Table 2 Characteristics of the included studies

J-O. Chen et al. (2021) Taiwan [45]

To develop and pilot test an advance care planning simulation based communication training program and to evaluate the feasibility and acceptability of the program

Medical center

12 nurses; 12 females, mean age 44.6 (range 26–55) years

Structured clinical communication through scenario simulation, roleplay, and guidance of the PREPARED^a model; use of standardized patients, debriefing, reflection and evaluation. Each participant took turn and roleplayed with standardized patients Self-reflection afterwards and feedback given by the facilitator and other members in the group. Timeframe: 25–30 min

Topics for role-play/simulation scenarios: refusing life sustaining treatments, signing documents for advance directive, weaning life sustaining treatment; palliative and home care

Pilot feasibility study

Role-playing was helpful for discovering their own shortcomings in communication skills while debriefing enabled them to identify their blind spots in the communication process. Role-play provided opportunities for peer observation and learning

Ellis et al. (2021) US [38]

To determine the effects of an advance care planning (ACP) communication education module on learner satisfaction and confidence in holding ACP-conversations

Family nurse practitioner graduate nursing program in university

44 students; 40 females; mean age 32.8 (standard deviation (SD) 8.36, range 23–53) years

First part was lecture and roleplaying activities where participants took turns playing the patient and the family practice nurse. Timeframe role-play was 1015 min. Debrief afterwards after students had played both roles. The second part was clinical simulation 4 weeks later with a standardized patient. Scenario focused on ACP conversations. Students had 15 min for the patient encounter, then time for documenting the conversation. Each simulation experience was followed by a debriefing session with the students, standardized patients and the investigator

First part of the program (roleplay): “Breaking Bad News: Case Study # 3” (not reported (NR)) Second part of the program (simulation): a son waiting after his mother was emergently taken to hospital with hemorrhagic stroke, loss of consciousness and poor prognosis of survival. The student was the sons first source of information, and the student should break the bad news using the SPIKES^b protocol

Pre-test post-test design

Significant increase in post intervention ACP communication knowledge scores (medium effect size), self-confidence in holding these conversations, and satisfaction with the learning experience

Ellman et al. (2012) US [37]

To describe the development, implementation, and evaluation of an innovative program that blends online learning with interactive simulation to teach interprofessional aspects of palliative care (PC)

Interprofessional PC education program

Free-text responses: 43 advanced practice registered nurse (APRN) students; 39 females, age NR

Postworkshop questionnaire: 65 nursing students, sex NR, age NR

First part of the program; online case, embedded video with professional actors addressing goals of care, symptom management, spiritual challenges and family conflict. Timeframe: 30–45. Students enter free-text responses to four reflection questions 90-min interprofessional workshop in groups of 6–8 students and a faculty facilitator: first the group discuss one PC simulation, then 20 min simulation of an interprofessional team meeting. Groups present a summary of their discussions

First part of the program (online case): 68-year-old African American woman with end-stage metastatic breast cancer. The case explores clinical challenges in the physical and psychosocial domains with particular emphasis on spiritual and cultural issues Second part of the program: a woman of Muslim faith with young children and carcinomatosis with bowel obstruction. With complexity in multiple domains, the case prompts students to experience firsthand the value of interprofessional collaboration

Evaluation study

APRN students experienced the program meaningful, effective and recognized important issues beyond their own discipline, roles of other professionals and the value of teamwork. APRN students experienced the online case and materials as instructive, relevant and challenging, the workshop and discussion groups as valuable and the online interactive case in combination with interdisciplinary discussion groups facilitated learning

Fuoto et al. (2019) US [44]

To increase nurse confidence and satisfaction engaging in end-of-life (EOL) communication following the implementation of the COMFORT^c model

PC unit in large tertiary care center

14 nurses; 14 females, mean age 46.9 (SD 11.9) years

4 h COMFORT class; lectures, group discussions, role-play scenarios to demonstrate skills learned. Each participant played the role as patient, nurse and family. After each role-play a debriefing session to discuss lessoned learned and reinforce how to use COMFORT to guide EOL communication

NR

Pre-test post-test design

Significant increase in nurses’ overall ability to communicate in difficult conversations across the 3 time points (before, right after and 3 months after) and a significant increase in satisfaction with managing emotional needs at EOL, managing conflict and overall communication in difficult EOL situations

Gentry and Dahlin (2020) UK [39]

To prove a brief highlight of educational strategies/learn er needs to consider in PC APRN education, describe outcomes of the PC APRN externship in 1 site, and discuss the application of such training in addressing PC workforce needs

A teaching hospital

20 nurse practitioners; sex NR, age NR

A day of classroom training based on the established ELNEC^d curriculum with focus on communication. Role-play used as an active learning strategy

Simulated family-meetings, delivering difficult news and eliciting goals of care

Mixed methods design

Most participants reported time spent in clinical areas to be the highlight of the week. Participants spoke of staff enthusiasm, role modeling teamwork contributing to the experience and wanted more practical content about pain and symptom management. Many comments reflected need for validation and support from others who have shared understanding. Participants found active learning strategies helpful

Lindberg et al. (2021) Sweden [41]

To explore postgraduate nursing students´ experiences with simulation training in EOL communication with intensive care patients and their families

Postgraduate diploma studies in Specialist Nursing in Intensive care at university

29 students; 19 females, 4 students gender NR, mean age 35 (range 25–47) years 29 answered a questionnaire, 9 participated in interviews; 6 females

3 h simulation training in groups of 4–6 students. The simulation training took place when students where halfway through intensive care education, in the midst of a 10-week clinical placement in an intensive care unit (ICU). All students were assigned roles as ICU nurse, family member or observer. Reflective seminar after each scenario

Scenario 1: Old man with multiple organ failure, been in ICU for several weeks. Decided that life-sustaining treatment will end. Wife and son/daughter part of the scenario

Scenario 2: 58-year-old woman with severe chronic obstructive lung disease diagnosed several years ago. Treated with CPAP^e in ICU without any signs of improvement. Family was informed that she will be moved to an ordinary hospital ward. Husband and son/daughter part of the scenario

Qualitative study with phenomenographic approach

EOL conversations was perceived as being different from the students’ previous experiences. The vulnerability of patients and family members became apparent to the students. The reflections following the simulation scenarios contributed to further development of thoughts about EOL conversations. Scenarios should be as authentic as possible, and information and preparations are important. Uncertainty can hinder learning

Students became aware of the importance of being open and reflective when encountering existential issues

Morita et al. (2014) Japan [43]

To determine the impact on nurses of a novel two-day education program focusing on care that addresses patients´ feelings of meaninglessness

Nurses in PC units/inpatient hospices, in PC consultation teams, or on general medical wards

Intervention group (n = 36); 35 females, age NR

Control group (n 40); 39 females, age NR

Two-day educational workshop: lecture, demonstration, role-play and group work based on case vignette using the SpiPas^f. Nurse facilitators coordinated all the activities

After being introduced to the case vignette participants were divided into small groups (6–7 nurses per group) and discussed relevant questions. On day two, each group created nursing care plans through group work and shared them for discussion. Role-play for communication with the patient were then performed

Case vignette: Terminally ill cancer patient suffering from increased dependency, being a burden and feeling of meaninglessness

Randomized controlled trial

A significant increase in nurse-reported confidence after the intervention (effect sizes of 0.8). No significant intervention effects identified in self-reported practice, in attitudes toward caring for patients who experience feelings of meaninglessness, in the burnout score, nurses’ own spiritual wellbeing, and knowledge

Northam et al. (2015) Australia [40]

To describe and evaluate the effectiveness of an educational innovation designed to develop graduate-level critical care nurses’ capacity for effective interpersonal communication, as members of a multidisciplinary team in providing culturally sensitive EOL care

Graduate critical care nursing course at university

12 graduate nursing students in critical care, sex NR, Age NR, 5 had and an international background

Weekly workshop (12 workshops): Teaching and learning sessions with integrated and aligned intervention utilizing the EXCELL^g tools, vignettes with discussion, simulation, and cases

Each student offered opportunity to share a story of their experience of their own culture and experience of death which was used as a discussion prompt and opened a new understanding between the students. Students were encouraged to develop a set of support strategies/a toolbox which were collaboratively developed using their own experienced scenarios and tested in a safe environment in the workshops. In the scenarios students were encouraged to explore the support available for them in complex scenarios, as part of alliance building within the team. A range of vignettes were developed to trigger discussion around EOL care

Care of critically ill child, interprofessional team and actor as mother who are present at the resuscitation bed in the emergency department; complicated cardiogenic shock; new admission to ICU of a critically ill patient when death is probable; interaction with family members with very limited ability to communicate in English language; care of the deceased in the emergency department; when clinical signs indicate the patient is brain dead; when there are indications that withdrawal of life sustaining treatment may be in the patients best interest; communication with families of suicide victims and survivors

A pilot mixed method design

Increase in students’ cultural learning scores in a range of areas including understandings of cultural diversity, interpersonal skills, cross cultural interactions and participating in multicultural groups (no statistical analyses provided). Enhanced levels of nurse confidence in approaching EOL care in both emergency department and intensive care environments

Okada et al. (2021) Japan [46]

To investigate how healthcare providers who attended the E-FIELD^h program changed before and after the course in terms of their ACP knowledge, confidence, communication difficulty, and practices

Hospitals with more than 500 beds, hospitals with less than 500 beds and others

160 nurses; 153 females, mean age 43.8 (SD 8.0) years

Ice-breaker, 4-h text-based lecture using a textbook common to all professions, 4 h of small group discussions on a case requiring decision support, 4 h of role-play in ACP-specific scenarios, and discussions on these role-plays. In the role-plays family members were placed in addition to the patient role. Discussions and role-play were conducted in groups of four, consisting of different professions. One facilitator assigned to each group. Facilitators participated in a 10-h training workshop to facilitate communication skills

Scenarios NR in detail, but described as specific to ACP, such as introduction to ACP, selection of surrogate decision maker and decision-making regarding life-sustaining treatment. Family treated as secondpart, considering the cultural characteristics of Japan

Longitudinal survey

Significant increase in knowledge and confidence scores from before training to immediately after training. There was a significant decrease in communication difficulty 6 months after training compared with before training

Roth et al., (2017) US [42]

To evaluate the effectiveness and usefulness of a COMFORT model in strengthening perceived communication confidence of APRN

An acute nurse practitioner program at university

24 adult gerontology acute care nurse practitioner students; 85% females, mean age 37.5 (SD 7.4, age range 27 and 53) years

Simulations completed over a 3 week period during course semester combing a didactic portion of the COMFORT model with a standardized family simulation experience. Participants were introduced to a disorienting dilemma to practice the principles of the COMFORT-model. Debriefing session following the simulation experience

Patient with chronic obstructive pulmonary disease, ischemic heart disease, hypertension and implanted cardiac defibrillator brought into the emergency room with severe respiratory distress. The patient requiring intubation and transfer to ICU. Patient´s exspouse and patient´s sister arguing at odds about the goals of care

Descriptive pre and post survey

Improvements in perceived confidence for initiating potentially difficult communication topics and managing emotional needs of families. APRN positively indicated the COMFORT model as a useful tool for guiding difficult discussion and an effective strategy for guiding APRN communication at EOL

Decrease in confidence levels after a SBL session with focus on a difficult family situation, feeling unprepared for family questions, overwhelmed by family emotions, and that they struggled with their role responsibility