Part of the nursing role is to provide compassionate care to patients at the end of life (American Nurses Association, 2016), yet many nurses feel unprepared to provide this care (Shaw & Abbott, 2017). Nurses with less professional experience display greater fears of death and have more negative attitudes toward caring for patients at the end of life (Peters et al., 2013). As nurses gain experience, they feel more confident about the quality of care they provide (Dunn, Otten, & Stephens, 2005). To facilitate nurses' confidence and competence, educators need to include palliative and end-of-life care concepts in the nursing curriculum (Ferrell, Malloy, Mazanec, & Virani, 2016). Observing positive role models in palliative care clinical practice can also enhance student learning (Baldwin, Mills, Birks, & Budden, 2014). By applying principles of experiential learning (Kolb, 2015), we assert that nursing students benefit from direct contact with seriously ill patients and their families. Experiential learning methods are useful in increasing palliative care competency (Kaasalainen, Brazil, & Kelley, 2014; Shahid et al., 2018).
To this end, we developed the Comfort Shawl Project, which is experiential service-learning project that immerses senior nursing students in palliative care (Glover, Horgas, Castleman, Turpening, & Kittelson, 2017). In brief, students attend the interdisciplinary team meetings of the palliative care consult service, gift handcrafted shawls to patients receiving palliative care, and participate in extracurricular events focused on palliative care, attitudes toward death and dying, and engagement with the local community. The handcrafted shawls are made by volunteers, including community volunteers, alumni, and nursing students. One example of an extracurricular activity students participate in is joining a crafting circle with volunteers who donate shawls to the project. Along with nurses, physicians, social workers, and others on the palliative care team, students identified patients and families who might like to receive a shawl. During the gifting process, students document thoughts and feelings about their experience. Unlike clinical rotations, the main objective when gifting shawls is to engage in communication and experience forming a caring relationship with the patient and family. Students participating in the year-long Comfort Shawl Project report that they feel much better prepared to care for dying patients during their first year of professional practice (Glover et al., 2017). The aim of the study was to more formally analyze nursing students' experiential learning as they gifted comfort shawls.
Students' experiences were assessed using a Three Words task and a Gifting Reflection narrative. Content analysis is a method of analyzing the frequency of specific terms or concepts (Seale, 2012); this was used to identify themes in the Three Words task. The Gifting Reflection narratives further demonstrate the identified themes. The research was conducted at a large academic medical center in the southern United States. All procedures were approved by the University of Florida's institutional review board.
Participants and Procedures
Participants were nine female senior nursing students who voluntarily participated in the Comfort Shawl Project and this study between June 2016 and April 2017. Each week over the 11-month period, two of the nine students attended the hospital's palliative care team meeting to discuss patient care and determine which patients might like to receive a shawl. As such, the number of shawls gifted each week varied. Students went on rounds in pairs to gift the shawls, visiting with each patient for 5 to 15 minutes. Patients were shown multiple shawls and asked if they would like to choose one. In cases where the patient was unresponsive, students interacted with the family or the nurse caring for the patient. Students completed the Gifting Reflection during or immediately after their rounds.
Three Words. This task was used to capture the feeling in the room when the nursing students were interacting with patients and/or families. The instructions were:
After you offer each comfort shawl, think about your personal experience as a nurse. Immediately after each visit, write down three words or three brief phrases that describe your experience. Do this before going to the next patient and even when the patient [or] family was unresponsive or declined a shawl. Do not share your three words with your student colleague. There are no right or wrong answers. Simply reflect on your experience.
Gifting Reflections. Students wrote a reflection about the gifting experience. The instructions were to comment on their experience of gifting a shawl. Most students described the interaction and commented on things such as who was in the room, the patient condition, and the patient or family response to receiving a shawl. These handwritten narratives were generally one to two paragraphs.
Three Words. Data were coded by three research assistants. The coding process was supervised by one of the co-authors (S.B.), who has extensive experience in content analysis methods. The unit of analysis for coding was each individual word. However, coders saw the words in sets of three, as produced by participants. This was done to offer context for the individual responses, ensuring more accurate coding. Coders viewed each word as describing the feel of the hospital room and not as specific to any one person or event in the room.
Coders were trained using pilot data—Three Words data from previous cohorts of students involved with the Comfort Shawl Project. As a first step, to help with codebook development, a word cloud was generated (Figure 1) using a free word cloud generator ( https://www.jasondavies.com/wordcloud/). The code-book categories were then developed through inspection of the word cloud, the pilot data iterating with the goals of the Comfort Shawl Project, and discussions with the research team.
Word cloud showing nursing students' Three Words task responses.
After codebook development was completed, reliability was attained using a subsample of 15% of the study data (kappa ranged from .82 to .88 across three coders). At the beginning of each coding session, coders reread the coding categories section of the codebook. They then began coding, reading each set of three words fully to gain a general feel for the nursing student's experience. The coders then repeated this procedure for each set of words, provided by a different nursing student, to prevent any bias about individual participants' three words responses across all shawls gifted. The data were coded in sets of 25 to 30 responses to the Three Words task. After each set, coders discussed any differences to resolve discrepancies and prevent coder drift. If the coder felt unsure about a word's meaning, definitions were researched using the online version of the Merriam-Webster™ dictionary ( https://www.merriam-webster.com). If a word did not belong in any category, it was coded as miscellaneous. Instances where no word was provided were coded as missing data.
Gifting Reflections. The gifting reflections that corresponded with the Three Words task were reviewed to identify exemplars. Reflections providing examples of each of the Three Words themes are described in the Results.
The pilot data on the Three Words task and Gifting Reflections were compiled in an Excel® workbook. The study data were entered using SPSS® software version 25, and content was verified by a second member of the research team.
Participants were nine female White senior nursing students between 20 to 23 years of age who voluntarily participated in the Comfort Shawl Project and this study. Between June 2016 and April 2017, the students gifted a total of 214 comfort shawls to patients and their families receiving palliative care during hospitalization. Shawl recipients included 118 females and 96 males ranging in age from 9 days to 103 years old, hospitalized for a variety of illnesses including cancer, heart disease, dementia, stroke, and congenital conditions.
With the Three Word responses given after gifting each shawl, a total of 642 responses were expected. Only one student during one gifting experience responded with two words instead of three. Therefore, one word was coded as missing data (0.15%).
Content Analysis: Three Words Task
Content analysis involved the following categories:
- Comfort and kindness: Warmth, compassion, and family.
- Thankfulness and appreciation: Gratitude, rewarding, and humility.
- Happiness and delight: Amused, content, and uplifted.
- Calm and reflective: Accepting, quiet, and thoughtful.
- Sorrow and need: Tired, alone, and scared.
The frequency of each category is shown in Figure 2. The category Comfort and Kindness was the most prevalent with 213 of the 642 words (33.2%). In descending order, the remaining categories were Thankfulness and Appreciation (23.2%), Happiness and Delight (13.2%), Calm and Reflective (11.7%), and Sorrow and Need (11.4%). The remainder were coded as miscellaneous or missing data.
Coding categories and the frequency of codes used for the Three Words task.
Gifting Reflections That Support the Three Words Concepts
The following reflections exemplify and support the most commonly used coding categories identified in the Three Words task (key concepts are underlined).
Comfort and Kindness. A nursing student wrote the following reflection after visiting a young boy with leukemia:
When we went into the patient's room he was sleeping soundly. We were going to leave the shawl on his bed for him; however, he opened his eyes and said he wanted the shawl on him. I covered him up with the shawl and he immediately grabbed it and snuggled up next to it. I immediately got goose-bumps. Having cancer, especially at such a young age, must be so hard. It was incredible to see how quickly the shawl made him happier and more comfortable. It made my heart full and happy.
Thankfulness and Appreciation. A nursing student wrote the following reflection after visiting a woman in her sixties with myelofibrosis:
The patient was lying in bed and stated that she did not want a shawl; however, her daughter seemed to be in some emotional distress and gladly accepted it. She was so thankful and loved the blue color. She seemed to need it more than the patient at this time and they both showed appreciation for it.
Happiness and Delight. A nursing student wrote the following reflection after visiting a woman in her fifties undergoing stem cell transplant:
The patient was alert and sitting in a chair by the window. She said that purple was her favorite color and she was so happy to have a fashionable way to keep her warm. She said she had a lot of nausea the night before but was now feeling much better.
Calm and Reflective. A nursing student wrote the following reflection after visiting a man in his sixties with stroke:
When we arrived [in] the patient's room, it was a very peaceful setting. The butterfly was on the door [signifying the patient was actively dying] and Frank Sinatra was playing softly in the background. It was sad to see him alone but the palliative care team said that his family would be there and would really appreciate a shawl.
Sorrow and Need. A nursing student wrote the following reflection after visiting an infant boy with leukemia:
Both the mother and father were in the room with their baby. The father was crying on the phone. It was very sad to see how difficult this was for him. I gave the gifted shawl to the mother. She was very appreciative, but I could tell she was really suffering. Gifting to this young, innocent baby really puts things into perspective for me. It made me realize that I shouldn't complain about trivial things like my school work because I am lucky to be healthy and be able to do the things that I love.
This article highlights the experiences of senior nursing students during immersion in a palliative care experiential learning program, the Comfort Shawl Project. Students participating in this program interacted with patients receiving palliative care by gifting them with a handmade comfort shawl. In addition to the direct patient–family interaction, students engaged in a variety of educational activities and experiences that prepare them to provide compassionate and patient-centered nursing care to those facing serious illness. The results of this study indicate that students, when asked to reflect on their interactions, overwhelmingly perceive Comfort and Kindness and Thankfulness and Appreciation as their prevailing experience. As would be expected in a palliative setting, in some cases students reported Sorrow and Need, but it is noteworthy that their interactions also involved positive themes of Happiness and Delight and Calm and Reflective as equally prevalent. These findings align with research demonstrating nurses' experience in caring for dying patients is influenced by the extent to which they have a supportive learning environment and positive nursing role models (Anderson, Kent, & Owens, 2015). In addition, results are in line with a meta-analysis of the positive affect of service-learning that shows students benefit in several areas, including attitudes toward self and social skills (Celio, Durlak, & Dymnicki, 2011). Students engaged in the Comfort Shawl Project activities outside of normal coursework and clinical education experiences and had the opportunity to personally engage in applying palliative care principles.
The two most common student responses were reflected by Comfort and Kindness and Thankfulness and Appreciation. Caring and compassion are key nursing concepts (Pazar, Demiralp, & Erer, 2017). Comfort care is included in most undergraduate nursing curricula but its importance may be undervalued as students strive to learn hands-on psychomotor skills. An immersion experience in providing comfort to palliative care patients may help students to connect with the fundamental human importance of this concept. Thankfulness and Appreciation was also a common theme. Indeed, many times shawl recipients were surprised by the gift and expressed appreciation that the student was not there to “take something from them.” This perception of the nurse as giving, not taking, is crucial to fostering compassionate communication in palliative care. In addition, as part of the interactional process, the students likely contributed to the thankful feelings in the room: patients were thankful for the experience and students reported being thankful for a meaningful experience—the opportunity to apply warm, caring palliative principles, or to be appreciated by the patient–family. Without specific interviews or explicit instructions to reflect on particular aspects of the gifting experience, it is impossible to discern the exact events, interactions, or feelings that occurred. Future research will seek to clarify the nature of communication exchanges that occur during gifting. Nonetheless, it is gratifying that students recognize and report not largely sorrow and need, but feelings of comfort, kindness, thankfulness, and appreciation amid interacting with patients facing a serious illness and their families.
There are several important limitations in applying our findings to clinical practice. First, the sample size is small and not representative of all nursing students. Palliative care research is a relatively new field of inquiry—a systemic review of palliative care undergraduate education shows only indirect evidence that patient care is positively affected (Centeno & Rodríguez-Núñez, 2015). Prospective and controlled studies are needed to further evaluate the effect of educational interventions on patient care. Second, the study took place at one academic medical center and may not apply to other settings. Third, the instructions for the Three Words and Gifting Reflections were general and nondirective. The goal was to avoid restraining students' experiences and to allow them to reflect more generally. In future research, we plan to structure the tasks in an effort to ascertain specific aspects of the interactions and to be more directive about which aspects of the interaction should be considered in the Three Words. Finally, although students' reflections were elicited as part of their immersion in palliative care learning through the Comfort Shawl Project, we cannot definitively attribute these findings to the program itself without a control group. These are issues that we seek to address in future work.
Students that participate in an experiential immersion in palliative care denote positive and valuable learning experiences in the words and narratives used to characterize their experiences as they gifted comfort shawls to patients facing serious illness and their families. The Comfort Shawl Project is an example of a program that provides explicit educational activities and experiences in palliative care that will prepare nurses to provide compassionate and patient-centered care to those facing serious illness.
- American Nurses Association. (2016). Nurses' roles and responsibilities in providing care and support at the end of life. Retrieved from https://www.nursingworld.org/∼4af078/globalassets/docs/ana/ethics/endoflifepositionstatement.pdf
- Anderson, N.E., Kent, B. & Owens, R.G. (2015). Experiencing patient death in clinical practice: Nurses' recollections of their earliest memorable patient death. International Journal of Nursing Studies, 52, 695–704. http://dx.doi.org/10.1016/j.ijnurstu.2014.12.005 doi:10.1016/j.ijnurstu.2014.12.005 [CrossRef]
- Baldwin, A., Mills, J., Birks, M. & Budden, L. (2014). Role modeling in undergraduate nursing education: An integrative literature review. Nurse Education Today, 34(6), e18–e26. doi:10.1016/j.nedt.2013.12.007 [CrossRef]
- Celio, C.I., Durlak, J. & Dymnicki, A. (2011). A meta-analysis of the impact of service-learning on students. Journal of Experiential Education, 34, 164–181. doi:10.1177/105382591103400205 [CrossRef]
- Centeno, C. & Rodríguez-Núñez, A. (2015). The contribution of undergraduate palliative care education: Does it influence the clinical patient's care?Current Opinion in Supportive and Palliative Care, 9, 375–391. doi:10.1097/SPC.0000000000000169 [CrossRef]
- Dunn, K.S., Otten, C. & Stephens, E. (2005). Nursing experience and the care of dying patients. Oncology Nursing Forum, 32, 97–104. doi:10.1188/05.ONF.97-104 [CrossRef]
- Ferrell, B., Malloy, P., Mazanec, P. & Virani, R. (2016). CARES: AACN's new competencies and recommendations for educating undergraduate nursing students to improve palliative care. Journal of Professional Nursing, 32, 327–333. doi:10.1016/j.profnurs.2016.07.002 [CrossRef]
- Glover, T.L., Horgas, A.L., Castleman, J., Turpening, P. & Kittelson, S. (2017). An experiential learning approach to primary palliative care nursing education: The comfort shawl project. Journal of Hospice & Palliative Nursing, 19, 534–538.
- Kaasalainen, S., Brazil, K. & Kelley, M.L. (2014). Building capacity in palliative care for personal support workers in long-term care through experiential learning. International Journal of Older People Nursing, 9, 151–158. doi:10.1111/opn.12008 [CrossRef]
- Kolb, D.A. (2015). Experiential learning: Experience as the source of learning and development (2nd ed.). Upper Saddle River, NJ: Pearson Education.
- Pazar, B., Demiralp, M. & Erer, I. (2017). The communication skills and the empathic tendency levels of nursing students: A cross-sectional study. Contemporary Nurse, 53, 368–377. doi:10.1080/10376178.2017.1359101 [CrossRef]
- Peters, L., Cant, R., Payne, S., O'Connor, M., McDermott, F., Hood, K. & Shimoinaba, K. (2013). How death anxiety impacts nurses' caring for patients at the end of life: A review of literature. The Open Nursing Journal, 7, 14–21. doi:10.2174/1874434601307010014 [CrossRef]
- Seale, C. (2012). Researching society and culture (3rd ed.). Thousand Oaks, CA: Sage.
- Shahid, S., Ekberg, S., Holloway, M., Jacka, C., Yates, P., Garvey, G. & Thompson, S.C. (2018). Experiential learning to increase palliative care competence among the Indigenous workforce: An Australian experience. BMJ Supportive & Palliative Care Published Online First: 20 January 2018. doi:10.1136/bmjspcare-2016-001296 [CrossRef]
- Shaw, P.A. & Abbott, M.A. (2017). High-fidelity simulation: Teaching end-of-life care. Nurse Education Today, 49, 8–11. http://dx.doi.org/10.1016/j.nedt.2016.10.014 doi:10.1016/j.nedt.2016.10.014 [CrossRef]