Volume 42, Issue 1, August 2012

Copyright © eContent Management Pty Ltd. Contemporary Nurse (2012) 42(1): 45–52.

Using children’s picture books for reflective learning in nurse education JOSEPHINE CRAWLEY, LIZ DITZEL AND SUE WALTON School of Nursing, Otago Polytechnic, Dunedin, New Zealand One way in which nursing students may build their practice is through reflective learning from stories. Stories in children’s literature offer a special source of narratives that enable students to build empathy and to examine and reconstruct their personal concepts around human experience. Illustrated storybooks written for children are a particularly attractive teaching resource, as they tend to be short, interesting, colourful and easy to read. Yet, little has been written about using such books as a reflective learning tool for nursing students. In this article we describe how we use two children’s books and McDrury and Alterio’s (2002) ‘Reflective Learning through Storytelling’ model to educate first year nursing students about loss, grief and death.

Keywords: nurse education; storytelling; children’s literature; reflective learning; McDrury and Alterio’s ‘reflective learning through storytelling’ model; grief, loss and death

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n this paper, we describe how we use children’s literature in the classroom to educate first year nursing students about loss, grief and death. As nurse academics we have found children’s stories to be a valuable teaching aid because they offer a unique range of perspectives on a variety of topics in the nursing curriculum. The topic of ‘grief, loss and death’ can provoke anxiety in nursing students (Johnsone, 2007). Yet facing loss and death is an everyday reality in many nursing settings, and emotional involvement (through empathic listening) is increasingly encouraged to prepare students for the experiences they will encounter in practice settings (Lewis, 1996). Personal reflection assists us to make sense of death and loss and may also help nurses learn to care for dying people and their families (Johnsone, 2007; Lewis, 1996; Schön, 1983). Although much has been written about death education in nursing, very little has been written by nurse academics about using children’s literature for this purpose (Freeman & Bays, 2007; Sakalys, 2002). However, results of a survey of our graduating students indicate that children’s books we use in the classroom (and discussed here) are fondly remembered and highly valued teaching resources (Crawley, 2011). In what follows, we explain how we use two children’s books; Death, Duck and the Tulip (Erlbruch, 2008) and Michael Rosen’s Sad Book (Rosen & Blake, 2004) guided by McDrury and Alterio’s (2002) ‘Reflective Learning through Storytelling’ model. The model has five stages (story: finding, telling,

expanding, processing and reconstructing) that we work to encourage reflective learning about loss, grief and death in our first year undergraduate nursing classes. The five stages of the model and key teaching considerations are summarised in Table 1. USING STORIES IN NURSE EDUCATION Literature is richly seamed with stories that illustrate human experience (Huber, 2000). 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, Mangum & 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). Literature can provide ‘a safe arena in which to rehearse reactions and feelings about large issues’ (Hargrave, 1985, p. 41). Well-chosen books provide the educator with a rich resource for teaching students about issues requiring an awareness or expression of feelings such as coping with one’s own death or the death of a loved one. Situations experienced vicariously through fictional or real characters portrayed in literature can widen a learner’s awareness and understanding of feelings such as loss, as well as introduce new ones (Barrow & Woods, 1975). Therefore, literature can make a vital contribution to nurses’ ways of knowing because it adds

Volume 42, Issue 1, August 2012

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Josephine Crawley, Liz Ditzel and Sue Walton

TABLE 1: CONSIDERATIONS FOR EDUCATORS USING CHILDREN’S BOOKS Key considerations Stage 1: Story ﬁnding

Select books with content that meets learning objectives for the course. Look for interplay of text and illustration. Choose books that are well illustrated. Choose books with emotion and humour.

Stage 2: Storytelling

Tell the story out loud and practice reading it. Read with conﬁdence and in an entertaining way. Make sure all students can see illustrations. Model emotional reactions. Allow thinking and page turning time. Select an appropriate venue for the group size.

Stage 3: Story expanding

Allow adequate time for discussion. Explore assumptions and beliefs. Explore the book character’s perspective. Discuss the values portrayed.

Stage 4: Story processing

Use questions that critically examine underlying beliefs. Invite and actively involve students in discussion by asking a range of questions based on the book’s content. Discuss and examine alternative perspectives.

Stage 5: Story reconstructing

Determine what has been learned. Identify ‘new’ knowledge. Explore how new knowledge can be used and how it might affect future practice.

an extra dimension to experiences that are usually are presented through factual material presented in textbooks and lectures, etc. (Carroll, 2011; Darbyshire, 1995; Krautz, 2007). Stories are a well-established way of developing reflective learning in nurse education (Benner, 1991; Bowles, 1995; Koenig & Zorn, 2002; Schwartz & Abbott, 2007). The major contribution of stories for undergraduate nurses is that they help make nursing practice visible (Koch, 1998). Well-written stories capture interest and attention; help recall of details by association, and bring facts to life by helping listeners to put them in personal scenarios (Davidhizar & Lonser, 2003). Stories have also been found to better demonstrate values than more formal ways and therefore may have a greater influence on learning (Bergman, 1991). Stories that capture the essence of the human

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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). Stories can help students to reflect upon and 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 & Severton, 2001; McAllister et al., 2009; McDrury & Alterio, 2000). The process of reflection involves examining an experience or a story, analysing, exploring emotion and actions. 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). 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.

USING CHILDREN’S STORIES IN NURSE EDUCATION The beauty of stories specifically written for children is that they are ‘… profusely illustrated books in which both words and illustrations contribute to the story’s meaning’ (Lynch-Brown & Tomlinson, 2008, p. 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, 1992; 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,

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Reflective learning through storytelling 1984; Lynch-Brown & Tomlinson, 2008). Art has also been used in nursing education (Brown et al., 2008; Freeman & Bays 2007; Johnson & Jackson, 2005) and provides 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. 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 a suitable story for nursing students ‘to understand death and dying and the purpose of life’ (Stowe & Igo, 1996, p. 18). The book Wilfred Gordon McDonald Partridge (Fox & Vivas, 1984) lends itself to an exploration of the concept of memory, and Giraffes Can’t Dance (Andreae & Parker-Rees, 2000) highlights the importance of confidence and assertiveness skills and the need to support one another in difficult situations. In children’s books the story is constructed by using a range of literary techniques, for example, fantasy, humour, different character perspectives, character development, illustrations, and by the story lines (Cass, 1984; Lynch-Brown & Tomlinson, 2008; Spitz, 1999). These work together to highlight differing realities contained in the story and invite students to explore their own construction of reality (Crawley, 2009). Good children’s literature therefore has the advantage of readability; illustrated books have the added advantage of captivating the reader’s imagination. USING STORIES IN THE CLASSROOM Nurse educators have used storytelling in the classroom to effectively teach concepts such as ethics, values, and cultural norms and differences and to foster reflection and promote critical thinking (Freeman & Bays, 2007; Hargrave, 1985; Ironside, 2006). An additional learning benefit is that stories provide students with an opportunity to explore personal roles and make sense of their lives (Koenig & Zorn, 2002). When using narrative literature in the classroom, it helps to have a model to assist us to choose the right book, deconstruct the story so we can examine students’ personal experiences related to the concept being taught, and use reflection to build students’


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awareness and skills so that this knowledge can be applied to practice. In the following section we describe the five-stage method of McDrury and Alterio’s (2002) ‘reflective learning through storytelling’ and show how we use the model to guide us through this process. STAGE ONE: FINDING THE RIGHT STORY Finding the right story is critical for those wishing to use children’s picture storybooks in their teaching practice. Educators should choose a book to which they have an emotional response, a story that contains a depth of emotion that is relevant to nursing experiences. The theme should also relate to the nursing curriculum and meet the learning objectives of the teaching session. The book needs to portray interpretations about a social or emotional situation, tell a good story, and be stimulating and magical enough to transport listeners into the story. Stories with an element of fantasy, reflected in the content of the pictures as well as the text, are likely to stimulate the imagination, question reality and give permission to explore being someone else with different values or think in a different way (Spitz, 1999). Characters are important whether they be personified animals or humans. It is best to choose characters that students respond to on a human level. They need to be alive, yet flawed, relating to each other and their environment with illustrations that work in sympathy with the text, portraying the character’s emotions. We have found that characters that best prompt reflective discussion are those that behave, feel, think and react to different experiences as they develop during the course of events in the story (Crawley, Ditzel & Walton, 2011). For McDrury and Alterio (2002, p. 60), good stories are an experience that was ‘noticed’ by the student; such stories command attention and invite further thought or analysis. We noticed two books: Death, Duck and the Tulip (Erlbruch, 2008) and Michael Rosen’s Sad Book (Rosen & Blake, 2004). These appealed because each story contains a depth of emotion and provides alternative perceptions of death and loss that meets our learning objective of building awareness of personal beliefs and values around death and grieving. In our view, Death, Duck and the Tulip provides an excellent starting point


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from which to build reflective learning about death, and Michael Rosen’s Sad Book humanises grief theory. Our chosen books have the narrative characteristics of excellent children’s literature (including humour) and artwork that visually helps to build empathy with the characters. In Duck, Death and the Tulip, death is portrayed as a friendly skull character named ‘Death’, attired in a dressing gown. Duck is originally afraid ‘scared stiff ’ (in children’s books, page numbers are usually not provided) of the character Death; yet she goes on to build an unexpected relationship with Death. Death is personified; in the text he expresses his point of view and talks to the dying duck. The illustrations provide stark, poignant visual cues that hint at possible meanings the death experience has for both characters. In Michael Rosen’s Sad Book, the character Michael Rosen is grieving because of the death of his son Eddie, and doing the things he does to cope with life. An illustration of a man grinning frenetically accompanies the first words ‘This is me being sad’ yet the effort of the forced cheerfulness somehow weighs the page down. The accompanying text: ‘Maybe you think I’m happy in this picture. Really I’m sad but pretending I’m happy. I’m doing that because I think people won’t like me if I look sad’, evoke empathy with the character. The page is illustrated to show sadness infusing and enveloping Michael. The accompanying words ‘Who is sad? Sad is anyone. It comes along and finds you’ draw in readers (students) to think about their experiences of loss and grief. STAGE TWO: STORY TIME – TELLING THE STORY Once we have chosen our story, we share it by reading the book aloud and inviting the students to listen. McDrury and Alterio (2002) consider that it is at this stage that students begin to make sense of the story, where the stories revolve around the values, attitudes and behaviour that effect practice. In the classroom we share our chosen stories by reading the books out loud to groups of 10–15 students. Reading children’s books aloud to a critical audience requires educators who are comfortable and confident reading the book – we practice, until the text and illustrations are familiar. A reader with a flair for the dramatic ‘must

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engage students by being involved with the story’ (Spitz, 1999, p. 2). Fortunately, ‘most picture books are designed to be read aloud … and their print, style and vocabulary is thus designed’ (Cass, 1984, p. 84). The storyteller can alter their tone of voice, emphasis, facial expressions and gestures to entertain the audience and communicate the book’s message. We have found that when the educator models their own emotional reactions when telling the story, students express their own emotional responses, wonder, amusement, sadness and surprise and talk about their emotional involvement with the characters and stories (Crawley, 2007). In our experience Michael Rosen’s Sad Book is a hard book to read without becoming emotionally involved. However, this in itself becomes the basis for a discussion about empathy, picking up on cues, and nurses’ emotional involvement when caring for a person who has experienced loss. It is also important to ensure all students can see the illustrations as well as hear the text. How this is done depends on the size of the group, the room and the technology available. When reading a story aloud we hold up the book so that the pictures can be easily seen. Illustrations are important as they can provide the narrative context for the story. In Michael Rosen’s Sad Book, Blake (the illustrator) uses the symbolism of a candle and dark clouds to shroud the page to show how something can be bright and joyous, and simultaneously dark and deeply sad. When reading Duck, Death and the Tulip we invite students to look at the comfortable looking dressing gown worn by Death, and ask students to think about that image by asking the question: what could it mean when Duck looks after Death and keeps him warm? This approach invites students to shift their focus from passive recipients of information to being actively involved in the story. We can draw listeners into the story by asking – what do you think happens next? – then we pause for student ‘thinking time’ before turning the page. STAGE THREE: EXPANDING THE STORY TO BUILD MEANING IN PRACTICE

Story expanding takes place when nursing students (listeners) reflect on their practice and explore possible meanings (McDrury & Alterio, 2002). In this stage we invite discussion of the


Reflective learning through storytelling book beyond the words and illustrations provided so that we can actively make meaning of the events in the story and explore alternative interpretations. To do this we use questions and statements that prompt expansion of the perspectives of the fictional characters; the ways events unfold, how one character influences another’s actions. We ask questions that expand the meaning of the story, go a step further, encouraging exploration of the children’s story from the perspectives of different characters to open up understanding around how one event affects another, the complex variety of human emotions, and start making links to nursing theory and practice. In the story expanding stage we actively seek the perspective of the listener, both as an individual and a health care professional. When reading Duck, Death and the Tulip, to meet a learning objective of building awareness of personal beliefs and values around death and grieving, we might say: How do you feel about being with a client who is dying? How is the physiology of the death process represented in the book? – Is this what you’ve noticed in practice? We encourage students to express their feelings about grief, loss and death by asking questions such as: How do you think Death felt when duck died? Would Death have felt the same if he and Duck hadn’t developed a friendly relationship? What does the author suggest about Duck’s attitudes about living and dying? If you’d written the story, how would it have gone?

By already involving students in the telling of the story (in stage two), the educator has encouraged active participation in the evolution of events and character perspectives as written by the author. STAGE FOUR: STORY PROCESSING The story processing stage involves: exploring multiple layers of perspectives, comparison of the context in which the story was presented with alternative contexts and how the story could be retold; and other theoretical evidence that link to the story (McDrury & Alterio, 2002; Rolfe, Freshwater, & Jasper, 2001). Processing the story is an opportunity for students to recognise and deconstruct their own narratives around loss and death; it is a non-threatening point of departure


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to explore alternatives. We ask questions that prompt students to dig deeper into their intuitive response to the story. Questions that critically examine student’s beliefs, assumptions and values, while at the same time recognising and challenging individual’s pre-conceptions are preferred (Evans & Severton, 2001). For example, after reading Michael Rosen’s Sad Book we direct discussion that builds confidence in communicating about death and loss by asking questions such as: What patterns can you identify from this story that echo in your life that feel familiar or that stands out as different? What grief theory was illustrated? What fitted? What was different from expected? What feelings are involved for Rosen (the author whose son died)?

When processing and reflecting on the story, we explicitly ask the students to think about: how the moral lessons are conveyed; how prejudices are subtly implanted; and how moral codes previously developed as children can now be applied to nursing situations. STAGE FIVE: RECONSTRUCTING – BUILDING NEW PRACTICE

The aim of story reconstructing is to assist students transform learning into changes, or affirm practice (McDrury & Alterio, 2002). We focus classroom dialogue on how the story has helped understanding, or will change personal practice; allowing students to share insights about their experiences of grief, loss or death, and internalise their learning. To encourage students to make the most of the reconstructing stage, we ask the group of students to explore how their ‘new’ knowledge, attitudes and values might affect practice when working with clients experiencing loss. In future clinical practice settings we provide opportunities for small group discussions, written and verbal reflection, and constructive feedback from clients and educators. There are times where it might be appropriate to ask a student in clinical practice to recall a lesson from one of the books that we have used in the classroom. For example we might prompt a student to remember how Michael felt in Michael Rosen’s Sad Book, to gently remind them that it is possible that death may not seem sad to the person dying. This may help the student focus


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their nursing actions on working in partnership with the client’s perception of their needs. A summary of what we consider to be the key teaching and learning considerations for educators wishing to add children’s books to their teaching repertoire is provided in Table 1. DISCUSSION McDrury and Alterio’s (2002) ‘reflective learning through storytelling’ model was developed through their experience of using storytelling as a learning tool in nurse education. Using their model helps us to choose a book that is appropriate for the teaching session. 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 storytelling stage, a listener through aural and visual stimulation attempts to make sense of the story’s context and of the human experience it portrays. In the story expanding stage 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 questions such as: Why did events unfurl in particular ways? 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 reconstructing 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 (2000, 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.

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In our experience, teaching and learning with children’s narratives has many advantages. Stories in our chosen books enable students to see the experience of death, grief and loss from the perspective of one the different characters, facilitating empathy and thus a deeper level of knowing an understanding. We find that these books provide a short, refreshing, interactive learning activity which gains the students attention quickly and exposes them to a range or life experiences in a controlled and safe setting where they can explore personal as well as emerging professional roles. We notice that many become more comfortable using storytelling to share stories of success and that this helps to develop a psychological sense of community and friendship among student groups in their first year of study. These social support systems are essential for all nurses, but particularly young nurses as they build a sense of place relationship and professional identity (Ditzel, 2008). Stories can be read, written or recorded, but we agree with Johnson and Jackson (2005) that they seem most powerful when told from the heart or read aloud. Reading a story aloud highlights the importance of listening and attending to our patients and client’s feelings. Regularly using stories in the classroom provides students with the opportunity to listen and practice these skills. Our teaching practice supports the views of others (Davidson, 2004; Krautz, 2007) that children’s books engage nursing students in reflective thinking in the classroom. 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). Finally, it should be noted that our teaching sessions about grief, loss and death do not standalone. It is important that educators are available for student de-briefing throughout all stages


Reflective learning through storytelling of learning and reflecting about loss and death through storytelling. We prepare first year students by exploring personal responses to losses that they have already experienced. This exercise creates fertile ground for examining personal constructs in comparison with those suggested within the books Michael Rosen’s Sad Book, and Duck, Death and the Tulip. We ensure students are aware of support systems when doing self-directed work, and work together when taking sessions, as one educator is always available to support a student if necessary. CONCLUSION We recommend using literature, particularly children’s picture story books as they provide a flexible approach to teaching in which educators can use their knowledge to extract concepts relevant to nursing, while stimulating both the aural and visual senses. We have found that reflecting on the detail in stories helps students make a bridge between space and time and enter the world of others. Educators who teach nursing students about death, grief and loss are aiming to strengthen student confidence and awareness, and build practice that is empathetic to the complexities involved. They know that many students find this topic ‘scary’, and want to make them feel able to safely explore this content. By employing well-chosen children’s picture educators can provide a non-threatening introduction to loss, grief and death for first year nursing students. With practice, nurse educators can enhance reflective learning opportunities for students when their teaching strategies are based on a model such as McDrury and Alterio’s (2002) ‘Reflective Learning through Storytelling’. References Andreae, G., & Parker-Rees, G. (2000). Giraffes can’t dance. London, England: Orchard Books. Barrow, R., & Woods, R. (1975). An introduction to the philosophy of education. London, England: Methuen. Benner, P. (1991). The role of experience, narrative, and community in a skilled ethical component. Advances in Nursing Science, 14(2), 1–21. Bergman, P. (1999). Story telling as a teaching tool. Clinical excellence for nurse practioners, 3, 154–157. Bishop, R. S., & Hickman, J. (1992). Four or fourteen or forty: Picture books are for everyone. In S. Benedict & L. Carlisle (Eds.), Beyond words: Picture books for


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Accepted 22 February 2012

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