Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners’ confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the “right way.” The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.
Death notification is an important and challenging aspect of Emergency Medicine. An emergency medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. On average 270,000 patients die in United States emergency departments each year1. This number is anticipated to increase as the population ages2. Unskilled death notification can lead to the development of pathologic grief and posttraumatic stress disorder3,4,5. It is paramount for emergency medicine physicians to be trained in and practice death notification.
Graduate and undergraduate medical educators employ a variety of death notification techniques when teaching residents and medical students to deliver bad news6,7,8. One example is the GRIEV_ING curriculum. It provides medical personnel a conceptual framework for death notification. The curriculum has demonstrated improvement in learners’ confidence and competence when delivering bad news8.
Rapid Cycle Deliberate Practice (RCDP) is a simulation-based medical education technique that uses within-scenario debriefing9. This technique is based on the concepts of mastery learning and deliberate practice9,10,11. It allows educators to pause a scenario, provide directed feedback, and then let learners rewind and continue the simulation scenario the “right way.” The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news12.
In preparation for this curriculum, learners are given a 45-minute lecture on the principles of death notification and the GRIEV_ING conceptual framework. Prior to starting the simulation session, faculty perform a prebrief of the objectives, RCDP and simulation environment logistic details, establish a fiction contract with the learners and pledge to respect the learners13,14,15. The learners are split into groups of 4-5 and assigned an examination room with a faculty member and standardized patient. Each learner is given a GRIEV_ING pocket card to reference during the simulation. To start, one learner is selected from each group to perform the first death notification scenario. This first death notification serves as a needs assessment for the faculty. It is allowed to run from start to finish without interruption. Next, the same learner performs a new death notification simulation using the same scenario, this time RCDP is used by the faculty to provide feedback throughout the death notification scenario. Faculty pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. The scenario is then restarted by the standardized patient.
All methods described here were found to be exempt from review by the Indiana University Institutional Review Board.
- E-mail the GRIEV_ING pocket card (Figure 1) to all faculty one week prior to the scheduled simulation session.
- E-mail the death notification simulation scenarios (Supplement 1), that include patient role and background history, to the standardized patients one week prior to the scheduled simulation session.
- Prepare the simulation examination rooms prior to beginning the death notification simulation exercise.
- Place a chair for the standardized patient and a stool for the learner in each examination room.
- Print patient scenario information (Supplement 2), which includes name, age, gender, background, present condition and survivor present, and post outside each exam room for learners. Have faculty read death notification scenarios prior to the start of the session.
2. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise Pre-brief
- Gather all faculty and learners in one room. Review the simulation session goals and objectives.
- Review logistic details about RCDP and the simulation environment.
- Form a fiction contract with the learners and pledge to respect the learners.
NOTE: A fiction contract is an agreement between the educators and learners. This creates the expectation that educators attempt to create as realistic of simulation environment as possible while the learners pretend that things are real and actively participate in the educational experience14.
- Divide the learners into groups of no more than 4-5 learners.
- Assign each learner group an examination room with a faculty member and standardized patient.
- Give each learner a GRIEV_ING pocket card to reference during the simulation (Figure 1).
3. Rapid Cycle Deliberate Practice GRIEV_ING Simulation Exercise
- Select one learner from each group to perform the initial death notification scenario.
- Position the standardized patient in the exam room. Have the learners to review the simulation scenario case details posted outside the exam room.
- Start the initial death notification scenario. Run the scenario from start to finish without interruption. Identify specific areas that necessitate feedback.
- Perform a micro-debriefing at the conclusion of first scenario. Give succinct feedback to learners on initial performance in less than 5 minutes.
- Reset the scenario and place the learners outside the room. Perform the same simulation scenario from the beginning. Begin with the same learner as the leader for the second round of the scenario.
- Apply the RCDP technique during the scenario. Pause the scenario, provide directed feedback and then rewind the scenario 30-60 seconds. Have the standardized patient to restart the scenario.
NOTE: In order to allow multiple students to participate in a single scenario, faculty can switch out the participating learner by “tagging in” observing students to continue the scenario. For example, if John started the scenario, faculty can stop, give feedback and rewind the scenario. Faculty then “tags in” Sam to resume the scenario as the new active participant from where John left off. Faculty should make sure all learners have an opportunity to be in the “hot seat” throughout the allotted training time.
- Perform a micro-debriefing at the conclusion of the scenario training period. Provide constructive feedback to the learners.
- Repeat the scenario again from the start and continue with the RCDP approach.
NOTE: The goal is to need less interruptions each time the scenario is performed. The RCDP simulation exercise requires 45-50 minutes.
4. Rapid Cycle Deliberate Practice GRIEV_ING Wrap Up
- Gather all faculty and learners in one room for a group wrap-up at the conclusion of the simulation training. Focus on key take-home points from the training and allow for learner feedback during the 15 minute wrap-up.
As noted in Ahmed et al., the study involved 22 emergency medicine residents12. Learners’ median self-efficacy and knowledge scores increased from 3 to 4 and 65 to 90, respectively, when comparing pre- and post-simulation results. In addition, pre- and post-intervention death notification performance scores improved (Table 1).
Qualitative themes from the post-curriculum surveys by Ahmed et al. were that this exercise was a great experience and provided instant feedback12. Residents felt the RCDP Death Notification Curriculum solidified their death notification skills and allowed them the opportunity to refine their technique. Only one resident preferred the tradition simulation method with no interruptions.
Figure 1: GRIEV_ING pocket card. Pocket card with overview of GRIEV_ING curriculum. This figure has been modified from research by Ahmed et al.12. Please click here to view a larger version of this figure.
|Self-efficacy Survey||3.0 (3.0-4.0)||4.0 (4.0-5.0)||<0.0001|
|MCQ Scores||65.0 (40.0-80.0)||90.0 (80.0-90.0)||<0.0001|
|Case A||Case B||P-Value*|
|Death Notification Scores||78.7 (72.3-85.1)||84.0 (80.9-93.6)||0.0303|
|*estimated using Wilcoxon|
Table 1: RCDP Death Notification Curriculum results. Scores from participants (N=22). Median pre- and post- scores were calculated. Wilcoxon rank sum test was used to test for score differences between pre- and post-intervention groups. All statistical analysis was performed using SAS Version 9.4. This table has been modified from research by Ahmed et al.12.
The RCDP death notification curriculum consists of several critical steps. First, the prebrief is critical to introduce the concept of RCDP and create psychological safety for learners. Learners who feel psychologically safe have less anxiety and feel more comfortable making mistakes, allowing for optimization of the learning experience13,14,15. In addition, the curriculum requires that educators provide learners with an overview of the GRIEV_ING framework and death notification materials prior to the simulation session. This allows the students to be more engaged in the simulation and use the session to refine death notification skills. Each learner is given a GRIEV_ING pocket card during simulation session. Learners in an observational role are able to follow along and remain actively engaged. Possible modifications of this simulation protocol include altering group size or providing the GRIEV_ING pocket card to the learners prior to the event.
During the simulation, a key step is running the first death notification scenario from start to finish without interruption. This needs assessment displays the learner’s baseline skill and enables the faculty member to identify areas of weakness and provides a roadmap when subsequently implementing the RCDP technique. RCDP provides the student an opportunity to incorporate the feedback provided and demonstrate optimal performance. It allows learners to practice through repetition with expert feedback and direct coaching. Faculty can correct performance gaps while maximizing the time spent practicing. This has been shown to increase learning without cognitive overload9.
Lastly, it is critical to repeat the same scenario again from the start and continue with the RCDP approach. The goal is to have fewer interruptions each time the scenario is performed. This allows learners to continuously improve throughout the simulation session and leads to mastery9,10,11. This differs from traditional simulation training in that faculty can immediately visualize improvement in performance.
There are few limitations to executing the RCDP death notification curriculum. This exercise does not require any particular equipment or setup. It does require one standardized patient per every 4-5 learners. Standardized patients should be trained and have experience playing the role of a grieving patient. This training includes acting methods on how to accurately portray psychosocial characteristics and emotions. It can be provided by the simulation staff or standardized patient liaison. In addition, faculty must be knowledgeable in RCDP in order to use this technique successfully in the training. Lack of faculty with formal simulation training and experience using RCDP creates practice variation. This introduces subjectivity into the training experience.
Currently, there is limited literature on improving delivery of bad news using RCDP. This innovative technique allows learners to rewind and practice each part of the scenario until mastery is achieved. Future directions for this study include assessment of skill retention using the RCDP technique, directly comparing this technique to traditional simulation approaches, and investigating how this curriculum translates to effectiveness of death notification in the clinical environment.
The authors have nothing to disclose.
The authors have no acknowledgements.
|Facial Tissues||Standardized patients will need for simulated crying|
|GRIEV_ING pocket card|
- US Department of Health and Human Services. National Hospital Ambulatory Medical Care Survey: 2016 Emergency Department Summary Tables. Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/nchs/data/nhamcs/web_tables/2016_ed_web_tables.pdf (2016).
- Sun, R., Karaca, Z., Wong, H. S. Trends in Hospital Emergency Department Visits by Age and Payer, 2006-2015. HCUP Statistical Brief #238. Available from: www.hcup-us.ahrq.gov/reports/statbriefs/sb238-Emergency-Department-Age-Payer-2006-2015.pdf (2018).
- Waiters, D. T., Tupin, J. P. Family grief in the emergency department. Emergency Medicine Clinics of North America. 9, (1), 189-206 (1991).
- Breslau, N., et al. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma. Archives of General Psychiatry. 55, (7), 626-632 (1998).
- Stewart, A. E. Complicated bereavement and posttraumatic stress disorder following fatal car crashes: recommendations for death notification practice. Death Studies. 23, (4), 289-321 (1999).
- Shoenberger, J. M., Yeghiazarian, S., Rios, C., Henderson, S. O. Death Notification in the Emergency Department: survivors and physicians. Western Journal of Emergency Medicine. 14, (2), 181-185 (2013).
- Park, I., Gupta, A., Mandani, K., Haubner, L., Peckler, B. Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol. Journal of Emergencies, Trauma, and Shock. 3, (4), 385-388 (2010).
- Hobgood, C., Harward, D., Newton, K., Davis, W. The educational intervention "GRIEV_ING" improves the death notification skills of residents. Academic Emergency Medicine. 12, (4), 296-301 (2005).
- Chancey, R. J., Sampayo, E. M., Lemke, D. S., Doughty, C. B. Learners' Experience During Rapid Cycle Deliberate Practice Simulations: A Qualitative Analysis. Simulation in Healthcare. 14, (1), 18-28 (2019).
- Hunt, E. A., et al. Pediatric resident resuscitation skills improve after "rapid cycle deliberate practice" training. Resuscitation. 85, (7), 945-951 (2014).
- Taras, J., Everett, T. Rapid Cycle Deliberate Practice in Medical Education- a Systematic Review. Cureus. 9, (4), 1180 (2017).
- Ahmed, R. A., et al. Rapid Cycle Deliberate Practice: Death Notification. The Clinical Teacher. (2020).
- Stephenson, E., Poore, J. Tips for Conducting the Pre-Brief for a Simulation. The Journal of Continuing Education in Nursing. 47, (8), 353-355 (2016).
- Rudolph, J. W., Raemer, D. B., Simon, R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simulation in Healthcare. 9, (6), 339-349 (2014).
- Hughes, P. G., Hughes, K. E. Briefing Prior to Simulation Activity. StatPearls. StatPearls Publishing. Treasure Island, FL. (2020).