using appreciative inquiry in the promotion & tenure process

Transcription

USING APPRECIATIVE INQUIRY
IN THE
PROMOTION & TENURE PROCESS
MARILYN SMITH-STONER, PHD, RN
Using Appreciative Inquiry in the Promotion and Tenure Process
© 2014 by Marilyn Smith Stoner
Resources: marilynstoner.com, Pinterest/Twitter/Diigo:drmstoner
Conflict of Interest
Many products and services are recommended in this document, there are no conflicts of interest
to declare. Most are free and the rest I am recommending as a satisfied customer.
Acknowledgements
Special thanks to Dr. Mikel Hand a respected scholar and friend and Dr. Gabriela Mustata Wilson.
They are joint investigators on the University of Southern Indiana Major as Home Grant that is
making this workshop possible. I also would like to thank Dr. Ann White, Dean of the College of
Nursing and Health Professions for her enduring support of faculty development and mentoring
and Dr. Shelly Blunt, Associate Provost for Academic Affairs for her leadership and support for the
Major as Home Grant competition.
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WORKSHOP AGENDA
Workshop Agenda
Appreciative Inquiry: Meaning and Momentum in Faculty Role
Facilitator:
Dr. Marilyn Smith-Stoner, PhD, RN, Professor Emeritus California State University San Bernardino
(www.marilynstoner.com)
Location:
Traditions Lounge, UC
Wednesday, February 25, 2015
8:00 am-8:30 am
Continental Breakfast
Welcome and Introductions
Part 1: Mentors (Mentors and Mentees should participate in both parts)
8:30 am – 10:00 am
Appreciating the tenure and promotion process.
Discover- collectively looking at strengths of CNHP, highlighting what works well.
10:30 am – 11:00 am
11:00 am -12:30 pm
Characteristics of an effective mentor. One person or one skill
and many people?
Break
Design and Planning: prioritize a mentoring processes that
would work well for the college and faculty.
Deploy the process by identifying mentors.
Plan follow-up video.
12:30 pm – 1:30 pm
Lunch
Part 2: Mentees (Mentors and Mentees should participate in both parts)
1:30 pm – 2:30 pm
Discover - collectively looking at strengths of individual faculty
and progress toward personal goals and promotion process.
Dream of a day when work is optimal and balanced.
Giving and receiving professional support.
2:30 pm – 3:00 pm
Break
3:00 pm – 4:00 pm
Design and Planning: collaboration with mentors to develop
a workable system that supports colleagues, realistic and
effective.
Deploy Matching mentors and mentees with time for planning
initial activities.
Plan for video follow-up.
4:00 pm
Closing
Discover (from survey)
Mentorship Values
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Important
Mutually beneficial, especially for the mentor
Is a comfortable and trusting relationship
Valued
Desired
Needed
Regular contact
Safe relationship with candid feedback
Considerations:
What is the essential knowledge needed after orientation?
University values the time of the mentor by assigning credit in promotion process
Voluntary role
Potentially a long term (1-2 year) relationship
Mentorship Content
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Professional development in the area of teaching
Advice on publications
Advice on service
Managing the tenure process in all types of forms, from those who have been successful
Critique, feedback, honest input, realistic point of view
Integrating clinical skill into instructional effectiveness
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Dream
Faculty experience from survey summarized: many have not had a mentor. Of those who have
had one it seemed to work best when the mentor was from the same discipline with a few exceptions.
How is mentor selected:
• Mutual agreement
Qualities of a mentor to select:
• Positive attitude
• Recognized as an expert in the area of mentorship: classroom instruction
• Desire to be a mentor
• Approachable for both easy and hard topics
• Mutual interest
• Necessary qualifications, share CV
• Teach similar courses
• Experience with academia
• Mutual time availability
Requested areas of mentorship (in order of frequency)
• Classroom instruction, teaching
• Clinical instruction (particularly evaluation methods)
• Curriculum development
• Blackboard, online teaching and other technology
• Student advising
• Student to faculty communication
• Professional writing
• Professional presentations
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Design
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Deploy
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Tenure and Promotion Process
Publication Process:
A great first manuscript is classroom action in action research model, built on Appreciative Inquiry
Circles (sample article)
(requires IRB at most places)
Mentor and mentee pairs, triads identify some changes, skills strategies to try, Agree on a plan to
implement, go out and try, 2 weeks is a good time. Come back together and talked about what
worked or didn’t work. Reframe plan and repeat. Repeat until the plan is completed.
Each reflection cycle should be recorded and transcribed, becomes the data for the article. A
simple literature review provides the background and add an analysis and future considerations
and you are done.
Want to get a book?
Create a PowerPoint presentation with all your best stuff, every single genius idea you have ever
had on your favorite topic. Spare nothing. Once you are done, narrate the slides. You can do in a
separate file. Then send to an online transcription service and you have 80% of your book text. You
have to edit and add the scholarly stuff, you are done. Consider selling as an eBook, a good eBook
will be found by a publisher and you will get a contract.
Start using an app like Skitch, if we have time we will play with it.
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Types of articles that can be published that are
significant and scholarly other than original data
• Commentary on adapting a new technology or teaching strategy (Class is about to Start Please
Turn Your Cell Phones on)
• Future: Commentary on promotion and tenure journey
• Future: I am composing one now: 5 Regrets of Connected Educators
Expert knowledge on a topic for colleagues
• Tibetan Buddhists Preferences for End of Life (the most cited article I have done)
• 10 Things….. (most downloaded articles from Home Healthcare Manager)
• Suggestions:
• Commentary on Millennials
• Commentary on regulations
Manageable and significant studies
• Atheists Preferences for End of Life (Cited by Richard Dawkins)
• Wiccan, EcoSpiritualist Preferences for End of Life
• Completed a study on visual analysis of deathbed scenes, EXTREMELY positive reaction when
presented. Publication to follow.
Student facilitated publications
• Answering the Call for Student Writers, the results was:
• Death Brokering in ICU and others
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Tips
Working smarter not harder, but everything in a blog. Share what you know freely, that is what
my mentors taught me. The single biggest advice or support I can give anyone is to freely support
each other. Together we are stronger. If someone proves thems not worthy of your trust, then
make changes, Assume people are trustworthy.
Be realistic. Aim to do something that enhances teaching, is fun and inspires you to do more.
Contact the authors of articles, books that inspire. Let them know there work means something.
Most of what we do is free and we never really know if it matters.
Master a representative toolbox of digital tools. Blog, social media of your choice, virtual storage. I
recommend Google because it is the easiest, not because it is perfect.
Don’t refrain from learning to use something because you might make a mistake, because you will.
Or because you might get embarrassed because you will. Follow this blog and with best practices
problems will be minimized. Best blog to follow: http://www.freetech4teachers.com/
Peer Review and Feedback
Generally speaking it is ineffective to get feedback from someone you live, work or sleep with. It is
very hard for those people to give you a critique, especially if they have no knowledge of writing.
Pay for an editor to help you. There are readily available, web based editors that charge reasonable
rates. The one I use most, depending on the article (sometimes I don’t use any) Dr. Sharon Baer
www.Bear-Write.com. In general I use an editor when I am going to submit an article on a topic I
love and I have lost sense of detachment from the subject and when I submitting a manuscript to
a journal with a very high impact factor.
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Assumptions
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No one want more email
Printing documents should be balanced with e-papers
Curation of personalized content is preferred
Time is limited
Storage and retrieve of information is as important as obtaining
Cost should be minimal, micropayments offered to developers of free apps and tools
Every professional must join their professional organization, at least one
Curation of a personalized stream of information
Feedly is a free ($ with upgrade) service that allows you to subscribe to all types of digital media.
As you subscribe to resources they appear in the feed. You can look at whenever you want and you
can add and delete easily. (The alternative is having all that information come to your email inbox).
What works really well in Feedly is:
• instead of subscribing to many journals, subscribe to the Table of Contents and then obtain
articles that interest you. Reviewing TOCs will help you stay abreast of the topic without
accumulating stack of journals
Social Media-General Guidelines. There are many types of social media. Here is a small list where
professionals are easy to find and I use. Like Feedly, you can use HootSuite to aggregate social
media feeds if you have multiple accounts
• Blogs
• Twitter
• Facebook (more organizations that individuals), still one of the biggest countries in the world.
• YouTube (owned by Google), second biggest search engine
(follow the feeds of channels you like in Feedly, watch videos when you want)
• Pinterest-- focuses on boards and “pinning”, very, very cool site.
• I love Google+, I use LinkedIn
• Podcasts are awesome, subscribe in iTunes, Stitcher, other apps
If you only want to use your email, there is an app UnrollMe that places all the subscription email
into one email and you can read at your leisure.
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Professional Learning Network Worksheet
What are the things you want to know about?
Who are the experts in your field:
What personal interests do you have?
Download and create an account for: Feedly.com and Twitter
Search for the above, Twitter (follow) others are called “subscribe”
Within Feedly search for blogs and other feed you like and add to content.
Play around with it and always take time to dump feeds that are now interest and look for new
ones.
It is really important and professional to leave feedback for the authors of sites, feeds and
podcasts. They can give you a feed for free because of advertisers. The advertisers measure
their worthiness for investment through the feedback given and number of subscribers. This
is critically important.
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References
Appreciative Inquiry Commons: http://appreciativeinquiry.case.edu/
Wikipedia Appreciative Inquiry https://en.wikipedia.org/wiki/Appreciative_inquiry
Examples of the working smarter not harder Publications:
He, Q., Smith-Stoner, M., Robinson, O. & Taha, A. (2013) Stranger in a Strange Land. American Nurse
Today, 8(8), access: http://www.americannursetoday.com/Article.aspx?id=10650&fid=10604
Smith-Stoner, M. (2011). Developing New Writers: Answering the Call for Student Manuscripts,
Dimensions in Critical Care Nursing, 30(3):160-3.
Smith-Stoner, M. & Molle, M. (2010). Collaborative action research: Implementation of cooperative
learning, Journal of Nursing Education, June 2010; 49(6):312-318.
Smith-Stoner, M. (2009). Using high fidelity simulation to educate nursing students about end of
life care. Nursing Education Perspectives, 30(2), 115- 120.
Smith-Stoner, M. & Rutledge, D. (2005). Ten statistics you should know. Home Healthcare Nurse,
23(3), 183-187. (not included)
Smith-Stoner, M. & Hand, M.W. (2008). A Criminal trial simulation: Pathway to transformative
learning. Nurse Educator, 35(3), 118-121.
Student article – Death Brokering
Personal Passion End of Life Preference Tibetan Buddhists
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Developing New Writers
Answering the Call for Student Manuscripts
Marilyn Smith-Stoner, Ph D, RN-BC
Abstract
considered sending one of my papers to a publisher.
What a crazy dream! This assignment opened
doors that we didn’t even realize were closed to us.
(Student nurse in a nursing research class)
Critical-care nurses play an important role in the
development of nursing students’ ideas about
clinical and professional issues. During a recent
critical-care nursing rotation, baccalaureate
nursing students learned about evidencebased practice through identifying a policy
that needed revision or creation. By integrating
clinical issues into an introduction to research
and issues and trends, the students were able
to answer a call for student abstracts.
The collaboration with critical-care nurses and
undergraduate research students was a winwin for both.
Introduction
Nursing education is changing in radical
ways. The accreditation standards1 provide a
blueprint for ensuring education is relevant,
Keywords: Developing writers, Student based on evidence, and focused on patient
safety. Nursing faculty develop integrated
writing, Writing for publication
assignments that are based on the complexities
[DIMENS (RIT (ARE NURS. 2011 ;30(3):160-163]
and realities of nursing practice and academic
cal care and
It ‘only took one call for student manuscripts to standards. Integrating clini
scholarship
are
part
of
several
of the newest
transform a traditional research course from a
traditional class to a powerhouse of creativity standards of the Commission on Collegiate
and critical thought. Although most of our Nursing Education.1 Two of the baccalaureate
nursing students look forward to their critical in nursing essentials requirements are to
care rotations, research class is not always as
well received. While students participated in a • use writing intensive assignments to promote
reflection, insight, and integration of ideas
critical-care rotation, they were also enrolled in
across disciplines and courses (essential 1);
an introductory research class. By integrating
and
the 2 course outcomes into learning the
process of evidence-based practice, students • develop a leadership or quality improvement
project that spans several courses (essential
were able to select a topic important to their
2).
own development and experience the entire
process of identifying a clinical issue to publish
In the process of meeting these and other
ing the results of their evidence-based practice
accredita
tion standards, a traditional research
search. Critical-care nurses in 2 local hospitals
were essential in assisting this class of students course was transformed from learning the
to enhance their clinical assessment skills. basics of research (designing quantitative or
Students also provided the agencies with qualitative studies and using statistics among
additional information for their own quality other topics) to a focus on the process of
assurance projects. The collaboration with utilizing evidence-based practice, including
critical-care nurses and undergraduate research dissemination of results. When Dimensions
of Critical Care Nursing published its call for
students was a win-win for both.
student abstracts,2 it provided the perfect fit to
I would have never in my wildest dreams ever the changes being implemented in the course.
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The culminating project, spanning 2 courses,
would be a manuscript submission to a
journal of the student’s choice. See Table as
a guide to teaching research through clinical
experience. Student reactions were to be
expected. One student wrote:
In the beginning of the research process,
it was tedious, time consuming, and I didn’t
feel that I was truly gaining anything from
the endless scrolling through research
articles and nursing journals. What I thought
was a simple task took endless an1ounts of
time and exhaustion .... It started to all come
together when we began writing the article.
I remember when we first began the article
process, I felt elation because I loved my idea:
a l (ardex specifically for patients withdrawing
support. It was at this moment too when I
felt all of my clinical nursing experience and
all of those endless hours of research come
together. I thought of what it was I wanted
to see in the hospital system as a nurse and
the care I want as a patient. This too made
me appreciate the assignment. Prior to this
endeavour, I didn’t realize how much time
and effort go into each.., in retrospect, I
appreciate those relentless hours of research
because I feel like an established nurse.
Table 1
Sequence of Course Activities for Evidence Based Project
Part 1. Breaking Down Assignment-Evidnce Based Research Project
Sequence
Activity
Resources
(1)
(1) Select topic in consultation with faculty and clinical
experts
(2)
Orientation to library and literature searching, including
intellectual property
American Library Association guidelines for computer
use
http://www.ala.org/ala/
mgrps/divs/acrl/standards/
informationliteracycompetency.
dm
(3)
Subscribe to eTable of Contents for selected journal
For example, Dimensions of
Critical Care Nursing
(4)
(a) Select a policy to update or create based on topic of http://delicious.com
interest
(b) Complete a literature search using several tools
including the online bookmarks to Delicious
(5)
Create/edit policy
(6)
Present editing policy to clinical staff, obtain feedback
on policy. Students were required to present the policy
and obtain written feedback for the instructor
(7)
Presentation of data using multimedia Photostory
(Windows) was done for class
Presentation of data using multimedia !Movie (Mac) was
done for class
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http://www.microsoft.
com/wlndowsxp/using/
digitalphotography/photostory/
default.mspx
http://www.apple.com/ilife/
imovie/
Part 2. Issues and Trends Class
Sequence
Activity
Resources
(8)
Prepare an outline of the article, with references
Instructor approved the outline
(9)
Create a draft, send to writing laboratory. Each article Student Guide to Getting
was formatted to meet the guidelines of the journal
Published: http://
nursestoner. com/resources/
gulde+to+getting+published.
pdf
(10)
Articles revised and resubmitted to writing laboratory
as needed
(11)
Once article was finalized by writing laboratory, facultyedited for clarity from a nursing perspective (something
the writing laboratory was not able to do), if student
wanted it
(12)
Submission to publication
Acceptance or rejection
Breaking Down The Process
their quality improvement projects in a
leadership class during their final quarter.
The students had ongoing collaboration
with the clinical staff with whom they had
worked and with the writing laboratory at
the university. One student summed the
editing process up this way:
The process of writing manuscripts based on
clinical experience is the same for students
and clinicians. From the start, the emphasis
is on identifying an important clinical topic,
researching the evidence base, and dissemi
nating results. Because students were in
their favorite clinical rotation-critical carethey were enthusiastic about finding a
clinical topic to which they could apply
research principles. Although they are often
shy to talk to critical-care nurses about issues
they see in practice, they are encouraged
to approach critical-care nurses with their
observations and suggestions, and they did
so. Students needed help narrowing their
topic ideas to something manageable and
relevant to their clinical agency. Although
not all nm•ses were enthusiastic about the
topics chosen by the students, they did help
direct them.
While students were identifying their
topics, course activities were progressing.
The activities are listed in Table. The students
worked in pairs, collected the evidence to
support their policy change/creation during
one quarter, and composed the manuscript
in the next quarter. They will further develop
I thought this assignment was very exciting from
start to finish. I enjoyed the constant revisions and
critiquing that both my partner and I made to our
paper, along with the help of the writing center
to offer a “fresh view” of what they thought of the
paper. The process seemed a little more difficult
in the beginning of the quarter because we didn’t
know which parts to revise or if we even needed
to change anything. But as the quarter progressed,
there were more flaws in the paper that were
becoming apparent to us. Constant revisions really
helped with our final product.
The students had ongoing
collaboration with the clinical staff
with whom they had worked and the
writing laboratory at the university.
University Resources To
Enhance A Manuscript
Our university provides additional resources
to enhance the final writing products
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(Table). One of the most im
portant is
access to a professional photographer. The
photographer was integral to helping the
students con
sider how to present their
ideas visually in print. Students now have a
selection of photographs that can be used
in the future. They also had a great lesson
in how to pose for professional, clinically
oriented photographs. We did not have
time during this pilot project to pose for
photographs in the local hospitals, so we
used the skills laboratory. However, the next
time the class is taught, photographs in the
unit will be built into the assignment. This
will further reinforce important privacy rules
and professional standards. As students’
articles were ac
cepted,3•4 we notified
the photographer of what pictures were
published to enhance her portfolio.
of creating an article. When I heard that our article
was accepted, I was very shocked and excited. Like I
said, I never thought that our article would ever be
accepted. Submitting and creating this article were
a valuable experience.
The process of submission to a journal, peer
review, and publication time schedules was
explained to students. Some chose journals
that were widely distributed and available
online. These students received immediate
feedback. A touching article on caring for the
homeless was one of the first published.5 The
process of post-acceptance final editing was
emphasized. Students were surprised that
there was work to be done after acceptance.
Many students had their manuscripts
accepted.6 The excitement in the class (and
in the program) was palpable! However, not
everyone was successful. One student whose
manuscript was not accepted had this to say:
I personally appreciate the encouragement and
push that the assignment gave me. Never would I
have thought that I’d even have the chance to be
published prior to even graduating. Although I did
not get published, I think this was a great exercise
and would like to try again sometime soon. I do feel
that I could have used a little more guidance on
what sort of journal would be best for my topic, as
well as about the progression of my article.
Preparing Students for Peer
Review Process
Students are required to read many articles
during their education and for the rest
of their careers. A personal goal was to
help students see the effort that goes into
producing a published article. Receiving
feedback from someone other than an
instructor was beneficial. The students were
courageous in being very engaged in the
entire process. Suddenly, the peer-review
process was theirs. They would be the
authors receiving feedback and responding
to editors. It was critical to make sure the
student manuscripts were well prepared
before allowing them_ to submit anything.
The step-by-step process was important
to ensure that an editor’s time was used
effectively in reviewing the manuscripts. One
student expressed a common sentiment:
The excitement in the class was palpable!
This student points out the biggest challenge,
which was helping a class of 22 pairs of
students simultaneously. Incorporating the
writing laboratory, breaking the process
down into manageable steps, and having
a class that was exceptionally enthusiastic
all helped to create the success. Editors
were especially kind in answering students,
queries and guiding them. A final student
comment:
In the beginning of the production of our article,
trying to get published was never our desire. We
were only concerned about writing the paper well
and getting a decent grade.... Writing the paper
wasn,t too hard, and it looked a lot better after
rewriting it based on the feedback we got from the
writing center.
At the beginning of the quarter when I heard that
we were going to submit an article to a nursing
magazine with the intent to have it published, I
highly doubted that ours would ever be published.
I thought that the quality of our article would not
be up to par . ... I wrote it just to get our points for
the assignment. I shuttered [sic] at the thought of
Our initial reaction to the acceptance e-mail was
shock and disbelief. Never in our minds did we think
we were capable of writing for a nursing Web site
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site and that nurses, student nurses, and just the
public in•general would be reading our evidencebased work. We felt so proud of ourselves that we
told our friends and family of our accomplishment
as if we won an Olympic gold medal or something.
Cloutier-Fernald D, Bauer MG. The nurse’s role
in medication reconciliation, 2010. ADVANCE
for Nurses. http://nursing.advanceweb.com/
Student-and-New-Grad-Center/Student
-Top
Story/Medication-Reconciliation,aspx. Accessed
July 10, 2010.
It takes a lot of people and effort to produce
a student article based on evidence,
especially one for a criticalcare journal.
Nursing education is a partnership between
clinicians and academics. Critical-care nurses
may want to ask nursing students who are
rotating through their units to complete
evidence-based projects with them. Asking
students to review a policy that needs to
be revised is a perfect assignment. Let
students do the work of collecting articles,
summarizing results, and presenting their
finding to the nursing staff. When a new
group comes to your unit, ask the instructor
what other classes students are taking
and make a request for assistance with
research. The best assignment is one that
is going to improve practice. Clinicians and
students working with the faculty is part
of the ultimate learning experience for all.
For further information concerning student
publicatiofi, please visit the author’s Web site
at rnstoner@csusb.edu.
About the Author
Marilyn Smith-Stoner, PhD, RN-BC, has been
a mentor for new authors for the last 5 years.
She teaches undergraduate and graduate
nursing students. Her clinical specialty is
end-of-life care.
Address correspondence and reprint
requests to: Marilyn Smith-Stoner, PhD,
RN-BC, California State University, San
Bernardino, 447 Sherie Ct, Beaumont,
CA 92223 (mstoner@csusb.edu, http://
nursestoner.com).
References
American Association of Colleges of Nursing.
The Essentials of Baccalaureate Education for
Professional
Nursing Practice. Washington,
DC: AACN; 2009. http://www.aacn.nche.edu/
education/pdf/BacEssToolkit.pdf. Accessed July
10, 2010.
Miracle VA. Call for student abstracts. Dimens Crit
Care Nurs. 2010;29(2):93.
Chakma N, Ocampo JP. Critical care visitation and
the headache that follows. Dimens Crit Care Nurs.
2011;30(1):39-40.
Rubio V, Voss K. Patients unsatisfied with palliative
care improving documentation. Dimens Crit Care
Nurs. 2011;30(2). (in print).
Patterson C, Brown B. Discharge of homeless
patients. Nurse Week. 2010. http://news.nurse.
com/article/20100614/ NATIONAL02/106140071.
Accessed July 10, 2010.
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Collaborative Action Research:
Implementation of Cooperative Learning Publication
Marilyn Smith-Stoner, PhD, RN; and Mary E. Molle, PhD, RN, PHCNS-BC
Abstract
Meeting the needs and desires of today’s
students provides a continuing challenge to
nurse educators. Some researchers report
that innovative instructional methods using
cooperative learning increase student
satisfaction (Johnson, Johnson, & Stanne, 2000;
Schell, 2006), and evidence suggests that these
methods may be successful in engaging the
younger generation of learners (Henry, 2006;
McGlynn, 2005).
Diekelmann (2005) observes that to change
their teaching methods, faculty members first
need to transform themselves by learning—
reading, asking questions, thinking, and
listening (p. 485). However, little research has
been done on the process that experienced
educators use to retool their instructional style
(Schell, 2006). We describe the results of our
collaborative research project, which focused
on the transformation of our instructional
methods from what we call “sage on the stage,”
in which students are passive learners, to “guide
on the side,” in which students are actively
engaged in learning throughout every class
session. We present the insights we gained
regarding the process of faculty transformation
from four cycles of action and reflection. We
include examples of successful discussion
activities and suggestions for other educators.
Nurse educators must continually improve
their teaching skills through innovation.
However, research about the process used by
faculty members to transform their teaching
methods is limited. This collaborative study
uses classroom action research to describe,
analyze, and address problems encountered
in implementing cooperative learning in two
undergraduate nursing courses. After four
rounds of action and reflection, the following
themes emerged: students did not understand
the need for structured cooperative learning;
classroom structure and seating arrangement
influenced the effectiveness of activities; highly
structured activities engaged the students; and
short, targeted activities that involved novel
content were most effective. These findings
indicate that designing specific activities
to prepare students for class is critical to
cooperative learning.
Received: January 23, 2009
Accepted: August 10, 2009
Posted: March 1, 2010
Dr. Smith-Stoner is Associate Professor of Nursing,
and Dr. Molle is Professor, California State University
San Bernardino, San Bernardino,
California. Dr. Molle was supported in part by NIH
Research Infrastructure Grant #P20MD002722.
The authors have no financial or proprietary interest
in the materials presented herein.
Generational Differences
Recent studies describe the values and
competencies of Generation Xers, born
between 1960 and 1980 (Sacks, 1999; Twenge,
2007), and Millennials, born between 1981 and
2002 (Howe, Strauss, & Matson, 2000; Lancaster
& Stillman, 2003), as different from those of
the Baby Boom generation, who comprise
the majority of nursing faculty. Qualities of
Generation X students relevant to instructional
Address correspondence to Marilyn Smith-Stoner,
PhD, RN, Associate Professor of Nursing, California
State University San Bernardino, HP 215, 5500
University Parkway, San Bernardino, CA 92407;
e-mail: mstoner@csusb.edu.
doi:10.3928/01484834-20100224-06
19
strategies include a focus on outcomes rather
than process, comfort with technology and
multitasking, and self-orientation with a goal
of having fun (Tulgan, 2006).
students. The most recent report emphasizes
the inclusion of high-impact activities, such as
creating a learning community, conducting
research with faculty, studying abroad, and
Table 1
Principles of Cooperative Learning
Principle
Sample In-Class Activity
Positive interdependence (students know that Students complete a focused-care plan as a group
everyone must participate for the group to be
successful)
Promotion of interaction (students interact face-to- Students collaborate on each activity or assignment
face)
Individual accountability (each student must be Students complete activity individually before class,
prepared to work in a group)
often through specific homework assignment
Interpersonal and small-group skills (students learn Instructor encourages students to discuss concepts
to listen and ask clarifying questions)
and question others
Group process (students discuss how well the group Students work on activity in preset groups;
achieved its goal)
instructor allows time after completion to discuss
successes and failures
Adapted from Johnson & Johnson (1990).
In their popular book, Millennials Rising,
Strauss and Howe (2000) portray the current
and upcoming generation of college
students, the Millennials, as the most diverse
generation ever. As students, they plan
to study little but have high expectations
for their instructors to meet their unique
needs. Most Millennials have led sheltered,
structured lives and are self-confident but
need affirmation. They prefer teamwork to
individual effort and creative, technologybased learning strategies to traditional
teaching methods; they demand a voice in
decision making; and they want to balance
life and work (Strauss & Howe, 2000).
Although Hoover (2007) warned against
taking these generalizations too seriously
and refuted some of Strauss and Howe’s
findings, our experience indicates that
Millennials do not respond well to traditional
teaching methods. Consequently, nursing
faculty must develop new, more effective
methods for improving the performance
of students who generally do not share
their instructors’ preferences for learning
strategies. The National Survey of Student
Engagement (NSSE) provides an annual
completing a culminating senior experience
(NSSE, 2007). Our experience suggests that
collaborative action research, in which
instructors work together to examine their own
educational practice systematically, can help
nursing faculty develop new, more effective
learning opportunities for Millennial students.
Classroom Action Research
Cross and Steadman (1996) defined classroom
research as cumulative and ongoing inquiry
about what affects student learning in the
classroom. A variation of classroom research
called classroom action research (CAR) involves
inquiry and discussion of what promotes
effective student learning (Baumfield, Hall,
& Wall, 2008; Cross & Steadman, 1996; Kur,
DePorres, & Westup, 2008; Macintyre, 2000;
Ragland, 2006). Focusing on systematic
inquiry by teachers in their own classrooms
(Macintyre, 2000), CAR involves more than
one researcher—in this case, two nursing
instructors who teach in a state-supported
undergraduate nursing department. Classroom
action research is particularly appropriate as a
method for faculty to develop new skills or to
transform their existing instructional skills.
20
Cooperative Learning
to evaluate instructors whose examinations
did not closely match the content of lectures
and prepared materials as “unorganized.”
We also talked repeatedly with our fellow
nursing instructors to determine their
concerns regarding teaching Millennials.
These conversations highlighted the need
to involve students more actively in their
education, in particular, the need to motivate
them to prepare for class. Our colleagues
noted that class sizes have steadily increased
(from 40 students to 80), leaving them with
less time and fewer resources to manage
instructional activities, such as grading
assignments, preparing and presenting
course materials in class, and updating
course content.
After attending a 2-day faculty development
workshop sponsored by the Teaching
Resource Center at our university,
we wanted to develop a method for
systematically implementing cooperative
learning. Cooperative learning is a collection
of skills that involve curriculum planning,
creativity, facilitation, and persistence
(Johnson & Johnson, 1999). Cooperative
learning is highly structured, with specific
elements outlined in Table 1. Several faculty
members thought that the implementation
of structured cooperative learning activities
would enhance the learning outcomes of the
program and prepare students for working
in groups once they graduated. In this first
phase of instructional transformation, we
worked through the basic skills we would
need to implement cooperative learning
fully, including classroom management
techniques to shift the focus from the whole
class to student-centered small groups and
back to the whole class. We also needed to
develop group learning skills and reduce the
amount of content we presented through
lectures, compared with group activities,
that promote student thinking. In planning
instructional changes, we needed to address
our students’ expectations, which we
determined by conducting a survey during
the first class. Besides expecting to do well
while multitasking (e.g., listening to music,
reading, instant messaging) and to be given
help when they are not doing well (McGlynn,
2005), our students preferred having their
instructors present a complete outline course
content on PowerPoint® slides rather than
through traditional lectures and expected
examinations to be derived directly from the
PowerPoint presentations. Some students
stated they no longer purchased any courserelated books because they expected the
instructor to synthesize important content
during class, which would eliminate the need
for purchasing a textbook. Students tended
Literature Review
To develop an integrated model that
focused on adapting teaching methods to
a new generation of students, we needed
to understand the process of transforming
teaching methods effectively. After a
review of the literature on transforming
instructional methods, we developed
an eclectic model based on continuous
dialogue (Lynn & Smith-Maddox, 2007),
constructivism (Gilles & Ashman, 2003),
and transformative learning (Mezirow,
1994). Our reflective model involved our
continuous dialogue with each other and
with our students, framed in constructivism
and focused on transforming not only our
thinking but also our students’ reactions to
changes in our teaching methods.
Design
The study was conducted at a rural statefunded university in Southern California.
There are approximately 500 nursing
students. The university is designated as a
Hispanic-serving institution. Most classes
are presented in a traditional format.
21
Classroom action research begins with
the identification of a problem and the
development of a question relating to the
classroom problem. We identified several
interrelated problems, including over-large
classes, too many failing students, and too
many unprepared students. In response to
these problems, we formulated the research
question: In what ways can cooperative
learning improve learning outcomes? The
two researchers met four times throughout
a 10-week period, following a standard
CAR design in two different undergraduate
nursing classes—an introductory medical
and surgical course and a senior-level
community health class. Reflections centered
on two concepts—the effectiveness of
cooperative learning and the challenges
involved in introducing cooperative learning.
The study was approved by the institutional
review board. Consent was obtained by the
two faculty conducting the research.
reflect on the successes and failures of
our methods and to discuss the students’
reactions to the cooperative learning
activities to determine the next step in the
process. During reflection, we were able to
describe our activities, frankly discuss the
successes and failures, determine a revised
approach, and support each other in the
project. Prior to this project, instructional
methods focused on the use of “sage on
the stage” methods as lectures, PowerPoint
presentations, and question-and-answer
sessions periodically throughout the class
period. Other activities were included
periodically in a course, but they were not
systematic. Of note, students preferred
highly structured lectures and did not object
to the instructional format.
Results
This section describes the four cycles of
action and reflection. Table 2 presents the
research process and the results.
Method
Action-Reflection Cycle 1
We met four times in the quarter to discuss
the instructional strategies used. The
sequence of working in the class and then
discussing the experience formed the four
action-reflection cycles used for the study.
We recorded the reflection cycles using
an audiorecorder and analyzed the action
cycles for themes, applying the results of
each action-reflection cycle to the next
cycle. Our goal was to explore the successes
and challenges of each step systematically.
Before conducting the study, we developed
specific course-related cooperative learning
activities, which we modified as necessary
during the experiment. Each activity included
the five elements described by Johnson,
Johnson, and Holubec (1990): positive
interdependence (participation by all
group members), promotion of interaction,
individual accountability, interpersonal and
small group skills, and group process. After
each 2-week period of action, we met to
Forming Groups. The initial cycle focused on
organizingthe class groups and on seating
arrangements. In accordance with the
literature, we deliberately assigned students
to create groups, which fixed their seating
arrangements, to ensure that each group
had students of varying abilities (Gilles,
2007; Gilles & Ashman, 2003; Johnson &
Johnson, 1999). One class used grade point
averages, and the medical-surgical class
used selfidentified introverts and extroverts.
We found arranging students by grade
point average to be as effective as randomly
assigning students to groups. For the
medical surgical class, we found that asking
students to identify themselves as introverts,
extroverts, or in between and then grouping
them accordingly worked well because
it led students to develop new skills. For
example, in groups composed of extroverts,
students learned new ways of listening and
22
Table 2
Process of Classroom Action Research
Process
Planning Stage
Identify a problem or set of problems. Over-large classes with too many failing students,
too many unprepared students, and some students
overwhelmed by the amount of required reading.
Pose a question about how faculty In what ways can students be more actively involved in
might solve the problem.
participating in the classroom?
Determine your focus and objectives. Implement collaborative learning using strategies from
faculty development workshop and research.
Establish timeline for cycles of action Four 2-week action cycles, each followed by a reflection
and reflection.
cycle.
Cycle 1
Action: Implement the change.
Assign seats and groups to minimize socializing. Use
prearranged quiet signal.
Observations:
Students perceived the quiet signal as childish and
ignored it but did respond when instructor signaled for
the class to stop talking. Students were more engaged
when they did not know in advance who would be
selected by the instructor to present the group’s findings.
Rooms, such as a theater, required more preparation and
students need to move around more.
Reflection: Focus on structure of the
room and the class.
Cycle 2
Action: Expand the use of cooperative Instructors should explain why cooperative learning is
learning strategies.
being implemented and how it will benefit students.
Instructors must actively engage in discussing the
concepts with students, walking around the class to
listen and encourage student participation during
cooperative learning activities. After the activity, the
instructor should select students who have successfully
demonstrated knowledge of the concepts to share
their findings with the rest of the class. Inconsistent
attendance made it more difficult to quickly identify
students ready to present knowledge and insights to the
class. Students were most involved in intense activities
that engaged both their emotions and their minds.
Sharing results with the whole class resulted in broader
engagement.
Reflection: The need for change to
structured cooperative learning was
not clear to students.
Cycle 3
Action: Promote more positive Students preferred printed instructions, even if the
interdependence in groups.
activity did not involve writing.
23
Cycle 1
Although all activities were preplanned, students
seemed to respond better to directions on paper than to
directions displayed on a screen or written on the board.
Reflection: The students stayed
engaged when the activities were
highly structured.
Cycle 4
Action: Identify the most effective
activities.
Reflection: The most effective 1. Were highly focused and brief (10 to 15 minutes).
cooperative
learning
activities 2. Involved selected students presenting group work to
involved three key factors:
the whole class.
3. Focused on an interesting patient-care problem that
required a solution.
organizing. In groups of introverts, students
were guaranteed opportunities to talk, which
they might not have had otherwise. Quiet
Signal. During the faculty development
workshop, the facilitator suggested using
a graphic of a raised hand as a quiet signal
(Kagan, 1994). Although the quiet signal
worked effectively during the workshop,
most students ignored it. Others verbally
commented “We are not children!” After
multiple discussions with students about the
goals of a quiet signal, students still objected
to the use of a quiet signal but understood
the goal more clearly. Some of the classes
decided that when the instructor raised her
hand, students would signal others to be
quiet.
feedback from students. Several weeks into
the quarter, students had begun to question
the need for and appropriateness of
collaborative class discussions. We identified
the following themes in student resistance:
• Many students did not prepare for class
and consequently had few insights to
contribute.
• Students, in general, focused on acquiring
the knowledge they needed to pass their
examinations. They viewed any discussion
beyond what they needed to know for
the examinations as unnecessary and
consequently contributed little to the
additional discussion.
• Not all cooperative learning activities
resulted in the level of engagement
necessary to produce critical thinking.
Transitions Between Group and Individual
Work. Because the transition from group
work to whole-class discussions was crucial
to the success of the experiment, the
second action reflection cycle focused on
managing time efficiently and ensuring that
students knew what was expected of them
in each activity. We displayed a timer using a
projection device so that all students could
see it. Limiting discussion periods to 10 or 15
minutes worked best to maintain students’
focus on the learning activity. In the second
reflection cycle, we focused on negative
During the third action-reflection cycle,
we continued to focus on the structure
of the learning activities and made some
adjustments. For example, we initially
planned to provide the directions for group
activities using overhead transparencies
or written instructions on the board.
However, we discovered that our students
needed instructions printed on paper to
focus their discussions within the group
and to promote participation by all group
24
members. As a result, we provided each
group with one hard copy of instructions
for each cooperative activity. We also wrote
instructions on the chalkboard before class.
Advance organizers, which gave students an
overview of activities to come, were critical
to students’ engagement.
definitions is essential to the success of
this activity. Instructors can easily see who
has not prepared for class because those
students tend to stand at the edge of the
lawn waiting for another student to find
them.
Discussion
During the fourth and final reflection
cycle, we shared successes related to more
dynamic cooperative learning activities. The
Figure describes a successful cooperative
learning activity related to death and dying
that was used in the beginning medicalsurgical course. This activity, which was first
learned at the Zen Hospice in San Francisco,
is commonly used by all kinds of educators.
The primary activity used in the community
health class was intervention matching. In
the traditional nursing education classroom,
the instructor describes 17 public health
interventions (i.e., broad, complex roles that
the nurse would assume in public health)
in a lecture followed by class discussion.
Rather than presenting the interventions
in a lecture format, the instructor directed
students to prepare for class by studying
the definitions. Mastering the definitions
provided a break from the classroom lecture.
After the instructor gave each student a
card containing either an intervention or
its definition, we met outside on a nearby
lawn. Students had to find the person with
the corresponding card within the specified
time. Once the pairs were matched, students
read aloud their matches and the group
confirmed whether they were correct. We
repeated the activity three times during
the same class period, with increasingly
shorter completion times. Students who
participated in this activity mastered the
names and definitions of the interventions
more thoroughly than did students taught
by traditional methods, as shown by their
performance on subsequent examinations
and their use of the terms during class.
Having enough carefully matched terms and
The results of our study support much
of the literature on cooperative learning.
For example, students did participate in
activities that they found meaningful. We
were not able to assess other measures
of effectiveness, such as performance on
examinations, that will be part of the next
step in fully incorporating active learning.
However, new concerns emerged.
Successes
The study succeeded in three ways. First,
more direct involvement with students
enabled us to identify students with learning
difficulties early in the course and help
them overcome barriers to their success
in the program. Second, we could address
students’ errors during class time, rather
than waiting for a test to demonstrate their
misunderstanding of course content. Finally,
the instructors could serve as role models
for collaboration by listening to student
discussions, asking clarifying questions,
acknowledging differences within a group,
and clarifying errors in thinking.
Failures
Because students’ expectations provided a
formidable barrier to moving through more
sophisticated cooperative learning activities,
the instructors spent much of the group
time encouraging students to participate
in discussions with each other, instead of
raising their hands to ask questions. Their
resistance may result, in part, from a failure to
acquire “the skills, techniques, and behaviors
25
for mastering the ‘hidden curriculum’ [Kegan,
2000, p. 45]” (Kerka, 2001, Beyond Life Skills
section, ¶ 4), such as the ability to make
meaning out of the material and activities in
a classroom.
We have increased our efforts to encourage
students to prepare for class and participate
in discussion. However, the collaboration
process needs to be introduced slowly and
continue throughout the curriculum.
The purpose of this activity is to simulate the gradual process of letting go that dying people
face.
Directions: On the list below, write each of the following on separate spaces in random order:
The names of the two people you love the most.
The two possessions you value the most.
Two dreams (goals or hopes) you have.
Two roles that you value the most.
The two activities or hobbies you enjoy the most.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
After each student has completed the list, the instructor calls out random numbers to cross off.
(Four to six items works best.) After seeing what they value, students reflect quietly on their
own lives and then discuss the impact of loss in pairs or in groups of four. After everyone has
contributed to the discussion, students consider how to apply this knowledge to the care of
dying patients.
Debriefing questions:
1. What is the quality of your life with the losses you experienced?
2. In what ways does this experience connect you to patients you have cared for who are dying?
Homework:
For the two people you wrote down as those you loved the most, you are to call or write to
them describing this activity.
Another obstacle we encountered was
that some students would not assume
the responsibility of preparing for class,
preferring to have instructors present
material using PowerPoint slides. Several
students voiced concern that instructors
were not properly prepared for class,
claiming that the students were “doing all
the work.” When students do not participate
in classroom activities, they miss a learning
opportunity. We have increased our efforts
to encourage students to prepare for class
Ideally, the entire nursing faculty would
participate in the process so that students
could gradually build the skills of discussion,
reflection, and cooperation in
all nursing students.
One problem that we encountered, the
effects of an unsuitable environment on
group learning, is mentioned only briefly
in the literature on cooperative learning.
Stiles (2006) reported that cooperative
learning can “be applied in various setting,
such as classrooms [and] lecture halls” (p.
26
257). However, we discovered that not
all classrooms are properly equipped for
cooperative learning. One classroom in our
experiment was actually a theater, which
was being used as a classroom because not
enough large classrooms were available to
accommodate 80 students. Fixed theater
seating and inadequate lighting in this
“classroom” made writing difficult and
restricted group interaction.
Facilitating critical thinking, probing
comments for clarification, and creativity
requires the instructor to demand that
students go beyond basic concepts to
deeper levels of synthesizing theory and
clinical curriculum content. As we continue
to transform our instructional styles, we will
use the insight gained from this experience
to increase the effectiveness of new
approaches. Our next step is to integrate
graded quizzes using audience-response
systems or clickers that will require students
to prepare prior to coming to class. We
will conduct additional classroom action
research studies on how to incorporate
laptop computers into a classroom, how to
use text messaging between faculty and
students effectively, and how to supplement
in-class
activities
with
Web-based
multimedia. To transform ourselves, we must
persist despite objections from students,
including unfavorable teacher evaluations.
To transform nursing education, we must
first transform ourselves.
Implications for the Future
To develop the requisite skills of designing,
implementing, and evaluating cooperative
learning, faculty members need a systematic
and collaborative process of implementation.
We recommend consultations with other
faculty members, nursing student leaders,
and faculty developers. Cooperative learning
must be integrated into the curriculum in a
thoughtful manner. It is especially important
to have faculty buy-in, as cooperative
learning skills require practice. Techniques
such as a quiet signal will work best when
all faculty members use the same signal.
Cooperative learning requires courage and
tenacity, especially during the initial period
when students must develop new classroom
behaviors. Designing specific activities to
ensure that students are prepared for class
is essential if cooperative learning is to result
in complex thinking. In the future, students
who come to class unprepared may be asked
to leave and to complete necessary work
before the next class. Assigning students to
groups based on their grade point averages
creates balanced groups and enables the
instructor to monitor the weaker students
throughout the term. During classroom
activities, the instructor can watch weaker
students’ responses to gauge how well
they are integrating material. However,
many students resisted being assigned to
particular groups, and instructors needed
additional time to modify groups if some
members were absent. Facilitating critical
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28
USING High-Fidelity Simulation to Educate Nursing
Students About End-of-Life Caretion
Marilyn Smith-Stoner, PhD, RN
Abstract
students a wide range of experiences related
to pre and post-mortem care in a clinical skills
lab. Providing students with opportunities to
practice such care will help them in preparing
for this potentially stressful nursing role. • For
the past two years, this author has found that
simulations designed to develop end-of-life
(EOL) care skills are well received by students.
Simulations offer important opportunities
for students to explore their own ideas about
death and what it means to care for patients
who are dying. The impact of tending to a
patient who dies during the simulation and
interacting with a standardized actor as family
member provides opportunities to overcome
fears and develop clinical skills. • A wide
variety of teaching tools are available to nurse
educators. In addition, nurse educators can use
sources from the popular media and literature
to develop scenarios that provide meaningful
learning experiences.
Despite some technical limitations, it is possible
to give students a wide range of experiences
related to pre- and post-mortem care using
high fidelity simulation in a clinical skills lab.
Simulations incorporating role play provide
important opportunities for students to
explore their own ideas about death and caring
for patients who are dying. This article reports
on the experience of caring for a simulated
patient who dies during the scenario and
interacting with a family member represented
by a standardized actor. Selected educational
models are described that provide guidance
in developing evidence-based and patientcentered care simulations. A specific, authordeveloped conceptual model is used to guide
development of specific learning activities;
the “Silver Hour” represents the 30 minutes
prior to the death and immediately following
the death. Care of the imminently dying
patient, in any setting, can be conceptualized
using this model. Specifically, the model
encourages students to explore care for the
patient as treatment is withdrawn and death is
pronounced and to focus on care for families in
managing transitions before and after death.
Sidebar. Teaching Tools for
End-of-Life Care
GUIDELINES
• End of Life Nursing Education Consortium
(ELNEC®): www.aacn.nche.edu/elnec/
• American Association of Colleges of Nursing
Peace Death Competencies: www.aacn.nche.
edu/Education/deathfin.htm.
NURSING STUDENTS HAVE REPORTED
HESITANCY AND DISCOMFORT WITH
CARING FOR PATIENTS WHO ARE DYING.
Some have even reported that caring for
someone who is dying is the most unpleasant
thing a nurse can do (Allchin, 2006; Beck, 1997).
Simulators provide an effective bridge between
the unknown of caring for a dying person and
developing the skills necessary to facilitate a
meaningful death experience for patients and
their families. • While simulators have some
technological limitations, it is possible to give
SOURCES OF LEARNING CONTENT AND
OBJECTIVES
• NCLEX® Test Blueprint 2007: www.ncsbn.
org/2007_NCLEX_RN_Detailed_Test_Plan_
Candidate.pdf
• Accreditation guidelines from National
League for Nursing Accrediting Commission
(2008) and Commission on Collegiate
Nursing Education (2008).
29
ADDITIONAL SOURCES THAT CAN BE
USED TO INTEGRATE EOL GUIDELINES
AND STANDARDS
• National Consensus Project for Quality
Palliative Care (2004)
• American Association of Colleges of Nursing
Peaceful Death (2004)
• Hospice and Palliative Nursing Standards
of
Care:
http://hpna.org/Item_Details.
aspx?ItemNo=HPN22
• Hospice and Palliative Nursing Association
Position Statements
expected to not only provide resuscitative
efforts, but to consider the needs of the
patient and family as death approaches. The
scenario is not stopped when the patient
dies. Rather, students are encouraged to
explore care for the patient as treatment is
withdrawn and death is pronounced.
For families, the focus of care is the
management of transitions. When the
patient dies from trauma, the role of the
family watching the resuscitation is explored
in order to bring closure. Postmortem rituals
focused on life closure and saying goodbye
are included in the scenario learning
objectives.
Jeffries’s Nursing Education Simulation
Framework (NESF) (2007) is used to develop
the actual simulation and integrate EOL
content into a standardized structure. A
key focus of the framework is the building
of complexity, not by reprogramming the
software but by adding variables to the
scenario. For example, one basic scenario
where complexity is added involves family
members at the patient’s bedside. Two
generations of family members may be at
the bedside; or the patient is from a different
culture and the family does not speak
English; or there is an issue of infection
control. For advanced practice nurses, the
simulation complexity can be increased by
incorporating more advanced concepts, such
as palliative sedation and pain management
for patients with addictions or multiple
conditions. The same scenario can be used
in courses other than medical surgical and
critical care. Research students can design
a study and test their research designs in
a programmed simulation. They can test
protocols and interventions on a simulator
before trying them on a study participant.
By trying out new types of equipment or
systems of providing care, students in an
issues and trends or leadership course can
apply new policies or evaluate the effects of
existing policies in caring for many types of
patients .
Integrating Simulation into a
Course
The most time-intensive and critical
component of preparing a simulation scenario
is the development of clear learning objectives
that can be accomplished in the specified
time frame. Careful advance preparation and
close attention to learning objectives are
critical to student learning (Brenner, Aduddell,
Benett, & VanGeest, 2006). Experience has
shown that when scenarios are difficult and
time-consuming to create, the problem is
not programming difficulty. Rather, there is a
fundamental problem of trying to do too much
in too little time. As recommended by Childs
and Sepples (2006), objectives can be posted
to reflect the purpose of the learning activity.
Table 1 provides an overview of a course plan
used to integrate a death-related simulation
into a lecture class.
The Silver Hour In order to develop a coherent
series of scenarios related to EOL care, the
author developed a concept called the “Silver
Hour” (Figure 1). This is the 30 minutes prior to
the death and the 30 minutes after death. Care
of the imminently dying patient, in any setting,
can be conceptualized using this model.
Course objectives for the Silver Hour are listed
in Table 2.
In the initial scenarios, students care for
patients who are dying from advanced disease.
In other scenarios, the patient dies as a result of
trauma. In trauma-related deaths, students are
30
Table 1
Course Plan for End-of-Life (EOL) Care
Sequence
Focus
Activity
Presimulation readings
Increase knowledge of EOL care
Selected readings from text,
Provide aesthetic description of poetry (A. Gerstler, Medicine)
EOL care
Experiential learning
Interactive instruction
(Ridley, 2007)
Sensitize students to personal
loss experienced by patients who
are dying
Principles of nurse-client
interaction/
Pain and symptom management
Patient safety/Correct positioning
Simulation
Focus on the last 10 minutes of life Students prepare the night
Patient’s heart stops with spouse before, given general focus
at bedside
of simulation
Work in pairs for simulation
Specific objectives for observers
Post-simulation
Focus on making sense of the Dialogue, reflection-in-writing,
experience, understanding
and debriefing
Case study in class
what a “natural death” is
List 10 things that matter most
Complete own advance directive
Watch TV film, “Wit” (specifically,
Popsicle episode)
Case studies/care planning
Watch movies in class: “Bucket
List,” “Two Weeks,” “Evening”
Table 2
Selected Learning Objectives for “Silver Hour” Imminent Death Scenario
SCENARIO
COMPONENTS
ORGANIZATIONAL GUIDELINES/STANDARDS/CONTENT AREA
Learning
Objectives
NCLEX-RN®
Test Plan
National
Consensus
Project
AACN Peace
Death
Component of
Scenario or
Debriefing
1. Student will
demonstrate
knowledge
of how to
effectively
manage
physiologic
symptoms
when death is
imminent.
Safe and
Effective Care
Environment
1.1 Assess
ongoing advance
directive
preferences.
1.4 Educate
family regarding
signs/symptoms
of approaching
death in
developmentally,
age, culturally
appropriate
manner (Domain
7: Care of the
Imminently
Dying Patient).
1.6 Demonstrate
respect for
patient’s views/
wishes during
EOL care.
Scenario:
Reviews and
reinforces plan
of care with wife.
Communicate in
reassuring ways
with patient.
Respond to
spouse with
supportive,
realistic
statements
about patient’s
imminent death.
1.2 Demonstrate
ethical practice
through caring
behaviours
veracity in
communication.
31
1.3 Maintain
plan of care
focused on
patient priorities
(pain/symptom
management).
.
Debriefing
questions:
Describe the
nursing skills
you were able to
incorporate into
scenario. What
interventions did
you feel spouse
needed?
2. Safety and
Infection Control
2.1 Demonstrate
correct
ergonomic
principles while
moving patient.
Scenario:
Properly
reposition
patient using
safe ergonomics.
Ask for assistance
in repositioning
patient if
necessary.
2.2 Maintain
medical asepsis.
2.3 Prevent
injury.
2. Student will
demonstrate
effective
therapeutic
communication
techniques with
patient and
family.
2.1
Communicate
effectively
compassionately
with patient,
family, health
care team
members about
EOL issues.
Respond to
spouse with
supportive,
realistic
statements
about patient’s
imminent death.
3. Student
reflects on
experience to
gain in sight
into views
regarding death
and dying.
3.1 Assist self
to cope with
suffering,
grief, loss,
bereavement in
EOL care.
Debriefing
questions: What
was it like to
care for a patient
who was dying?
How did you
feel throughout
simulation
experience?
When you care
for patient who
is dying during
clinical, what
might you do
differently?
How did this
experience relate
to any patient
care experiences
you have had
caring for a dying
patient?
32
Debriefing
question:
How effective
were your
interventions
in supporting
spouse?
Situating the Simulation in the Course
Simulations must fit into an overall course
and curriculum plan, and both pre- and postsimulation learning activities must fit into a
holistic plan for achieving course objectives.
The educational activities that lead to and
follow the simulation serve as bookends that
support learning. Faculty can integrate the
simulation experience into related theory and
clinical courses by participating in pre- and
post learning activities when separate lab
faculty manage the simulations.
Students often observe simulations in class.
At the author’s university, clinical groups
are limited to 10 students. Two students
work together in a scenario while the others
observe. The importance of keeping students
who are observing the simulation engaged in
the learning activities cannot be overstated.
Observers are given meaningful assignments
that require advance preparation and
encourage involvement and critical thinking.
Table 3 describes the observer assignment
during a simulation.
Table 3
Observing Student Assignment, Imminent Death
Name:
Date:
Directions: Complete this assignment as you observe the simulation. This is an individual assignment.
You will be graded on your analysis of the simulation and can use it to contribute to the debriefing.
You will need several pieces of paper in addition to this form. Make sure your name is on all papers.
Sign where indicated.
Topic
Activity
Paper
Turn In For A
Grade
Nursing Process
As the simulation
progresses, utilize the
nursing process to
develop your own plan
of care. If you do not
observe something
you think should be
addressed during
simulation, make a
notation on your care
plan. Underline this
information to show it
is a comment that was
not included.
Keep notes of vital
signs and other
observations you
see and hear. If
some assessment
information is missing,
make a note to discuss
it later.
Complete the
assessment sheet
provided.
Care Planning
Develop a list of two to As you observe the
simulation, create a
three priority nursing
concept map on key
issues.
issues related to this
patient. Utilize only the
priority issues related
to his imminent death.
Documentation
Keep a record of the
nursing interventions
that need to be
documented.
33
Complete the
documentation sheet
provided.
Include concept
map in the
paperwork you
turn in. You will
not have time
to rewrite it, so
be careful in
developing it.
Concise
documentation
notes for the
patient’s chart
using your
observations from
the simulation.
Complete this
documentation
in real time
as simulation
progresses.
Patient Safety
Identify patient safety
issues. Incorporate
these issues into your
concept map.
Concept map with
patient safety issues
clearly identified.
Make a notation
of patient safety
issues in your
concept map.
Student Feedback
Describe actions and
comments made by
students that reflect
an understanding of
caring for a patient at
end of life.
Describe actions that
did not occur but may
have been helpful in
caring for a patient at
end of life.
What was your
reaction to the
simulation?
Create a concise
paragraph
evaluating
effectiveness of
the care given by
each student. Use
non evaluative
feedback.
Simulation Design Elements
SETTING UP THE SIMULATION
depending on the level of the student. For
example, a first-quarter student is expected
to call the nurse and ask that the patient be
medicated for pain; a second-quarter student
gives the pain medication in a relatively short
period of time; a student in the beginning
critical care course gives intravenous
medication within an even shorter period of
time; and a student in a complex care class gives
opoid analgesia and implements additional
symptom management interventions. In
each case, the scenario is not reprogrammed.
Rather, the learning objectives are altered and
the same scenario is used.
On simulation days, the class is given an
overview of the day. Even if students have
used the simulator prior to class, nothing is
assumed about the student’s knowledge of
the simulator (Childs & Sepples, 2006). Each
student and faculty member is asked to sign
a form giving consent to be photographed
and to participate in an ongoing study using
National League for Nursing evaluation tools
(Simulation Design Scale and the Educational
Practices in Simulation Scale) (Jeffries, 2007).
Video recordings and evaluation instruments
are used to assess the degree of effectiveness
To increase fidelity, the patient area in the
skills lab is prepared before beginning the
simulation. The simulator is dressed in pajamas
and surrounded by personal memorabilia, for
example, pictures painted by children in the
family. Images can be scanned and reprinted
as necessary. Each time a simulation is set up,
it is photographed and the entire patient care
area is evaluated in the faculty debriefing that
follows the simulation day.
Student Preparation
Students are given an overview of the simulation
and directed to prepare for caring for a patient
with advanced disease who is dying. Students
dress in uniforms and use clinical forms and
resources, similar to an agency based clinical
experience. With a short simulation (death is
imminent, 10 to 15 minutes) students have
not found it helpful to spend time looking
up material during the simulation. Learning
objectives and performance standards
outcomes are adjusted, depending on the
34
the degree of effectiveness of the scenarios
and for the debriefing of instructors about their
debriefing techniques. Students also complete
the Concerns About Dying Scale (CAD) (Mazor,
Schwartz, & Rogers, 2004) as a specific measure
of effectiveness of death-related scenarios. The
CAD is a simple, validated tool that measures
the concerns of health care workers about
their own death and caring for people who are
dying. It is useful for identifying students with
a high degree of death anxiety who may need
additional preparation prior to participating
in the simulated experience. A student who
has experienced a significant loss in the last
year will be given the option to play the role
of an observer, rather than participate directly
in patient care. Learning objectives and
standards of behavior are reinforced before
beginning the simulation. In order to establish
a clear delineation between the discussion
section of the class and the simulation, the
author always begins the scenario with the
patient making a sound, for example, moaning
in pain. The patient is also positioned to
look as if he is trying to get out of bed. The
patient will continue to moan occasionally
until the student intervenes, repositioning
him correctly and addressing his pain. If the
student does not address the patient’s pain
within 10 minutes, the scenario is over and
debriefing occurs. During the simulation, an
instructor runs the manikin and the simulator
equipment. As recommended by Alinier, Hunt,
Gordon, and Harwood (2006), instructors take
a limited role during simulations, acting only as
resources. When possible, a second instructor
acts as a standardized actor and assumes the
role of the patient’s spouse. No coaching is
given to students, who work in pairs. However,
students are allowed to ask questions of the
instructor, and one student may act in the
dual role of a nurse colleague when only one
faculty member is present. Students who are
observing the simulation are given a set of
learning objectives the night before and are
expected to be able to complete them during
the simulation. (See Table 3.)
Grading the work of observing students is
one way to encourage them to fully engage.
When observers are disengaged and
laughing, or even talking among themselves,
students in the simulation are distracted.
Student Responses
Debriefing
During
Student responses consistently demonstrate
the value of including simulations focused
specifically on death in the nursing
curriculum. Initial typical student reactions
include a sense of being overwhelmed,
which is similar to responses observed
by Allchin (2006) in students caring for
dying patients. The occasional student
has pediophobia, or a fear of dolls, and is
resistant to participating in a simulation.
This initial resistance is overcome when
students have the opportunity to work with
simulators in advance of participating in a
simulation scenario. When students hear a
patient moaning, even an occasional moan,
they report a moment of hesitation and are
not sure what to do. However, most students
quickly overcome this sense of not knowing
and begin to use the nursing process to
address the patient’s needs. Even students
who are in the first quarter of nursing school
have been able to assess the patient and
correctly seek assistance from the nurse to
ensure that pain medication is given in a
timely manner. Students consistently ask for
more EOL content after they experience caring
for a patient close to death.
Evaluation
An evaluation of the series of end-of-life
scenarios is under way. The tools used for
evaluation include those developed by the
NLN and the Concerns About Dying Scale
(Mazor et al., 2004). The CAD scale was
designed for use with health care providers and
35
can be completed quickly. The tool has good
psychometric properties and has been used in
a variety of pilot tests. An international effort
to determine the transcultural implications of
EOL care is also under way in Scandinavia and
Brazil. This effort is in the first stages of testing
the simulation, with and without the simulator
(see
www.aacn.nche.edu/Education/pdf/
toolkit.pdf ).
days of online education, new ways of
learning require new ways of teaching.
Simulation demands that nurse educators,
researchers, and administrators engage in
the thoughtful shaping of best practices to
benefit students and their future patients.
About the Author
Marilyn Smith-Stoner, PhD, RN, CHPN, is
associate professor, Department of Nursing,
California State University, San Bernardino.
Contact her at marilyn@nursestoner.com.
Information about the Silver Hour and endof-life simulations for a Laerdal Medical
simulator are available on her website
at
http://nursestoner.com/simulation/
imminent.
Future Needs
Incorporating EOL care into simulation practice
and research is essential if nursing education
is to promote quality experiences for dying
patients and their families. At present, the
technology has many physical limitations in
the simulation of death. For example, skin does
not change temperature or color. Advanced
programming is needed to simulate EOL
respiratory changes such as Cheyne Stokes
respiration. However, these technological
limitations have not diminished the learning
experience.
The use of simulation presupposes that
students have specific learning skills, such as the
ability to collaborate, self-reflection, and such
experiences with interactive teaching methods
as Socratic questioning. Careful attention to
ensuring that students have the necessary
skills to fully benefit from the use of high
fidelity simulation is critical to achieving the
desired learning outcomes. Learning methods
have a continuum of intensity. Once students
learn to collaborate in low-stress situations,
such as a didactic classroom, they can transfer
those skills to a simulation. Increasing faculty
utilization of simulations is another important
aspect of further development. Similar to the
innovations of distance education, simulation
can unbundle the learning experience from
rigid days and times of the week. Rather than
relying on the uncertainty of a specific learning
experience happening in the clinical setting
or discussing it in a lecture class, a simulation
can help students more effectively develop
their clinical reasoning. Just as in the early
Key Words
Simulation – End-of-Life Care – Nursing
Education
References
Alinier, G., Hunt, B., Gordon, R., & Harwood, C. (2006).
Effectiveness of intermediate-fidelity simulation
training technology in undergraduate nursing
education. Journal of Advanced Nursing, 54(3),
359-369.
Allchin, L. (2006). Caring for the dying: Nursing
student perspectives. Journal of Hospice and
Palliative Nursing, 8(2), 112-117.
American Association of Colleges of Nursing.
((2004))..Peaceful
Death:
Recommended
competencies and curricular guidelines for end-oflife nursing care. Retrieved from http://www.aacn.
nche.edu/Publications/deathfin.htm
Beck, C. T. (1997). Nursing students’ experiences
caring for dying patients. Journal of Nursing
Education, 36(9), 408-415.
Bremner, M., Aduddell, K., Bennett, D., & VanGeest, J.
(2006). The use of human patient simulators: Best
practices with novice nursing students. Nurse
Educator, 31(4), 170-174.
Childs, J., & Sepples, S. (2006). Clinical teaching by
simulation: Lessons learned from a complex
patient care scenario. Nursing Education
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Perspectives, 27(3), 154-158.
Childs, J., & Sepples, S. (2006). Clinical teaching by
simulation: Lessons learned from a complex
patient care scenario. Nursing Education care
scenario. Nursing Education
Commission on Collegiate Nursing Education.
(2008). Revision of the essentials of baccalaureate
education for professional nursing practice. [Draft].
Retrieved from: http://www.aacn.nche.edu/
education/pdf/BEdraft.pdf End of Life Nursing
Education Consortium. (2008). Retrieved from
http://www.aacn.nche.edu/ELNEC/
Copyright of Nursing Education Perspectives
is the property of National League for Nursing
Incorporated and its content may not be copied
or emailed to multiple sites or posted to a listserv
without the copyright holder’s express written
permission. However, users may print, download, or
email articles for individual use.
Gerstler, A. (2000). Medicine. New York: Penquin.
Hospice and Palliative Nurses Association. (2008).
Listing of position statements. Retrieved August
1, 2008, from http://hpna.org/ DisplayPage.
aspx?Title=Listing%20of%20Position%20
Statements.
Jeffries, P. (Ed.) (2007). Simulation in nursing
education: From conceptualization to evaluation.
New York: National League for Nursing.
Mazor, J., Schwartz, C., & Rogers, H. J. (2004).
Development and testing of a new instrument
to measure concerns about dying in healthcare
providers. Assessment, 11(3), 230-237.
National Consensus Project for Quality Palliative
Care. (2004). Clinical practice guidelines for
quality palliative care. Retrieved August 2, 2008,
from http://www.nationalconsensusproject.org/
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Test plan for the national council licensure
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1, 2008, from https://www.ncsbn.org/RN_Test_
Plan_2007_Web.pdf
National League for Nursing Accrediting
Commission. (2008). Standards and criteria
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Ridley, R. (2007). Interactive teaching: A concept
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37
A Criminal Trial Simulation
Pathway to Transformative Learning
Marilyn Smith-Stoner, PhD, RN CHPN; and
Mikel W. Hand, EdD, MSN, RN, OCN, CNA, BC
Abstract
content during the quarter session and retain
key course concepts long after the course was
completed. Second, we wanted to provide
undergraduate students with the opportunity
to observe graduate students in the learning
process. Previously, no other faculty members
had attempted to integrate students in
related courses in this way. Although it is more
common for graduate and undergraduate
students to work together in clinical courses,
it had not been the case in theory courses.
Lloyd and Bristol3 reported positive results
in a master of science in nursing/ bachelor
of science in nursing mentorship project
between medical-surgical undergraduates and
community health master’s students. Their pilot
study demonstrated that the benefits of master
of science in nursing/bachelor of science in
nursing student collaboration included a
positive impact on facilitating professional
development.
The simulation was based on a proposed trial
of a nurse who was involved in a medication
error. A medication intended for epidural use
was administered intravenously, resulting in
patient death. This case was selected because
of the complexity of legal issues, which allowed
students to see how issues within the course
could be used to understand a number of
important nursing issues. Those factors included
staffing patterns, fatigue and sleep deprivation,
legitimate versus inappropriate access to
epidural medications, compliance with facility
safeguards for medication administration, and
the intent of the nurse in her actions. Although
no evidence exists that this was a deliberate
act, the district attorney investigating the case
elected to seek a criminal indictment in the
case. This was because of the severity of the
outcome. Although the nurse reached a plea
bargain related to the criminal charges in this
case, the simulated trial was an opportunity to
Simulation is gaining popularity as an
instructional method in education. The
authors describe the simulation of a criminal
trial stemming from a medication error. The
simulation took place as a collaborative
effort between undergraduate and graduate
faculty teaching an issues and trends course.
Bradshaw’s model of transformative learning
was used to design the simulation. Graduate
students role played the individuals involved
in the trial, and the undergraduate students
acted as jurors. The curriculum design, the
preparation, and the debriefing process are
discussed. Lessons learned and suggestions
for future simulated learning experiences are
provided.
Simulation is not a new learning strategy1;
however, most nursing education literature
focuses on using patient simulators to develop
clinical skills, with the rare exception of
Haidnyak.1 The simulation described in this
article was part of a comprehensive faculty
self-improvement plan that we designed to
reduce the use of lecture and expand the
use of experiential teaching methods in
undergraduate and graduate nursing courses.
Bradshaw’s2 model of transformative learning
was used to design the simulation. We had
2 main objectives. First, we wanted to provide
a dynamic learning experience in courses that
were traditionally lecture and discussion. We
found that as the undergraduate program
increases in size, it is more difficult to provide
dynamic learning activities. With class size
reaching 80 students, we found that our courses
contained less discussion and used paper-andpencil testing methods as the primary method
of assessing learning. We wanted to see all
80 students engaged in exploring the course
38
provide graduate and undergraduate
students with a dynamic learning opportunity.
The graduate student preparation for
participation in the simulation included
community observations in courtrooms,
interviews with experts in the legal field,
and rich discussions with each other on the
nature of professional nursing. The graduate
students assumed the role of legal ‘‘experts’’
and spent the quarter immersing themselves
in their assumed role in preparation for a
trial that would include testimony, crossexamination, and jury deliberations. The
undergraduate students, who played the
jurors, did not receive any preparation
beyond usual course content for their role.
The instructor for the undergraduate course
role played the judge in the trial, and the
instructor for the graduate course served as a
facilitator for the entire process. He met with
the graduate students twice in preparation
for the trial to assist with refining court room
rules and defining specific legal issues that
would be addressed in the simulation.
This simulation was designed using
Bradshaw’s2
conceptual
model
of
transformative learning. Bradshaw’s model
is based on 4 key principles: multiplicity,
connectedness, critical intelligence, and
transformation. There are also 8 lifelong
learning goals. See Table 1 for a description
of the goals that were used to inform the
course design.
The 4 key principles are interrelated within
each of the goals. The principle of multiplicity
refers to integrating complexity, different
ways of communicating, and different
delivery methods. A simulation of a complex
patient care or public policy scenario reflects
the principle of multiplicity. The second
principle, connectedness, refers to seeing
patterns between concepts and actions.
Connectedness in a simulation translates
to students assuming different roles,
taking different views, and participating in
different types of learning activities. In the
medication-error trial simulation, students
were randomly assigned to the roles of
Table 1
Bradshaw’s 8 Principles of Transformative Lives Transforming Communities Model2
Bradshaw’s Principles
Understand complex
unpredictably.
Application to Trial Simulation
systems
that
interact Court procedures were observed.
The students participated in framing the activity.
The students explored laws and standards from the
Identify and integrate existing and emerging state where medication error occurred compared
personal, local, national, and global perspectives.
with California.
A dialogue about personal issues related to
challenges of providing care during nursing
shortage was conducted.
Graduate and undergraduate students were
included in the same simulation.
Prosper with different paradoxical and multiple sets The fact that nurses are patient advocates and a
of realities.
patient died of a medication error was integrated.
The challenge of the realities of working short
staffed on a holiday weekend and the need to follow
basic nursing safety procedures was stressed.
ANA position statement on nurses working fatigued
was used as reference.
See and make connections between past, present, Online and classroom discussions on knowledge
and future.
related to nursing workplace quality in the
immediate past, present, and future, as well as
implications of the shortage, were conducted.
39
Trends in medication errors, including the
implementation of medication safety systems such
as bar coding, were discussed.
Encourage sustainability in relationships and the Graduate students made multiple connections in
environment.
the legal community, who then connected with the
university and students.
Learning relationships between undergraduate and
graduate nursing students were developed.
Wider knowledge of the DON was made when
the university filmed the class for inclusion in a
recruiting video.
Engage in a process of change, privately, publicly, Students’ knowledge of civic engagement was
civically, and occupationally throughout life.
expanded through courtroom observations,
simulation, and exploration of how perspective
change occurred .
Extend learning styles and repertoires.
Learning style was extended through incorporation
of role play and experiential learning.
Develop insights through questioning.
Students engaged in constant questioning of the
deeper, systemic issues related to nursing roles and
responsibilities online, in the classroom, and during
debriefing after the simulation.
Students sought out individuals directly involved in
original case to explore their insights.
Abbreviations: ANA, American Nurses Association; DON, department of nursing.
involvement of students to prepare for the
simulation, often going well beyond what
was expected for the course. Students and
faculty both reported their perspectives
on the court system, professional nursing,
and legal remedies in class discussions
throughout the course.
attorneys, experts, defendant, and bailiff. The
undergraduate students were assigned the
tasks of jurors and were required to participate
in jury deliberations and debriefing.
The third principle, critical intelligence,
is focused on the continuous process
of deconstruction and reconstruction
of knowledge. This process occurs as
participants make informed decisions, ask
questions, and weigh choices. Students
who prepared the simulation continuously
engaged in questioning about the learning
outcomes, legal principles, professional
issues, and personal reactions to the events
leading up to and after the fatal medication
error. Continuous questioning incorporated
outside experts and, where possible,
individuals involved in the original case.
Finally,
the
fourth
principle,
transformation, was evidenced by the full
Simulation
Description of Simulation
Terminology
It is important to clarify terminology
as instructional methods evolve over
time. Historically, the word mock was
used to describe role-playing activities,
and the Oxford English Dictionary4
defines it as ‘‘The action of imitating a
40
person or thing.’’ However, mock is
defined by many, including the Oxford
English Dictionary (2007), as ‘‘A derisive or
contemptuous action or utterance; an act
of mockery or derision,’’ and it has negative
connotations. To more accurately describe
this type of learning activity, the word
simulation is suggested. This simulation
involved careful planning and modification
of an event that had instructional potential
within the 2 selected courses. Three primary
modifications were made in order to design
the simulation. Accommodations were
(1) focusing on legal issues that could be
adequately presented in a 110-minute class
period and most relevant to the course,
(2) focusing on specific selected learning
objectives for both courses, and (3) selecting
the most significant issues from the myriad
of issues in the original case.
legal experts who volunteered to help
students prepare for their roles. One district
attorney graciously volunteered to come
to class and assist students in preparing
their arguments for the simulation. Another
graduate student is now working with the
defence attorney who helped her with her
simulation role as an attorney. Students
were excited about the opportunity to reach
beyond the classroom and experience the
court first hand.
Online and class discussions were used
to synthesize the knowledge of the case
and of legal proceedings. Online discussions
provided an opportunity to explore the
multiple points of view and demonstrate
the deconstruction and reconstruction of
knowledge. We facilitated student learning
and assisted as necessary; however,
planning, completion, and debriefing
related to the simulation were done by the
graduate students. The student who role
played the bailiff served as the organizer
and coordinator of the simulation logistics,
which was key to keeping students on track
in preparation for the trial.
Before the actual simulation, a dress
rehearsal was conducted. This was a key
component of the success of the final
simulation. This complex simulation was the
first one held in this department of nursing.
The need for using different types of rooms,
instructional support technology, and
classroom setups required this additional
practice. During the dress rehearsal, several
important last-minute changes were made
in the room setup and timeline for the trial
presentation and debriefing.
Preparation
Once the specific legal case was identified,
students participated in library and online
research. Although students were experts
in accessing health related information
from the university library database,
additional instruction was needed to
familiarize students with legal databases.
A key issue when doing trial simulations is
that online library databases are of limited
use if atrial was never held. Students had to
use other research methods such as online
searches. Table 2 lists potential sources of
trial simulations. An amazing array of legal
reports are readily available on the Internet
and by request through regulatory agencies.
In previous versions of the course, a lecture
or guest speaker discussed courtroom
dynamics. This has been replaced with actual
observations and spontaneous interactions
with court officials. This allows students the
opportunity to explore the multiplicity and
connectedness of the issues in the case
by using critical questioning. Actual court
observations also connected students to
Debriefing
While the simulation is a central part of
learning in this instructional method,
debriefing is essential to assist students in
the process of connecting events observed
during the simulation to actual events that
may take place in professional practice.5,6
41
Debriefing is similar to a clinical post
conference in that the instructor facilitates
a rigorous review and analysis of the
experience. Debriefing includes a dialogue
by the participants on the structure of
the experience and the impact of the
simulation and reflection on perspective
transformation experienced by students
because of participation. Debriefings ideally
occur immediately after the experience.
Comments made by the graduate and
undergraduate
students
illustrated
Bradshaw’s 4 key principles: multiplicity,
connectedness, critical intelligence, and
transformtion possible in a simulation
learning experience.
Connectedness
During debriefing, one graduate student
reported, ‘‘I didn’t expect to feel the emotions
that I felt. I became passionate for the cause,
for nursing, and for the example we were
setting for the undergraduate students.’’
Critical Intelligence
Both the graduate and undergraduate
students noted that the most significant
learning from participation in this simulation
was surprise at the deep level of emotional
involvement. Many expressed comments
similar to those of this undergraduate
participant: ‘‘I have to be honest. After
watching that trial, I was hesitant about my
decision to go into nursing because, as was
stressed, humans do make mistakes.’’
Multiplicity
Graduate students used multiple methods
of learning in this course. They used the
library in new ways, researched legal issues
using Internet databases, observed court
proceedings, and contacted many of the
individuals involved in the original case.
Students remained in contact with each
other via the online learning management
system and periodic class meetings. All
students reported that they appreciated the
opportunity to actively engage in learning,
although the lack of traditional detailed
learning activities was a challenge at the
beginning of the course.
Transformation
Many students spoke of the changes in
their perspectives regarding their roles as
students and as professional nurses. The
student who played the bailiff said, ‘‘I was
empowered to become a leader in this class.’
Table 2
Sources of Simulation Content
Source
Location/Reference
Court cases and administrative proceedings of Legal Eagle Newsletter
interest to nursing
(www.nursinglaw.com)
Newspaper articles on civil and criminal cases Lexus Nexus search
related to nursing and health topic
Public policy issues
Center for Nursing Advocacy
(www.nursingadvocacy.org)
Public policy related to health
Institute of Medicine (www.iom.edu)
42
Evaluation
students asked questions about graduate
school and expressed a new interest in
continuing their education after an initial
period of practice as a registered nurse.
Undergraduate students were impressed
by the engagement of the graduate
students in the role play. Their preparation
and care in presenting complex issues were
demonstrated in a typical comment: ‘‘I’ve
known nurses could learn so much about
anything in one quarter.’’ Other comments
expressed appreciation for the graduate
students’ ability to ‘‘stay in character’’; when
describing the student who played the
defendant, students described the ‘‘realism’’
in which she presented her ‘‘testimony.’’
During the debriefing, she shared that until
the trial started, she had not made a decision
about testifying. Because a defendant is
innocent until proven guilty, there was no
legal imperative to provide her own account
of what happened. She demonstrated the
connectedness described by Bradshaw’s
model and used this principle to move
outside her own comfort zone and provide
her own account of the event.
The 2 objectives of the project were
determined to have been met through
student comments such as those described
above. All students reported being energized
by the experience, and many hours of
discussion about the issues and trends of
the initial case followed the trial simulation.
Evaluation of the learning effectiveness was
based on 3 major themes from debriefing
sessions with both groups of students. The
most common comment was the unexpected
degree of emotional involvement in the
actual trial simulation. Students reported
physiological and psychological signs
of high levels of engagement: ‘‘I found
myself becoming angry during our
deliberation that we were possibly going
to let someone guilty of murder walk away
due to our inability to agree on a verdict.’’
The second most common theme was
the understanding of the complexity of
the issues and how they related to one’s
individual sense of professional vulnerability.
Most undergraduate students expressed
common concerns of being human, being
capable of making a mistake, and one day
being in the same situation.
The final theme reflected a universal
desire to have more time for the simulation.
The entire trial simulation, jury deliberation,
and rendering of the verdict took place in a
110-minute class period, 15 minutes of which
was reserved for deliberation. Students
expressed the feeling of ‘‘being rushed to
reach a decision.’’ Based on this feedback,
future legal simulations of this complexity
will take place over 2 class periods rather
than 1. This modification would allow
deeper and more substantive discussion of
the case during the deliberation process. The
second faculty objective was to provide an
opportunity for undergraduates to observe
graduate students in the process of learning
in hopes of sparking their interest to pursue
graduate school. Many of the undergraduate
Recommendations
This complex legal simulation of a criminal
trial resulting from a fatal medication error
was described as a transformative learning
experience by all participants. The students
consistently verbalized the concern of
‘‘being human’’ and that they too could
make a similar mistake with very serious,
if not fatal, consequences for a patient.
Instrumental issues, such as allotting the
time for preparation versus the simulation
and debriefing, are subjects of future
research. Simulations based on public policy,
such as the legalization of physician assisted
suicide, would also provide valuable content
for transformative simulations that could
incorporate larger numbers of students.
Methods of debriefing and evaluating longterm learning outcomes for complex legal
43
and public policy simulations are yet to
be developed. This trial simulation was
the beginning of 2 faculty members’
desire to replace lecture presentations
with transformative learning activities
across the undergraduate and graduate
nursing curriculum. The ability to fully
engage students in complex issues was
demonstrated to be both feasible and
desirable.
References
Haidnyak G. Try a mock trial. Nurse Educ.
2006;31(3):119-123.
Bradshaw D. Transforming Lives, Transforming
Communities: A Conceptual Framework for
Further Education. 2nd ed. Melbourne, Australia:
Language Australia; 1999. http://www.eric.
ed.gov/ERICDocs/data/ericdocs2sql/content_
s to r a g e _ 0 1 / 0 0 0 0 0 1 9 b / 8 0 / 1 6 / 4 b / 6 8 . p d f.
Accessed September 29, 2007.
Lloyd S, Bristol S. Modeling mentorship and
collaboration for BSN and MSN students in a
community clinical practicum. J Nurs Educ.
2006;45(4):129-132.
Oxford English Dictionary [online]. 2007. http://
dictionary.oed.com. Accessed June7, 2007.
Fanning R, Gaba D. The role of debriefing in
simulation-based learning. Simul Healthc.
2007;2(2):115-125.
Peters VAM, Vissers GAN. A simple classification
model for debriefing simulation games. Simul
Gaming. 2004; 35(1):70-84.
44
Personal Reflection
Death Brokering for Critical Care Nurses
Lorena Bajer, SN
Abstract
how to care for grieving family members?’’My
clinical instructor shook her head vigorously,
nose wrinkled. She was also employed full-time
as a nurse on the medical intensive care unit to
which our class was assigned. Her response was
of slight disgust and largely dismissive. No, the
hospital did not have a policy for critical care
nurses in the event of patient death, and staff
were encouraged to ‘‘go about their business’’
in such a case: document, complete paperwork,
complete post-mortem care, and send the body
off to the morgue. It was as sterile and clinical
as a confidentiality statement or standardized
procedure for infection control.
My interest in creating a patient- and family
centred policy at the end of life became
more intense when the only death my group
experienced in clinical that quarter occurred.
I was saddened by the reaction of the staff to
a patient who was actively dying. The nurse,
a skilled clinician, was busily going in and
out of the room, furiously documenting care,
silencing alarms, and, finally, disappearing from
the scene at the moment of death.
I began to think about the implications. What
if a nurse’s priority at the patient’s moment of
death became creating a plan of care for the
family? What if the power of caring and comfort
that nuclear power of nursing became the
priority as a person takes his/her last breaths?
As part of a project for nursing research, I
and 2 other classmates began gathering the
best evidence on bereavement research and
practices within both critical care and hospice
settings.1-14 We developed our own policy to
suggest key interventions that can be taken to
improve the death-brokering process within
the critical care unit (see Appendix A).
End-of-life care and the dying patient have
been an area lightly covered in my nursing
school experience. While I expected the topics
to surface in more detail in conjunction with
the critical care nursing unit, this was not the
case. This article is a personal reflection on
my experience in critical care nursing and the
deficits involving death and dying education in
both institutional and professional settings.
Keywords: Bereavement, Critical care policy,
Death brokering, Grief
[DIMENS CRIT CARE NURS. 2012;31(5):287/289]
Throughout my nursing education, my ears
would always perk up, and my interest always
piqued, when the professor would begin a
lecture on nursing care of the dying patient or
post-mortem care. Although nursing care of
the dying is as important as that of the living,
I would quietly wonder why these topics were
so swiftly covered, reviewed as quickly as the
5 vital signs or steps to doing a bed bath. I
always looked forward to understanding the
many complex facets of death and dying and
yet was continually disappointed. Grieving and
assisting the deceased patient’s family seemed
so worthy of a day’s lecture. I was surprised to
have finally found my education in a senior
nursing research class. As a pairing to complex
care theory and clinical, nursing research
challenged the class to identify a policy at our
clinical agency, which required a revision or one
that needed to be newly created. Post-mortem
was a topic assigned specifically to my group.
Knowing death is rarely discussed by students
and clinicians, I was not shocked to learn that my
clinical site had no active bereavement policy
for the critical care unit. I asked, ‘‘Do you have a
policy or protocols regarding patient death and
What if a nurse’s priority at the
patient’s moment of death became
creating a plan of care for the family?
45
The goal of creating such a policy was to
provide a guide to nurses who come face-toface with dying every day in critical care to
better provide for patients and their families.
The policy addresses the breadth of needs
of the staff, the varied needs of the family,
the sensitive and complex care of the dying
patient, grief-support resources in the wake
of the patient’s death, and advanced referrals
for those who are experiencing complicated
grieving. Based on the best available evidence,
it is with great hope that, by designing such
a policy, awareness about the importance
of bereavement care within the hospital
setting will spread throughout the health care
profession.
For critical care nurses, it is important not to
forget that death is as important as life. A nurse
has the privilege to be present at both to (1) aid
and console, (2) guide anguish to acquiescence,
and (3) provide dignity at that final moment of
life. Privilege, as I see it, only begins to describe
it.
5-year post-bereavement group study. J Soc Work
in End Life Palliat Care. 2011;7(2-3): 195-215.
Davidson KM. Evidence-based practice guideline
family preparedness and end-of-life support
before the death of a nursing home resident. J
Gerontol Nurs. 2011;37(2):11-16.
Hadders H. Negotiating leave-taking events in
the palliative medicine unit. Qual Health Res.
2011;21(2):223-232.
Hansen L, Goodell T, DeHaven J, Smith M. Nurses’
perceptions of end-of-life care after multiple
interventions for improvement. Am J Crit Care.
2009;18(3):263-271. doi:10.4037/ajcc2009727
Llamas K, Llamas M, Pickhaver A, Piller N. Provider
perspectives on palliative care needs at a major
teaching hospital. Palliat Med. 2001;15(6):461470.
Pattison N. Caring for patients after death. Nurs
Stand. 2008; 22(51):48-56.
Roberts A, McGilloway S. Bereavement support in a
hospice setting. Bereavement Care. 2010;29(1):1418.
Smith-Stoner M. Environment of Care Considerations,
2011.
http://silverhour.info/resources/
Silver+Hour+table+.pdf. Accessed March 4, 2012.
Tyrie L, Mosenthal A. Care of the family in the
surgical intensive care unit. Surg Clin North Am.
2011;91(2):333-342.
Acknowledgments
Walsh T, Foreman M, Curry P, O’Driscoll S, McCormack
M. Bereavement support in an acute hospital: an
Irish model. Death Stud. 2008;32(8):768-786.
The author acknowledges her classmates
who worked on this policy with her: Sarah
Austin and Amanda Belcher and her
instructor Dr Marilyn Smith-Stoner for their
assistance with this article and enthusiasm
for end-of-life care.
Warren N. Critical care family members’ satisfaction
with bereavement experiences. Crit Care Nurs Q.
2002;25(2):54-60.
About the Author
References
Lorena Bajer, SN, is a clinical care partner at
the Ronald Reagan UCLA Medical Center, Los
Angeles, California, and patient care associate
at Huntington Memorial Hospital, Pasadena,
California. She is in her final year of the BSN
program at California State University, San
Bernardino. The author has disclosed that
she has no significant relationships with,
or financial interest in, any commercial
companies pertaining to this article. Address
correspondence and reprint requests to:
Lorena Bajer, SN, Department of Nursing,
Birtwistle J, Payne S, Smith P, Kendrick T. The role of
the district nurse in bereavement support. J Adv
Nurs. 2002;38(5): 467-478.
Cacciatore J, Flint M. ATTEND: Toward a MindfulnessBased Bereavement Care Model. Death Stud.
2012;36(1):61-82.
3. Celik S, Ugras G, Durdu S, Kubas M, Aksoy G.
Critical care nurses’ knowledge about the care of
deceased adult patients in an intensive care unit.
Aust J Adv Nurs. 2008;26(1):53-58.
Clark PG, Brethwaite DS, Gnesdiloff S. Providing
support at time of death from cancer: results of a
46
management by charge nurse/
administrators following death of a
patient, allowing the nurse to focus care
on the deceased and their family without
neglecting other patients on the unit
California State UniversityY San Bernardino,
47 West Bonita Ave, Sierra Madre, CA 91024
(lorenabajer@gmail.com).
Editor’s Note: Authors are encouraged to
write about their experiences, feelings, or
opinions on a wide array of topics of interest
to critical care nurses. These reflections can
be published anonymously if so desired by
the author. For more information, contact the
editor at vmiracle@aol.com.
II. Support for the Patient and His/Her
Family
This category includes psychosocial, cultural,
and spiritual support.
A. Offer the family the option to include and
participate in the patient’s dying process
(ie, viewing, grooming, or simply being
present at death)
Appendix
Death Brokering for Critical Care Nurses: A
Policy for the Critical Care Unit and Health
Care Team
B. Provide written materials to the family
about end of life and what to expect
I. Support for Staff
This category provides direct resources to the
nurse and nursing staff to assist in end-of-life
care and the bereavement process.
C. Provide bereavement materials to
the patient’s family (ie, memory box,
envelope for a lock of hair, materials to
make a print of the patient’s hand)
A. Access to a staff counselor to provide
psychological support to nurses and
nursing staff in the event of a patient
death
D. Incorporate cultural and spiritual end-oflife values, beliefs, and practices into the
end-of-life care
E. Organize family conferences with
physician(s), chaplain, and other
members of the health care team for
open discussion of the patient’s dying
process
B. Organize team meetings regarding
patient care to ensure patient and family
wishes regarding end-of-life care are
being implemented
F. Provide greater privacy and better
accommodations for relatives during the
patient’s dying process (ie, unrestricted
visits, providing water and blankets for
comfort)
C. Mandatory debriefing sessions for nurse
and nursing staff after a patient has died
D. Periodic staff education programs
regarding end-of-life care, with
continuing education credits offered as
incentive for participation
G. Present family with staff-signed sympathy
card or follow-up supportive contact via
telephone call
E. Availability of peer support groups or inservice sessions relating to grief
III. Care of the Dying
This category provides nursing interventions
and teaching opportunities to perform
during active dying and in the post-mortem
period.
F. Encourage physicians, nurses, and other
providers to consider thanatologically
focused continuing education
G. Ongoing emphasis on the importance of
clear and timely communication
A. Manage the patient’s pain effectively and
facilitate comfort measures during the
H. Swift and effective case load
47
IV. Community Referrals and Support
Programs
This category addresses the needs of the
normal grieving process for family.
A. Referral to local bereavement group(s)
B. Referral to http://www.hellogrief.org
V. Complex Needs and Special
Bereavement Support
This category addresses needs of the family
and nurse that go beyond the normal
grieving process.
A. Referrals for those family members who
request care related to complex needs,
such as depression and post-traumatic
stress disorder
B. Nurse access to mental health
psychological referrals in the event he/
she is experiencing complicated grieving,
such as an employee assistance program
48
End-of-Life Needs of Patients Who Practice
Tibetan Buddhism
Marilyn Smith-Stoner, PhD, RN
Abstract
newer practitioners are New York, Minnesota,
California, and Colorado. However, many
teachers have extended access to Buddhism
throughout the country. It is likely that a center
of practitioners is within reach of most hospices.
An Internet search with the term “Buddhism”
and the name of your city or county will give
you an idea of the center closest to your agency.
Practitioners honor the Buddha or “Awakened
One,” who was born approximately 2500
years ago. He was “awakened” in India and
traveled extensively throughout his life. Born
a prince, he turned his life’s work to attaining
enlightenment when he realized the suffering
of the people around the palace in which he
lived. His teachings emphasize the pervasive
suffering of sentient beings, and meditation
as a means to tame the mind and emotions.
There are variations in the teachings from one
tradition to another. For example, the period
for special rituals and prayers for the deceased
has sometimes been reported as 100 days1;
however, in the Vajrayana tradition, the period
is generally 49 days. Although this may seem
like a subtle difference, it is highly relevant in
the provision of individualized bereavement
services in hospice.
In all Buddhist traditions, four fundamental
contemplations compose the foundation of
understanding and meditation2: first, that
a human rebirth is extremely precious and
should be used to its highest spiritual potential;
second, that all compounded phenomena are
impermanent, and whoever is born is bound
to die; third, that beings experience relative
reality as compared to ultimate nature that
arises interdependently with their own actions;
fourth, that all beings suffer, and human beings
suffer particularly from birth, sickness, old age,
and death (Figure 1).
Despite the clear acknowledgement of the
suffering of sickness and death, the teachings
Practitioners of Tibetan Buddhism are rapidly
increasing in the United States. The care they
request at the end of life is different in many
aspects from traditional end-of-life care.
It is necessary for hospice professionals to
understand these needs and prepare to care
for Buddhist practitioners who may utilize
their services. This article will describe how to
use the nursing process to plan for their endof-life care and suggest how each member of
the hospice team can support the dying patient
and bereavement needs of the family.
Keywords: Buddhism, Death,End of life,
Nursing interventions, Spirituality
Buddhism, like other religions, is not a single
entity. The two main traditions of Buddhism
are the Theravadin philosophy practiced in
Thailand, Cambodia, Laos, and other countries
in Asia.1 The second is the Mahayana tradition
practiced in many places throughout the world,
including China, Japan, Vietnam, and Tibet. The
Vajrayana subcategory of Mahayana, including
the Tibetan Buddhist practices discussed in this
article, are from this philosophical tradition.
Although the Dalai Lama is the most recognized
representative of Tibetan Buddhism, many
very realized masters live in the United States
and are accessible to hospice care providers.
Because some requests from Buddhists are very
different from those in the dominant culture,
this article aims to create some dialogue with
hospice nurses about these end-of-life needs.
This article should be considered a beginning
rather than a conclusive description of hospice
practices for Tibetan Buddhists.
Tibetan Buddhism is one of the fastest
growing religions in the United States. The
major population centers of native Tibetans and
49
of Buddhism offer no support for any type
of physician-assisted suicide. Should a
patient make a request to end his or her life,
a teacher should be contacted immediately,
in addition to incorporating the traditional
hospice interventions for a situation that
requires immediate psychological attention.
bathroom, it’s too late to build a latrine.”2
Preparation for death is a central feature of
the tradition, and recognizing that there
is no certainty about how and when death
will occur is implicit in all practices. Hospice
professionals are experienced in supporting
the needs of patients from many religions.
Although many Tibetan Buddhists’ requests
differ from more common expectations at
the end of life, they are well within the ability
of hospice workers. This article will describe
how to use the nursing process to plan
for end-of-life care and suggest how each
member of the hospice team can participate
in order to support the dying patient and the
bereavement needs of the family.
The most widely known and useful book on
death and dying from a Buddhist perspective
is the Tibetan Book of the Dead, which
describes each step of the dying process in
detail.5 There are many editions of the text,
with different styles of explanations, and
it is widely available in a variety of printed
and multimedia formats. Basic versions of
this text can be read by volunteers or family
members. If no one is available to read to the
patient, tapes or CDs can be played as part of
the plan of care.
The place to begin is the Tibetan Buddhist
definition of death. This definition, as
described by Chagdud Khadro, is quite
precise and based on the perception of
subtle energies in the body (Tibetan rlung,
usually translated as ‘wind’ but ranging from
respiratory breath to synapses). According to
the Tibetan teachings, after the last breath,
the subtle energies of the body draw toward
the heart area. Then the subtle energy that
maintains the white, masculine energy,
received from one’s father at the moment
of conception and maintained in the crown
of the head throughout one’s life, drops
toward the heart. The deceased has a visual
experience like moonlight. Then the red,
feminine energy, received from one’s mother
at conception and maintained below the
navel, rises toward the heart. The deceased
In horror of death, I took to the mountains—
Again and again, I meditated on the uncertainty
of the hour of death
Capturing the fortress of the deathless
unending nature of mind
Now all fear of death is over and done.
The Buddha
Figure 1. Tibetan death mantra recitation. Data from
Rinpoche.3
Since the notion of eliminating suffering
is a central focus of hospice care, further
explanation is warranted. A famous story
told by Sogyal Rinpoche4 illustrates the basic
belief about the universality of suffering
and the inability to eliminate suffering
from life. Krisha Gotami lived in the time
of the Buddha. She was completely grief
stricken after the death of her infant. She
searched throughout her area for someone
to restore her baby to life. A wise man told
her the Buddha had the power to restore life.
She went to the Buddha and asked that he
restore her child to life. The Buddha indicated
he would bring the baby back from the dead
if she obtained mustard seeds from any
house in the local village in which a death
had not occurred. After searching the entire
area, Krisha Gotami was not able to find any
home where death had not occurred. When
her search proved unsuccessful, she realized
that suffering is universal and she should
direct her efforts toward spiritual practice.
All Vajrayana practices are focused on
training the mind, and it is considered wise
to start early, especially in preparing for
death. Chagdud Rinpoche, a Tibetan lama,
used to say, “When you have to go to the
50
has a visual experience of redness, like the
sky at dawn or sunset. The masculine and
feminine energies merge and one swoons
into unconsciousness, like passing into
a clear, dark night. This is death, beyond
resuscitation.
However, it is believed that the nexus of
consciousness— at its most subtle level of
cognizance and movement— can remain
in the body for up to 3 days or longer,
depending on the circumstances of death.
If the body dies by accident or violence, if
the body is undisturbed, or if certain rituals
are performed to liberate it from the body,
the consciousness may exit immediately. In
these cases, the body is merely a corpse and
nothing unusual needs to be considered.
But, after a peaceful death, Tibetan Buddhists
are exceptionally concerned about what
happens to the body in the moments and
days after death, and they try to ensure that
the consciousness exits from the crown of
the head.
to be at the time of death is critical. This
is especially important if hospice care is
delivered in a long-term-care facility or
location other than the patient’s home.
It is necessary to have an environment
conducive to practicing rituals that require
silence when possible.
Concept of a “Good Death”
Many practitioners of Tibetan Buddhism
receive specific instructions on the rituals
associated with death and on p’howa, which
means “transference of consciousness”6 as
part of the ongoing spiritual training. P’howa
prayers may be recited for years prior to the
actual time of death. In these prayers the
practitioners are encouraged to consider
various death scenarios and explore what
the actual experience of death would be like.
Practicing the death experience beforehand
gives the practitioner an opportunity
to adapt to the unpredictable nature of
death. It also provides practitioners with
opportunities to learn to accept death as
part of daily life.7 The optimal conditions of
death include the ability to be totally aware
of the death experience in an environment
of silence while completing special practices
such as the transference of consciousness.
It is not considered helpful to have friends
and family who are crying and disturbing
the patient when death is imminent, or
immediately thereafter. As a result, it is not
uncommon for friends and family to leave
the room if they are unable to remain calm
or maintain their own meditative state of
mind.
The nurse should explore how the hospice
team and other caregivers—paid and
unpaid—feel about these requests. When
practitioners feel any of them are unusual,
for example, leaving the patient alone at
the time of death, the nurse is in the best
position to advocate for the patient’s needs.
It is necessary to seek out the team members’
views of the religious practices so they can
NURSING PROCESS
Patient Assessment
During the initial patient assessment, the
nurse can speak to the patients about their
individual wishes pertaining to the death
experience and record what is desired. Areas
of specific difference are outlined below.
There may be tremendous variation between
patients as to the specific practices desired
leading up to the death and during the death
experience. It is especially important to ask
about whether the patient has a teacher or
“lama” and whether contact between the
hospice chaplain and teacher is desired.
Be especially alert to where the patient’s
teacher lives, which may be far away. The
“sangha,” or community of practitioners
of which the patient is a member, can also
provide support throughout the process.
After establishing details about the
religious support system, consideration of
the environment where the patient is likely
51
also have an opportunity to explore their
own thoughts and reactions to the plan of
care.
Although Buddhists understand that
suffering is a part of life, generally there is
a desire to avoid suffering when possible.
While assessing the patient, as with all
patients, determine the level of sedation
and pain relief desired. Interventions
regarding pain management may have the
widest variation in requests. Considerations
regarding analgesia are very similar to
natural childbirth. Some women prefer
sedation. Others prefer to avoid analgesia
if possible. In general, individuals want to
be as comfortable and as alert as possible,8
so they are able to continue to practice and
visit with loved ones.
It is also important to assess the use of
other medications. Careful attention to other
medications in the plan of care is critical.9
Many Buddhist practitioners use a wide
variety of herbal preparations, especially if
they are seeing a Tibetan doctor in addition
to a Western doctor. Encourage patients to
maintain communication between all of
their care providers.
Care Planning –
Interdisciplinary Team
Once team members complete the patient
assessment, a plan can be developed
to support the patient’s preferences. A
determination of how best to provide a
peaceful environment and who will be
present may take the greatest amount of
planning if the patient is in a long term-care
facility or other public living arrangement.
Suggestions might include:
a. Maintaining a visitation schedule that
allows for uninterrupted periods for
religious practice. The patient may want
to have team members visit at the same
time.
b. Maintaining an altar with religious photos
and relics. This altar may include candles
and incense.
c. Specifying who the patient would like
to be present at the time of death. The
preference may be for no one to be
present, especially if family and friends
are very emotional or unsupportive of the
religious practices.2,4
Table 1
Suggested Areas of Focus for Members of the Hospice Team*
Team Member
Suggested Areas of Focus
Physicians and nurses
Provide patient-centered care individualized to the patient’s needs to control
the level of alertness and other measures of quality of life and death
Hospice aides
Do work quietly and mindfully
Work with humor (as with all others)
Chaplain
Sit silently with patient. Contact patient’s teacher when there is one. Be aware
that many practitioners get their direction from books, videos, and presentations
at seminars and workshops, and are without a local teacher
Social worker
Assist patient in reconciling past issues, to both seek and give forgiveness for
self and others, speaking with family and friends. Facilitate the completion of a
will, which will assist the individual to lessen attachments.
Volunteer
Keep the altar fresh and clean. You may bring in a small flower for the altar each
visit.
Write letters. Help with making a scrapbook of positive life accomplishments.
*Caution: Before picking up a Buddhist religious text and reading it to the patient, be sure to enquire as to whether this is
appropriate. Some texts cannot be read by others who have not received a special empowerment to read them.
52
Implementation
the dying process (Table 2). The transfer of
consciousness is the key to a “good death.” To
facilitate this:
As the hospice plan of care is implemented,
the team can also provide support in a
number of other ways that should be
documented in the patient’s record. Many
of these strategies pertain to all patients
and may be common practice for hospice
workers (Table 1). In addition to patientspecific requests for a peaceful environment,
the patient may request help with managing
visitors, both sangha and non-sangha
members. Placement of the patient in a room
may need extra attention when hospice care
is being provided in a group living or long
term-care facility. Many will request a room
farthest away from the nurses’ station with
a quiet roommate. Additional suggestions
include:
a. When visiting the patient, turn your pager
and cell phone to vibrate.
b. The quality of the mind of the hospice
team member is also very important.
Before entering the room, take a deep
breath in order to clear your own mind
and relax.
c. Take and make phone calls outside of the
room.
d. During each visit, try to spend a few
minutes in silence, perhaps saying a
prayer from your own religion.
e. Ensure the altar is kept clean and in the
patient’s line of vision.
f. Suggest that the patient play audio
tapes, or make use of other multimedia
sometime during the day, to support his
or her religious practice.
g. Contact the religious teacher and family as
death approaches.
h. Suggest team members to provide the
patient with specific reminders for their
practice. These might include:
1. Give and receive
2. Slow down
3. Pay attention to details7
a. Disturb the patient as little as possible;
especially, avoid touching the hands and
lower parts of the body.
b. Gently tap the top of the head as death
occurs to draw the patient’s focus upward.
c. Leave the body undisturbed for as long as
practically possible after death. Buddhists
believe the dying process continues for
3–4 days after what is usually accepted as
“dead.”7 Although many laws do not allow
for the body to remain in a natural state
for 3–4 days, remain mindful of this to be
supportive as the family is approached
about the death.
d. You may want to help the patient sit up in
order to practice, or to lie on the right side,
which was the position of the Buddha at
his death.
Evaluation of the Plan of Care
The hospice plan of care is successful when a
patient is able to maintain his or her desired
practice schedule. Asking patients about
their ability to meditate and pray will help to
establish the effectiveness of care planning.
Documenting that the patient remained
at peace during decline and the transition
of death is also a method of determining
effectiveness. A description of those present
at the death, their activities, and the amount
of time the body was left undisturbed also
help document the individualized care
planning.
Bereavement Support
If the family of the deceased is Tibetan
Buddhist, specific prayers and practices are
usually conducted during the 49 days after
death. It is appropriate to make offerings of
money to the family to contribute toward
Additional planning will be needed during
53
Table 2
Tasks of Dying*
Task
Hospice Teams Activities That Support That Task
1. Understanding and
transforming suffering
Write out medical and end-of-life directives
Instructions for the time of death
Express fears, hospice team validates fears
Encourage medication on the principle of eliminating the suffering of
others
2. Making connections, healing Foster forgiveness in self and others
relationships
Encourage loving relationships with self and others
Encourage empathy toward self and others
3. Preparing spiritually for death
Practicing P’howa—the transference of consciousness at the time of
death
Play tapes and read texts with specific teachings from the lineage
tradition
4. Finding meaning in life
Reflect on positive accomplishments throughout life
Accept self and others
Perform loving acts, such as participating in research, donating organs,
donating possessions
*Data from Longaker.10
the ceremonies. The funeral may occur
anytime after death is ascertained, and is
often a cremation. Bereavement visits may
or may not be requested during the 49-day
interval. Interventions for support in the
year following death will be typical of most
patients. These interventions include grief
support visits and referral for social support
for family and friends.
Acknowledgment
Special thanks to Judy Vorfield and Chagdud
Khadro for their assistance in completing
this article. May all beings benefit from this.
References
Kemp C, Bhungalia S. Cultural perspectives in
healthcare. Culture and the end of life: a review
of major world religions. J Hosp Palliat Nurs.
2002;4(4):235-242.
Conclusion
Tibetan Buddhism is a rapidly growing
religious tradition and one that requires
specific care planning. Hospice professionals
are dedicated individuals who strive to
provide care relevant to the culture and
religion of the patient. This article is one
small step in the effort to provide education
to the hospice community. This article has
focused on specific needs for practitioners
who are at the end of life. Individual
variations do exist among Buddhists. This
is only a general framework. I suggest you
seek out a practitioner from a local Buddhist
group to give a presentation at your hospice
to learn more about local practices.
Rinpoche CT. Gates to Buddhist Practice: Essential
Teachings of a Tibetan Master. Junction City, Calif:
Padma Publishing; 2001.
Rinpoche S. Glimpse After Glimpse: Daily Reflections
on Living and Dying. New York: Harper Collins;
1995.
Rinpoche S. The Tibetan Book of Living and Dying.
New York: Harper Collins; 2001.
Coberly M. Sacred Passage: How to Provide
Compassionate Care for the Dying. Boston, Mass:
Shambala Publications; 2002.
Khadro C. P’howa Commentary. Junction City, Calif:
Padma Publishing; 1998.
Lief J. Making Friends With Death: A Buddhist Guide to
Encountering Mortality. Boston, Mass: Shambala
Publications; 2001.
54
Smith-Stoner M. Controlling pain. How Buddhism
influences pain control choices. Nursing,
2003;33(4):17.
Varela F, ed. Sleeping, Dreaming, and Dying: An
Exploration of Consciousness With the Dalai Lama.
Boston, Mass: Wisdom Publications; 1997.
Longaker C. Facing Death and Finding Hope: A Guide
to the Emotional and Spiritual Care of the Dying.
New York: Doubleday; 1993.
55
Nursing education challenge: A student with cancer
Marilyn sm;th-Stoner PhD, RN, CHPNa•*, Kristin Halquist BSN, RNa,
Barbara Calcagnie Glaeser PhDb
a Department of Nursing, California State University San Bernardino, San Bernardino, CA, USA
b Induction and Mild-Moderate Credential, California State University Fullerton, USA
Abstract
Abstract Information on how to best
accommodate students with disabilities,
including temporary disabilities, such as
cancer are lacking. In presenting a case study
of a nursing student with cancer, we will
show that the concept of”accommodation”
can be a fluid one which will expand the
discourse on nursing students with cancer.
Accommodating a student with cancer differs
from accommodating a student with other
types of disabilities such as learning or sensory
impairment and requires a team approach to
support. Caring for a student facing a crisis
like a cancer diagnosis requires adherence to
university procedures, coordination with openminded faculty, and support from oncology
nurse experts. This case study presents a
collaboration between the faculty and student
(smith-stoner) who was diagnosed and
treated and who recovered from Hodgkin’s
lymphoma during a baccalaureate program.
The experience of accommodating a student
during a nursing program is presented as a
contribution to the literature on understanding
of the experience of accommodating a nursing
student with cancer.
Keywords: Disability, Nursing, Education,
Cancer.
Information on how to best accommodate
students with disabilities, including temporary
disabilities, such as cancer are lacking. The
literature on nursing students with disabilities
is very limited. Prior literature includes a call to
nursing faculty to reassess their own views of
nursing students with disabilities (Arndt, 2007;
Maheady, 1999; Marks, 2000, 2007; Sowers
& Smith, 2004) and the need to include more
content on disability in the curriculum (Smeltzer,
56
Dolan, Robinson-Smith, & Zimmerman, 2005).
In presenting a case study of a nursing student
with cancer, we will show that the concept of
“accommodation”can be a fluid one which will
expand the discourse on nursing students with
disabilities. Accommodating a student with
cancer differs from accommodating a student
with other types of disabilities such as learning
or sensory impairment. Supporting a student
facing a crisis like a cancer diagnosis requires
coordination with university and nursing
program resources and open-mindedness from
faculty.
This case study presents an essential
component of the discussion of educating
students with disabilities-the student’s voice
(Goode, 2007). It is presented by one of the
nursing faculty who had this student (IO.) in a
research class, the student, and an educational
disability expert. Similar to the transformational
stories of Arndt (2007) and Evans (2005), we
chronicle a year in the life of a student with
a disability. We present a case study of a
student diagnosed with Hodgkin’s lymphoma
during the first year of a rural state-funded
baccalaureate program with approximately
500 nursing students. The experience of
accommodating a student during a nursing
program is presented as a contribution to the
literature on understanding of the experience
of accommodating a nursing student with
cancer. On a larger scale, this experience could
also inform the practices of other faculty in
similar professions that serve the public, such
as teacher and social work education.
K.I. is an incredible person and was able to
remain in our nursing program throughout
the course of her treatment and journey
into lymphoma remission. Other students
may choose another direction once a cancer
diagnosis is made or their physical condition
may not allow for an accommo
dation that
is reasonable enough to permit them to
continue to function in the profession. We
want to encourage other nursing educators
to be flexible in approaching students
with disabilities, to be open to providing
reasonable accommoda
tions as required
by law. Educators should assess each case
individually and ultimately use guidelines
that are not so rigid that they would
exclude someone who could be a great
asset to the field if provided the appropriate
accommodations (McCleary-Jones, 2008).
Reflections on lessons learned and
suggestions for other faculty who have
students with temporary disabilities such as
cancer are provided. Our goal is to address
the challenge that Marks (2007) presents
to society: “...while nature can impair, only
society can disable, and it is society that
must be fixed to ameliorate disability’’ (p. 73).
This case study is an attempt to “ameliorate”
a temporary, significant disability.
months. None of the tests produced any
definitive reason for my fatigue. However,
my situation reached a crisis 11months
later when I woke up one morning with
severe bilateral kidney pain. Despite an
initial diagnosis of a kidney infection by the
physician in the emergency department, my
family doctor ordered a nuclear scan and
found the evidence for what resulted in a
diagnosis Hodgkin’s lymphoma.
Faculty response to diagnostic interval
K.I.’s experience showed that the defining a
disabling condition may not be an overnight
process. Although K.I. remained under a
physician’ s care for 11 months, it was not
clear what was wrong with her until a visit
to the emergency department and followup by her family physician. K.I. selfregulated
her own needs and created her own
accommodations to allow her to continue
in the nursing program. Her first step was
to give up participation on the university
volleyball team. As a talented athlete, this
was one of the first indications that her
condition was serious. During this time,
faculty supported K.I. through continued
encouragement to seek medical care and to
be persistent until the cause of her fatigue
and pain was identified. Absences were
minimal during this time and she was able
to attend most class sessions and complete
work on time.
The period of unknowing to
knowing
K.I.’s story: initial discovery of the swollen
gland to diagnosis, in her own words
After a year of fatigue, headaches, body
aches, and multiple misdiagnoses such as
cat scratch fever and bladder infections, I
was finally diagnosed with Stage 4 Hodgkin’s
lymphoma. It all started when I got into
nursing school and had to stop playing
college volleyball. Like many students, I was
studying hard and not getting very much
sleep. I started to get frequent headaches
and was not able to feel fully rested. One
day, while practicing physical assessment
on each other in our Health Assessment
class, a fellow nursing student and I noticed
a lump on the side of my neck. My instructor
encouraged me to follow up as soon as
possible with my physician, which I did.
My first needle biopsy was negative. I was
tested for several diseases during multiple
trips to several physicians over the next few
Knowing the diagnosis
completion of treatment
to
K.I.’s experience of cancer treatment
After the diagnosis of Stage 4 Hodgkin’s
lymphoma was made, I was started
on chemotherapy treatments with the
possibility of radiation therapy in the future.
The plan was to start out with six cycles of
chemotherapy. During this time, I was not
allowed to attend clinical courses due
to my compromised immune system. After
some discussions with the chair of the
57
department, I was allowed to continue with
my classes that did not involve patient care.
It was a relief to be able to keep in contact
with my classmates who provided a lot of
support. Not being able to stay would have
made it more difficult to cope with cancer
and increase the sense of loss.
Once my hair fell out, everyone knew I
had cancer. Very few people spoke directly
to me about the cancer. I wanted to talk
about it, but I didn’t want anyone else to
feel uncomfortable. I know everyone was
interested in helping me but didn’t know
how.
missed step focused on the lack of formal
documentation of the disability through the
Students With Disabilities Office. Following
established procedures would have
provided guidance on how to accommodate
her specific needs during the course of her
treatment. Many faculty were supporting
K.I. in her journey, but none emphasized the
need for following this procedure. A student
may choose not to ask for accommodations
and cannot be coerced to do so; however, it
is beneficial for both students and faculty if
the services are utilized.
Legal safeguards-disability expert speaks
It is a requirement of most universities
that faculty inform students of their rights
regarding disabilities and to provide
accommodations when requested to do so
(P.M., director, Office of Disabled Student
Services, personal communica
tion, May
20, 2009). Many faculty, however, do not
consider an acquired disability to be of
concern because it is a rare occurrence.
However, based on the experiences in this
case, the authors are recommending that all
students be informed at the beginning of a
term of their rights to obtain these services
if they currently have a disability or acquire a
disability during the course of a term.
Section 504 of the Rehabilitation Act of
1973 (10), amended as the Americans With
Disabilities Act of 2009 (ADA; 42 U.S.C.
§12101), and more recently in 2009, is a federal
law designed to prohibit discrimination
against persons with disabilities in programs
and activities that receive Federal financial
assistance (P.L. 110-325). Specif ically, the law
states that ‘’No otherwise qualified individual
with a disability in the United States...shall,
solely by reason of her or his disability,
be excluded from the participation in, be
denied the benefits of, or be subjected to
discrimination under any program or activity
receiving Federal financial assistance”
including public school districts, institutions
of higher education, and other state and
Faculty response to adaptation during
chemotherapy
As a hospice nurse, I feel more comfortable
taking care of a patient at the end of life
than one undergoing active treatment for
cancer. Working with a student undergoing
chemotherapy was a completely new
experience for me. I had not been told a
student with a disability was coming into my
class (there is no requirement to disclose),
so I was surprised to see a young woman
without any hair walk into undergraduate
research. It is the student’s responsibility
to disclose the presence of a disability and
describe the accommodation needed.
While many disabilities are not obvious, K.l.’s
alopecia made it clear that something was
wrong.
After a short discussion about her illness,
class continued. Her classmates were well
aware of her condition and had followed
the twists and turns of the lengthy period
from diagnosis through the treatment.
Publicly talking about the student with
cancer seemed second nature to the cohort
of students. The ease with which everyone
presented their thoughts and feelings about
having a student in the class with cancer was
a transformational experience for me.
In talking to her about her experiences,
one important issue was missed in the
process of accommodating K.I.’s illness. The
58
and local education agencies (34 C.F.R. Part
104). According to government regulations,
to be covered by Section 504, a person in
higher education must be identified as
having a disability under specific conditions.
The first is “a physical or mental impairment
that substantially limits one or more of the
major life activities of such individual” (45
CFR 84.3(j)(2)(i)). A limitation is considered
substantial when the individual’s important
life activities are restricted as to the conditions,
manner, or duration under which they can be
performed in comparison with most people.
This can include such things as caring for
oneself, performing manual tasks, walking,
seeing, hearing speaking, breathing, and
working. The term impairment may include
any disorder, condition, or disease, including
cancer, that substantially limits life activities.
As chemotherapy proceeded for the student
in this case study, it became apparent
that she was experiencing restricted life
activities and could be considered as having
a disability under Section 504, although her
restricted life activities would most likely not
be permanent.
It should be noted that the term temporary
is not addressed in the law; many cases have
arisen regarding temporary disabilities
and regulations indicate that ‘’The question
of whether a temporary impairment is a
disability must be resolved on a case-bycase basis, taking into consideration both
the duration (or expected duration) of
the impairment and the extent to which
it actually limits a major life activity of the
affected individual” (www.ada.gov/reg2.
html). Although the results of chemotherapy
are not necessarily permanent, according to
government regulations, this student could
be considered as having a disability during
the time she was experiencing limitations.
Fortunately, my body responded well to
the treatments. I went into remission after
only 12 treatments, and didn’t have to have
radiation on my hip because the cancerous
lesion had healed. My battle changed my
life and put everything I knew on hold. I had
to stop working, I wasn’t able to continue
with clinical courses in the hospital, and the
chemotherapy had a profound effect on my
body. Although I went through a tough time,
I had great support all around me. Knowing I
did not have to give up my nursing education
lessened the stress of the cancer.
The things that made a big difference in my
day were simple. I liked it when an instructor
asked me directly how I felt. I appreciated
the personal touch. I never wanted to do
less than my fair share of assignments, but
when instructors could be flexible around
assignment due dates, it was very helpful.
For a few days after chemotherapy, I did
not always feel like I could get assignments
done. Sometimes, I did assignments early;
sometimes, I needed additional time to do
them. I want to thank my nursing instructors
and fellow students for accommodating
me. Their support, along with that of my
family and fiancé, made it possible for me to
graduate in June 2009,which was only two
quarters after my original completion date. I
currently work in an emergency department
but have applied to work at a local cancer
center where I can care for oncology patients
to help them recover from cancer.
Discussion
Students with cancer represent an emerging
group of potential nurses who can be
accommodated in relatively simple ways.
As Arndt (2007) points out, “Fairness is not
achieved by treating everyone the same,
but rather by giving each person what
he or she needs...” (p. 205). InK.I.’s case,
her needs varied from quarter to quarter.
With an open dialogue about the hazards
presented by clinical nursing course work, a
Completion of treatment to
return to full participation
K.I.’s recovery
59
mutually negotiated solution could always
be achieved. The accommodation in the
beginning was more informal, until the
diagnosis was made and chemotherapy
began. Later, the accommodation involved
the chair negotiating with the student
regarding the overall plan of study. Ideally,
the faculty is involved in understanding
what is needed so that everyone can work in
a coordinated way to support the needs of
any student with a temporary or permanent
disability. Arndt goes on to suggest that “...
nurse educators cannot keep students from
completing a nursing program if there are
nurses with that same disability already in
clinical practice “(p.205). Because cancer is
increasingly common in society, it stands
to reason more nursing students will also
have cancer and will need varying levels of
support and accommodation.
Preliminary studies recommend that
a person with disability be incorporated
into the programs of study (Barnard,
Stevens, Siwatu, & Lan, 2008; Carroll, 2004;
Chenoweth, Pryor, & Hall-Pullin, 2004;
Seccombe, 2006; Tervo, Palmer, & Redinius,
2005). Having a student in the program,
someone with whom the students share
many characteristics, is an important
opportunity to reinforce appreciation for
diversity.
Nursing faculty attitudes toward students
with disabilities may be a significant barrier
in accommodating students who are not
able to fully function during their education.
The study of Sowers and Smith (2004) of 88
faculty in eight nursing programs suggests
that in the two decades since the passage of
the Rehabilitation Act and 10 years after the
passage of the ADA, nursing faculty attitudes
toward nursing students with disabilities
continues to serves as a barrier to these
students (p. 218). Maheady’s (1999) study
of 10 students with disabilities describes
the sometimes compli
cated nature of
succeeding in nursing school and being a
person with disability. Among her findings
was the theme of ‘’nursing students with
disabilities have personal experiences that
benefit themselves and patients by turning
the tables” (p. 168), which is consistent with
K.I.’s plan to become an oncology nurse and
use her insight into cancer as part of her
professional role.
If the goal of nursing faculty is to promote
profession
alism among the students,
supporting a student nurse with a disability,
even a temporary one, enables students
to understand issues to be faced in the
workplace. Encouraging student nurses with
disabilities to seek accommodations will
promote self-advocacy and independence.
These characteristics will in turn promote
more positive work experiences and
retention among nurses with disabilities. In
a time in which there is a shortage of nurses,
faculty should consider these factors when
making accommodation decisions for the
students. Faculty can role model professional
values of flexibility and acceptance, which
may not be an initial characteristic of nursing
students (Tervo et al., 2005).
In this case study, we found that there was
a general openness to provide the necessary
accommodations. However, working in a
more coordinated way within the larger
university community could have produced
greater benefits to the student and to the
collective experience of faculty, who may
find a future student in their classroom with
cancer.
Summary
Optimism and patience are required of
all nursing students who are undergoing
normal life changes. Many are moving out of
their parent’s home and taking responsibility
for their own lives and, ultimately, for the
lives of others. When a disability occurs in
addition to the normal development that
students undergo, success in the program
is threatened. K.I.’s case study shares the
experience of one student and one faculty
60
member in a baccalaureate nursing program
who came together in a nursing research
class. The student became the teacher and
the teacher became the student of what it is
like to live in the world of nursing education
with cancer. For K.I., this presentation is
an opportunity to stop and explore the
experiences of the preceding year. For the
instructor, it was an opportunity to describe
new ways of promoting learning and to
expand insight into the fluid process of
accommodating students with disabilities.
Maheady, D. (1999). Jumping through hoops.
walking on egg shells: The experience of nursing
students with disabilities. Journal of Nursing
Education, 38(4), 162-170.
McCleary-Jones, V. (2008). Strategies to facilitate
learning among nursing students with learning
disabilities. Nurse Educator, 33(3), 105-106.
Marlcs, B. (2000). Jumping through hoops and
walking on egg shells or discrimination.
hazing,and abuse of students with disabilities?
Marks, B. (2007). Cultural competence revisited:
Nursing studenUI with disabilities. Journal of
Nursing Education, 46(2), 70-74.
Smeltzer, S.,Dolan, M. A., Robinson-Smith, G., &
Zimmerman, V. (2005). Integration of disability
related content into nursing curricula. Journal of
Nursing Education Perspectives, 26(4), 210-216.
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Chenoweth, L., Pryor, J., & Hall-Pullin, L. (2004).
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plays an important role in shaping students’
attitudes toward disablement and patients with
disabilities. Learning in Health am:/ Social Care, 32,
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Evans, B. (2005). Our students. Annual Review of
Nursing Education, 3, 3-22.
Goode, J. (2007). “Managing” disability: Early
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using appreciative inquiry in the promotion & tenure process

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