Education

Perspectives of an international education initiative in children’s palliative care

Abstract

Education is viewed as central to improving future palliative care for children and families across all countries. International education initiatives will ensure practitioners are aware of global health issues and can provide culturally sensitive care. Creative and innovative means of meeting such directives are required to achieve meaningful student learning. This paper focuses on one innovation, a children’s palliative care workshop using case studies as a teaching method, with nursing students from the USA and nursing and midwifery students from the UK. Key learning points arising from student evaluation were recorded under three main themes, these were: differences across countries, similarities across countries, and making learning fun and memorable. Findings indicated that this joint learning activity was viewed positively by all students and has enabled them to learn with and from each other, potentially impacting on their future practice. Key words: International l Innovation l Learning l Students l Children’s palliative care l Case studies This article has been subject to double-blind peer review.

Jayne Price, Associate Professor of Children’s Nursing, Kingston University, St George's University, London, UK; Jacqueline S Janicki MS RN CHPN,Lecturer, Salve Regina University, Newport, Rhode Island, US; Heather McKee, Lecturer (Education) in children’s nursing, Queens University Belfast, UK; Sharon Nurse, Senior Lecturer (Education) in midwifery, Queens University Belfast, UK; Eileen Gray DNP RN CPNP, Chair of the Department of Nursing, Salve Regina University, Newport, Rhode Island, US Correspondence to: Jayne Price [email protected]. co.uk

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onsensus across many countries indicates that nursing and midwifery education should provide opportunities for students to increase their knowledge and experience of cultural differences, and lead to the globalisation of healthcare. Indeed, the American Association of Colleges of Nursing’s (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice (2008: 30) states: ‘...the increasing globalisation of healthcare requires that professional nurses be prepared to practice in a multicultural environment and possess the skills needed to provide culturally competent care.’

Furthermore, the Nursing and Midwifery Council (NMC) in the UK recognises that undergraduate programmes should incorporate education regarding the principles of international health policy, including public health internationally as well as nationally (NMC, 2010). Within

the UK, the importance of culturally sensitive care is highlighted by the NMC (2009, 2010). Several nursing and midwifery programmes across the world have developed short-term study abroad programmes to address the goal of providing international experiences for their students. Indeed, midwifery students at Queens University Belfast (QUB) have a 4-week flexible placement with specific learning outcomes, during which they can travel anywhere in the world, and many work in countries in Africa and South America. Programmes reported within the international literature range from direct service learning opportunities in developing countries, (Bosworth et al, 2006; Levine, 2009) cultural immersion programmes (Walsh and DeJoseph, 2003; Caffrey et al, 2005; McAuliffe and Cohen, 2005) and observational programmes in developed countries (Haloburdo and Thompson, 1998). Kulbok et al (2012) conducted a review of the literature regarding nursing study abroad experiences and concluded that most reported only ‘one way exchanges’ where nursing students were involved in immersion programmes. Evaluation of the outcomes of the international experiences contained within the review produced commonalities including: personal growth, increased cultural awareness and sensitivity, and increased appreciation for the similarities and differences among people throughout the world (Haloburdo and Thompson, 1998; Walsh and DeJoseph, 2003; Caffrey et al, 2005; Bosworth et al, 2006; Kulbok et al, 2012). In addition, Haloburdo and Thompson (1998) described an increased knowledge of socio-political influences on the delivery of health care as well as an increased awareness of the positive and negative aspects of US healthcare systems through study abroad programmes. The need for culturally sensitive care is also necessary within children’s palliative care. International cross-cultural learning is one way of enabling nurses to provide such cultural care; indeed, education in children’s palliative care is central to strategic direction within the fledgling

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Jayne Price, Jacqueline S Janicki, Heather McKee, Sharon Nurse and Eileen Gray

Education

specialty (Price et al, 2013). This paper will discuss the value of shared experiences for students from the US and Belfast (Northern Ireland, UK) through joint learning sessions centred around case studies on children’s palliative care. The workshop was held at QUB as part of an international programme developed through a partnership between Salve Regina University and Inch House Center for Irish Studies. To provide some context for this discussion, a brief explanation of this study abroad programme will is provided below.

The US student visit Salve Regina University, a Catholic university in Northeastern USA, has partnered with Inch House Centre for Irish Studies for the past 2 years to develop an international service learning educational programme for baccalaureate nursing students entering their fourth (senior) year of study. The programme has successfully run for 2 weeks during the summer session (May/June) in 2012 and 2013 and is planned again for 2014. The students and accompanying faculty reside at Inch House, County Donegal, Ireland, on the border of the Republic of Ireland and Northern Ireland. This provides the students with a unique opportunity to learn about the historical and political influences in this part of Ireland and to identify some health-care issues that impact the area. Many of the formal presentations and observational experiences focus on palliative care for both adults and children. This programme combines service opportunities and observational experiences, and within this two week programme, the US students are introduced to the health-care systems of Ireland and Northern Ireland (UK) as well as being exposed to the differences in nursing education.

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The educational initiative As part of the overall service learning programme, the US nursing students spent a day in Belfast; the focus of their visit was to learn about care and service provision for children with palliative care needs within this part of the UK. They had previously spent time at hospices in Northern Ireland and Donegal, Ireland gaining insight into palliative care and service provision for adults. To address the needs of children and families, a one-day programme was drawn together by QUB in partnership with Northern Ireland Children’s Hospice (NICH). As part of the programme, the students from the US spent the morning at the hospice, learning about the work done here through a number of formal presentations about services and research, which helped set the context for the afternoon session.

Table 1. Breakdown of students involved (n=69) Variables

US nursing students

UK nursing students

UK midwifery students

Total

2012

19

7

-

26

2013

25

8

10

43

This was deemed as important, since children’s hospice is quite an unknown service option in the US, and previous visits had highlighted this as a valuable learning experience (Price et al, 2013). In the afternoon, students visited the university (QUB) and took part in a joint workshop with UK students. In 2012, third-year children’s nursing students, who had recently completed a module in children’s palliative care, took part in the workshop, and following this success, we decided to further develop the initiative in 2013 by involving midwifery students as well. Owing to a change in the curriculum involving the palliative care module, second-year children’s nursing students participated in the workshop in 2013. US students had also completed their courses in paediatric and maternal child health nursing at this time. Advances in antenatal scanning has led to many babies with life-limiting conditions being diagnosed before birth, thus increasing the recognition of perinatal palliative care (British Association of Perinatal Medicine (BAPM), 2010). This has also lead to an increased overlap between the role of the midwife and the children’s nurse in providing care to this group of families and children (NHS Scotland, 2013). The workshop planners felt that including the midwifery students would increase the interdisciplinary focus of student learning. The second-year midwifery students involved had previously covered aspects of neonatal care and bereavement (Kilby et al, 2011; School of Nursing and Midwifery, 2013). The total number of students who took part over the 2-year period was (n=69), as shown in Table 1. The workshop was 3 hours in duration (with breaks) and started with a short presentation about health care and nurse education in the US (given by the US lecturers) followed by a similar presentation by a QUB nursing lecturer about the UK system. Following an ice-breaker exercise, students explored case studies in groups of 6–8 (see Box 1). They considered the individual needs of the child and family and responsive care required. Feedback was given to the whole group and further debate was generated as each group had only worked on one of the two scenarios, thus widening the areas for student learning. Areas for consideration included

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Case Study 1 Lauren is a two-month-old girl who has an undiagnosed life-limiting condition and associated complex health-care needs. Lauren was born by caesarean section at 36 weeks gestation. Lauren has prolonged seizures, a tracheostomy and requires overnight nasogastric feeding. She is currently in a neonatal unit and her mother Carol stays during the day. Her father, Dave comes in the evenings after work. They have two other children: Carly, aged 2 years and Jake, aged 5 years. The family are keen to care for Lauren at home. Lauren was not expected to live beyond three weeks of age so the family are living with sustained uncertainty. Case Study 2 Jack and Jill are expecting their first baby together. Jill has two children from a previous marriage: Rachel, aged 9 years and Lenny, aged 6 years. They are in their late 30s and have longed for a baby throughout their 5-year relationship. At the 20 week scan, it is suspected that the baby has Edwards syndrome (Trisomy 18). The news is broken to Jack and Jill, and they are both devastated. Jack is very angry and Jill is leaning on her faith.

learning compared to other ways of learning about health care and service provision in other countries, i.e. in specific lecture, or reading international policy independently. In addition, they were also asked to rate their overall learning experience using the Likert scale. A free text question asked students to list three main learning aspects from participating in the case study learning with international students. The free text was examined within and across evaluations and commonalities were identified and this gave rise to a number of reoccurring themes (presented below). As this was not research per se and was viewed as an evaluation of a new teaching method, ethical approval was not sought. Students were aware however that their perspectives may be used in publications and future curriculum planning.

Student perspectives

ethical issues, loss, child/family-centred care, communication, interprofessional roles, care and service provision. Case studies have been positively used within nurse education as a tool to engage learners, enable them to apply theory to practice, integrate different perspectives, promote thinking and practice decision-making skills (Popil, 2011). For these reasons, the use of case studies seemed to be appropriate for students undertaking international learning. An open invitation was issued to the children’s nursing (in 2012 and 2013) and midwifery students (in 2013) to attend the workshop. Attendance was optional, as this was not a core part of the curriculum, but rather a new optional initiative. Numbers had to be restricted, and we had allowed 10 first-year students and 20 second-year students to attend, to ensure the size of the group was manageable and that adequate time was available to fully explore issues and elicit feedback. Some students indicated their interest, but did not attend on the day. The following section of this paper examines the evaluation from students following this international face-to-face learning activity on caring for children/infants with palliative care needs (in the perinatal/neonatal period) and their families.

Over the combined 2-year period, 57 of the 69 students completed the evaluation (82.6%). The students were very positive regarding this type of learning, seeing the value of helping them gain insights about international issues pertaining to health care and service provision in a meaningful and memorable way. To this end, 53 students rated this type of international learning activity as much better than, for example, reading international strategy documents in isolation. The remaining four said it was better. Students were asked to highlight three main learning points from participating in this international workshop and were also given a section for overall comments. These three main themes arose from students’ lists and comments. The themes were: differences across countries, similarities across countries, and making learning fun and memorable. The themes are summarised in Table 2. The themes which arose from open questions in the student evaluations demonstrated that learning occurred in a memorable and fun manner. Such findings were congruent with how students rated their overall experience on the Likert scale question, with all students reporting a positive experience, shown in Table 3.

Collecting student views

The overall comments provided by students endorsed the sense that they really enjoyed learning with and from each other in this type of international workshop. The only negative aspect raised by some students was that their time was limited to one 3- hour session. In their responses to the questionnaire, which is the focus of this paper, students from the US and UK clearly demonstrated that changes in

Establishing the views of students through the university evaluation process was seen as key in planning future international teaching activities. Given that this was a unique activity, a specific evaluation form was developed. The short evaluation was very focused and consisted of two main questions with Likert scales; for example, students were asked to rate this type of international

Discussion

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Box 1. Case studies used in 2013

Education

Table 2.Themes arising from student evaluations Theme name

Content of theme

Evidence from student quotations

Differences across countries

Many differences across countries in relation to care delivery for children and their families were commented on, such as:

‘Fantastic opportunity to get a sense of [the] differences between health care and perspective from other students’

●●Different models of health care within the UK and US ●●Different role of finance/insurance and health care across countries. ●●In the UK there was a much more nurse- and midwife-led focus than in the US, students felt this had a more positive impact on career pathways ●●Students drew conclusions around contrasting aspects of patient care. For example, they cited the different abortion laws in countries and the potential consequence on perinatal palliative care (Parliament of the United Kingdom, 1861) ●●In the UK, palliative care for children is much more established than in the US. Thus the US students see the importance of future care and service development within this field (Friedrichsdorf et al, 2007; Friebert, 2009) ●●Students recognised the differences in nursing practice, with US students expected to utilise stethoscopes in performing a physical assessment

Similarities across countries

Making learning fun and memorable

‘Health care systems are so different, particularly the cost in USA, I was shocked’

‘Services for children with palliative care needs seems so much more established in UK’ ‘Less focus on the nurse and the stethoscope in UK’

Despite the multiple contrasting aspects noted by students, some core similarities were highlighted as pertinent and evidenced through the second theme.

‘Compassion is central to nursing irrespective of location’

●●Similarities related to what students appeared to class as core principles of being a nurse, these being compassion, passion, enthusiasm and the same health-care beliefs regarding quality care ●●These core principles according to the students transcended geographical location ●●It was noted that for all students from whatever location and profession (i.e. nursing or midwifery) the individual needs of the patient/ family was paramount

‘Within scenarios care was the same – and despite differences in service delivery, we all came together round the needs of the patient/family’

The overall sense from students was that they really enjoyed learning with and from each other in this type of international workshop.

‘Excellent learning opportunity’

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●●Students made clear that working with other students to examine care and solve patient problems stimulated their learning in a meaningful and memorable way ●●They valued the workshop, recognising that not all students had this opportunity ●●Using a case-study approach appeared to be valued by students, and they felt that examining palliative care for children worked particularly well for international students in a workshop setting ●●The international aspect of learning gave students, as they saw it, a broader perspective and encouraged them to think about care in new and different ways ●●The inter-professional aspect of learning was also commended by students as extending their knowledge

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‘Learning by being integrated with other students was a wonderful experience’ ‘I enjoyed comparing and contrasting international perspectives of nursing care’ ‘the scenarios and different answers from different groups were very educational’ ‘Great workshop to explore different healthcare systems – worked well with palliative care topic’ 'Extending the MDT to international status is an excellent contribution to our learning and education’

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Number of students who responded (n=57)

Percentage

Excellent

46

81%

Very good

9

16%

Good

2

3%

Fair

0

0

Poor

0

0

Very poor

0

0

perceptions had taken place as a result of joint international learning. Levine (2009: 156) similarly stated ‘Informants spoke of profound changes in their personal and professional lives as a direct result of their work or study abroad’

Comments from students of both universities were consistent with the findings of studies of direct service study abroad programmes, suggesting that a variety of multicultural learning strategies have a place in advancing an appreciation for global health-care concerns (Kulbok et al, 2012). Moreover, previous literature regarding case studies have suggested that if written correctly and appropriately, they have the power to enable students to integrate different perspectives, promote thinking, and practice decisionmaking skills (Popil, 2011) which has been demonstrated here by student responses. Salve Regina and QUB students developed a broader view of the health-care systems, and a comparison between them, consistent with the findings of Bosworth et al (2006). Haloburdo and Thompson (1998) cited increased cultural sensitivity, increased nursing knowledge, development of a global perspective, and the opportunity for evaluation of positive and negative aspects of other health-care systems as outcomes of international experiences in their study of US nursing students in developed and developing countries. This too, is consistent with the US and UK students who attended the workshop, although measurable outcomes may be more apparent in service opportunities than in our model, which emphasised cognitive learning exercises. Given this was a small group, examining the longer term effects on learning would be an area for further study. The US students were required to write a paper identifying some aspect of their experience in Ireland and Northern Ireland. Several of them wrote about the differences in nursing education between the countries or contrasted the differences in paediatric palliative care services. This further illustrated the impact the shared experience had on the US students.

Students endorsed the value of face-to-face learning in small, internationally mixed groups focusing on children’s palliative care case studies, in terms of knowledge generation, and they enjoyed their learning. Kulbok et al (2012) suggested concerns related to evidence of ‘benefits and mutuality’ of international exchange programmes. It would seem that international learning utilising a case study workshop format such as the one developed by QUB and Salve Regina can demonstrate such mutual benefits. Similarly, US and UK students felt that the shared learning experience altered their view of palliative and hospice care, as well as health care in general. Students were positive about this type of learning activity because it gave them new and broader insights into service provision within children’s palliative care. They felt it should be developed and included as a core component of nursing/ midwifery curricula.

Limitations One limitation that we noted was that the evaluation did not ask the students to identify whether they were nursing, midwifery, US or UK students. A further examination of learning and experience across the professional groupings would have been an interesting angle and one which could be explored further in future initiatives of this nature. Midwifery students verbally expressed that they had not previously perceived palliative care as part of their role, and the workshop enabled them to see that in some cases, introduction of a palliative care approach within the perinatal period was central to individualised, quality care. Further delineation of student backgrounds, including country of nursing educational programme, theoretical and clinical experience, and perception of professional roles might elicit further insights into the differences or similarities across student groups.

Recommendations Encouraging nursing and midwifery students to think more globally about health and health-care services is an obligatory part of nursing education in aiding them to obtain an appreciation of global health (Kulbok et al, 2012). However, developing innovative teaching methodologies that stimulate meaningful learning for students can be challenging. Organising these international experiences takes time and commitment on the part of staff. Given the sensitive nature of the material being discussed, the facilitators have to be readily available to provide emotional support and follow up if required by students. It is important to develop strong partnerships

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Table 3. Student overall rating

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Education

with academic staff from participating universities who share similar goals and objectives to provide appropriate learning opportunities for students. Partnerships with staff in the clinical area is also important, for example, in this case the Northern Ireland Children’s Hospice. Small groups allow for easier identification of students needing further support. The groups also provide a safe way for students to engage one another. Case studies focused on care and services for children with palliative care needs which seemed particularly suitable for this student audience. It enabled examination from a multiprofessional perspective and generated discussion about care and service provision in both countries. While the value of case studies as an educational method has been supported previously and our evaluation certainly endorsed it, it is clear that there is a reliance on well written case studies (Harrison, 2012). We feel that this was crucial to the success of our learning and teaching initiative. We followed directives set for the development of well written case studies (Harrison, 2012). The cases for this initiative were therefore drawn up and verified by lecturers from both countries and professions represented to ensure relevance to the whole group. Clinical staff from the children’s hospice also had some input into the case studies used. We therefore, strongly recommend a collaborative approach to writing the case studies. Another important recommendation is to ensure that the visit to the hospice be provided to the US students prior to the joint learning workshop. This addressed differences in knowledge between the two student groups about hospice care. This was evidenced in the workshop by students referring to their visit to the hospice and applying it to the case scenarios. While scenarios focusing on care and service appeared to provide the broadest learning opportunity, the scenarios could be adapted and related to adult palliative care or for children with other health-care needs and their families. Disciplines in addition to nursing and midwifery, such as social work or physical therapy might also benefit from inclusion in such learning activities. While face-to-face learning was clearly valued, this may not be always possible. International online groups could be created where case studies could be discussed for future international learning. Use of teleconferencing technology could also be developed for inclusion in selected courses within partnering schools, thereby affording more students the opportunity to participate in international learning initiatives.

Conclusion Overall, the perspectives of the students presented here support the value of an international, interprofessional workshop based on case studies relating to children’s palliative care. This workshop generated broader, meaningful and fun learning for students. Students from both the UK and US were able to identify differences and similarities across countries in terms of nursing practice and availability of healthcare services. In doing so, they developed greater insight into the global nature of their chosen professions. The need for education regarding children’s palliative care is essential in undergraduate nursing and midwifery programmes, as are educational opportunities that encourage students to think more globally about care provision and care sensitive to cultural need. One way to advance such directives is through joint education opportunities made possible by international shared learning in workshops such as the one described here. Through discussion and application of knowledge to selected case studies, students are able to identify potential opportunities to apply principles of palliative care to the care of children with chronic and complex health-care needs. Similar opportunities for appropriate nursing students, as well as other disciplines, could be explored and adapted to address the needs of other populations. One student said it best:

❛ This workshop generated broader, meaningful and fun learning for students ❜

‘International learning should be encouraged more.’ Acknowledgments Thanks to Tony Johnston and the Inch House Team and to all the staff at Northern Ireland Children’s Hospice for their support. Declaration of interests: The authors have no conflicts of interest to declare.

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Care. http://tiny.cc/qg5hox (accessed 29 October) Nursing and Midwifery Council (2009) Standards for Pre-Registration Midwifery Education. NMC London. http://tiny.cc/aj5hox (accessed 29 October 2014) Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education. NMC London. http://tiny.cc/ek5hox (accessed 29 October 2014) Parliament of the United Kingdom (1861) The Offences against the Person Act 1861, London. http://tiny.cc/8ivsox (accessed 4 November 2014) Popil I (2011) Promotion of critical thinking by using case studies as teaching method. Nurs Educ Today 31(2): 204–7 Price J, Dornan J, Quail L (2013) ‘Seeing is believing’ - reducing misconceptions about children’s hospice care through effective teaching with children’s nursing students. Nurse Educ Pract 13(5): 361–5 School of Nursing & Midwifery (2013) Mandatory Study Days on Specialised Topic: Bereavement and Loss. BSc(Hons) Midwifery Sciences Curriculum document, School of Nursing & Midwifery, Queen’s University, Belfast. http://tiny.cc/ft5hox (accessed 29 October 2014) Walsh L, DeJoseph J (2003) “I saw it in a different light”: International Learning experiences in Baccalaureate nursing education. J Nurs Educ 42(6): 266–72

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Perspectives of an international education initiative in children's palliative care.

Education is viewed as central to improving future palliative care for children and families across all countries. International education initiatives...
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