Date of Completion


Embargo Period



advance care planning, simulation, palliative care, registered nurses

Major Advisor

Dr. Carol Polifroni

Associate Advisor

Dr. Carrie Eaton

Associate Advisor

Dr. Millicent Malcolm

Field of Study



Doctor of Philosophy

Open Access

Open Access


Background: Advance care planning (ACP) conversations aim to ensure the articulation and documentation of patients’ health care goals. These conversations should occur early and longitudinally. However, they are often not done or not done iteratively. Clinicians lack training and knowledge in ACP to have effective conversations. Therefore, a simulation was developed and tested among registered nurses (RN).

Aim: This study aimed to examine the feasibility of an ACP simulation called Conversations Had at Trying Times (CHATT) among RNs, and to explore changes in knowledge, attitudes, and self-efficacy.

Theoretical Framework: A framework was developed with the National League of Nursing Jeffries Simulation Theory and Bandura’s Self-Efficacy Theory.

Method: The study consisted of two phases: a) simulation development, and b) simulation testing. Construct and content validity guided the development of the simulation using DeVellis’s (2017) scale development guidelines and the International Association of Clinical Simulation in Learning Standards of Best Practice: Simulation DesignSM. Simulation testing consisted of a pilot one-group pre/posttest design. The Caring Efficacy Scale and the Advance Care Planning Knowledge, Attitudes, and Practice Behaviors Scale were used to assess knowledge, attitudes, and self-efficacy among RNs. Evaluation of the simulation was done with the Simulation Design Scale and Student Satisfaction and Self Confidence in Learning Scale. Data analysis consisted of statistical analysis of mean change from pre-to-post simulation, and calculations of correlations between variables and demographics.

Results: A researcher-designed high-fidelity simulation enhanced nurses’ skills with CHATT. Thirty-six RNs completed the simulation in groups of four to eight in six simulation sessions. Knowledge, attitudes, and self-efficacy increased pre-to posttest. Evaluations post-simulation confirmed the feasibility of the simulation. The largest variation in results was found among the scores and experiences of the graduate nurse resident groups who worked as RNs for less than one year.

Significance and Conclusions: This is the first high-fidelity simulation that was developed and validated for RN education in ACP conversations. Newer nurses with less than one year of experience had the lowest scores, which suggests a need for professional development in hospice and palliative care, curriculum development among nursing schools, and strong mentorship in caring for seriously ill patients.

Available for download on Friday, April 23, 2021