Research in Learning Technology

ALT's Open Access Journal

Introduction

Psychology is regarded as a crucial element of nursing undergraduate curricula, particularly in light of reports that highlight nurses’ alleged shortcomings in meeting the personal, moral and organisational challenges in their work place (Frances 2013). However, student nurses report that learning psychology is challenging due to overly theoretical syllabuses and ambiguous ‘facts’ that contrast with their need for unambiguous and practical information (Jansen and Nicholl 2007). First-year nursing students struggle to recognise the relevance and value of theoretical concepts such as psychology when they are overly concerned with familiarising themselves with nursing tasks rather than with topics that have little immediate application (Benner 2000). A challenge for lecturers is to engage students who have minimal exposure to practice and have little experience upon which to pin psychological knowledge (Fitzpatrick and McCarthy 2014; Quinn 2007).

In consideration of this, an educational strategy was developed aimed at enhancing students’ engagement with psychology, and which would encourage students to develop an awareness of patients’ psychological and social experiences by which to explore first-hand the lived experience of patients and inform empathetic, individualised and holistic care (Cummings and Bennet 2012). Although the use of digitally-facilitated storytelling is thought to have an ‘evolving role in nurse education’ (Haigh and Hardy 2011), there is little evaluation of psychology teaching methods in undergraduate nursing curriculums (de Vries and Timmins 2012). Accordingly this paper reports on the technical, pedagogical and administrative challenges of developing a ‘Talking Head’ or patient digital story. We discuss student and staff evaluations of the facility in relation to their understanding of the role psychology plays in the first year of the nursing undergraduate programme.

Literature review

A key challenge for nurse educationalists is integrating theory with practice. An increasing number of texts illustrate the application of psychology to nursing; however, students may employ a narrow over-simplified application consistent with the example they have been exposed to (Goddard 2010; Jansen and Nicholl 2007; Meyhew 2000; Mulholland 1997). For learning and application to take place, psychology content should be relevant and meaningful with global application (Jansen and Nicholl 2007; Mowforth, Harrison, and Morris 2005). Case study scenarios are proposed as an effective method (Jansen and Nicholl 2007; Jordan 1998; Painter and Lemkau 1992). Nevertheless, a review of teaching methods to determine the effectiveness of one approach over another highlights that there is no one method that has a clear advantage (Thompson and Stapley 2011). Nonetheless, the use of service users in health education has gained momentum in recent years. The driver has emerged from two directions: first, UK governments’ proposal to include person-centred partnerships in health and social care; and second the emphasis on service user experience in educational standards for nursing (DOH 1998; NMC 2010). The contribution of service users in nurse education is thought to provide students with first-hand knowledge and meaningful perspectives by which to facilitate patient-centred care (Perry and Linsley 2006). Schwartz and Abbott (2007) proposed that patients’ stories led to a change of approach by students to the patients in their care and an improvement in the way that they sourced information about their patient. Rush reported that ‘Live’ service user-led sessions in mental health undergraduate education demonstrated transformative learning with all students reporting examples of actions or insights resulting from service user sessions. The main influences on learning were hearing the lived experience of the services users, the emotional impact of the condition, the reversal of roles (patient as teacher), reflection by the students and the training/preparation for service users (Rush 2008). Further research shows service user involvement in the design and implementation of educational sessions produces improvement in student knowledge around coping skills, communication and empathy, and promotes reflection in nursing students (Stickley et al. 2009). The benefits of storytelling itself include development of skills and imagination required to follow a narrative which may be complex, contradictory with multiple points of view: an ability to enter the storytellers’ reality and to understand how the story teller makes sense of that reality and to gain insight into the use of image and metaphor (Charon 2005).

In comparison, Morgan and Sanggaran (1997) concluded that service users’ opinions were not significant and Costello and Horne's respondents felt they had learned little or nothing from service users in the classroom (Costello and Horne 2001). Garrett (2006) reported students showed various levels of engagement with the stories and the storytellers, with some not appreciating the richness and diversity that the stories demonstrated. Students regard service user's stories as real and raw but students should be motivated, prepared and ground rules should be laid down to protect service users and guide students’ behaviour (Abma 2003; Terry 2012). ‘Live’ service users may value participation but repeated visiting of a distressful event has been associated with increased stress and anxiety of the service user (Costello and Horne 2001). Repeated use of service users also requires on-going financial and organisational commitment from institutions and from service users themselves who may feel overused, overburdened or simply may not appear due to a variety of reasons (Terry 2012).

As an alternative to ‘live’ service users, advancing technologies has led to increasing use of video clips of authentic service users in e-learning, either as stand-alone clips or in more complex learning resources (Mathews 2014). Remote learning opportunities offer a useful method of engaging service users in educational initiatives enabling students to gain insight into a patient's experiences, allowing students to visualise situations yet to be experienced, equipping students to relate patient care theory to practice, with added value of sustainability and reusability (Blake 2010; Bleiker, Knapp and Frampton 2011; Haigh and Hardy 2011).

Technology is often used to supplement more traditional teaching and may form part of a ‘blended learning pedagogy’ or combination of face-to-face and online approaches (Brodwski 2003; Garrison and Vaughan 2008; Klein, Noe, and Wang 2006). In this project, a decision was made to develop and evaluate alternative and complementary ways to deliver the psychology component of the pre-registration nursing course. It was envisaged that a combination of e-learning with a traditional lecture, that is, a ‘blended learning pedagogy’ to encourage engagement, active learning and problem solving would encourage meaningful application of theory to practice through the use of real-life experiences related by patients (Hwang and Kim 2006; Jones and Chen 2008). We took note of the NMC standard ‘to produce graduates who are compassionate and caring’ and recommendations for flexible, blended approaches to learning (NMC 2010). We were guided by Bruner's constructivist spiral model which advocates a reiterative pedagogy with students’ revisiting and building on knowledge throughout the syllabus (Bruner 1986). In keeping with this, the permanency of our video clips enables naïve students to initially engage with an area of practice (chronic conditions) but that would feed into future clinical practice and allow them to reengage with the Talking Head in an increasingly informed way throughout the course.

Study aim

The aim of the study was to develop and evaluate a Talking Head video clip for use in a pre-registration nursing programme for first-year student nurses and as part of a blended learning approach to an introduction to applied psychology.

Study objectives

• To evaluate the role of the Talking Head in facilitating student nurses’ knowledge and application of psychological concepts to nursing practice and their understanding of chronic illness and its effect on sufferers
• To evaluate students and staff attitudes towards the Talking Head learning package

Study design

The project design was informed by principles of narrative inquiry and enquiry-based learning (EBL). EBL is a learning approach which may involve the exposure of students to clinically related scenarios which act as triggers for critical thinking, exploration and reflection (Rush and Barker 2006). The project also draws on principles of narrative where patients’ stories are viewed as rich source of data and gives expression to peoples’ lived experience (Huyler, Mason, 2005; Loeser 2005). Although patient stories may be chaotic, even contradictory (Strawson 2004), we propose that patient stories facilitate empathy and understanding within an educational setting (Bleakley 2005). The key psychological concepts to be explored in the teaching sessions related to recognising individuality and authenticity, culture and stereotyping, active listening and empathy.

Methods

Methods of data collection

Results

Student focus group

Staff focus group

The following themes were identified from the analysis of the staff data: authenticity of the service user story, quality of the learning resource, students’ awareness of psychological concepts, staff training and resources, and ethical issues.

Discussion

The aim of this small-scale education intervention was to engage student nurses with psychology and develop their understanding of chronic illness. This was an exploratory study with low levels of online evaluative responses limiting the representation of the findings. We speculate that low levels of participation related to students’ perceptions of demand and prioritisation of topics. A participating student commented, ‘Psychology is a low priority for overstretched students’. Such views support suggestions that for first-year students, psychology is subordinate to acquiring more meaningful nursing knowledge and the adoption of a superficial learning style for more abstract topics (Snelgrove 2004). It is likely that attending to obvious and relevant practice topics rather than applied psychology reflects an imperative to ‘fit in’ to clinical situations (Benner 2000) and satisfy physical and psychological safety needs before developing a higher level of thinking and understanding (Maslow 1954). According to Benner, novices ‘smell of the textbook’ because they do not have enough experiential knowledge to make clinical decisions independently and creatively. In the absence of this experiential and tacit knowledge/intuition, they have to rely on rules of practice and support their search for practice information rather than abstract theories (Benner 2000). Although Benner referred to nursing, it is possible that such a concrete orientation is uppermost in other health professional student populations.

Despite the small sample, we suggest that the rich and informative focus group data offers valuable insight into how exposure to authentic experiences in a classroom setting enabled students to gain holistic understanding of chronic illness and enhanced empathetic listening skills. Of particular note was that the students engaged with the psychological and social impact of chronic illness rather than developing situated understandings of psychological concepts (Thorell-Ekstrand and Bjorvell 1995).

Moreover, student evaluations showed that the service user's narrative was judged as a more convincing modality than purely text book information but not as useful as a live service user. It is likely that the use of videos and patient narrative engages listeners because the narrator is delivering personal accounts of a complex, individual, lived experience not easily captured by text. Although emotional engagement is probably best captured by use of a face-to-face encounter, the operational drawbacks of using live service users have been well documented (Terry 2012).

Students were also alerted to the service user's reports of not being believed and ‘felt stigma’. The students’ perceived that this knowledge would be useful for future practice and acknowledged the video clip had encouraged them to look beyond the information given and consider patients’ subjective understandings of their situation. Of particular importance were suggestions that the video clip helped students recognise their stereotypical attitudes towards people with chronic illness. These were not necessarily negative although it has been proposed that students enter the nursing profession with preconceived ideas about chronic illness which in turn may have a detrimental effect on patients’ self-concept and illness experience (Cervantez Thompson, Emrich, and Moore 2003; Shaw 2010; Tervo 2004). Well-designed curriculums incorporating personal encounters and engagement with people with potentially stigmatising conditions outside the clinical environment as well as within may encourage professional attitudes and serve to negate any stereotypical ideas (Cervantez Thompson, Emrich, and Moore 2003; Packer et al. 2000; Seccombe 2007). We suggest the controlled exposure of students to patient experiences prior to clinical placements may act as a catalyst for uncovering judicial attitudes and promote reflection although may be insufficient to instigate significant attitudinal change. In addition, the students’ engagement with the service user's story accompanied by group tasks and discussion encouraged students to take a reflective turn which is thought to promote self-awareness and professional growth (Bleiker, Knapp, and Frampton 2011; Mann, Gordon, and Macleod 2009).

Student feedback also showed that exposure to an authentic patient enabled empathetic understanding of living with a chronic condition. Empathetic nursing skills are effective responses to patient's needs and can be learned, (Cunico et al. 2012; Ozcan, Oflaz, and Cicek 2010). Empathy is more than sympathy or compassion as it implicates the ability to put oneself in the patient's situation and reassure them their concerns are understood (Eisenberg and Eggum 2009). Students may care ‘for patients’ but novices may exhibit little sign of caring ‘with the patient’ (Orland-Barak and Wilhelmem 2005). Conversely, the participating students in our institution reported feeling empathetic despite perceptions of a polished and unemotional rhetoric from the service user. The mechanisms of this are not clear although it is likely that the students were able to see beyond the rather rehearsed discourse by paying close attention and being empathetic which reflected their rapport with the service user. Furthermore, staff also commented upon the lack of emotionality expressed by the service user but agreed it would be inappropriate to encourage authentic service users to be demonstrable on cue. An alternative may be the use of actors enacting scenarios based on service users’ accounts (Bleiker, Knapp, and Frampton 2011) but authenticity may be sacrificed.

There is very little written about the obstacles to successful implementation of technologies in the curriculum. In this study, we found three main obstacles: scarcity of resources (time); lack of IT skills and associated technical problems (Button, Harrrington, and Belan 2013). The latter may point to a failure to prepare the appropriate expert resources (Brodwski 2003). In our case, technical problems arose because of little support and unanswered queries relating to streaming options which in turn interfered with pre-session information and varied student accessibility to the Talking Head. Participating staff were wary of the technology and requested opportunities for gaining nursing informatics skills. Students were enthused but initial technical difficulties reinforced a general reluctance to participate in additional work (such as the online quiz and ad hoc observations of the Talking Head) outside their busy personal and institutional timetables.

The staff and student feedback fed into revising the video streaming arrangements, improving student online accessibility and the positioning of psychology in the curriculum. For the future, we would maximise learning opportunities by choosing a patient with a common clinical condition rather than a little recognised disease. This would enable wider use of the Talking Head across modules. We would consider providing a stronger bridge between theory and practice by integrating the Talking Head with relevant practice skills sessions. We learnt how a lack of pedagogical IT skills may hinder the development of educational practice and how IT skills sessions for staff could facilitate agency (Fangehanel 2007).

Conclusion

The study is a chronicle of the challenges of developing and evaluating a Talking Head in higher education. Although the project took place within a particular context, the findings may be of value across disciplines. A combined approach of narrative and EBL encased in a technological intervention allowed students to safely explore a patient's story in an empathetic and critical fashion within the context of their discipline and psychological concepts. Attention was drawn to the technological and ethical demands associated with developing online teaching facilities and points to the need for support and training resources for lecturers. Further research may be directed towards investigating how a Talking Head influences the application of psychology in practice. We suggest that Talking Heads are a useful pedagogical tool but further design and evaluative work is necessary.