final hours be like?” For our purposes it may be best to incorporate such questions into a scenario with an older child. Finally, the fourth scenario provides students with an opportunity to experience inpatient hospice care, as it is not included in the undergraduate curriculum.

One of the main limitations with these previous studies, in relation to our topic of concurrent care, is that often the scenario relies on a more immediate injury or crisis the child experiences, rather than a slower disease progression. Code simulations are already included in our undergraduate simulation curriculum for adult patients. It seems that hospice care is not addressed at all. This means that the skills needed for alleviating the disease progression in a child who is still receiving curative treatment is not well understood by nursing students, even in theory. By drawing on these examples we can create a simulation which compliments our work. Thus further explaining what we do and how to provide high quality care to children and their families.