Implementing a Goals of Care Simulation for Student Nurse Practitioners: An Evidence-based Practice Project

Goals of Care discussions help patients clarify what they value most and what they hope to see happen with their medical care. These conversations require patients and clinicians to zoom out and talk about plans and potential decisions if a patient's course doesn't go as hoped. Patients prefer to discuss this with someone they know, trust, with whom they have built a relationship; primary care is the setting where most patients find this longitudinal provider relationship. Outpatient Primary Care Providers are confronted with many barriers regarding the conduct of Goals of Care-focused conversations including perceived lack of confidence, skills, and knowledge. Planning ahead in the primary care setting helps patients and families avoid tumultuous in-the-moment decisions because the discussions around values and preferences occur when the patient is not acutely ill and still able to make decisions for themselves. Local Problem: Providers with low confidence and skills in conducting Goals of Care focused- conversations cause delayed conversations, which leads to poorer patient-reported quality of life, more frequent hospitalizations, and increased likelihood of Intensive Care Unit admission. Evidence shows communication skills and confidence do not reliably improve with experience in practice and exposure alone, but that training is needed. Goals of Care-focused simulations result in an overwhelmingly positive response from participants and improves knowledge, skill performance, critical thinking, and user satisfaction. The large teaching hospital and Doctor of Nursing Practice (DNP) program where this project was implemented cares for a large number of adults over the age of 65. This DNP program previously had no simulation geared towards Goals of Care. Methods: This quality improvement project involved the implementation of a three-scene simulation for third-year Doctor of Nursing Practice (DNP) students that focused on Goals of Care conversations in the outpatient setting. A single post-implementation survey was distributed to gauge how confident Student Nurse Practitioners (S-NP) felt before and after participating in simulation. Interventions: A Goals of Care-focused simulation was created and implemented for third-year DNP students. A single post-implementation survey was provided and collected quantitative data regarding feasibility, acceptability, and satisfaction of the simulation. The survey also included questions about their confidence regarding Goals of Care conversations. Additionally, a 30- minute focus group with S-NP simulation participants, Standardized Patient (SP) actors, and simulation staff was conducted to collect qualitative data. The focus group was recorded, transcribed, and analyzed to identify themes. Demographic data from all participants were analyzed with descriptive statistics. Results: Post intervention, all Student Nurse Practitioners (S-NP) (n=10) reported the prework and simulation experience to be highly feasible, acceptable, and satisfactory. All S-NP's reported increased confidence in discussing Goals of Care in the outpatient setting. Themes that emerged from the 30-minute focus group following the simulation experience included: positive feelings about the amount and type of prework, the simulation felt very valuable and meaningful, and feelings of empowerment developed regarding Goals of Care conversations. S-NP participants shared desire for a Goals of Care-focused simulation to be a permanent part of third-year DNP curriculum. Conclusion: Goals of Care-focused simulation for DNP students emerges as a feasible, acceptable, and satisfactory tool for enhancing student confidence. This project provided necessary data for this DNP program to consider permanently implementing a Goals of Care- focused simulation into third-year DNP curriculum. Establishing a safe environment where students can engage in sensitive discussions with patients about their care preferences and values is essential for enhancing the quality of life for their prospective patients.