A Simulation-Based Quality Improvement Project to Improve Medical Student Confidence in Frailty Recognition and End-of-Life Care

Introduction

Frailty affects around half of older adult inpatients and is associated with higher mortality. Newly qualified doctors are expected to recognise frailty and deliver end-of-life care (EOLC) but report low confidence due to limitations in undergraduate clinical exposure. We developed a simulation-based quality improvement project (QIP) to strengthen medical student confidence in recognising frailty and managing patients approaching the end of life. 

Method

Using the Model for Improvement and three iterative Plan–Do–Study–Act (PDSA) cycles, we designed and refined simulations for medical students undertaking an elderly medicine placement. Scenarios involved an 86-year-old man living with frailty, deteriorating following hospital-acquired pneumonia. The scenarios addressed learning objectives relating to the recognition of dying, ReSPECT form interpretation, communication with relatives and anticipatory prescribing. Self-assessed confidence was measured using pre- and post-session Likert scales (0–10). Free-text responses were thematically analysed to inform subsequent PDSA cycles. Ethical approval was not required as this was an institutionally approved QIP.

Results

Nine teaching sessions involving groups of three to four students were delivered over five months. Mean confidence improved across all learning objectives, with the greatest gains following the final simulation-based version. Three themes emerged from qualitative analysis: improved understanding of frailty and EOLC, high engagement through active participation, and desire for further simulation opportunities. Iterative feedback resulted in increasingly interactive scenarios, culminating in a ward-based simulation integrating clinical assessment, prescribing, and communication.

Conclusions

A simulation-based programme improved medical student confidence in recognising frailty and delivering EOLC, while providing structured experience of scenarios that are difficult to encounter consistently during placements. The intervention is sustainable, requires minimal resources, and aligns with national training priorities. This transferable model offers a practical approach to preparing future doctors for the complexities of caring for older adults living with frailty and approaching the end of life.