Nurses are in a unique position to respond to the needs of cliente who have experienced losses and are grieving. Yet, nurses, like other health professionals, experience anxiety and discomfort when facing grieving cliente. A common response to these emotions is to nee or to display avoidance behaviors (Bumey-Banfield, 1994; Lockard, 1989). For example, when asked to role play in a simulated loss situation, nursing students at the University of Minnesota often respond with, "I don't know what to say," Tm afraid the client will say something and I won't know what to do," or "I just want to get out of here." They also express anxiety about their ability to remain professional when they feel sad for the thent or family. Studies have focused on death education and on nurses' coping with their own responses to the dying client (BumeyBanfield, 1994; Clingerman, 1996; Combs, 1981; Johansson & LaUy, 1990; Lockard, 1989) rather than on broader losses or on how the nurses' personal cultural experiences influenced their responses.
At the University of Minnesota School of Nursing, faculty have used a number of teaching strategies to facilitate students' knowledge of loas and grief, comfort in being present for the grieving client and family, and skill in communication with clients from diverse backgrounds. The purpose of this article is to describe a learning activity that stimulates students' reflections of their cultural experiences with lose and facilitates sharing within a safe environment.
Course instructors have typically introduced the concepts of loss and grief by providing content on several theories (Bowlby, 1961; Cooley, 1992; Kubler-Ross, 1968; Solari-Twadell, Schmidt Bunkers, Wang, & Snyder, 1995) through lecture, class discussion, audio-visual materials, and readings. Students have practiced communicating with grieving clients by role playing in small groups with clinical scenarios. An important element in becoming skilled in responding to others' grief experiences is self-understanding. One method for accomplishing the goal of students reflecting on their own experiences was a loss paper in which students described a loss that continued to have an impact on their lives. They reflected OQ the grieving process with reference to one of the theories of grief and described how others helped or hindered movement through the process. Although the individual students gained insight through this method, there was no opportunity to share with others or for the rest of the class to practice listening to the story. Course instructors searched for a strategy to help students move toward achievement of a number of goals, including:
* Gaining self-awareness of their personal responses to loss.
* Recognizing the diversity of responses to loss based on cultural differences and individual variations.
* Developing skills in being present for another who is grieving.
The author's reading of Schon's (1987) work on teaching the reflective practitioner and attendance at a 2-week "Diversity and Public Problem Solving Summer Workshop" at the Hubert H. Humphrey Institute of Public Affairs (University of Minnesota) provided the impetus for the learning activity presented in this article. Schon's (1987) emphasis on professional artistry provided a new perspective on developing a therapeutic relationship and responding to the needs of grieving clients. The diversity workshop's emphasis on integrating cultural content into professional courses highlighted the cultural influencée and individuality of personal responses to loss (Alford & Catlin, 1993; Solari-Twadell et al., 1995).
Schon (1987) characterized the intermediate zones of practice as addressing uncertainty, uniqueness, and value conflict. Responses to loss reflect all the characteristics of the intermediate zones of practice. Schon suggested learning professional artistry requires a relatively lowrisk setting with coaches to guide students into the tradition of the profession. Reflection as a tool enables students to explore personal aspects and understand how their personal lives mediate responses in their professional lives (Palmer, Burns, & Bulman, 1994).
Creating a safe classroom atmosphere and providing opportunities for self-generated knowledge were strategies identified by Tatum 1992} for helping students overcome resistance to learning about racerelated content. This article describes a learning activity called Culture and LOBS. It incorporates Schon's and Tatum's notions of a safe classroom environment using an assignment that facilitates selfreflection of a loss within the context of the student's own culture.
Culture and Lose Project
Culture and Loss: A Project of SelfReflection was developed as a learning activity for the first interpersonal communications course in the junior year of the baccalaureate nursing program. It has been a course requirement since 1995.
Purpose. The purpose of the assignment is to stimulate students' reflections on the cultural experiences of lose and to offer them practice in conveying this col' lective representation to their peers in any way they choose. Guidelines for the assignment follow:
* Explore the ways in which your cultural community handles the experience of loss. You may choose to talk with family, friends, and community leaders; examine historical documents or library materials; or recall the details of customary expressions in your own past.
* Develop a presentation to share with peers in class. This presentation may be a visual, a demonstration, or a written expression, or may take whatever form your imagination and creativity desires.
* Describe your project, its meaning, and connections to your cultural community in a 5-minute presentation in class.
Leininger emphasized the importance for nurses to shift their thinking from a unicultural to a multicultural focus. She has defined culture as:
the lifeways of a particular group with its values, beliefs, norme, patterns, and practices that are learned, shared, and transmitted intergenerationally (1996, p. 73).
If nurses are to recognize the cultural components of grief reactions and design culturally appropriate interventions (Pickett, 1993), they first need to understand the important role culture plays in shaping the experience and expression of grief I Alford & Catlin, 1993) and to examine their own culture so they may be less judgmental about others' cultural beliefs and practices Arnold & Boggs, 1995; Vaughan, 1997; Warren, 1997).
Presentation Content*. The diversity of examples students presented clearly demonstrated the range of cultures and the types of losses they experienced. Culture was represented by race, country of origin, religion, regions within the state and the country, and affinity groups. Most of the losses students described were related to the death of a significant other, including natural death of grandparents, death of friends due to illness or accident, suicide of family members, and loss of pets. Students also shared losses associated with chronic illness in the family, loss of relationships, loss of homeland, loss of roots, loss of treasured objects, and developmental losses.
Students chose to present their cultural responses to loss through various means. Most students verbally shared with the class, often augmenting their descriptions with music, videotape segments, poetry, pamphlets, essays written previously about loved ones, posters, ritual objects, recipes, and food. One student, who described her losses associated with her family moving frequently during childhood, brought a shoe box full of the ways she handled grief. The box was closed and tied with string, depicting how she hides her grief. Inside, the box contained food, a leash that represented her attempts to remain in control of her grief, running shoes, and a book on humor. Another student played her country's national anthem as she talked about how ahe remembered her homeland and coped with multiple losses. Another student described her feelings of loss as she matured and moved out of her family's home. She brought care packages for each of her classmates, just as her parents sent her care packages of food, newspaper clippings, and notes of affection.
Many students described the rituale surrounding deaths in then· families and the purposes they served in the grieving process. A student discussed her family, sharing stories about her great grandmother and how this brought closure. Cultural rituals from different countries, parts of the country, and religions were described. Students also discussed differences within their families in regard to grieving. For example, a few students described how their parents' families responded very differently to loss. This prompted several to comment on how difficult it was for one parent to support the other because of the differences in norms and values related to grieving. Finally, a student described the grief surrounding her mother's chronic illness, the anger and despair of the family, and how important it was for health care providers to understand the needs of the families. She described her family as using information to help them cope, and she brought brochures for each student to help them better understand her mother's disorder.
Presentation Formate. Studente presented their projects during Week 8 of a 10-week quarter. Presentations were made hi two different formate. In the first year, students presented in one class period to small groupe of eight students. During the second year, students presented during one of two class periods to the entire class of approximately 24 students. The larger group presentations provided students with a broader range of examples. The potential concern with comfort hi presenting to a larger group was decreased because of the nature of the seminar in which ground rules were established for open discussion and respect for each others' contributions. Also, these students had been together in courses and clinical laboratories for two quarters. There were no differences noted in the content or ease of delivery for presentations in either format.
Project Grading, Points were assigned to the project that reflected 10% of the course grade. At the beginning of the session, the instructor clarified that all students who thoughtfully shared their cultural experiences with loss in ways that helped the class understand the diversity of grief responses would receive fall credit. This established an atmosphere of striving for mutual goals without a sense of competition.
Project Evaluation, Informal feedback from students consistently included their surprise at the intensity of their emotions surrounding their losses, the value of talking with family members about these topics, and the insights they gained in how to help clients. Students evaluated the project as part of the formal course evaluation. In the first year this prqject was assigned, students rated the extent to which it helped them:
* Understand the diversity of people's responses to loss.
* Gain awareness of their own values, beliefs, and customs related to loss.
* Work with cliente experiencing loes. The mean ratings from 24 studente based on a 7-point scale (1 = not at all, 7 = an exceptional amount), were 5.4, 5.2, and 5.6, respectively for each of the abovementioned items.
Reflections on the Project
The content of the presentations provided students with a wide range of examples of grief responses. The process that evolved during the class provided opportunities for students to listen to others share intimate, painful experiences. The classroom became a practicum, with real-life situations, and true emotions.
Because it was a safe environment in which their only roles were to share and to listen respectfully, students could reflect on the situation and respond to each other as they felt comfortable. As suggested by Schon (1987), the instructor acted as a coach during the sessions. The atmosphere of respect and positive regard was evident. Students were frequently surprised the stories they shared were accompanied by strong emotions. Several commented they thought they were "over the loss by now." One student began in a matter-of-fact way to describe her grandmother's death 12 years ago. All of a sudden she was overcome by tears and could not go on. Students, tike clients, become uncomfortable when they emotionally break down in front of others.
To help students realize the normalcy and importance of expressing feelings during grieving and to link the experience to related theoretical knowledge, the instructor reminded them of one of the modele of bereavement. The authors of the pinwheel model (Solari-Twadell, 1995} suggested that events in Ufe can cause the person to revisit the loss, and this is a normal part of the grieving process. After this brief discussion, the student was able to finish her story. Reflecting on their own responses to loss gave students insight into ways to facilitate clients sharing their feelings of loss.
A few weeks following the class sessions, a student approached the author in the hallway saying she had talked with a client that morning about hie impending death. She said, "You were right there with me in the back of my mind through the whole conversation." The student related she felt good about her ability to listen and be with the client.
Nurse educators continually seek ways to provide students with practice in communicating in an environment that reflects the clinical situation but offers a safe setting to use their skills. The culture and loss assignment is aimed at increasing students' cultural awareness of responses to loss and sets the stage for experiencing and responding to others' expressions of loss and grief. More research needs to be conducted on grief associated with losses other than death, particularly grief in chronic illness (Lindgren, Burke, Hainsworth, & Eakes, 1992} and interventions with chronic sorrow. Strategies euch as the culture and loss assignment provide students with insight into a wide range of losses and responses within a cultural context.
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