Children experience grief in different ways then adults. Each child’s response is unique and individual; they express their grief in a variety of behaviors and responses. Nurses have a key role in providing therapeutic interventions for grieving children. Preparing nurses to be competent in providing grief support to children and families is a learned competence. Interprofessional opportunities for nursing students to engage in interactive learning with those outside their profession can provide experiences in grief work. The findings show that nursing students who participated in an interprofessional academic service learning course to learn and practice grief skills gained confidence to work effectively with children in their grief journey.
interprofessional education, academic service learning, grief in children
Preparing nurses to be competent in providing grief support to children and families is a learned competence. Children experience grief in different ways then adults. Each child’s response is unique and individual; they express their grief in a variety of behaviors and responses. Camp Hope is a resource for children who need a safe, caring environment to express their grief and receive support while experiencing childhood activities of a summer camp. Wolfelt  refers to children as the forgotten mourners stating all children grieve when someone dies, but we as a society, as families, and as individuals do not encourage them to mourn.
Camp Hope is sponsored by a Midwestern hospice provider. It is a 3 day, 2 night bereavement camp for children ages 6 to 17 who have lost a loved one. Children are referred to the camp via self-referrals, hospice staff, school counselors, or through community networks. Annually 45-50 children have the opportunity to cope and heal via this grief camp framework.
Service learning partnership: Identification of need
Providing opportunities outside of the traditional classroom in nursing education is necessary to provide a framework for development of grief skills. To provide BSN nursing students the opportunity to move towards competency in grief care and the opportunity to practice interprofessionally, an intensive academic service learning intensive elective nursing course was developed. The key components of a service-learning program as defined by the International Service Learning Task Force (Sigma Theta Tau International) include reciprocal relationships between academic and community partners, connection to a course, structured reflection, and learning activities to meet community need . This could include a range of activities and outcomes, such as community service, civic engagement, citizenship, social responsibility, and cultural competence . Successful partnerships in academic service learning courses need to be developed with goals for each partner. Camp Hope was in need for caring, competent, professional volunteers to attend camp and work with the children; the Midwestern public university needed a clinical setting for student nurses to have opportunities to develop skills in grief care and to work interprofessionally. “Service combined with learning, adds value to each and transforms both ”.
To prepare nurses to provide grief care for children, it is imperative to have opportunities to gain competence. While children are many times excluded from death and dying of a loved one, their loss and grief needs are paramount. Wolfelt identifies the exclusive features of childhood grief are unique because "children are still taking form; loss acts as a carving tool that helps shape them and they look to others to help define them as they grow [5,6]."
Interprofessional skills and preparation for camp hope
The Interprofessional Collaborative Practice Report  recommendations include "opportunities for health professions students to engage in interactive learning with those outside their profession as a routine part of their education. Interprofessional learning is to prepare all health professions students for deliberatively working together with the common goal of building a safer and better patient-centered and community/population oriented U.S. health care system. (p 3). For the past 10 years, ten nursing students from a BSN program at Midwestern public university function as interprofessional members of the grief staff of Camp Hope. They work as integral members of the grief team of Camp Hope providing both grief support services and developmentally appropriate camp activities for children who have lost a loved one. Nursing faculty provides camp nursing services while supervising students in their role as grief counselors. Camp Hope staff companion students in their grief learning journey while they actively participate in learning therapeutic activities during a 2 session orientation.
Preparing an interprofessional successful team is vital for the success of Camp Hope. The preparations begin with selection of the student nurses. Student nurses submit a letter of intent addressing three questions:
- Why are you interested in this experience?
- What will you personally bring to this academic service learning/service course?
- What do you hope to gain from this experience?
Nursing students submit a letter of reference from a clinical faculty and if selected to participate will complete assignments prior to attending Camp Hope. Assignments include activities related to normal growth and development of children, therapeutic communication, and bereavement theories. Students and faculty attend 2 three hour orientation sessions provided by the professional staff of Camp Hope. The sessions include preparation for grief activities, camp schedules, and review of the emotional and physical needs of the children attending Camp Hope. The orientation sessions for all participants provide for team building to ensure a seamless transition to immersion into Camp Hope .
The immersion experience
Camp Hope begins with family members dropping off children at a local community center. The excitement, apprehensions, and fears of the children and family are nurtured with meet and greet fun activities by the nursing students while Camp Hope staff organize the departure needs and nursing faculty receive mediations and health histories from family members. Children, nursing students, and Camp Hope staff board busses for an hour drive to the camp's location.
Grief activities vary depending on the age groups of the children. The activities include team building with use of a ropes course for the older children, journaling, hands on activities such as a “fishbowl of feelings”, where children have the opportunity to put food coloring into a fishbowl to describe their feelings. Grief activities are planned to reach all children in their grief stage of mourning. The use of horse and pet therapy, art, and music often times will awaken a quiet or reserved child to new levels of interactions of therapeutic communications and movement in their grief. A bereavement activity is always followed by a camp activity such as kayaking, swimming, or hiking (Figure 1).
Figure 1. Fishbowl of Feelings
Relationships between the children attending Camp Hope, Camp Hope staff, and nursing students are quickly formulated to establish an environment of respect, trust, acceptance, and understanding. This model provides for a culture of a safe environment allowing for children to openly express their grief.
Recognizing the intensity of a three day camp experience where feelings and healings are shared with children and adults alike, it is important to begin closing exercises to prepare the children for return to their home environments. To begin closing activities, each child receives a large photo of their lost loved one; children create a pillow with the image of their loved one. The final activity is building “moving on boxes.” Children design and decorate a wooden box and write messages to their lost loved one in self-expressions of their plans for the future.
Words of encouragement, support, acceptance, and healing are provided by a Camp Hope staff in the closing session. In a group expression of healing and loss, all children write a message on a helium filled balloon. The children and the balloons are released with the messages going to their loved ones (Figure 2).
Figure 2. Balloon Messages and Release to the Sky
Arrival home /Course reflections
Children are reunited with their family members with an ice cream social and an award ceremony. Nursing students and Camp Hope staff have the opportunity to meet with family members and provide information about the child’s progress. This is a powerful experience for the nursing students to share their therapeutic interactions with children and to communicate children’s movements towards grief healing with family members.
According to Eyler and Giles, they cite the combination of high interest, emotional ties, and rich experiential contexts in well integrated service learning classes to help students to a more complex understanding of issues as well as practical knowledge . Evaluation of achievement of course objectives, personal and professional growth is achieved in a variety of methods. Nursing students use journaling as a method of self-reflection during the camp course experience. A pre and post survey is completed and a final self-analysis paper is written addressing achievement of course objectives.
Results of students’ self-reported learning experiences
The author surveyed 44 baccalaureate nursing students one week before and two weeks after returning from a 2- credit bearing undergraduate course titled “Bereavement in Children: An Academic Service Learning Course” offered during the summer semester. Students spent 5 weeks preparing for the course, 3 days and 2 nights at the camp, and two weeks after returning from camp the students reflect on their experiences via self-analysis. In addition, the faculty and the hospice staff conducted periodic individual and small group debriefing sessions while at camp.
The author administered the following pre-survey of anticipated learning and post-survey of frequency of learning using a five point Likert-style instrument. The results reveal that, for each survey item, the mean score was between 4.92 and 5.0.The results demonstrate that students gained a greater understanding of the complexity of bereavement, children's development and concept of death, and increased skills in communication with children as well as experiencing both professional and personal growth. While working as a member of a team with the hospice staff, the nursing students enhanced their communication and team building skills as they were challenged to relate in an interprofessional practice model. The nursing students learned how to work effectively and efficiently with others. The students increased their competence in grief skills and applied many nursing skills learned previously to the care of children experiencing grief. Lastly, the nursing students reported that they gained first–hand knowledge working with other disciplines.
The following survey was disseminated to students participating in the course before and after participating in Camp Hope.
Bereavement in children-pre academic service learning survey
Last Semester completed_______Cohort _______ Male/Female Ethnicity_________
What led you to apply for the Bereavement in Children Service Learning course?
Anticipated Learning: Please indicate how important each item is in your learning in the Bereavement in Children Academic Service Learning course. Circle one of the following choices for each item.
Very important=5 Most important=4 Somewhat important=3 Not important =2 Uncertain =1
Deeper understanding of grief concepts I have already learned about in nursing classes 1 2 3 4 5
Applying skills I have already learned in nursing classes to real life problems 1 2 3 4 5
Understanding how complex the problems are with the children I will be servicing 1 2 3 4 5
Understanding myself better/personal growth 1 2 3 4 5
Developing communication skills with children 1 2 3 4 5
Appreciating different cultures concepts of death and bereavement 1 2 3 4 5
Increasing my comfort level in working in bereavement situations 1 2 3 4 5
I anticipate much of my learning to come from the hospice orientation 1 2 3 4 5
I anticipate much of my learning to come from providing real life service to children 1 2 3 4 5
I anticipate much of my learning to come from reflections in journals/written assignments 1 2 3 4 5
I anticipate much of my learning to come from working with professionals in the field 1 2 3 4 5
I anticipate much of my learning to come from debriefing sessions 1 2 3 4 5
What apprehensions do you have?
How do you anticipate this course will affect your clinical practice as a registered nurse?
Bereavement in children-post academic service learning survey
Last Semester completed_______Cohort _______ Male/Female Ethnicity_________
Describe Your Learning: For each item, circle the number that best describes the frequency of learning opportunities during your Academic Service Learning course related to the following.
Very often=5 Often=4 Sometimes=3 Seldom=2 Never=1
A deeper understanding of grief concepts I have already learned about in nursing classes 1 2 3 4 5
Application of skills I had already learned in nursing classes to real life problems 1 2 3 4 5
An understanding of how complex the problems were with the children I serviced 1 2 3 4 5
An understanding of myself better/personal growth 1 2 3 4 5
Development of communication skills with children 1 2 3 4 5
An understanding of different cultures concepts of death and bereavement 1 2 3 4 5
An increase in my comfort level to work in a bereavement situation 1 2 3 4 5
Much of my learning to came from the hospice orientation 1 2 3 4 5
Much of my learning to came from providing real life service to children 1 2 3 4 5
Much of my learning to came from reflections in journals/written assignments 1 2 3 4 5
Much of my learning to came from working with professionals in the field 1 2 3 4 5
Much of my learning to came from debriefing sessions 1 2 3 4 5
Discuss the apprehensions you had prior to this course. Did you overcome them? If so, how?
How do you anticipate this course will affect your clinical practice as a registered nurse?
The following are selected quotes from the participating students’ reflections on their experience at Camp Hope upon return from the experience.
Statement by a senior nursing student reflects: “Looking at what I have learned, I think I would be more confident in a situation that required me to help families deal with grief. I think as a nurse I would be bold to ask the tough question rather than shy away from them. I think seeing firsthand how grief affects families will allow me to be a better help to my patients and their children. I would be able to address parents’ concerns about their kids and teens in particular. I could recognize when help is needed and refer them to the proper programs. Helping parents to understand their teen’s response to stressful situations can help them to communicate effectively with their child. This class has even helped me as a parent to understand my own teen. I have utilized some of the skills learned to respond to his emotional needs. If given the opportunity, I would volunteer for this experience again.”
A freshmen level student reflects: “I will have to conscientiously remember to take one day at a time, and remember what I have learned. Children deserve to express loss in a way that is understandable and within their age context. I have to remember that I am not invincible of crying with those grieving. I have ears for listening, eyes for seeing and interpreting, a mouth for consoling, and hands and arms for therapeutic touch. Lastly, I am blessed to be part of these children’s lives.”
A junior level indicated that: “This course helped to realize the variety of symptoms that can accompany grief. The experiences I had and the lessons I learned in this course will only help me to recognize some of the more obscure signs of grief and become a more compassionate and knowledgeable nurse. Death is part of life, and knowing how to help others cope with death and loss is an invaluable skill to have as a nurse.”
As children come to terms with grief they are permitted to proceed in their own growth and development as children. A role of nurses is to identify children who need grief support, refer them to resources such as Camp Hope, and provide an environment where children can openly mourn. Student nurses need to have the career skills and competence to work with children and grieving families. Academic service learning can provide for interdisiplinary practice and educational opportunities for nurses resulting in competent grief care of children.
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