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Using QSEN competencies to assess nursing student end-of-life care in simulation

Lindemulder, Lorinda MSN, RN; Gouwens, Sarah MSN, FNP-BC; Stefo, Kathryn MSN, RN

doi: 10.1097/01.NURSE.0000531006.94600.28

Sarah Gouwens and Kathryn Stefo are assistant professors of nursing at Trinity Christian College in Palos Heights, Ill., where Lorinda Lindemulder was also an assistant professor at the time of the study. Ms. Lindemulder is now a lecturer at the Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences at the University of Colorado in Colorado Springs.

Research Corner is coordinated by Ruth A. Mooney, PhD, MN, RN-BC, the former nursing research facilitator at Christiana Care Health System in Newark, Del.

The content in this article has received appropriate institutional review board approval and/or administrative approval for publication.

Trinity Christian College provided a Summer Research Grant 2016. The authors have disclosed no other financial relationships related to this article.

For more information about the QSEN competencies for undergraduates, see


Purpose. This study's purpose was to measure the impact of end-of-life (EOL) simulation that incorporated Quality and Safety Education for Nurses (QSEN) competencies on the self-assessment of selected competencies for 36 senior BSN students. QSEN integration into EOL simulation seeks to prepare nursing students with knowledge, skills, and attitudes that will enhance the quality and safety of their professional practice in caring for patients at EOL. Methods. The mixed-method study used two student groups, producing both qualitative and quantitative data. The qualitative method used content analysis related to observation and reflection journal analysis. Quantitative data were gleaned using a pre- and posttest design using a reliable and valid tool found in the literature. Results. The study's findings indicated that three categories had statistically significant P values for both simulation groups. These categories were teamwork and collaboration, evidence-based practice, and quality improvement. Additional qualitative findings from students' reflection journals most often mentioned the importance of teamwork and collaboration, patient-centered care, and spiritual care. Students' reflections also revealed common themes of enhanced awareness and appreciation for exposure to an EOL simulation experience before completing their BSN education. Conclusions. The significance of this study was twofold: It addressed a gap in one clinical program's EOL curriculum, and it increased nursing's body of knowledge related to use of QSEN competencies in EOL simulation. This increase in knowledge could impact the assimilation of QSEN competencies into future EOL care and nursing practice for BSN students.

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Healthcare associations and providers are calling for BSN programs to prepare nursing students to provide quality EOL care.1-3 Because of changing demographics in the United States, nurses are and will increasingly be caring for older adults who may have greater health needs.2,4 Nursing schools have an imperative to prepare students to provide EOL care for this growing group of patients.2,3

A literature review revealed that BSN students have inadequate education on EOL care and limited clinical opportunities to provide EOL care.5,6 The literature review also revealed that EOL care is becoming increasingly multidisciplinary.3,5,7

In response to the issues highlighted in the literature review, this study focused on nursing students' perceptions of their preparedness for providing EOL care in their student and professional practice. This project's purpose was to measure students' self-perceived EOL care preparedness, as quantified by their integration of QSEN competencies in a high-fidelity multidisciplinary EOL simulation.

Preparing nursing students to provide high-quality EOL care requires an organized approach supported by evidence-based methodology.8 The Quality and Safety Education for Nurses (QSEN) Project addresses the “challenge of preparing future nurses with the knowledge, skills, and attitudes necessary to continuously improve the quality and safety of the healthcare systems within which they work.”9

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Literature review

The search terms were developed by the research team. Terms used for this study were QSEN, EOL simulation, BSN education, and tools for QSEN EOL. Search engines used were the CINAHL database, EBSCO Host, and Ovid.

Literature was systematically evaluated following the methodology described in Preparing Literature Reviews: Qualitative and Quantitative Approaches.10 Articles were assigned a level of evidence, their quality was appraised, and they were summarized. These literature review processes enabled the research team to identify a gap in the literature related to EOL simulation in BSN education.

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  1. To measure students' perceived EOL care preparedness and effectiveness, as quantified by their integration of QSEN competencies in a high-fidelity multidisciplinary EOL simulation.
  2. To identify themes with a self-assessment tool, journals, and observation based on the students' descriptions of their experiences during participation in pre- and post-EOL simulation self-assessments, faculty observation, and debriefing of the high-fidelity simulation.
  3. To promote self-awareness and collection of data, which was accomplished by assigning and analyzing reflection journal entries.11,12


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The mixed-method study design used simulation for a more controlled and safe environment.11,13,14 (See Glossary of research terms.) The qualitative method used content analysis related to observation and reflection journal analysis. Observation consisted of researchers viewing all the simulations while taking notes. Quantitative data were gleaned with a one-group pre- and posttest design using a reliable and valid tool adapted for the study.15

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This research study was conducted at Trinity Christian College's nursing lab, simulation lab, and videoconference room. The researchers obtained informed consent before students participated in the study.

Selected QSEN competencies and a self-assessment tool adapted with permission from Luetke and Bembenek from Colorado Mountain College were selected as the framework and tool for the project.9,15 The assessment tool was adapted to measure QSEN-related self-assessed competencies as well as associated skills in seven areas using the study's mixed-method design.13,16 The same tool was used for pre- and postassessment data collection. Data were also collected during simulation enactment, debriefing, and review of reflection journals.

Participating nursing students were divided by their previously assigned clinical groups. The study's 36 senior BSN students completed the QSEN-based Simulation Evaluation Self-Assessment tool before and after enacting a high-fidelity simulation on EOL care. (See Study demographics.)

The study's tool was adapted to focus on students' self-assessment of competencies related to the EOL. The scenario used was based on Elsevier's Simulation Learning System: Acquired Immune Deficiency Syndrome with Pneumocystis carinii Pneumonia.17 Simulation is an effective teaching methodology that actively engaged the students in this important area of practice.18-20 For the study, students wrote a one-page journal entry reflecting on their preparation and use of QSEN competencies during their simulated experience in EOL care.

The journal entries were analyzed for frequency of topics discussed, and themes related to their perceptions of the simulation experience were identified.21 The relevant competencies included teamwork and collaboration, patient-centered care, spiritual care, professionalism, and safety. Students' verbalizations about their reactions and perceptions of simulated EOL care were collected from direct observation of EOL simulations and journal data.



The students interacted with the high-fidelity simulator and an actor who played the role of the significant other. Students assumed the role of the nurse in the safe simulation environment as they provided comfort care to a patient and family during the EOL phase. Interdisciplinary collaboration was a valuable component of this study. Besides interacting with the actor portraying the patient's significant other, students could call in a chaplain to assist with the spiritual care of the patient and family.7,8 The debriefing session was conducted with the assistance of students pursuing master's degrees in psychology, who gained experience with processing student reactions after the EOL scenario and brainstorming with nursing students about how they may cope with similar situations within their practice.21,22

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The results of the pre- and postassessment were analyzed as matched pairs tests. The results were recorded as P values set at .05. Because all the P values are less than .05, they're all significant. Of the seven QSEN competencies, three had a significant mean increase for the entire group of 36 students, four showed a significant mean increase for Group 2, and only one showed a significant mean increase for Group 1. A few results have P values between .05 and .10. These results providing moderate evidence deserve further study with larger sample sizes.



A statistician completed data analysis. The research team provided content analysis of qualitative data from student reflection journals. Their analysis focused on the frequency with which students mentioned QSEN competencies related to teamwork and collaboration, patient-centered care, spiritual care, professionalism, and safety during the EOL simulation scenario.

The compilation of student discourse frequencies in journals and direct observation allowed the identification of themes. Students' verbalizations about their reactions to and perceptions of simulated EOL care that were collected from direct observation of EOL simulation videos and journal data were organized by researchers into themes according to frequency.

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Seven QSEN categories from the self-assessments of both simulation groups were analyzed, revealing that three had statistically significant P values in both simulation groups: teamwork and collaboration, evidence-based practice, and quality improvement. The results were teamwork and collaboration (M=0.917, SD=1.228, t(35)=4.48, P=0.0001); evidence-based practice (M=0.472, SD=1.028, t(35)=2.75, P=0.0093); and quality improvement (M=0.583, SD=0.967, t(35)=3.62, p=0.0009). Reflection journals most often included mentions of the importance of teamwork and collaboration, patient-centered care, spiritual care, and professionalism. (See Reflection journalthemes.) This study showed an increase in BSN students' self-assessed ability to perform these selected QSEN competencies after participating in the EOL simulation project. (See QSEN-based simulation evaluation self-assessment.)

Students identified teamwork and collaboration as significant in allowing them to work more effectively. For instance, one commented, “The three of us walked into the room with a plan that divided up the work that needed to be done. We then effectively executed this plan.”

Student comments revealed that they recognized a benefit in including other healthcare team members in the patient's care: “We also incorporated the chaplain into the plan of care as a resource to provide emotional and spiritual support to the patient and his significant other.” “Teamwork helps magnify our professionalism and also [lets us] accomplish our goals more effectively.”

During the simulation, the students could collaborate by calling the hospital chaplain. Students made a phone call to the hospital chaplain in seven out of nine simulations. This finding indicates their willingness to use interdisciplinary collaboration in EOL care.

As students considered the importance of patient-centered care, they often reflected on the importance of holistic care and how the focus of care shifts to different areas during the EOL: “We knew that it wasn't our job to save the patient, but it was [our job] to make him feel as comfortable as possible.... We were also able to focus our whole attention on trying to care for the patient in a holistic way rather than specifically focusing on his specific physical symptoms and needs.”

One student mentioned assessing the patient and family's “source of comfort and helping them use their source of comfort to help them through the dying process.” These statements reflect the awareness that holistic care incorporates spiritual assessment.23

When discussing the importance of professionalism, students identified these themes: providing culturally appropriate care, being respectful of patients' wishes, and controlling one's own emotions in order to provide support for the patient and family. A student demonstrated cultural awareness, saying, “Being respectful to your patient and family members will require different types of care as you deal with different people from various cultures and backgrounds.”

Debriefing groups discussed the appropriateness of showing emotion in front of patients and families related to professional boundaries. A student's journal highlighted the topic with this: “Shedding a few tears, yes, but sobbing and falling on our knees isn't [professional].”

A few students who had recently dealt with a death within their own family or during their clinical experience took time to share their feelings with the group. One student mentioned that “I didn't even realize that I hadn't taken the time to process the [death] or how much it had affected my life.”

Students' journals also revealed a common theme of an enhanced awareness of EOL issues. Students appreciated being exposed to an EOL simulation experience during their BSN education. Several students mentioned that interactions during the simulation scenario involving the significant other and chaplain added realism. A student said, “I thought it was beneficial that we experienced such [a] situation: because as a student I haven't yet experienced a patient dying on my shift.”



An unexpected study finding was that the competency of safety was rarely addressed in student reflection journals. Observation of simulation enactment indicated that students did not uniformly use personal protective equipment (PPE) and standard precautions when performing care for the simulated patient. This is particularly relevant because the “patient” had a communicable disease. The use of standard precautions, as outlined by the World Health Organization, highlights the importance of PPE based on risk assessment.24 These findings may indicate the need for increased emphasis on safety in the education of BSN students in their care of patients during EOL.25

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The American Association of Colleges of Nursing developed competencies related to high-quality EOL care. The nursing curriculum should include courses that help nursing students identify and assess their own attitudes about death as well as teach them to respect others' attitudes and values.2 The opportunity for students to reflect on their personal definition of a “good” death lets students consider how their beliefs and experiences about death could influence their EOL care.2,26 Students recognized that a “good” death would be different for each person. In reference to a “good” death, they also mentioned common elements, such as loved ones being present, saying goodbye, being at peace emotionally and spiritually, being comfortable and free of pain, and (when the patient requested) being offered assurance of life after death.

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Conclusion and recommendations

The data analysis of pre- and post-assessments showed an increase in the participating students' self-assessment of their ability to perform selected QSEN competencies after being involved in the study's EOL care simulation. Including the students pursuing master's degrees in psychology and faculty during the participants' debriefing process reinforced an increasingly relevant interdisciplinary approach to EOL.2,27 The faculty and psychology students also emphasized that providing EOL care can cause anguish for nursing students and healthcare providers.28 The debriefing included a discussion of how to develop self-care and coping skills.6

Future studies will include informed-consent forms that include permission to videotape the students who voluntarily participated. As previously mentioned, observing the nursing students' simulation enactment revealed inconsistent use of PPE and standard precautions in the EOL setting. Students' inconsistent use of PPE and standard precautions in this study's EOL simulation experience differed from their use of PPE and standard precautions in other simulations. This observation has prompted further exploration into the students' understanding of the role that safety plays in EOL care and an increased focus on the use of standard precautions in all settings and levels of care.25

In their reflection journals, students most frequently mentioned teamwork and collaboration (35), patient-centered care (32), spiritual care (31), professionalism (25), and safety (7). This indicates the relative importance of these competencies to the students. The authors hypothesize that the frequency of students' comments relate to the use of selected QSEN skills and competencies during EOL care. Involvement in this study may increase the likelihood that QSEN will be integrated into the involved student's professional practice.27

To enhance the students' understanding of the role of the parish or congregational nurse in EOL care, the simulation scenario for future studies will include a parish or congregation nurse instead of a hospital chaplain for collaboration related to the patient's spiritual care.23

The study aligned with the literature review's purpose, which was to provide BSN students with a safe, high-quality EOL experience.2,5 The study also aimed to assess the program's BSN students' perceived level of preparedness to provide EOL care by using a multidisciplinary high-fidelity EOL simulation-based study.

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Implications and limitations

Due to the lack of a control group and the use of a convenience sample, study results might not be representative of all BSN students. Generalizability could also be enhanced by using a larger and more diverse sample.

The students' use of QSEN competencies could not be studied in detail because the students were not videotaped during simulation enactment. Without videotaping, student actions could not be studied in the in-depth detail required for data collection.

Collecting more data about this group of participants, 1 and 2 years after graduation, using the same assessment tool via e-mail or Survey Monkey is also being considered. This will provide data related to the EOL simulation project's impact on previous students' perceived level of preparedness to integrate QSEN competencies into their professional practice when delivering EOL care. The researchers have continued to enact and collect data on this QSEN-based EOL simulation study every spring semester.

The researchers are also exploring partnering with other colleges of nursing that would also use the adapted Luetke and Bembenek QSEN tool in conjunction with an EOL simulation to develop a comparison or control group design.15 They have recently collected data about a second phase of the study with a sample size of 27 senior BSN students. This ongoing data collection includes videotaped simulation enactment data that will be analyzed. An updated report of findings is forthcoming.

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Measuring students' perceived effectiveness in integrating QSEN competencies in EOL simulation added to the body of nursing knowledge related to increased self-assessment and simulation-based preparation of BSN students. This increase could impact the assimilation of QSEN competencies into future EOL care and nursing practice for BSN students.26 In the words of one student, “Being in a scenario like this made me better equipped to think with a patient-centered mind.”

The high-fidelity EOL simulation closes a curriculum gap by letting each senior nursing student gain experience in the nurse's role during an EOL scenario.6,12,13 Although the topic of EOL is part of the BSN curriculum, a simulation provided students with an experience that involved not only Bloom's cognitive domain of learning but also the psychomotor and affective domains.29 Lewis outlines four ways nurses act during the EOL phase: care provider, educator, advocate, and facilitator.27 The adapted EOL scenario provided practice in each of these areas.17

Some students showed they could advocate for the patient's wishes, educate the significant other, and facilitate the patient-centered plan of care. In their debriefing and reflection journals, students examined their personal experiences with death, ethical assumptions, perspectives about a good death, personal biases, and ways they would cope with death in their practice.8,30 Ladd et al. found that “students' responses confirm the significance of past experiences to present attitudes, values, and behaviors.”14

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