YNEDT-02709; No of Pages 6 Nurse Education Today xxx (2014) xxx–xxx

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Little people, big lessons: An innovative strategy to develop interpersonal skills in undergraduate nursing students Kerry Reid Searl, Margaret McAllister ⁎, Trudy Dwyer, Katrina Lane Krebs, Carina Anderson, Loretto Quinney, Sandy McLellan School of Nursing and Midwifery, Higher Education Division, CQ University, Queensland, Australia

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Article history: Received 27 September 2013 Received in revised form 3 April 2014 Accepted 7 April 2014 Available online xxxx Keywords: Child Compassion Interpersonal nursing Peplau Puppet Pup-Ed (KRS simulation) Solution focused nursing

s u m m a r y Learning the skills of child health nursing requires more than technical skill development. Humanistic attributes such as being genuine, accepting and empathic are imperative in gaining the trust of a child and in helping them feel comforted and safe in a health care setting. Interpersonal theory has a long history in nursing and numerous contemporary theories have drawn on the seminal work of Peplau to advance nursing practice. However, rarely has this theory been applied to simulation learning. This paper reports on an innovative simulation technique that blends interpersonal theory with puppets. Qualitative evaluation using focus group method with fifteen undergraduate nursing students revealed that the pedagogy had a positive impact on characteristics of the learner, the learning process and on interpersonal communication skills development. The study deepened insights about the educative process and led to learning impacts that suggest that puppet-based learning is a powerful medium to bridge theory and practice, bringing the importance of interpersonal theory to life for students. © 2014 Elsevier Ltd. All rights reserved.

Introduction The interpersonal relationship has long been described as the crux of nursing practice (Horsfall and Stuhlmiller, 2000; Peplau, 1962) and forms part of a range of nursing theories (Beeber et al., 2004; McAllister, 2003). In paediatric, child and youth health settings, skills to develop interpersonal relationships with children are central to practice. Thus, nursing students need to learn this applied theory in order to work effectively in this environment and to become competent graduates. Peplau's interpersonal theory of nursing posits that, through the interpersonal relationship with a nurse, a patient or client undergoes three stages of healing in their journey from illness to well-being (Peterson, 2009). The three stages are identification, exploitation and resolution. Although implemented differently, these stages compare with the phases of Solution Focused Nursing (SFN) developed by McAllister: joining, building and extending (McAllister et al., 2013a, 2013b). SFN is a contemporary nursing theory that fits with current national and global agendas to shift health care professionals from a secondary prevention approach to health care towards a more holistic, comprehensive approach in which prevention and rehabilitation are ⁎ Corresponding author at: CQ University, 90 Goodchap Street, Noosaville, Queensland 4556, Australia. Tel.: +61 407280939. E-mail address: [email protected] (M. McAllister).

equally emphasized (McAllister, 2010). In SFN, nurses work collaboratively with clients to emphasize their strengths, set goals and help restore and maintain well-being and resilience. Both interpersonal theory and SFN value the interpersonal relationship. The first aim of this paper is to explore contemporary applications of interpersonal theory. The second is to describe a learning strategy that has been designed to innovatively convey interpersonal theory and to equip student nurses with the knowledge and skills to work with children in health-promoting ways. The learning strategies are designed for engagement to ensure the lessons are memorable and will transfer from the classroom into practice. This empowering approach builds student skills to confidently interact with children.

Interpersonal theories applied to the nurse–child relationship In the first phase of Peplau's interpersonal relationship, a patient begins the process of identification, that is, they identify problems to be worked on. This process occurs when the nurse cultivates a relationship with the patient within which the patient feels safe to acknowledge the problem and to share its weight. In SFN, this phase is called “joining.” Joining can occur at any time in a relationship with a child when a nurse approaches the relationship with a conscious intent to be genuine, accepting and empathic. These are the humanistic attributes espoused by Peplau and others (Gamble and Brennan, 2000; Rogers,

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Peplau's final phase is termed “resolution.” In this phase, the relationship is ready to be terminated because the patient has become self-reliant. In SFN, the parallel phase is termed “extending” because the aim is for the patient to transfer skills learned in the building phase to other contexts, and for these skills to be practiced without the close support of the nurse. In each phase, knowing how to skilfully listen, empathize, communicate and teach is vital. Whilst Peplau's theory was not explicitly strengths focused, its emphasis on the psychosocial attributes of the nurse and mutual goal setting within the nurse–patient relationship are mirrored in the SFN approach.

Play therapy has been widely studied and reported within the fields of counselling and occupational therapy and, to a lesser extent, nursing (Landreth, 2002; Saucier, 1989). Nurses can employ play for both therapy and learning. Role-play games feature heavily in the literature on computer simulation for teaching abstract concepts such as science (Foster, 2008), and their use is increasing within nursing simulation education (Muir-Cochrane et al., 2010). However, the use of puppets in simulation learning for nursing students in higher education has not been reported. Puppets have been more widely used for learning than for therapy. Studies demonstrate that they can be effective in a variety of ways. Puppets have been used to teach children about the importance of caring for the environment, in family planning, and to transmit knowledge about HIV (Pradesh, 2011). Jacono and Jacono (2008) found that the use of puppets was an engaging way to raise awareness about mental health and to improve optimism amongst a group of North American aboriginal young people at risk of suicide and self-harm. Burke Mackenzie (2012) used puppets to improve teaching skills in future educators. She explains that the visual power of the puppets assists student teachers to release inhibitions that may prevent them from engaging with classroom learners. The puppets are an indirect, yet effective, way to enhance the student teachers' communication skills. Puppets may also improve learner engagement. Epstein et al. (2008) found that learners became so engaged with the puppets that they talked to and interacted directly with the puppets rather than with the puppet operator. Similarly, Hackling et al. (2011) found that puppets helped the educator interact more fully with learners and facilitate deeper discussion through which learners could clarify and consolidate their understanding. The evidence on the effectiveness of puppets in learning suggests they might also be an effective tool to improve the communication skills of nursing students in a simulation learning context.

Teaching Students To Apply Interpersonal Skills in Child Health

The simulation innovation

Teaching undergraduate nursing students interpersonal theories and giving them opportunities to apply the theory and practice the skills to develop confidence can be challenging in the context of Australian higher education. The curriculum is crowded (Ironside, 2004), and clinical placements, particularly in child health settings, are scarce (Health Workforce Australia, 2010). Students and educators are time poor (McAllister et al., 2011). In addition, today's learners are looking for excitement and innovation—something to hook their interest and capture their imagination (Morris and Faulk, 2012). Simulation learning provides an exciting and relevant solution. Strong evidence that simulation can adequately replace clinical learning, especially in specialty fields, is not yet available (Brown et al., 2012). However, simulation learning can allow students to learn client-focused skills in a safe environment where mistakes can be made without causing harm to actual clients (Baxter et al., 2009; Warland, 2011). Learners can then make more effective use of their limited time on clinical placements. Pre-placement laboratory learning allows students to take as much time as they need to practice the skills required for competency in the clinical context. Highly sophisticated simulation equipment is available, which may appeal to today's “tech-savvy” students and prove useful in developing technical proficiency (Oblinger, 2006). However, such equipment requires significant investment in infrastructure (Gant, 2007). In addition, whether these simulations are effective for developing interpersonal skills, particularly in the context of child health nursing, is unknown.

Within the School of Nursing and Midwifery programme at a regional Australian university, innovative, well-developed simulation strategies (Mask-Ed) using props and masks to hide the educator in the role of patient are being employed (McAllister et al., 2013b). However, this approach has been limited to learning about adult health care because the teacher-in-role is necessarily an adult. The portrayal of the needs of paediatric patients using scenarios to encourage nurse–child interaction had not been developed. This deficiency prompted the development of puppetry to mimic a child patient and thereby encourage nurse–child interaction. We named the technique “Pup-Ed (KRS Simulation)”; the acronym is based on the first letters of key aspects of the puppet simulation pedagogy (Table 1). Two types of commercially available puppets were used to develop this technique. Character puppets are 65 cm hand-controlled puppets. These little puppets (Living Puppets™, Germany; www. living-puppets.de) are made of washable material. The opening in the back of the head gives the user full mouth control and the gloved hands allow the user to make hand movements, which bring the puppet to life (Fig. 1). The second puppet type is procedure puppets. These puppets (Patient Puppets, Canada; www.patientpuppets.mb.ca) are also made from cloth and foam but have more complex components than the character puppets. They allow students to practice technical procedures such as insertion of catheters, naso-gastric tubes and cannulas and establishing a port access. In comparison with both computerized and non-computerized manikin simulations, the puppet simulation allows the learner to actually perform a procedure on the puppet, which moves and responds as a child would. The learner becomes immersed in the world of this “little person”; the puppet can express feelings (e.g., portray fear), ask questions and, most importantly, respond. The

1975). However, joining has a further simple, yet profound, aspect: to be respectfully curious (McAllister et al., 2013a, 2013b). Peplau's next phase is called “exploitation.” In this phase, the patient's trust is fully developed. Thereby, the patient can make full use of the available nursing care. In SFN, the equivalent phase is called “building.” In this phase, skills are learned and practiced within a safe space cultivated and maintained by the nurse to allow shared, purposeful time with the child. This purposeful approach involves more than the delivery of treatments, although treatments may be offered. With a solution-focused orientation, the nurse may use treatment encounters to build the child's knowledge, courage, resilience and optimism. This building phase involves exploiting opportunities. This building phase involves finding opportunities to build the patient's trust and collaboratively find solutions to health issues. At every available opportunity, a solution-focused nurse should ask themselves questions: 1. What is happening here that could be changed? 2. How can we give more space to this imagined change, rather than to the present problem? 3. What steps being made towards change do we need to notice and reinforce?

The use of play to teach communication skills A medium that captures the imagination of almost all children and learners is play, specifically puppetry (Friedman, 2006).

Please cite this article as: Reid Searl, K., et al., Little people, big lessons: An innovative strategy to develop interpersonal skills in undergraduate nursing students, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.004

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Table 1 the Pup-Ed pedagogy. P U P

E D K R S

The puppet is worn by an informed professional—be it nursing educator, or clinical nurse engaged with a child client. The informed professional sets out to understand the learner—being genuine, accepting, empathic and curious. Play takes place between the educator and learner. Using artistry, the educator transforms the puppet into a little person—sometimes a client, sometimes a shy or curious child. This child has a life-story relevant to the learning experience. Learning occurs in the context of an interpersonal relationship that takes place between educator, puppet and learner. The puppet talks only with the educator, and in turn the educator rephrases, clarifies, summarizes and probes using humanistic and solution focused techniques, enhancing engagement with the puppet and the learner. In the play, the learner learns two things: skills in communicating with a child, and more about this little person's life. Essential to the learning or the nursing work is that the interpersonal interaction be evaluated to continually improve teaching and learning. In coming out of role, further learning occurs as learner and educator debrief, asking each other questions about what happened, how it happened, and what the interaction meant in the scheme of things. Like other developed humanistic simulation techniques, for this strategy to work, it depends on the educator being knowledgeable and for the simulation to be realistic and spontaneous.

learner connects with the puppet and, if the learner is relating effectively, the puppet can show how fear is allayed and anxiety reduced. Reid-Searl (2012) states it is imperative that the puppet operator have a deep understanding of the health knowledge being explored through the puppet's interaction with the learner; they must also appreciate that learners learn in different ways. Reid-Searl also maintains that the puppet should engage in a health care experience which mimics or amplifies reality. In addition, spontaneity is important in the relationship, that is, the puppet should react in an unprompted, unscripted manner similar to the flow in authentic human relationships. This spontaneity increases and sustains learner engagement with and immersion in the experience. During training, educators name their puppet and develop a realistic life and health story for it. For example, little Lu Lu Searl is a 6-year-old puppet who experiences diabetes and asthma. Lu Lu was diagnosed with diabetes at 4 years of age. She lives with her mother, brother and older sister. Lu Lu is often hospitalized, and during this time, she loves to work with other children who also have asthma or diabetes. She learns from their experiences and shares stories of the little things that nurses do which make her feel better. Lu Lu not only relates to other children by mimicking their behaviour, but she also shares her wisdom with nursing students. She responds to the student nurses' communication with the responses of a real child, and she is quick to pass on what she loves best about the students who are kind. Lu Lu is an advocate for children and knows how she likes to be spoken to and cared for. The puppets were introduced into a first year course (N = 60; 90% female) that explores foundations of nursing practice. Participating nurse educators (N = 4) were provided with training in a customized pedagogical method to improve their skills and promote the reliable implementation of Pup-ED (KRS simulation). The educator training involved pre-reading of a learning guide, a 1-hour lecture and supervised practice. Within the course, the puppets were presented in two modalities. They were first introduced online through learning activities on the course site within the university's learning management platform, Moodle. They were then used in the laboratory context in sessions to develop skills in communication, monitoring vital signs, assessing elimination and nutrition, and intervention practice (Table 2). Each simulation session with the puppets lasted between 20 and 50 minutes, which included time for reflection. The puppets also featured in engagement activities throughout the nursing program. For example, the puppets would appear at Table 2 Questions asked to evaluate Pup-ED (KRS Simulation). 1. 2. 3. 4. 5.

Tell me about your experiences with puppets in your undergraduate degree. In what ways were the puppets used? Tell me about any positive aspects of interacting with the puppets. Tell me about any challenging aspects with the puppets. In what ways do you think the puppets facilitated your learning? What did the puppets teach you as a nursing student about communication with a child client?

important speeches. They were also visible on marketing and promotion days. Evaluation The innovative simulation was evaluated one year after implementation within a foundational nursing course and in engagement activities in the undergraduate nursing programme. A qualitative exploratory study sought information from students about the simulation's acceptability and impact. Students enrolled in the course or who had been engaging with the puppets were invited to participate in a focus group interview conducted by one member of the teaching team. Ethical clearance was obtained through the Human Research Ethics Committee of the university. Participants were advised that all participation was voluntary and that, although students would be identifiable during the data collection, all reports and subsequent publications would protect their identity. As well as meeting ethical guidelines, these strategies encouraged students' openness, honesty and critical evaluation of the innovation. Typical questions asked during the interview were: • Tell me about your experiences with puppets in your undergraduate degree. • In what ways were the puppets used? • Tell me about any positive aspects of interacting with the puppets. • Tell me about any challenging aspects with the puppets. • In what ways do you think the puppets facilitated your learning? • What did the puppets teach you as a nursing student about communication with a child client? Interviews were audiotaped and later transcribed verbatim. The transcripts were reviewed by the research team and analyzed using the framework for thematic analysis described by Ritchie and Spencer (1994). In brief, the researchers first familiarized themselves with the data to obtain an overview of the interview transcripts. They then indexed, charted, mapped and interpreted the emerging themes relevant to learning nursing skills and practicing child health care (Ritchie and Spencer, 1994). To identify a thematic framework, data were examined to extract key issues and themes. Indexing labeled the data into manageable units for subsequent retrieval and exploration. During charting, the data were abstracted and synthesized: each passage of transcript data was annotated with a particular issue or theme, re-examined, and a summary of the participants' perceptions entered on a chart. In the mapping and interpreting stages, participants' experiences were compared and contrasted to identify patterns, connections and explanations within the data set. Results Fifteen students volunteered to participate in three focus group interviews. Three significant themes were identified as important characteristics or factors influencing the effectiveness of the simulation and engagement with the puppets: the learner, the learning process,

Please cite this article as: Reid Searl, K., et al., Little people, big lessons: An innovative strategy to develop interpersonal skills in undergraduate nursing students, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.004

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Fig. 1. Pup-ED learning experience. (For interpretation of the references to colour in this figure, the reader is referred to the web version of this article.)

and interpersonal communication (Fig. 2). These themes are discussed below using examples of verbatim interview data; participants are identified with codes (P1 to P15).

I got a High Distinction for foundations and I really think a lot of it was the introduction of … the paediatric puppets because it took it from a text book environment to things you can relate to …it really took us out of that box so I think it's fantastic. (P15)

The learner Within this theme, learners revealed a variety of characteristics about themselves that facilitated engagement with the simulation. For example, participants identified that the puppets catered for their different learning styles: It was a visual way of learning which I found really good, and it's good for people who aren't good with writing it down in like million words because you can see it demonstrated right in front of you (P2)

Use of the puppets was an effective way to reduce anxiety in students, improving their ability to focus and learn within the experience: I think they helped me to relax and I was enjoying it so I was taking the information in. (P3) … it kind of relaxes us a bit as well in class because we are going in there not knowing what to expect but these puppets come into the picture and you just relax. (P11)

Participants also felt that the puppets engaged them in learning: The learning process I always felt engaged in the lesson and there was an element of surprise which made you look out for what was coming (P2) Some participants felt the engagement not only helped their learning but also improved their grades: I found I got better grades in the class with the puppets than I did in other classes because they engaged all parts of your thinking and facilitated the way you think. (P2)

• Caters to the visual learner • Reduces anxiety • Improves grades

Learner

Learning process • Enlivened learning • Authenticity

• Knowing how to provide comfort • Knowing how to communicate with a sick child

Interpersonal communication

Fig. 2. Student perceptions of the benefits of Pup-Ed. (For interpretation of the references to colour in this figure, the reader is referred to the web version of this article.)

The innovation was appraised as a novel strategy that enlivened the learning process. There was an element of fun with the puppets It always livened things up in the lab when they were in … I guess it was good because it gave me confidence to do things and I reckon, well, it was just a bit of fun that helped me learn really. (P4) The puppets are really interesting … they liven up the labs a bit and you get to see how a sick child might not be able to understand it if you didn't get down to their level It just made it easier … more real. (P6) Because the puppets had life stories that were drawn from real characters and were operated by an informed educator, the experience had an authenticity that facilitated learner engagement. The active role of the educator brought the puppets to life, in contrast with simulations that use manikins. Although students knew these characters were puppets, they could not be ignored; students, educator and puppet were engaged in an ongoing interaction. They were fun and they helped you learn by making it all a bit more real. It was just about, you know, seeing things like they might unfold. You can forget that the puppet isn't real, well not really, but I found myself wanting the puppet to look at me. (P4)

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… we're learning a very important thing and I think with the introduction of puppets when you're in a learning environment and your head's swimming with so many textbooks, when you introduce a little bit of fun and humour too, they are the things that really stick and you can recall too you can relate it back to a physical thing not just something you've read in a textbook. (P 15) Interpersonal communication skills Participants discussed what they had learned as a result of the experience. A common response was that they had learned how to relate to and communicate with a sick child. This extended quote demonstrates that not only did students learn technical communication skills, but they also learned how to be present with a child to enable the child to feel more relaxed and at ease. Not only can you relate the puppet to the child, but you can also relate the child to the puppet so it's sort of a double edged sword. It's an excellent tool and from a communication side of things. It really does open up those barriers not just to the paediatric client, but also to the nurse as well because you're actually going into more of a relaxed atmosphere straight away. The client is going to feel at ease and therefore the nurse is going to feel at ease as well … with puppets you're going to break a lot of barriers … trust is going to be built a lot quicker … [in a] more comfortable and relaxed atmosphere I think you'll get a lot more information from the client … so you're going to [be able to] delve a little bit deeper into the diagnosis instead of just getting yes/no answers. (P15) Clearly, this participant learned the importance of relaxing child clients and communicating with them at their level and at their pace. However, the participant also indicated that they intended to use puppets in their future practice as a tool to help the student be more relaxed and engaging when interacting with children. Thus, the Pup-Ed learning strategy may be a useful tool to demonstrate how nurses can enter the joining phase articulated in SFN. Other participants began to more fully appreciate strategies to comfort a child. In paediatric clients you have to get down to their level you have to talk directly to them in a way that they find comforting and perhaps like give them hug when they need it to calm them down. With kids sometimes they just need someone to talk to. (P2) Participants also realized the value of using child-centered language and a light-hearted tone. They also saw how using the puppet to introduce the child to treatments could be a powerful way to provide comfort, reassurance and psychological safety: Understanding the way kids think. And why it's important to use simple everyday language—[for example] call the body parts by normal things. [Don't] say Panadol. Call it the pill or the tablet. Use a bandage or give a needle to the puppet first as it takes the scariness away … [it's] reassurance really. (P1) It's completely different from talking with adults, in more ways than I thought. I learnt you need to keep it light hearted. (P3) Particpants also understood the importance of childhood developmental stages: They aren't mini adults and not to look at them like they know what you're saying. I guess as a parent as well, you tend to talk to your child the way you've always talked to them but with other people's children, you don't know whereabouts in those stages they are and you just have to step back and explain things more simply … also the pain thing—

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don't just start doing something you've got to ask permission and to explain it and make sure they understand it. (P1) In addition, the experience emphasized the importance of connection: … made me realise about how important it is to use everything you can find to connect because then it will be easier to get the child to do things and maybe it will help them understand why they have to have things done. (P4)

Discussion As confirmed by the evaluation, undergraduate nursing students found the Pup-Ed learning experience enjoyable and enriching. Perhaps the most significant aspect of this innovative methodology is that students were simultaneously engaged in knowledge play and learning the skill and artistry of child health nursing. This experience of occupying two worlds—the “what if” world that is created in imaginative play, and the real world of clinical practice—contributes to the power of learning experiences that use applied theatre, including Mask-Ed (KRS Simulation), the “cousin” of Pup-Ed. Through the applied theatre experience students hold two worlds in their mind at the same time, the fictional and the real, and through the experience of the fictional world, learning and understandings from the real world can shift or be revised with greater clarity. (McAllister et al., 2013b) Because classroom learning is deeply entwined with clinical practice, correctly implemented Pup-Ed pedagogy likely produces transformative learning experiences for nursing students in the context of child health nursing; students perceive the learning experiences as relevant and authentic. Similar to the findings of Burke Mackenzie (2012), the Pup-Ed innovation may improve the detection of visual cues, which can enrich learning. The theory of interpersonal learning can be understood by reading the works of Peplau, McAllister and others. However, its practice may be improved first through the peripheral participation of observing the interaction between nurse educator and puppet, and then through active involvement when the student is brought into the dynamic. In addition, incorporating puppets into the learning experience can diminish students' anxieties, which may otherwise be an impediment to learning (McAllister et al., 2013a, 2013b). The novel addition of puppets to the skills laboratory enlivened learning for students. Although the puppets were patently not real patients, their life histories brought an authenticity to the interaction. Students knew they were interacting with a puppet, yet found themselves eagerly awaiting responses from the puppet and changing their communication strategy if required on the basis of feedback from the puppet. This element of realism is an important characteristic of Pup-Ed. As a humanistic simulation method, it works because disbelief is suspended (as it is in theatre), which allows students to more fully immerse themselves in the learning experience. Thus, engagement and deep learning occur (McAllister et al., 2013b). Simulation learning offers the potential for more transactional learning than occurs through the often-criticized lecture format, which emphasizes knowledge transmission and results in student passivity (McAllister et al., 2013a, 2013b). However, nursing skills laboratories can also become boring if simulations are routine and predictable. Not only did participants find the Pup-Ed learning process novel and engaging, but it also seemed to achieve productive learning outcomes. Students described in detail the communication strategies they developed, which they believed would help them engage more fully with child clients in the future. Participants also said they developed a wider repertoire of skills to comfort a child. Furthermore, they began

Please cite this article as: Reid Searl, K., et al., Little people, big lessons: An innovative strategy to develop interpersonal skills in undergraduate nursing students, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.004

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to appreciate that paediatric nursing is not only about acquiring technical skills but also requires a sophisticated level of interpersonal know-how. Participants perceived an immediate benefit from this learning experience in the form of improved assessment grades. Perhaps the deep level of engagement and the reduction in anxiety helped students to remember and retain key concepts for subsequent assessment activities. The qualitative exploratory evaluation performed in this study was small and particularistic. We also acknowledge that the participants were self-selected, which may have led to a positive bias in the evaluation of the technique. This limitation of focus group evaluation is well known (Stewart et al., 2007). As such, the findings may not be generalizable. Nonetheless, the focus group did produce rich descriptions about why students found the learning experience with puppets highly valuable. Therefore, we will further refine the pedagogy and are confident the technique is powerful when correctly and precisely implemented. Future research should investigate the longer-term outcomes of this kind of learning experience on student nurses' interactions with children, given the positive student feedback and apparent benefits to their learning, the learning process and interpersonal skills development. Pup-Ed (KRS Simulation) offers a creative strategy that other educators can use to teach nurse–child interactions and to enhance the art of nursing. As Callaway (2000) states in her biography of Peplau, nursing is “a science and a spirit.” Our hope is that students who engage in immersive learning experiences such as Pup-Ed simulations will understand that competent child health nursing involves much more than technical proficiency (Callaway, 2000). It also rests on the ability to be genuine, accepting, empathic and curious. References Baxter, P., Akhtar-Danesh, N., Valaitis, R., Stanyon, W., Sproul, S., 2009. Simulated experiences: nursing students share their perspectives. Nurse Educ. Today 29, 859–866. Beeber, L., Canuso, R., Emory, S., 2004. Instrumental inputs: moving the interpersonal theory of nursing Into practice. Adv. Nurs. Sci. 27 (4), 274–286. Brown, R., Guinea, S., Crookes, P., McAllister, M., Levett-Jones, T., Kelly, M., Reid-Searl, K., Churchouse, C., Anderson, P., Chong, N., Smith, A., 2012. Clinical simulation in Australia and New Zealand: through the lens of an advisory group. Collegian 19, 177–186. Burke Mackenzie, K., 2012. Imagination and transformation: performing a universal narrative theme. Art. Educ. 65 (3), 12–16. Callaway, B., 2000. Hildegard Peplau: Psychiatric Nurse of the Century. Springer, New York. Epstein, I., Stevens, B., McKeever, P., Baruchel, S., Jones, H., 2008. Using puppetry to elicit children's talk for research. Nurs. Inq. 15 (1), 49–56. Foster, A., 2008. Games and motivation to learn science: personal identity, applicability, relevance and meaningfulness. J. Interact. Learn. Res. 19 (4), 597–614. Friedman, S., 2006. A hand in the action: an arts-based inquiry of metaphor and meaning making as tools for inspiring transformation (Master's thesis, available online at circle.ubc.ca.).

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Please cite this article as: Reid Searl, K., et al., Little people, big lessons: An innovative strategy to develop interpersonal skills in undergraduate nursing students, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.04.004