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Loss, grief and bereavement in interprofessional education, an example of process: Anecdotes and accounts
Nurse Education in Practice (2005) 5, 281–288
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Loss, grief and bereavement in interprofessional education, an example of process: Anecdotes and accounts Wendy Greenstreet
*
Department of Adult Nursing Studies, Faculty of Health, Canterbury Christ Church University College, Canterbury, Kent CT1 1QU, UK Accepted 25 February 2005
KEYWORDS
Summary The example of educational provision considered here is an elective module on an Interprofessional Masters programme that demonstrates the use of research based accounts and clinical anecdotes to effect learning and so, potentially, to enhance professional practice. Those who have suffered a significant loss, whether of an individual, or, part of their physical, psychological, social or spiritual selves, will present in most health and social care settings. An educational forum provides the opportunity to explore theory that promotes an understanding of loss and the process of grief as well as an awareness of the levels of support available for the bereaved. The nursing presence in health care has fuelled experienced nurses’ adeptness at niche roles, and filling gaps in service provision. Interprofessional education potentially strengthens competence and enhances confidence in cross-boundary working, increasing the permeability of professional boundaries and reflecting role overlap. An interprofessional context also allows a sharing of views that enhances a collegiate ambience. The inherent challenge is to identify the educational process that best makes theory accessible and meaningful in practice. Module evaluation confirmed that students were able to evaluate the relevance of theory in practice and that the teaching sequence that had evolved resembled a modified constructivist format. c 2005 Elsevier Ltd. All rights reserved.
Interprofessional education; Loss; Grief process; Bereavement
Introduction * Tel.: +44 1227 782627. E-mail address: [email protected].
Health and social care professionals bring their experience of encounters with practice realities to educational contexts. These provide a rich
1471-5953/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2005.02.003
282 resource of ‘stories’ or anecdotes about real incidents or persons, ‘the everyday stuff of clinical practice’ (Aldridge, 2000, p. 24). They provide a subjective, qualitative view of events. Education centred on relating theory to practice can ill afford to ignore anecdotes as the ‘very stuff of social life and the fabric of communication in the healing encounters’ (Aldridge, 2000, p. 24). An account on the other hand, demands a more objective, quantitative record. However, reports that painstakingly avoid anecdotal evidence may well become anecdotal themselves (Miller, 1998). The example of educational provision considered here is an elective module on an Interprofessional Masters programme that encourages students to critically examine the relevance of research accounts about loss, grief and bereavement to real anecdotes from their practice. In this way loss is explored as a wide concept and students from different professions assess the potential for integration of theoretical perspectives into varied health and social care practice contexts. Interprofessional ambience, teaching sequence and educational process are considered. Evaluation reflects that this process enabled students to achieve module learning outcomes.
Loss, grief and bereavement The disciplinary knowledge embedded in different professions can preclude collegiate working. Contemporary philosophy advocating ‘holistic’ care is ‘divergent’ (George and Sykes, 1997), challenging a biomedical model which supports the ‘false god of objectivity’ (Fish, 1998) and its worship of the visible and quantifiable. The consequent shift in focus from efficiency and task to authentic relationship (Aranda, 2001), responsive to patient//client need and reciprocal in nature (Aranda and Street, 1999), raises the profile of the more nebulous psycho/social/spiritual perspectives of care. This shift potentiates the need for ‘emotional labour’ (James, 1989) rather than observable behavioural professional activity. The novice entering a profession looking to the example of experienced practitioners may well miss the nuance of such care or observe distancing techniques used as a defence against the demands of ‘emotional labour’ (Mackintosh, 2004). Those who have suffered a significant loss, whether of an other, or, part of their physical, psychological, social or spiritual selves will be present in most health and social care settings. So the intuitive professional, having gained more experience, may identify the need for a greater understanding of how to provide appropriate support.
W. Greenstreet An educational forum provides the opportunity to explore theory that promotes an understanding of loss and the process of grief as well as an awareness of the levels of support available for the bereaved. An interprofessional context allows a sharing of views that enhances a collegiate ambience. The inherent challenge is to identify the educational process that best makes theory accessible and meaningful in practice.
Interprofessional education Scholes and Vaughan (2002) suggest the terms multidisciplinary, multiprofessional and interprofessional are often used interchangeably and without careful consideration. They go on to describe the term interprofessional as one that refers to interactions between team members and multiprofessional as referring more readily to a group of people who come from different health and social care professions but do not necessarily interact. Multidisciplinary refers to practitioners who share the same professional background but practice within different specialities. The group of 17 students that opted for this module were clearly multiprofessional, including representation from socially focussed work (5), occupational therapy (3), radiography (1), nursing (6) and midwifery (2). They were also multidisciplinary with a wide variety of institutional and non-institutional practice contexts represented both within the professional groups and also between them. These included Intensive Care, Renal Specialist Care, Mental Health, Rehabilitation, Sonography, and Chronic Care contexts involving patients with debilitating diseases such as motor neurone disease and dementia. The use of clinical anecdotes encouraged interprofessional interaction in the group. Modernised health and social services potentially undermine professional identity (Biggs, 1997; Adams, 2003). Cross-boundary working and interprofessional education strike at the heart of conventional professional socialisation, undermining modernist tribalism (Beattie, 1995) and present a postmodern challenge to the power of professionals. However, interprofessional education that enhances cross-boundary working, and increases permeability of professional boundaries, can reflect role overlap and facilitate fluidity in staff utilisation and prevent duplication. Strengthening competence within overlap will harness experienced professionals’ adeptness in using their skills (Scholes and Vaughan, 2002). This does not deny
Loss, grief and bereavement in interprofessional education, an example of process the identity located in core professional expertise and the importance of accessing wider multiprofessional input according to patient need so that ‘core’ professional expertise is acknowledged. In this case, module content uses accounts of contemporary truth(s) regarding the nature of loss and the process of grief for interprofessional discourse to explore anecdotes sourced from practice experience illustrating multiprofessional and multidisciplinary support for those who have suffered loss. In identifying levels of support needed by patients, students potentially grow more confident of those supportive skills that they own that fall within ‘role overlap’. This also promotes greater clarity of the support that is profession specific requiring referral. In this way core professional expertise is reaffirmed.
The shape of the module The module constituted an elective option accessed in the first two years (or the equivalent for part time students) on an Interprofessional Masters programme. In this instance, 15 students registered on a Masters programme opted for this module and two students accessed the module as associate students. The aim of the module was to encourage students to critically examine the relevance and potential for integration of theoretical perspectives about loss, grief and bereavement into health and social care practice. Most of the forty hours of
Table 1
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taught content chosen to facilitate achievement of learning outcomes (Table 1), was delivered over three units, each of two days duration, with a one month interval between each unit. Remaining taught time was used for tutorials, access to provision supporting the development of skills facilitating study on the Masters programme, for example, the use of virtual learning environments, and shared study days accessible to all Masters students. The style of delivery, assessed course work and availability of learning resources were designed to enable student progression in programme key skills (Table 2).
Unit one The timetabling of each unit was themed. The first unit focussed on exploring loss. The intent of starting with experiential exploration of a personal lifespan perspective, personal and professional communication skills and professional vulnerability in relation to loss was to use an educational forum to raise awareness of the need for support for both those who have lost and those who care for them. Campbell (1984) points out the high cost of care in relation to human resources due to constant presence with, and sharing, suffering. The carer as a professional cannot be separated from the carer as a person (Martocchio, 1987). This investment of self is described by Campbell (1984) as ‘moderated love’ and takes the form of companionship; a ‘good companion’ (p. 49) is one who shares the route but allows patients/clients to make their
Learning outcomes
By the end of the module students should be able to: Critically evaluate theories of loss, grief and bereavement in health and social care professional practice Analyse evidence of cultural and spiritual determinants of interpreting loss and the style of grief Discuss the impact of ethical dilemmas on bereavement Reflect critically on the role of communication skills as a resource for personal and professional support Appraise the relevance of social and health policy in provision of care for the bereaved
Table 2
Key skills
Communication Application of number Information technology
Critically evaluate empirical and theoretical literature Critically interpret data in bereavement research studies Access and use efficiently the internet, college databases and computer software for assignment content and presentation Working with others Work with students from other professions to share relevant practice experience and enhance their own and others learning Problem solving Reflect critically on interprofessional practice in supporting the bereaved and consider strategies for improvement Improving own learning and performance Determine strategies for improving own practice in bereavement care
284 own journey. This sharing of self with those who are suffering enriches the quality of care but renders the ‘self’, that is the professional, vulnerable. The need for professionals to preserve personal integrity needs to be acknowledged (Davies and Oberle, 1990) and facilitated. Theoretical input included in unit one introduced loss as a wide concept, not just in relation to bereavement as ‘the loss of someone significant through that person’s death’ (Stroebe and Schut, 1998), which could be time limited and construed as related only to the death of a significant other, but bereavement as the state of being deprived of something; ‘that is, bereavement identifies the objective situation of individuals who have experienced loss’ (Corr et al., 1997). This later view incorporates a much wider perspective in relation to health and social care, including disability and the non-finite nature of associated loss(es). Published accounts considered included: grief work (Parkes, 1996), assumptive world, psychosocial transition (Parkes, 2000), anticipatory grief (Fulton, 2003), the cyclic nature of non-finite grief (Bruce and Schultz, 2001) and a review of theory of dying (Copp, 1998).
Unit two The second unit focussed on the process of grief. Published accounts of traditional views considered included attachment theory and the phase model of grief (Bowlby, 1969; Parkes, 1972, 1986, 1996), tasks of mourning (Worden, 1982, 1991), and the more contemporary views reflected by the dual process model (Stroebe and Schut, 1999), a new model of grief (Walter, 1996) and work on continuing bonds (Klass et al., 1996). Systems theory (e.g., Kissane and Block, 2002) provided a tool for exploration of the process of grief in relationship and loss and a wide review of literature (e.g., Staudacher, 1991; Martin and Doka, 2000) outlined gender based issues. Spiritual and cultural perspectives on grief centred on meaning and loss (Frankl, 1984; de Vries, 1997; Speck, 2001) and ritual (Wikan, 1988; Parkes et al., 1997; Grainger, 1998; Walter, 1999).
Unit three The third unit considered social, political and ethical perspectives of loss, grief and bereavement. Government documents provided published accounts of guidance/targets. Content included suicide and effecting government targets to reduce incidence (Department of Health, 1999) and levels
W. Greenstreet of support (National Institute of Clinical Excellence, 2004) and appropriate referral for the bereaved. Legal and professional guidance on decision making in situations presenting ethical dilemmas was also considered. Student seminars were also presented in unit three. These offered a formative opportunity to present an outline of work prepared for coursework assignment.
Educational process and method Milligan (1995) defines andragogy as: the facilitation of adult learning that can best be achieved through a student centred approach that, in a developmental manner, enhances the students’ self-concept, promotes autonomy, selfdirection and critical thinking. Establishing a climate conducive to learning is a fundamental element of andragogy (Knowles, 1990). Introductions encouraging openness and authenticity are important if students are to share sensitive personal and practice experiences to enhance learning. Mutual trust is strengthened in establishing ground rules including the importance of confidentiality of all shared narrative both in containing its use for exploration and debate within the confines of the classroom, and in complying to professional codes (College of Occupational Therapists, 2000; Nursing and Midwifery Council, 2002; College of Radiographers, 2004; General Social Care Council, 2004). Problem-based learning, also known as enquiry based learning, is promoted as fulfilling andragogical philosophy in encouraging a shift to studentcentred education using process-oriented methods. Its use is increasingly evident in the education of health professionals (e.g., Newman, 2003; Bechtel et al., 1999). However, Milligan (1999) suggests problem based learning limits emancipatory generation of knowledge and is potentially rather than necessarily andragogical in its educational ambience. The pre-selection of scenarios as triggers in problem-based learning undermines student choice. Brookfield (1993) argues that self directed learning may result in compromise which supports social conformity rather than bring students to an uncomfortable and often unsought confrontation with inequitable political realities, and with their own acknowledged collusion in these realities. Milligan (1999) goes on to advocate that andragogy should embrace a wide range of methods to facilitate learning.
Loss, grief and bereavement in interprofessional education, an example of process A variety of methods were used in the delivery of this module, which included some experiential exploration as described in unit one, some role play in unit two and discussion based activity in unit three. However, it is particularly those sessions that utilised student anecdotes of practice reality in relation to critical evaluation of presented theory that will be considered here. In these anecdotes, students presented their own problem based scenarios that provided an uncensored look at real practice. Student-centred humanistic theory is closely related to phenomenological philosophy, which asserts that reality lies in an individual’s perception of the event and not in the event itself. Aldridge (2000) claims that it is not only the content but the way it is told that reflects the validity of the ‘story’. The reinterpretation of the story from multiprofessional and multidisciplinary perspectives is potentially emancipatory in challenging assumptive knowledge conveyed in relating narrative. The use of student anecdote shifted as the module progressed. In unit one, during the delivery of an overview of accounts of theory related to loss, student anecdotes were ad hoc and relatively spontaneous as were questions. Pre-module reading regarding theories of dying was then used as a focus for discussion of relevance to practice and, again, short anecdotes were used to illustrate points raised. For unit two, students were asked to bring anecdotes from their practice experience that exemplified loss in that context. Following the delivery of an outline of accounts of traditional and contemporary theory these were used to critically evaluate the relevance of theory to practice. Anecdotes showed a predisposition by most students to apply traditional bereavement theory to practice although there was some consensus that the process of grief was not time limited. In considering spiritual and cultural perspectives of grief, anecdotes were used to initiate the session; incidentally the group composition added richness to discussion. Short block provision facilitated access for students who lived at some distance from the educational institution delivering the module as well as those who lived locally. There was therefore representation of difference within British culture in the group. In addition, as one student was of Asian origin and three were European, the group also embodied difference across cultures. Scenarios of and from practice were then reviewed in relation to presented theory. In unit three seminars required students to outline a critical evaluation of theories of loss, grief and bereavement to their practice. In using anec-
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dote to exemplify issues these seminars provided the opportunity for interprofessional interaction.
Evaluation Research has evidenced the importance of evaluation in highlighting the value of exploring the theoretical basis of intended outcomes (McEvoy and Richards, 2003) to ensure educational provision is relevant and impacts professional practice (Jordan et al., 1999). Module evaluation constitutes part of Programme quality monitoring and so contributes to improving future delivery and potentially to Institutional Audit. Triangulation of evaluation strengthens feedback in determining the most significant achievement of learning and the greatest shortfalls. Student and module leader evaluation, comment from sessional contributors and student assessed work all provided sources of data.
Student evaluation Students voiced formative feedback in the throes of module delivery. Much of this was specific to the individual student but a shared request in unit one was for more time for discussion. Summative evaluation was achieved by the completion of a questionnaire providing some quantitative data and qualitative comment. This was distributed during the last day of the module. Feedback was overall positive. Students felt that the course achieved what it had set out to achieve. Comments included greater insight into and application of theory as well as the benefits of sharing the different perspectives and experiences of a multiprofessional group. The student seminar produced a mixed response. Some students commented on how beneficial they had found this forum and the feedback given. An equal number of students had found them unhelpful and suggested a one to one tutorial might be a better alternative. They also felt there was little guidance on what was expected from the presentations.
Student assessed work Results reflected a slightly positive distribution of academic ability within the group. The two associate students chose not to submit summative course work. Of the fifteen pieces of coursework submitted, two were referred, eight passed, four were good passes and one was excellent. Assessed work demonstrated student ability to critically evaluate the value of theories of loss, grief and
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W. Greenstreet
bereavement to their practice including relevant ethical, socio-cultural, spiritual and communication issues. Interestingly, in the same way that students’ use of anecdotes in class reflected a predisposition to apply psychologically based traditional bereavement theory to practice their selection of theory to evaluate in assessed work was predominantly traditional. This popularity of traditional theory may be that it is amenable to misinterpretation as being similar to the conventional medical model, grief constituting suffering as a problem implying the need for recovery rather than as a normal process (Costello, 1995). Another explanation is possibly Walter’s (1994) suggestion that normalizing the moving toward recovery response provides hope for professionals sharing the
pain of the bereaved. However, more than one third of the students made some reference to the more sociologically based contemporary theory, with a couple strongly supporting its relevance to their practice. Choice of theory was not profession specific.
Module leader evaluation Group dynamics contribute to an evolving rather than mechanistic plan of delivery of taught provision. Group cohesion facilitated an increasing shift from front loading taught theory to working from anecdotes of practice experience in relation to theoretical account. Facilitating access to published accounts of theory, as improved access to
Elicitation of ideas from anecdotes
Clarification and exchange of ideas in interprofessional discussion Input of theoretical account
Comparison with previous ideas
Restructuring of ideas
Evaluation of alternative ideas
Application of ideas to practice
Assessed coursework Review change in ideas
Figure 1
Teaching sequence that evolved: a modified constructivist format (adapted from Driver and Oldham, 1985).
Loss, grief and bereavement in interprofessional education, an example of process virtual learning environments makes electronic access to published material easier, will enable increased pre modular reading and increase opportunity for interprofessional discussion of relevance of theory to practice-based anecdotes. Initial seminar presentations were more inclusive of discussion, but as group size was relatively large and time pressed the presentations became more focused and less inclusive. Rather than retreat into individual tutorials and lose the opportunity for interprofessional debate centred on evaluating accounts of theory in real practice-base narrative, some experimentation in creative grouping and allocation of time might provide a better experience. Student requirement to use their allocated seminar time for formative presentation of coursework was the extent of guidance provided to all. Limited guidance was a positive intent to leave students free to present as they wished. Peer presentation can be uncomfortable as discussion potentially undermines treasured assumptions, but then, in a safe learning environment, uncomfortable and unsought confrontation may herald an emancipatory moment of development! Constructivist views regarding the creation of knowledge include three perspectives (Bruce and Weil, 1996). Firstly, a personalistic view referring to the unique internal frame of reference of each individual resulting in difference in conception and meaning of knowledge. Secondly, a social point of view in which groups inquire together and construct ideas; therefore, knowledge cannot be separated from the social process within which it is manufactured and, lastly, discipline based enquiry that helps students try on ideas and approaches in discipline processing models. The process of education is building knowledge and checking it against the concepts of others. The module started with a personal view of loss, then used anecdote from the social context of practice in the social process of education to critically evaluate theoretical account and facilitate interprofessional discourse enabling ideas to be tried in a multiprofessional context. The teaching sequence that evolved appeared to resemble a modified constructivist format (Fig. 1).
Conclusion Theoretical account concerning loss, grief and bereavement needs to be freed from incarceration in academic debate by meaningful interpretation within educational settings. The appropriateness and currency of research underpinning developments strengthens the case for challenging the old and supporting the new for students practicing in a
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contemporary clinical ambience of evidence based practice. Health and social care professionals need to be encouraged to consider what is new in recent theory, its research base and how these compare with the truth of their experience in practice. Learning is facilitated by moving from the known, and what ‘feels’ comfortable, onwards to pioneer new thought, but presented in terms of practice realities. Reflection in practice (Schon, 1988) may well have identified a problem, a shortfall in confidence in practice that motivated students to opt for an elective module that provided formal opportunity to reflect on practice (Schon, 1988) in relation to understanding loss and the process of grief and providing appropriate support for the bereaved. Problem or enquiry based learning might limit student choice and emancipatory generation of knowledge. However, the use of anecdotes that are ‘the everyday stuff of clinical practice’ (Aldridge, 2000, p. 24) provide the known realities against which theoretical account can be critically evaluated. A modified constructivist teaching sequence contributed to an evaluation that confirmed students had achieved their learning outcomes. This paper has considered the delivery of a module that exemplified the use of anecdote and account in educational practice. It is in itself an anecdote that may be of interest to others offering similar provision. The qualitative ‘stories’ of practice shared within a safe learning environment were utilised to achieve learning outcomes that were quantitatively measured in summatively assessed work.
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288 Bruce, J., Schultz, C., 2001. Nonfinite Loss and Grief. Jessica Kingsley, London. Bowlby, J., 1969. Attachment and Loss. Attachment, vol. 1. Hogarth, London. Campbell, A.V., 1984. Moderated Love, a Theology of Professional Care. SPCK, London. College of Occupational Therapists, 2000. Code of Ethics and Professional Conduct for Occupational Therapists. College of Occupational Therapists, London. College of Radiographers, 2004. Statements for Professional Conduct. The College of Radiographers, London. Copp, G., 1998. A review of current theories of death and dying. Journal of Advanced Nursing 28 (2), 382–390. Corr, C.A., Nabe, C.M., Corr, D.M., 1997. Death and Dying, Life and Living. Brooks Cole, Pacific Grove. Costello, J., 1995. Helping relatives cope with the grieving process. Professional Nurse 11 (2), 89–92. Davies, B., Oberle, K., 1990. Dimensions of the supportive role of the nurse in palliative care. Oncology Nursing Forum 17 (1), 87–94. de Vries, B., 1997. Kinsip bereavement in later life. Omega 35 (1), 1–7. Department of Health, 1999. National Service Framework for Mental Health. DoH, London. Driver, R., Oldham, V., 1985. A Constructivist Approach to Curriculum in Science. Paper prepared for the Symposium ‘A personal Construction of Meaning in Educational Settings’, British Educational Research Association, Sheffield, August. Fish, D., 1998. Appreciating Practice in the Caring Professions: Refocusing Professional Development and Practitioner Research. Butterworth Heinemann, Oxford. Frankl, V., 1984. Man’s Search for Meaning. WSP, New York. Fulton, R., 2003. Anticipatory mourning: A critique of the concept. Mortality 8 (4), 342. General Social Care Council, 2004. Codes of Practice for Social Care Workers and Employers. General Social Care Council, London. George, R., Sykes, J., 1997. Beyond cancer? In: Clark, D., Hockley, J., Ahmedzai, S. (Eds.), New Themes in Palliative Care. Open University Press, Buckingham. Grainger, R., 1998. The Social Symbolism of Grief and Mourning. Jessica Kingsley, London. James, N., 1989. Emotional labour: Skill and work in social regulation of feelings. Sociological Review 37 (1), 15–42. Jordan, S., Coleman, M., Hardy, B., Hughes, D., 1999. Assessing educational effectiveness: The impact of a specialist course on the delivery of care. Journal of Advanced Nursing 3094, 796–807. Kissane, D.W., Block, S., 2002. Family Focused Grief Therapy. Open University Press, Buckingham. Klass, D., Silverman, P.R., Nickman, S.L. (Eds.), 1996. Continuing Bonds, New Understandings of Grief. Taylor and Francis, Philadelphia. Knowles, M., 1990. The Adult Learner: A Neglected Species. Gulf Publishing, Houston. Mackintosh, C., 2004. Professional attitudes to pain and the impact of socialisation. RCN Pain Points Summer, 1–3. Martocchio, B.C., 1987. Authenticity, belonging, emotional closeness, and self-representation. Oncology Nursing Forum 14 (4), 23–27.
W. Greenstreet Martin, T., Doka, K., 2000. Men Don’t Cry . . . Women Do. Transcending Gender Stereotypes of Grief. Brunner/Mazel, Philadelphia. McEvoy, P., Richards, D., 2003. Critical realism: A way forward for evaluation research in nursing? Journal of Advanced Nursing 43 (4), 411–420. Miller, R., 1998. Epistemology and psychotherapy data: The unspeakable, unbearable, horrible truth. Clinical Psychology: Science and Practice 5 (2), 242–250. Milligan, F., 1995. In defence of andragogy. Nurse Education Today 15, 22–27. Milligan, F., 1999. Beyond the rhetoric of problem-based learning: Emancipatory limits and links with andragogy. Nurse Education Today 19, 548–555. National Institute of Clinical Excellence, 2004. Improving Supportive and Palliative Care for Adults with Cancer. NHS, NICE. Newman, M., 2003. A Pilot Systematic Review and Meta-analysis on Effectiveness of Problem Based Learning. LTSN. Nursing and Midwifery Council, 2002. Code of Professional Conduct. NMC, London. Parkes, C.M., 1972. Bereavement, Studies of Grief in Adult Life. Penguin, Harmondsworth. Parkes, C.M., 1986. Bereavement, Studies of Grief in Adult Life. Tavistock, London. Parkes, C.M., 1996. Bereavement, Studies of Grief in Adult Life. Routledge, London. Parkes, C.M., 2000. Bereavement as a psychosocial transition, processes of adaption to change. In: Dickenson, D., Johnson, J., Katz, J.S. (Eds.), Death, Dying and Bereavement. Sage/ Open University Press, London, pp. 325–331. Parkes, C.M., Laungani, P., Young, B., 1997. Death and Bereavement Across Cultures. Routledge, London. Schon, D., 1988. Educating the Reflective Practitioner. JosseyBass, California. Scholes, J., Vaughan, B., 2002. Cross-boundary working: Implications for the multiprofessional team. Journal of Clinical Nursing 11 (3), 399–408. Speck, P., 2001. Spirituality and well-being in women over 45 years – a topic ripe for study? Pennell Initiative for Women’s Health, Oxford. Staudacher, C., 1991. Men and Grief. New Harbinger, California. Stroebe, M., Schut, H., 1998. Culture and grief. Bereavement Care 17 (1), 7–11. Stroebe, M., Schut, H., 1999. The dual process model of coping with bereavement: Rationale and description. Death Studies 23, 197–224. Walter, T., 1994. The Revival of Death. Routledge, London. Walter, T., 1996. A new model of grief: Bereavement and biography. Mortality 1, 7–25. Walter, T., 1999. On Bereavement, the Culture of Grief. Open University Press, Buckingham. Wikan, U., 1988. Bereavement and loss in two muslim communities: Egypt and Bali compared. Social Science and Medicine 27, 451–460. Worden, J.W., 1982. Grief Counselling and Grief Therapy. Springer, New York. Worden, J.W., 1991. Grief Counselling and Grief Therapy, a Handbook for the Mental Health Practitioner. Routledge, London.
Nurse Education in Practice www.elsevierhealth.com/journals/nepr
Loss, grief and bereavement in interprofessional education, an example of process: Anecdotes and accounts Wendy Greenstreet
*
Department of Adult Nursing Studies, Faculty of Health, Canterbury Christ Church University College, Canterbury, Kent CT1 1QU, UK Accepted 25 February 2005
KEYWORDS
Summary The example of educational provision considered here is an elective module on an Interprofessional Masters programme that demonstrates the use of research based accounts and clinical anecdotes to effect learning and so, potentially, to enhance professional practice. Those who have suffered a significant loss, whether of an individual, or, part of their physical, psychological, social or spiritual selves, will present in most health and social care settings. An educational forum provides the opportunity to explore theory that promotes an understanding of loss and the process of grief as well as an awareness of the levels of support available for the bereaved. The nursing presence in health care has fuelled experienced nurses’ adeptness at niche roles, and filling gaps in service provision. Interprofessional education potentially strengthens competence and enhances confidence in cross-boundary working, increasing the permeability of professional boundaries and reflecting role overlap. An interprofessional context also allows a sharing of views that enhances a collegiate ambience. The inherent challenge is to identify the educational process that best makes theory accessible and meaningful in practice. Module evaluation confirmed that students were able to evaluate the relevance of theory in practice and that the teaching sequence that had evolved resembled a modified constructivist format. c 2005 Elsevier Ltd. All rights reserved.
Interprofessional education; Loss; Grief process; Bereavement
Introduction * Tel.: +44 1227 782627. E-mail address: [email protected].
Health and social care professionals bring their experience of encounters with practice realities to educational contexts. These provide a rich
1471-5953/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2005.02.003
282 resource of ‘stories’ or anecdotes about real incidents or persons, ‘the everyday stuff of clinical practice’ (Aldridge, 2000, p. 24). They provide a subjective, qualitative view of events. Education centred on relating theory to practice can ill afford to ignore anecdotes as the ‘very stuff of social life and the fabric of communication in the healing encounters’ (Aldridge, 2000, p. 24). An account on the other hand, demands a more objective, quantitative record. However, reports that painstakingly avoid anecdotal evidence may well become anecdotal themselves (Miller, 1998). The example of educational provision considered here is an elective module on an Interprofessional Masters programme that encourages students to critically examine the relevance of research accounts about loss, grief and bereavement to real anecdotes from their practice. In this way loss is explored as a wide concept and students from different professions assess the potential for integration of theoretical perspectives into varied health and social care practice contexts. Interprofessional ambience, teaching sequence and educational process are considered. Evaluation reflects that this process enabled students to achieve module learning outcomes.
Loss, grief and bereavement The disciplinary knowledge embedded in different professions can preclude collegiate working. Contemporary philosophy advocating ‘holistic’ care is ‘divergent’ (George and Sykes, 1997), challenging a biomedical model which supports the ‘false god of objectivity’ (Fish, 1998) and its worship of the visible and quantifiable. The consequent shift in focus from efficiency and task to authentic relationship (Aranda, 2001), responsive to patient//client need and reciprocal in nature (Aranda and Street, 1999), raises the profile of the more nebulous psycho/social/spiritual perspectives of care. This shift potentiates the need for ‘emotional labour’ (James, 1989) rather than observable behavioural professional activity. The novice entering a profession looking to the example of experienced practitioners may well miss the nuance of such care or observe distancing techniques used as a defence against the demands of ‘emotional labour’ (Mackintosh, 2004). Those who have suffered a significant loss, whether of an other, or, part of their physical, psychological, social or spiritual selves will be present in most health and social care settings. So the intuitive professional, having gained more experience, may identify the need for a greater understanding of how to provide appropriate support.
W. Greenstreet An educational forum provides the opportunity to explore theory that promotes an understanding of loss and the process of grief as well as an awareness of the levels of support available for the bereaved. An interprofessional context allows a sharing of views that enhances a collegiate ambience. The inherent challenge is to identify the educational process that best makes theory accessible and meaningful in practice.
Interprofessional education Scholes and Vaughan (2002) suggest the terms multidisciplinary, multiprofessional and interprofessional are often used interchangeably and without careful consideration. They go on to describe the term interprofessional as one that refers to interactions between team members and multiprofessional as referring more readily to a group of people who come from different health and social care professions but do not necessarily interact. Multidisciplinary refers to practitioners who share the same professional background but practice within different specialities. The group of 17 students that opted for this module were clearly multiprofessional, including representation from socially focussed work (5), occupational therapy (3), radiography (1), nursing (6) and midwifery (2). They were also multidisciplinary with a wide variety of institutional and non-institutional practice contexts represented both within the professional groups and also between them. These included Intensive Care, Renal Specialist Care, Mental Health, Rehabilitation, Sonography, and Chronic Care contexts involving patients with debilitating diseases such as motor neurone disease and dementia. The use of clinical anecdotes encouraged interprofessional interaction in the group. Modernised health and social services potentially undermine professional identity (Biggs, 1997; Adams, 2003). Cross-boundary working and interprofessional education strike at the heart of conventional professional socialisation, undermining modernist tribalism (Beattie, 1995) and present a postmodern challenge to the power of professionals. However, interprofessional education that enhances cross-boundary working, and increases permeability of professional boundaries, can reflect role overlap and facilitate fluidity in staff utilisation and prevent duplication. Strengthening competence within overlap will harness experienced professionals’ adeptness in using their skills (Scholes and Vaughan, 2002). This does not deny
Loss, grief and bereavement in interprofessional education, an example of process the identity located in core professional expertise and the importance of accessing wider multiprofessional input according to patient need so that ‘core’ professional expertise is acknowledged. In this case, module content uses accounts of contemporary truth(s) regarding the nature of loss and the process of grief for interprofessional discourse to explore anecdotes sourced from practice experience illustrating multiprofessional and multidisciplinary support for those who have suffered loss. In identifying levels of support needed by patients, students potentially grow more confident of those supportive skills that they own that fall within ‘role overlap’. This also promotes greater clarity of the support that is profession specific requiring referral. In this way core professional expertise is reaffirmed.
The shape of the module The module constituted an elective option accessed in the first two years (or the equivalent for part time students) on an Interprofessional Masters programme. In this instance, 15 students registered on a Masters programme opted for this module and two students accessed the module as associate students. The aim of the module was to encourage students to critically examine the relevance and potential for integration of theoretical perspectives about loss, grief and bereavement into health and social care practice. Most of the forty hours of
Table 1
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taught content chosen to facilitate achievement of learning outcomes (Table 1), was delivered over three units, each of two days duration, with a one month interval between each unit. Remaining taught time was used for tutorials, access to provision supporting the development of skills facilitating study on the Masters programme, for example, the use of virtual learning environments, and shared study days accessible to all Masters students. The style of delivery, assessed course work and availability of learning resources were designed to enable student progression in programme key skills (Table 2).
Unit one The timetabling of each unit was themed. The first unit focussed on exploring loss. The intent of starting with experiential exploration of a personal lifespan perspective, personal and professional communication skills and professional vulnerability in relation to loss was to use an educational forum to raise awareness of the need for support for both those who have lost and those who care for them. Campbell (1984) points out the high cost of care in relation to human resources due to constant presence with, and sharing, suffering. The carer as a professional cannot be separated from the carer as a person (Martocchio, 1987). This investment of self is described by Campbell (1984) as ‘moderated love’ and takes the form of companionship; a ‘good companion’ (p. 49) is one who shares the route but allows patients/clients to make their
Learning outcomes
By the end of the module students should be able to: Critically evaluate theories of loss, grief and bereavement in health and social care professional practice Analyse evidence of cultural and spiritual determinants of interpreting loss and the style of grief Discuss the impact of ethical dilemmas on bereavement Reflect critically on the role of communication skills as a resource for personal and professional support Appraise the relevance of social and health policy in provision of care for the bereaved
Table 2
Key skills
Communication Application of number Information technology
Critically evaluate empirical and theoretical literature Critically interpret data in bereavement research studies Access and use efficiently the internet, college databases and computer software for assignment content and presentation Working with others Work with students from other professions to share relevant practice experience and enhance their own and others learning Problem solving Reflect critically on interprofessional practice in supporting the bereaved and consider strategies for improvement Improving own learning and performance Determine strategies for improving own practice in bereavement care
284 own journey. This sharing of self with those who are suffering enriches the quality of care but renders the ‘self’, that is the professional, vulnerable. The need for professionals to preserve personal integrity needs to be acknowledged (Davies and Oberle, 1990) and facilitated. Theoretical input included in unit one introduced loss as a wide concept, not just in relation to bereavement as ‘the loss of someone significant through that person’s death’ (Stroebe and Schut, 1998), which could be time limited and construed as related only to the death of a significant other, but bereavement as the state of being deprived of something; ‘that is, bereavement identifies the objective situation of individuals who have experienced loss’ (Corr et al., 1997). This later view incorporates a much wider perspective in relation to health and social care, including disability and the non-finite nature of associated loss(es). Published accounts considered included: grief work (Parkes, 1996), assumptive world, psychosocial transition (Parkes, 2000), anticipatory grief (Fulton, 2003), the cyclic nature of non-finite grief (Bruce and Schultz, 2001) and a review of theory of dying (Copp, 1998).
Unit two The second unit focussed on the process of grief. Published accounts of traditional views considered included attachment theory and the phase model of grief (Bowlby, 1969; Parkes, 1972, 1986, 1996), tasks of mourning (Worden, 1982, 1991), and the more contemporary views reflected by the dual process model (Stroebe and Schut, 1999), a new model of grief (Walter, 1996) and work on continuing bonds (Klass et al., 1996). Systems theory (e.g., Kissane and Block, 2002) provided a tool for exploration of the process of grief in relationship and loss and a wide review of literature (e.g., Staudacher, 1991; Martin and Doka, 2000) outlined gender based issues. Spiritual and cultural perspectives on grief centred on meaning and loss (Frankl, 1984; de Vries, 1997; Speck, 2001) and ritual (Wikan, 1988; Parkes et al., 1997; Grainger, 1998; Walter, 1999).
Unit three The third unit considered social, political and ethical perspectives of loss, grief and bereavement. Government documents provided published accounts of guidance/targets. Content included suicide and effecting government targets to reduce incidence (Department of Health, 1999) and levels
W. Greenstreet of support (National Institute of Clinical Excellence, 2004) and appropriate referral for the bereaved. Legal and professional guidance on decision making in situations presenting ethical dilemmas was also considered. Student seminars were also presented in unit three. These offered a formative opportunity to present an outline of work prepared for coursework assignment.
Educational process and method Milligan (1995) defines andragogy as: the facilitation of adult learning that can best be achieved through a student centred approach that, in a developmental manner, enhances the students’ self-concept, promotes autonomy, selfdirection and critical thinking. Establishing a climate conducive to learning is a fundamental element of andragogy (Knowles, 1990). Introductions encouraging openness and authenticity are important if students are to share sensitive personal and practice experiences to enhance learning. Mutual trust is strengthened in establishing ground rules including the importance of confidentiality of all shared narrative both in containing its use for exploration and debate within the confines of the classroom, and in complying to professional codes (College of Occupational Therapists, 2000; Nursing and Midwifery Council, 2002; College of Radiographers, 2004; General Social Care Council, 2004). Problem-based learning, also known as enquiry based learning, is promoted as fulfilling andragogical philosophy in encouraging a shift to studentcentred education using process-oriented methods. Its use is increasingly evident in the education of health professionals (e.g., Newman, 2003; Bechtel et al., 1999). However, Milligan (1999) suggests problem based learning limits emancipatory generation of knowledge and is potentially rather than necessarily andragogical in its educational ambience. The pre-selection of scenarios as triggers in problem-based learning undermines student choice. Brookfield (1993) argues that self directed learning may result in compromise which supports social conformity rather than bring students to an uncomfortable and often unsought confrontation with inequitable political realities, and with their own acknowledged collusion in these realities. Milligan (1999) goes on to advocate that andragogy should embrace a wide range of methods to facilitate learning.
Loss, grief and bereavement in interprofessional education, an example of process A variety of methods were used in the delivery of this module, which included some experiential exploration as described in unit one, some role play in unit two and discussion based activity in unit three. However, it is particularly those sessions that utilised student anecdotes of practice reality in relation to critical evaluation of presented theory that will be considered here. In these anecdotes, students presented their own problem based scenarios that provided an uncensored look at real practice. Student-centred humanistic theory is closely related to phenomenological philosophy, which asserts that reality lies in an individual’s perception of the event and not in the event itself. Aldridge (2000) claims that it is not only the content but the way it is told that reflects the validity of the ‘story’. The reinterpretation of the story from multiprofessional and multidisciplinary perspectives is potentially emancipatory in challenging assumptive knowledge conveyed in relating narrative. The use of student anecdote shifted as the module progressed. In unit one, during the delivery of an overview of accounts of theory related to loss, student anecdotes were ad hoc and relatively spontaneous as were questions. Pre-module reading regarding theories of dying was then used as a focus for discussion of relevance to practice and, again, short anecdotes were used to illustrate points raised. For unit two, students were asked to bring anecdotes from their practice experience that exemplified loss in that context. Following the delivery of an outline of accounts of traditional and contemporary theory these were used to critically evaluate the relevance of theory to practice. Anecdotes showed a predisposition by most students to apply traditional bereavement theory to practice although there was some consensus that the process of grief was not time limited. In considering spiritual and cultural perspectives of grief, anecdotes were used to initiate the session; incidentally the group composition added richness to discussion. Short block provision facilitated access for students who lived at some distance from the educational institution delivering the module as well as those who lived locally. There was therefore representation of difference within British culture in the group. In addition, as one student was of Asian origin and three were European, the group also embodied difference across cultures. Scenarios of and from practice were then reviewed in relation to presented theory. In unit three seminars required students to outline a critical evaluation of theories of loss, grief and bereavement to their practice. In using anec-
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dote to exemplify issues these seminars provided the opportunity for interprofessional interaction.
Evaluation Research has evidenced the importance of evaluation in highlighting the value of exploring the theoretical basis of intended outcomes (McEvoy and Richards, 2003) to ensure educational provision is relevant and impacts professional practice (Jordan et al., 1999). Module evaluation constitutes part of Programme quality monitoring and so contributes to improving future delivery and potentially to Institutional Audit. Triangulation of evaluation strengthens feedback in determining the most significant achievement of learning and the greatest shortfalls. Student and module leader evaluation, comment from sessional contributors and student assessed work all provided sources of data.
Student evaluation Students voiced formative feedback in the throes of module delivery. Much of this was specific to the individual student but a shared request in unit one was for more time for discussion. Summative evaluation was achieved by the completion of a questionnaire providing some quantitative data and qualitative comment. This was distributed during the last day of the module. Feedback was overall positive. Students felt that the course achieved what it had set out to achieve. Comments included greater insight into and application of theory as well as the benefits of sharing the different perspectives and experiences of a multiprofessional group. The student seminar produced a mixed response. Some students commented on how beneficial they had found this forum and the feedback given. An equal number of students had found them unhelpful and suggested a one to one tutorial might be a better alternative. They also felt there was little guidance on what was expected from the presentations.
Student assessed work Results reflected a slightly positive distribution of academic ability within the group. The two associate students chose not to submit summative course work. Of the fifteen pieces of coursework submitted, two were referred, eight passed, four were good passes and one was excellent. Assessed work demonstrated student ability to critically evaluate the value of theories of loss, grief and
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bereavement to their practice including relevant ethical, socio-cultural, spiritual and communication issues. Interestingly, in the same way that students’ use of anecdotes in class reflected a predisposition to apply psychologically based traditional bereavement theory to practice their selection of theory to evaluate in assessed work was predominantly traditional. This popularity of traditional theory may be that it is amenable to misinterpretation as being similar to the conventional medical model, grief constituting suffering as a problem implying the need for recovery rather than as a normal process (Costello, 1995). Another explanation is possibly Walter’s (1994) suggestion that normalizing the moving toward recovery response provides hope for professionals sharing the
pain of the bereaved. However, more than one third of the students made some reference to the more sociologically based contemporary theory, with a couple strongly supporting its relevance to their practice. Choice of theory was not profession specific.
Module leader evaluation Group dynamics contribute to an evolving rather than mechanistic plan of delivery of taught provision. Group cohesion facilitated an increasing shift from front loading taught theory to working from anecdotes of practice experience in relation to theoretical account. Facilitating access to published accounts of theory, as improved access to
Elicitation of ideas from anecdotes
Clarification and exchange of ideas in interprofessional discussion Input of theoretical account
Comparison with previous ideas
Restructuring of ideas
Evaluation of alternative ideas
Application of ideas to practice
Assessed coursework Review change in ideas
Figure 1
Teaching sequence that evolved: a modified constructivist format (adapted from Driver and Oldham, 1985).
Loss, grief and bereavement in interprofessional education, an example of process virtual learning environments makes electronic access to published material easier, will enable increased pre modular reading and increase opportunity for interprofessional discussion of relevance of theory to practice-based anecdotes. Initial seminar presentations were more inclusive of discussion, but as group size was relatively large and time pressed the presentations became more focused and less inclusive. Rather than retreat into individual tutorials and lose the opportunity for interprofessional debate centred on evaluating accounts of theory in real practice-base narrative, some experimentation in creative grouping and allocation of time might provide a better experience. Student requirement to use their allocated seminar time for formative presentation of coursework was the extent of guidance provided to all. Limited guidance was a positive intent to leave students free to present as they wished. Peer presentation can be uncomfortable as discussion potentially undermines treasured assumptions, but then, in a safe learning environment, uncomfortable and unsought confrontation may herald an emancipatory moment of development! Constructivist views regarding the creation of knowledge include three perspectives (Bruce and Weil, 1996). Firstly, a personalistic view referring to the unique internal frame of reference of each individual resulting in difference in conception and meaning of knowledge. Secondly, a social point of view in which groups inquire together and construct ideas; therefore, knowledge cannot be separated from the social process within which it is manufactured and, lastly, discipline based enquiry that helps students try on ideas and approaches in discipline processing models. The process of education is building knowledge and checking it against the concepts of others. The module started with a personal view of loss, then used anecdote from the social context of practice in the social process of education to critically evaluate theoretical account and facilitate interprofessional discourse enabling ideas to be tried in a multiprofessional context. The teaching sequence that evolved appeared to resemble a modified constructivist format (Fig. 1).
Conclusion Theoretical account concerning loss, grief and bereavement needs to be freed from incarceration in academic debate by meaningful interpretation within educational settings. The appropriateness and currency of research underpinning developments strengthens the case for challenging the old and supporting the new for students practicing in a
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contemporary clinical ambience of evidence based practice. Health and social care professionals need to be encouraged to consider what is new in recent theory, its research base and how these compare with the truth of their experience in practice. Learning is facilitated by moving from the known, and what ‘feels’ comfortable, onwards to pioneer new thought, but presented in terms of practice realities. Reflection in practice (Schon, 1988) may well have identified a problem, a shortfall in confidence in practice that motivated students to opt for an elective module that provided formal opportunity to reflect on practice (Schon, 1988) in relation to understanding loss and the process of grief and providing appropriate support for the bereaved. Problem or enquiry based learning might limit student choice and emancipatory generation of knowledge. However, the use of anecdotes that are ‘the everyday stuff of clinical practice’ (Aldridge, 2000, p. 24) provide the known realities against which theoretical account can be critically evaluated. A modified constructivist teaching sequence contributed to an evaluation that confirmed students had achieved their learning outcomes. This paper has considered the delivery of a module that exemplified the use of anecdote and account in educational practice. It is in itself an anecdote that may be of interest to others offering similar provision. The qualitative ‘stories’ of practice shared within a safe learning environment were utilised to achieve learning outcomes that were quantitatively measured in summatively assessed work.
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