Palliative care, which includes end-of-life (EOL) care, helps those with advanced, progressive, incurable illness to live as well as possible until they die (U.S. National Library of Medicine, 2016). Part of quality EOL care is advanced care planning, which is enabling people with a life-limiting illness to make decisions about their care preferences (National Hospice and Palliative Care Organization, 2016). High-quality EOL care is patient centered (National Quality Strategy, 2014). An important consideration when teaching students how to provide person-centered care is the development of students' cultural competence through knowledge building and the acquisition of appropriate attitudes and behaviors (Riner, 2011). Cultural competence has been defined as “the capacity to provide effective healthcare taking into consideration people's cultural beliefs, behaviors, and needs” (Papadopoulos, 2003, p. 5). Although challenging, teaching nursing students about cultural considerations involved in EOL care to promote patient-centeredness is important because education can have a direct and positive effect on students' attitudes toward the care of dying patients (Bailey & Hewison, 2014). However, to be effective, the educational delivery needs careful consideration.
The pedagogical environment in higher education is rich with digital learning opportunities (Lock, 2015) and there has been an increase in the availability of e-learning on mobile and tablet devices. Students also have access to an array of asynchronous digital technologies, which can support independent learning (e.g., virtual discussion forums and e-learning packages), and synchronous technologies, which can be used to engage in learning with others remotely (e.g., expert lectures via videoconferencing), that support current teaching practices. It has been argued that this represents a “paradigm shift in educational thinking” (Murgatroyd & Couture, 2010, p. 20), contributing to the development of a “new culture of learning” (Thomas & Brown, 2011, p. 17).
Although the potential of digital technology to enhance learning is acknowledged (Thomas & Brown, 2011), its application does not guarantee learning or collaboration (Larusson & Alterman, 2009). Therefore, educators have to consider how best to integrate learning technologies in the curriculum to engage students and deliver high-quality education. Following publication of the End-of-life Care Strategy in England (Department of Health, 2008), the content focused on EOL care in undergraduate nursing curricula has increased (Bailey & Hewison, 2014). Although no direct equivalent national strategy exists in the United States, the End-of-Life Education Consortium project is a national education initiative with the goal of providing nurses with the knowledge and skills they need to provide care that has a positive effect on the lives of patients and their families at the EOL (American Association of Colleges of Nursing, 2016). In addition, a landmark study recommended that educational institutions, credentialing bodies, accrediting boards, state regulatory agencies, and health care delivery organizations in the United States establish appropriate training, certification, and licensure requirements to strengthen palliative care knowledge and skills of all clinicians who care for individuals with advanced serious illness and who are nearing the EOL (Institute of Medicine, 2014). In recognition of this combination of factors, an educational intervention was designed that would address the overarching policy need by focusing on a key element of person-centered care—cultural competence. To manage this effectively, an established service improvement model was used. The overall aim was to develop a global classroom using online technology to enhance the learning of nursing students in EOL care.
The global classroom project was designed to enhance the educational experience of nursing students and expand their knowledge of person-centered EOL care. The PDSA (Plan-Do-Study-Act) method was used to structure the work. The elements of the tool include: Plan—the change to be put in place, predict what will happen, and identify data to be collected; Do—implement the change collecting the necessary data; Study—consider the data collected before and after the change; Act—identify further changes needed based on study phase to continue improvement (Langley et al., 2009; Kilo, 1998).
The underlying rationale of the approach is that short-cycle, small-scale tests, linked to reflection, can enable health care teams to learn from actions taken and their effects (Berwick, 2003; Iles & Sutherland, 2001). It is recommended as a helpful tool in health care (National Health Service Improvement, 2010; Scoville, Little, Rakover, Luther, & Mate, 2016) and is widely used, as it provides a framework for collaborative working (Boaden, Harvey, Moxham, & Proudlove, 2008; Powell, Rushmer, & Davies, 2009).
Plan: The Global Classroom
A global classroom is where two or more groups of students work together (in this case, from two countries) to study a common topic (Nelson, 2008). Many design principles for the global classroom were considered. Manso and Garzón (2011) suggest that four components are essential in the development of effective collaborative global projects: (a) the topic needs to be relevant and connected to the core curriculum or discipline; (b) the integration of information and communications technology; (c) the collaboration, which implies a commitment to learn together and to cooperate in the achievement of something that cannot be achieved individually; and (d) the exchange of information to allow the activity to advance with clear criteria that specify the nature of student participation (Manso & Garzón, 2011).
The project team considered each component when making decisions and planning the structure and delivery of the global classroom. Advance care planning was identified as a crucial process in EOL care that the students could explore in classroom lectures and group activity. It was selected because it is central to practice, incorporates consideration of cultural competence as part of person-centered care, and was consistent with the learning outcomes at both universities. With the assistance and support of information technology staff at both institutions, virtual platforms were chosen that were reliable, user friendly, and allowed for asynchronous and synchronous collaboration. Finally, a group activity was chosen that was achievable in a short time frame, realistic in terms of workload so as not to overburden the students, and purposeful in terms of developing their learning. The expectations in terms of student participation, professionalism, and peer communication were clearly delineated in a supporting document provided for both groups.
Three synchronous classroom sessions were planned over a 6-week period using Zoom. Zoom is an innovative Web-based conferencing system that allows for video, audio, and screen-sharing capabilities (Zoom Video Communications, Inc., 2016). The first planned session was an introduction where students and faculty could meet and a technology check for proper functioning could be conducted. Students were required to view films produced by the faculty team that summarized the English and U.S. health care systems prior to the scheduled introduction session to provide necessary background information. The second session was a joint lecture from faculty at both sites on advance care planning, highlighting the differences between the approaches in the United States and England, particularly regarding cultural competence. Finally, the third session was an interactive discussion about the movie Wit (Bosanquet & Nichols, 2001), specifically the patient's experience of EOL care and the roles of members of the health care team. Palliative care clinical colleagues from both sites were invited to contribute to the discussion along with the faculty. In addition, the students were asked to organize two virtual small-group meetings to work synchronously on a group activity (i.e., an e-resource on advance care planning for patients and families). Each group included participants from both countries who were able to connect using Slack™. Slack is a messaging application that allows group members to create channels for conversations, both synchronized and archived, and to share files (Slack, 2016). Seventy-five students from the United States and 54 students from England participated. This planning provided a firm basis for the next phase of the project.
Do: Global Connections
The global classroom brought together experts in EOL care from the United States and England to provide undergraduate nursing students in the two countries with a unique learning opportunity. During the course of the project, the students built a relationship with the lecturers from both countries, as well as with their peers. In the Slack channel project groups, there existed a sense of camaraderie, and comments indicated that learning about different health care systems, as well as differences in nursing education in the two countries, occurred. The students commented that they enjoyed working together. All of the groups produced an electronic resource on advanced care planning. These took the form of blogs, infographics, leaflets, Web pages, and e-presentations. These outputs indicate that the global classroom was purposeful and had significance for student learning.
Study: Evaluation and Limitations
As with any change, evaluation of the global classroom was important to make any modifications necessary to improve the quality of the learning experience for students and to integrate this approach into the curricula at both institutions on a permanent basis, if it was found to be effective in enhancing learning. Because this first offer was a feasibility study, most attention was given to the logistics. The authors evaluated whether the content was placed in the right place in the two curricula, whether the information technology platform was fit for purpose, whether the students were able to participate in both the synchronous classroom and the group work, and whether their group assignments were meaningful.
The authors collected feedback from students via e-mail and personal conversations. Overall, the feedback received was positive, and suggestions for improvement corresponded with areas identified by the project team. Students commented on the difficulties presented by different time zones and how working patterns made it challenging to meet up virtually to work on the group activity; however, the majority of comments were positive, with one student stating:
It was definitely a challenge being busy students working with other busy students across the world, but I love the idea of the program, and it was neat to learn about another country and their nursing processes.
Although the authors focused their efforts on ensuring that students knew how to connect via Slack, their schedules were also a limiting factor. Further issues existed with the synchronous global classroom, as the first one was cancelled due to a snowstorm in the United States. This limited the time available for the students to meet each other and familiarize themselves with the global classroom before they were taught some of the more difficult areas of EOL care (e.g., a discussion of cultural sensitivities), so engagement of students was delayed. At times, both the faculty and students felt that insufficient time existed to reflect on content, learning, and development of next steps in depth. Despite this, the reflective comments were positive. For example, after the first session, students said:
- I am quite excited about working with [the U.S. university]. I think this is a great opportunity and cannot wait to see the differences.
- I'm greatly looking forward to this opportunity, as I am interested in the [United States] and really appreciate the hard work you have put in to making this a reality.
Act: Plans for the Next Global Classroom
The global classroom is a beneficial educational innovation that can be incorporated into the curriculum with careful planning. Based on the current evaluation, in future iterations the global classroom will be delivered using a cumulative approach. Instead of having all content about EOL care in one course at each university, content will be delivered over three semesters and three courses. The authors plan to have an introductory session in semester one, a second session in semester two, and a third session in semester three. The authors hope this will afford the students time to digest the content and to get to know each other better in the activity peer groups, which is what they enjoyed the most. In addition, the EOL care content will feel more like an integral part of the respective educational programs that provides consistency and constancy as a whole rather than being viewed as an additional project in one course. The authors are also exploring how to expand the global classroom to include students from the wider health care team (e.g., students from medicine and the allied health professions).
The intention of engaging in a detailed planning process was to try to ensure that the global classroom was based on sound educational principles and that the complex logistical challenges involved in delivering the experience were addressed. Four components were considered in the planning stage to engage students and promote inclusive learning in a global context. First, the topic needed to be engaging and appropriate for all students. The focus on EOL care, and specifically cultural competence as part of advance care planning, was appropriate because it was an issue of concern for both groups of students. Second, the virtual platform had to be stable but flexible enough to meet the requirements for learning, such as the easy uploading of documents, sharing views of documents, and enabling virtual discussion to foster student cohesion. Zoom worked successfully for the virtual links for the classroom activities and Slack was an ideal platform for the group work, as it enabled students to work together in small groups, share ideas, and learn from the experiences of their peers. Third, collaboration was key to the success of this project, which involved 129 students. Having buy in from the universities, other faculty, and students was essential, as was the expertise of subject and technology specialists. Also, regular and frequent communication between faculty was important. Fourth, the group activity had to be purposeful and achievable. All groups produced e-resources on advance care planning, and feedback was positive in terms of international linking and learning opportunities (e.g., https://endoflifecaresite.wordpress.com/, https://prezi.com/3aa8mkdhgpwr/advanced-care-decisions/). The development of cultural competence was apparent in the e-resources produced, as demonstrated by those that focused on the individualized needs of patients and their families. For example, one group created a Google™ document highlighting the issues involved in agreeing to a do-not-resuscitate order as part of EOL decision making (Figure).
Google™ document on advance care planning. Note. DNR = do not resuscitate.
The global classroom was a success, but to increase its influence in the future, the authors plan to deliver the global classroom over three semesters. The authors have witnessed the value of using a global classroom, in that students are able to learn much more when international perspectives and the associated discussion of different cultural contexts are incorporated into their learning. The PDSA cycle was useful, as were the four components of an effective collaborative global project. Lessons learned can inform others to use this work as a framework when designing and implementing a global classroom. The authors' hope is that the use of a global classroom approach to teach concepts that are central to EOL care, such as advance care planning and cultural competence, will become part of educational programs in health care to enhance learning in an international context.
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