Using children’s picture books for reflective learning in nursing education

Josephine Mary Crawley
Senior Lecturer, School of Nursing, Otago Polytechnic, Dunedin

Liz Mary Ditzel
Senior Lecturer, School of Nursing, Otago Polytechnic, Dunedin.

Sue Walton
Senior Lecturer, School of Nursing, Otago Polytechnic & Educator, Otago Community Hospice

Abstract

One way that nursing students build their practice is through reflective learning from stories. Stories in children's picture books offer a special source of narratives that enable students to build empathy and examine and reconstruct their personal concepts around human experience. Picture books tend to be short and provide an efficient learning tool. Yet, little has been written about using children's literature as a reflective learning tool for nursing students. In this article we describe how we apply McDrury and Alterio's (2002) Reflective Learning through Storytelling Model to our practice of using children's books to educate first year nursing students about loss, grief and death.

Keywords

Nursing education, children’s picture books, reflective learning through story telling, grief, loss and death

Article Text

Storytelling is one of the oldest methods of communication. It is firmly embedded as a teaching and learning tool in nursing education (Benner, 1991; Darbyshire, 1995; Nehls, 1995; Younger, 1991). Like nursing, the subject matter of oral and written stories is concerned with concepts such as birth, growth, disability, aging, and death. Although much has been written about death education in nursing, very little has been written by nurse academics about how to encourage student reflective learning about death and grief through the mechanism of children's picture books. Few articles give a theoretical base for incorporating literature as a teaching strategy that results in purposeful learning (Freeman & Bays, 2007; Sakalys, 2002). In this article we describe how we apply McDrury & Alterio's (2002) model of learning through storytelling as a theoretical framework to our teaching. In our practice exemplar we discuss how we use two children's books - Death, Duck and the Tulip (Erbluch, 2008) and Michael Rosen's Sad Book (Rosen & Blake, 2004) - to educate first year student nurses about loss, grief and death.

Using stories for reflective learning in nursing education

Literature is richly seamed with stories that illustrate human experience (Huber, 2000). Stories from popular literature can contribute to nurses' different ways of knowing because experiences are extended beyond the explanations contained in standard nursing textbook. Nurse educators looking for appropriate literary teaching resources have used material from a variety of sources. These include novels, biographies, poetry and films (Brown, Kirkpatrick, Magnum & Avery, 2008, Koenig & Zorn, 2002; Leffers & Martin, 2004; Raingruber, 2009; Sakalys, 2002; Stowe & Igo, 1996; Winland-Brown, 1996); and text and digital resources that represent client's lived experiences (Nehls, 1995). Stories that capture the essence of the human spirit are valued as they can provide students with the opportunity to vicariously experience a health condition such as suffering and despair (Donohoe & Danielson, 2004). While the use of literary works in nursing education is well supported by educational outcome studies (Sakalys 2002), our experience shows a growing interest in using children's literature as a reflective learning tool for nursing students (Brown et al., 2008; Crawley 2007, 2009; Krautz, 2007; Stowe & Igo, 1996).

Stories have long been used as the basis of reflective learning in nurse education (Benner, 1991; Bowles, 1995; Davidhizar & Lonser 2003; Koenig & Zorn 2002; Schwartz & Abbott, 2007). Stories help students to develop an understanding of peoples' lived experiences and learn about practice and the world around them: building, interpreting and deconstructing narrative knowing (Diekelmann, 2001; Evans & Severtson, 2001; McDrury & Alterio, 2002; McAllister et al., 2009). Through stories, nursing students can be engaged in reflective thinking, writing and learning activities in the classroom (Davidson, 2004; Krautz, 2007). Teaching and learning with narratives has many advantages. Stories can be read, written or recorded, but they seem most powerful when told from the heart or read out loud and adapted to individual situations (Johnson & Jackson, 2005). Thinking is promoted when listeners become immersed in the process of sequencing, analysing and synthesising information as they write, tell or listen to stories (Nehls, 1995). This creative process allows links to be made between the story and other similar situations. When applied to a nursing context, educators can encourage students to reflect on chosen stories, challenge their pre-conceptions, build empathy, bridge theory and practice and envisage diverse practice experiences with an interpretative approach (Diekelmann, 2001; Freeman & Bays, 2007; Ironside, 2006; McAllister et al., 2009).

Learning through reflection happens when students critically examine their own responses to the story and knowledge foundation thereby informing, developing and advancing their professional practice (Fitzgerald, 1994). The process of reflection involves examining an experience or a story, analysing, exploring emotion and actions. Research by McAllister et al. (2009) found that narrative reflection assisted students understanding the complexity of providing care - including community care, awakened political consciousness, raising cultural awareness and professional growth. Other writers such as Sakalys (2002) have developed or evaluated models to conceptualise teaching and learning from stories, but have focused on storytelling exemplars from practice, rather than stories from literature. This paper contributes to knowledge on using stories from children's literature in nurse education.

Children's picture books

Children's picture books have been defined as '...profusely illustrated books in which both words and illustrations contribute to the story's meaning' (Lynch-Brown & Tomlinson 2008: 91). Such books are crafted to hold the listener's attention. Retelling human experience in a unique way, they can concertina complex human concepts into illustrations interplaying with about 100 words - ready to be unfurled. The combination of art with text adds to the appeal of this type of literature. Pictures, symbols and images have been used throughout time to suggest ideas and concepts (Bishop & Hickman, 1994; Spitz, 1999). Artful illustrations in children's picture books communicate atmosphere, mood and emotion through colour, line, space and picture arrangement; retelling and interpreting the story (Cass, 1984; Lynch-Brown & Tomlinson, 2008). Art has also been used in nursing education (Brown et al., 2008; Freeman & Bays 2007, Johnson & Jackson, 2005) and as visual enhancement when a story is being used for teaching (Shieh, 2005). By weaving art and text together - emotional depth and complexity is achieved; children's picture books create multiple possible layers of meaning.

Well-written children's literature abounds with narrative techniques that highlight the subjective nature of truth such as inversion, subversion and irony (McMillian, 2003). The constructed nature of knowledge is highlighted by different techniques - fantasy, humour, different character perspectives, character development, illustrations, and by the story lines (Cass, 1984; Lynch-Brown & Tomlinson, 2008; Spitz, 1999). These narrative techniques magnify the construction and differing realities contained in the story and invite students to explore their own construction of reality (Crawley, 2009). Many children's stories provide situations that can be applied to nursing practice. For example, the short story The Fall of Freddie the Leaf (Buscaglia, 1982) is described as a suitable story for nursing students 'to understand death and dying and the purpose of life (Stowe & Igo, 1996: 18). However, the authors do not unpick how to encourage student reflection specifically from this children's picture book.

Reflective learning through storytelling

Storytelling is recognised as 'a traditional means of exploring experiences and valuing affective responses' (McDrury & Alterio, 2000: 1). Based on constructivist learning theory and their experience of using storytelling as a learning tool in nurse education, McDrury and Alterio (2002) developed the 'Reflective Learning through Storytelling Model'. The model has five stages: story finding, telling, expanding, processing and reconstruction. The first stage emphasises the importance of finding a story that has emotional appeal. The content of such stories may entice, excite, frighten or amuse the reader or listener. Once selected, stories are told for the purpose of understanding the story itself. In the second storytelling stage, listeners attempt to make sense of the story's context and of the human experience it portrays.

Next, listeners attempt to make meaning of the events being shared. Important aspects of the story can be expanded and feelings evoked by the story can be surfaced, discussed and clarified. The educator can ask the question; 'Why did events unfurl in particular ways, and why did characters behave in certain ways?' A key aspect of the story processing stage is deep learning that is developed through reflective dialogue and questioning, and unveiling different perspectives of the story's events. This stage frequently surfaces aspects that have been forgotten and can help listeners recall other stories that are connected in some way to present situations. In the final stage, tellers and listeners demonstrate an ability to critically evaluate stories from as many perspectives as possible. Potential resolutions or solutions may be explored and provide opportunities to bring about change to practice. However, McDrury and Alterio (2002) note such transformative change does not always occur, acknowledging that a missed learning opportunity may mean that some stories are told and retold without any obvious sense of advancement of resolution.

In the following exemplar we show how we use McDury and Alterio's (2002) 'Learning through Storytelling Model' and two children's picture books to encourage reflective learning about grief, loss and death in undergraduate nursing classes.

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