Dr. Gazarian is Assistant Professor, Simmons College, Boston, Massachusetts.
The author has no financial or proprietary interest in the materials presented herein.
The author thanks Sean Wright, Instructional Technologist, Simmons College, for his advice on preparing digital stories.
Address correspondence to Priscilla K. Gazarian, PhD, RN, Assistant Professor, Simmons College, 300 The Fenway, Boston, MA 02115; e-mail: Priscilla.firstname.lastname@example.org.
The current health care environment requires nurses who can approach clinical problems from a range of perspectives and synthesize multiple sources of knowledge. Teaching higher level thinking skills such as synthesis of nursing knowledge and clinical decision making cannot be accomplished wholly through conventional pedagogies and traditional teaching methods. To teach nursing students the skills of clinical judgment and decision making necessary in today’s complex health care system requires new and innovative teaching strategies (Andrews et al., 2001; Diekelmann, 2001; Ebright, Patterson, Chalko, & Render, 2003; Ironside, 2006; Tanner, 2006). The temptation for educators might be to continue to focus on critical thinking skills alone. However, including narrative pedagogy methods of teaching and learning also will serve to develop reflective and interpretive thinking (Ironside, 2006). This article describes the use of digital storytelling in a senior-level baccalaureate clinical decision making and synthesis course as a method to develop holistic thinking skills.
Narrative pedagogy was the framework used to conceive a digital story assignment for a senior-level synthesis and clinical decision making course. Ironside (2006) described narrative pedagogy as:
a research based interpretive phenomenological pedagogy that gathers teachers and students into converging conversations wherein new possibilities for practice and education can be envisioned.
Emphasis is on the learning community, public interpretive scholarship, and concernful practices (Andrews et al., 2001
; Ironside, 2006
Narrative pedagogy provides a context for learning wherein students and teachers can have conversations based on common everyday experiences that arise from nursing practice (Ironside, 2006; Young, 2004). Narrative pedagogy values multiple pedagogical perspectives such as conventional, feminist, critical, postmodern, and phenomenological. Nurses’ use of all perspectives and ways of thinking is required in complex, ambiguous, and often uncertain clinical situations (Scheckel & Ironside, 2006).
Digital Stories as Narrative Pedagogy
Storytelling is a uniquely human activity that has guided learning since ancient times. When students are asked to tell a story, they are engaging in “meaning making,” reflecting on what they know and examining their assumptions (Matthews-DeNatale, 2006).
Digital stories are simply stories or narratives created by an individual using a combination of computer-based tools. They are multidimensional stories conveyed through images, music, narration, text, and video clips. Digital stories are created in a form that makes swapping, critiquing, and revising stories accessible and enjoyable (Matthews-DeNatale, 2006).
Through the use of images and sounds, students can creatively enhance their stories by adding emphasis and meaning to the stories they are telling. Digital stories are intended to be viewed on computers and therefore can be made widely accessible. Many individuals are familiar with digital storytelling through projects such as StoryCorps (2009), an independent nonprofit project whose mission is to honor and celebrate one another’s lives through listening.
Storytelling reveals the storytellers’ cognitive development as they engage with the subject matter. To be useful as a learning tool, digital stories need to be situated within the goals of the curriculum and should not constitute an isolated exercise (Ohler, 2005/2006). In addition, it is important to emphasize that technology should be secondary to the telling of the story (Banaszewski, 2002). In this assignment, the digital story was one part of a semester-long project aimed at exploring and synthesizing concepts embedded in clinical practice.
Digital storytelling captures narrative pedagogy’s emphasis on the learning community and public interpretive scholarship. Many of the stories students may choose to tell are deeply personal. Of course, this is the root of what makes storytelling meaningful as a learning tool. However, sharing these stories requires an environment of trust facilitated by the teacher. When stories are publicly available or shown in class, it is essential that feedback begin with appreciation of the story (Banaszewski, 2002). The class then can openly discuss and raise questions about the concepts and ideas brought out by the digital story.
For this assignment, a trusting environment was facilitated and public interpretive scholarship was modeled by the instructor through sharing and discussing a digital story that the instructor created during the first weeks of class. Students were not required to use technology or make their stories public; instead, students could make alternative arrangements for completing the assignment with the instructor.
Digital Story Assignment
In this capstone course, learners were required to synthesize concepts and ideas from their previous coursework and clinical experiences. Students were placed simultaneously in clinical preceptorships in various settings and specialties. Classroom content was partially guided by unmet learning needs as identified by the class community, and students were asked to share experiences from their clinical placements throughout the course. In this way, students who were placed in a pediatric experience, for example, could share their experiences during class discussion related to pediatric content.
Students viewed the digital stories in class as a way to open class discussion or emphasize a point related to classroom content. After viewing a digital story in class, the instructor facilitated a discussion related to the digital story. Discussion always began with a statement of appreciation for sharing of the story and a specific comment about something that resonated in the situation or about how an image or phrase enhanced the story.
Open-ended questions were posed to the class to elicit comments about the concepts identified and how well they were communicated in the story. The story’s creator was able to receive feedback about the clarity of concepts and how these worked together in the situation. This aided the creators in validating or clarifying their synthesis of concepts for the formal written assignment. In addition, the stories were available on the e-learning site and could be accessed by students enrolled in the course at any time. This ease of accessibility is one of the advantages of the digital story format.
The digital story was one part of a three-part, semester-long project. The first part of the assignment required students to identify a clinical situation of interest and propose three concepts within the clinical situation that they were interested in exploring in detail. For the digital story assignment, students were asked to produce a 3- to 5-minute audiovisual presentation, using a first person voice, that described the chosen clinical situation. The final part of the assignment was a paper in which students synthesized the three identified concepts in relation to the clinical experience.
The digital stories could be created in iMovie®, PowerPoint® with audio, traditional video, or Voice Threads®. Students were given the option to complete the assignment without the use of technology if they felt the technology would be a barrier to communicating their stories. Technology support was available through the college, and resources were made available to assist students in using their chosen software applications. Students also were directed to several digital storytelling Web sites (Table). Students submitted their completed presentations to the class e-learning site.
Table: Digital Storytelling Web-Based Resources
Discussion and Evaluation of the Use of Digital Stories
This was the first time this assignment had been used in this course. To complete the assignment, 42 students used Voice Threads, 2 students used iMovie, 1 student used Power-Point with audio, and 1 student used PowerPoint with text. No student requested to be allowed to complete the assignment without the use of technology. Voice Threads proved to be an easy-to-use Web-based application, even for students with limited technology skills. Video presentations were completed by midsemester, so students could view them during the remainder of the semester.
The instructor kept notes on the content of the digital stories and how these might relate to upcoming classroom topics. When a digital story was pertinent to class, the creator was asked for permission for the digital story to be viewed by the class. After two in-class examinations, movie days, complete with popcorn, were scheduled. Students whose videos had not yet been shown in class volunteered to show their digital stories.
Most students were honored and proud to share their stories with their classmates. However, a few students were uncomfortable with viewing their movies in class as evidenced by their statement that “You can watch it if I can leave the room when it is on.” All of the students gave permission for their stories to be shown when asked, and none of the students were pressured into volunteering on movie day.
At the end of the semester, after grading had been completed, students were asked for written permission to share their digital stories in presentations or as teaching tools for future classes. Only one student requested that her story not be used.
The stories the students chose to tell came from a wide variety of situations and every clinical nursing course. The following are two examples of stories that students chose to tell.
Methadone and Pregnancy
This story was created in Voice Threads using publicly available still pictures and voice narration. In this story, the student explored her interest in caring for pregnant women who were dealing with drug addiction. She related how she became sensitized to this issue during her community health placement in a women’s shelter while caring for a woman who was addicted to methadone and was pregnant with her second child. The student reflected on how hard it was to hear the woman’s story and to listen to the woman casually describe how the baby would spend his or her first 2 weeks of life in a neonatal intensive care unit. The student then described how she tried to make a connection with the woman and build trust.
The student remembered this experience when she again encountered another woman receiving methadone treatment on a labor and delivery unit during her precepted clinical experience. She related how she resolved to view this woman as a “clean slate” as she cared for her during labor and the delivery of her infant. During the next few weeks, the student visited the mother and infant while the baby remained hospitalized for detoxification. In the story, the student thanked the woman for her honesty and openness about her drug use. She further reflected that because she did not prejudge the woman, she was able to view “the incredible love” this mother had for her baby.
For her course paper, this student chose to explore the concepts of therapeutic communication, caregiver trust, and drug abuse. The student articulated the dangers of drug addiction during pregnancy and the need for caregivers to work in partnership with the mother to ensure a positive outcome. To effectively care for the substance-using pregnant woman, the student had to synthesize knowledge from the pathophysiology of addiction on the fetus, pharmacology of drug use on the mother and fetus, and principles of therapeutic communication and the therapeutic relationship.
In addition to these concepts, her story included critical, reflective, and interpretive thinking. Reflective and interpretive thinking were evident as she recalled “how hard it was for me to hear the woman’s story” but saw “incredible love” between mother and baby.
It also was evident the student was developing her personal philosophy of nursing from a feminist perspective (Ironside, 2001). The student modeled a beginning exploration of a feminist perspective as she intentionally sought to approach the clinical situation as a clinical partnership with the mother based on mutual respect and trust (Ironside, 2001). Class discussion allowed the student to reflect that her initial emotional reaction of shock and frustration for pregnant mothers who use drugs matured to a point where she was able to articulate that “being open minded with every patient helps me connect with their [sic] own personal situation.”
This story was created in Voice Threads using publicly available still pictures and voice narration. For this story, the student related the semester-long experience of caring for a Chinese graduate student hospitalized with paranoid schizophrenia in a locked inpatient psychiatric setting. This patient was reported as being sexually inappropriate and was prohibited from attending group therapy. The student related how this made her apprehensive about interacting with him.
As the weeks went by and the patient’s medication was adjusted, his condition improved, his affect became brighter, and his thoughts became more organized, so the student was able to engage with him about his discharge plans. She and a few other students talked with him in the day room, and he told them that his mother was coming from China to care for him. The student reflected on how a comment made by another student, “That will be nice to have your mother here,” revealed how easily we make assumptions about what is desirable for patients after observing that the patient subtly flinched at the comment.
Further conversation revealed the patient viewed his mother’s visit as stressful. The student then explored the meaning of illness with the young man and, during the course of the semester, the student came to understand the responsibility of the therapeutic relationship. At the end of the semester, the student thanked him for sharing his story with her and he thanked her for listening.
The student reflected on how she was struck by the connection she had made with a patient who had initially made her apprehensive. At the end of the semester, the student related that “This patient who [sic] I was almost a little scared of when I first encountered him was suddenly someone with who [sic] I had a connection.”
Again this story illustrates multiple perspectives and levels of knowledge. The student broadened her understanding of schizophrenia. She stated, “In fact I didn’t really know what the term flat affect looked like until I saw it in him.” She also learned about the effects of treatment as she cared for him when he was readmitted after stopping his medication because of severe side effects. The student demonstrated interpretative thinking when she tried to empathize with how the patient must choose between the symptoms of schizophrenia or the side effects of medication by asking, “How do you decide how bad you are willing to feel in order to not hear voices?”
Aside from being a well-told story about schizophrenia, therapeutic relationships, and assumptions, the public viewing of the story in class modeled narrative pedagogy in action. In this case, the student volunteered to show her video in class on movie day. This was risky because the student who made the assumption and comment about it being nice that the patient’s mother would be coming from China also was present in the class. Through the intentional inclusion of narrative pedagogy’s emphasis on the learning community and public interpretive scholarship, the discussion that followed this viewing was thoughtful and respectful. In fact, several members of the class had known this patient as a part of a clinical group placed in that clinical setting, and they participated in the discussion on the complexities of navigating the therapeutic relationships and the ease with which we can all make assumptions.
Although this was the first time this assignment was used, the students’ willingness to use technology to tell their stories was overwhelming. Clearly, students are facile with the use of technology and can quickly adapt to its use. Further enhancing students’ skills with multiple forms of technology will serve to strengthen their adaptation to the current complex health care system.
Access to easy-to-use software applications made telling stories digitally an enjoyable and rich learning experience for all involved, which greatly facilitated incorporating narrative pedagogies into this course-work. This assignment met the learning objectives for the course within which it was used. Further investigation is warranted so faculty can better understand how technology can enhance the sharing of interpretative and reflective thinking among nursing students.
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Digital Storytelling Web-Based Resources