Empowering Students
1. Setting the scene
Nursing students learn from both the sciences and the arts. Spiritual care, an example of teaching and learning about the art of nursing, has been and remains a key area of health and nursing practice (NMC, 2010). Spiritual care is identified as intrinsic to nursing
programmes and considered part of the work of health care staff (NES, 2009; NMC, 2010).
In this paper we discuss the teaching and learning experiences of students undertaking an established module in spiritual health. Students take this module in their final year of a pre- registration nursing programme and the module is an elective. During this academic session 2012 - 13, the 10th year that the module has run, there were 60 students taking the module.
As the art of care is intrinsic to the module, the teaching methods are drawn from literature, symbols, story-telling, film and museum or gallery visits which are well known approaches to learning and researching about spiritual and emotional health (Kellehear et al, 2009;
Sandelowski and Carson Jones, 1996; Seymour 2009).
Existential loneliness afflicts people in troubled times. These include relationship troubles and breakdown, work problems, illness, dying and death. Such problems prompt a
consideration of existential questions and bring to the fore the spiritual issues normally deeply buried by every day material living.
When confronted with these difficulties there is a desire to find peace within ourselves, balance, resolve and acceptance. However developing these personal qualities requires attention, awareness and skill and includes taking responsibility for ourselves and
eradicating blame. The emotional labour of reconciliation is considerable but enables people to come to a place of resolve and acceptance, to move forward at times when their inner selves are most troubled (Robinson et al 2003).
1.1 The purpose of this paper
In purpose of this paper is to suggest innovative teaching and learning methods which use story-telling and reflection to expand health care students' personal and professional understandings of spiritual and emotional care. We will discuss how students are encouraged to hear the stories of patients/clients, reflect on their own personal and professional stories and find meaning in themselves and the lives of their patients. Our teaching strategies have been developed over many years within the context of the module under discussion and a module entitled, 'Understanding caring through the arts and
humanities'. In addition we will discuss the findings of an evaluation study undertaken by this year's student cohort as they wrestled with the concept of reconciliation, a key topic within the module.
1.2 Background considerations relating to spirituality and reconciliation
There are pressing incentives to find ways of teaching spirituality and reconciliation to students of nursing/health and those incentives relate to the less attractive aspects of the human condition. Reports such as those investigating the failings of the Mid Staffordshire NHS Foundation Trust (Francis 2013) indicate that society needs to find ways of dealing with the painful consequences that arise due to violating the intrinsic dignity of human life. Such human failings raise serious questions about why we fail and point to the need to find ways of defusing conflict which arises when different beliefs, values and perhaps cultures,
supersede the intrinsic worth of being human. In putting spirituality on the curriculum agenda it is hoped to raise consciousness of the various manifestations of the human spirit in the belief that if it is an aspect of humanity that applies to anyone of us, it applies to us all.
It is possible to consider the noumenal, the kind of knowing which cannot be gained through the senses - such as that of spiritual knowing - in a similar vein to aesthetic knowing,
perhaps even as one and the same thing. For example, in an effort to emphasise spirituality as central to holism, McSherry and Draper (1998: 688) describe it as 'a unifying force at the foundation of holistic philosophy'.
It is difficult to investigate a concept like spirituality as it has many different meanings and the significance of any one interpretation of the concept can vary according to individual beliefs, values and circumstance but it invariably has something to do with personal truth - as Cicero states, 'For that man whom your outward form reveals is not yourself; the spirit is the true self' (De re publica bk. 6, ch 26). However we teach this module believing that students cannot understand the world they live in, with its joys, conflicts and suffering
unless, to borrow a phrase from Glen (1995), they have enough critical spirit, the force which motivates people to be willing and sufficiently discerning to arrive at well-thought-through, albeit tentative, views of their own. So, difficult though the area of study may be, it is
essential to examine the personal thoughts and values which direct educated nurses as they endeavour to provide spirited, critical and compassionate care to patients irrespective of race, lifestyle, culture and religious or political beliefs (NMC, 2010).
By its very nature education in relation to spirituality in nursing has to be evocative of the personal beliefs, values and experiences of the student; it includes the kind of knowledge
Carper (1978) described as 'personal'. Thus, the teaching methods in most of the classes enable a time for discussion so that students can talk about their own experiences of spirituality both in relation to themselves and patients. The emphasis on centring learning round the thinking and experiences of students leads naturally to the course culminating in a reflective assessment, a method chosen because it offers students the opportunity to
examine a prior spiritual experience thereby uncovering insights that can inform future spiritual care practice. In a sense, reflective inquiry helps students assert a degree of control over their own theorising or metacognition (Eraut, 1994) thereby developing their cognitive and affective skills in a way that opens up new perspectives. By applying the skills of self- awareness, description, critical analysis, synthesis and evaluation (Atkins and Murphy, 1993) students can tease out their learning from practice - in Schon's (1987) sense of reflection-on-practice.
Another reason for the reflective assignment is to capture students' thinking about what they perceive to be a spiritual experience rather than colouring their thinking by providing a more fixed directed assessment framework. Bearing in mind our increasingly secular culture it is important to give credence to the breadth and depth of experiences that students report as spiritual, whether those transpire to be grounded in a belief system or not.
This assessment approach was chosen to try to uncover what individual students believe constitutes a spiritual experience and is an attempt on our part as lecturers to avoid prescribing what students ought to believe thereby conforming to our notions of a spiritual experience. Reflecting on that experience was based on the premise that in so doing, students would gain deeper understanding of the meaning of the experience and be able to connect their experiences to practice (Glen, 1995). Thus, reflection facilitates the
development of professional expertise by bringing to consciousness tacit knowledge inherent in practice (Schon, 1987).
Spiritual knowing also embraces the kind of knowledge that Carper (1978) described as 'aesthetic'. Aesthetic knowledge requires perception and empathy to form creatively elements of a situation into a cohesive whole. There is a sense of occasion, a coming together, even enlightenment in aesthetic knowledge as well as a sense in which this 'all at once' interpretation of the situation results in transformation (Carper, 1978, 1992; Smith 1992).
1.3 Students' accounts of their spiritual experiences: an example
The following story illustrates one student's (Mary's) experience of the transformative power of a spiritual experience:
Mary: The spiritual experience I have chosen to reflect on is a personal one that happened to me nearly seven years ago, its not a particularly pleasant one, but it is the strongest one that I've had, and it changed my life.
I was married with a four year old and a six-month-old baby and my husband was becoming increasingly violent. On the night that the incident happened we had been at a function and had had a pleasant evening but when we got back to the house the atmosphere changed.
My husband started an argument and it escalated, to him putting his hands around my neck and strangling me.
Well at first I struggled and fought back but it was pointless as he was stronger. As I couldn't breathe I was terrified, panic-stricken, fighting. Then suddenly those feelings just vanished.
Disappeared. I still couldn't breathe but there was no panic and I thought I'm going to die but I wasn't scared anymore and I felt strangely uplifted. It wasn't a superficial thought that I was going to die it was a fact. No bright light at the end of a tunnel, just a warm peaceful feeling that everything was ok.
I must have passed out; when I came to I was alone except for my four-year-old standing in the doorway, silent. I do not know how long he was there, or why he woke up he never
usually did overnight. Did he disturb his father? What woke him? These are my unanswered questions. I believe that something woke my son, and he disturbed his father saving me.
Why else that overwhelming feeling of peace?
Although I had a Christian upbringing and did the usual Sunday school things went to church etc. I didn't have any serious beliefs in religion. In fact I had rebelled against it became a bit cynical about the whole religion thing. But since this experience I feel that there is a force, a God whatever, and it controls when it is our time to live and die.
However unpleasant the incident leading up to my 'spiritual experience' was, it has been a positive experience. I felt that I had been given a second chance for a reason and it was time to make changes. So over the next few months/years I divorced my husband, made a new home and settled environment for my kids, went back to education & married a new man, basically completely changed my life for the better.…
I wouldn't wish my experience on anyone else, and I certainly don't want to experience anything like it again. But it did change my life for the better, or was that me? One thing I know is that when my time to die does come it's not something to be frightened of.
I am more aware of other people's spiritual needs now, how many other people have had similar experiences and I do try to be aware of that in my practice.
Characteristics of this spiritual experience include suffering, transcendence, feelings of peace and of finding that life has meaning ('I felt that I had been given a second chance for a reason'). The resultant transformation was characterized by actions that required courage, an ability to learn through suffering, a balanced perspective on life, a desire to seize the moment and pursue desires, sensitivity towards others, and reconciling the past.
This reflective account is a good example of the 'transformative' nature of spirituality. It demonstrates how a spiritual interpretation of events can bring about a radical change in a person's life-style, beliefs, values and attitudes. Moreover spiritually significant events can have an impact across contexts. As the above story illustrates, there were positive outcomes in the student's professional work as well as the more obvious transformation of her personal life. To use popular educational language, spiritual learning may be transferable from one situation to another. Also it indicates that personal spirituality, although a unique and private experience, affects other people in that it can change family life and professional practice.
1.4 Key considerations when teaching reconciliation.
When we teach reconciliation we clarify that we are addressing personal reconciliation and not political/mass/post-war reconciliation. The teaching focus is the importance of
reconciliation in the end-times of a person's life which Robinson et al (2003) suggest is an important part of end of life care for many.
As students are concerned with providing care for other people, as a first step, it is important that they learn to experience reconciliation in their own lives. Therefore self awareness is key to the process of reconciliation and students are encouraged to develop a sense of understanding and meaning of life, a sense of fulfilment and wellbeing.
Students can relate to and engage with scenarios such as broken relationships causing unease and needing resolution and the therapeutic nature of reconciliation in terminal care (Cellarius 2008). Skills to promote and understanding and reconciling state of health, illness and lifespan need careful development.
What proves difficult is developing the skills of finding and helping patients find reconciliation of matters which do not have 'fairytale endings' or unrealistic wishes.
The teaching of the skills to be able to work with patients in reconciliation promotes dignity in death, closure and improves quality of life (Mok et al 2010; Johnston et al 2012).
We presently only teach this to senior student nurses but their engagement with this work and their feedback has led us to believe that this could be taught more widely and be valuable to many students not just students of healthcare.
1.5 Evaluating student's learning of reconciliation- Academic year 2012-13
From the 52 students on the module, 64% completed the evaluation questionnaire.
Overall there were no negative comments and students were highly positive of their experience of the module and its value.
Quotes from feedback
'It's about finding individuals' own answers to their own questions with guidance'
'It has helped me make sense of a long term disagreement with s family member that I have not seen for a long time'
'I can distinguish between reconciliation and forgiveness'
'Will be able to approach the matter with knowledge and confidence'
'allow understanding of patient behaviour in their past experiences they have encountered in their life.'
'Has opened my mind on various elements of spirituality and how to effectively utilise them in my practice and personal life.'
'This module has been great, uplifting and refreshing.'
We were interested in how the students thought the session would be valuable and how much they felt it would be of personal and professional value so we asked the students two different questions that were really asking the same thing to see if their answers were consistent.
We asked them 1. To rate the value on a 1-10 scale of the value in both their personal and professional lives. 2. To rate on a 1-10 scale the value in palliative care, nursing, with family and friends and for themselves.
Both these question yielded the same results as can be seen in these pie charts.
References:
Atkins, S. and Murphy, K. (1993). Reflection: A review of the literature. Journal of Advanced Nursing, 18, 1188-1192.110-116.
Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 13-23.
Cellarius V, 2008. Considering the Ethics of Hope. Journal of Palliative Care 24:2 Eraut, M. (1994). Developing professional knowledge and competence. London: Falmer Press.
Eraut, M. (1994). Developing professional knowledge and competence. London: Falmer Press.
Francis, R. (Chair) (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. 6 Feb 2013 HC 947 London: HMSO
Glen, S. (1995). Developing critical thinking in higher education. Nurse Education Today, 15(3), 170-176.
Johnston J, Hillier L M, Purdom M, Pears D, & Robinson M, 2012. Opportunities for
Improving the Quality of Life of Dying Persons: Use of technology to connect people at the end of life. Journal of Palliative Care 28:3 178-180.
Kellehear, A., Pugh, E. & Atter, L. (2009) Home away from home? A case study of bedside objects in a hospice. International Journal of Palliative Nursing. 15 (3), pp. 148-152.
McSherry, W., & Draper, P. (1998). The debates emerging from the literature surrounding the concept of spirituality as applied to nursing. Journal of Advanced Nursing, 27(4), 683- 691.
Mok E, Kau K, Lam W, Chan Ng J F C & Chan K, 2010. Healthcare professionals'
perceptions of existential distress in patients with advanced cancer. Journal of Advanced Nursing 66:7 1510-1522.
NES (2009) Spiritual Care Matters. NHS Education for Scotland.
NMC (2010) Standards for pre-registration nursing education. Nursing and Midwifery Council Robinson S, Kendrick K & Brown A, 2003. Spirituality and the Practice of Healthcare.
Basingstoke, Palgrave Macmillan.
Sandelowski M. & Corson Jones L. (1996) 'Healing fictions': stories of choosing in the aftermath of the detection of fetal anomalies Soc. Sci. Med. 42, (3), pp. 353-361 Schon, D. A. (1987). Educating the reflective practitioner: Towards a new design for teaching and learning in the professions. San Francisco, CA: Jossey-Bass.
Seymour, B. (2009) What do nursing students understand by spirituality and spiritual care?
Scottish Journal of Healthcare Chaplaincy, 12 (2), pp38-46
Smith, M. (1992). Is all knowing personal knowing? Nursing Science Quarterly, 5(1), 2-3.
Empowering students to articulate into second year of a nursing degree programme
Joan Irwin & Louise Johnston University of the West of Scotland Abstract
As an institution the University of the West of Scotland (UWS), School of Health, Nursing &
Midwifery has endeavoured to enhance the articulation of nursing students from Further Education (FE to Higher Education (HE) with involvement & support of local Health Boards.
This area of work also recognises that the Nursing & Midwifery Council (2010) require HE Establishments to recognise students prior learning to facilitate career pathways. Students articulating into second year need to feel empowered to succeed. Long standing partnership working with local colleges and the work of the South West Articulation Hub saw the
development of a module to facilitate some students joining the degree programmes in second year. The module provided by UWS over the summer time enables those selected from their HNC year to commence early engagement with UWS. The empowerment process then begins socially and academically to facilitate the transition from FE student to HE students equipped with the skills and practice hours to succeed in second year.
This presentation will discuss the module and its role in empowering the students and highlight the evaluations of the first group of students through the module. The findings will suggest the empowerment process is vital to student's engagement and success.
Introduction
Following the Project 2000 proposals (UKCC 1986) nurse education changed fundamentally and moved into Higher Education Institutions (HEI's) from traditional schools of nursing. The Nursing and Midwifery Council (NMC 2004) stipulate the standards of proficiency for pre- registration nurse education. These standards also incorporate a requirement for HEI's to acknowledge students prior learning and this has contributed to a widening of access to pre- registration nursing courses. This widening access has allowed students to enter in greater numbers and has increased the diversity of the student nurse population (McCarey et al.
2007).
Over the last number of years the widening of access to Further and Higher Education in Scotland has also been encouraged by various policy initiatives (Scottish Executive 1999, Scottish Executive 2003). The Scottish Credit and Qualifications Framework (SCQF), established in 2001 amalgamated the main qualification frameworks creating a single structure with an aim to ''assist people of all ages and circumstances to access appropriate education and training over their lifetime to fulfil their personal, social and economic
potential'' (SCQF 2001, p.1) further supporting lifelong learning in Scotland.
The development of articulation routes into Higher Education Institutions has become key to facilitate the creation of additional pathways into university. (Scottish Funding Council 2011).
Articulation is the process whereby a previous qualification allows a student to enter directly into second or third year of a university degree programme. Gallacher (2006) suggests that these articulation pathways require close partnership working between Further and Higher Education Institutions to adequately prepare students for advanced entry into university. This facilitation of career pathways endorses the Scottish Government's undertaking to promote the creation of adaptable articulation routes (Scottish Government 2011).
This paper explores the long standing partnership working with local colleges, Health Boards and the South West Articulation Hub in the development of a model to facilitate the
articulation of a number of students into second year of the University of the West of Scotland (UWS) undergraduate nursing degree programme.
Articulation
As an institution UWS School of Health, Nursing & Midwifery (HNM) has endeavoured to enhance the articulation of nursing students from FE to HE with involvement of local Health