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Helping students process a simulated death experience: integration of an NLN ACE.S evolving case study and the ELNEC curriculum.


The nursing literature supports the need for end-of-life (EOL) education, but the ability to provide quality clinical experience in this area is limited by the availability of patients and nursing instructors' and preceptors' comfort and expertise in teaching EOL care. Clinical simulation allows faculty to provide the same quality EOL experience to all students. This article discusses an effective teaching strategy integrating End-of-Life Nursing Education Consortium core content with National League for Nursing ACE.S unfolding case studies, clinical simulation, and social media.

KEY WORDS ACE.S--Simulation--ELNEC- End of Life--Nursing Education


The need for end-of-life (EOL) care in the nursing curriculum has been well documented, but standard teaching strategies are often inadequate. This article describes an effective teaching strategy for pre-licensure nursing students that integrates the End-of-Life Nursing Education Consortium (ELNEC) core curriculum, National League for Nursing (NLN) Advancing Care Excellence for Seniors (ACE.S) unfolding case studies, clinical simulation, and social media, specifically Facebook. The focus was on helping students process a patient death and gain confidence and skills when interacting with a dying patient and the patient's family. This fourfold teaching strategy for EOL care proved to be efficient, engaging for faculty and students, and successful in improving students' skills in this critically important area.

The simulation took place as part of a three-credit didactic gerontology course for senior nursing students. Preparation for the simulation began with the ELNEC curriculum known as ELNEC-Core (American Association of Colleges of Nursing [AACN], 2000), introduced concurrently with the NLN ACE.S unfolding case study on Julia Morales and Lucy Grey (Cato, 2012; NLN, n.d.). Both were used throughout the course in large and small groups. Prior to the simulation, students watched the video "Evan Mayday's Good Death" ( and completed an individual reflection. Faculty members led student discussion about the film.

To enhance realism, a Facebook page was developed for Julia, the ACE.S character. Students could "friend" or email Julia, and faculty responded as Julia. The course culminated in a simulated death experience for groups of 10 students. The teaching strategies are summarized in Table 1.


Dying is an Intrinsic part of life, and nursing curricula need enriched didactic and clinical content on EOL care (Allchin, 2006). Classes on the end of life for baccalaureate students generally stir feelings of fear and hesitancy (Allchin). White and Coyne (2011) found that many students reported having only two hours or less of EOL education in the preceding two years.

According to the Institute of Medicine (2008), the number of older adults in the United States will nearly double by 2030, leading to a need for nurses who are competent and comfortable In providing quality EOL care. The AACN published competencies for EOL care for older adults in 2010. ELNEC offers modules on pain and symptom management, ethics, communication, and other key EOL issues (AACN, 2000).

Simulation can be an effective means of preparing students to address EOL issues effectively and compassionately. A key to providing effective education through simulation and enhancing clinical reasoning is the realism and complexity of the scenario. The NLN ACE.S initiative is designed to improve care of older adults by providing curriculum resources, unfolding case studies, and teaching strategies. ACE.S unfolding cases are evidence-based and include first-person monologues and simulation templates for classroom, clinical, and skills lab activities; they can be modified to meet individual course and curriculum needs.

The unfolding case used as the basis for this simulation involved Julia Morales, age 65, her son Neil, and her partner of 25 years, Lucy Grey. The three scenarios offered by ACE.S begin with Julia's story and her current battle with lung cancer, continue to her death, and conclude with her grieving partner, Lucy, in the emergency department.

This class used the second scenario, which was adapted to be observational rather than interactive, with faculty conducting the role-play; debriefing conducted by faculty followed immediately after the simulation. The case study was expanded to incorporate core ELNEC curricula, and both Julia and Lucy were considered patients throughout the final five weeks of the course. Faculty-led discussions focused on ethics from the perspective of Julia's decision to stop treatment, and quality of life and caregiver burden as Lucy took on more of Julia's care. Students were very familiar with Julia and Lucy by the time of Julia's death. The Facebook page was used to enhance the reality of the characters. (See Table 1.)


Students responded positively to the Facebook page, as social media are an integral part of their daily activity. Schmitt, Sims-Giddens, and Booth (2012) support the use of social media as a means to help students gain in understanding and skill. In this case, Facebook was used to enhance empathy, a quality vital for caring for dying patients and their families. Students shared that they felt they actually knew Julia and Lucy, which made Julia's death real to them. At first, Julia received numerous Facebook "friend" requests from across the country, but by changing the Facebook settings, limiting access to students, and identifying Julia as a "fictional person," this problem was resolved.

The use of the ACE.S case study facilitated the implementation of the simulation. Teaching resources provided for faculty enhanced the realism and quality of the scenarios; these included the evaluation tool provided with the ACE.S unfolding case studies as well as case study content and simulation templates and scripts. Faculty added questions to the debriefing specific to students' feelings about EOL issues and their perceived ability to address these issues after the simulation.

Feedback from students supported the effectiveness of this teaching strategy in increasing their comfort with the dying process and helping them communicate with patients and their families. Comments on the death included: "Felt sad but peaceful that it was such a nice environment for her to die in" and "I felt emotional and connected to the experience." Feedback on the simulation as a learning activity included: "Beneficial. I think I will remember this when I come across it in my nursing career." One student stated: "Helped me know what to say to patient and family at EOL. Support is so important to help patient and family have a good death experience." Another described it as the "best learning experience I ever had."

Judith A. Kopka, MSN, RN, CNE, is a clinical instructor, University of Wisconsin Milwaukee College of Nursing. Ann P. Aschenbrenner, PhD, RN, is a clinical assistant professor, University of Wisconsin Milwaukee College of Nursing. Mary B. Reynolds, MSN/ed, RN, is an adjunct clinical instructor in the Milwaukee area, and director of professional services, Heartland Home Health Care, Milwaukee. For more information, contact Ms. Kopka

doi: 10.5480/14-1329


Allchin, L. (2006). Caring for the dying: Nursing student perspectives. Journal of Hospice and Palliative Care, 8(2), 112-117.

American Association of Colleges of Nursing. (2000). ELNEC-Core. Retrieved from

American Association of Colleges of Nursing. (2010). Recommended baccalaureate competencies and curricular guidelines for the nursing care of older adults. Retrieved from

Cato, M. L. (2012). Julia Morales and Lucy Grey [ACE.S Unfolding Cases], Retrieved from

Institute of Medicine. (2008). Retooling for an aging America: Building the health care workforce. Washington, DC: National Academies Press.

National League for Nursing, (n.d.). NLN Center for Excellence In the Care of Vulnerable Populations. Retrieved from vulnerable-populations

Schmidt, T., Slms-GIddens, S., & Booth, R. (2012). Social media use in nursing education. Online Journal of Issues in Nursing, 77(3), Manuscript 2. doi:10. 3912/OJIN.Vol17No03Man02)

White, K. R., & Coyne, P. J. (2011). Nurses' perception of educational gaps in delivering end-of-life care. Oncology Nurse Forum, 38(6), 711-717.
Table 1: Teaching Strategies for End-of-Life Simulation

Teaching Strategies     Implementation

The simulation was      Introduce the Julia Morales and
conducted during the    Lucy Grey ACE.S unfolding case study
final class of the      throughout the ELNEC core curriculum.
semester as part of     ELNEC topics (pain management, caregiving,
a 3-credit didactic     and symptom management) were integrated
gerontology course.     throughout the last five weeks of the course,
Preparation included    with Julia and her caregiver Lucy and son
class and online        Neil as patient and family during small-group
modules on the ELNEC    work and discussion activities.
core curriculum.

Use of Social Media     Develop a realistic Facebook page for Julia
                        with pictures of Julia and Lucy, their
                        travels and family, and "Likes," such as
                        favorite sports teams. Students are required
                        to either "friend" Julia and post a comment
                        on her wall or send her an email.
                        Faculty respond as Julia.

Simulation              A high-fidelity manikin is dressed and placed
                        in a small room decorated to look like a home
                        environment. The manikin is programmed to
                        display common signs of impending death,
                        including Cheyne-Stokes respirations with
                        lengthening intervals of apnea progressing
                        to death. Faculty enact a loosely scripted
                        role-play of the interaction involving the
                        hospice nurse, Julia's son Neil, and partner
                        Lucy based on the ACE.S simulation template.
                        After approximately 10 minutes, Julia dies,
                        and the hospice nurse offers to make
                        necessary calls and provides sympathy,
                        reassurance, and hugs to the grieving family.

Evaluation              Faculty conduct a 20-minute focus group for
                        debriefing after the simulation, encouraging
                        students to share their responses and process
                        feelings that arose during the simulation.
                        A written questionnaire incorporating
                        debriefing questions from the ACE.S case
                        study is distributed. Faculty added questions
                        on students' reactions to the death.
                        Students complete this anonymously, allowing
                        them to provide feedback they may not feel
                        comfortable sharing in a group.
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Title Annotation:Innovation Center; Advancing Care Excellence for Seniors and End-of-Life Nursing Education Consortium
Author:Kopka, Judith A.; Aschenbrenner, Ann P.; Reynolds, Mary B.
Publication:Nursing Education Perspectives
Article Type:Case study
Date:May 1, 2016
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