Background

The aim of palliative care is to improve the quality of life among seriously ill and dying patients and their families. A holistic approach is essential to meet the complex needs of these patients [1, 2]. Recent publications have highlighted the need for a shift from a disease-centred to a more person-centred approach in palliative care [3, 4]. Palliative care should be offered to all patients with a progressive chronic illness [5] and integrated as early as possible into the patients’ treatment trajectory [3, 6]. The number of patients requiring palliative care services due to both chronic illness and old age is expected to increase in the future [7].

Nurses belong to the largest group of healthcare professionals involved in palliative care [8]. They hold a unique position, since they are available for patients around the clock and often serve as coordinators of healthcare services [1]. Hökkä et al. [9] identified six types of competencies that nurses need in palliative care: leadership, communication, collaboration, clinical, ethical-legal, psychosocial and spiritual competence. In addition, studies have reported that nurses want more knowledge and skills in palliative care, especially regarding the palliative care philosophy and symptom management, and how to communicate with families and provide end-of-life (EOL) care [1, 10, 11]. Increased complexity in palliative care may occur when patients have multiple needs, when communication challenges arise or when the primary care staff lacks confidence [12].

Nurses’ ability to make sound clinical judgements through clinical reasoning and critical thinking is important for delivering individually tailored palliative care [13]. In contrast, inadequate nursing skills and capacities could be a potential barrier to palliative care services [14]. In order to meet the complex needs of these patients and to provide them (and their families) with high-quality palliative care, nurses require advanced education and training, but dramatic variations exist in nursing education regarding the prioritization of palliative care across Europe [8]. Further, the field of postgraduate nursing education has an evident shortage of opportunities for clinical placement [15, 16]. A solution to this challenge is necessary.

Simulation-based learning (SBL) is conceptualized in nursing education as ‘a dynamic process involving the creation of a hypothetical opportunity that incorporates an authentic representation of reality, facilitates active student engagement and integrates the complexities of practical and theoretical learning with opportunity for repetition, feedback, evaluation and reflection’, according to Bland et al., p. 668 [17]. SBL may include computer-based programmes, virtual reality, standardized patients, or manikin-based or hybrid simulations for students to learn their professional responsibilities [18, 19]. The integration of SBL can enable nursing students to develop clinical skills and increase their knowledge, critical thinking and confidence [16, 20, 21]. By using SBL based on real-life scenarios in a setting where learners feel confident to practice different skills, students may increase their critical thinking skills and practice patient-centred care and nontechnical skills without the risk of causing further strain or burden on the patients [22, 23]. Nurse practitioner students seem to be more satisfied with SBL than other learning activities [20]. The transition from traditional learning to SBL, however, may be challenging for postgraduate students, who may experience performance anxiety, be unfamiliar with simulation and perceive a lack of facilitator guidance as hinderances to their learning [24].

We conducted an initial search for previous reviews on the use of SBL in palliative care in nursing education in the databases Cinahl and Medline.

Several literature reviews have examined the research on SBL as a teaching method in palliative care. One systematic review evaluated the use of SBL as a learning experience among multidisciplinary clinical teams to learn about palliative and EOL care [25]. Other systematic reviews have examined skills training and the use of SBL to teach nursing students and healthcare professionals’ palliative care and EOL communication [18, 26]. A scoping review mapped the literature on the psychological outcomes reported following the debriefing of healthcare professionals or healthcare students who experienced expected and unexpected patient death during SBL or in clinical practice [27], while a literature review examined SBL in medical education in the training of palliative care skills. This review was not limited to nursing education, however, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) was not searched [23].

Previous literature reviews have also examined the use of SBL in palliative and EOL care simulations within undergraduate nursing education [28, 29]. Kirkpatrick et al. [29] found that in SBL involving sensitive issues that included psychosocial responses, nursing students preferred unfamiliar professional actors to portray the patient rather than high-fidelity manikins. After participating in SBL, nursing students reported several positive outcomes, including increased confidence, self-efficacy and knowledge and improved communication skills, reassurance, and understanding of the complexity and competing priorities of palliative care.

SBL is increasingly applied as a learning activity in nursing education within palliative care, and prior reviews have examined the experiences of undergraduate nursing students, but these experiences may not be transferable to SBL for postgraduate nursing students with more competence and clinical experience in palliative care. Postgraduate nursing students may also have different learning needs from undergraduate students when participating in SBL [24]. Conducting a scoping review appears relevant for summarizing the range of studies and existing findings, in addition to identifying research gaps in the research literature [30]. Our initial search for previous reviews showed that no reviews have mapped the use of SBL in palliative care in postgraduate nursing education. Therefore, the aim of this scoping review was to systematically map published studies on the use of SBL in palliative care within postgraduate nursing education.

Methods

A scoping review was conducted using the five stages of the framework described by Arksey and O’Malley [30]: (1) identifying the research question; (2) identifying the relevant literature; (3) selecting the studies; (4) charting the data; and (5) collating, summarizing and reporting the results. The reporting of our scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [31]. Deviations from the published protocol (https://osf.io/agz6f/) are described in Appendix 1.

Identifying the research question

What is known about postgraduate nursing students’ experiences in the use of SBL in palliative care?

Identifying the relevant literature

The inclusion and exclusion criteria are shown in Table 1.

Table 1 Inclusion and exclusion criteria
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CINAHL, the Education Resources Information Center (ERIC), Ovid MEDLINE, Ovid EMBASE, Allied and Complementary Medicine (AMED) and PsycINFO were searched to identify relevant published studies. These databases were searched from 1 January 2000 to 18 February 2021 and were updated on 21 April 2022. Because technology has improved in this time period and has played a vital role in the further development of SBL, the search was limited by year of publication. The same period has seen a strong focus on how SBL can be used to improve patient safety [22].

The search strategy was built in CINAHL by an experienced research librarian (MAØ) in collaboration with the other authors using CINAHL subject headings and text words. A second experienced research librarian peer reviewed the search strategy using the Peer Review of Electronic Search Strategies (PRESS) checklist [32]. The final CINAHL search strategy was then adapted to the subsequent databases. Detailed search histories are shown in Appendix 2.

The database search was limited to publications in Dutch, French, Portuguese, English, Spanish, Danish, Swedish and Norwegian, since the authors understand these languages and lack funding for the translation of papers. Publication-type filters were used in EMBASE and Medline to exclude letters, conference abstracts and editorials, since we only wanted to include published studies.

A hand search was performed in the reference list of papers. Studies that had cited the studies included in our review were not tracked, since the updated search should have identified these citations.

Selecting the studies

The research librarian (MAØ) exported the search results to EndNote to remove duplicates, then exported the search results to the web application Rayyan QCRI to facilitate storage and blinding and the screening of publications for the study selection process [33].

Six pairs of authors (KS & HMB, AGGN & CO, KH & HVS, DH & DS, MHL & MTS and SAS & CLH) independently assessed whether the titles, abstracts and full-text publications met the inclusion criteria. A third author (KS, AGGN or SAS) conducted an independent assessment when there was any doubt whether a publication should be included, and discussions to reach consensus then took place. Reasons for the exclusion of full-text publications were recorded using the PRISMA 2020 flow diagram.

Charting the data

A standardized data-charting form was developed to be able to capture relevant information on key study characteristics [31]. The content of the charting form was discussed among all the authors, and the following information was included: author, year and country; aim; participants; simulation procedures; scenarios; design; and key results related to experiences of SBL in palliative care. The charting form was piloted by the first and last authors, who extracted data from one of the articles to be included. The same six pairs of authors extracted the data. In each pair, one author extracted the data, while the other verified the data’s accuracy. Any disagreements among the two authors were resolved by an independent assessment by a third author (KS, AGGN or SAS). Agreement was based on discussion and consensus among the three authors.

Collating, summarizing and reporting the data

In a scoping review, the results are not synthesized in the same way as in a systematic review, although some thematic construction or analytic frameworks are still warranted [30]. To answer the research question, the extracted results from the results section of the papers included in the review were thematically summarized and organized. KS read the results several times to gain an overview of the whole data material and then read the results to identify any patterns of differences and similarities across the papers regarding postgraduate nursing students’ experiences of SBL in palliative care. During this process, AAGN and SAS asked critical questions to facilitate alternative interpretations and groupings of the data [34, 35]. We used a low level of interpretation and abstraction. The findings were thoroughly discussed among all the authors, all of whom agreed upon the final thematic groupings. Trustworthiness was enhanced by the diverse research and pedagogical expertise of the authors, several of whom have extensive competence in SBL or palliative care. The discussions among the authors thus facilitated competing interpretations.

Results

The database searches identified 9165 publications, and the titles and abstracts from 5646 publications were screened after removal of 3519 duplicates. The full text of 75 publications were read, and 10 papers from 10 studies were included. Figure 1 shows the study selection process in the PRISMA 2020 flow diagram [36].

Fig. 1
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PRISMA 2020 flow diagram

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Description of the studies

The studies included in the review were conducted in the United States (US; n = 4), Japan (n = 2), the United Kingdom (UK; n = 1), Australia (n = 1), Sweden (n = 1) and Taiwan (n = 1). The sample size of the studies ranged from 12 to 160 participants. In nine papers the sample consisted of under 70 participants, while four studies had 20 participants or less. Papers included nurses with varying backgrounds who participated in different education programmes. The participants were advanced practice registered nurse students [37]; family nurse practitioner students [38]; advanced practice registered nurses [39]; graduate nursing students in critical care [40]; postgraduate students in intensive care [41]; acute nurse practitioner students [42]; and nurses employed in palliative care units / inpatient hospice, palliative care consultation teams, general medical wards or medical centres [43,44,45]. In one paper, participants’ workplaces and specialties were not reported [46].

Two papers used a mixed-methods design [39, 40], three used a pre- and post-test design [38, 42, 44], one used a randomized controlled trial design [43], one was a pilot feasibility study [45], one used a qualitative phenomenographic approach [41], one used a longitudinal survey design [46] and one used an evaluation study design [37].

In three papers the main focus was on communication [42, 44, 45], while two papers focused primarily on communication about advance care planning [38, 46]. Six papers used role playing as the SBL activity [38, 39, 43,44,45,46], while six described simulation training with the use of scenarios [37, 38, 40,41,42, 45]. One study used an online case module first, later combined with a workshop [37]. All the studies described a variety of active participation from the students. The papers described and used different models and tools, including the COMFORT communication model (a holistic, patient-centred communication model consisting of seven tenets [42, 44]), the EXCELL programme (an educational innovation to develop nurses’ intercultural communication skills [40]), the E-FIELD programme (an EOL communication skills training programme [46]), the PREPARED model (a communication guide with eight steps [45]) and the Spiritual Pain Assessment Sheet (a structured assessment sheet to document spiritual pain [43]). The characteristics of the studies included in the review are described in Table 2.

Table 2 Characteristics of the included studies
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Three thematic groupings were identified in the data analysis: (1) enhanced understanding of the importance of teamwork, interdisciplinarity and interpersonal skills; (2) preparedness and confidence in one’s ability to communicate during emotionally challenging situations; and (3) impact and relevance to one’s own clinical practice. Table 3 shows the papers included in the thematic groupings.

Table 3 Papers included in the thematic groupings
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Thematic groupings

Enhanced understanding of the importance of teamwork, interdisciplinarity and interpersonal skills

In two of the studies, the participants highlighted how SBL had enhanced their understanding of the importance of teamwork and interdisciplinarity in palliative care [37, 42]. After participating in SBL, participants also reported that they had a greater understanding of the contributions of other healthcare professionals and the importance of the interdisciplinary team in the care of dying patients [37]. Common themes in several debriefings included reflecting and discussing the importance of interdisciplinary approaches, coordinating family meetings and engaging other disciplines when faced with families in crisis situations [42]. In one study that focused on participation in multicultural groups, the participants felt the training to be useful, and they were more confident and comfortable after participating in the SBL [40].

Preparedness and confidence in one’s ability to communicate during emotionally challenging situations

The participants reported that SBL had improved their ability to communicate during difficult conversations [42, 44, 45]. Participants felt a significant increase in satisfaction and competence in their management of emotional needs at the EOL [44]. The use of SBL improved the participants’ ability to initiate potentially difficult communication topics and to manage the emotional needs of patients and families, and it increased their overall confidence in communicating during difficult situations [42]. Another study noted a significant increase in the participants’ competence in communicating with families in crisis [44]. After participants were involved in a two-day workshop with a focus on care that addressed patients’ feelings of meaninglessness, there was a significant positive effect observed in the participants reported confidence after the intervention [43]. Participants in two different educational programmes with a focus on advance care planning in SBL showed a significant increase in advance care planning communication knowledge and self-confidence in holding these conversations [38, 46].

In one study, the participants had to manage a conflict among family members concerning the goals of care [42]. The participants positively evaluated the COMFORT model as an effective strategy for guiding difficult discussions. The participants experienced a decrease in confidence levels after an SBL session with a focus on a difficult family situation, however. During the debriefing, these students expressed that they felt unprepared for the family’s questions and felt overwhelmed by the family’s emotions, and they struggled with the responsibility of their role [42].

Impact and relevance to one’s own clinical practice

In three of the studies, participants indicated improved communication in their practice as nurses following the use of SBL [39, 44, 45]. For example, participants highlighted that they felt more confident, prepared and aware after the COMFORT training [44] and that they could use the COMFORT model as a guide for communication in their daily practice [42]. In another study, participants reported that they were more patient when communicating with patients after the training, and they tried to explore the real meaning of what the patients were saying [45]. Participants wanted more practical content during SBL, however, with a focus on pain and symptom management [39].

Regarding the application to practice, the participants’ responses consisted of specific changes to future clinical practice. Some participants indicated improved communication and symptom-management skills, while others spoke of programme-development ideas. On a more personal note, participants spoke of personal growth and development [39]. Others reflected on the use of the COMFORT model as a useful guide for effective communication and a reminder of the importance of a team approach. Other participants offered insight to future practice that would incorporate listening more deeply and addressing the grief, guilt and anticipatory loss of families who face difficult EOL decision-making [42]. In one study, participants pointed out that acting as a relative in the scenario gave them new insights from a new perspective into the family members’ experience of vulnerability during the situation [41]. The participants saw reflection after the SBL as useful for their own clinical practice in various ways as they became better acquainted with their weaknesses [45] and experienced courage and strength to meet patients and families in clinical practice [41].

Discussion

The aim of this scoping review was to systematically map published studies on the use of SBL in palliative care in postgraduate nursing education. Our findings indicate that SBL enhanced postgraduate nursing students’ understanding of the importance of teamwork and interdisciplinarity in palliative care. The students also gained an enhanced ability to communicate during difficult conversations after participating in SBL, and they experienced personal growth and development after participation in SBL. In one study, however, the postgraduate students reported decreased confidence in their communication with families [42].

Interprofessional teamwork is essential when delivering high-quality palliative care [47]. The participants in Klarare et al.’s [48] study had long experience of working in palliative care teams but emphasized that teamwork was challenging, as was working interprofessionally and not in a multidisciplinary manner. Multidisciplinary teams consist of different professionals working in parallel, while interprofessional teams work together, share information and are involved in making joint decisions based on a patient-centred approach [49]. The World Health Organization (WHO) [50] recommends interprofessional activity in education to promote collaboration in healthcare and underlines that the only way healthcare professionals can understand and be ready to collaborate interprofessionally is through interprofessional focus and training in education. SBL may be used to enhance the interprofessional understanding of roles and enable interprofessional teamwork [51].

We were able to include only ten studies, indicating that this is a limited research field. Of the ten studies included in our scoping review, six primarily focused on communication training in different forms. SBL is generally recommended as a learning activity to teach communication skills in palliative care [14] and has been used to develop skills related to communication and the provision of EOL care [52]. Communication is one of several important competencies for nurses in palliative care [9, 53, 54], and the most common form of SBL in palliative care is role playing with an actor and a focus on communication skills [55]. Healthcare professionals may feel anxious and unprepared to talk about death and EOL [56]. Nurses in palliative care may perceive communication with families as challenging, since they may lack competence within this area of communication [1]. Our findings suggest that even though the use of SBL enhanced postgraduate nursing students’ confidence in their communication skills, in one of the studies [42] in our review, the students experienced decreased confidence levels after an SBL session that focused on a difficult family situation. The nursing students felt overwhelmed and unprepared, and they struggled with role responsibility [42]. Students may feel frustrated after participating in SBL, and they may need constructive feedback and a skilled educator to help them transform feelings of mistakes into a positive learning experience [57].

Novaes et al. [52] concluded in their study that the facilitator is the most crucial factor in the implementation of role playing for teaching communication skills in palliative care. Effective facilitation of an SBL experience requires a facilitator who has specific skills and knowledge in simulation pedagogy, and the facilitator’s competence can be key for the participants’ opportunities to learn and to be able to achieve the expected learning outcomes [58]. Two of the studies included in our review did not report whether a facilitator was present [39, 44], and no studies described facilitator characteristics such as experience, training, profession or sex, as recommended by Cheng et al. [59]. Sevdalis et al. [60] found a lack of consistent reporting and the potential for improvement in the quality of reporting on SBL research.

Palliative care patients are especially vulnerable [61], and the provision of palliative care can be stressful because of the emotional impact caused by the frequent contact with suffering and death [62, 63]. Palliative care nurses must have personal resources to cope with stressful events, and personal growth is often considered an important protective factor [64]. Our findings indicate that postgraduate nursing students felt more confident after participating in SBL and experienced personal growth and development, but some of the participants wanted more practical content, such as symptom management. Postgraduate nursing students should receive relevant training and education to feel prepared for meetings with patients and their families during palliative care. Inadequate skills, capacities, education and training for nurses could be potential barriers to palliative care [14, 65].

Various reasons could explain the low number of studies included in our review. Since several countries do not offer postgraduate education in palliative care nursing [8], nurses could be offered shorter courses and receive training related to palliative care that includes SBL at their workplaces [66,67,68]. Providing education in palliative care may also pose challenges due to possible lack of faculty expertise [54]. Palliative medicine is also a relatively young specialty [23], and education in the palliative field has been slow to use SBL [55]. One reason for this slow introduction of SBL into the palliative field may be due to lack of financial resources as SBL could be an expensive and time-consuming learning method [55]. There is a focus on required competencies in palliative care for nurses such as communication, observation, evaluation, symptom management and collaboration [53, 54], and SBL in addition to other active learning methods are recommended in undergraduate and postgraduate education [14, 69]. Gillan et al. [28] found that SBL with a focus on teaching undergraduate nursing students EOL skills was first used in 2009. SBL may be perceived as less relevant in palliative care because such care is often considered a less acute specialty than, for example, anaesthetics [55]. High-technology simulation for learning and teaching for example resuscitation has experienced comprehensive growth [70]. Palliative care may be described as ‘high touch’ [71], and André et al. [72] have noted a conflict between high tech and high touch in the palliative field. SBL can be low tech, however, and still maintain high fidelity [73].

Future research should explore postgraduate nursing students’ experiences with symptom management using standardized patients and manikin-based or hybrid simulations and determine whether such simulation strategies can improve the students’ symptom-management skills. Based on the crucial role of the facilitator, the field requires research with thorough descriptions of how simulations are carried out, what the facilitator’s role is, and the facilitator’s background and education. The scenarios should be described in a more in-depth manner, in line with guidelines on reporting on SBL research. Research focused on how participants experience the relevance and application of SBL within their own clinical practice is also lacking at the postgraduate level.

Strengths and limitations

One strength of this review was the use of an acknowledged framework for conducting scoping reviews, as described by Arksey and O’Malley [30], while the reporting was supported by the PRISMA-ScR checklist [31]. The development of the search strategy and the comprehensive search for published studies was done in close cooperation with an experienced research librarian, and the search strategy was discussed several times and peer reviewed by another research librarian. The study selection and data extraction were done individually in pairs. Our protocol was published before the database searches, and study selection was performed.

We excluded studies where postgraduate nursing students participated in SBL with different disciplines and where the studies did not report separate results for postgraduate nursing students. Because of language limitations, we may have excluded some relevant studies. The studies included in this scoping review featured a variety of types, scopes and duration of SBL, which may have affected the findings. Because we did not assess the methodological quality of the studies nor synthesise their findings, as recommended in the literature [30], any implications for education and policy should be interpreted with caution.

Conclusion

The use of simulation-based learning (SBL) in postgraduate nursing education seems to enhance students’ understanding of the importance of teamwork and interdisciplinarity, which is a challenging, but crucial, part of providing palliative care. Even though most of our evidence suggests that SBL enhanced postgraduate nursing students’ confidence in their communication skills, we also found contradictory findings. The students experienced personal growth after participating in SBL, which can be an important protective factor against stress. Our findings suggest that limited research has been conducted within this field and that facilitator characteristics and scenarios have been poorly reported. Future research should explore postgraduate nursing students’ experiences with SBL, with a focus on more practical content and other essential competencies within palliative care such as clinical and ethical competencies and on SBL’s relevance and application within the nurses’ own clinical practice. Future research should also be reported in line with recommendations regarding the reporting of SBL research.