Although nursing education aims to equip nursing students to provide care to dying patients and their families, nurses often feel ill-prepared to cope with the emotional labour involved in end-of-life care.
The aim of the study was to explore and describe nursing students’ experiences of end-of-life care through experiential learning within a constructivist educational model.
A qualitative, descriptive design was used. As part of introducing experiential learning, innovative educational practices were initiated during a second year level undergraduate nursing module on end-of-life care. Qualitative data on second-year nursing students’ experiences were collected through written reflections and analysed using open coding.
The themes that emerged revealed participants’ sensory and emotional experiences during the learning opportunities. Participants reflected on what they learnt and clarified their values related to death and dying. They indicated how they would apply the new meanings constructed in clinical practice.
A constructivist educational model of experiential learning holds potential to enhance value clarification and nursing students’ sensory and emotional awareness of death and dying. Experiential learning is recommended to develop nursing students’ competency in providing end-of-life care.
Learning how to face death and dying is inevitable for nurses who are often the caregivers at the end-of-life (Todaro-Franceschi & Lobelo
To facilitate learning of end-of-life-care is also a challenging task for nurse educators (Dobbins
There is a clear call for a paradigm shift in nursing education. Instead of lecture-based teaching where students are passive recipients, models and methods enhancing active student participation are proposed (Brandon & All
Nursing care requires nurses to be emotionally competent and able to deal with others’ emotions, whilst regulating their own (Vilelas & Diogo
In a study by Todaro-Franceschi (
A literature review by Gillan
Many examples of experiential opportunities to facilitate learning for end-of-life care are available in scholarly literature. Dobbins (
Experiential learning is described as a philosophy and a teaching method that focuses on the relationship between students, their concrete experiences and their reflective processes about the experience (Fenwick To learn is not the special province of a single specialized realm of human functioning such as cognition or perception. It involves the integrated functioning of the total organism-thinking, feeling, perceiving and behaving. (p. 31)
Experiential learning stems from Schön’s ‘epistemology of practice’ (1983:49, 66–68), Mezirow’s transformative learning theory (Mezirow
The constructivist view underpins experiential learning (Fenwick
End-of-life care is considered to be a complex area of practice in intensive care units, and nurses expressed the need for emotional support (Ranse, Yates & Coyer
Teaching and learning that focus on knowledge and skills development only is not considered the most effective way to equip nursing students to cope with the emotional and existential challenges of end-of-life care (Chan & Tin
Gillan
The aim of the study was to explore and describe nursing students’ experiences regarding end-of-life care through experiential learning within a constructivist model.
The study findings may contribute to nursing education, practice and research. The article illustrates the use of a constructivist model of experiential learning (Kolb
A qualitative design (Polit & Beck
A psychiatric nursing module for second-year students, dealing with end-of-life care, was used to integrate innovative educational practices such as co-operative learning and reflective processes. Opportunities were created to engage students in experiential learning. Students were divided into co-operative learning groups. Each group was assigned the learning task of presenting their experiences on a theme related to death and dying based on an applicable film, an article, a story, a poem or a case study of their choice. Students used a variety of methods (demonstrations, acts, posters, video clips and mind maps) to present the themes during four learning opportunities as scheduled on the timetable. Each presentation was followed by an open class discussion where applicable theoretical models and practical interventions were introduced, for example, ‘breaking the bad news’.
Sixty four students registered for the second year of a four-year undergraduate nursing science programme in a higher education institution constituted the population for the study. All the students participated in the experiential learning opportunities and were invited to write reflective narratives on the experience of learning of end-of-life care. Sixty two students voluntarily handed in written reflections.
Qualitative data were collected through the use of students’ written reflections which served as a narrative account of their experiences (Mendieta
Look back on the situation.
Examine the detail: What happened? How were you involved? How did you feel? What were you thinking? Who else was involved? What did others say?
Analyse: What influenced the experience? What role did the values of different people play? What have you learned? Will it influence your practice?
Revise: What would you do differently next time? Are there any learning issues? How can you use what has been learned? What needs to change?
New perspective: Recommendations for learning in similar future situations.
Qualitative data analysis of written reflections was done according to the steps as described by Tesch (cited in Creswell
The research setting constitutes a four-year undergraduate nursing science programme in a higher education institution in Gauteng Province, South Africa.
This programme includes a module on end-of-life care in the second year.
The themes ‘I saw’, ‘I heard’ and ‘I did’ that emerged from participants’ reflective narratives illustrate their sensory experiences during the learning opportunities. The feelings participants experienced during the presentations are reflected in the theme, ‘I felt’. The theme ‘I learnt’ indicate what and how participants learnt. The theme ‘I clarified my values’ reveals participants’ reflections on their values related to death and dying. Participants applied what they have learnt to practice: what ‘I will do’ differently next time when encountering death and dying in clinical practice. The results are discussed according to these themes, supported by excerpts from different students’ verbatim narratives.
Different participants specifically mentioned that the visual material enhanced their learning as in the following examples: ‘We looked at various videos and we watched various physical performances by our classmates. In these, various principles of how to deal with grief and how grief present itself, was presented.’ (Participant 15, male) ‘The experience was influenced by the use of video clips, visual learning made it easy for me to relate the topic with the actual reality.’ (Participant 22, female) ‘I found the videos are an effective way of showing us how children grieve in a visual way – a way that can easily be remembered.’ (Participant 30, female) ‘Different groups drew pictures and made posters to help us visualise the process.’ (Participant 46, female)
Participants who observed other students demonstrating some of the skills indicated that it also enhanced learning: ‘I think the acting out part was also helpful because most of the time what you have seen is not easily forgotten.’ (Participant 12, female) ‘Making the students demonstrate the management allows other learners to learn in a more realistic way.’ (Participant 35, male)
Participants observed each other’s emotional expressions during the learning opportunities and sensed the emotional atmosphere elicited by the presentations: ‘… expression of sadness could be seen through their faces, especially the group members.’ (Participant 5, male) ‘Students that were sitting next to me were smiling because of the wonderful lessons that we got.’ (Participant 32, female) ‘The rest of the class also became quiet and depressed.’ (Participant 43, female)
Some participants (fewer than in the ’I saw’ group) mentioned that hearing – hearing music, poetry and others’ experiences – enhanced their learning experience: ‘The issue of calm music is also recommended to facilitate the audience’s emotions.’ (Participant 12, female) ‘I appreciated the music to explain the class content. I feel music is a great indirect way of explaining a subject.’ (Participant 24, female) ‘In poems and scenarios read we witnessed different maladaptive behaviours that people manifest.’ (Participant 41, female) ‘I was listening.’ (Participant 52, female) ‘Others express a feeling of sadness, by shouting out or verbalising words like hah.’ (Participant 60, female)
Participants commented on and appreciated their own and others’ participation and involvement in the co-operative learning opportunities: ‘We spoke about principles in management of grief … about different ways in which children may respond … different cultural needs … I was involved in the presentation.’ (Participant 8, female) ‘I was involved by giving the feedback on each topic discussed; this made me feel more involved.’ (Participant 13, female) ‘Class interaction is very crucial.’ (Participant 28, female) ‘I read out the case study and applied the learning content … I felt good because I at least contributed something in the class.’ (Participant 36, female) ‘My other group members were involved.’ (Participant 42, female) ‘Others said they have also been in similar situations.’ (Participant 55, female) ‘We got to participate, do some presentations and acting. This helped me to concentrate throughout the lecture and to be willing to know more.’ (Participant 58, female) ‘At first I was shy until I got involved and gain my confidence.’ (Participant 60, female)
Most participants mentioned their emotional experiences during the learning opportunity as significant. The learning material triggered intrapersonal experiences of loss and bereavement: ‘During the presentations I felt very interested in what was said, but some of the clips got me emotional. Because grief is a difficult subject to understand as people experience it so differently, I felt a level of sadness.’ (Participant 4, female) ‘… they really dragged my emotions into reality.’ (Participant 13, female) ‘Well during the presentation I got emotional … I have been faced with the loss of two grandparents … so I could relate somehow.’ (Participant 22, female) ‘A young girl lost her close friend in a movie, it made me feel so sad and I started imagining myself losing the one I love then I cried. Others said it’s good to cry.’ (Participant 28, female) ‘I was thinking how I reacted or it just reminded me of the loved one that I have lost few years back … my friends and I and the whole class was involved in the class discussion.’ (Participant 39, female) ‘I also related to the grief because I also experienced the same stages of grief.’ (Participant 53, female) ‘It brings back old memories of what happened to me … I almost cried during class discussion.’ (Participant 58, female)
Some participants felt guilty for getting emotionally involved: ‘And next time I will try not to identify myself with the clips we view in class.’ (Participant 10, female) ‘Next time I will make sure that I try to be as objective as possible and that I do not let my emotions overwhelm me.’ (Participant 24, female) ‘Next time I will listen effectively, I won’t let my past interfere with my attention … I want to learn about death without being sad.’ (Participant 36, female)
Participants expressed their appreciation for the way in which learning was facilitated: ‘The effective manner in which learning was enhanced leaves me with no idea of how I could change anything.’ (Participant 15, male) ‘I have experienced that if the lessons are taught with the use of presentations, some acting and some pictures it gives a lot of understanding and it is not easy to forget.’ (Participant 23, female) ‘I have learnt a world’s worth of information on reflection and feel that I have grown in leaps and bounds as a person. Thank you!’ (Participant 49, female)
Participants also experienced the joy of learning: ‘I enjoyed the acts the students put on because they made it funny and I think it will be easy for me to remember.’ (Participant 12, female) ‘Thank God for school! I really learnt a lot.’ (Participant 16, female) ‘Videos, case studies and presentations made the learning fun and understandable.’ (Participant 37, female) ‘The topic was very emotional and sensitive; however some plays made us laugh and move away from the sorrow.’ (Participant 50, female)
New meaning was constructed: ‘… as the class went on and I learnt more skills; I saw it is possible to be there for someone who is grieving.’ (Participant 11, female) ‘I now better understand why I need to go through the stages [ ‘I never understood why children act differently … what I’ve learned I’ll be able to use throughout my life.’ (Participant 37, female) ‘I never considered how much different these processes are for children than for adults.’ (Participant 54, female) ‘Death can have a calming or beautiful effect when done in a gracious and gentle manner.’ (Participant 56, female)
Participants shared the existential intelligence they obtained through the learning opportunities: ‘What I should do differently is to talk about death. I was afraid of talking about it previously. I have realised that if we are afraid of death we are afraid of life itself.’ (Participant 14, female) ‘Dying is part of life. We all get born and live our lives and eventually will die.’ (Participant 47, female)
They also obtained interpersonal intelligence on how to appreciate and respect others’ values with regards to death and dying: ‘I will be more understanding and empathic … I will have more respect for people and how they grief.’ (Participant 11, female) ‘I will not bring my own frame of reference into other people’s situations especially when they experience loss.’ (Participant 36, female) ‘The clip that was shown was very beautiful and showed the respect that was needed to take care of someone that died.’ (Participant 48, female)
Most participants were able to relate the learning to their clinical practice and how it will affect the care they provide. They verbalised feeling more competent to deal with challenging clinical situations: ‘… we should actually give time to people that are grieving and be there for them … this will influence the way I view other people’s culture … I won’t judge.’ (Participant 2, female) ‘I learnt a lot about dying, how to break the bad news, what to say and not to say.’ (Participant 7, female) ‘I now, however feel I can provide the support I need to give to a grieving patient.’ (Participant 15, male) ‘I will comfort the grieving family members and not judge them.’ (Participant 22, female) ‘… principles that can help each of us to be caring and helpful.’ (Participant24, female) ‘Compassion is important.’ (Participant 31, female) ‘… it is important to positively regard other people’s feelings of loss as important.’ (Participant 47, female) ‘I can use the lessons to different culture groups, in the children’s wards because I now have a knowledge of the process of grieving.’ (Participant 48, female) ‘Don’t ever deny people the opportunity to cry and go through grief … don’t always feel the necessity to say something. If you have nothing to say just reflect.’ (Participant 55, female)
Permission to conduct the research was obtained from the Research Ethics Committee (Information removed to ensure blind peer review). The principles of the Belmont Report (Polit & Beck
Students benefited directly from the research, and the findings may contribute to educational nursing practice. Students were invited to discuss any emotional discomfort and personal experiences they experienced during participation in private with the researcher, a psychiatric nursing specialist, or with the student advisor who is available to all students at the faculty. Two students made use of the opportunity and shared the way they benefited from the learning opportunity as it facilitated their own grieving. They did not require referral for emotional support.
Students were invited and given freedom to choose to either participate in the study or discontinue at any given time without the risk of incurring adverse consequences. Students had an equal chance to be included in and benefit from the research.
Participants were provided with a participant information leaflet to explain the nature of and likely consequences of the research and signed informed consent prior to participation.
Reflective reports were assigned a code number to ensure confidentiality. Reflective reports will be stored for 15 years in a safe place at the Nursing Science Department.
Lincoln and Guba’s model (cited in Polit & Beck
Video clips, music, demonstrations, posters, case studies, poems and pictures were used during the learning opportunities. The participants reflected on their sensory (visual, auditory and kinaesthetic) and emotional experiences. They experienced co-operative learning in groups (Johnson, Johnson & Stanne
Participants in this research identified certain competencies they acquired during the learning opportunities. Chan and Tin (
Sensory awareness enhances learning. The senses offer a means of contact and communication with the external world, but the raw sense data need to be constructed through perception (Beard & Wilson
Confrontation with death and dying, be it a direct or indirect experience, elicits emotions. The participants acknowledged their feelings of sadness during the experiential learning. The encounter with dying in clinical practice may trigger more than sadness. For example, medical and nursing students in a study in Argentina described feelings of helplessness, vulnerability and sympathy for patients (Mutto
Nursing curricula that incorporated competencies associated with emotional intelligence positively related to students’ well-being and effective stress-management skills. Emotional intelligence focuses on self-awareness and identifying and monitoring own and others’ emotions to guide thoughts and behaviour (Por
Some students who participated in the study reported in this article felt guilty about getting emotionally involved; this might be a product of socialisation or the expectation that nurses must suppress their emotions. In the class discussion the students had the opportunity to talk about emotional expression: If to be encouraged in patients, why do nurses have to feel guilty when they experience sadness and pain? A study by Jack and Wibberley (
Participants in the study also experienced positive emotions as they expressed their appreciation for the learning opportunities. A storyboarding technique to address end-of-life experiences in practice yielded positive experiences as students appreciated the opportunity to discuss their feelings in a supportive group (Lillyman
Some students who participated in this study expressed existential awareness as they realised the different values people assign to dying and clarified their own values related to death and dying. They reflected on dying as part of life, similar to nursing students exposed to end-of-life curriculum content in an USA study (Dobbins
The results suggested nursing students’ perceived clinical competency. The use of cinemeducation as a strategy of facilitating learning yielded similar results as students experienced a decrease in fear of death and increased comfort to care for dying patients (Dobbins
The results indicate that students who actively participate in learning opportunities experience sensory and emotional awareness. Nurse educators need to plan learning opportunities that will facilitate learning about end-of-life- care to raise students’ emotional awareness and provide opportunities for students to clarify personal values about death and dying. The learning opportunities need to be followed by open discussions focusing on emotional intelligence: ways to express and manage the complicated emotions nurses may experience during the provision of end-of-life care once in practice.
In this study only qualitative data were collected. The data provided in-depth insight into the students’ learning experiences, but quantitative data, for example student questionnaires to rate the facilitation of learning, could have provided the researcher with an opportunity to identify areas of progress and areas to improve on.
The findings did not illuminate real-life experiences. It would have been helpful to assess how the experiential learning opportunities affected students’ real-life encounters with death and dying in clinical practice.
A variety of innovative educational methods can be utilised to facilitate experiential learning to teach end-of-life care. Nurse educators need to use creative experiential learning opportunities to ensure students participate and use their senses during learning end-of-life care. The learning opportunities should also be designed to facilitate emotional awareness and invite students to clarify their values in relation to death and dying.
It is essential for nurse educators to obtain feedback (both qualitative and quantitative) on students’ learning experiences. These findings need to be published so that other educators can benefit from the process. Research in different areas of nursing education and the use of different educational methods will enhance the quality of nursing education. Action research is proposed as an appropriate research design to accomplish exactly this.
Experiential learning opportunities opened doors for students and the nurse educator in question responsible for facilitating learning. Participants’ creative presentations facilitated their own and other participants’ learning. The reflections illustrated participants’ constructivist learning experiences that enhanced the construction of meaning. Participants experienced heightened emotional awareness as they reflected on their own encounters with death and dying. Participants were challenged to clarify their values, but realised their obligation to respect others’ values. They perceived themselves as more competent to care for dying patients and bereaved families with compassion and empathy.
The authors wish to acknowledge the contributions of the undergraduate nursing students who freely shared their experiences. To observe their openness and willingness to learn is an uplifting experience.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
A.E.v.d.W. (University of Pretoria) was responsible for the title, methodology, analysis and interpretation of data, revision of the manuscript and approval of the final version. P.H.d.T. (University of Pretoria) contributed in a supervisory capacity and assisted with the revision of the manuscript and approval of the final version.