Scenario for simulation training on the communication of hard news: A validation study

Abstract

Objective

to build and validate a realistic simulation scenario about the communication of hard news in the context of palliative care for undergraduate Nursing students.

Method

a methodological study that followed three stages; construction of the scenario, which was based on the frameworks about simulation, communication of hard news and palliative care; content validation, in which nine judges analyzed adequacy of the scenario, through a Likert scale, to calculate the Content Validity Index (CVI) and of the suggestions described in the scenario analysis instrument; and scenario test, which was conducted with 15 undergraduate Nursing students who analyzed it using the Simulation Design Scale (SDS). In this sample, the analysis of the scale's reliability was verified by Cronbach's Alpha.

Results

the judges considered the scenario's content as adequate. The scenario's CVI was 0.84. After testing the scenario, the students pointed out the simulation design's suitability and considered it adequate to solve the problem. The overall Cronbach's alpha for the SDS scale was 0.89.

Conclusion and implications for the practice

the process of constructing and validating the scenario on the communication of hard news resulted in the production of valid and consistent material for teaching and research in the area of Palliative Care.

Keywords:
Simulation Training; Communication; Nursing; Validation Studies; Palliative Care

Resumo

Objetivo

construir e validar um cenário de simulação realística sobre comunicação de notícias difíceis no contexto de cuidados paliativos para graduandos de enfermagem.

Método

estudo metodológico, que seguiu três etapas; construção do cenário, fundamentada nos referenciais sobre simulação, comunicação de notícias difíceis e cuidados paliativos; validação de conteúdo, na qual nove juízes analisaram a adequação do cenário, por meio de uma escala Likert, para computar o Índice Validade de Conteúdo (IVC) e, de sugestões descritas no instrumento de análise do cenário; teste do cenário, que ocorreu com 15 estudantes de graduação em enfermagem que o analisaram pela Escala de Design da Simulação (EDS). Nesta amostra, a análise da fidedignidade da escala foi verificada pelo alfa de Cronbach.

Resultados

os juízes consideraram o conteúdo do cenário adequado. O IVC do cenário foi 0,84. Após o teste do cenário, os estudantes apontaram a adequação do design da simulação considerando-a adequada para a resolução do problema. O alfa de Cronbach foi 0,89 para o total da EDS.

Conclusão e implicações para a prática

o processo de construção e validação do cenário sobre comunicação de notícias difíceis resultou na produção de um material válido e consistente para ensino e pesquisas na área de cuidados paliativos.

Palavras-chave:
Treinamento por Simulação; Comunicação; Enfermagem; Estudos de Validação; Cuidados Paliativos

Resumen

Objetivo

construir y validar un escenario de simulación realista sobre la comunicación de noticias difíciles en el contexto de los cuidados paliativos para estudiantes de enfermería.

Método

estudio metodológico, que se desarrolló en tres etapas; construcción del escenario, basada en referencias sobre simulación, comunicación de noticias difíciles y cuidados paliativos; validación de contenido, en la que nueve jueces analizaron la adecuación del escenario, a través de una escala Likert, para computar el Índice de Validez de Contenido (IVC) y de las sugerencias descriptas en el instrumento de análisis de escenarios; prueba de escenario, que se llevó a cabo con 15 estudiantes de licenciatura en enfermería que lo analizaron mediante la Escala de Diseño de Simulación (EDS). En esta muestra, el análisis de confiabilidad de la escala se verificó por el alfa de Cronbach.

Resultados

los jueces consideraron adecuado el contenido del escenario. El CVI del escenario fue 0,84. Luego de testear el escenario, los estudiantes señalaron la idoneidad del diseño de la simulación y lo consideraron adecuado para resolver el problema. El alfa de Cronbach fue de 0,89 para la EDS total.

Conclusión e implicaciones para la práctica

el proceso de construcción y validación del escenario sobre la comunicación de noticias difíciles resultó en la producción de material válido y consistente para la docencia e investigación en el área de cuidados paliativos.

Palabras-clave:
Entrenamiento Simulado; Comunicación; Enfermería; Estudio de Validación; Cuidados Paliativos

INTRODUCTION

The development of human relationships is closely related to the ability to communicate. Every day, individuals adapt their verbal and non-verbal expressions to communicate in different contexts. Even so, this process can subjected to interference when it comes to the need for communication with people who are receiving health care and with their family members¹.

Thus, the health team must be prepared to communicate effectively in the various services that comprise the health care network. Thus, it is evident that the ability to communicate is a fundamental attribute for the training of Nursing professionals, as they are active agents in the communication of information to people and their families who are under their care².

In addition to that, nurses deal with hard news and different moments in the professional context, which can be before, during or after people are informed of a diagnosis, need for treatment or test results, in the management of consequences of the health condition imposed by the disease, in the management of emotions generated by the hard news, and during end-of-life care³.

Hard news is understood as “any information that is likely to drastically alter the patient's future perspective”^4:1597, which contributes to the expression of feelings in different ways and has different meanings for those who receive it^3-5. These characteristics make the hard news communication process challenging for the professionals, as well as for training communication skills during qualification.

In palliative care, communication of hard news frequently occurs to inform about the care measures proposed, experiences imposed by the treatment, evolution and progression of the disease, specific issues at the end of life and promotion of spiritual comfort^4,5. Achievement of good results in palliative care depends on the effectiveness of communication between the team, users of the health services and their family members.

To carry out communication on these topics, hard news communication skills are required from the professionals; such skills require preparation and knowledge of strategies to provide distressing information and handle the reactions resulting from this information^6,7.

However, it is still challenging to state that Nursing professionals and students in the health area in general are sufficiently prepared to communicate in these situations⁸ since, during their training, communication experiences are not provided in this context and, many times, this skill is developed during the years of professional life, which is not ideal, as it exposes the professionals to distressing and stressful moments⁷. Knowing this reality, insertion of active and innovative methodologies, such as simulation, in the training context of these professionals is crucial⁹.

Studies that analyzed the effect of simulation in preparing professionals to communicate hard news in palliative care showed that fundamental skills were improved, such as developing active listening, empathy and non-verbal communication, in addition to improving confidence to communicate and take care of people in palliative care^1,7.

Currently, training through simulation has been identified by several studies as the main way to teach health professionals to communicate hard news in palliative care¹⁰. This type of learning experience offers an opportunity to improve communication skills in students and professionals, as they are activities that represent real or potential situations of the practice and allow the participants to develop or improve their knowledge, skills and attitudes in a simulated environment¹¹.

Despite the essentiality of the practice, simulations require adequate planning. One of the fundamental elements for this planning is the scenario that needs to be carefully developed to guarantee the quality of the learning experiences^8,12.

The scenarios consist in documenting the details that will happen during the simulation, with information on determining who will be the simulation participants, instructions for these participants, learning objectives, environment preparation, equipment, assessment tools, clinical case and duration, among others. The detailed construction of these scenarios, plus validation by specialists, is a way to elaborate complete scenarios, capable of being reproduced by different groups, contexts and of representing reality, resulting in successful learning through simulation.

In view of this, this study aimed at building and validating a realistic simulation scenario about communication of hard news in the context of palliative care for undergraduate Nursing students.

METHOD

This is a methodological study aimed at building and validating a scenario for training through simulation, developed in three stages, namely; construction of the scenario, scenario content validation by an experts' panel, and scenario test with undergraduate Nursing students. It was developed from August 2017 to December 2018.

Initially, construction of the scenario was supported by scientific evidence on the communication of hard news, from a literature review in databases to gather the main protocols and references on the communication of hard news, which were incorporated in the writing of the fundamental elements of the scenario. The scenario elaborated considered the recommendations set forth in the International Nursing Association for Clinical Simulation and Learning (INACSL), which proposes good practices and fundamental elements for the construction of scenarios¹³. In addition to that, the scenario's script contemplated the elements proposed for their description, as described in Chart 1 ¹⁴.

Chart 1
Definitions of the elements used in the scenario description.

Element of the scenario	Definition
Context	Description of the name of the scenario, participant's profile and prerequisites, location where the simulation will take place, purpose of the simulation (educational or assessment) and methods employed to assess the participant.
People in charge	Description of the facilitators responsible for the scenario.
Learning objectives	Description of what is intended to be achieved in the learning context, described by the general (broad and reflects the simulation proposal) and specific (related to the participants' performance measures and comprising technical and non-technical skills) objectives.
Duration	Definition of the time for the simulation and debriefing.
Preparation of the participants	Description of the resources employed to prepare the participants for the simulation (Example: recommended readings, participation in courses, teaching sessions, review of laboratory skills).
Simulation modality	Discrimination regarding the simulation modality: using simulators, actors, digital, in the laboratory, in situ or hybrid.
Design	Description of the necessary equipment and materials, detailing the participants' roles and characteristics of the simulators, actors or both.
Pre-briefing	Description of the general guidelines for the simulation, with definition of the roles among the participants, presentation of the environment, equipment and documentation used in the simulation.
Briefing	Description of the information provided immediately before starting the simulation with brief information about the case to be experienced.
Instructions for the actors	Detailed information for actors about the characteristics of the character, lines, equipment and case.
Simulation progression	Description of the scenes with the respective time information, speeches by the facilitator and actors, actions expected from the participants, planning for the participants to be able to achieve the objectives (clues), strategies that help the participants to maintain the simulation focus, if necessary, and outcomes for completing the simulation.
Debriefing	Description of the debriefing model chosen for the simulation.

For content validation, a panel of judges was assembled based on the following inclusion criteria: being a health professional; having clinical experience in the Palliative Care area, with professional experience in the area for a minimum period of six months; or being a researcher in the field of communication and/or palliative care, with scientific publications on the topic(s); or being a clinical simulation facilitator, with certification of this training, or having experience in facilitating simulation-based activities for a minimum period of six months. No exclusion criteria were established. The number stipulated to make up the panel of judges was between six and twenty, following recommendations from the literature for studies of this nature¹⁵.

The judges were selected based on a search in Brazilian publications on the theme, in the Lattes Platform of the National Council for Scientific and Technological Development (http://lattes.cnpq.br), and following the snowball strategy (when a participant indicates a potential judge they know). Thus, nine judges participated in this stage.

For the scenario test, the participants were selected based on the following inclusion criteria: being a Nursing student; having attended or attending courses in the areas of communication and children's health, and being 18 years old or older. The scenario considered that the target audience of the scenario would be students who had already had some level of approximation with children's health care, due to the characteristics of the clinical case prepared; thus, the researchers' intention was that the test was conducted with participants who met these characteristics. The following was established as an exclusion criterion: having some emotional or psychological condition that limited participation in the simulation; this criterion was evaluated when the researchers explained the study procedures and the participants were encouraged to verbalize such conditions to the researchers at any moment.

The students were selected for convenience, based on social media recruitment and voluntary enrollment. As there is no standardization regarding the minimum number of participants for scenario test studies, the authors established a minimum number of 10, based on a publication about scenario validation¹⁶. Therefore, 15 students took part in this stage.

Content validation by the panel of judges took place virtually; they were contacted via email and invited to participate in the study. After acceptance, the data collection instruments were sent via an access link to a form developed in the Google Forms ^® application. In this form, in addition to the scenario to be analyzed, there were some questions to characterize the judges and others to validate the scenario's content.

The information collected to characterize the judges was as follows: professional training, experience with simulation, palliative care and communication, and length of experience with each topic. For the validation of the scenario's content, each element was analyzed for suitability and, for this, criteria were elaborated that allowed for this analysis. Each of the criteria, presented in their entirety in Table 1, was answered according to the following scale: 1=totally adequate, 2=partially adequate and 3=inadequate. If the judges wished so, it was possible to make notes and suggestions regarding the content, in spaces that were left at the end of the content assessment of each element of the scenario.

Table 1
Content Validity Index (CVI) of the hard news simulation scenario. São Carlos, SP, Brazil, 2018. (n=09).

	Adequacy
Evaluation Criteria	1	2	3	CVI
The information in context allows for an overview of the scenario	7	2	0	0.78
The learning objectives are adequately described	6	3	0	0.67
The data on the scenario design are complete	5	4	0	0.56
The strategies for preparing the participants are adequate	6	3	0	0.67
The information provided in the pre-briefing and briefing is sufficient	7	2	0	0.78
The instructions offered to the actress are sufficient	4	7	0	0.44
The scenes are consistent with the speeches and clues	9	0	0	1
The scenes allow the participants to perform the expected actions	9	0	0	1
The outcomes are clearly described	9	0	0	1
The debriefing structure is appropriate	7	2	0	0.78
Coherence between the clinical case and the simulation purpose	9	0	0	1
Scenario realism	7	2	0	0.78
Complexity in relation to the student's level of knowledge and skills	9	0	0	1
Information provided to the participants before the simulation	7	2	0	0.78
Information provided to the participants during the simulation	9	0	0	1
Support provided to the participants during the simulation	8	1	0	0.89
Promotion of critical thinking	9	0	0	1
Promotion of the ability to employ communication strategies	8	1	0	0.89
Promotion of autonomous problem solving	9	0	0	1
Overall CVI	0.84

• ^*
  CVI: Content Validity Index Source: Research data.

The scenario test took place in a simulation unit at a public higher education university in the inland of the state of São Paulo, among participants of an educational strategy called “Workshop on the Communication of Hard News”, in which they attended an expository class and talked about hard news communication strategies to later participate in the simulation. Each workshop was offered to five students at a time and, during the simulation, two of them voluntarily participated in the simulation in an active and the others only attended it. Before starting the Workshop, the students were informed about the study and, after consenting to participate, they filled out a characterization instrument and the FICF. At the end of the simulation, the students answered the Simulation Design Scale (SDS)¹⁷.

The instrument to characterize the students included information on age, period in which they were in the Nursing course and previous experience in curricular and/or extracurricular activities on the communication of hard news.

The purpose of the SDS scale is to assess the structure of scenarios based on participation in the simulation. It was developed by the National League for Nursing, originally in English, but has been translated, adapted and validated for use in Brazil. It is a 20-item scale, consisting of five factors that assess the following: objectives and information, support, problem solving, feedback and reflection, and realism. Each item is answered in a five-point Likert-type scale varying from 1 = Totally disagree with the statement to 5 = Totally agree with the statement, with the possibility of answering “not applicable”, when the statement expressed in the item does not concern the simulation performed. To obtain the score, the mean of each factor and the total of the scale are calculated; the higher results represent a better perception of the respondent in relation to the scenario design¹⁷.

The data obtained in this study were compiled into a Microsoft Excel^® spreadsheet and analyzed according to the specificity of the research stage (content validation and scenario test).

The data resulting from content validation were analyzed in two ways: analysis of the suggestions made by the researchers, and calculation of the Content Validity Index (CVI). Analysis of the suggestions consisted in discussing them among the researchers for the decision to incorporate them into the scenario. The CVI was verified by each scenario analysis criterion and, by the total set of criteria, it was established that a value equal to or greater than 0.70 for each criterion was considered valid¹⁵. Data regarding the study participants' characterization (specialists and students), as well as the results of applying the SDS scale, were analyzed using descriptive statistics. Reliability of the SDS scale in this sample was assessed by Cronbach's alpha: values above 0.70 indicated adequate reliability¹⁸.

The ethical precepts established by Resolution No. 466/2012 of the National Health Council were followed, so that the study proposal was appreciated and approved by the Research Ethics Committee (CAAE: 91085318.6.0000.5504) with opinion number 2,847,470.

RESULTS

Thirteen judges were invited to the panel to validate the scenario's content, nine of which agreed to participate. The panel consisted of six nurses, an obstetrician, a physiotherapist and a physician. Regarding the areas of experience, four (44.4%) had between one and five years in simulation; three (33.3%) between eight and 12 years in palliative care and one (11.1%) had five years of experience in communication.

The CVI was satisfactory for the general analysis of the scenario by the specialists with a value of 0.84, and the values​for each criterion analyzed varied from 0.44 to 1 (Table 1).

The CVI values of the elements of the scenario about the learning objectives, design, preparation of the participants and instructions for the actress were below 0.70, which was the minimum value previously established to be valid. However, the specialists pointed out suggestions for adapting these elements, with a view to improving clarity of the wording and realism of the scenario, which were fully incorporated in the final version of the scenario.

Therefore, for the general learning objective, it was suggested to change the verb ‘train’ to ‘develop’, ‘employ’ or ‘demonstrate’ and the addition of a description of which communication strategies would be used. Thus, the overall objective moved from “Training hard news communication skills by applying specific communication strategies” to “Employing hard news communication skills by applying SPIKES, NURSE or Ask Tell Ask strategies”.

Regarding the scenario design, the judges pointed out suggestions for preparation of the materials, in order to clarify that the intravenous and oxygen therapy devices are connected to the toddler mannequin, in addition to changes in the hierarchy proposed by the roles of the simulation participants. With this, the initial proposal was that two participants would play the roles of nurse and intern, with evaluation by the judges, the two participants played the same role, that of nurses.

Based on the judges' suggestions, the element of preparation of the participants included the content of the lecture and dialog on hard news communication strategies, changes in the wording of the term “exclusive palliative care” to “general palliative care”, use of a fictitious name for the company mentioned in the case, informing that the child's mother is religious without mentioning a specific religion so as not to generate religious conflicts, clarifying in the case that the child is an only child and that the mother knows about the seriousness of the situation.

In the elements of the simulation progression and the instructions for the actresses, inclusions were suggested about greater detailing of the roles of the actresses who participate in the simulation and a possible outcome in case the participant was unable to continue the simulation due to high emotional involvement, suggestions that were readily incorporated.

In this way, a scenario entitled Communication of Hard News in the context of Palliative Care was completed, aimed at undergraduate Nursing students who were attending or attended courses in the areas of communication and children's health, with the educational purpose of training in communication skills. The general learning objective was to employ the skill of communicating hard news, applying the SPIKES, NURSE or Ask Tell Ask strategies and the specific ones were as follows: to apply the steps of the SPIKES protocol in the communication of hard news, to apply the NURSE strategies to respond to the emotions generated by the communication of hard news, and to apply the Ask Tell Ask strategy to explore more information. The modality of this simulation was scenic, with an estimated duration of 60 minutes (15 minutes for the pre-briefing and briefing, 15 minutes for the simulation, and 30 minutes for the debriefing).

Preparation of the participants took place through an educational intervention called “Workshop for the Communication of Hard News”, comprising an expository and dialogued class on hard news and communication strategies in the context of hard news (SPIKES, NURSE, Ask Tell Ask), lasting three hours.

This scenario provided for the participation of two volunteer students and two actresses with roles of physician and mother of a child hospitalized for cancer treatment. The environment had its realism adjusted so that it resembled a pediatric inpatient unit, in the bed there was a toddler mannequin with an intravenous device, 1,000 ml saline solution with identification; equipment and fixation and installed nasal catheter, stethoscope hanging from an IV stand, oxygen humidifier bottle connected to the flowmeter, bedside table with toys, bag with the child's personal items, bottle with water and disposable cups, wall clock indicating the current time, three chairs, a notebook and a pen.

The briefing presented was “You are nurses in the pediatric oncology sector and a nursing technician, after checking the vital signs of the child named João, ask the physician and you to go to the room immediately. João, five years old, with a medical diagnosis of osteosarcoma in the right tibia, underwent chemotherapy and radiotherapy treatment for one year, evolved with metastasis and has been in general palliative care for 4 months. The child and family were being monitored by a multidisciplinary team and hospitalized for 30 days. At the moment he was sleeping with his mother”.

In the simulation progression, the participants, together with the actress who plays the role of physician, identify that the child has died and need to communicate this information to the mother. From the prediction of the scenes and possibilities of outcomes of this scenario, the students were expected to perform the following actions: introduce themselves, approach or touch the mother, pick up chairs to sit next to the mother, be silent so that the mother expresses her emotion, convey attention and calm, ask about what the mother was understanding about João's condition, apply NURSE, resume the news and employ appropriate and direct language without the using specific terms and/or jargon, and offer help (check if the mother wants to call someone from the family, receive spiritual/religious support, be alone with the child, participate in body care).

Three outcomes were proposed depending on the participants' performance, first: if they offered help promptly and identified the mother's wishes, the simulation was ended; second: in the absence of the offer of help, the actress who represented the mother would ask what she should do at that moment (cue) and, once the students offered support and identified the mother's wishes, the simulation was ended and, third: in front of great emotional involvement or non-availability of help to the mother, even with the clue previously offered, the physician returns to the simulation and helps them to identify the mother's help and desires, ending the scenario. After the simulation, the participants were leaded to the debriefing, which was based on the structured model.

The scenario test took place with 15 undergraduate Nursing students, 10 (66.6%) enrolled in the fourth semester, two (13.3%) in the sixth semester, two (13.3%) in the second semester and one (6.8%) in the first semester. Their age varied between 17 and 33 years old, and participation of female students was predominant (n=14; 93.3).

When asked about the experience of situations that required communication of hard news in the internship field, all reported not having witnessed it, 14 (93.3%) reported that the topic was not addressed during the course, and 12 (86.6%) stated that they had never participated in extracurricular activities for this purpose.

Table 2 shows the results of the evaluation of the scenario design by the students, based on the answers in the SDS scale, as well as the analysis of the reliability of this scale in this sample. It is noteworthy that the Cronbach's alpha results show adequate data reliability from the application of the SDS scale, with values above 0.70, with the exception of the Problem solving and Realism factors.

Table 2
Description of the mean and reliability of the Simulation Design Scale. São Carlos, SP, Brazil, 2018. (n=15).

Simulation Design Scale	Mean	Cronbach's Alpha
Objectives and Information	4.78	0.80
Support	4.90	0.90
Problem solving	4.88	0.60
Feedback/Reflection	4.88	0.88
Realism	4.83	0.45
Total	4.85	0.89

• Source: Research data.

Based on the responses in the SDS subscales, the students considered the scenario adequate, since all (n=15; 100%) agreed with the adequacy of “Objectives and Information”, “Support”, “Feedback/Reflection” and “Realism”, as they answered items 4 and 5 (I agree and I strongly agree with the statement) for each item of these factors, indicating compliance with these elements in the simulation. The “Problem solving” factor obtained 93.3% agreement.

DISCUSSION

In the context of children's care in palliative care, questions about the professionals' difficulty communicating hard news to the parents are evident and are related to how parents perceive the quality of care offered^19,20. In addition to that, the communication and support received at the end of life experienced by the parents exert an important impact on the experience and coping with grief²¹.

These difficulties are frequent in the description of parents who have experienced palliative care with their children, evidenced in studies in the area^19,21. In India, parents who lost their children to cancer reported that they did not receive emotional support at the time they were informed of their children's death; in addition to that, this communication was brief, insensitive and not empathic²¹. Dutch parents of children who were in palliative care reported a desire to have more time to talk with the health professionals, to receive honest and realistic information in an appropriate environment and time and to have their doubts clarified, in addition to receiving help to make decisions¹⁹.

Although communication is a transcendental component of health care, communicating hard news is often considered a challenging situation, capable of causing emotional suffering in part of the health professionals, which can be mitigated by strengthening communication skills^21,22. Therefore, simulation appears as a powerful and frequently used strategy for the development and improvement of communication skills in palliative care, especially for difficult news¹⁰.

A number of literature reviews reinforced the benefit of simulation to strengthen hard news communication skills in palliative care, but take into account the importance of building scenarios that consider interprofessionality, that have clear learning objectives and that are validated^7,9.

In the process of preparing the scenario for the communication of hard news, interprofessionality was taken into account when including the roles of physician and nurse, as it is understood that communication of hard news occurs completely when performed as a team and that nurses mainly deal with emotions generated by this information¹⁴.

In the context of children's care, there is an indication that the communication of hard news is made by the professional who monitors the child and, when it is technical, it is indicated that it should be the physician's responsibility, although with the presence of other professionals involved in child and family care, as each profession has specific duties and skills, which together make up a complete approach to health care²³.

Specifically, the nurse plays different roles when communicating hard news, whether as responsible for conveying the news, accompanying another professional at this time, and managing the impact promoted by the news with patients and/or family members^3,23. It is noteworthy that it is possible that most of the times, the role of the nurse involves talking to people who have already received hard news and, therefore, communication skills will be necessary to access issues related to the spiritual dimension, clarify doubts, assist in decision-making and resolutions necessary for the health context, offer support, and manage emotions, feelings and fears²⁴.

It is understood that emotion is a factor that favors learning through simulation; however, the importance of balancing emotion and participant integrity is understood, despite this being a good practice item for the use of simulation^13,25,26. When harming the participant's integrity during the simulation, unforeseen behavior and/or interference in the results may occur, as well as participants' difficulty in immersing in the experience and loss of a safe learning environment, in addition to more serious consequences such as career and self-esteem impairments²⁷.

Effectiveness of the simulation is completely related to the rigor of planning in the scenario, especially to guaranteeing realism of the environment, materials, models, actors, resources, clinical case, simulation starting point and progression of actions during the activity^12,27,28. All these aspects converge to achieve fidelity in the simulated activity, that is, the creation of a context capable of reproducing the participant's perception of being in a real environment and promoting learning¹¹.

Content validation of scenarios allows analyzing to what extent all the elements incorporated correspond to the content, that is, how well was the material on the content collected¹⁵. Thus, testing the scenarios under development makes sense, as it allows for the analysis and evaluation of elements that are specific to the activities simulated by the participants, in a different dimension from content validation, that is, from the development of the simulation.

Testing the scenario with the target audience is a good practice recommendation in scenario planning by the INACSL, considering that it is a way to ensure that the simulation is effective and takes place as expected by the developers, in order to identify confusion or absence of elements that can be corrected in time¹³.

The use of a scenario assessment instrument by the participants is also a good practice guideline in scenario planning, strengthening the validation, consistency and reliability of the scenario¹¹. From the SDS validation for use in Brazil¹⁷, several studies used it as a way to analyze the structuring of scenarios^14,28-30; however, this study expanded investigations into the reliability of this measure, and analyzed Cronbach's alpha, which was adequate for the total score and most of the factors¹⁸.

Thus, it is understood that the results obtained on the reliability of the SDS scale in this sample are reliable and accurate, although the sample with a reduced number of participants may have influenced the Cronbach's alpha values obtained in the “Problem Solving” and “Realism” factors, which were below 0.70 and lower than the limit established as adequate¹⁸.

Finally, it is important for the professionals to acknowledge that, in the context of children's care, there is great appreciation on the part of parents and children themselves regarding communication with the health professionals. The parents expect communication to be established in a clear, honest, objective and empathetic way; in addition, they associate good communication skills with trust in the professional²².

Furthermore, it is important to reinforce the uniqueness of communicating hard news in the pediatric context of palliative care, as it always goes beyond the person in need of care, also involving their parents or guardians. In addition to that, the use of communication strategies that address the intellectual, cultural and psychological aspects of the children and their families must be considered ^4.23.

Therefore, training to expand the skills of communicating hard news proves to be essential for qualifying the training of health professionals, as well as the care provided.

CONCLUSION AND IMPLICATIONS FOR THE PRACTICE

A scenario for the communication of hard news was rigorously designed, adopting guidelines from entities specializing in simulation, as well as scientific evidence on the topic, followed by content validation by a panel of judges who evaluated the elements presented in the scenario as adequate, clear, capable to promote the objectives proposed and, therefore, valid in relation to its content. Finally, testing the scenario with the target population reasserted its suitability by the participants. Further studies are recommended to assess the effectiveness of this scenario in improving the students' ability to communicate hard news.

As a limitation of this study, it is pointed out that the scenario, after the analysis by the specialists and the changes made based on what was proposed by this panel, did not undergo a new round to validate its content, in order to make sure that the CVI would be in accordance with what was previously expected (CVI≤0.70).

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Edited by

ASSOCIATED EDITOR

Rafael Celestino da Silva https://orcid.org/0000-0002-5211-9586

SCIENTIFIC EDITOR

Marcelle Miranda da Silva https://orcid.org/0000-0003-4872-7252

Publication Dates

• Publication in this collection
  25 Oct 2021
• Date of issue
  2022

History

• Received
  08 Mar 2021
• Accepted
  16 Aug 2021