Nurse Education in Practice 13 (2013) 361e365

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Seeing is believing e Reducing misconceptions about childrens hospice care through effective teaching with undergraduate nursing students
Jayne Price a, *, Jean Dornan a, Lorraine Quail b
a b

School of Nursing and Midwifery, Queens University Belfast, 97 Lisburn Road, Belfast BT97BL Northern Ireland, United Kingdom Childrens Hospice, Horizon House, 18 ONeill Road, Newtownabbey BT36 6WB, Northern Ireland, United Kingdom

a r t i c l e i n f o
Article history: Accepted 26 September 2012 Keywords: Undergraduate students Educational visits Hospice Childrens nursing

a b s t r a c t
Childrens palliative care has evolved in recent years and is now recognised as a distinct area of health and social care practice. Whilst childrens hospices are viewed as central to quality care for these children and families, lack of knowledge regarding the exact nature of care they provide exists. Education can go part way to changing attitudes and knowledge about the key contribution of hospices, thus improving future care. Alternative and innovative strategies to stimulate meaningful learning are pivotal to childrens nurse education and this paper examines one such innovation adopted with 2nd year childrens nursing students. Aiming to help students explore the ethos of childrens hospice an educational visit was arranged, followed by an on line discussion. Although some practical challenges were encountered, the visit heightened student awareness moving them from the readily held perception that childrens hospices were exclusively for dying children and was viewed by students as more effective than a traditional classroom session. 2012 Elsevier Ltd. All rights reserved.

Introduction Childrens palliative care has evolved as a distinct area of practice internationally, as the number of children requiring such care increases. Education has been placed central to future developments within the eld as evidenced through strategy (Association for Childrens Palliative Care (ACT), 2009) and research (Price et al., 2012). Whilst historically childrens palliative care has its roots in the hospice movement (Price and McFarlane, 2009) and moreover since care from childrens hospices is seen as central to quality care provision within the United Kingdom (Kirk and Pritchard, 2011) misconceptions exist regarding services childrens hospice provide. Professionals and parents often see childrens hospice synonymous with death, providing care exclusively at the end of life (Steele et al., 2008). Research suggests that these attitudes and lack of knowledge can lead to delayed referral to hospice service leaving families struggling without the support they require (Price et al., 2012). Hence the centrality of timely referral is clear as is the importance, of ensuring professionals are aware of the availability of hospice provision for children and families.

Driven by research ndings (Price et al., 2012), this paper highlights an educational initiative which aims to part way ensure that nurses from an early stage in their career have clear knowledge about childrens hospice care. Practice context Northern Ireland Childrens Hospice is one of 43 childrens hospices within the UK, and is a 10 bedded unit providing care to children and families across the province. Ensuring comprehensive care straddling hospice and home, services include provision of short breaks, symptom management, step down care from hospital to home, hospice at home, end-of-life care, bereavement up to two years following their childs death. Hospice offers placements for childrens nursing students with only approximately 4 students per cohort undertake a placement there. Additionally, some get to visit hospice when on community placement. Hospice offer ongoing monthly visits to accommodate professionals interested in learning more about hospice care for children. Diversity of learning e childrens nursing Undergraduate education programmes within the UK aim to prepare nurses who are competent, skilled and t for the work

* Corresponding author. Tel.: 44 (0) 2890975756. E-mail address: j.price@qub.a.uk (J. Price). 1471-5953/$ e see front matter 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2012.09.013

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place. Nursing programmes encompass the notion of the student evolving as a skilled knowledgeable and competent practitioner within the required guiding NMC principles reecting the full spectrum of learning and practice (NMC, 2004, 2010). Nurse educators need to encourage this full spectrum of learning through planned and purposeful educational interventions (Quinn, 2007). Some of the challenges for nurse educators in the 21st century include changing student populations, evolving learning environments, strategies and perceptions about learning particularly in aspects of technology. Developments in science, medical procedures, legal, ethical demands, increasing numbers of children with complex needs, reduced numbers of children being cared for in clinical environments and the shift to community care. There is a need for a exible educational approach which provides meaningful learning opportunities to develop the nurse who is competent, skilled, able to inuence care delivery and development of future services for children and families. The value of educational visits or eld visits as they are often referred to is well-established and recognised as techniques that can provide rich meaningful learning opportunities for nursing students (Quinn, 2007; Ekenbergh, 2011). They enable students to engage in real experience and facilitate opportunities to make connections between classroom teaching and the real life practice environment. Utilisation of the students episodic memory permits creation and development of long term memory through the use of sights, sounds, smells, touch, location and emotions, experiences which develop emotional triggers that enhance the creation, storage and recall of the experiences resulting in a more permanent deeper learning (Shepherd, 2012). Cummings et al. (2010) further endorse the value of eld visits to childrens nursing students regarding learning in the community. This nding supported the case for using an educational visit as a learning strategy regarding the care and services provided by a childrens hospice. Whilst the importance of palliative care education in undergraduate programmes has been highlighted (Lloyd-Williams and Field, 2002; Adriaasen and van Achterberg Adriaansen, 2008), to our knowledge this is the rst time that the value of educational visits have been formally examined in terms of undergraduate student learning and awareness of childrens hospice role in caring for children with complex needs and their families. Given that the United Kingdom is recognised as pioneers in childrens hospice care worldwide, this educational activity may have international relevance. Educational initiative e hospice visit The visit was introduced for 2nd year childrens nursing students undertaking a module which examined the care of children and families with complex needs. Module content includes all aspects of death, dying and bereavement and hence can be emotionally challenging for students. The module team include experienced childrens nurses within this eld and thus are able to offer appropriate advice and support. Sixty two students were registered on the module. The visit was organised to take place during scheduled reading time and attendance was optional. The optional nature of the activity enabled those students who may have found the visit particularly difcult to choose not to attend. For example one student who recently suffered a family bereavement opted out, appreciating the exibility. An overview of the proposed format of the visit was given to the students, they were divided into groups of no more than 8 and various dates were offered. There was the opportunity to ask questions and to express any specic concerns to the module co-ordinator beforehand. Hospice aware of the vulnerability of the children in their care, seeks at all times to both protect and maintain their privacy. Visits as per hospice policy are facilitated at appropriate times by a senior

member of staff. The staff check with the Care Team Manager where it is appropriate to go on the day of the tour depending on which children are in house and their individual well being at that time. The rationale for choosing groups of 8 students was twofold; rstly the small group sizes made it possible for the facilitator (an experienced childrens hospice nurse and educator) to monitor if any of the students were negatively affected emotionally by the visit, second, smaller groups ensured a more respectful/ethical approach to the children and their families who were in hospice during the visit. Students had the opportunity to be introduced to children, parents and staff in house (as deemed appropriate in advance with the Care Team Manager). Towards the end of the visit time for questions, discussion and debrieng with the students was available (See Table 1). Following the visit students were offered the opportunity to reect on their learning. Previously nurses at times have used reection to look back on incidents that have happened or their own deciencies (Gustafsson et al., 2007) but here the aim was to utilise reection to move forward. Since on line discussions have been identied as powerful learning strategies enabling reection and knowledge development in a controlled environment, this was chosen as a means of assisting students to further develop their learning with and from each other. Students who had not visited during the module were also encouraged to participate permitting them the opportunity to consider the role of the hospice in caring for children and families. The discussion forum focussed on one topic: e Childrens hospices provide a range of services for children with life limiting conditions and their families discuss and students led the discussion and took it in different directions. The forum was regularly moderated by the module co-ordinator who challenged students to unravel points raised and encouraged them to integrate literature to substantiate points made. Evaluation Evaluating the effectiveness of new teaching strategies is an integral part of quality teaching within higher education. Students were requested to complete an evaluation whether or not they had visited the hospice to establish the value students placed on the on line discussion and hospice visit as a means of stimulating their learning and generating knowledge. A series of questions were posed which involved rstly establishing whether or not the student visited the hospice and whether or not they had taken part in the on line discussion. Reasons for non-participation were also examined and further students were asked if they found the activities benecial and encouraged to elaborate on their experience. Student participants Twenty two of the 62 students visited the hospice and 38 participated in the on line discussion. Thirty eight completed the
Table 1 Questions asked by students.            How are children referred? What types of conditions do the children have? What ages are the children you look after? What is the staff ratio to child? Describe a typical day in hospice. Who is allowed to come and visit the children in hospice? Who are the MDT? What happens when a child dies? Do the children know they are dying? Do they question the staff? Bereavement care and support, what does this mean? How long is it for? Nurse led unit, what does this mean?

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evaluation. Students were not identiable in the submitted questionnaires. The relevant School Research Ethics Committee was contacted however as this was viewed as an evaluation of a new teaching method and not a research study, full ethics clearance was deemed as not required. Issues regarding how hospice dealt with the vulnerability and the potential emotional impact of this visit and the module as a whole were important considerations (Page 6 and 7). When invited to complete the evaluation students were made aware that the information would be used for planning future and possible publication. Numbers of students who completed the evaluation are displayed in Table 2. Students perspectives on hospice visit All students who replied and visited the hospice during the module felt that the visit was benecial in terms of their learning. The 10 students who had previously undertaken a visit endorsed the value of such a visit. Discussion from the on line forum indicated development also. Students evaluations indicated that development of knowledge and change of attitude from the real experience afforded to them by the hospice visit had occurred, consistent with the work of Chang (2002) which highlighted how opinions of rst year and third year students had changed once they had been exposed to the reality of life, acquired some knowledge and studied with a diversity of people. Themes arising from all data collected fell into two distinct areas, those being Challenge to attitudes and increased knowledge resulting from visit and Impact on future practice. Excerpts will be used from students comments in the questionnaire to substantiate the discussion. What became apparent from the evaluations (and through views voiced in the discussion forum) was that prior to the visit students had held the common belief that hospice provided exclusively end of life care, was a dark place where children with cancer died and where families care for their child to the point of death. I associated hospice with death Whilst students seemed clear that hospice offered end-of-life care the visit enabled students to extend their knowledge regarding the range of services and care offered, these included respite services, bereavement care, sibling care, symptom management. First hand insight into the service a hospice provides for life limited children I had not realised hospice offered bereavement care for families up to 2 years after their childs death Further students became aware of the wide range of conditions which necessitate hospice care for children, and not what many see as traditionally a place for cancer patients to die. Overall, there was the sense that students attitudes and previously held assumptions were challenged in a positive way. I have a wider idea of what a hospice does Changed my views of the hospice Made me aware the range of conditions they care for
Table 2 Numbers of student participation. Activity Hospice visit during module Hospice visit previously Evaluation Online discussion forum Number of student participants 22 10 38 38 Percentage of full cohort (n 62) 35.5% 16% 61% 61%

Indeed students expressed their surprise at the size of the facility and the welcoming, homely environment. Additionally they reported how that through meeting families they felt enabled to gain a deeper appreciation of the impact of life limited illness on the child and family and were more acutely aware of the pressures families lived through and how the hospice could offer support. The staff were very friendly and welcoming and the atmosphere within the hospice was warm relaxed and caring It helped me to further understand what the hospice does it brought home to me how essential it was to the parents and children to be able to avail of these services Knowledge generation occurred through the visit in a number of notable ways. Firstly, it linked theory to practice and secondly it brought their learning to life in a memorable and meaningful way. The visit to the hospice went hand and hand with the module content as it enabled me to link theory and practice and further understand the role of the hospice and the children and families which it provides for Gives learning more meaning Good to see what you are learning about Whilst this learning activity increased students knowledge and challenging students assumptions, the positive impact on their future practice was also highlighted. Students appeared through viewing hospice for themselves, able to recognise how such insights would enhance the care they could provide to children and families in the future. Students felt empowered with knowledge and information which they could readily share with families It provides students an insight into seeing what the hospice is really for and to let us see it is not just a place to die in. This will enable us to paint a better picture of the hospice and be able to better inform prospective parents of the benet the hospice does offer If a parent now was to ask me about a hospice...I can tell them what services it provides Overall students felt the visit was a powerful tool which evoked a deep and meaningful learning experience. Students perspectives on associated on line discussion Of the 38 students that completed the evaluation 27 participated in the on line discussion forum. 11 students who took part in the discussion forum did therefore not complete the evaluation. Students posted comments about what they learnt about hospice services and brought in literature to back up their thinking and the forum was facilitated by the module co-ordinator. The School has specic etiquette for on line discussions relating to condentiality and respect. Students adhered to these guidelines. The reasons for noting the value of the discussion forum mainly centred round the opportunity the forum afforded to hear the perspectives of others in the class. Other reasons included the fact that you had to focus on what you saw and what you learnt, bringing thoughts, feelings and learning together. Further students who may not have contributed had the discussion been in a traditional classroom, felt empowered to make a contribution in the virtual learning environment. Good to see everyones point of view re the visit Helped bring thoughts together about the hospice Allowed my thinking to be more in depth

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It focused me to think about what I saw and the role hospice plays for families Students who did not value the opportunity to discuss role of the hospice on line expressed their belief that it was repetitive, as many people said the same thing and the discussion did not go anywhere. Reasons given for non-participation in the on line discussion included no time, simply forgot or had not realised they could partake (despite clear information to state otherwise) if they had not visited the hospice they were allowed to take part in discussion. Discussion Quality nursing care for children and young people is inextricably linked to quality nurse education. Given the diversity of learning required, multi modal teaching should be incorporated to ensure integration of the full range of technical, cognitive and interpersonal skills necessary for a childrens nurse (Corkin and Clarke, 2007). As such an educational visit and subsequent reection proved a potent means to achieve cognitive learning and change attitudes regarding the care and services provided by a childrens hospice whilst permitting time for reection on learning (Cummings et al., 2010). Introducing the Hospice visit required much time, commitment and organisation by both the hospice personnel and university module co-ordinator. Many challenges were experienced when implementing this learning activity including ensuring the groups were of manageable size to cause least disruption to the running of the hospice. Other challenges included students with transport problems and personal issues which made attendance difcult. Further the hospice being closed since a child with rota virus was transferred in on the day before the rst visit, necessitated postponement and rescheduling. Such challenges highlighted the need for early organization within the 6 weeks of the module, thus if a visit is delayed due to for example rotavirus then rescheduling is more readily achievable. Further a good collaborative relationship between the hospice and educational providers was a particular strength of this initiative ensuring careful planning and support was available. Overall despite organisational challenges, the main aim of the initiative was achieved as student evaluations indicated how the visit and the subsequent discussion, helped them learn in a meaningful way. Seeing the hospice rst hand was viewed by students as more effective in helping them learn, than if they had been taught about hospice as part of a university based classroom session. In crossing the theory practice gap, Allan (2011) expresses the importance of being exible as teachers to look at the theory, the research and draw on personal experiences past and present, thus the exibility of the visit enabled the meshing of all these goals. Students prior to the visit despite their previous learning held the common belief that childrens hospices exclusively provided end of life care and further that this care was primarily for children with cancer. In reality few children with cancer actually use hospice care (Vickers et al., 2007) and students were enabled to gain understanding regarding which children require such care. Many misconceptions concerning childrens hospices continue to prevail among public and professionals alike, it is imperative to seek new ways of increasing awareness (Malcolm et al., 2008). One such new way introduced for nursing students which clearly increased awareness and promoted a greater understanding by allowing the students was to view hospice for themselves and then following this up with on line discussion. The impact of this innovation is also highlighted in the fact that students indicated how their learning would have a positive impact on their practice as they could talk more knowledgably to parents regarding the services provided by a childrens hospice.

Whilst some negative comments were expressed regarding the on line discussion as a learning strategy, overall students felt it positive as permitting them the opportunity to reect and think more deep sharing of experiences allows students to critically think and undertake structured reection on how the events may inuence their personal circumstances. This facilitative approach to teaching teases out previous learning and helps students make sense of experiences in relation to real world events (Gregory, 2002). Future developments with a similar on line discussion forum will centre round possibly broadening the topic to let students have more to debate amongst each other, more frequent moderation may reduce perceived repetition by advancing the students discussion with pointers and suggestions. In addition, placing the discussion forum at an earlier stage of the module, where students may be less prone to feel it interferes with their assignment preparation may encourage participation. Conclusion Given the diversity of learning required by childrens nursing students to enable them to practice as safe competent practitioners (Nursing and Midwifery Council, 2004; 2010), multi modal teaching strategies need to be incorporated to ensure integration of the full range of technical, cognitive and interpersonal skills necessary for a childrens nurse. Teachers need to be innovative in their teaching, learning and assessment strategies. Reective practice in learning and teaching is encouraged to enhance the quality of the learning experiences for the student (Leckey and Neill, 2001). Educators are therefore charged with the responsibility to continuously search for innovative and creative ways to stimulate students helping them to reach their full learning potential not just for the duration of the course but for life. The learning activity which has been the focus of this paper meets those goals proving its worth in stimulating learning in a way that is meaningful and can impact practice and care for children and families now and in the future. References
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