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Simulations help nursing students deal with patient deaths

Nurses practicing patient care simulation.

Nursing students Kayla Croom (far right) and Brianna Churakos (center) practice caring for a dying patient as simulation coordinator James Cozza (left) checks the patient's vital signs. Photo: Douglas Levere


Published June 5, 2023

“I didn’t really know how to handle it. I had never experienced a patient die in front of me at the time. ”
Rafael Diaz, May graduate
School of Nursing

School of Nursing senior Rafael Diaz was caring for a patient in the Intensive Care Unit at Buffalo General Medical Center. “The next thing” he knew, “she was unresponsive,” he recalls.

“I didn’t really know how to handle it,” says Diaz. “I had never experienced a patient die in front of me at the time.”

Before graduating from the traditional nursing program in May, Diaz underwent patient death simulation training, one of the latest examples of how the nursing school is using simulation to prepare students for actual patient care. It’s now part of the required curriculum.

“Before this simulation, I didn’t truly know how health care providers handled situations like this,” says Diaz, who will soon be working as a nurse in a New York City hospital.

“Having done this simulation, I believe the way I approach patient deaths has changed significantly. I was able to make mistakes with no true consequences and learn from them. I was able to ask questions after our simulation and understand why certain things are done in events like this,” he says. “A few months after, I took the knowledge I had learned in the simulation and applied it to real-world scenarios, where I had patients die in front of me, and without the simulation, I believe I wouldn’t have handled those events as well.”

Diaz is not alone, say nursing administrators and faculty, who understand patient death is a universal experience. Patients die, and what happens then?

Kelly Foltz-Ramos, assistant professor and director of simulation for the nursing school, can relate. Foltz-Ramos clearly knows where the idea came from for the student simulation program she designed, and Diaz and other UB students took part in: It was the first time Foltz-Ramos experienced death working as a medical/surgical nurse.

Kelly Foltz-Ramos, Director of Simulation, runs the nursing simulation.

Kelly Foltz-Ramos, assistant professor and director of simulation, runs the nursing simulation. Photo: Douglas Levere

“I remember not feeling prepared, not knowing what to do — for my patient, the patient’s family or even myself,” she says.

Years later, as a nurse educator and simulation expert, Foltz-Ramos searched the professional literature and found that education about patient death was “universally lacking,” even outside of nursing.

“In the health care simulation realm, it was frowned upon to let the patient die during simulation, with the reasoning that it could decrease student self-confidence, something we are trying to boost in simulation,” says Foltz-Ramos. “I felt strongly that simulation in a controlled, safe environment was a perfect place to better prepare students for patient death.”

That was then. Foltz-Ramos has become a prominent expert and advocate of teaching nurses through simulation. She says most nursing educators agree that simulation — including using standardized patient actors and virtual reality experiences — will play a greater role in nursing education in the future. The training Diaz and other UB nursing students received is now part of the senior course “Wellness & Illness: Concepts with Individuals, Families and Communities II.”

“In simulation, you can give students opportunities to collaborate with other professionals and teach skills like communication and conflict resolution, which we know leads to lower patient mortality,” Foltz-Ramos says.

“There is also research showing nursing students are lacking in clinical judgment skills needed for decision-making during an event, and that affects their retention rate,” she explains. “If we can increase their judgment skills prior to graduation, they will be better-equipped, and we will do a better job of retaining them.”

While clinical experience will always be important, there’s no guarantee a student’s hours spent in a hospital setting will include a high-pressure event like a difficult birth or a cardiac arrest, Foltz-Ramos notes. And even if it does, their role would be as an observer, not a decision-maker.

“Using high-tech simulation, we can make those experiences possible ahead of time, so all of our students will have experienced a crisis situation that they know how to respond to if it occurs when they are caring for a patient,” she says.

Research reinforces value of simulation

Foltz-Ramos’ views regarding patient death simulation are reinforced by a study she led that found that debriefing following a patient death improved the emotional state of nursing students.

“In debriefing immediately following the scenario for the students who experienced patient death, the first thing I stressed was that no matter what they had done during the scenario, the patient was going to die,” Foltz-Ramos says.

“The results of the study, to me, showed that simulation can be an effective method to teach students how to handle patient death, stressing the importance of debriefing,” she says.

The benefits of simulation are far-reaching. In the current state of nursing education — with a shortage of clinical placements and changing patient population — simulation can bridge the gap, giving students the experience they need to be successful.

“I would argue that simulation is better than a bridge though, because the experiences are guaranteed, in a safe environment, with students making clinical decisions, followed by self-reflection. Practice in the clinical setting is critical and necessary, but I believe learning in simulation is just as critical and necessary.”

Simulations stressful for students

Her students agree.

Brianna Churakos, who graduated this May with a BS in the traditional nursing program, was in the Hospice rotation and had experienced deaths in her family. “So the concept of death was not all that new to me,” she says.

“Nevertheless, going into any simulation is stressful,” Churakos adds. “And having your patient decompensate quickly like ours did is even more so.”

The students were told their simulated patient was a DNR/DNI (do not resuscitate/intubate), giving them some idea how to care for them.

“Regardless of having an idea, the simulation brought high feelings of stress and emotions, as our patient decompensated and passed away,” says Churakos, who plans on working in the pediatric ICU at Oishei Children’s Hospital. 

She says the simulation was especially helpful for those who haven’t experienced much death in their personal or professional lives.

“The simulation showed us the importance of having a moment with our patient to give them and ourselves that much needed emotional validation, as we sat with the patient for a few moments following their death.

“Should I experience this event in real life, I feel that I will have just a bit more insight as to how I go about caring for the patient, addressing other health care professionals, and then reaching out to the family,” Churakos says.

“Death is inevitable and unfortunately the health care field sees a lot of it. It is so important to at least become acquainted with events such as this so you can realize what you know, don’t know and how to address your thoughts and feelings.”