Original Manuscript
Effectiveness of narrative pedagogy in developing student nurses’ advocacy role
Nursing Ethics 1–10 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014557718 nej.sagepub.com
Priscilla K Gazarian Brigham and Women’s Hospital, USA; Simmons College, USA
Lauren M Fernberg and Kelly D Sheehan Simmons College, USA
Abstract Background: The literature and research on nursing ethics and advocacy has shown that generally very few nurses and other clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern and that often advocacy in nursing is not learned until after students have graduated and begun working. Objective: To evaluate the effectiveness of narrative pedagogy on the development of advocacy in student nurses, as measured by the Protective Nursing Advocacy Scale. Design: We tested the hypothesis that use of a narrative pedagogy assignment related to ethics would improve student nurse’s perception of their advocacy role as measured by the Protective Nursing Advocacy Scale using a quasi-experimental nonrandomized study using a pre-test, intervention, post-test design. Data collection occurred during class time from October 2012 to December 2012. The Protective Nursing Advocacy Scale tool was administered to students in class to assess their baseline and was administered again at the completion of the educational intervention to assess whether narrative pedagogy was effective in developing the nursing student’s perception of their role as a patient advocate. Ethical considerations: Students were informed that their participation was voluntary and that the data collected would be anonymous and confidential. The survey was not a graded assignment, and students did not receive any incentive to participate. The institutional review board of the college determined the study to be exempt from review. Setting: School of Nursing at a small liberal arts college in the Northeastern United States. Participants: A consecutive, nonprobability sample of 44 senior-level nursing students enrolled in their final nursing semester was utilized. Findings: Results indicated significant differences in student nurse’s perception of their advocacy role related to environment and educational influences following an education intervention using an ethics digital story. Conclusion: Using the Protective Nursing Advocacy Scale, we were able to measure the effectiveness of narrative pedagogy on nursing student’s perception of the nurse’s advocacy role. Keywords Digital stories, FESOR, narrative pedagogy, nursing advocacy, nursing ethics, Protective Nursing Advocacy Scale
Corresponding author: Priscilla K Gazarian, School of Nursing and Health Sciences, Simmons College, Room S 338 B, 300 The Fenway, Boston, MA 02115, USA. Email: [email protected]
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Introduction The literature and research on nursing ethics and advocacy has shown that only 5%–15% of nurses and other clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern.1 This has resulted in situations in which patients have been harmed when nurses and other clinicians did not advocate for them.2 Additionally, it has been noted that advocacy in nursing is inconsistently taught and often learned after students have graduated and begun working.3 This gap in skill and preparation demonstrates the need to develop effective educational interventions to teach advocacy for nursing students and new to practice nurses. One innovative educational method is the use of narrative pedagogy, in which the shared experiences of students, teachers, and clinicians can be examined and analyzed in order to examine clinical practice.4 This type of education involves using an alternative method of teaching in which the narrated experiences are analyzed, and themes and patterns emerge that become the framework for learning.5 The effectiveness of this educational intervention for teaching advocacy holds promise but has not been objectively evaluated. The Protective Nursing Advocacy Scale (PNAS) is a tool developed and tested by Hanks,6 which looks at the advocacy of nurses in terms of protecting their patients and has the potential to be used to assess pre- and post-intervention levels of advocacy in nurses. The literature describes narrative pedagogy as aiding students in thinking through situations, challenging assumptions, and interpreting situations.5 By reforming nursing education techniques and including alternative teaching in the curriculum, students can potentially learn to be more confident and secure about speaking up when issues of patient advocacy arise. This new method of advocacy education could, in turn, lead to better patient outcomes and higher nursing satisfaction; however, its effectiveness in specific situations has not yet been measured.
Background Nursing ethics Nursing is a profession in which ethical and safe treatment of the patient is the highest priority. According to the American Nurses Association (ANA)7 Code of Ethics for Nurses (2010), provision 3.5 states that ‘‘The nurse’s primary commitment is to the health, well-being, and safety of the patient’’ (p. 7). On the subject of ‘‘Acting on questionable practice,’’ provision 3.5 further states that the nurse has an ethical responsibility and obligation to the patient to address and report ‘‘incompetent, unethical, illegal, or impaired practice’’ observed within their work environment (p. 7).7 If the issue in care is not able to be resolved within the employment setting, the nurse should seek assistance from outside practice committees, licensing bodies, and/or regulatory agencies.
Nursing advocacy: qualities of an advocate Just as patient advocacy is characteristic to nursing, so too are the qualities of advocacy essential to the nurse. According to a study by O’Connor and Kelly,8 what leads nurses to advocate for a patient include a professional obligation as a nurse, a moral obligation to uphold the patients’ rights, and vulnerability of the patient, including when vulnerability is related to a physical impairment or knowledge deficit. Nurses see themselves as the protector of the patient’s rights, the informer, the patient supporter, and able to empower the patient through advocacy.9 Hanks’10 study similarly found that nurses felt compelled to act on behalf of patients in need. Qualities of the nurse advocate have been identified and described as both innate and learned. Characteristics of the emotional part of the nurse advocate have been identified as the nurse’s self-concept, values, confidence, and beliefs.10 The physical portion of the nurse advocate consists 2
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of the nurse’s education and work setting, including the physician–nurse relationship and a supportive work environment conducive to addressing patient care problems. A higher level of education and training has also been associated with more effective advocacy.11 An effective advocate has a sense of caring, respect, and conviction for the patient’s welfare10 and is able to bridge the gap in communication between the patient and complex healthcare environment.8 While patient advocacy is an expectation of those working in healthcare, research has shown that generally only 5%–15% of nurses and other healthcare clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern.1 As a result, there have been incidences in which patients have been harmed by nurses and other clinicians not advocating for them. In 2008, 115 patients who had undergone endoscopic procedures at two southern Nevada health clinics were infected by hepatitis C, which had been caused by unsafe patient care practices that had gone unreported. The infection had been spread through the reuse of medication equipment intended for single use only, including syringes and medication vials. It was discovered that many staff had known about the unsafe practices and had not spoken up. Those staff who had spoken up had found that their concerns were not addressed, and some even chose to seek employment elsewhere. Under investigation, clinic staff reported that they were told that was ‘‘how things were done there’’ and nurses feared being fired, mistreated, or blackmailed if they were to report the malpractice.2 As a result, there was a significant amount of patient harm done.
Barriers to patient advocacy According to literature and research, it appears there are many barriers that nurses face when advocating for their patients. Potential barriers include fear of repercussions or punishment, an unsupportive organizational climate, labeling, blame, ritualized nurse–doctor relationships and nursing activities hindering the nurse’s ability to act, and the feeling as though nurses would not be able to make a difference.2,10,11 Hanks9 cites the most common barrier to nursing advocacy as a conflict of interest between nurse’s responsibility to the patient and the nurse’s duty to their institution of employment. In a study conducted among 564 Registered Nurses (RNs) in Nevada following the incident of Hepatitis C transmission, Black2 found that while 61% of respondents felt they could report a patient safety concern without experiencing workplace retaliation, 41% knew of a nurse who had experienced workplace retaliation after reporting the unsafe actions of another nurse. Given the potential risk involved with failing to advocate for a patient contrasted with the consequences of advocating, including professional and personal standing, it is apparent why nurses sometimes fail to advocate for their patients.
Whistleblowing Many hospitals have established internal procedures for reporting patient care concerns, including ethics committees, while others have established hotlines to anonymously report concerns.12 When the internal chains of command fail to address the problem, a nurse is confronted with the choice to further pursue the issue with higher authorities. Whistleblowing occurs when the nurse reports wrongdoing to a governmental or law enforcement agency for the public’s best interest.12,13 While 20 states have passed legislation protecting nurses from reporting unsafe practices, also known as whistleblower protection, there still exists fear of repercussions among nurses, hindering patient advocacy.2 This fear was strengthened after an incident in 2009 when two Texas RNs reported the unsafe practices of a physician to the Texas Medical Board and were subsequently fired from their jobs and charged for a thirddegree felony.14 While the state of Texas Nurse Practice Act (NPA) had clauses protecting nurses acting on behalf of patient advocacy prior to this event, the case of these two RNs showed the weaknesses in that act. 3
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Thomas and Willmann14 advocate for whistleblower protection for nurses in all states to promote and encourage nurses to advocate against unsafe patient care.
Narrative pedagogy Narrative pedagogy refers to the use of narrative storytelling in order to provide an alternative method of learning for students. This practice uses research in interpretative phenomenology in order to explore and analyze the lived experiences of the students, instructors, and clinicians involved in nursing education.4 By analyzing the narratives of these different groups, themes and patterns are able to emerge, which become the framework for learning.5 The process of incorporating narrative pedagogy into the classroom setting does not involve throwing out the traditional methods of learning, but rather it uses the form of storytelling to enhance the student’s learning. By learning to interpret situations in the context of the clinical setting and applying the knowledge learned through traditional methods, there is a stronger emphasis on critiquing, examining, exploring, and deconstructing clinical situations that students have experienced.4,5 The power of narrative pedagogy is its ability to communicate and share contextual ideas related to ethics, values, culture, and relationships to create change and action within the learner.15 Additionally, narrative pedagogy can be used in a classroom setting in order to gain the attention of students, expose them to moral dilemmas and problem-solving exercises in a controlled environment, share stories of success and learning, develop a sense of community, help them explore the personal and professional roles in their lives, and overall to help the students develop their understanding and professional identity.15 In using an open discussion teaching method, the students are more able to engage with each other and work together to interpret the meaning and significance of their experiences.5 The use of narrative pedagogy can be seen around the world. In the traditional Japanese educational system, the school environment has centered on rote learning with a teacher-driven focus. However, this teaching style has resulted in students who are overwhelmed in university settings where learning is more self-directed. At a conference in 2002 at a Japanese university, the need to review and amend these practices in order to provide students with greater learning experiences was discussed. One suggestion for this revision by Kawashima16 includes the use of narrative pedagogy to accompany the traditional method of teaching. In this way, the students, faculty, and clinicians would be able to share their own experiences and learn from one another through discussions and analysis. This method could also be beneficial to the Japanese students in helping them learn to feel more comfortable expressing their own ideas and opinions in the classroom setting.16 Narrative pedagogy has also been used and studied among nursing and midwifery schools in Australia. One university in particular that is adopting this program described their initial framework for their curricula as using the concept of ‘‘caring in community’’ (p. 158).15 Incorporating narrative pedagogy into this nursing education environment involves helping students to appreciate their different clinical experiences and to help them develop a professional identity in their nursing career. Through critical analysis of the stories of others and by expressing their own stories, students were able to gain insight into both their own experiences as well as others, which could help them on their pathway to developing their professional identity.15
Digital stories One method of narrative pedagogy in the classroom, and the method we used for our intervention, is in the form of digital stories. Digital stories are narratives created by an individual with the use of computer technology and may contain music, video clips, narration, text, or images to add dimension to the story.17 Digital stories allow students to share their personal learned experiences in a creative way, and they provide the 4
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potential for multiple viewings and rich discussion in the classroom setting. This form of narrative pedagogy may also be beneficial in giving a stronger voice to those who are quieter in the classroom.18 Use of digital stories allows for classroom viewing and discussions of the topics brought up by the narrative. This analysis and feedback of concepts allows for rich learning and discussion through these shared experiences.17
FESOR ethical framework model In our intervention, structured debriefing of the ethics digital story was conducted using the FESOR ethical framework model to discuss and process students’ clinical experiences prior to completing the post-test PNAS. The FESOR framework, which stands for Facts, Ethical questions, Stakeholders, Options, and Re-evaluate the options chosen, is a method which was developed to help providers address ethical problems in their practice.19 The use of the FESOR model allows the nurse to learn to reflect, assess, and analyze the different factors in the case in order to promote the best ethical decisions in the situation.19,20
Methods Aim The purpose of this study is to evaluate an educational innovation that aims to teach nursing advocacy. Specifically, we sought to evaluate the effect of narrative pedagogy on the development of advocacy in student nurses, as measured by the PNAS. In this study, the question is how effective is the use of narrative pedagogy related to an ethical concern in affecting student nurses’ perception of their advocacy role as measured by the PNAS. The study aims to address this research question through a pre-test, post-test design, using the educational intervention of narrative pedagogy and FESOR ethics debriefing. In order to assess the changes in the perceived advocacy of students following the educational intervention, we measured nursing advocacy with the PNAS tool.
Hypothesis In this study, we tested the hypothesis that use of a narrative pedagogy assignment related to ethics (an ethics digital story) would improve student nurse’s perception of their advocacy role as measured by the PNAS.
Design The study conducted was a quasi-experimental nonrandomized study using a pre-test, post-test design.
Participants and setting A consecutive, nonprobability sample of senior-level nursing students enrolled in their final nursing semester was utilized with the goal of representing the student nursing population. All participants in this study were enrolled as post-baccalaureate accelerated nursing students in their final semester of nursing school at a small liberal arts college in the Northeastern United States. Eligibility criteria included being enrolled in the clinical decision-making nursing course at their college. 5
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Instruments: PNAS The PNAS6 measures the advocacy of nurses based on their beliefs and actions from a standpoint of protecting their patients. The scale was created using theoretical models and current nursing advocacy literature surrounding the protective viewpoint of patient advocacy. It was pilot-tested on 108 nurses, and subsequent revisions resulted in the current 43-item PNAS survey. The items on the PNAS are broken down into four components that include the following: Acting as an advocate, Work status and advocacy actions, Environment and educational influences, and Support and barriers to advocacy. These groups were determined through the results of a correlational study design in which the survey was mailed to 5000 nurses in Texas. Out of the 419 complete surveys that were returned, the PNAS items were analyzed, and the author used this data to determine the components of each of the groups, as well as the items that did not correlate well. Since the scale contained items that did not fit into any groups as well as items that were negatively scored, the author found that the PNAS scale should be evaluated by measuring and evaluating the group scores, rather than looking at the overall score. Testing by Hanks6 on each of the four subscales as well as the overall tool showed sufficient internal consistency measured with Cronbach’s alpha of 0.80 for the overall PNAS and 0.93–0.70 for each of the subscales and was considered a reliable tool to utilize. Hanks6 also successfully tested the scale for content validity and convergent validity. Participants were asked to rank each of the 43 items on a 5-point Likert scale ranging from 5 (strongly agree) to 1 (strongly disagree). In this study, we utilized the PNAS scale before and after our educational intervention to compare scores and mark improvement in nursing student perception of their advocacy role.
Data collection Nursing students enrolled in their final semester undergraduate Capstone clinical decision-making course were asked to fill out a demographics questionnaire and the PNAS prior to and after their clinical decisionmaking class project. Data collection occurred during class time between October 2012 and December 2012. The PNAS tool was administered to students in class prior to beginning their digital story project in order to assess their baseline perspective on nursing advocacy. The PNAS tool was administered again at the completion of the two scheduled debriefing sessions in order to assess whether narrative pedagogy was effective in developing the nursing student’s perception of their role as a patient advocate. The intervention implemented included the narrative pedagogy teaching strategy using digital storytelling17 and debriefing using the FESOR framework.19 Students were instructed to create a digital story about an ethical concern encountered in clinical practice. Digital stories were then shared in class. Classroom debriefing used the steps of the FESOR framework as follows: (a) determine the facts of the case, or the current situation that is causing a moral dilemma; (b) identify the ethical problem or issues; (c) identify the stakeholders in the case, or those who are involved in the situation with an ethical duty; (d) determine the options for resolution of the situation through discussion with the stakeholders; and (e) re-evaluate the situation and assess the satisfaction of the stakeholders with the decision.
Ethical considerations The institutional review board of the college determined the study to be exempt from review. Students were informed that the data collected would be anonymous and that their participation was voluntary. Confidentiality was maintained and surveys were administered prior to and after the completion of their digital story projects, which spanned over the course of the semester. This survey was not a graded assignment, and students had no incentive provided to participate in the study or to embellish or misconstrue their perceptions 6
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Table 1. Demographics of sample. Gender (Female) Age Previous degree Social science Business/public policy Biology/chemistry Foreign language English/writing Math Other
36 27 (24–40) 36 15 8 6 4 2 1 1
of patient advocacy. Students were informed that their participation was voluntary and that PNAS scale would assist in measuring the effectiveness of the innovative teaching strategy.
Data analysis During statistical analysis, we focused on the four subscales as validated by Hanks.6 In Category IV ‘‘Support and Barriers,’’ we found two items were supports and the remaining questions were barriers. The ‘‘Support’’ category items were neutrally worded, and the ‘‘Barriers’’ items were negatively worded, so we divided this subscale and scored these categories separately in order to reflect the difference in average score. Using SPSS, we computed descriptive statistics of each subscale. Depending on whether the data demonstrated a normal distribution for each subscale pre- and post-issuance of the PNAS, we utilized either the paired t-test or the Wilcoxon signed-rank test to determine whether the results from each subscale were statistically significant.
Results Sample characteristics The original sample size consisted of 44 (n ¼ 44) enrolled nursing students. There were eight instances in which the student was unable to complete either the pre- or the post-survey; therefore, the final sample consisted of 36 (n ¼ 36) participants. Given that the college is an all-female undergraduate institution, all study participants were female. Participants ranged in age at the time of the study from 24 to 40 years with a mean age of 27 years. A total of 15 students had previously majored in the social sciences, with 11 majoring in psychology; 6 in biology and/or chemistry; 8 in business/public policy; 4 in a foreign language; 2 in English/ writing; 1 in math; and 1 in other. Table 1 summarizes the sample demographics.
Pre-test/post-test score differences Results of this study indicated significant differences in student nurse perception of their advocacy role related to environment and educational influences following an education intervention using an ethics digital story, supporting our hypothesis. During the initial data analysis, we computed statistics on each item. Subsequently, the questionnaire items were divided by subscale, and a paired t-test was conducted on the pre- and post-test items for each subscale. However, the data were only normally distributed for subscale IV, which indicated that a Wilcoxon signed-rank test should be used to determine significance. A Wilcoxon signed-rank test was completed on each subscale, and the results showed significance in subscale III 7
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Table 2. Subscale Wilcoxon signed-rank test results. Component subscale
Significance
I Acting as an advocate II Work status and advocacy actions III Environment and educational influences IV Support and barriers to advocacy
0.058 0.700 0.001 0.184
Table 3. Supports and barriers to advocacy Wilcoxon signed-ranks test results. Component subscale IV
Significance
Support to advocacy Barriers to advocacy
0.008 0.918
at an a ¼ 0.05 level, with an a ¼ 0.001 (Table 2). The Wilcoxon signed-rank test for subscale I, although not significant, was also noteworthy with an a ¼ 0.058, suggesting that further research may be indicated on the type of advocacy represented by this subscale. An additional data analysis was conducted on the items in subscale IV, as it included both neutrally and negatively worded questions. Subscale IV consisted of ‘‘Supports and Barriers to Advocacy,’’ and the ‘‘Supports’’ included the neutrally worded items, while ‘‘Barriers’’ included negatively worded items. In order to determine the difference in level of advocacy from the pre- and post-test, this subscale was divided into these two categories and analyzed separately. A Wilcoxon signed-rank test was conducted on these categories and the ‘‘Supports’’ category was found to be significant at an a ¼ 0.05 level, with an a ¼ 0.008 (Table 3). Of note, we chose to do this divided subscale analysis on our own and it has not been previously tested in Hanks’6 research. Additionally, the subscale category of ‘‘Supports,’’ although found to be significant, consisted of only two survey items, which may have impacted the results.
Discussion The research described in this article takes the use and research of narrative pedagogy a step further by using a tool specialized in measuring nursing students’ perception of patient advocacy to understand the effectiveness of such a teaching method. The results show that students had an increase in perceived advocacy role related to ‘‘Environment and educational influences’’ after the narrative pedagogy intervention. The findings from the other subscales ‘‘Acting as an advocate,’’ ‘‘Work status and advocacy actions,’’ and ‘‘Support and barriers to advocacy’’ did not demonstrate statistical significance after the intervention. Additionally, when subscale IV was broken down by ‘‘Support’’ and ‘‘Barriers,’’ we found that the students had a significantly improved level of advocacy related to the support of advocacy, but not to the barriers of advocacy. These results show that nursing students’ perceptions of patient advocacy increased during the educational experience as evidenced by the PNAS results. Areas significant for increased change include environment and educational influences and support to advocacy, which make sense due to the clinical and educational experiences that occurred during the semester. The literature suggests that a higher level of education is associated with a greater perceived autonomy, yielding a greater likelihood for the nurse to advocate for his or her patient.11 Hanks,11 O’Connor and Kelly,8 and Duffy et al.21 all recommend including nursing ethics and patient advocacy in the curriculum for nursing student education. Duffy et al.21 advocate for early intervention with nursing students to utilize 8
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clinical experiences as opportunities for reflection about patient care concerns, while providing feedback and support to the student. O’Connor and Kelly8 acknowledge that teaching an abstract concept such as nursing advocacy requires active engagement with a clinical experience through the use of workshops or role play scenarios in order for students to learn. Utilizing narrative pedagogy as a framework for digital storytelling was found to enhance nursing students’ clinical thinking strategies.17 By including alternative nursing education methods and teaching in the curriculum, students can learn to be more confident and secure about speaking up when issues of patient advocacy arise. This new method of advocacy education could, in turn, lead to better patient outcomes and higher nursing satisfaction. Given our small sample size, lack of control group, and randomization, opportunities for further research include replication of this study as a well powered randomized controlled trial. Best practices of advocacy education for all clinicians, at all levels of practice, need to be documented, and this educational intervention could be tested on an interprofessional group of learners.
Limitations Some of the limitations of this study are related to the sample population, including having a small sample size, a female-only sample, students who all have a previous bachelor’s degree, and students who are older than the traditional undergraduate nursing student. There is minimal generalizability from this study as the sample cannot be considered representative of the overall nursing student population. In addition, the PNAS has a limited use, as it has not been widely used and tested on all nursing populations. This research is the first time the PNAS tool has been used in this manner to analyze data and make comparisons. Some of the questions in Hanks’6 PNAS tool were found to be unreliable or have a questionable meaning, such as the six items that were not included in the analysis. Additionally, Hanks6 used both positively, neutrally, and negatively worded questions in his survey, which led to our decision to divide subscale IV into ‘‘Support’’ and ‘‘Barriers.’’ The division of subscale IV is also a limitation, as this was not originally tested in Hanks’6 research. The PNAS tool is also limited in that it does not allow for overall conclusions to be drawn, as the data must be analyzed by subscale. An additional limitation is that our research does not measure the effect of the narrative pedagogy assignment on the nursing students independently, as the students are simultaneously at various clinical sites. As a result, it is unknown whether the effect on nursing student advocacy is due to the narrative pedagogy intervention or whether it is related to the experience of being in the field at a clinical site.
Conclusion This research study aims to explore and enhance the research available on the use of narrative pedagogy and the development of the advocacy role to nursing students. Ideally, this research could be extended to reach the advocacy of current practicing nurses as well, as studies have shown that there are a significant number of practicing nurses who fail to advocate for their patients. It is vital to find a way to improve the rate of patient advocacy in order to decrease errors in practice as well as to provide a higher standard of care to the patient. The use of narrative pedagogy and the FESOR model also helps to identify ethical concerns and works to analyze how they can be addressed. The PNAS serves as a tool that can be used to measure the outcomes of perceived patient advocacy in nurses after narrative pedagogy has been instituted. There is an abundance of literature surrounding the use of narrative pedagogy and barriers to advocacy. However, while this study showed using narrative pedagogy in conjunction with clinical experience can enhance nursing students’ perceptions of patient advocacy, further research is needed on this topic in order to assess the effectiveness of narrative pedagogy educational techniques in nursing and how barriers to advocacy may be overcome. 9
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Conflict of interest No conflict of interest has been declared by the authors. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References 1. Maxfield D, Grenny J, McMillan R, et al. Silence kills: the seven crucial conversations for healthcare. Provo, UT: VitalSmarts, 2005. 2. Black LM. Tragedy into policy: a quantitative study of nurses’ attitudes toward patient advocacy activities. Am J Nurs 2011; 111: 26–37. 3. Foley BJ, Minick MP and Kee CC. How nurses learn advocacy. J Nurs Scholarsh 2002; 34: 181–186. 4. Diekelmann N.Narrative pedagogy: Heideggerian hermeneutical analyses of lived experiences of students, teachers, and clinicians. Adv Nurs Sci 2001; 23: 53–71. 5. Ironside PM. Using narrative pedagogy: learning and practising interpretive thinking. J Adv Nurs 2006; 55: 478–486. 6. Hanks R. Development and testing of an instrument to measure protective nursing advocacy. Nurs Ethics 2010; 17: 255–267. 7. American Nurses Association (ANA). The Code of Ethics for Nurses with interpretive statements. Silver Spring, MD: ANA, 2010. 8. O’Connor T and Kelly B. Bridging the gap: a study of general nurses’ perceptions of patient advocacy in Ireland. Nurs Ethics 2005; 12: 453–467. 9. Hanks RG. Barriers to nursing advocacy: a concept analysis. Nurs Forum 2007; 42: 171–177. 10. Hanks RG. The lived experience of nursing advocacy. Nurs Ethics 2008; 15: 468–477. 11. Hanks R. The medical–surgical nurse perspective of advocate role. Nurs Forum 2010; 45: 97–107. 12. Delk KL. Whistleblowing—is it really worth the consequences? Workplace Health Saf 2013; 61: 61–64. 13. Lachman VD. Whistleblowers: troublemakers or virtuous nurses? Imprint 2014; 61: 36–39. 14. Thomas MB and Willmann J. Why nurses need whistleblower protection. J Nurs Regul 2012; 3: 19–23. 15. McAllister M, John T, Gray M, et al. Adopting narrative pedagogy to improve the student learning experience in a regional Australian university. Contemp Nurs 2009; 32: 156–165. 16. Kawashima A. The implementation of narrative pedagogy into nursing education in Japan. Nurs Educ Perspect 2005; 26: 168–171. 17. Gazarian PK. Digital stories: incorporating narrative pedagogy. J Nurs Educ 2010; 49: 287–290. 18. Ohler J. The world of digital storytelling. Educ Leadersh 2005; 63: 44–47. 19. McCormick-Gendzel M and Jurchak M. A pathway for moral reasoning in home healthcare. Home Healthc Nurse 2006; 24: 654–661. 20. Jurchak M and Pennington M. Strengthening moral agency in new ICU nurses. In: Hickey M and Kritek PB (eds) Change leadership in nursing: how change occurs in a complex hospital system. New York: Springer, 2012, pp. 157–163. 21. Duffy K, McCallum J, Ness V, et al. Whistleblowing and student nurses—are we asking too much? Nurs Educ Pract 2012; 12: 177–178.
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Effectiveness of narrative pedagogy in developing student nurses’ advocacy role
Nursing Ethics 1–10 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014557718 nej.sagepub.com
Priscilla K Gazarian Brigham and Women’s Hospital, USA; Simmons College, USA
Lauren M Fernberg and Kelly D Sheehan Simmons College, USA
Abstract Background: The literature and research on nursing ethics and advocacy has shown that generally very few nurses and other clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern and that often advocacy in nursing is not learned until after students have graduated and begun working. Objective: To evaluate the effectiveness of narrative pedagogy on the development of advocacy in student nurses, as measured by the Protective Nursing Advocacy Scale. Design: We tested the hypothesis that use of a narrative pedagogy assignment related to ethics would improve student nurse’s perception of their advocacy role as measured by the Protective Nursing Advocacy Scale using a quasi-experimental nonrandomized study using a pre-test, intervention, post-test design. Data collection occurred during class time from October 2012 to December 2012. The Protective Nursing Advocacy Scale tool was administered to students in class to assess their baseline and was administered again at the completion of the educational intervention to assess whether narrative pedagogy was effective in developing the nursing student’s perception of their role as a patient advocate. Ethical considerations: Students were informed that their participation was voluntary and that the data collected would be anonymous and confidential. The survey was not a graded assignment, and students did not receive any incentive to participate. The institutional review board of the college determined the study to be exempt from review. Setting: School of Nursing at a small liberal arts college in the Northeastern United States. Participants: A consecutive, nonprobability sample of 44 senior-level nursing students enrolled in their final nursing semester was utilized. Findings: Results indicated significant differences in student nurse’s perception of their advocacy role related to environment and educational influences following an education intervention using an ethics digital story. Conclusion: Using the Protective Nursing Advocacy Scale, we were able to measure the effectiveness of narrative pedagogy on nursing student’s perception of the nurse’s advocacy role. Keywords Digital stories, FESOR, narrative pedagogy, nursing advocacy, nursing ethics, Protective Nursing Advocacy Scale
Corresponding author: Priscilla K Gazarian, School of Nursing and Health Sciences, Simmons College, Room S 338 B, 300 The Fenway, Boston, MA 02115, USA. Email: [email protected]
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Introduction The literature and research on nursing ethics and advocacy has shown that only 5%–15% of nurses and other clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern.1 This has resulted in situations in which patients have been harmed when nurses and other clinicians did not advocate for them.2 Additionally, it has been noted that advocacy in nursing is inconsistently taught and often learned after students have graduated and begun working.3 This gap in skill and preparation demonstrates the need to develop effective educational interventions to teach advocacy for nursing students and new to practice nurses. One innovative educational method is the use of narrative pedagogy, in which the shared experiences of students, teachers, and clinicians can be examined and analyzed in order to examine clinical practice.4 This type of education involves using an alternative method of teaching in which the narrated experiences are analyzed, and themes and patterns emerge that become the framework for learning.5 The effectiveness of this educational intervention for teaching advocacy holds promise but has not been objectively evaluated. The Protective Nursing Advocacy Scale (PNAS) is a tool developed and tested by Hanks,6 which looks at the advocacy of nurses in terms of protecting their patients and has the potential to be used to assess pre- and post-intervention levels of advocacy in nurses. The literature describes narrative pedagogy as aiding students in thinking through situations, challenging assumptions, and interpreting situations.5 By reforming nursing education techniques and including alternative teaching in the curriculum, students can potentially learn to be more confident and secure about speaking up when issues of patient advocacy arise. This new method of advocacy education could, in turn, lead to better patient outcomes and higher nursing satisfaction; however, its effectiveness in specific situations has not yet been measured.
Background Nursing ethics Nursing is a profession in which ethical and safe treatment of the patient is the highest priority. According to the American Nurses Association (ANA)7 Code of Ethics for Nurses (2010), provision 3.5 states that ‘‘The nurse’s primary commitment is to the health, well-being, and safety of the patient’’ (p. 7). On the subject of ‘‘Acting on questionable practice,’’ provision 3.5 further states that the nurse has an ethical responsibility and obligation to the patient to address and report ‘‘incompetent, unethical, illegal, or impaired practice’’ observed within their work environment (p. 7).7 If the issue in care is not able to be resolved within the employment setting, the nurse should seek assistance from outside practice committees, licensing bodies, and/or regulatory agencies.
Nursing advocacy: qualities of an advocate Just as patient advocacy is characteristic to nursing, so too are the qualities of advocacy essential to the nurse. According to a study by O’Connor and Kelly,8 what leads nurses to advocate for a patient include a professional obligation as a nurse, a moral obligation to uphold the patients’ rights, and vulnerability of the patient, including when vulnerability is related to a physical impairment or knowledge deficit. Nurses see themselves as the protector of the patient’s rights, the informer, the patient supporter, and able to empower the patient through advocacy.9 Hanks’10 study similarly found that nurses felt compelled to act on behalf of patients in need. Qualities of the nurse advocate have been identified and described as both innate and learned. Characteristics of the emotional part of the nurse advocate have been identified as the nurse’s self-concept, values, confidence, and beliefs.10 The physical portion of the nurse advocate consists 2
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of the nurse’s education and work setting, including the physician–nurse relationship and a supportive work environment conducive to addressing patient care problems. A higher level of education and training has also been associated with more effective advocacy.11 An effective advocate has a sense of caring, respect, and conviction for the patient’s welfare10 and is able to bridge the gap in communication between the patient and complex healthcare environment.8 While patient advocacy is an expectation of those working in healthcare, research has shown that generally only 5%–15% of nurses and other healthcare clinicians will speak up about an issue they have witnessed regarding a patient advocacy concern.1 As a result, there have been incidences in which patients have been harmed by nurses and other clinicians not advocating for them. In 2008, 115 patients who had undergone endoscopic procedures at two southern Nevada health clinics were infected by hepatitis C, which had been caused by unsafe patient care practices that had gone unreported. The infection had been spread through the reuse of medication equipment intended for single use only, including syringes and medication vials. It was discovered that many staff had known about the unsafe practices and had not spoken up. Those staff who had spoken up had found that their concerns were not addressed, and some even chose to seek employment elsewhere. Under investigation, clinic staff reported that they were told that was ‘‘how things were done there’’ and nurses feared being fired, mistreated, or blackmailed if they were to report the malpractice.2 As a result, there was a significant amount of patient harm done.
Barriers to patient advocacy According to literature and research, it appears there are many barriers that nurses face when advocating for their patients. Potential barriers include fear of repercussions or punishment, an unsupportive organizational climate, labeling, blame, ritualized nurse–doctor relationships and nursing activities hindering the nurse’s ability to act, and the feeling as though nurses would not be able to make a difference.2,10,11 Hanks9 cites the most common barrier to nursing advocacy as a conflict of interest between nurse’s responsibility to the patient and the nurse’s duty to their institution of employment. In a study conducted among 564 Registered Nurses (RNs) in Nevada following the incident of Hepatitis C transmission, Black2 found that while 61% of respondents felt they could report a patient safety concern without experiencing workplace retaliation, 41% knew of a nurse who had experienced workplace retaliation after reporting the unsafe actions of another nurse. Given the potential risk involved with failing to advocate for a patient contrasted with the consequences of advocating, including professional and personal standing, it is apparent why nurses sometimes fail to advocate for their patients.
Whistleblowing Many hospitals have established internal procedures for reporting patient care concerns, including ethics committees, while others have established hotlines to anonymously report concerns.12 When the internal chains of command fail to address the problem, a nurse is confronted with the choice to further pursue the issue with higher authorities. Whistleblowing occurs when the nurse reports wrongdoing to a governmental or law enforcement agency for the public’s best interest.12,13 While 20 states have passed legislation protecting nurses from reporting unsafe practices, also known as whistleblower protection, there still exists fear of repercussions among nurses, hindering patient advocacy.2 This fear was strengthened after an incident in 2009 when two Texas RNs reported the unsafe practices of a physician to the Texas Medical Board and were subsequently fired from their jobs and charged for a thirddegree felony.14 While the state of Texas Nurse Practice Act (NPA) had clauses protecting nurses acting on behalf of patient advocacy prior to this event, the case of these two RNs showed the weaknesses in that act. 3
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Thomas and Willmann14 advocate for whistleblower protection for nurses in all states to promote and encourage nurses to advocate against unsafe patient care.
Narrative pedagogy Narrative pedagogy refers to the use of narrative storytelling in order to provide an alternative method of learning for students. This practice uses research in interpretative phenomenology in order to explore and analyze the lived experiences of the students, instructors, and clinicians involved in nursing education.4 By analyzing the narratives of these different groups, themes and patterns are able to emerge, which become the framework for learning.5 The process of incorporating narrative pedagogy into the classroom setting does not involve throwing out the traditional methods of learning, but rather it uses the form of storytelling to enhance the student’s learning. By learning to interpret situations in the context of the clinical setting and applying the knowledge learned through traditional methods, there is a stronger emphasis on critiquing, examining, exploring, and deconstructing clinical situations that students have experienced.4,5 The power of narrative pedagogy is its ability to communicate and share contextual ideas related to ethics, values, culture, and relationships to create change and action within the learner.15 Additionally, narrative pedagogy can be used in a classroom setting in order to gain the attention of students, expose them to moral dilemmas and problem-solving exercises in a controlled environment, share stories of success and learning, develop a sense of community, help them explore the personal and professional roles in their lives, and overall to help the students develop their understanding and professional identity.15 In using an open discussion teaching method, the students are more able to engage with each other and work together to interpret the meaning and significance of their experiences.5 The use of narrative pedagogy can be seen around the world. In the traditional Japanese educational system, the school environment has centered on rote learning with a teacher-driven focus. However, this teaching style has resulted in students who are overwhelmed in university settings where learning is more self-directed. At a conference in 2002 at a Japanese university, the need to review and amend these practices in order to provide students with greater learning experiences was discussed. One suggestion for this revision by Kawashima16 includes the use of narrative pedagogy to accompany the traditional method of teaching. In this way, the students, faculty, and clinicians would be able to share their own experiences and learn from one another through discussions and analysis. This method could also be beneficial to the Japanese students in helping them learn to feel more comfortable expressing their own ideas and opinions in the classroom setting.16 Narrative pedagogy has also been used and studied among nursing and midwifery schools in Australia. One university in particular that is adopting this program described their initial framework for their curricula as using the concept of ‘‘caring in community’’ (p. 158).15 Incorporating narrative pedagogy into this nursing education environment involves helping students to appreciate their different clinical experiences and to help them develop a professional identity in their nursing career. Through critical analysis of the stories of others and by expressing their own stories, students were able to gain insight into both their own experiences as well as others, which could help them on their pathway to developing their professional identity.15
Digital stories One method of narrative pedagogy in the classroom, and the method we used for our intervention, is in the form of digital stories. Digital stories are narratives created by an individual with the use of computer technology and may contain music, video clips, narration, text, or images to add dimension to the story.17 Digital stories allow students to share their personal learned experiences in a creative way, and they provide the 4
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potential for multiple viewings and rich discussion in the classroom setting. This form of narrative pedagogy may also be beneficial in giving a stronger voice to those who are quieter in the classroom.18 Use of digital stories allows for classroom viewing and discussions of the topics brought up by the narrative. This analysis and feedback of concepts allows for rich learning and discussion through these shared experiences.17
FESOR ethical framework model In our intervention, structured debriefing of the ethics digital story was conducted using the FESOR ethical framework model to discuss and process students’ clinical experiences prior to completing the post-test PNAS. The FESOR framework, which stands for Facts, Ethical questions, Stakeholders, Options, and Re-evaluate the options chosen, is a method which was developed to help providers address ethical problems in their practice.19 The use of the FESOR model allows the nurse to learn to reflect, assess, and analyze the different factors in the case in order to promote the best ethical decisions in the situation.19,20
Methods Aim The purpose of this study is to evaluate an educational innovation that aims to teach nursing advocacy. Specifically, we sought to evaluate the effect of narrative pedagogy on the development of advocacy in student nurses, as measured by the PNAS. In this study, the question is how effective is the use of narrative pedagogy related to an ethical concern in affecting student nurses’ perception of their advocacy role as measured by the PNAS. The study aims to address this research question through a pre-test, post-test design, using the educational intervention of narrative pedagogy and FESOR ethics debriefing. In order to assess the changes in the perceived advocacy of students following the educational intervention, we measured nursing advocacy with the PNAS tool.
Hypothesis In this study, we tested the hypothesis that use of a narrative pedagogy assignment related to ethics (an ethics digital story) would improve student nurse’s perception of their advocacy role as measured by the PNAS.
Design The study conducted was a quasi-experimental nonrandomized study using a pre-test, post-test design.
Participants and setting A consecutive, nonprobability sample of senior-level nursing students enrolled in their final nursing semester was utilized with the goal of representing the student nursing population. All participants in this study were enrolled as post-baccalaureate accelerated nursing students in their final semester of nursing school at a small liberal arts college in the Northeastern United States. Eligibility criteria included being enrolled in the clinical decision-making nursing course at their college. 5
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Instruments: PNAS The PNAS6 measures the advocacy of nurses based on their beliefs and actions from a standpoint of protecting their patients. The scale was created using theoretical models and current nursing advocacy literature surrounding the protective viewpoint of patient advocacy. It was pilot-tested on 108 nurses, and subsequent revisions resulted in the current 43-item PNAS survey. The items on the PNAS are broken down into four components that include the following: Acting as an advocate, Work status and advocacy actions, Environment and educational influences, and Support and barriers to advocacy. These groups were determined through the results of a correlational study design in which the survey was mailed to 5000 nurses in Texas. Out of the 419 complete surveys that were returned, the PNAS items were analyzed, and the author used this data to determine the components of each of the groups, as well as the items that did not correlate well. Since the scale contained items that did not fit into any groups as well as items that were negatively scored, the author found that the PNAS scale should be evaluated by measuring and evaluating the group scores, rather than looking at the overall score. Testing by Hanks6 on each of the four subscales as well as the overall tool showed sufficient internal consistency measured with Cronbach’s alpha of 0.80 for the overall PNAS and 0.93–0.70 for each of the subscales and was considered a reliable tool to utilize. Hanks6 also successfully tested the scale for content validity and convergent validity. Participants were asked to rank each of the 43 items on a 5-point Likert scale ranging from 5 (strongly agree) to 1 (strongly disagree). In this study, we utilized the PNAS scale before and after our educational intervention to compare scores and mark improvement in nursing student perception of their advocacy role.
Data collection Nursing students enrolled in their final semester undergraduate Capstone clinical decision-making course were asked to fill out a demographics questionnaire and the PNAS prior to and after their clinical decisionmaking class project. Data collection occurred during class time between October 2012 and December 2012. The PNAS tool was administered to students in class prior to beginning their digital story project in order to assess their baseline perspective on nursing advocacy. The PNAS tool was administered again at the completion of the two scheduled debriefing sessions in order to assess whether narrative pedagogy was effective in developing the nursing student’s perception of their role as a patient advocate. The intervention implemented included the narrative pedagogy teaching strategy using digital storytelling17 and debriefing using the FESOR framework.19 Students were instructed to create a digital story about an ethical concern encountered in clinical practice. Digital stories were then shared in class. Classroom debriefing used the steps of the FESOR framework as follows: (a) determine the facts of the case, or the current situation that is causing a moral dilemma; (b) identify the ethical problem or issues; (c) identify the stakeholders in the case, or those who are involved in the situation with an ethical duty; (d) determine the options for resolution of the situation through discussion with the stakeholders; and (e) re-evaluate the situation and assess the satisfaction of the stakeholders with the decision.
Ethical considerations The institutional review board of the college determined the study to be exempt from review. Students were informed that the data collected would be anonymous and that their participation was voluntary. Confidentiality was maintained and surveys were administered prior to and after the completion of their digital story projects, which spanned over the course of the semester. This survey was not a graded assignment, and students had no incentive provided to participate in the study or to embellish or misconstrue their perceptions 6
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Table 1. Demographics of sample. Gender (Female) Age Previous degree Social science Business/public policy Biology/chemistry Foreign language English/writing Math Other
36 27 (24–40) 36 15 8 6 4 2 1 1
of patient advocacy. Students were informed that their participation was voluntary and that PNAS scale would assist in measuring the effectiveness of the innovative teaching strategy.
Data analysis During statistical analysis, we focused on the four subscales as validated by Hanks.6 In Category IV ‘‘Support and Barriers,’’ we found two items were supports and the remaining questions were barriers. The ‘‘Support’’ category items were neutrally worded, and the ‘‘Barriers’’ items were negatively worded, so we divided this subscale and scored these categories separately in order to reflect the difference in average score. Using SPSS, we computed descriptive statistics of each subscale. Depending on whether the data demonstrated a normal distribution for each subscale pre- and post-issuance of the PNAS, we utilized either the paired t-test or the Wilcoxon signed-rank test to determine whether the results from each subscale were statistically significant.
Results Sample characteristics The original sample size consisted of 44 (n ¼ 44) enrolled nursing students. There were eight instances in which the student was unable to complete either the pre- or the post-survey; therefore, the final sample consisted of 36 (n ¼ 36) participants. Given that the college is an all-female undergraduate institution, all study participants were female. Participants ranged in age at the time of the study from 24 to 40 years with a mean age of 27 years. A total of 15 students had previously majored in the social sciences, with 11 majoring in psychology; 6 in biology and/or chemistry; 8 in business/public policy; 4 in a foreign language; 2 in English/ writing; 1 in math; and 1 in other. Table 1 summarizes the sample demographics.
Pre-test/post-test score differences Results of this study indicated significant differences in student nurse perception of their advocacy role related to environment and educational influences following an education intervention using an ethics digital story, supporting our hypothesis. During the initial data analysis, we computed statistics on each item. Subsequently, the questionnaire items were divided by subscale, and a paired t-test was conducted on the pre- and post-test items for each subscale. However, the data were only normally distributed for subscale IV, which indicated that a Wilcoxon signed-rank test should be used to determine significance. A Wilcoxon signed-rank test was completed on each subscale, and the results showed significance in subscale III 7
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Table 2. Subscale Wilcoxon signed-rank test results. Component subscale
Significance
I Acting as an advocate II Work status and advocacy actions III Environment and educational influences IV Support and barriers to advocacy
0.058 0.700 0.001 0.184
Table 3. Supports and barriers to advocacy Wilcoxon signed-ranks test results. Component subscale IV
Significance
Support to advocacy Barriers to advocacy
0.008 0.918
at an a ¼ 0.05 level, with an a ¼ 0.001 (Table 2). The Wilcoxon signed-rank test for subscale I, although not significant, was also noteworthy with an a ¼ 0.058, suggesting that further research may be indicated on the type of advocacy represented by this subscale. An additional data analysis was conducted on the items in subscale IV, as it included both neutrally and negatively worded questions. Subscale IV consisted of ‘‘Supports and Barriers to Advocacy,’’ and the ‘‘Supports’’ included the neutrally worded items, while ‘‘Barriers’’ included negatively worded items. In order to determine the difference in level of advocacy from the pre- and post-test, this subscale was divided into these two categories and analyzed separately. A Wilcoxon signed-rank test was conducted on these categories and the ‘‘Supports’’ category was found to be significant at an a ¼ 0.05 level, with an a ¼ 0.008 (Table 3). Of note, we chose to do this divided subscale analysis on our own and it has not been previously tested in Hanks’6 research. Additionally, the subscale category of ‘‘Supports,’’ although found to be significant, consisted of only two survey items, which may have impacted the results.
Discussion The research described in this article takes the use and research of narrative pedagogy a step further by using a tool specialized in measuring nursing students’ perception of patient advocacy to understand the effectiveness of such a teaching method. The results show that students had an increase in perceived advocacy role related to ‘‘Environment and educational influences’’ after the narrative pedagogy intervention. The findings from the other subscales ‘‘Acting as an advocate,’’ ‘‘Work status and advocacy actions,’’ and ‘‘Support and barriers to advocacy’’ did not demonstrate statistical significance after the intervention. Additionally, when subscale IV was broken down by ‘‘Support’’ and ‘‘Barriers,’’ we found that the students had a significantly improved level of advocacy related to the support of advocacy, but not to the barriers of advocacy. These results show that nursing students’ perceptions of patient advocacy increased during the educational experience as evidenced by the PNAS results. Areas significant for increased change include environment and educational influences and support to advocacy, which make sense due to the clinical and educational experiences that occurred during the semester. The literature suggests that a higher level of education is associated with a greater perceived autonomy, yielding a greater likelihood for the nurse to advocate for his or her patient.11 Hanks,11 O’Connor and Kelly,8 and Duffy et al.21 all recommend including nursing ethics and patient advocacy in the curriculum for nursing student education. Duffy et al.21 advocate for early intervention with nursing students to utilize 8
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clinical experiences as opportunities for reflection about patient care concerns, while providing feedback and support to the student. O’Connor and Kelly8 acknowledge that teaching an abstract concept such as nursing advocacy requires active engagement with a clinical experience through the use of workshops or role play scenarios in order for students to learn. Utilizing narrative pedagogy as a framework for digital storytelling was found to enhance nursing students’ clinical thinking strategies.17 By including alternative nursing education methods and teaching in the curriculum, students can learn to be more confident and secure about speaking up when issues of patient advocacy arise. This new method of advocacy education could, in turn, lead to better patient outcomes and higher nursing satisfaction. Given our small sample size, lack of control group, and randomization, opportunities for further research include replication of this study as a well powered randomized controlled trial. Best practices of advocacy education for all clinicians, at all levels of practice, need to be documented, and this educational intervention could be tested on an interprofessional group of learners.
Limitations Some of the limitations of this study are related to the sample population, including having a small sample size, a female-only sample, students who all have a previous bachelor’s degree, and students who are older than the traditional undergraduate nursing student. There is minimal generalizability from this study as the sample cannot be considered representative of the overall nursing student population. In addition, the PNAS has a limited use, as it has not been widely used and tested on all nursing populations. This research is the first time the PNAS tool has been used in this manner to analyze data and make comparisons. Some of the questions in Hanks’6 PNAS tool were found to be unreliable or have a questionable meaning, such as the six items that were not included in the analysis. Additionally, Hanks6 used both positively, neutrally, and negatively worded questions in his survey, which led to our decision to divide subscale IV into ‘‘Support’’ and ‘‘Barriers.’’ The division of subscale IV is also a limitation, as this was not originally tested in Hanks’6 research. The PNAS tool is also limited in that it does not allow for overall conclusions to be drawn, as the data must be analyzed by subscale. An additional limitation is that our research does not measure the effect of the narrative pedagogy assignment on the nursing students independently, as the students are simultaneously at various clinical sites. As a result, it is unknown whether the effect on nursing student advocacy is due to the narrative pedagogy intervention or whether it is related to the experience of being in the field at a clinical site.
Conclusion This research study aims to explore and enhance the research available on the use of narrative pedagogy and the development of the advocacy role to nursing students. Ideally, this research could be extended to reach the advocacy of current practicing nurses as well, as studies have shown that there are a significant number of practicing nurses who fail to advocate for their patients. It is vital to find a way to improve the rate of patient advocacy in order to decrease errors in practice as well as to provide a higher standard of care to the patient. The use of narrative pedagogy and the FESOR model also helps to identify ethical concerns and works to analyze how they can be addressed. The PNAS serves as a tool that can be used to measure the outcomes of perceived patient advocacy in nurses after narrative pedagogy has been instituted. There is an abundance of literature surrounding the use of narrative pedagogy and barriers to advocacy. However, while this study showed using narrative pedagogy in conjunction with clinical experience can enhance nursing students’ perceptions of patient advocacy, further research is needed on this topic in order to assess the effectiveness of narrative pedagogy educational techniques in nursing and how barriers to advocacy may be overcome. 9
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Conflict of interest No conflict of interest has been declared by the authors. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References 1. Maxfield D, Grenny J, McMillan R, et al. Silence kills: the seven crucial conversations for healthcare. Provo, UT: VitalSmarts, 2005. 2. Black LM. Tragedy into policy: a quantitative study of nurses’ attitudes toward patient advocacy activities. Am J Nurs 2011; 111: 26–37. 3. Foley BJ, Minick MP and Kee CC. How nurses learn advocacy. J Nurs Scholarsh 2002; 34: 181–186. 4. Diekelmann N.Narrative pedagogy: Heideggerian hermeneutical analyses of lived experiences of students, teachers, and clinicians. Adv Nurs Sci 2001; 23: 53–71. 5. Ironside PM. Using narrative pedagogy: learning and practising interpretive thinking. J Adv Nurs 2006; 55: 478–486. 6. Hanks R. Development and testing of an instrument to measure protective nursing advocacy. Nurs Ethics 2010; 17: 255–267. 7. American Nurses Association (ANA). The Code of Ethics for Nurses with interpretive statements. Silver Spring, MD: ANA, 2010. 8. O’Connor T and Kelly B. Bridging the gap: a study of general nurses’ perceptions of patient advocacy in Ireland. Nurs Ethics 2005; 12: 453–467. 9. Hanks RG. Barriers to nursing advocacy: a concept analysis. Nurs Forum 2007; 42: 171–177. 10. Hanks RG. The lived experience of nursing advocacy. Nurs Ethics 2008; 15: 468–477. 11. Hanks R. The medical–surgical nurse perspective of advocate role. Nurs Forum 2010; 45: 97–107. 12. Delk KL. Whistleblowing—is it really worth the consequences? Workplace Health Saf 2013; 61: 61–64. 13. Lachman VD. Whistleblowers: troublemakers or virtuous nurses? Imprint 2014; 61: 36–39. 14. Thomas MB and Willmann J. Why nurses need whistleblower protection. J Nurs Regul 2012; 3: 19–23. 15. McAllister M, John T, Gray M, et al. Adopting narrative pedagogy to improve the student learning experience in a regional Australian university. Contemp Nurs 2009; 32: 156–165. 16. Kawashima A. The implementation of narrative pedagogy into nursing education in Japan. Nurs Educ Perspect 2005; 26: 168–171. 17. Gazarian PK. Digital stories: incorporating narrative pedagogy. J Nurs Educ 2010; 49: 287–290. 18. Ohler J. The world of digital storytelling. Educ Leadersh 2005; 63: 44–47. 19. McCormick-Gendzel M and Jurchak M. A pathway for moral reasoning in home healthcare. Home Healthc Nurse 2006; 24: 654–661. 20. Jurchak M and Pennington M. Strengthening moral agency in new ICU nurses. In: Hickey M and Kritek PB (eds) Change leadership in nursing: how change occurs in a complex hospital system. New York: Springer, 2012, pp. 157–163. 21. Duffy K, McCallum J, Ness V, et al. Whistleblowing and student nurses—are we asking too much? Nurs Educ Pract 2012; 12: 177–178.
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