Nurse Education Today 35 (2015) 777–781
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Perceptions and experiences of nursing students enrolled in a palliative and end-of-life nursing elective: A qualitative study Judith L. Hold a,⁎, Barbara J. Blake b,1, Elizabeth N. Ward b,2 a b
Wellstar School of Nursing, Kennesaw State University, 1000 Chastain Road, Building 41, Office 3127, United States Wellstar School of Nursing, Kennesaw State University, 1000 Chastain Road, Kennesaw, GA 30144, United States
a r t i c l e
i n f o
Article history: Accepted 16 February 2015 Keywords: End-of-life Apprenticeship Nursing education Qualitative
s u m m a r y Background: The Carnegie Foundation has identified three professional apprenticeships in nursing that are key to helping students acquire a professional identity. These apprenticeships integrate knowledge acquisition (cognitive apprenticeship), practical experience (practical apprenticeship), and an ethical identity (ethical comportment) for guiding conduct. To ensure that patients have a good death, it is important that faculty incorporate diverse teaching strategies from all three apprenticeships into palliative and end-of life nursing education. Objective: The purpose of this study was to examine perceptions and experiences of nursing students enrolled in a palliative and end-of-life nursing elective that was developed and implemented using the three professional apprenticeships. Design: A qualitative research design was used to obtain data from students who completed the palliative and end-of-life nursing elective. Setting: The study was implemented at a state supported baccalaureate nursing program located in the south eastern United States. Participants: A purposive sample of 19 students who had completed the palliative and end-of-life nursing elective was included in the study. Methods: After completing the course, focus groups were conducted with the student participants. Discussion was guided by questions to elicit which experiences were most helpful to student learning. Thematic analysis of the data was conducted by three researchers. Findings: Three themes reflecting the apprenticeships were identified: learning from stories, learning from being there, and learning from caring. Students' understandings about end-of-life care were enhanced by incorporating teaching strategies addressing the apprenticeships. Conclusion: In end-of-life nursing education, teaching strategies must provide meaningful connections between the student, course content, practical experience, and the dying patient. © 2015 Elsevier Ltd. All rights reserved.
Background A professional identity links together the roles, responsibilities, values, and ethical standards that are exclusive to a profession (Goltz, 2014). In nursing, research has found that professional identity evolves and changes throughout a person's career based on area of practice and level of education (Crigger and Godfrey, 2014; Johnson et al., 2012). Student nurses begin to form a professional identity early in their
⁎ Corresponding author at: WellStar School of Nursing, Kennesaw State University, 1000 Chastain Road, Kennesaw, Georgia 30144, United States. Tel.: + 1 470 578 2965; fax: + 1 470 578 9069. E-mail addresses: [email protected] (J.L. Hold), [email protected] (B.J. Blake), [email protected] (E.N. Ward). 1 Tel.: +1 470 578 6385; fax: +1 470 578 9069. 2 Tel.: +1 678 549 5399.
http://dx.doi.org/10.1016/j.nedt.2015.02.011 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
educational program and educators play an important part in socializing students to the professional role (Hensel, 2014). The Carnegie Foundation has identified three apprenticeships in nursing that are key to helping students acquire a professional identity (Sullivan and Rosin, 2008). The apprenticeships integrate knowledge acquisition (cognitive apprenticeship), practical experience (practical apprenticeship), and an ethical identity (ethical comportment) for guiding professional conduct. Moreover, there is a societal expectation that nursing professionals seek and maintain these three apprenticeships throughout their career. Apprenticeships integrate learning, doing, and critical self-reflection. The cognitive apprenticeship includes knowledge or learning about natural sciences, theory, and principles needed for practice. The practical apprenticeship involves actual know-how and skills for using knowledge within clinical settings. The ethical comportment apprenticeship is necessary for deepening one's commitment to social responsibility
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J.L. Hold et al. / Nurse Education Today 35 (2015) 777–781
and honorable practice identity (Hamilton, 2012). Integrating all three apprenticeships into education is crucial for embedding nurses with a professional identity to meet the demands of a complex health care environment (Benner et al., 2010; Noone, 2009). Nursing education on end-of-life care is just one example where curricula often do not keep pace with current knowledge and practices. This deficiency in academia has resulted in a lack of preparation or competence to provide quality end-of-life care (Allchin, 2006; Barrere and Durkin, 2014). Increased longevity, improved pharmacological options for symptom management, advanced technology to sustain life, and an emphasis on patient autonomy warrant the need for nursing students to enhance their understanding about end-of-life care. By providing specific knowledge, practice skills, and an ethical platform to guide conduct, students can learn to provide end-of-life care that facilitates a good death. The Institute of Medicine (IOM) defined a good death as one that is “free from avoidable distress and suffering for patients, families and caregivers; in general accord with patients' and families' wishes; and reasonably consistent with clinical, cultural and ethical standards” (1997, p. 4). To achieve this outcome, it is vital that curricula address the nurse's role in end-of-life care through innovative teaching strategies based on the three apprenticeships. The purpose of this qualitative study was to examine perceptions and experiences of nursing students enrolled in a palliative and end-of-life elective nursing course that was developed based on the three professional apprenticeships (Hold et al., 2014). Methods Design and Ethics This was a qualitative exploratory study using focus groups. Work for this study was done in accordance with the Institutional Review Board of the researchers' university. A cover letter consent form was used to protect the student's anonymity. At the beginning of each focus group, the consent was distributed and participants' questions were answered by the facilitators. Permission to audio record the focus group sessions was included in the consent. If a student chose not to participate, he or she had the opportunity to leave the group at any time. Participants and Setting Purposive sampling was used to recruit baccalaureate nursing students at a state university located in the southeastern United States. Only students enrolled in a Palliative and End-of-Life Care nursing elective at that university were eligible (N = 52). Students were assured that participation or non-participation would not affect their class grade. Nineteen nursing students volunteered to participate, 17 females and two males. The mean age was 24 years with a range from 21 to 49. The majority of students was Caucasian (n = 15) and reported no previous experience in caring for a dying person (n = 14). All participants had completed at least one semester of nursing school. Procedure Focus groups were formed to obtain the nursing students' opinions and experiences of the Palliative and End-of-Life Care course. Using focus groups assisted in unraveling aspects that may otherwise be less accessible in a one-to-one interview or through a survey (Doody et al., 2013). In a group setting, students are inclined to share their personal views while interacting with their peers. Most importantly, the focus group interviews prompted students to individually and collectively construct meaning related to their learning in the course. Three focus groups were conducted during the first two academic semesters that the elective was offered. Recruitment occurred approximately two weeks before the focus groups were scheduled to happen and all eligible students were invited to participate. The invitations
were extended via email, announcements in class, and flyers. Date, time, and location for the group were included in the invitation. No confirmation from the students was required. The first focus group was conducted immediately after the semester ended. Because of the number of students willing to participate during the second semester, the decision was made to conduct two focus groups at different times on the same day. Limiting the number of participants in each group allowed for more input from each student. These focus groups were conducted during the last week of the course. The room used to conduct the focus group provided privacy and confidentiality and students were asked to use fictitious names when speaking during the session. An open ended question guide was developed as a tool to guide the focus group discussions. By using this tool, the facilitator could concentrate on the focus group dialogue and encourage participation. For the first focus group, two of the course instructors were the facilitators as the course had ended and students already received their final grades. For the second focus group, a faculty member not involved in the course facilitated the interviews as the course was in progress. Sample questions included “What components of the course were most beneficial to your learning” and “Have your perceptions in caring for dying patients changed?” Each focus group was about one hour in length. At the end of the focus group, a demographic questionnaire was distributed for students to complete. Thematic analysis of the focus group interviews was used to cluster data and identify themes from the transcribed audio recordings. Each researcher became familiar with the data by reading the transcripts several times in their entirety. If there were any questions about the accuracy of the transcripts, comparisons were made with the audio recordings. As recommended by Braun and Clarke (2006), notes were made regarding sections of data that were significant to the researchers. After familiarization, the researchers independently identified initial codes within each transcript. Coding was done manually by highlighting specific data excerpts and designating relevant codes beside each selection. To preserve context, the surrounding data for each code was left intact. After all data were coded, they were collated. The correlation across data sets provided a list of different codes. Working together, the researchers reviewed and then sorted all codes to form major themes. The location of codes was adjusted to ensure that each theme formed “a coherent pattern” and similar themes were “collapsed into each other” (Braun and Clarke, 2006, p.91). Codes and themes irrelevant to the purpose of the study were discarded. At the end of the analysis, three themes strongly supported by the narrative data were identified. Methods to Assure Rigor Qualitative researchers evaluate the trustworthiness of the research study's data using four criteria: credibility, dependability, conformability, and transferability (Lincoln and Guba, 1985). Member checking and peer debriefing were integrated into this study's research design to establish credibility. By summarizing and clarifying students' responses during the focus groups, member checking transpired. Peer debriefing amongst the researchers occurred through reflective and collaborative dialogue (Hayes and Singh, 2012). Dependability and conformability were accomplished by having each researcher independently code the data for themes. To obtain transferability, rich and dense data from purposive sampling was used. This type of sampling permits identification and selection of participants who have information relevant to the study's purpose (Lincoln and Guba, 1985). Findings The researchers identified three major themes that were linked to the professional apprenticeships: learning from stories (cognitive apprenticeship), learning from being there (practical apprenticeship), and learning from caring (ethical comportment).
J.L. Hold et al. / Nurse Education Today 35 (2015) 777–781
Learning from Stories The primary teaching strategy used to address the cognitive apprenticeship was guest speakers who had experience in working with dying patients. Students gained knowledge and insight by listening to individuals who shared their expertise through personal stories. These professionals included social workers, a hospice nurse, a palliative care nurse, a chaplain, and a professional harpist. One student stated, “I just really appreciate the candor of a lot of the speakers. They were really honest. They talked about some things that, you know, were real life situations.” Another student said “That was the best part, people talking, because I would actually pay attention versus a PowerPoint, I doze off. The people that came and talked, and shared stories about their experiences; it's a little more engaging and you actually pay attention.” Students also talked about learning from patient stories. A student commented, “I love talking to older people. I always love their stories, and their lives.” Learning from Being There Teaching strategies used to address the practice apprenticeship involved service learning through collaboration with a local hospice agency. Students became volunteers with the agency and were required to spend 10 hours with a patient at their personal residence, assisted facility, or wherever they were receiving hospice care at the time. One student stated, “At clinical you want to do, do, do. So this experience was a lot more about just being, and being with the patients and trying to get to know them and their needs.” Other students said that through the volunteer hours, “I learned how to just listen” and “communicate in a lot of different ways than just talking.” Students also validated that the service learning was an effective teaching strategy by stating “…the service learning hours…the volunteer. Because one-on-one, hands on, very personal, rather than sitting in a classroom and learning about it” and “The true teachers in this course were the patients you saw.” Learning from Caring for Patients The final theme addressed the ethical comportment apprenticeship. Teaching strategies used were the service-learning requirement along with reflective journaling and classroom discussion. This was the most difficult apprenticeship to assess, but students readily expressed ideas or thoughts that reflected an understanding of what their role was in caring for dying patients. One student who was discussing the class stated, “I think I realized we make such a big impact, especially when people are dying. I think every little thing…they just grab it and they hold on to it. So we need to be more compassionate, and be more…I don't know…watch our actions and how we speak to them and show them that we care.” Other students said “Just recently I had an actively dying patient who received a diagnosis and I'm not…I don't feel like I have to run out the door…you know…when they start crying or having all these emotions. I can actually sit there and talk to them…” and “They were people before, and it's important to let them know that they still matter.” Another student indicated that the class content makes you think about …“spirituality, values, what you believe in, and faith.” These internal reflections exemplify the effect that the Palliative and End-of-Life course had on their personal value system. Discussion The cognitive apprenticeship includes the acquisition and integration of conceptual knowledge from different fields (Benner et al., 2010). In this study, students gained essential knowledge about death and dying from health care professionals, patients, families, and other students. These individuals openly shared personal and professional experiences by telling their stories.
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Storytelling is a fundamental component of narrative pedagogy, an interpretative phenomenological method that fosters a sense of community between teacher and students. More specifically, storytelling in nursing is an approach to teaching and learning that develops from the lived experiences of teachers, clinicians, students, and patients. The emphasis of storytelling in nursing education is to engage students in sharing and interpreting narratives (Diekelmann, 2001). Through interpreting stories, students develop multi-perspective thinking inclusive of unique backgrounds, experiences, and concerns (Engstrom and Hunter, 2007). However, it is not only important to hear a story, but to position the story within a social framework (Benner, 1991). In this study, stories provided a nested dialogue based on the experiences of practicing professionals, bringing context to the forefront. As expert end-of-life care professionals told their stories, students discovered knowledge embedded in practice. The practical apprenticeship refers to developing specific skills and engaging in different ways of thinking (Benner et al., 2010). In nursing practice, experiential knowing occurs through repeated exposure to situations that ultimately lead to refinement of novice ideas and thoughts (Benner, 1982; Benner and Wrubel, 1982). This type of learning is personal, distinctive, and evolutionary (Burnard, 1992). Students in this study served as hospice volunteers for five weeks. Through this experience, personal relationships with patients and families were formed and experiential knowledge was gained. From an Aristotelian perspective, the practical apprenticeship focuses on the fundamental difference between theory and practice. Theoretical knowledge is scientific, definitive, and focused on understanding, not application (Saugstad, 2002). Knowledge in the practical realm changes and is based on learning experiences contextualized within social interactions (Benner, 1991). Theory and practice are integrated in nursing education through didactic learning to support and guide acquisition of nursing skills in the clinical setting. The ethical comportment apprenticeship provides students with knowledge and skills to help them resolve ethical predicaments (Benner et al., 2010). In this study, the acquisition of ethical knowhow was fostered through the students' interpersonal bonds with patients and families and reflective journaling. Through these activities students learned to care, which is the root of compassion and ethical action (Noddings, 1984; Watson, 2008). Because of their volunteer experience, students viewed the hospice patient as a person and not a medical diagnosis. By visiting patients in a more personal environment, students were able to view them as a family member within a social community. Journaling about this experience created an avenue for critical reflective thinking, which is important for questioning ideas and values (Benner et al., 2008) Additionally, students understood the importance of just being present. They observed the personal suffering that occurs during someone's end of life and recognized that their presence was a source of comfort. Learning to be present during patient and family suffering is a key formative experience for developing ethical knowledge and social responsibility (Benner et al., 2008). An outline of the relationship between identified themes with student learning outcomes, professional apprenticeships, and learning activities is shown in Table 1. Although the learning activities are aligned with respect to a specific apprenticeship, teaching strategies were often applicable to more than one apprenticeship. For example, through the service learning experience students visited patients and families for five weeks. They learned about current trends in nursing care at the end-of-life while participating in real life situations. In addition, the students practiced communication skills about serious illness and death with patients and families. Writing a reflective journal about their service learning experience revealed an understanding of personal values and beliefs regarding death and dying. Integrating the three professional apprenticeships in this manner provided an opportunity to simulate professional practice.
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Table 1 Relationships between themes, learning outcomes, apprenticeships, and learning activities. Theme
Professional apprenticeship
Student learning outcome
Learning activity/teaching strategies
Learning from stories
Cognitive
Personal stories: Guest speakers including social workers, a hospice nurse, a palliative care nurse, a chaplain and a professional harpist who shared their expertise
Learning from being there
Practice
Learning from caring for patients
Ethical comportment
Explain historical and current trends in nursing care at the end of life. Distinguish between palliative and end of life care. Identify systems of support that assist with grief, loss and bereavement. Demonstrate skill at communication about serious illness and death. Identify one's own values and beliefs about dying and death and how these influence care planning for patients and their families.
Implications The three apprenticeships have a strong theoretical and practical basis, but nursing education has had limited success with integrating them into nursing education (Noone, 2009). According to Benner et al. (2008, 2010), teaching the professional apprenticeships independently fragments and compartmentalizes student learning. Findings from this study support the importance of incorporating all three apprenticeships into one nursing course. In learning about end-of-life nursing care, experts from the field provided context for students to envision how nursing knowledge and principles are used. Reflection and interactive exercises helped students work through abstract concepts such as respect for patients, empathetic understanding, and feelings of despair. Spending time with patients and family members allowed students the opportunity to experience their physical and emotional needs. Personal interaction with dying patients provided a meaningful experience in which students' values, beliefs, and stereotypes about end-of-life care were challenged. Through these learning activities students were exposed to the complexities of nursing practice, which contributes to the formation of their professional identity (Noone, 2009). Service learning is defined as a teaching method that enhances knowledge development while strengthening communities through integrating service with learning and self-reflection (National ServiceLearning Clearinghouse [NSLC], 2011). The American Association of Colleges of Nursing (AACN, 2008) states that service learning is an appropriate student centered learning strategy for nursing students at the baccalaureate level. Service learning offers nursing students' opportunities to learn about theories and principles, implement practical and skilled knowledge, and self-reflect on their actions. Including service learning may be the ideal approach for integrating the three professional apprenticeships into nursing education. Traditionally, student learning within a course is assessed using quantitative techniques. For this study, summative assessment was conducted using a qualitative method, focus groups. This approach provided students with an opportunity to verbalize and discuss specific aspects of the course that were important to their learning. In particular, researchers were able to capture students' personal emotions and thoughts and assess for learning within the ethical comportment apprenticeship. Using a qualitative method provided rich feedback for this study. In the future, a mixed method approach could also prove useful in assessing student learning and contribute to improved learning outcomes.
Conclusion End-of-life nursing care draws on the apprenticeships of knowledge, practice, and ethical commitment to ensure a good death. Effective strategies for teaching end-of-life care provide meaningful connections between students, course content, practical experience, and most
Service learning: As hospice volunteers, students visited assigned patients over five weeks Reflective journaling: Students retrospectively reflected about service learning experience
importantly the dying patient. By unifying theoretical learning with practical experience and ethical know how in palliative and end-oflife nursing care, students enhance their understanding and application of nursing knowledge and move toward forming a professional identity.
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Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Perceptions and experiences of nursing students enrolled in a palliative and end-of-life nursing elective: A qualitative study Judith L. Hold a,⁎, Barbara J. Blake b,1, Elizabeth N. Ward b,2 a b
Wellstar School of Nursing, Kennesaw State University, 1000 Chastain Road, Building 41, Office 3127, United States Wellstar School of Nursing, Kennesaw State University, 1000 Chastain Road, Kennesaw, GA 30144, United States
a r t i c l e
i n f o
Article history: Accepted 16 February 2015 Keywords: End-of-life Apprenticeship Nursing education Qualitative
s u m m a r y Background: The Carnegie Foundation has identified three professional apprenticeships in nursing that are key to helping students acquire a professional identity. These apprenticeships integrate knowledge acquisition (cognitive apprenticeship), practical experience (practical apprenticeship), and an ethical identity (ethical comportment) for guiding conduct. To ensure that patients have a good death, it is important that faculty incorporate diverse teaching strategies from all three apprenticeships into palliative and end-of life nursing education. Objective: The purpose of this study was to examine perceptions and experiences of nursing students enrolled in a palliative and end-of-life nursing elective that was developed and implemented using the three professional apprenticeships. Design: A qualitative research design was used to obtain data from students who completed the palliative and end-of-life nursing elective. Setting: The study was implemented at a state supported baccalaureate nursing program located in the south eastern United States. Participants: A purposive sample of 19 students who had completed the palliative and end-of-life nursing elective was included in the study. Methods: After completing the course, focus groups were conducted with the student participants. Discussion was guided by questions to elicit which experiences were most helpful to student learning. Thematic analysis of the data was conducted by three researchers. Findings: Three themes reflecting the apprenticeships were identified: learning from stories, learning from being there, and learning from caring. Students' understandings about end-of-life care were enhanced by incorporating teaching strategies addressing the apprenticeships. Conclusion: In end-of-life nursing education, teaching strategies must provide meaningful connections between the student, course content, practical experience, and the dying patient. © 2015 Elsevier Ltd. All rights reserved.
Background A professional identity links together the roles, responsibilities, values, and ethical standards that are exclusive to a profession (Goltz, 2014). In nursing, research has found that professional identity evolves and changes throughout a person's career based on area of practice and level of education (Crigger and Godfrey, 2014; Johnson et al., 2012). Student nurses begin to form a professional identity early in their
⁎ Corresponding author at: WellStar School of Nursing, Kennesaw State University, 1000 Chastain Road, Kennesaw, Georgia 30144, United States. Tel.: + 1 470 578 2965; fax: + 1 470 578 9069. E-mail addresses: [email protected] (J.L. Hold), [email protected] (B.J. Blake), [email protected] (E.N. Ward). 1 Tel.: +1 470 578 6385; fax: +1 470 578 9069. 2 Tel.: +1 678 549 5399.
http://dx.doi.org/10.1016/j.nedt.2015.02.011 0260-6917/© 2015 Elsevier Ltd. All rights reserved.
educational program and educators play an important part in socializing students to the professional role (Hensel, 2014). The Carnegie Foundation has identified three apprenticeships in nursing that are key to helping students acquire a professional identity (Sullivan and Rosin, 2008). The apprenticeships integrate knowledge acquisition (cognitive apprenticeship), practical experience (practical apprenticeship), and an ethical identity (ethical comportment) for guiding professional conduct. Moreover, there is a societal expectation that nursing professionals seek and maintain these three apprenticeships throughout their career. Apprenticeships integrate learning, doing, and critical self-reflection. The cognitive apprenticeship includes knowledge or learning about natural sciences, theory, and principles needed for practice. The practical apprenticeship involves actual know-how and skills for using knowledge within clinical settings. The ethical comportment apprenticeship is necessary for deepening one's commitment to social responsibility
778
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and honorable practice identity (Hamilton, 2012). Integrating all three apprenticeships into education is crucial for embedding nurses with a professional identity to meet the demands of a complex health care environment (Benner et al., 2010; Noone, 2009). Nursing education on end-of-life care is just one example where curricula often do not keep pace with current knowledge and practices. This deficiency in academia has resulted in a lack of preparation or competence to provide quality end-of-life care (Allchin, 2006; Barrere and Durkin, 2014). Increased longevity, improved pharmacological options for symptom management, advanced technology to sustain life, and an emphasis on patient autonomy warrant the need for nursing students to enhance their understanding about end-of-life care. By providing specific knowledge, practice skills, and an ethical platform to guide conduct, students can learn to provide end-of-life care that facilitates a good death. The Institute of Medicine (IOM) defined a good death as one that is “free from avoidable distress and suffering for patients, families and caregivers; in general accord with patients' and families' wishes; and reasonably consistent with clinical, cultural and ethical standards” (1997, p. 4). To achieve this outcome, it is vital that curricula address the nurse's role in end-of-life care through innovative teaching strategies based on the three apprenticeships. The purpose of this qualitative study was to examine perceptions and experiences of nursing students enrolled in a palliative and end-of-life elective nursing course that was developed based on the three professional apprenticeships (Hold et al., 2014). Methods Design and Ethics This was a qualitative exploratory study using focus groups. Work for this study was done in accordance with the Institutional Review Board of the researchers' university. A cover letter consent form was used to protect the student's anonymity. At the beginning of each focus group, the consent was distributed and participants' questions were answered by the facilitators. Permission to audio record the focus group sessions was included in the consent. If a student chose not to participate, he or she had the opportunity to leave the group at any time. Participants and Setting Purposive sampling was used to recruit baccalaureate nursing students at a state university located in the southeastern United States. Only students enrolled in a Palliative and End-of-Life Care nursing elective at that university were eligible (N = 52). Students were assured that participation or non-participation would not affect their class grade. Nineteen nursing students volunteered to participate, 17 females and two males. The mean age was 24 years with a range from 21 to 49. The majority of students was Caucasian (n = 15) and reported no previous experience in caring for a dying person (n = 14). All participants had completed at least one semester of nursing school. Procedure Focus groups were formed to obtain the nursing students' opinions and experiences of the Palliative and End-of-Life Care course. Using focus groups assisted in unraveling aspects that may otherwise be less accessible in a one-to-one interview or through a survey (Doody et al., 2013). In a group setting, students are inclined to share their personal views while interacting with their peers. Most importantly, the focus group interviews prompted students to individually and collectively construct meaning related to their learning in the course. Three focus groups were conducted during the first two academic semesters that the elective was offered. Recruitment occurred approximately two weeks before the focus groups were scheduled to happen and all eligible students were invited to participate. The invitations
were extended via email, announcements in class, and flyers. Date, time, and location for the group were included in the invitation. No confirmation from the students was required. The first focus group was conducted immediately after the semester ended. Because of the number of students willing to participate during the second semester, the decision was made to conduct two focus groups at different times on the same day. Limiting the number of participants in each group allowed for more input from each student. These focus groups were conducted during the last week of the course. The room used to conduct the focus group provided privacy and confidentiality and students were asked to use fictitious names when speaking during the session. An open ended question guide was developed as a tool to guide the focus group discussions. By using this tool, the facilitator could concentrate on the focus group dialogue and encourage participation. For the first focus group, two of the course instructors were the facilitators as the course had ended and students already received their final grades. For the second focus group, a faculty member not involved in the course facilitated the interviews as the course was in progress. Sample questions included “What components of the course were most beneficial to your learning” and “Have your perceptions in caring for dying patients changed?” Each focus group was about one hour in length. At the end of the focus group, a demographic questionnaire was distributed for students to complete. Thematic analysis of the focus group interviews was used to cluster data and identify themes from the transcribed audio recordings. Each researcher became familiar with the data by reading the transcripts several times in their entirety. If there were any questions about the accuracy of the transcripts, comparisons were made with the audio recordings. As recommended by Braun and Clarke (2006), notes were made regarding sections of data that were significant to the researchers. After familiarization, the researchers independently identified initial codes within each transcript. Coding was done manually by highlighting specific data excerpts and designating relevant codes beside each selection. To preserve context, the surrounding data for each code was left intact. After all data were coded, they were collated. The correlation across data sets provided a list of different codes. Working together, the researchers reviewed and then sorted all codes to form major themes. The location of codes was adjusted to ensure that each theme formed “a coherent pattern” and similar themes were “collapsed into each other” (Braun and Clarke, 2006, p.91). Codes and themes irrelevant to the purpose of the study were discarded. At the end of the analysis, three themes strongly supported by the narrative data were identified. Methods to Assure Rigor Qualitative researchers evaluate the trustworthiness of the research study's data using four criteria: credibility, dependability, conformability, and transferability (Lincoln and Guba, 1985). Member checking and peer debriefing were integrated into this study's research design to establish credibility. By summarizing and clarifying students' responses during the focus groups, member checking transpired. Peer debriefing amongst the researchers occurred through reflective and collaborative dialogue (Hayes and Singh, 2012). Dependability and conformability were accomplished by having each researcher independently code the data for themes. To obtain transferability, rich and dense data from purposive sampling was used. This type of sampling permits identification and selection of participants who have information relevant to the study's purpose (Lincoln and Guba, 1985). Findings The researchers identified three major themes that were linked to the professional apprenticeships: learning from stories (cognitive apprenticeship), learning from being there (practical apprenticeship), and learning from caring (ethical comportment).
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Learning from Stories The primary teaching strategy used to address the cognitive apprenticeship was guest speakers who had experience in working with dying patients. Students gained knowledge and insight by listening to individuals who shared their expertise through personal stories. These professionals included social workers, a hospice nurse, a palliative care nurse, a chaplain, and a professional harpist. One student stated, “I just really appreciate the candor of a lot of the speakers. They were really honest. They talked about some things that, you know, were real life situations.” Another student said “That was the best part, people talking, because I would actually pay attention versus a PowerPoint, I doze off. The people that came and talked, and shared stories about their experiences; it's a little more engaging and you actually pay attention.” Students also talked about learning from patient stories. A student commented, “I love talking to older people. I always love their stories, and their lives.” Learning from Being There Teaching strategies used to address the practice apprenticeship involved service learning through collaboration with a local hospice agency. Students became volunteers with the agency and were required to spend 10 hours with a patient at their personal residence, assisted facility, or wherever they were receiving hospice care at the time. One student stated, “At clinical you want to do, do, do. So this experience was a lot more about just being, and being with the patients and trying to get to know them and their needs.” Other students said that through the volunteer hours, “I learned how to just listen” and “communicate in a lot of different ways than just talking.” Students also validated that the service learning was an effective teaching strategy by stating “…the service learning hours…the volunteer. Because one-on-one, hands on, very personal, rather than sitting in a classroom and learning about it” and “The true teachers in this course were the patients you saw.” Learning from Caring for Patients The final theme addressed the ethical comportment apprenticeship. Teaching strategies used were the service-learning requirement along with reflective journaling and classroom discussion. This was the most difficult apprenticeship to assess, but students readily expressed ideas or thoughts that reflected an understanding of what their role was in caring for dying patients. One student who was discussing the class stated, “I think I realized we make such a big impact, especially when people are dying. I think every little thing…they just grab it and they hold on to it. So we need to be more compassionate, and be more…I don't know…watch our actions and how we speak to them and show them that we care.” Other students said “Just recently I had an actively dying patient who received a diagnosis and I'm not…I don't feel like I have to run out the door…you know…when they start crying or having all these emotions. I can actually sit there and talk to them…” and “They were people before, and it's important to let them know that they still matter.” Another student indicated that the class content makes you think about …“spirituality, values, what you believe in, and faith.” These internal reflections exemplify the effect that the Palliative and End-of-Life course had on their personal value system. Discussion The cognitive apprenticeship includes the acquisition and integration of conceptual knowledge from different fields (Benner et al., 2010). In this study, students gained essential knowledge about death and dying from health care professionals, patients, families, and other students. These individuals openly shared personal and professional experiences by telling their stories.
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Storytelling is a fundamental component of narrative pedagogy, an interpretative phenomenological method that fosters a sense of community between teacher and students. More specifically, storytelling in nursing is an approach to teaching and learning that develops from the lived experiences of teachers, clinicians, students, and patients. The emphasis of storytelling in nursing education is to engage students in sharing and interpreting narratives (Diekelmann, 2001). Through interpreting stories, students develop multi-perspective thinking inclusive of unique backgrounds, experiences, and concerns (Engstrom and Hunter, 2007). However, it is not only important to hear a story, but to position the story within a social framework (Benner, 1991). In this study, stories provided a nested dialogue based on the experiences of practicing professionals, bringing context to the forefront. As expert end-of-life care professionals told their stories, students discovered knowledge embedded in practice. The practical apprenticeship refers to developing specific skills and engaging in different ways of thinking (Benner et al., 2010). In nursing practice, experiential knowing occurs through repeated exposure to situations that ultimately lead to refinement of novice ideas and thoughts (Benner, 1982; Benner and Wrubel, 1982). This type of learning is personal, distinctive, and evolutionary (Burnard, 1992). Students in this study served as hospice volunteers for five weeks. Through this experience, personal relationships with patients and families were formed and experiential knowledge was gained. From an Aristotelian perspective, the practical apprenticeship focuses on the fundamental difference between theory and practice. Theoretical knowledge is scientific, definitive, and focused on understanding, not application (Saugstad, 2002). Knowledge in the practical realm changes and is based on learning experiences contextualized within social interactions (Benner, 1991). Theory and practice are integrated in nursing education through didactic learning to support and guide acquisition of nursing skills in the clinical setting. The ethical comportment apprenticeship provides students with knowledge and skills to help them resolve ethical predicaments (Benner et al., 2010). In this study, the acquisition of ethical knowhow was fostered through the students' interpersonal bonds with patients and families and reflective journaling. Through these activities students learned to care, which is the root of compassion and ethical action (Noddings, 1984; Watson, 2008). Because of their volunteer experience, students viewed the hospice patient as a person and not a medical diagnosis. By visiting patients in a more personal environment, students were able to view them as a family member within a social community. Journaling about this experience created an avenue for critical reflective thinking, which is important for questioning ideas and values (Benner et al., 2008) Additionally, students understood the importance of just being present. They observed the personal suffering that occurs during someone's end of life and recognized that their presence was a source of comfort. Learning to be present during patient and family suffering is a key formative experience for developing ethical knowledge and social responsibility (Benner et al., 2008). An outline of the relationship between identified themes with student learning outcomes, professional apprenticeships, and learning activities is shown in Table 1. Although the learning activities are aligned with respect to a specific apprenticeship, teaching strategies were often applicable to more than one apprenticeship. For example, through the service learning experience students visited patients and families for five weeks. They learned about current trends in nursing care at the end-of-life while participating in real life situations. In addition, the students practiced communication skills about serious illness and death with patients and families. Writing a reflective journal about their service learning experience revealed an understanding of personal values and beliefs regarding death and dying. Integrating the three professional apprenticeships in this manner provided an opportunity to simulate professional practice.
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Table 1 Relationships between themes, learning outcomes, apprenticeships, and learning activities. Theme
Professional apprenticeship
Student learning outcome
Learning activity/teaching strategies
Learning from stories
Cognitive
Personal stories: Guest speakers including social workers, a hospice nurse, a palliative care nurse, a chaplain and a professional harpist who shared their expertise
Learning from being there
Practice
Learning from caring for patients
Ethical comportment
Explain historical and current trends in nursing care at the end of life. Distinguish between palliative and end of life care. Identify systems of support that assist with grief, loss and bereavement. Demonstrate skill at communication about serious illness and death. Identify one's own values and beliefs about dying and death and how these influence care planning for patients and their families.
Implications The three apprenticeships have a strong theoretical and practical basis, but nursing education has had limited success with integrating them into nursing education (Noone, 2009). According to Benner et al. (2008, 2010), teaching the professional apprenticeships independently fragments and compartmentalizes student learning. Findings from this study support the importance of incorporating all three apprenticeships into one nursing course. In learning about end-of-life nursing care, experts from the field provided context for students to envision how nursing knowledge and principles are used. Reflection and interactive exercises helped students work through abstract concepts such as respect for patients, empathetic understanding, and feelings of despair. Spending time with patients and family members allowed students the opportunity to experience their physical and emotional needs. Personal interaction with dying patients provided a meaningful experience in which students' values, beliefs, and stereotypes about end-of-life care were challenged. Through these learning activities students were exposed to the complexities of nursing practice, which contributes to the formation of their professional identity (Noone, 2009). Service learning is defined as a teaching method that enhances knowledge development while strengthening communities through integrating service with learning and self-reflection (National ServiceLearning Clearinghouse [NSLC], 2011). The American Association of Colleges of Nursing (AACN, 2008) states that service learning is an appropriate student centered learning strategy for nursing students at the baccalaureate level. Service learning offers nursing students' opportunities to learn about theories and principles, implement practical and skilled knowledge, and self-reflect on their actions. Including service learning may be the ideal approach for integrating the three professional apprenticeships into nursing education. Traditionally, student learning within a course is assessed using quantitative techniques. For this study, summative assessment was conducted using a qualitative method, focus groups. This approach provided students with an opportunity to verbalize and discuss specific aspects of the course that were important to their learning. In particular, researchers were able to capture students' personal emotions and thoughts and assess for learning within the ethical comportment apprenticeship. Using a qualitative method provided rich feedback for this study. In the future, a mixed method approach could also prove useful in assessing student learning and contribute to improved learning outcomes.
Conclusion End-of-life nursing care draws on the apprenticeships of knowledge, practice, and ethical commitment to ensure a good death. Effective strategies for teaching end-of-life care provide meaningful connections between students, course content, practical experience, and most
Service learning: As hospice volunteers, students visited assigned patients over five weeks Reflective journaling: Students retrospectively reflected about service learning experience
importantly the dying patient. By unifying theoretical learning with practical experience and ethical know how in palliative and end-oflife nursing care, students enhance their understanding and application of nursing knowledge and move toward forming a professional identity.
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