Digital Story Analysis Utilizing the Advancing Care Excellence for Seniors Framework

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Title:
Digital Story Analysis Utilizing the Advancing Care Excellence for Seniors Framework
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1 online resource (142 p.)
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english
Creator:
Bassell, Kellie A
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University of Florida
Place of Publication:
Gainesville, Fla.
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Thesis/Dissertation Information

Degree:
Doctorate ( Ed.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Curriculum and Instruction, Teaching and Learning
Committee Chair:
Black, Erik Wade
Committee Members:
Kumar, Swapna
Pace, Barbara G
Krueger, Charlene Ann

Subjects

Subjects / Keywords:
digital -- geriatrics -- storytelling
Teaching and Learning -- Dissertations, Academic -- UF
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Curriculum and Instruction thesis, Ed.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
The purpose of this study was to explore the effectiveness of using digital storytelling as an end of rotation assignment, in a long-term care setting, for pre-licensure nursing students as a means to demonstrate an understanding of the Advancing Care Excellence for Seniors (ACES) framework. The research sought to explore the relationship between the student’s digital story and their understanding of the required knowledge to care for geriatric patients.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Kellie A Bassell.
Thesis:
Thesis (Ed.D.)--University of Florida, 2013.
Local:
Adviser: Black, Erik Wade.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-02-28

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lcc - LD1780 2013
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UFE0045654:00001


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1 DIGITAL STORY ANALYS IS UTILIZING THE ADV ANCING CARE EXCELLEN CE FOR SENIORS FRAMEWORK By KELLIE BASSELL A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF EDUCATION UNIVERSITY OF FLORIDA 2013

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2 2013 Kellie Bassell

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3 To my mother ~Kathleen Nina Williams~ January 5, 1934 November 20, 2012

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4 ACKNOWLEDGMENTS This dissertation would not have been possible without the encouragement, inspiration and guidance of many. I owe heartfelt and sincere gratitude to my husband Eddie. He has been with me every step of this journey helping in every way possible to achieve this goal. His love and understand me to press on. To my daughter Katherine, thank you for your patience and needed a hug. I am truly indebted and thankful to my parents who presented me the opportunity of an education from the best institutions and help throughout my life. To my father, I would like to thank you for leading your family by example by never giving up on what you believe in. To my mother, you were right, it just took me a while to figure out what you for your love and support. Thank you for understanding those missed holidays, birthdays and other occasions during this adventure. Heartfelt thanks and accolades to my dissertation committee. I am truly indebted and thankful to my Chair, Dr. Erik Black. From the very beginning of this venture he told me he would be there for me and thankfully he was! Your ongoing guidance and support has shaped both my research and continued professional growth. Thank you Dr. Swapna Kumar you always had the ability to help me see the small but important things that brought me back on target. Thank you Drs. Pace and Kruger for the insights and support you gave me during this dissertation. Your comments encouraged me to dig deeper and reach farther with my research.

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5 I am obliged to many of my colleagues who supported me during this quest. The ful discussions always encouraged me to think outside the box. I owe a special thank you to DJ Marshall. It gives me great pleasure in acknowledging the support of the administration of Palm Beach State College and faculty and staff of Palm Beach State College program who continually supported me in the pursuit of this doctorate. I would especially like to thank Dr. Sharon Sass and Dean Jacqueline Rogers for being incredible role models, mentors and friends.

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6 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ .......... 10 LIST OF FIGURES ................................ ................................ ................................ ........ 11 LIST OF ABBR EVIATIONS ................................ ................................ ........................... 15 ABSTRACT ................................ ................................ ................................ ................... 16 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 17 Overvi ew of Nursing Education ................................ ................................ ............... 17 Historical Perspective ................................ ................................ ....................... 17 Foundation of Nursing ................................ ................................ ...................... 19 Current trends in nursing education ................................ ................................ 20 Silver Tsunami ................................ ................................ ................................ ........ 20 Advancing Care Excellence for Seniors ................................ ................................ .. 22 Challenges for Nursing Education ................................ ................................ .......... 23 Storytelling ................................ ................................ ................................ .............. 24 Tradition of Sto ries ................................ ................................ ........................... 25 The Story ................................ ................................ ................................ .......... 25 Storytelling in Higher Education ................................ ................................ ....... 26 Digital Storytelling ................................ ................................ ................................ ... 26 Defining a Digital Story ................................ ................................ ..................... 26 Hist ory of Digital Storytelling ................................ ................................ ............. 27 Implications for the use of Digital Storytelling in Higher Education ................... 27 Purpose ................................ ................................ ................................ ............ 28 Methodology ................................ ................................ ................................ ..... 29 2 LITERATURE REV IEW ................................ ................................ .......................... 30 Current Trends in Nursing Education ................................ ................................ ...... 3 0 Complex patient centered care ................................ ................................ ........ 30 Aging America and the Implications for Nursing Practice and Education ......... 31 Advancing Care Excellence for Seniors ................................ ................................ .. 32 ACES Essential Knowledge Domains ................................ .............................. 32 Individualized Aging ................................ ................................ ................... 32 Complexity of care ................................ ................................ ..................... 32 Vulnerabil ity during life transitions ................................ .............................. 33 ACES Essential Nursing Actions ................................ ................................ ...... 33 Assess function and expectations ................................ .............................. 34

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7 Coordinate and manage care ................................ ................................ ..... 34 Use evolving knowledge ................................ ................................ ............ 34 Make situational decisions ................................ ................................ ......... 35 Digital Storytelling in Higher Education ................................ ................................ ... 35 Digital Storytelling as a Teaching and Learning Tool ................................ ....... 35 Individual Reflective Learning ................................ ................................ ........... 36 Individual & Peer Reflective Learning ................................ ............................... 39 Technology Competencies ................................ ................................ ............... 46 Best Practices ................................ ................................ ................................ .. 47 Summary ................................ ................................ ................................ ................ 49 3 METHODOLOGY ................................ ................................ ................................ ... 52 Overview ................................ ................................ ................................ ................. 52 Purpose ................................ ................................ ................................ .................. 53 Research Design ................................ ................................ ................................ .... 54 Population ................................ ................................ ................................ ............... 54 Sample ................................ ................................ ................................ .................... 55 Instrumentation ................................ ................................ ................................ ....... 56 Data Collection ................................ ................................ ................................ ....... 57 Data Analysis ................................ ................................ ................................ .......... 58 Limitations ................................ ................................ ................................ ............... 59 Summary ................................ ................................ ................................ ................ 59 4 RESULTS ................................ ................................ ................................ ............... 66 Overview ................................ ................................ ................................ ................. 66 Sample ................................ ................................ ................................ .................... 66 Results ................................ ................................ ................................ .................... 68 Re search Question 1 ................................ ................................ ........................ 68 Individualized aging. ................................ ................................ .................. 68 Comple xity of care ................................ ................................ ..................... 69 Vulnerability during life transitions ................................ .............................. 69 Total rubric scores ................................ ................................ ..................... 70 Research Question 2 ................................ ................................ ........................ 71 Digital Stories ................................ ................................ ................................ ... 72 Digital stor y 1 ................................ ................................ ............................. 72 Digital story 2 ................................ ................................ ............................. 72 Digital story 3 ................................ ................................ ............................. 73 Digital story 4 ................................ ................................ ............................. 73 Digital story 5 ................................ ................................ ............................. 74 Digital story 6 ................................ ................................ ............................. 74 ACES framework themes ................................ ................................ ................. 74 Individualized aging ................................ ................................ ................... 74 Assessme nt of function ................................ ................................ .............. 75 Assessment of cognitive function ................................ ............................... 75 Assessment of atypical presentation of pain and management of pain ..... 76

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8 Assessment of geriatric syndromes ................................ ........................... 76 Assessment of sexuality ................................ ................................ ............ 77 Assessment of violence and elder abuse ................................ ................... 77 Complexity of Care ................................ ................................ ........................... 77 Geriatric syndromes ................................ ................................ ................... 78 Hydration status ................................ ................................ ......................... 78 Infection ................................ ................................ ................................ ..... 78 Poly pharmacy ................................ ................................ ........................... 79 Depression ................................ ................................ ................................ 79 Dementia ................................ ................................ ................................ .... 79 Acute vs. chronic disease process ................................ ............................. 80 Vulnerabilities during Life Transition s ................................ ............................... 80 Health care decision making ................................ ................................ ...... 80 Palliative care ................................ ................................ ............................. 81 Iatrogenesis ................................ ................................ ............................... 81 Frailty ................................ ................................ ................................ ......... 81 Advocacy ................................ ................................ ................................ ... 81 Environment of care ................................ ................................ ................... 82 Additional Identified Themes ................................ ................................ ............ 82 Individual Perception of Current Life Status ................................ ............... 82 Identity ................................ ................................ ................................ ....... 83 Reminiscing ................................ ................................ ............................... 83 Attitude ................................ ................................ ................................ ....... 83 Summary ................................ ................................ ................................ ................ 84 5 DISCUSSION AND IMPLICATIONS ................................ ................................ ..... 107 Summary of the Study ................................ ................................ .......................... 107 Overview of the problem ................................ ................................ ................. 107 Purp ose statement and research questions ................................ ................... 107 Review of the methodology ................................ ................................ ............ 108 Major Findings ................................ ................................ ................................ ...... 108 Research Question 1: Does the digital story rubric assess the student learning outcomes as they relate to the ACES framework? ........................ 108 Findings ................................ ................................ ................................ ... 108 Discussion of caring qualities ................................ ................................ ... 110 Discussion of attitudes toward older adults ................................ .............. 111 Discussion of contextual teaching strategy ................................ .............. 112 Discussion of instructor impacts ................................ ............................... 113 Discussion of the ACES rubric ................................ ................................ 114 Discussion of the assignment context ................................ ...................... 114 Research Question 2: What themes are found in the digital stories in addition to those assessed by the ACES rubric? ................................ ........ 115 ACES framework themes findings ................................ ........................... 115 Discussion ................................ ................................ ................................ 118 Additional ident ified themes findings ................................ ........................ 119 Discussion ................................ ................................ ................................ 120

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9 Limitations ................................ ................................ ................................ ............. 122 Conclusions ................................ ................................ ................................ .......... 122 Implications for action ................................ ................................ ........................... 123 Recommendations for further research ................................ ................................ 124 Closing remarks ................................ ................................ ................................ .... 125 APPENDIX A INSTITUTIONAL REVIEW BOARD ................................ ................................ ...... 126 B PALM BEACH STATE COLLEGE RESEARCH APPROVAL ............................... 127 C LONG TERM CARE ROTATION -SUMMARY OF EXPERIENCE ...................... 128 D ACES FRAMEWORK RUBRIC ................................ ................................ ............. 130 LIST OF REFERENCES ................................ ................................ ............................. 134 BIOGRAPH ICAL SKETCH ................................ ................................ .......................... 142

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10 LIST OF TABLES Table page 4 1 Individualized Aging Descriptive Statistics ................................ .......................... 85 4 2 Complexity of Care Descriptive Statistics ................................ ........................... 85 4 3 Vulnerabilities During Life Transitions Descriptive Statistics .............................. 85 4 4 Total Rubric Scores Descriptive Statistics ................................ .......................... 86 4 5 Digital Story Properties ................................ ................................ ....................... 86

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11 LIST OF FIGURES Figure page 2 1 Conceptualization of the ACES framework. ................................ ........................ 51 3 1 Schematic representation of concurrent triangulation design (Creswell, 2009) .. 6 1 3 2 Age demographics comparison ................................ ................................ .......... 62 3 3 Gender demographics comparison ................................ ................................ ..... 62 3 4 Race demographics comparison ................................ ................................ ........ 63 3 5 Schematic representation of the qualitative data analysis method ..................... 64 3 6 Schematic representation of the student digital storytelling assignment in context and resources ................................ ................................ ........................ 65 4 1 Gender distribution of the sample, the 1st semester enrolled students in this ADN program, the overall student p opulation in the ADN program and overall national enrollment. ................................ ................................ ............................ 86 4 2 Age distribution of the sample, the 1st semester enrolled st udents in this ADN program, the overall student populaiton in the ADN program and the overall national enrollment. ................................ ................................ ................. 87 4 3 Race distribution of the sample, the 1st semester enrolled students in this ADN program, the overall student populaiton in the ADN program and the overall national enrollment. ................................ ................................ ................. 87 4 4 Student individual score on the ACES rubric. DS = digital story. ........................ 88 4 5 Predetermined Themes for the ACES Framework ................................ ............. 89 4 6 Frequency distribution of the characteristics identified in the individual dig ital stories as defined in the Individualized Aging knowledge domain. ..................... 90 4 7 Digital image from digital story 2 representing the Individualized Aging characteristic of assessment of function. ................................ ............................ 90 4 8 Digital image from digital story 4 representing the Individu alized Aging characteristic of assessment of function. ................................ ............................ 91 4 9 Digital image from digital story 1 representing the Individualized A ging characteristic of assessment of function. ................................ ............................ 91 4 10 Digital image from digital story 3 representing the Individualized Aging characteristic of assessment of cognitive function. ................................ ............. 92

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12 4 11 Digital image from digital story 4 representing the Individualized Ag ing characteristic of assessment of cognitive function. ................................ ............. 92 4 12 Digital image from digital story 3 representing the Individualize d Aging characteristic of assessment of atypical presentation of pain and management of pain. ................................ ................................ .......................... 93 4 13 Digital image from digital story 4 representing the Individualized Aging characteristic of assessment of atypical presentation of pain and management of pain. ................................ ................................ .......................... 93 4 14 Digital image from digital story 6 representing the Individualized Aging characteristic of assessment of geriatric syndromes. ................................ ......... 93 4 15 Digital image from digital story 4 representing the Individualized Aging characteristic of assessment of geriatric syndromes. ................................ ......... 94 4 16 Digital image from digital story 4 representing the Individualized Aging characteristic of assessment of sexuality. ................................ .......................... 94 4 17 Digital image from digital story 1 representing the Individualized Aging characteristic of assessment of violence and elder abuse. ................................ 94 4 18 Frequency distribution of the characteristics identified in the individual digital stories as defined in the Complexity o f Care knowledge domain. ...................... 95 4 19 Digital image from digital story 1 representing the Complexity of Care characteristic of geriatri c syndromes. ................................ ................................ 95 4 20 Di gital image from digital story 4 representing the Complexity of Care characteristic of geriatric syndromes ................................ ................................ 96 4 21 Digital image from digital story 2 representing the Complexity of Care characteristic of hydration status. ................................ ................................ ....... 96 4 22 Digital image from digital story 2 representing the Complexity of Care characteristic of infection. ................................ ................................ ................... 96 4 23 Digital image from digital story 2 representing the Complexity of Care characteristic of poly pharmacy. ................................ ................................ ......... 97 4 24 Digital image from digital story 3 representing the Complexity of Care characteristic of depression. ................................ ................................ ............... 97 4 25 Digital image from digital story 5 representing the Complexity of Care characteristic of depression. ................................ ................................ ............... 97

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13 4 26 Digital image from digital story 1 representing the Complexity of Care characteristic of dementia. ................................ ................................ .................. 98 4 27 Digital image from digital story 4 representing the Complexity of Care characteristic of depression. ................................ ................................ ............... 98 4 28 Digital image from digital story 4 representing the Complexity of Care characteristic of acute vs. chronic disease process. ................................ ........... 98 4 29 Digital image from digital story 4 representing the Complexity of Care characteristic of acute vs. chronic disease process. ................................ ........... 99 4 30 Frequency distribution of the characteristics identified in the individual digital stories as defined in the Complexity of Care knowledge domain ....................... 99 4 31 Digital image from digital story 1 representing the Vulnerabilities during Life Transitions characteristic of health care decision making. ................................ 100 4 32 Digital image from digital story 1 representing the Vulnerabilities during Life Transitions characteris tic of health care decision making. ................................ 100 4 33 Digital image representing the Vulnerabilities during Life Transitions characteristic of palliative care. ................................ ................................ ......... 101 4 34 Digital image representing the Vulnerabilities during Life Transitions characteristic of palliative care. ................................ ................................ ......... 101 4 35 Digital image from digital story 1 representing the Vulnerabilities during Life Transitions characteristic of frailty. ................................ ................................ ... 101 4 36 Digital image from digital story 2 representing the Vulnerabilities during Life Transitions characteristic of a dvocacy. ................................ ............................. 102 4 37 Digital image representing the Vulnerabilities during Life Transitions characteristic of environment of care. ................................ ............................... 102 4 38 Digital image representing the Vulnerabilities during Life Transitions characteristic of environment of care. ................................ ............................... 103 4 39 Additional themes identified beyond the ACES framework pre determined themes. ................................ ................................ ................................ ............. 104 4 40 Digital image representing the sub theme Identity. ................................ ........... 105 4 41 Digital image representing the sub theme Identity. ................................ ........... 105 4 42 Digital image representing the su b theme Reminiscing. ................................ ... 105 4 43 Digital image representing the sub theme Reminiscing. ................................ ... 106

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14 4 44 Digital image representing the sub theme Attitude. ................................ .......... 106 4 45 Digital image representing the sub theme Attitude. ................................ .......... 106

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15 LIST OF ABBREVIATION S ACES Advancing Care Excellence for Seniors ADN Associate degree in nursing ANA American Nurses Association CCNE Commission on Collegiate Nursing Education NLN National League for Nursing NLNAC National League for Nursing Accrediting Commission

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16 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Education DIGITAL STORY ANALYSIS UTILIZING THE ADVANCING CARE EXCELLENCE FOR SENIORS FRAMEWORK By Kellie Bassell August 2013 Chair: Erik Black Major: Curriculum and Instruction The purpose of this study wa s to explore the effectiveness of using digital storytelling as an end of rotation assignment, in a long term care setting, for pre licensure nursing students as a means to demonstrate an understanding of the Advancing Care Excellence for Seniors (ACES) fr amework. The research sought to the required knowledge to care for geriatric patients.

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17 CHAPTER 1 INTRODUCTION Chapter 1 provides an overview and the framework for the use of digital storytelling in geriatric nursing education. The introduction outlines the historical and current trends in nursing education It provides information on the prevailing state of the aging adult in our society and implications for nursing practice and care. Included in C hapter 1 are the historical underpinnings of storytelling in tradition and education as well as contemporary tr ends in the use of di gital storytelling. Finally C hapter 1 discusses an overview of the research project, including the purpose, research questions, methodology and design. Overview of Nursing Education Historical Perspective Nursing education as formalized training can trace its roots to the work done by Florence Nightingale following the Crimean War. In the mid 19 th century, Florence Nightingale recognized more soldiers were dying from common illnesses than war injuries. She instituted protocols for maintaining cleanliness in all areas, including the kitchens, the wards, and the patients. These interventions led to improved survival rates for the injured. She also was responsible for founding the first nursing training program, the Nightingale Tra ining School, at St. Thomas' Hospital in London, England (Baly, 1995; National League for Nursing, 2007; Rush, 1992; Zerwekh & Garneau, 2012) This formalization of nursing care was focused on training nurses to work in hospitals, to train other nurses and to work with the sick poor in the community. Practices were based on the same tenets of hygienic care she had established during the war (National League for Nursing, 2007; Zerwekh & Garneau, 2012; Rush, 1992). With the outbreak

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18 of the Civil War in the Un ited States, a similar need for sanitary care of wounded soldiers led to the development of a formalized healthcare system, including nursing training. Hospitals were recognized as arenas to promote healing instead of asylums for the infirm and with this s hift came an increased demand for trained nurses (Keating, 2006; National League for Nursing, 2007; Rush, 1992; Toman & Thifault, 2012; Zerwekh & Garneau, 2012) In 1899, the first formal university training program was established for nursing education at Teachers College, Columbia University. The intent was to provide didactic content to enhance the science of nursing hand in hand with clinical education (Rush, 1992; Toman & Thifault, 2012) In 1903, the profession saw the first state legislation passed in North Carolina for the mandatory registration of trained nurses. This precedent made it illegal to practice nursing in the state of North Carolina, without a formal education (Bullough, 1976; Nelson, 2002; Nursing Education History, 2012) New York beca me the first state in 1938 to pass a specific scope of practice for the registered nurse, to include minimal education requirements (Bullough, 1976; Smith, 1969) Until the early 1950 s, nursing education was primarily based in hospital diploma programs, with a small percentage of practitioners attending university training either for a degree or certificate. Those attending in a university setting were acknowledged as needing additional education to either act as a nursing administrator or nurse educators (Keating, 2006; National League for Nursing, 2007; Rush, 1992; Zerwekh & Garneau, 2012) As with the Crimean War, post World War II led to a significant shortage of trained nurses for an increasingly complex healthcare system. This prompted the

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19 developme nt of Associate degree nursing programs at junior colleges to help meet the demands ( Orsolini Hain & Waters, 2009). The American Nurses Association (ANA) and the National League for Nursing ( NLN ) had published standards of practice for registered nurses b y 1965 (Bullough, 1976; Nursing Education History, 2012) These standards included education requirements which addressed training nurses in technical skills as wel l as the ability to care for the physiological and psychosocial needs of the patient (Nelson 2002; Orsolini Hain & Waters; Saylor, 1990) In the late 1990 s, two nursing education accrediting bodies were developed and recognized by the U.S. Department of Education. They are the National League for Nursing Accrediting Commission (NLNAC) and the American Association of College of regulation of minimum curriculum requirements for those educational institutions seeking accreditation which included specific standards address ing the congruency of theory to clinical practice ( Ironside, 2001; Lasater, 2011; Nursing Education History, 2012). Foundation of Nursing Registered nurses account for one of largest professions involved in direct patient care. There are over 3.1 million r egistered nurses in the United States (American Association of Colleges of Nursing, 2011; Benner, Benner, Sutphen, & Leonard, 2009; Health Resources and Sevices Administration, 2010) The nursing profession is described as encompassing both art and science within its defining characteristics. The art of nursing has been illustrated as an expression of sympathy, attitudes of concern, ethical and moral commitment and sensitivity to feelings of others. The scientific aspect

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20 of the profession is primarily focus ed on objectivity, rational examination and measurement, verification of evidence, disciplined critical thinking, skepticism and rigorous intellectual honesty regarding conclusions drawn from facts (Dunphy, 2001; Peplau, 1988) To further the understanding put forth models of caring as being central to the profession. The most well known of Nursing as Caring ( McCance, McKenna, & Boore, 1999, Parker, 2001). Current trends in nursing education Nursing education is increasingly challenged with a demand for including new content or concepts in an already overburd ened curriculum (Pressler & Kenner, 2009). Current research has demonstrated a need for registered nursing curricula to include teaching and learning strategies which will facilitate the development of clinical reasoning, to include understanding the conte xt of the situation from the viewpoint of the multiple lenses of culture, daily environment, illness experience and their relationships with significant others in their li ves (Benner et al., 2009; Diekelmann, Ironside, & Gunn, 2003;Ironside, 2006) Silver Tsunami In 2011, the first baby boomers began to turn 65 years old. It is estimated that there are over 78 million Americans born between the years of 1946 to 1964 (Centers for Disease Control and Prevention, 2003; Centers for Disease Control and Prevention and Th e Merck Company Foundation., 2007; U.S. Census Bureau, 2008). Over the next 25 years, the number of individuals over the age of 65 in the United States will almost

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21 double. This translates into individuals over the age of 65 making up approximately 20 perce nt of the total population (Centers for Disease Control and Prevention, 2003; Centers for Disease Control and Prevention and The Merck Company Foundation., 2007; U.S. Census Bureau, 2008). During the past decade, improved medical care and prevention effort s have contributed to dramatic increases in life expectancy in the United States (Centers for Disease Control and Prevention, 2003;Centers for Disease Control and Prevention and The Merck Company Foundation, 2007). The life expectancy rate has increased 45 % since 1960 with a current life expectancy of 78.2 years. There has been a decline in mortality related to infectious disease and acute illness with an increase of mortality related to chronic disease and degenerative illness (Bodenheimer, Chen, & Bennett 2009; Centers for Disease Control and Prevention, 2003). The combination of these two factors will lead to an increase in individuals over the age of 65 seeking health care during the next two decades (Bodenheimer, Chen, & Bennett, 2009; Centers for Dise ase Control and Prevention, 2003; Centers for Disease Control and Prevention and The Merck Company Foundation., 2007). The American Hospital Association (2007) reports that 37 million baby boomers will be managing more than one chronic condition by 2030, w ith one out of four, or 14 million, living with diabetes; almost half will be living with arthritis and more than one third, or over 21 million, will be classified as obese and living with all the health risks associated with obesity. The combination of an increase in the aging population and the complexity of their healthcare calls for an increase in preparing nurses with the ability to deliver competent care to this vulnerable population.

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22 The National Council of State Boards of Nursing (2012) report that 56.1% of new graduates report caring for older adult clients aged 65 to 85 with an additional 27.8% reporting caring for older adult clients aged 85 or older (NCSBN, 2012).In 2008, the Institute of Medicine (IOM) published a report calling for a national agenda to improve the ability of health care workers to care for older Americans. Specifically addressed in this, was a need for increasing the competence of all individuals, including nurses, in the delivery of geriatric care (Institute of Medicine of the National Academies, 2008). Given the growing population over the age of 65, there is a need to implement innovative strategies to prepare pre licensure nursing students in the care of older adults (Ironside, Tagliareni, McLaughlin, King, & Mengel, 2010; M ion, 2003; National League for Nursing, 2009; Tagliareni & McLaughlin, 2007). Advancing Care Excellence for Seniors The John Hartford Foundation in conjunction with the Independence Foundation of Philadelphia funded a study to research the geriatric content in associate degree nursing (ADN) programs across the United States (Ironside, et al., 2010; Tagliareni, et al., 2 012; Tagliareni & McLaughlin, 2007) The results of this study demonstrated a critical need to develop curriculum to prepare nursing graduates in the care of older adults (Ironside, Tagliareni, McLaughlin, King, & Mengel, 2010; National League for Nursing, 2009) In 2008, The Hartford Foundation, The Independence Foundation of Philadelphia and Laerdal Medical funded a collaborative project between the NLN and the Community College of Philadelphia to develop a set of minimum standards of knowledge, skills an d attitudes to care for older adults for per licensure nursing students (Tagliareni, Cline, Mengel, McLaughlin, & King, 2012; Tagliareni & McLaughlin, 2007; National League for Nursing, 2009) In September 2009 the Advancing Care

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23 Excellence for Seniors fr amework developed by this grant was launched at the NLN Education Summit. It provides for a conceptual framework that was utilized in this research study, in which students can gain understanding of the importance of individualized aging, complexity of car e and life transitions, using evolving geriatric knowledge to provide care for the older adult (NLN, 2011; Tagliareni, et al., 2012) .This researcher has developed a rubric to assess student learning outcomes in the three specific identified knowledge domai ns of individualized aging, complexity of care and life transitions based on the ACES framework. The rubric has been reviewed for content validity by ACES experts and piloted. Challenges for Nursing Education Current practices in nursing education can tra ce th eir foundation back to the 1950 s (Benner, Benner, Sutphen, & Leonard, 2009) Modern nursing educators utilize teaching strategies which frequently mirror how they were taught. Skill based learning, classroom learning and clinical learning are taught i n silos. It is rare for students to encounter educational environments where they are asked to integrate what they have learned in the classroom into the clinical arena. This leads to a fragmented and superficial understanding of how to holistically care f or patients (Benner, Benner, Sutphen, & Leonard, 2009; Diekelmann, 2001; Diekelmann, Ironside, & Gunn, 2003) methods to facilitate student learning. Nurse educators feel pressur ed by the vast amount of information covered in current nursing curricula and over compensate by attempting to lecture all to cover the content (Pressler & Kenner, 2009). The nursing education profession has been challenged to implement innovative teaching strategies to promote situational decision making within a contextual model of teaching and

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24 learning (Benner, et al., 2009; Ironside, 2006) .One innovative means to encouraging pre professional nurses to engage with older patients is storytelling. Stories provide the ability for nurses to reflect on their values and attitudes in a manner they may not be able to achieve otherwise. Stories provide a means to recall details and bring experiences to life to enhance the students understanding of the encounter ( Benner, et al., 2009; Brown, Kirkpatrick, Mangum, & Aver y, 2008; Ironside, 2006). Story telling as a teaching and learning tool in nursing education is an established mechanism to promote reflecion and demonstrate a deeper understanding of events (Diekelman n, 2001; Ironside, 2003; Nehls, 1995). It is through both the telling and sharing of stories that nursing students come to recognize and understand qualitative distincition in patien t situations (Benner, Hooper Kyriakidis, & Stannard, 1999; Ironside, 2003) Narrative presentation of experiences encourages reflective thinking of both students and teachers and may increase the understanding of what was learned and how it was learned (Diekelmann, 2004). Digital storytelling provides a potential new medium to d ability to consider a patient through the multiple lenses of culture, daily environment, illness experience and their relationships with significant others in their lives (Benner et al ., 2009; Diekelmann, Ironside, & Gunn, 2003;Ironside, 2006). Storytelling The following sections will present an overview of storytelling. Included are highlights of the historical context of stories, their use in education and development and use of digit al storytelling in education.

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25 Tradition of Stories Storytelling has played a significant role in how we perceive history. It was/is the mechanism by which knowledge and culture are passed onto others. It is both a form of education and entertainment for a ll ages. Stories impact the way we see our world and can sway our beliefs and values ( Abrahamson, 1998; Robinson, 2004) Stories can represent life as it was, is or could be (Parkinson, 2001). The Story Scholes, Phelan and Kellogg (2006) define a narrative as having two central characteristics. They are the existence of a story and story teller. Bonifer (2010) delineates the difference between a narrative and a story. He describes a narrative as a flow of events connected to a theme and a story as being the cognizant ordering of these events to stimulate a meaning. Worth (2008) further depicts a narrative as the way individuals order their experience in time within a unified sequential structure. It is wit h the addition of the two aspects of a plot, chronological and non chronological, that a story if formed. These two facets allow for both the timeline of events and the context which they are grounded in, to guide one into making sense of the events that c reate the story. Labov (2011) identifies three basic elements of a story which will be used for the purpose of this research. The three structural elements are temporal organization, orientation and coda. Temporal organization refers to the order of events within a given timeframe. Orientation is the introduction and identifying of the action in the context of time, place and initial behavior. The coda refers to the end of a narrative in which the temporal setting is returned to the present.

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26 Storytelling i n Higher Education Storytelling in education has been instrumental in helping students make meaning of complex human conditions and life events (Burk, 2000). Abrahamson (1998) identifies critical reflection as an outcome to utilizing stories in the classr oom. Stories become the manner in which students can process the complex nature of what they are being presented within the classroom thus forging a learning community of shared views. Digital Storytelling Defining a Digital Story The ability for individ uals to bring their personal stories to life is increasing in popularity, with the widespread availability of personal computers and the ease of creating multimedia productions with low cost software. This has given birth to a new genre of storytelling: di gital storytelling. The Digital Storytelling Association defines stories derive their power through weaving images, music, narrative and voice together, thereby giv ing deep dimension and vivid color to characters, situations and in (Rule, 2011). Rossiter and combine the art of telling stories with multimedia objects including images, audio and video person video narrative created by combining recorded voice, still and moving images of this research, a digital story will follow the defi nition as outlined by Rossiter and Garcia (2010).

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27 History of Digital Storytelling Digital storytelling emerged in the 1990s as a distinct storytelling tool. Joe Lambert and Dana Atchley at the Center fo r Digital Storytelling (CDS) housed at the University of California, Berkley have been credited with the origins of digital storytelling (Bull & Kajder, 2004; Chung, 2007). The CDS continues to train individuals in the art of digital storytelling using the ir prescribed seven elements of effective digital storytelling (Robin, 2008). Over the past 2 decades, digital storytelling has grown from a venue for individuals and communities to preserve their history to a widely used tool in the bin, 2008). Implications for the use of Digital S torytelling in Higher E ducation Digital storytelling has been demonstrated as a powerful teaching and learning tool in higher education. Studies have demonstrated the use of digital storytelling can support individual reflective learning of students when employed in the classroom (Christ iansen, 2011; D'Alessandro, Lewis, & D'Alessandro, 2004; Skouge & Rao, 2009). Digital storytelling has also been demonstrated as having an impact on reflective learning when utilized as a teaching strategy for both individual and peer settings (Cheng & Cha u, 2009; Jenkins & Londsdale, 2007; McLellan, 2007; Sandars & Murray, 2009; Stacey & Hardy, 2010). Digital storytelling has been revealed to promote reflective learning in healthcare professional education. Digital storytelling promotes the use of reflecti on as a means to integrate new understanding, within the context of in the future. It has been shown that the sharing of stories, particularly in health and medicin e can promote new insights and knowledge through reflection for both patients and healthcare providers as either creators and/or consumers of these digital stories

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28 establis hment of competency in the use of technology has been confirmed as a positive outcome of using digital storytelling in the literature (Czarnecki, 2009; Heo, 2009). Purpose The purpose of this study wa s to explore the effectiveness of using digital storytel ling as an end of rotation assignment, in a long term care setting, for pre licensure nursing students as a means to demonstrate an understanding of the Advancing Care Excellence for Seniors (ACES) framework. National accrediting organizations for nursing programs require the documentation of student learning outcomes to include valid and reliable mechanisms to assess them (Halstead, 2007; Lowenstein & Bradshaw, 2001; National League for Nursing Certification Governance Comm ittee, 2005). The research sought to explore the relationship between the geria tric patients. The research aimed to investigate the use of digital storytelling as an innovative situational teaching strag ey in the context of geriatric care to promote a greater understanding of the ACES framework. The essential information required to care for geriatric patients is based on the understanding of the three knowledge domains of the ACES framework: individualiz ed aging, complexity of care and vulnerabilty during life transitions. Additionally the purpose of this research wa s to those outlined in the ACES framework. As such, the research questions which guide this study are: RQ1. Does the digital story rubric assess the student learning outcomes as they relate to the ACES framework?

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29 RQ2. What themes are found in the digital stories in addition to those assessed by the A CES rubric? Methodology This study employ ed a mixed method, non experimental research design using a concurrent triangulation approach (Creswell, 2009; Onwuegbuzie & Leech, 2006). In the concurrent triangulation approach the data for the quantitative and qualitative research wa s be collected at the same t ime. The research questions sought to discern whether quantitative and qualitative data provide d opportunity to inform the research questions.

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30 CHAPTER 2 LITERATURE REVIEW Chapter 2 provides a review of the literature related to key areas salient to this research project. They include current trends and expectations in nursing education, the Advancing Care Excellence for Seniors (ACES) framework, and the utilization of digit al storytelling as a tool for teaching and learning in higher education. Current T rends in Nursing Education Nursing education ha s changed little since the 1950 s while the healthcare environment in which nurses practice has changed dramatically (Benner, e t al., 2009; Institute of Medicine, 2011; Ironside, 2004). Nursing curricula have been charged with being content laden and guilty of incorporating more material rather than reworking the content to reflect current practice (Benner et al., 2009; Ironside, 2004; Tanner, 2004). Recent research has called for fundamental changes in the way nurses are educated (Benner, et al., 2009; Institute of Medicine, 2011; Ironside, 2004; 2004, Orsolini Hain L; Tanner, 2008). Two of the central areas of identified need for nursing education reform are related to the requirement for nurses to be competent in understanding the relationship of the patient and/or family in the continuum of care and to be competent in caring for emerging health needs such as geriatrics (Benner, et al., 2009; Institute of Medicine, 2011; Ironside, 2004; 2004, Orsolini Hain L; Tanner, 2008). Complex patient centered care Nurse educators need to engage students with teaching and learning strategies which will facilitate the development of clinical reasoning, to include understanding the teaching students to consider a patient through the multiple lenses of culture, daily

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31 environment, illness experience and their rela tionships with significant others in their lives (Benner et al., 2009; Diekelmann, Ironside, & Gunn, 2003; Institute of Medicine, 2011; Ironside, 2004; Ironside, 2006, Tanner, 2004). Aging America and the Implications for Nursing Practice and Education The need for competent and holistic care for older adults is imperative in the changing landscape of our population in the United States (Centers for Disease Control and Prevention, 2003; AARP Public Policy Institute, 2009; NLN, 2011; Tagliareni, et al., 2012 ). Research has demonstrated that fewer nurses are interested in specializing in gerontology than other areas of care (Tagliareni, et al., 2012; Tagliareni & McLaughlin, 2007; National League for Nursing, 2009). Yet, it has been established that nurses who care for older adults and personalize and internalize the importance of their care have a positive impact on their outcomes (Tagliareni, et al., 2012; Tagliareni & McLaughlin, 2007; National League for Nursing, 2009). The Institute of Medicine ( IOM ) repo rt (2008) called for a national agenda to improve the ability of health care workers to care for older Americans. Specifically addressed in this, was a need for increasing the competence of all individuals, including nurses, in the delivery of geriatric ca re. Currently, geriatrics rarely constitutes more than 25% of associate degree nursing programs (Ironside, Tagliareni, McLaughlin, King, & Mengel, 2010; National League for Nursing, 2009; Tagliareni & McLaughlin, 2007). Research has demonstrated that older patients receive less information related to their health, illness and available resources than younger patients (Ayranci & Ozdag, 2006). Negative attitudes toward the elderly can lead to miscommunication or less than optimal patient education and result in poor patient compliance and/or outcomes (Ayranci & Ozdag, 2006; Cozort, 2008; Sinnott, 1983).

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32 Advancing Care Excellence for Seniors ACES Essential Knowledge Domains The ACES framework provides the conceptual framework for this research study. Figure 2 1 summarizes the ACES framework. The ACES framework identifies three essential knowledge domains as being fundamental in providing quality care to older adults. They are: individualized aging, complexity of care and vulnerability during life transitions ( NLN, 2011; Tagliareni, et al., 2012). These knowledge domains are key components of ensuring that nursing students understand how older adults and their families interact along the continuum of care and how they make decisions during life transitions (NLN, 2011; Tagliareni, et al., 2012). The following three sections will describe the fundamental tenets of these knowledge domains. Individualized Aging Each individual manifests and interprets the aging process in a unique manner. Older adults live in various settings and represent an expansive variety of strengths, resources, needs, wishes, and expectations (NLN, 2011; Tagliareni, et al., 2012). Central adults to believe all older adults follow the same sequel as they grow older (NLN, 2011; Taglia reni, et al., 2012). Complexity of care 2012). Hospitalized older adults are at increased risk for a variety of geriatric syndromes. Included among these are delirium, fall s, incontinence, pressure ulcers, and sleep disturbances (Inouye, Studenski, Tinetti, & Kuchel, 2007; NLN, 2011; Tagliareni,

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33 et al., 2012). The care of older adults requires specialized knowledge in both the art and science of gerontological nursing. Ident ifying and understanding the complex relationship of aging with acute and chronic conditions may better enable nurses to prevent such complications, thus improving the outcomes of older adults (Inouye, et al., 2007; NLN, 2011; Tagliareni, et al., 2012) Vu lnerability during life transitions A transition is defined as moving from one state, activity, or place to another. With aging, an older adult is likely to make many transitions across this spectrum. Transitions for the older adult can cause disruption fo r both the individual and family (NLN, 2011; Tagliareni, et al., 2012). Nurses need to function as advocates for older adults during these transitions. It is in this role that the nurse has the ability to improve the quality of care provided and to incorpo management of disease and promotion of health (NLN, 2011; Tagliareni, et al., 2012). ACES Essential Nursing A ctions The essential nursing actions enable nursing students to transform their knowledge of in dividualized aging, complexity of care, and vulnerabilities during life transitions into activities that promote competent care for older adults. It involves the development of nursing judgment and supports students in being attune to what is happening, by assessing the older adult's functional status; strengths, resources, needs, and cultural traditions as well as their wishes and expectations (NLN, 2011; Tagliareni, et al., 2012). The following three sections will provide a brief overview of these essenti al nursing actions and their role in caring for the older adult.

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34 Assess function and expectations A comprehensive assessment to include ability and personal expectations are an integral part of evaluating function. Together physical assessment findings, t he inclusion of function and personal expectations and wishes produce a comprehensive view of the older adult's condition. This relationship of assessment findings is essential to ensure the understanding of individualized aging. In addition, the use of th erapeutic understanding, wishes and expectations (NLN, 2011; Tagliareni, et al., 2012). Coordinate and manage care When older adults enter the health care system for an acute exac erbation of a chronic condition, they require care to not only repair health but to stabilize other chronic health diseases (AARP Public Policy Institute, 2009). Coordinating and managing care for the older adult includes a multidisciplinary approach to ca re. It is necessary to provide mechanisms for the older adult and their families/caregivers to access knowledge and resources to facilitate promoting maximum function and independence for the older adult. Considerations regarding life transitions must also be taken into account to afford the potential for maximum function and maintain the older adult's quality of life ( Inouye, et al., 2007; NLN, 2011; Tagliareni, et al., 2012). Use evolving knowledge Over the past several years, developing knowledge regar ding care of older adults has emerged. This evolving knowledge is crucial information for students to understand in order to provide competent care to older adults (NLN, 2011; Tagliareni, et al., 2012). Identifying geriatric syndromes and recognizing atypi cal presentations, along with their

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35 potential impact on acute/chronic conditions will help improve patient outcomes (Inouye, et al., 2007). Make situational decisions Students need to be able to evaluate individual situations and analyze the risks and bene fits of decisions based on the expectations of the older adult and family. As with individualized aging, each circumstance is unique and should be evaluated as such (NLN, 2011; Tagliareni, et al., 2012). An additional role of the nurse is to help the older adult gather information and understand the risks and benefits associated with treatment options and life choices. Ensuring older adults are able to make informed choices, consistent with their preferences, culture, and values, is essential for quality nu rsing care (NLN, 2011; Tagliareni, et al., 2012). Digital Storytelling in Higher Education As previously discussed in the introduction, digital storytelling has been demonstrated as a powerful teaching and learning tool in higher education. Studies have d emonstrated the use of digital storytelling can support individual and peer reflective learning of students when employed in the classroom (Christiansen, 2011; D'Alessandro, Lewis, & D'Alessandro, 2004; Skouge & Rao, 2009; Cheng & Chau, 2009; Jenkins & Lon dsdale, 2007; McLellan, 2007; Sandars & Murray, 2009; Stacey & Hardy, 2010). The establishment of best practices and competency in the use of technology has been confirmed as a positive outcome of using digital storytelling in the literature (Czarnecki, 20 09; Heo, 2009). Digital Storytelling as a Teaching and Learning Tool Digital storytelling in higher education has been employed as a teaching tool by integrating the constructive learning of creating a digital story with the reflective aspect

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36 of learning i nvolved in the creation of a personal story. In this employment of digital storytelling, the construction of the digital story is as integral to the learning process as the final product (Cheng & Chau, 2009; Czarnecki, 2009; Heo, 2009; McLellan, 2007; Sand ars & Murray, 2009; Skouge & Rao, 2009; Stacey & Hardy, 2010). The use of digital storytelling in higher education has also been employed as a learning resource. Research has demonstrated both individual and peer reflective learning by observing digital st ories created by others. Students are able to integrate new understanding of the circumstances into their personal conceptualization of the content (Cheng & Chau, 2009; Christiansen, 2011; Czarnecki, 2009; D'Alessandro, Lewis, & D'Alessandro, 2004; Heo, 20 09; McLellan, 2007; Sandars & Murray, 2009; Stacey & Hardy, 2010) Individual Reflective Learning Skouge and Rao (2009) believe the process of storytelling is as important as the resulting digital story. They present their experiences utilizing digital sto rytelling in the Pacific islands of Hawaii. The authors employed digital storytelling as a means to bring lessons about community, culture, local values and traditions into the classroom. The project allowed students to gain an authentic experience about l ife in different communities through the development and sharing of digital storytelling. The authors identified that through the use of digital storytelling, students were able to comprehend inclusion, advocacy and accommodations for individuals. The auth ors emphasize the ability for any interested educator to employ digital storytelling as a teaching tool due to the available simplistic tools now widely available. Skou ge and Rao (2009) do not include a specific definition of the elements of a story in the ir published research. One key component the educators employed was the de emphasis on the product outcomes

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37 in favor of the experiential outcomes. The authors found the digital stories were transformative to the students who worked on the projects. They us ed three key principles to sum up their technique: explore, reflect and envision. Christiansen (2011) utilized a phenomenographic approach in researching learning. This allowed for understanding how the same event may be interpreted differently across a population rather than variation within an individual experience. The sample consisted of 20 pre registered nursing students recruited from a university in the United King dom, following a call for volunteers. Students ranged from 22 41 years old. Data collection was done using phenomenographic interviews following the viewing of a prepared digital patient story. The author does not indicate what specific parameters were dem onstrated to define what constituted a story in this research. Data analysis revealed the following categories representing the different ways in which the patient digital story was experienced or understood: as a learning resource, as an emotional experie nce, as a reflective experience and as a transformative experience. Students who experienced the digital story as a learning resource found the story had little personal relevance to them or their professional practice. The students focused more on the tec hnology than engaged in the message. Those students identified as experiencing the digital story as an emotional experience identified a make sense of the emotional implication and gain understanding of the patient experience. The students who were categorized as having experienced the digital story

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38 as a reflective exercise identified as experiencing the patient in a holistic way and made connections between the per experiences contained an emotional element which they used to bring new meaning through reflection to formulate an ethical judgment about the patient experience. The students identified as having a transformative experience gained new perspectives through critical engagement with the digital story which lead to new insights about themselves and their developing professional identity. Although specific data collection was not presented in this article regarding the number of students who fell into each of these experience categories, the study results clearly support the conclusion of reflective learning for the observer. This study def ines a higher order of reflective learning by incorporating the transformative experience as a potential level of understanding, indicating the ability of observing a digital patient story could elicit a change in professional behavior towards other patien ts. This study demonstrates the importance of learning spaces in the promotion of usefulness of the digital stories is embedded in their belief of how this fit into their personal and professional being. digital storytelling in a computer based patient simulation program. Eight digital stories were developed based on common pediatric problems. The digital stories were in their own voice with a clinical narrator. A first person approach to the story is the only published information regarding a requirement of the story. The second section

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39 constructed a problem differential diagnosis, history & physical and diagnostic testing. The third section d on research. The last section was a brief conclusion and follow digital library. This service provided free, anonymous use of the collect ion. The digital stories were evaluated for use and hyperlink citations. Additionally, an anonymous, voluntary survey was added which reported that 91.4% of the respondents over a four year period indicated they would remember some part of the case for fut ure reference in practice. The survey results identified although the original digital stories were designed for medical students, they were viewed by a variety of health science students and practitioners who also found them useful. Study limitations wer e identified as a small percentage of users filled out the voluntary survey which may account for a potential positive bias. The survey also did not target specific information regarding what the respondents learned. Although precise information was not av ailable on what they participants learned the description that 91.4% of the respondents specified they would use information from this exercise in the future indicates reflection occurred by their intent to enable better choices in the future (Rogers, 2001 ). Individual & Peer Reflective Learning Stacey and Hardy (2011) worked with the Patient Voices Programme to create reflective digital stories of newly qualified nurses. This study demonstrates the use of reflection as a means to integrate new understandi ng, within the context of transitioning

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40 future. Reflection in this circumstance is identified as being retrospective reflection for both the individual creating the story a nd the group presentations (Rogers, 2001). These nurses developed stories using personal photos and their own words to communicate an event they found particularly challenging in their transition from student to nurse. This research utilizes first person o rientation as the basis of their story creation. The research reports participants were guided in what constitutes a good story but the specifics of this are not included in the publication. The intent was to utilize these stories as an educational opportu nity for future nursing students to learn from and to provide faculty with the opportunity to consider how best to utilize these digital stories healthcare system. The study is based on the concept of learning through reflection as outlined by Dewey (1938) and Kolb (1984). The research is broken into three distinct phases. The first phase implemented focus group discussions with the creators of the digital stories. The second ph ase used focus group discussion with faculty to guide the implementation of the stories into the nursing curriculum. The third utilized focus group discussions with finishing nursing students in whose classroom the stories were shared. The storytellers ide ntified the emotion of the project as being both a challenge and a benefit due to the depth of reflection they engaged in. The storytellers ultimately felt they had learned by reflection to be more aware of their challenges as a nurse and to be more suppor tive of future new nurses they worked with. The faculty felt the stories reflected their own personal experiences and what they had heard from other new nurses as well as reaffirmed the vulnerability of new nurses. The students who watched the videos discu ssed the

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41 benefits of reflecting on these stories to gaining personal insight in how they might react in a similar situation and made them more aware of how reflective learning could improve their professional practice (Stacey & Hardy, 2010). In conclusion deeper understanding of this project. They expanded on this model by identifying a new model of learning which they named The Spiral of Growth through Stories (SGTS). This new model incorpo rates both the benefits of reflection and observation in developing new understanding for both the creators of the stories and those who shared in them through watching them. Similarly, McLellan (2006) in Digital Storytelling in Higher Education provides an overview of the various possibilities for employing digital storytelling in higher education include personal stories, archives, memorials, avocational and digita l stories in health and medicine. The author emphasizes the importance of the first person voice within a story and includes a discussion on the problematic situations which a story should show a resolution to. As with Stacey and Hardy (2011), the author i dentifies how the sharing of stories, particularly in health and medicine can promote new insights and knowledge through reflection for both patients and healthcare providers as either creators and/or consumers of these digital stories. Each of these ident ified areas of application has the potential for students to experience in action or retrospective reflection (Rogers, 2001). Sandars and Murray (2009) conducted a pilot study to test their hypothesis that digital storytelling had the potential to offer an innovative approach to engage first year undergraduate medical students in reflection. The theoretical framework for their study

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42 was based on transformative reflective learning theory. The pilot sample was comprised of 12 first year undergraduate medical students who volunteered to use digital storytelling for a reflective learning exercise. Each student visited a patient in their home and were assigned to identify their thoughts and feelings of what it was like to communicate with a patient they had not m et before while also considering the thoughts and feelings of the patient. The students used photos they took and PowerPoint to create their presentations. PowerPoint was chosen as the digital story platform because of the familiarity and availability of t he software to the students. Students were not given specific information on what elements should be included in the creation of their story. They described their reflections with the aid of photos. The assignment also included presenting their digital sto ries to the other participants. Sandars and Murray (2009) identified the following limitations to their pilot study: sample size, self selected participants, no technical issues with the creating of the digital stories and no external analysis of their da ta. They identified a need for future research to compare reflective learning with the use of digital storytelling versus text based reflections. The authors conducted focus group interviews after the presentations were completed. Three themes emerged from these interviews. They were: engagement in the process, facilitation of reflection by the creation of the digital story and facilitation of reflection by the presentation of the digital story for both the creator and the observer. These themes coincide wi th the findings a nd presentation of both Stacey and Hardy

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43 (2011) and Mclellan (2006) where attributes of reflective learning are ascribed to both the creation of the digital story and the sharing of them. They were guided through their development of a di gital story in their reflective observation of the events, both their own and their peers. New concepts and inferences were revealed by the focus groups which will lead to new active assimilation with future patient interactions. Rogers (2001) considers th is type of structured experience as having the potential for anticipatory, reflection in action and retrospective reflection properties. In 2009, Cheng and Chau published the result of their study examining the use of digital storytelling as a tool to dev elop reflective insight in an e Portfolio format. The authors stress the need for considering pedagogical and technological concerns that are significant for all parties involved in the digital storytelling process. Two primary research questions are addre ssed: Do students have the confidence to create their own digital videos for reflection and do they find this activity relevant to their learning needs? To what extent does digital video affect the level of self reflection and the nature of peer feedback ? The authors identify some concepts which are central to their study. The first is their belief that to promote effective reflection, the process must involve both individuals and peers. They acknowledge that the ability to self reflect is widely recogniz ed as a desirable learner trait that can stimulate deep learning. This perception is based in the blended constructivist view of both Piaget and Vygotsky. The second is the adoption of

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44 the ARCS model which focuses on four motivational characteristics for l earning: attention relevance, confidence and satisfaction as the framework for the study. The participants were voluntary, cohort based students in a Workplace English course. Students were required to produce a video of a mock job interview and upload it for sharing to their e portfolio. A questionnaire was developed to evaluate the quality of the reflection and a two dimensional evaluation was conducted regarding peer feedback. The study results found that the creating of digital video for reflection wa s video based reflection demonstrated a high level of self reflection. It also demonstrated an increased amount of peer feedback when the project was a digital story ver sus text files. The results of this study support the pedagogy of use of digital storytelling to promote personal reflection in the production (both reflection in action and retrospective reflection) as well as retrospective reflection in the sharing of p ersonal digital stories (Rogers, 2011). Jenkins and Lonsdale (2007) present their findings on the effectiveness of digital storytelling as a means to enhance student learning through reflection. The study identifies four curricular areas at the University of Gloucestershire in which digital storytelling have been piloted. They are: student induction (transition into higher education), landscape design, accountancy and second year sports development. The student induction and landscape design student example s were the main focus of the findings presented.

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45 In the student induction program digital storytelling was introduced as a technique to encourage and embed student reflection in the activities. Emphasis was placed on the importance of recognizing reflecti on as being enhanced in a collaborative process. Twenty nine total digital stories were produced. The landscape design students utilized a case study approach to their digital story production. Students were not given specific instruction on what elements were necessary for the development of a story. Individual students captured their reflections on the development of their designs, their skills and The authors collected feedback from both the students and instructors using questionnaire and interview techniques. The stories were evaluated against the Moon Map of Learning and McDrury and Alterios Model of Reflective Learning through Storytelling. This article focuses on the analysis of the pil ot digital stories against the latter evaluation structure. Of the 29 student induction stories, 25 rated level 1or 2, with none rating level 5. Three of the five landscape design rated level 4 and one rated level 5. The different stages of enrollment at t he university level may have contributed to the difference (the induction students were on their 4 th day). Jenkins and Lonsdale (2007) concluded that digital stories should be considered as a discipline specific resource to promote reflection and encourage deep learning. They identify the potential for sharing these stories for peer leaning which additionally might give students an opportunity to connect with the thought process of others and allow for scaffolding to occur. This reflective learning approach is an example of the importance of the contextual factor in supporting reflective learning (Rogers, 2001).

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46 Technology Competencies How digital storytelling builds 21st century skills (2009) published in Library Technology Reports examines how digital storytelling can be used to build skills as outlined by The International Society for Technology in Education (ISTE). The specific skills identified are: creativity and innovation, communication and collaboration, research and informa tion fluency, critical thinking, problem solving and decision making, digital citizenship and technology operation and concepts. Czarnecki (2009) describes individual projects which meet each of these standards. She outlines how when students are able to look at their research and translate it to a story it leads to more personal and meaningful learning. Specific elements of a story are not outlined in this research. These five identified skills when employed in digital storytelling have the prospective to facilitate reflective learning before, during and after the production (Rogers, 2001). Additionally, the author describes how the creating of a video is an exercise in what ISTE would label digital citizenship. The author discusses how digital storytelling promotes 21 st Century job skills. This is accomplished in the building process of a digital story by integrating the modern skills requir ed as identified by the Department of Education. These skills are comprised of basic skills (reading, writing and computation), technical skills and organizational skills. The author also connects the need for teachers to become involved in the epistemolog ical process called for by the learners to adopt and sustain the cultural conceptions and behaviors. Heo (2009) conducted research on the impact of digital storytelling on pre service efficacy and dispositions towards educational technolog y. The author defined self efficacy as a personal belief about his/her performance capabilities in a

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47 given domain of activity. The study examined the effects of the experience of digital storytelling on pre efficacy in educational te chnology and other personal dispositions. The study is grounded in a constructivism framework which proposed that learning is an active process of constructing knowledge and meaning from personal experience. A quasi experimental study design was employed using a pre/post survey model. Students were given a tutorial in the development of a digital story. They were assigned 6 minutes long. Specific instructions on necessary elements of a story were not included in the tutorial for creating a digital story. As hypothesized, pre efficacy toward educational technology was greatly improved with the digital storytelling experience. The findings provided initial evide nce that knowledge and skills of personal technology can be transferred to educational technology settings with the help of digital storytelling. this study design ha s the potential to be a reflective learning tool. The steps as outlined would lend itself to reflection before, in action and retrospective of the context they were asked to develop a digital story on (Rogers, 2001). Each of these competencies is integral to the success of these pre service teachers incorporation of technology in their future teaching. This type of approach enables the participant to move to a higher perceived level of self efficacy by having concrete experience with this technology integra tion. Best Practices Sandars, Murray and Pellow (2008) present an overview of the essential elements inherent in creating a digital story and the potential reflective learning that may

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48 accompany this type of enterprise. The authors begin by discussing th e power of reflective learning. They put forth that the process of reflective learning allows learners to make sense of an experience and develop a deeper understanding of it based on the work of Moon. The authors include a discussion of the sharing of dig ital storytelling and how this may also increase the reflective learning. The authors emphasize 12 tips to promoting reflective learning in the creation and sharing of digital storytelling. They are: choose a topic that is personal to the learner, write th e story keeping in mind an audience, collect media to support your personal feelings or understanding of the situation, select those media which best represent the story, build the digital story with multimedia with a 3 to 5 minute timeframe in mind, prese nt or share the digital story to allow feedback, encourage reflection at all stages of development, avoid being too ambitious in the development of the digital story, provide adequate technical support, consider the creative and reflective process in gradi ng the project, use with an overall approach of reflective learning and persuade others of the value of digital storytelling The concept of reflective learning as discussed in this article is corrobo rated by the findings of Cheng and Chau (2008), Library T echnolo gy Reports (2009), and Skouge and Rao (2009). Each identifies the construction of the digital story as pivotal in developing a deeper understanding of the content being taught and a more personalized integration of the subject. Rogers (2001) support s this pedagogic employment as it identifies the importance of reflection before, during and after the structured experience.

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49 Summary The use of digital storytelling provides learning through reflection across higher education curriculums both as a teaching and learning tool. Each of these studies has inherent in their analysis the following key tenets: learning is best conceived as a process, not in terms of outcomes, learning is relearning, learning necessitates the resolution of conflicts, learning is a holistic process of reworking the world we know, learning results from transactions between the person and the environment and learning is the process of creating knowledge. Key components of the definition of reflec tive learning have been demonstrated in these studies. Included in the definition is the requirement of active engagement on the part of the individual or group (Rogers 2001). Stacey and Hardy (2011), Sandars and Murray (2009) and Jenkins and Lonsdale (200 8 ) each describe how the use of digital storytelling as a pedagogic tool facilitates the active engagement on part of both the individual students and the group observers. Rogers (2001) also puts forth the concept of a trigger which constitutes an unusual or perplexing situation or experience that then the reflective th eory definition. Stacey and Hardy (2011), Sandars and Murray (2009) and Cheng and Chau (2008) each repo rted this type of finding in their research. Digital storytelling has the potential to provide valuable insights and understanding through reflective or transformative learning both with the construction of personal digital stories and observation of digi tal stories. An added benefit of employing this pedagogical methodology as a constructive assignment is the integration of technology skills in our students (Library Technology Reports, 2009). One reoccurring theme in the reviewed literature, which bears c onsideration for any faculty considering the integration

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50 digital storytelling into their course, is the need for technology support for both students with this type of assi gnment is disputed as being misleading because it assumes all students of a given age group are digital natives and can therefore already possess the skills to produce a digital story (Cheng & Chau, 2009; Skouge & Rao, 2009; Sandars, Murray & Pellow, 2008) This literature review has revealed a lack of detailed research, either quantitative or qualitative in format, as it pertains to the benefits of utilizing digital storytelling in higher education. Additional, a lack of what defining characteristics const ituted a story was noted in the literature related to digital storytelling. The benefit of exploring this pedagogical format bears further research.

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51 Figure 2 1 Conceptualization of the ACES framework.

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52 CHAPTER 3 METHOD OLOGY Overview Chapter 1 introduced the challenges faced in nursing education today to develop and implement innovative teaching strategies to promote situational decision making within a contextual model of teaching and learning (Benner, et al., 2009; Iro nside, 2006). Stories were identified as a method employed to enhance the ability of the nursing student to reflect on their values and attitudes as a means to bring experiences to life and enrich their understanding of the encounter (Benner, et al., 2009; Brown, Kirkpatrick, Mangum, & Avery, 2008; Ironside, 2006). The literature further demonstrates the development of digital stories as a mechanism to promote and communicate these stories (Cheng & Chau, 2009; Christiansen, 2011; D'Alessandro, Lewis, & D'Al essandro, 2004; Jenkins & Londsdale, 2007; McLellan, 2007; Sandars & Murray, 2009; Skouge & Rao, 2009; Stacey & Hardy, 2010 ). In conjunction with the need to expand the teaching and learning strategies in nursing education is the need to improve the ability of health care workers to care for older Americans (Ironside, Tagliareni, McLaughlin, King, & Mengel, 2010; Mion, 2003; National League for Nursing, 2009; Tagliareni & McLaughlin, 2007). Specifically there is a need for increasing the competence of all individuals, including nurses, in the delivery of geriatric care (Institute of Medicine of the National Academies, 2008). Chapter 3 outline s the overall research design for the project It will review the overarching purpose of the project to include the research questions. The population and sample will be described as they pertain to this project. The research design will be addressed to include the methodology, data collection and analysis. Potential limitations

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53 of this project are discussed C hapt er 3 will conclude with a summary outlining the potential significance to the greater community this project may have implications for. Purpose The purpose of this study wa s to explore the effectiveness of using digital storytelling as an end of rotation a ssignment, in a long term care setting, for pre licensure nursing students as a means to demonstrate an understanding of the Advancing Care Excellence for Seniors (ACES) framework. National accrediting organizations for nursing programs require the documen tation of student learning outcomes to include valid and reliable mechanisms to assess them (Halstead, 2007; Lowenstein & Bradshaw, 2001; National League for Nursing Certification Governance Comm ittee, 2005). The research sought to explore the relationship between the geria tric patients. The research aimed to investigate the use of digital storytelling as an innovative situational teaching stra t egy in the context of geriat ric care to promote a greater understanding of the ACES framework. The essential information required to care for geriatric patients is based on the understanding of the three knowledge domains of the ACES framework: individualized aging, complexity of car e and life transitions. Additionally the purpose of this research wa s to determine if there are ACES framework. As such, the research questions which guide this s tudy are: RQ1. Does the digital story rubric assess the student learning outcomes as they relate to the ACES framework? RQ2. What themes are found in the digital stories in addition to those assessed by the ACES rubric?

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54 Research Design This study employ ed a mixed method, non experimental research design using a concurrent triangulation approach. Figure 3 1 is a schematic representation of concurrent triangulation (Creswell, 2009; Onwuegbuzie & Leech, 2006). In the concurrent triangulation approach the data for the quantitative and qualitative research was collected at the same t ime. The research questions sought to discern whether quantitative and qualitative data provide opportunity to inform the research questions. stories were examined for mastery of the ere examined using a thematic or content analysis approach to identify common characteristics within the digital stories. This represe nts a systematic approach to analyzing the themes derived from the stories into major categories for the purpose of interpretation ( Bowen, 2009; Glesne, 2011). These themes were then be compared to the identified components of the knowledge domains of the ACES framework. This will allow ed for the potential to discover any additional themes within the digital stories beyond the identified ACES knowledge domains. Approv al to conduct this study was obtained from the Institutional Review Board (IRB) of the Uni versity of Florida (Appendix A) Permission to collect data was also obtained from Palm Beach State College (Appendix B) Population tal storytelling stories were collected from 1 st semester nursing students in an associate degree nursing (ADN) program at a public state college in the Southeastern United States This nursing program has a concurrent enrollment of over 400 students with a wide range of diversity of both age and race. The

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55 1 st semester is comprised of seventy eight percent female students. This is slightly lower than the program and national enrollment of female students at eighty two percent and eighty five percent respectfully. Fifty four percent of the 1 st semester st udents are thirty years old or younger. This is slightly higher than the overall program where forty two percent are thirty years old or younger. Nationally, fifty one percent of students enrolled in an ADN program are thirty years old or younger. The 1 st semester students are primarily white, non Hispanic at sixty nine percent of those enrolled. This is higher than the percentage in the overall program at fifty percent and comparable to the national average of fifty percent. Figures 3 2, 3 3 and 3 4 repre sent the age, gender and race of the 1 st semester nursing students, the nursing program and other U.S. ADN programs. Sample All first semester nursing students, in this ADN program are assigned a clinical rotation in a skilled nursing facility (SNF). Ther e are between 10 and 12 individual clinical groups with eight to nine students per group, each academic semester. Of these clinical groups, three faculty utilize digital storytelling as their required end of course assignment (Appendix C ). The students in these three groups were given additional resources to facilitate their ability to create the digital stories. In addition to the resources in the assignment, the three faculty members teaching these sections have worked in previous semesters with students on this assignment. They are familiar with using either PowerPoint voiceovers or Photostory to assist students. Students are also referred to the college Computer Lab for additional technical skill assistance with building their digital stories. Each facul ty member utilizes their post conference time in the clinical setting to

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56 accounts for a maximum of two hours per week, for the 7 week rotation. See Figure 3 5 for a schematic of this assignment in context and student support resources. The Utilizing this type of sampling approach is consistent with a purposive sampling design specifically convenience and homo genous in nature (Creswell, 2009; Onwuegbuzie & Leech, 2006; Polit & Tantano Beck, 2004). This is relative to this study because the data is retrospective in nature (thus convenience sample) and from a uniform group of participants (1 st semester, pre licen sure nursing students) (Patton, 2002; Polit & Tantano Beck, 2004 ; Sage Publication, 2 007). Research Question 1 u tilized a sample size of 2 2 digital stories based on the final number of students in each sec tion. Research Question 2 evaluate d six purposively selected digital storytelling stories which demonstrate the three elements of a story as identified by Labov (2011). The three structural elements are temporal organization, orientation and coda. Temporal organization refers to the order of events within a given timeframe. Orientation is the introduction and identifying of the action in the context of time, place and initial behavior. The coda refers to the end of a narrative in which the temporal setting is returned to the present. Instrumentation The AC ES digi tal storytelling grading rubric (Appendix D) was developed by the researcher. It is based on the understanding and work the researcher has done on the ACES project. Key components of the three knowledge domains of Individualized Aging, Complexity of Care and Vulnerability during Life Transitions are identified. The rubric is based on a three point score ranging from little or no evidence of the knowledge domains to significant components of the knowledge domains represented.

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57 The rubric was sent to co ntent experts for review and to establish content validity. The rubric was piloted by the researcher and two additional faculty. The researcher has been a project staff member of the ACES grant since its inception. The researcher has presented faculty deve lopment workshops on the ACES framework at the local, state and national level. Each of the two faculty reviewers attended 2 national workshops on the ACES framework. Additiona lly, both faculty reviewers presented the ACES framework at various professional development workshops within the state. The two faculty reviewers teach the ACES framework to students in the specified ADN program. Three digital stories from a previous semester were evaluated using the rubric by all three reviewers. This approach demon strates investigator triangulation (Polit & Tantano Beck, 2000; Sage Publication, 2007). Inter rater reliability was determined using rater reliability, 2012). The rubric was finalized after the content validity and pilot was completed. Data Collection The digital stories were collected during the spring 2013 term from assignments submitted during the fall 20 12 term. Three instructors utilize d the rubric to grade the digital stories. Each of the three instructor s has attended a minimum of 2 faculty development workshops on the ACES framework. The three instructors have taught the ACES framework in the clinical setting for a minimum of two years. Each instructor was for review and the associated graded ACES rubric. This represents a retrospective data collection method (Polit & Tantano Beck, 2004). From the dig ital stories submitted, 6 were purposively selected based on containing the three elements of a story for in depth content analysis. Adequacy of data

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58 will be collected so that the previously collected data are confirmed and understood (Glesne, 2011; Sage Publication, 2007). Data Analysis The ACES rubric data was al stories demonstrate the expected learning outcomes of the assignment. The nursing program has a minimum passing score of seventy five percent. This level was used to evaluate the digital stories. The rubric is based on a 0 3 point system, w ith the maximum score being 9 for a digital story. Therefore, seventy five percent would equate to a minimum score equal to 6.75 on the rubric. Deeper review utili zing descriptive statistics determine d which ACES knowledge domains were the most prevalent demonstrated in the assignment and which were the least. The six digital stories sele cted for in depth review were analyzed using a thematic and template or content analysis format (Glesne 2011; Mayring, 2000; Polit & Tantano Beck, 2004). This research design allow ed for potential emergent themes not identified by the ACES framework to be discovered. The data from the template review was used in an interpretive manner to add further conten t validity to the ACES rubric (Bowen, 2009; Polit & Tantano Beck, 2004). The filtering of pre determined content of the ACES framework allows for a deeper review of themes, topics or perpectives that may have been ignored (Bowen, 2009; Glesne, 2011; Polit & Tantano B eck, 2004). Each analysis was reported on separately. However, additional data compariso n was used to explore possible convergence among the results (Creswell, 2009; Onwuegbuzie & Leech, 2006). See Figure 3 5 for a schematic representation of th e qualitative data analysis.

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59 Limitations Limitations for this study include d both quantitative and qualitative concerns (Creswell, 2009; Onw uegbuzie & Leech, 2006). There wa s a threat to external validity due to the participants belonging to a convience sa mple. This may limit the generalizability of the findings (Creswell, 2009). Inter rater reliability and content validity of the ACES rubric w ere established. However, this wa s the fi rst time the ACES rubric was used on a large scale to assess the level of student learning outcomes. Additionally, researcher bias in evaluating the digital stories for thematic analysis cannot be ignored (Glesne, 2011). The researcher is a project staff member and has worked with the project throughout the development and nati onal launch of the ACES framework. Summary The potentia l consequence of this research wa s the ability to impact patient older adult. It is imperative nursing curricula st rive to increase the likelihood that students will graduate and select geriatrics as their primary area of focus to practice in. older adults, they are less likely to choose this area to practice in. Yet, it has been reported that already 80% of home care visits and 49% of acute care admission days are attributed to the older adult patient (Mion, 2003). This translates into a potential workforce that does not value the import ance of quality care for the elderly but whose primary care responsibilities will be this population. An added challenge to nursing education is the stimulus by national nursing rning

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60 while still in school (Diekelmann, 2001). Pre licensure students are currently measured as being successful in their educational endeavors based on their ability to perform a skill or answer a test question correctly. Minimal opportunities are provid ed for learning in context, at this level due to the type of assessment both at the program and national level to measure competency (Ironside, 2003). The benefits of this research may establish a new tool to evaluate students understanding of the ACES fr amework.

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61 Figure 3 1. Schematic representation of concurrent triangulation design (Creswell, 2009)

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62 Figure 3 2. Age demographics comparison Figure 3 3. Gender demographics comparison 0 5 10 15 20 25 30 35 Under 25 26-30 31-40 41 and over % 1st Semester ADN Program National ADN Programs 0 10 20 30 40 50 60 70 80 90 1st Semester ADN Program National ADN Programs % Female Male

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63 Figure 3 4 Race demographics comparison 0 10 20 30 40 50 60 70 80 White African American Hispanic Asian Other % 1st Semester ADN Program National ADN Programs

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64 Figure 3 5. Schematic representation of the qualitative data analysis method

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65 Figure 3 6 Schematic representation of the student digital storytelling assignment in context and resources

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66 CHAPTER 4 RESULTS Overview and their understanding of the required knowledge to care for geriatric patients. The research aimed to investigate the use of digital storytelling as an innovative situational teaching strategy in the context of geriatric care to promote a greater understanding of the Advancing Care Excellence for Seniors (ACES) framework (NLN, 2011; Tagliareni, et al., 2012). The essential information required to care for geriatric patients is based on the understanding of the three knowledge domains of the ACES framework: individualized aging, complexity of care and life transitions. Additionally, the research sought to determine whether there were further themes prese stories in addition to those outli ned in the ACES framework. C hapter 4 will present the results of this mixed method research project. First, the quantitative results from the research which explored the effectiveness of using d igital storytelling as an end of rotation assignment, in a long term care setting, for pre licensure nursing students as a means to demonstrate an understanding of the ACES framework will be presented In the latter section of C hapter 4 the results of the qualitative research, which investigated those outlined in the ACES framework. Sample The sample for this research study was purposively selected from first semester nu public state college in the Southeastern United States. The purposive sampling

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67 approach was specifically convenience and homogenous in nature (Creswell, 2009; Onwuegbuzie & Leec h, 2006; Polit & Tantano Beck, 2004). The sample was comprised from students who were assigned to one of the three clinical faculty who utilize digital storytelling as a required end of course assignment in a long term care clinical rotation. The digital s tories in these three clinical groups form the data set for the quantitative explorat ive component, which addressed Research Question 1 Six digital stories selected for qualitative inquiry were purposively selected from the same group of students based o n the previously identified characteristics of a story as defined by Labov (2011): temporal organization, orientation and coda. These characteristics are relative to this study because the data is retrospective in nature and from a uniform group of partici pants (1st semester, pre licensure nursing students) (Patton, 2002; Polit & Tantano Beck, 2004; Sage Publication, 2007). The initial sample consisted of twenty five students. The final sample size was twenty two students; three students were excluded due to program attrition. The gender distribution of the sample was predominantly female (n=14, 64%), a proportion that is slightly lower than the typical ADN class seen at this college. Figure 4 1 represents an overview of the gender distribution of the sampl e, the 1 st semester enrolled students in this ADN program, the overall student population in the ADN program and overall national enrollment. The sample was relatively young, comprised of 15 students under the age of thirty representing sixty eight percent of the sample. In comparison to the program enrollees, fifty four percent of the 1st semester students are thirty years old or younger. Figure 4 2 represents the age distribution of the sample, the 1 st semester enrolled students in this

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68 ADN program, the o verall student population in the ADN program and overall national enrollment. white, non Hispanic (n=15, 68%). This is higher than the overall program which is fifty percent, wh ite, non Hispanic. Figure 4 3 represents the race distribution of the sample, the 1 st semester enrolled students in this ADN program, the overall student population in the ADN program and overall national enrollment. Results Research Question 1 The first r esearch question sought to explore the relationship between the r geriatric patients. Research Question 1 is: Does the digital story rubric assess the student learning outc omes as they relate to the ACES framework? Descriptive statistics and analysis of variance procedures were used to analyze the data. All of the digital class correlation fo r the sample while not significant provided evidence of acceptable reliability. Individualized a ging Seventeen students in the sample demonstrated a mastery of the individualized aging knowledge domain at a minimum of 75% (raw score of 2.25), which is c onsidered passing for this ADN nursing program. The individualized aging scores were analyzed descriptive statistical results for individualized aging are presented in Table 4 1.

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69 The group data were analyzed by using a one way between subjects ANOVA, where instructional group served as the factor and score served as the outcome variable. With an alpha level of .05, the effect of the instructor was significant, F (2,19) = 23.08 p = .000. Results indicate there was a significant difference between at least o ne of the instructional groups b ased on the means being equal in value in group one and two; there is a significant difference between group three and groups one and two. Complexity of care Sixteen students in the sample demonstrated a mastery of the complexity of care knowledge domain at a minimum of 75% (raw score of 2.25), which is considered passing for this ADN nursing program. The complexity of care scores were analyzed descriptive statistical results for individualized aging are presented in Table 4 2. The group data were analyzed by using a one way between subjects AN OVA, where instructional group served as the factor and score served as the outcome variable. With an alpha level of .05, the effect of the instructor was significant, F (2,19) = 8.78, p = .002. Results indicate there was a significant difference between a t least one of the instructional groups. Using the Bonferroni correction to adjust for multiple comparisons at a 95% confidence level there is a significant difference between group three and groups one and two. Vulner ability during life transitions F ourteen students in the sample demonstrated a mastery of the complexity of care knowledge domain at a minimum of 75% (raw score of 2.25), which is considered passing for this ADN nursing program. The vulnerability during life transition scores were analyze

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70 separately. The descriptive statistical results for vulnerability during life transitions are presented in Table 4 3. The group data were analyzed by using a one way between subjects ANOVA where instructional group served as the factor and score served as the outcome variable. With an alpha level of .05, the effect of the instructor was significant, F (2,19) = 11.11, p = .001. Results indicate there was a significant difference between at least one of the instructional groups Using the Bonferroni correction to adjust for multiple comparisons at a 95% confidence level there is a significant difference between group three and groups one and two. Total rubric scores Seventeen students in the sample demonstrated an overall mastery of the ACES knowledge domains at a minimum of 75% (raw score of 6.75), which is considered passing for this ADN nursing program. The total rubric scores were analyzed using s were analyzed separately. The descriptive statistical results for total rubric scores are presented in Table 4 4. The group data were analyzed by using a one way between subjects ANOVA, where instructional group served as the factor and score served as the outcome variable. With an alpha level of .05, the effect of the instructor was significant, F (2,19) = 22.65, p = .000. Results indicate there was a significant difference between at least one of the instructional groups. Using the Bonferroni correctio n to adjust for multiple comparisons at a 95% confidence level there is a significant difference between group three and groups one and two.

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71 Research Question 2 The second research question sought to explore what themes are found in the digital stories in addition to those assessed by the ACES rubric. Six purposively selected digital storytelling stories which demonstrated the three elements of a story as identified by Labov (2011) were analyzed. The three structural elements are temporal organization, orie ntation and coda. Temporal organization refers to the order of events within a given timeframe. Orientation is the introduction and identifying of the action in the context of time, place and initial behavior. The coda refers to the end of a narrative in w hich the temporal setting is returned to the present. The six digital stories selected for in depth review were analyzed using a thematic and template or content analysis format (Glesne, 2011; Mayring, 2000; Polit & Tantano Beck, 2004). This research desig n allowed for potential emergent themes not identified by the ACES framework to be discovered. The range of scores for these six digital stories based on the ACES rubric was from six to nine. The maximum possible score was nine. The mean score was 7.83 (Fi gure 4 4). The digital stories were first transcribed by the researcher. They were then coded using the distinguishing characteristics of the three knowledge domains in the ACES framework. Figure 4 5 represents the predetermined themes utilized. These cha racteristics were defined in the ACES rubric. The results of this analysis will be presented first in the following section. The digital stories were then reviewed for additional themes. The results of the additional coding and themes will be presented in the latter part of this section.

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72 Digital Stories The six digital stories analyzed were created by first semester students who had completed their first clinical rotation with patients. They were assigned to a long term care facility and followed an individ ual patient for seven weeks. These stories represent their end of course assignment. The six digital stories selected for qualitative a nalysis are summarized in Table 4 5. The digital stories represent a variety of patients in age and gender. Each digital story was created using presentation software with the majority of students using PowerPoint. Two of the digital stories were submitted as PowerPoint slide shows. The remaining 4 digital stories were submitted as in an MP4 file format. Digital s tory 1 Thi s digital story portrays an 89 year old, female. The student presented the story in the first person format from the point of view of the patient. The orientation of the story is set by the student speaking in first person and reflecting on their outcome o f the long term care rotation. The student reflects on their ageist attitudes at the outset of the rotation and how it changed during the rotation. The student introduces the patient. The temporal sequence of the story follows a description of the struggle s and triumphs of being in the long term care facility and transitions into the life she had and lost. The coda brings the viewer back to present time for the patient and a closing sense of the respect. Digital s tory 2 The second story analyzed portrays a 78 year old male. The story is presented in the first person from the point of view of the patient. The orientation of the story begins with the patient introducing himself and describing wher e he is at this point in his life. The temporal sequence follows a brief description of his life before the long term care

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73 facility and segues into his daily life in the facility. The story wraps up with the patient bringing us back to his current situatio n and acknowledging his understanding that he will be in the long term care facility for the remainder of his life. Digital s tory 3 In the third digital story, the student presents a 77 year old female patient. The story is presented in the first person fr om the viewpoint of the patient. The orientation to the story begins with the patient introducing herself and telling the viewer where she lives now. The temporal sequence takes us through a brief history of her life highlighting significant events through out her marriage. The coda brings us back to the patient this experience of caring for this patient has led her to believe any day can be a good day and it is up to you to make it positive. Digital s tory 4 Digital story 4 is about a 95 year old male. The story is told in the first person from tation is set by the student in his introducing us to the patient and describing how the patient came to be in the long term care facility. The temporal organization draws us into the daily routine of the patient as witnessed by the student. It leads us th seven weeks from requiring minimal assistance with his activities of daily living to hospice care. Th e student included an ending personal reflection of his role transition to

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74 Digital story 5 This digital story is presented in the first person point of view of the patient. Her age was not identi fied in the presentation. The orientation of the story is demonstrated by the patient introducing herself and setting the scene of where she lives, in this long term care facility. The temporal orientation follows with the patient telling us about signific ant events which have occurred during her life, concluding with present day. The patient then returns us to her current situation and acknowledges she likes it where she is and that the nurses take really good care of her. The presentation closes with the student talking in first person. She identifies that she will never forget this rotation and has learned with age comes wisdom. Digital story 6 This digital story depicts a 67 year old male patient. It is told in the first person from the viewpoint of the patient. The orientation of the story begins with the patient introducing himself and offering us with an understanding of where he lives (in a long term care facility). The temporal sequence of this story follows a timeline of significant life events and brings us to the present day. The patient then returns us to his current living situation. He acknowledges to the viewer his understanding that although he would like to return to independent living, due to his health challenges this is not possible. ACES framework themes Individualized aging There are five potential characteristics which comprise the knowledge domain of Individualized Aging. They are: assessment of function, assessment of cognitive function, atypical presentation of pain and management o f pain, assessment of geriatric

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75 syndromes, assessment of sexuality and assessment of violence and elder mistreat. Figure 4 6 demonstrates the distribution of the characteristics across the six digital stories. Although each story included some elements of this knowledge domain, no single story included all characteristics. Assessment of function activities: activities of daily living, independent activities of daily living, age related changes, nutrition and sensory changes. The author of digital story two used the se, the student chose the picture in Figure 4 7 to highlight the type of chair and transfer he/she was referring to. In digital story four, the student demonstrates assessment of function his own by 8 The student author of 9 to further demonstrate this assessment. Assessment of cognitive function following activities: memory status (long term and short term), cognitive impairment, learning needs and substance misuse. Assessment of cognitive function was the most common theme, found in all six digital stories. Students were acutely aware of the cognitive state of the patient they were caring for and the potential impacts on their care this present

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76 digital story three along with the photo in Figure 4 Figu re 4 11, are examples of cognitive assessment in the first person and third person format. Assessment of atypical presentation of pain and management of pain Assessment of atypical presentation of pain and management of pain includes the assessment of the following activities: knowledge of pain, use of pharmacologic and non pharmacologic agents. Two of the six digital stories addressed this aspect of individualized aging. The author of digital story three used the first person format in th 12 in F igure 4 13 to demonstrate the pain assessment. As sessment of geriatric syndromes the presence of the following attributes: sleep disorders, problems with eating or feeding, pain, incontinence, confusion, evidence of falls and/or skin breakdown. Digital story three was the only one which did not have evidence of assessment of geriatric syndromes. The student described the assessment of geriatric syndromes in digital story six student used the picture in Figure 4 14 in conjunction with this statement. The author in digital story four, using third person used the following statement to represent assessmen 15.

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77 Assessment of sexuality of the followi ng attributes: influence of medications, normality, desire and mechanics, intimacy, sexually transmitted infections and orientation. been se Figure 4 16 to demonstrate this attribute. The author of this digital story used the same picture in various components to demonstrate the physical limitation of his patient and how it impacted multiple areas of his life. Assessment of violence and elder abuse assessment for the following types of abuse and/or neglect: physical, psychological, financial an d verbal. Assessment of violence and elder mistreatment was not an identified theme in any of the six digital stories transcripts. The picture in Figure 4 17 is an example of multiple characteristics of this attribute found in digital story one. The stude nt presented this picture at a place in their story where they were describing despair and depression. However, it is clearly demonstrative of elder abuse and misuse as well. Complexity of C are There are seven potential characteristics which comprise the knowledge domain of complexity of care. They are: geriatric syndromes, hydration status, infection, poly pharmacy, depression, dementia and acute vs. chronic disease process. Figure 4 18 demonstrates the distribution of the characteristics across the six d igital stories.

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78 Geriatric syndromes Geriatric syndromes are comprised of any of the following qualities: presence of sleep disorders, problems with eating or feeding, pain, incontinence, confusion, evidence of falls, and/or skin breakdown. The presence of geriatric syndromes was the 19 four accompanied by the picture in Figure 4 20 are examples of geriatric syndromes presented in the first person and third person narrative format. Hydration status The defining characteristics of hydration status are: dehydration, constipation, medicat ion toxicity and/or fluid overload or congestive heart failure. Hydration status was an identified theme in one of the six digital stories. The author of digital story two ve type 2 diabetes, hypertension, chronic kidney disease and coronary artery 21 demonstrates the photo the student presented with this statement. Infection Infection was evaluated based on the following specifications: present, increased risk of, and atypical presentation. Two of the six digital stories presented phrases related to infection. The student specified the following statement in digital story two along with the picture in Figure 4 22 to represent this complexity of ca arms are wrapped in dressings. If not attended to regularly, the cellulitis could become

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79 Poly pharmacy Poly pharmacy pertains to the use of multiple medications. Additional specific attributes for this theme include medication reconciliation and financial implications. Poly pharmacy was an identified theme in only digital story two. The student the adverse effects related to my COPD drug treatment are unavoidable and I cannot Figure 4 23 represents the a ssociated picture to these statements. Depression Depression traits included the following characteristics: lethality assessment, social isolation, treatment and atypical presentation. Depression was identified as an attribute of complexity of care in fou r of the six digital stories. The student author in Figure 4 24 to demonstrate this concept. Digital story five demonstrate this attribute with 25. Dementia The defining elements of dementia were: types of dementia, behavioral concerns, treatment, client/family education and caregiver burden. Two of the six authors identified dementia in the remember who I am. I try to remember what I might have done to be placed in a place 26 along with this stat ement. Digital story four provides an additional example of the attribute of dementia

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80 this statement, the student provided the picture in Figure 4 27. Acute vs. chronic d isease process Acute vs. chronic disease process is defined by the identified presence of either disease process and recognition of the difference between them. The attribute of acute vs. chronic disease process was found in four of the six digital stories reviewed. The the picture in Figure 4 28 to illustrate this attribute. The student author of digital story 29. Vulnerabilities during Life Transitions There are six potential characteristics which comprise the knowledge domain of Vulnerabilities during life transitions. They are: health care decision making, palliative care, iatrogenesis, frailty, advocacy and environment of care. Figure 4 30 demonstrates the dis tribution of the characteristics across the six digital stories. Health care decision making Health care decision making encompasses the following aspects in regard to care patient belief systems (religious and/or spiritual), cultural considerations and the risk vs. w, smoking is not 32) are examples of this attribute.

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81 Palliative care Palliative care includes the areas of hospice and end of life decision making in its defining characteristics. Three of the six digital stor statements of this attribute. Figures 4 33 and 4 34 respectfully were used with these statements by the authors. Iatrogenesis Iatrogenesis refers to the potential or actual cascade disease pattern frequently found in the elderly client. Iatrogenesis was not an identified theme in any of the six digital stories. Frailty Defining characteristics for frailty included: n eeds assistance with activities of daily living, dependent on others for care, generalized weakness and weight loss. Five of the frail. He no longer assisted moving h describe this in digital story four. The picture in Figure 4 35 (a shadow of a person standing) was used with this statement in the digital story. Advocacy Advocacy characteristics include who is the pati ent advocate and how is patient advocacy being demonstrated. The student author of digital story two used the following student nurse asked me why I never bring the orange j uice they bring me every day and 36 is the associated photo the student employed with this statement.

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82 Environment of care In considering the presence of themes related to environment of care the following considerations for the patient, resources necessary for care (including access to care and financial) and safety of the environment and inte rdisciplinary collaboration. The presence of environment of care was the most common theme, found in all of the six f the same staff for several presented in the first person and third person narrative format. Figures 4 37 and 4 38 respectfully represent the visual elements the students used wit h these phrases. Additional I dentified T hemes The six digital stories were additionally analyzed for themes other than those identified in the ACES framework employing a content analysis approach (Glesne, 2011; Mayring, 2000; Polit & Tantano Beck, 2004) One major theme and three sub the mes were identified. Figure 4 3 9 represents the taxonomy of these themes and associated codes. The major theme identified was Individual Perception of Current Life Status The three identified sub themes associated with this are: identity, reminiscing and attitude. A discussion of this theme and the three associated sub themes is presented below. I ndividual P er ception of Current Life Status Each of the six digital stories contained information pertaining to the individual in a holistic view. Who they are based on their life experiences and the implications for their present state were identified in the three sub themes.

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83 Identity Identity is a classified sub theme discovere d in the analysis process. The following codes were recognized as attributes of this sub theme as they pertain to information presented about the patient: self, spouse, parent, child, grandparent, sibling and/or friend. The most common attribute among thes e was the identification of the individual Associated pictures to represent this attrib u te included those in Figure 4 40 and Figure 4 41 Reminiscing Reminiscing was an identified sub theme and was characterized as evidenced by These attributes can be support these st atements inc luded those shown in Figure 4 42 and Figure 4 4 3 Attitude Attitude was an additional sub theme identified in the content analysis. Included in the characteristics found during coding were elements of positive and negative attitude toward the p lement of attitude. Figures 4 44 and 4 4 5 are visual representations associated with these statements.

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84 Summary The research presented sought to explore the relationship between nursing geriatric p atients. The research aimed to investigate the use of digital storytelling as an innovative situational teaching strategy in the context of geriatric care to promote a greater understanding of the Advancing Care Excellence for Seniors (ACES) framework (NLN 2011; Tagliareni, et al., 2012). The essential information required to care for geriatric patients is based on the understanding of the three knowledge domains of the ACES framework: individualized aging, complexity of care and life transitions. Addition ally, the purpose of this research was to determine if there are further themes framework. The results of Research Q uestion 1 which sought to evaluate if the digital story rubric assesses the student learning outcomes as they relate to the ACES framework demonstrated an overall mastery of the ACES knowledge domains in groups one and two but not group three. The re sults presented in relation to Research Q uestion 2, which sou ght to those outlined in the ACES framework demonstrated qualitative data to support the presence of the individual knowledge domains of the ACES framework presen t in the digital stories. An additional theme and three sub themes were identified to support this research question using content analysis. An in depth discussion of these re sults is presented in the C hapter 5 of this study.

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85 Table 4 1. Individualize d aging descriptive s tatistics Range Variable n M (SD) S Potential Actual Group 1 Instructor 6 3 (.00) .00 0 3 3 3 Researcher 6 3 (.00) .00 0 3 3 3 Group 2 Instructor 6 3 (.00) .00 0 3 3 3 Researcher 6 3 (.00) .00 0 3 3 3 Group 3 Instructor 10 1.7 (.67) .46 0 3 1 3 Researcher 10 2.9 (.32) .10 0 3 2 3 Table 4 2. Complexity of care descriptive s tatistics Range Variable n M (SD) S Potential Actual Group 1 Instructor 6 3 (.00) .00 0 3 3 3 Researcher 6 2.67 (.52) .27 0 3 2 3 Group 2 Instructor 6 3 (.00) .00 0 3 3 3 Researcher 6 2.83 (.41) .17 0 3 2 3 Group 3 Instructor 10 1.5 (.71) .50 0 3 1 3 Researcher 10 2.5 (.85) .72 0 3 1 3 Table 4 3. Vulnerabilities d uring life transitions descriptive s tatistics Range Variable n M (SD) S Potential Actual Group 1 Instructor 6 3 (.00) .00 0 3 3 3 Researcher 6 2.67 (.52) .27 0 3 2 3 Group 2 Instructor 6 2.83 (.41) .17 0 3 2 3 Researcher 6 2.17 (.75) .57 0 3 1 3 Group 3 Instructor 10 1.30 (.48) .23 0 3 1 2 Researcher 10 2.8 (.42) .18 0 3 2 3

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86 Table 4 4. Total rubric scores descriptive s tatistics Range Variable n M (SD) S Potential Actual Group 1 Instructor 6 9 (.00) .00 0 9 9 3 Researcher 6 8.33 (1.03) 1.07 0 9 7 9 Group 2 Instructor 6 8.83 (.41) .17 0 9 8 9 Researcher 6 8 (.1.10) 1.20 0 9 6 9 Group 3 Instructor 10 4.5 (1.35) 1.83 0 9 3 7 Researcher 10 8.2 (.79) .62 0 9 7 9 Table 4 5. Digital story p roperties Digital Story Length ( in minutes ) # of Digital Images Patient Gender Patient Age Point of View Digital Story 1 4.3 7 Female 89 years old 1 st person patient Digital Story 2 8.3 9 Male 78 years old 1 st person patient Digital Story 3 2.1 10 Female 77 years old 1 st person patient Digital Story 4 6.1 10 Male 95 years old 1 st person student Digital Story 5 3.1 12 Female Not identified 1 st person patient Digital Story 6 3.3 10 Male 67 years old 1 st person patient Figure 4 1 Gender distribution of the sample, the 1st semester enrolled students in this ADN program, the overall student population in the ADN program and overall national enrollment. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Sample 1st Semester ADN Program National ADN Programs % Gender Female Male

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87 Figure 4 2 Age distribution of the sample, the 1st semester enrolled studen ts in this ADN program, the overall student populaiton in the ADN program and the overall national enrollment. Figure 4 3 Race distribution of the sample, the 1st semester enrolled students in this ADN program, the overall student populaiton in the AD N program and the overall national enrollment 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% 40.00% 25 and under 26-30 31-40 41 and over % Age Group Sample 1st Semester ADN Program National ADN Programs 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% White African American Hispanic Asian Other % Race Sample 1st Semester ADN Program National ADN Programs

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88 Figure 4 4 Student individual score on the ACES rubric. DS = digital story. 0 1 2 3 4 5 6 7 8 9 10 DS1 DS2 DS3 DS4 DS5 DS6 Student Score Rubric Score

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89 Figure 4 5. Predetermined Themes for the ACES Framework

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90 Figure 4 6 Frequency distribution of the characteristics identified in the individual digital stories as defined in the Individualized Aging knowledge domain. Figure 4 7. Digital image from digital story 2 representing the Individualized Aging characteristic of assessment of function. Sour ce author digital story two. Digital image courtesy of digital story two author. 0 2 4 6 8 10 12 Assessment of Function Assessment of Cognitive Function Atypical presentation of pain and management of pain Assessment of geriatric syndromes Assessment of sexuality Assessment of violence and elder mistreatment Frequency DS1 DS2 DS3 DS4 DS5 DS6

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91 B Figure 4 8. Digital image from digital story 4 representing the Individualized Aging characteristic of assessment of function. Digital image courtesy of digital story four author. Figure 4 9. Digital image from digital story 1 representing the Individualized Aging characteristic of assessment of function. Digital image courtesy of digital story one author.

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92 Figure 4 10 Digital image from digital stor y 3 representin g the Individualized Aging characteristic of assessment of cognitive function. Digital image courtesy of digital story three author. Figure 4 11 Digital image from digital stor y 4 representing the Individualized Aging characteristic of assessment of cog nitive function. Digital i mage courtesy of digital story four author.

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93 Figure 4 12 Digital image from digital stor y 3 representing the Individualized Aging characteristic of a ssessment of atypical presentation of pain and management of pain Digital image courtesy of digital story three author. Figure 4 13 Digital image from digital story 4 representing the Individualized Aging characteristic of assessment of atypical presentation of pain and management of pain. Digital image courtesy of d igital story four author. Figure 4 14 Di gital image from digital story 6 representing the Individualized Aging characteristic of assessment of geriatric syndromes Digital i mage courtesy of digital story six author.

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94 Figure 4 15 Digital image from digital story 4 representing the Individualized Aging characteristic of assessment of geriatric syndromes. Digital im age courtesy of digital story four author. Figure 4 16 Digital image from digital story 4 representing the Individu alized Aging characteristic of assessment of sexuality Digital image courtesy of digital story four author. Figure 4 17 Digital image from digital story 1 representing the Individualized Aging characteristic of assessment of violence and elder abuse Digital image courtesy of digital story one author.

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95 Figure 4 18 Frequency distribution of the characteristics identified in the individual digital stories as defined in the Complexity of Care knowledge domain. Figure 4 19 Digital image from digital story 1 representing the Complexity of Care characteristic of geriatric syndromes Digital image courtesy of digital story one author. 0 2 4 6 8 10 12 14 Frequency DS1 DS2 DS3 DS4 DS5 DS6

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96 Figure 4 20 Di gital image from digital story 4 representing the Complexity of Care characteristic of geriatric syndromes Digital image courtesy of digital story four author. Figure 4 21 Digital image from digital story 2 representing the Complexity of Care characteristic of hydration status Digital image courtesy of digital story two author. Figure 4 22 Digital image from digital story 2 representing the Complexity of Care characteristic of infection Digital image courtesy of digital story two author.

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97 Figure 4 23 Digital image from digital story 2 representing the Complexity of Care characteristic of poly pharmacy Digital i mage courtesy of digital story two author. Figure 4 24 Digital image from digital story 3 representing the Complexity of Care characteristic of depression Digital i mage courtesy of digital story three author. Figure 4 25 Digital image from digital story 5 representing the Complexity of Care characteristic of depression Digital image c ourtesy of digital story five author.

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98 Figure 4 26 Digital image from digital story 1 representing the Complexity of Care characteristic of dementia Digital image courtesy of digital story one author. Figure 4 27 Digital image from digital story 4 representing the Complexity of Care characteristic of depression Digital image courtesy of digital story four author. Figure 4 28 Digital image from digital story 4 representing the Complexity of Care characteristic of acute vs. chronic disease process Digital image courtesy of digital story four author.

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99 Figure 4 29 Digital image from digital story 4 representing the Complexity of Care characteristic of acute vs. chronic disease process Digital image courtesy of digital story four author. Figure 4 30 Frequency distribution of the characteristics identified in the individual digital stories as defined in the Complexity of Care knowledge domain 0 1 2 3 4 5 6 7 8 9 Health care decision making Palliative care Iatrogenesis Frailty Advocacy Environment of care Frequency DS1 DS2 DS3 DS4 DS5 DS6

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100 Figure 4 31 Digital image from digital story 1 representing the Vulnerabilities during Life Transitions characteristic of health care decision making Digital image courtesy of digital story one author. Figure 4 32 Digital image from digital story 1 representing the Vulnerabilities during Life Transitions characteristic of health care decision making Digital image courtesy of digital story one author.

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101 Figure 4 33 Digital image representing the Vulnerabilities during Life Transitions characteristic of palliative care Digital image courtesy of digital story two author. Figure 4 34 Digital image representing the Vulnerabilities during Life Transitions characteristic of palliative care Digital image courtesy of digital story four author. Figure 4 35 Digital image from digital story 1 representing the Vulnerabilities during Life Transitions characteristic of frailty. Digital image courtesy of digital story one author.

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102 Figure 4 36 Digital image from digital story 2 representing the Vulnerabilities during Life Tra nsitions characteristic of advocacy. Digital image courtesy of digital story two author. Figure 4 37 Digital image representing the Vulnerabilities during Life Transitions characteristic of environment of care Digital image courtesy of digital story six author.

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103 Figure 4 38 Digital image representing the Vulnerabilities during Life Transitions characteristic of environment of care. Digital image courtesy of digital story four author.

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104 Figure 4 39 Additional themes identified beyond the ACES framework pre determined themes.

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105 Figure 4 40 Digital image representing the sub theme Identity. Digital image courtesy of digital story one author. Figure 4 41 Digital image representing the sub theme Identity. Digital image courtesy of digital story six author. Figure 4 42 Digital image representing the s ub theme Reminiscing. Digital image courtesy of digital story three author.

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106 Figure 4 43 Digital image representing the sub theme Reminiscing. Digital image courtesy of digital story five author. Figure 4 44 Digital image representing the sub theme Attitude Digital image courtesy of digital story two author. Figure 4 45 Digital image representin g the sub theme Attitude Digital image courtesy of digital story four author.

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107 CHAPTER 5 DISCUSSION AND IMPLI CATIONS C hapter 5 of this dissertation presents a summary of the study, to include a discussion of important findings derived from the data presented in Chapter 4. It offers a discussion of the implications and recommendations for prospective research. Summary of the Study Overview of the problem In conjunction with the need to expand the teaching and learning strategies in nursing education is the need to improve the ability of health care workers to care for older Americans (Ironside, Tagliareni, McLaughlin, King, & Mengel, 2010; Mion, 2003; National League for Nursing, 2009; Tagliareni & McLaughlin, 2007). Specifically there is a need for increasing the competence of all individuals, including nurses, in the delivery of geriatric care (Institute of Medicine of the National Academies, 2008). Purpose statement and research questions This dissertation explored the relatio and their understanding of the required knowledge to care for geriatric patients. The research aimed to investigate the use of digital storytelling as an innovative situational teaching strategy in the contex t of geriatric care to promote a greater understanding of the Advancing Care Excellence for Seniors (ACES) framework (NLN, 2011; Tagliareni, et al., 2012). The essential information required to care for geriatric patients is based on the understanding of t he three knowledge domains of the ACES framework: individualized aging, complexity of care and life transitions. Additionally, the research stories in addition to those outlined in the ACES framework. As such, the research questions which guided this study are:

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108 RQ1. Does the digital story rubric assess the student learning outcomes as they relate to the ACES framework? RQ2. What themes are found in the digital stories in addition to those assessed by the ACES rubric? Review of the methodology This study employed a mixed method, non experimental research design using a concurrent triangulation approach (Creswell, 2009; Onwuegbuzie & Leech, 2006). In the concurrent triangu lation approach, the data for the quantitative and qualitative research is collected at the same time. The research questions sought to discern whether quantitative and qualitative data provide opportunity to inform the research questions. Graded rubrics f examined using a thematic or content analysis approach to identify common characteristics within the digita l stories. This represented a systematic approach to analyzing the themes derived from the stories into major categories for the purpose of interpretation (Bowen, 2009; Glesne, 2011). These themes were then compared to the identified components of the kno wledge domains of the ACES framework. This allowed for the potential to discover any additional themes within the digital stories beyond the identified ACES knowledge domains. Major Findings Research Question 1: Does the digital story rubric assess the stu dent learning outcomes as they relate to the ACES framework? Findings The research aimed to investigate the use of digital storytelling as an innovative situational teaching strategy in the context of geriatric care to promote a greater understanding of the Advancing Care Excellence for Seniors (ACES) framework. The

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109 story and their understanding of the required knowledge to care for geriatric patients. Descriptive sta tistics and analysis of variance procedures were used to analyze the researcher. The intra class correlation for the sample while not significant provided evidence of ac ceptable reliability. The three knowledge domains of the ACES framework are individualized aging, complexity of care and vulnerability during life transitions (NLN, 2011; Tagliareni, et al., 2012). Seventeen students (77%) in the sample demonstrated a mas tery of the individualized aging knowledge domain at a minimum of 75% (raw score of 2.25), which is considered passing for this ADN nursing program. Sixteen students (73%) in the sample demonstrated a mastery of the complexity of care knowledge domain at a minimum of 75% (raw score of 2.25). Fourteen students (64%) in the sample demonstrated a mastery of the complexity of care knowledge domain at a minimum of 75% (raw score of 2.25). Seventeen students (77%) in the sample demonstrated an overall mastery of the ACES knowledge domains at a minimum of 75% (raw score of 6.75). The group data were analyzed by using a one way between subjects ANOVA, where instructional group served as the factor and score served as the outcome variable. Results for each individual knowledge domain and the total rubric scores indicate there was a significant difference between at least one of the instructional groups. Using the Bonferroni correction to adjust for multiple comparisons at a 95% confidence level there was a significant difference in each knowledge domain and in the total rubric score results between group three and groups one and two. These findings are consistent with current research utilizing digital storytelling as a teaching tool. Digital storytelling has been demo nstrated as having the ability to facilitate gaining experience

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110 and understanding about life in a variety of contextual settings (Jenkins & Londsdale, 2007; McLellan, 2007; Sandars & Murray, 2009; Skouge & Rao, 2009; Stacey & Hardy, 2010). Overall, the ru ACES framework. The utilization of the rubric provided the ability to discern which knowledge domains were most reflected in the digital stories and those least present. The group three rub ric scores were significantly different than those of group one and two. Discussion of caring qualities The art of nursing has been illustrated as an expression of sympathy, attitudes of concern, ethical and moral commitment and sensitivity to feelings of others(Dunphy, 2001; Peplau, 1988). The National League for Nursing (NLN) (2011) describes caring as pro moting health, healing and hope in response to the human condition and considers it a central tenet in the nursing profession. It includes the intentionally formed relationships and competencies developed over time through self reflection, observation of role models and experience (Sadler, 2003). The National League for Nursing Accreditation Commission (NLNAC) requires ADN programs to include components which address caring in their curriculum as requirements for accreditation (NLNAC, 2011). Duffy (2003) d emonstrated the nurse patient relationship characterized by caring has a positive influence on the outcomes for patients/families, and healthcare systems. The federal government has attached funding and reimbursement incentives to many of the caring quali ties, with mandatory reporting using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This has led to

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111 attitudes towards caring for othe rs. This is an additional reason to incorporate intentional opportunities to provide students with educational experiences that will expand their caring attitudes, in nursing educational programs. Issel and Khab (1998) identified seven specific behaviors related to caring which have economic value in healthcare. The authors identified five consequences of the outlined caring behaviors related to finances of a healthcare organization. Patient satisfaction as a consequence has the potential to generate reven ue for the healthcare organization. Physiological, self disclosure and self esteem are individual consequences which when met with caring behaviors have the prospective to avoid additional costs. Lastly, legal is considered a probable cost saving consequen ce as a result of the other four. Digital storytelling has been demonstrated as having the ability to facilitate gaining experience and understanding about life in a variety of contextual settings (Jenkins & Londsdale, 2007; McLellan, 2007; Sandars & Murra y, 2009; Skouge & Rao, 2009; Stacey & Hardy, 2010). The successful outcomes demonstrated by the ACES rubric scores provide evidence for continued promotion of digital storytelling to enhance the students were identified as demonstrating expressions of sympathy, attitudes of concern, ethical and moral commitment and sensitivity to feelings of others (Dunphy, 2001; Peplau, 1988). Discussion of attitudes toward older adults In addition to carin g being central to potential patient outcomes, attitudes toward the elderly are likewise an important factor to outcomes for the elderly in health care predisposes a class of action

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112 Dwyer (Dwyer, 1993) expanded on this definition by identifying three key components to attitudes. These include: a cognitive component (the idea), an effective component (the emotion) and a be havioral component (the action). Ageism is defined as predisposition toward older adults through attitudes and resulting actions (Stanley, Blair, & Beare, 2005). Ageism can be seen in the arena of patient education. Research has demonstrated that older pa tients receive less information related to their health, illness and available resources than younger patients (Ayranci & Ozdag, 2006). Negative attitudes toward the elderly can thus lead to miscommunication or less than optimal patient education and resul t in poor patient compliance and/or outcomes. There is research which supports the belief that behavior toward older adults appears dependent upon their attitudes of the elderly (Sinnott, Raval, & Shiffman, 1983). Cozart (2008) identified the need for posi tive attitudes towards older adults to provide optimal care and that historically nursing students attitudes toward the elderly are negative. The overall postive outcome of the ACES rubrics signifies a deeper understanding of the complex nature of the car e of the elderly patient. The digital stories demonstrated respect for the elder patient and lacked signs of ageism. One digital story author began his reflection with identifying his own negative beliefs about aging which have changed since this experienc e. Discussion of contextual teaching strategy Research has demonstrated a need for registered nursing curricula to include teaching and learning strategies which will facilitate the development of clinical reasoning, to include understanding the context o f the situation from the viewpoint of the multiple lenses of culture, daily environment, illness experience and their relationships

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113 with significant others in their lives (Benner et al., 2009; Diekelmann, Ironside, & Gunn, 2003;Ironside, 2006). Story telling as a teaching and learning tool in nursing education is an established mechanism to promote reflecion and demonstrate a deeper understanding of events (Diekelmann, 200 1; Ironside, 2003; Nehls, 1995). Narrative presentation of experiences encourages reflective thinking and may increase the understanding of what was learned and how it was learned (Diekelmann, 2004). The overall results of the outcomes of this research stu dy based on the rubric scores, validates the use of digital storytelling as prescribed in this assignment as a mechanism for this type of learning to occur.and the ability for students to be assessed. Discussion of instructor impacts The teaching methods o f the individual clinical instructors may have impacted the Nursing clinical instructors have been identified as having two distinct views of nursing, patient centered or nurse centered. The clinical instructors view has been demonstrated to impact the view of the students they are teaching (Dahike, Baumbusch, Affleck, & Kwon, 2012). The clinical instructor who has a nursing view which is nurse centered would be less li kely to view the elderly through the multiple knowledge domains of th e ACES framework. Gignac Caile and Oermann (2001) identified a significant difference in the perception of students and faculty as it related to effective clinical instructors. Students i dentified evaluation characteristics as most import while faculty identified interpersonal relationships as most important. These findings may have impacted rubric grading if during the clinical rotation the clinical instructor did not recognize the studen t as having developed an interpersonal relationship with their patient. Clinical instructors have identified an ambiguity in their defined role as a facilitator of student learning.

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114 Included in this is a lack of knowledge related to the curriculum ( Finn, King, & Thorburn, 2000). As each of these instructors have attended professional development workshops related to the ACES framework and its implementation in the current nursing curriculum this should not have impacted the outcomes on the ACES rubric. One of the acknowledged differences in the three clinical instructors is one of the instructors was Finnish and English is her second language. This may have influenced her es. Discussion of the ACES rubric The ACES rubric was shared with the students as part of the assignment. The rubric focused solely on the ACES content within the digital story; as such it was not an ies. It did not evaluate the digital story for any additional considerations, including but not limited to the presence of elements of a story or the use of technology in the finished product. This rubric design limited the ability to assess the full depth of the assignment for critical elements to a successful digital story. The rubric would have benefited from incorporating areas to enhance the likelihood of more students demonstrating the inclusion of rich story elements and increased sophistication of t he integration of technology to deliver their message. Discussion of the assignment context The context of the assignment in the curriculum adds an additional area for consideration. This assignment is part of a first semester nursing course at a public s tate college in the Southeastern United States Many of these students are just beginning their foray into the healthcare arena and are overwhelmed with both the coursework and the responsibility of caring for another human being. Time management

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115 skills al ong with higher course expectations could have impacted the potential end product for this assignment. The course this assignment is attached to is graded pass/fail and students understand this is a small portion of their final clinical grade. The amount o f time required to produce a well crafted digital story after the seven week rotation may have been overwhelming in conjunction with their other course, work and family responsibilities. The use of technology which they were unfamiliar with may have caused additional strain in their lives. This assignment may be better served either later more successful at understanding the time and knowledge required to successfully produce an exemplar digital story. Research Question 2: What themes are found in the digital stories in addition to those assessed by the ACES rubric? The second research question sought to explore what themes are found in the digital stories in addition to those assessed by the ACES rubric. Six purposively selected digital storytelling stories, which demonstrated the three elements of a story as identif ied by Labov (2011), were analyzed. The six digital stories selected for in depth review were analyzed using a thematic and template or content analysis format (Glesne, 2011; Mayring, 2000; Polit & Tantano Beck, 2004). This research design allowed for pote ntial emergent themes not identified by the ACES framework to be discovered. ACES framework themes findings The analysis of the six digital stories revealed the presence of each of the knowledge domains as defined by the ACES framework. Within the knowledg e domain of individualized aging, the most common themes identified were related to the functional ability of the patient, both physical and cognitive. The themes most prevalent

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116 within the knowledge domain of complexity of care were geriatric syndromes, de pression and acute vs. chronic disease conditions. The knowledge domain of vulnerability during life transitions was noted to have the following themes represented most frequently: healthcare decision making and environment of care. Digital storytelling p romotes the use of reflection as a means to integrate new 2006). The first semester nurs ing students who authored these digital stories have completed along with their clinical course, a didactic course which introduces the fundamentals of nursing. The focus in the didactic course is patient assessment, to include geriatric syndromes, introdu ction to altered cognitive status and healthcare decision making for patients and families. Consistent with the research these are the most prominent ACES themes demonstrated in the digital stories. Within each of the six digital stories transcripts, elder mistreatment or abuse was not present. However, within the digital pictures one student utilized a photo which represented this sub theme. Elder abuse is defined as intentional actions that cause harm or the potential serious risk of harm to a vulnerable elder by a person who stands in a trust relationship to the elder. This includes failure by a caregiver to insure the or unintentional in nature (Hooyman & Kiyak, 2011; L achs & Pillemer, 2004; Touhy & Jett, 2010). The incidence of elder abuse is estimated at between 7.6% 10% annually (Department of Health & Human Services, 2013; McBride, 2011; Plitnick, 2008). With the significant actual and/or potential of elder abuse, nu rsing students need to understand this multifaceted healthcare issue. Review of the current textbook used by

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117 the students in this ADN program revealed one paragraph dedicated to this topic. Although the topic is discussed in their didactic course, the cour se resource does not substantiate the importance of this topic. The use of digital storytelling in higher education has been employed as a learning resource. Research has demonstrated both individual and peer reflective learning by observing digital storie s created by others. Students are able to integrate new understanding of the circumstances into their personal conceptualization of the content (Cheng & Chau, 2009; Christiansen, 2011; Czarnecki, 2009; D'Alessandro, Lewis, & D'Alessandro, 2004; Heo, 2009; McLellan, 2007; Sandars & Murray, 2009; Stacey & Hardy, 2010). Based on these findings, additional intentional learning encounters should be developed to aid students in identifying and understanding the nature and prevalence of elder abuse. Iatrogenesis is defined as the emerging development of multiple medical conditions as a result of the health care environment or health provider interventions. An example of iatrogenesis is the elderly patient, who is agitated and sedated, which may lead to disorientat ion, dizziness and falling. This in turn could lead to additional injury resulting in an extended hospital stay associated with the need for surgery or complex medical attention from the injury and increased health care costs. These events themselves have the ability to perpetuate the cascade of iatrogenesis further. It occurs more frequently with older adult patients in hospitals, rehabilitation and long term care settings. The associated outcomes for these patients are a poorer discharge prognosis and an increase in potential medical care costs (Klein, 2002; Mitty, 2010; Thornlow, Anderson, & Oddone, 2009). Iatrogensis as a sub theme was not identified within the transcripts or photos in all six digital stories. Review of the current textbook used by th e students in this ADN program revealed five sentences dedicated to iatrogenic

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118 infections only. The textbook does not discuss or define model of iatrogenesis in the health care system. As with elder abuse, although the concept of iatrogenesis is discussed in their didactic course, the course resource does not substantiate the importance of this topic. Based on these findings, additional intentional learning encounters should be developed to aid students in identifying and understanding iatrogenesis. Discus sion The National Council of State Boards of Nursing (2012) report that 56.1% of new graduates report caring for older adult clients aged 65 to 85 with an additional 27.8% reporting caring for older adult clients aged 85 or older (NCSBN, 2012).In 2008, the Institute of Medicine (IOM) published a report calling for a national agenda to improve the ability of health care workers to care for older Americans. Specifically addressed in this, was a need for increasing the competence of all individuals, including nurses, in the delivery of geriatric care (Institute of Medicine of the National Academies, 2008). In 2011, the first baby boomers began to turn 65 years old. It is estimated that there are over 78 million Americans born between the years of 1946 to 1964 (Centers for Disease Control and Prevention, 2003; Centers for Disease Control and Prevention and The Merck Company Foundation., 2007; U.S. Census Bureau, 2008). Over the next 25 years, the number of individuals over the age of 65 in the United States will almost double. This translates into individuals over the age of 65 making up approximately 20 percent of the total population (Centers for Disease Control and Prevention, 2003; Centers for Disease Control and Prevention and The Merck Company Foundation., 2007; U.S. Census Bureau, 2008). Given the growing population over the age of 65, there is a need to implement innovative strategies to prepare pre licensure nursing

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119 students in the care of older adults (Ironside, Tagliareni, McLaughlin, King, & Mengel, 20 10; Mion, 2003; National League for Nursing, 2009; Tagliareni & McLaughlin, 2007). These students demonstrated their understanding of the unique needs and challenges faced when caring for the older adult through their digital stories. This understanding ha s the potential to improve geriatric patient care and outcomes thus decreasing medical costs. It has been established that nurses who care for older adults and personalize and internalize the importance of their care have a positive impact on their outcome s (Tagliareni, et al., 2012; Tagliareni & McLaughlin, 2007; National League for Nursing, 2009). Additional identified themes findings The six digital stories were additionally analyzed for themes other than those identified in the ACES framework employing a content analysis approach (Glesne, 2011; Mayring, 2000; Polit & Tantano Beck, 2004). One major theme and three sub themes were identified. The major theme identified was Individual Perception of Current Life Status. The three identified sub themes assoc iated with this are: identity, reminiscing and attitude. Each of the six digital stories contained information pertaining to the individual in a holistic view. Who they are based on their life experiences and the implications for their present state were i dentified in the three sub themes. older adults is Maturity. Erikson describes each stage as a process of working through a set of psychosocial tasks. In the Maturity stage th e psychosocial tasks are integrity vs. despair. The main components of this stage surround the adult feeling satisfied with their life (Salkind, 2004). Characteristics of integrity include: realistic and insightful self awareness, reasonably optimistic, co nnected to family, friends and the community and

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120 content with their experiences and achievements. Characteristics of despairing include: depressed about life disappointments and failures, missed chances in life, expressions of sadness, regret or failure an d insufficient sense of belonging and not enough time left to find fulfillment (Hearn, et al., 2012). The identified theme and three sub themes are reflective of this theoretical context. Discussion Nursing education is increasingly challenged with a d emand for including new content or concepts in an already overburdened curriculum (Pressler & Kenner, 2009) Faculty consider the teaching of caring a difficult process and a concept that is less important than one they would designate as critical. Addition ally, the literature identifies a lack of understanding or empathy among nursing students towards the clients they care for (Gramling & Nugent, 1998) (students) in it just for the money, their development of caring. The art of nursing has been illustrated as an expression of sympathy, attitudes of c oncern, ethical and moral commitment and sensitivity to feelings of others (Dunphy, 2001; Peplau, 1988). The National League for Nursing (NLN) (2011) describes caring as promoting health, healing and hope in response to the human condition and considers it a central tenet in the nursing profession. It includes the intentionally formed relationships and competencies developed over time through self reflection, observation st ories clearly demonstrated expressions of sympathy, attitudes of concern, moral and ethical commitment and sensitivity to feelings of others. This demonstrates the positive

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121 potential impact digital storytelling can have on guiding students to develop deepe r caring constructs in their practice. Storytelling in education has been instrumental in helping students make meaning of complex human conditions and life events (Burk, 2000). Abrahamson (1998) identifies critical reflection as an effect of utilizing sto ries in the classroom. Stories become the manner in which students can process the complex nature of what they are being presented in the classroom thus forging a learning community of shared views. Digital storytelling has been revealed to promote reflect ive learning in healthcare professional education. Digital storytelling promotes the use of reflection as a means to integrate new understanding, within the context of transitioning to professional nurse, es in the future. It has been shown that the sharing of stories, particularly in health and medicine can promote new insights and knowledge through reflection for both patients and healthcare providers as either creators and/or consumers of these digital The discovery of the additional theme and sub themes demonstrates the approac h to patient care in geriatrics. It is through both the telling and sharing of stories that nursing students come to recognize and understand qualitative distinctions in patient situations (Benner, Hooper Kyriakidis, & Stannard, 1999; Ironside, 2003). Digi tal storytelling provides a potential new medium to develop, deliver and share these lenses of culture, daily environment, illness experience and their relationships with

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122 significant others in their lives (Benner et al., 2009; Diekelmann, Ironside, & Gunn, 2003;Ironside, 2006). Limitations Limitations for this study include both quantitative and qualitative concerns (Creswell, 2009; Onwuegbuzie & Leech, 2006). There is a threat to external validity due to the participants belonging to a convenience sample. This may limit the generalizability of the findings (Creswell, 2009). Inter rater reliability and content validity of the ACES rubric were established. However, thi s is the first time the ACES rubric will be used on a large scale to assess the level of student learning outcomes. Additionally, researcher bias in evaluating the digital stories for thematic analysis cannot be ignored (Glesne, 2011). The researcher is a project staff member and has worked with the project throughout the development and national launch of the ACES framework. As previously discussed, two of the instructor/graders were American, Caucasian women. The third instructor was Finnish and English is her second language. This may have and impacted the study outcomes. Conclusions in meeting learning outcomes related to understanding and integrating the ACES framework in their digital stories. The ACES rubric consistently measured the associated defined characteristics within the distinct knowledge domains of the ACES framework. Th e use of the ACES rubric also identified which areas of the knowledge domains were most prevalent and those the least represented.

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123 The thematic analysis using the predetermined ACES knowledge domains and characteristics reaffirmed the findings using the A CES rubric. This demonstrated concurrent triangulation of data by using the data collected simultaneously in both a quantitative and qualitative research approach to compare results afterward. These research methods led to an increase confidence in the abi lity of the ACES rubric to measure the stated ACES framework knowledge domains and be utilized to measure learning outcomes. e of development, Maturity (Salkind, 2004). The use of digital storytelling allowed students to express their understanding of growing old. Although this was not an outlined part of the reflective assignment, it demonstrates how through the construction of their digital story, the students were encouraged to reflect on the seven weeks they spent with this individual patient and were able to translate this into meaning in thei r stories. Implications for action The ACES framework was launched by the NLN in 2009. It provides for a conceptual framework in which students can gain understanding of the importance of individualized aging, complexity of care and life transitions, usin g evolving geriatric knowledge to provide care for the older adult (NLN, 2011; Tagliareni, et al., 2012). National accrediting organizations for nursing programs require the documentation of student learning outcomes to include valid and reliable mechanism s to assess them (Halstead, 2007; Lowenstein & Bradshaw, 2001; National League for Nursing Certification Governance Committee, 2005). With the need to demonstrate student

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124 accomplishments through measurable outcomes, the successful implementation of the ACE S rubric will allow for a widespread dissemination of the rubric through the NLN and serve as a tool to assist other nursing programs with measuring these outcomes. The research aimed to investigate the use of digital storytelling as an innovative situatio nal teaching strategy in the context of geriatric care to promote a greater understanding of the ACES framework. The success of this research will empower others to utilize digital storytelling in a variety of healthcare settings, to enhance rstanding of contextually specific care for their patient population. Recommendations for further research Findings in this dissertation were void of direct student analysis in conjunction with the thematic analysis of the digital stories. Qualitative rese arch which would seek to understanding of the ACES framework. Additionally, this appr oach has the potential to discover any additional interpretations of the transcribed stories and associated pictures frame work by viewing these stories created by others and the potential for enhanced reflective learning in this situation as described in other educational venues would be an area for future research exploration (Cheng & Chau, 2009; Jenkins & Londsdale, 2007; M cLellan, 2007; Sandars & Murray, 2009; Stacey & Hardy, 2010). Investigation into the impact sharing digital stories among a single cohort has additional implications for reflective learning to occur is an additional consideration for future research (Chris tiansen, 2011; D'Alessandro, Lewis, & D'Alessandro, 2004; McLellan, 2007).

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125 Closing remarks In conclusion, this study demonstrated the ACES rubric as being successful in measuring student learning outcomes related to the ACES framework. The qualitative res earch further strengthened this finding by establishing the presence of the ACES knowledge domains and defining characteristics embedded in the digital stories. The additional thematic analysis of the digital stories demonstrated reflective processing by t he student in understanding the life stage of their patient in the aging continuum. I believe the use of digital storytelling in nursing education has the potential to engage the student in forming a deeper understanding of the varied population and needs of the patients they care for.

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126 APPENDIX A I NSTITUTIONAL R EVIEW B OARD

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127 APPENDIX B PALM BEACH STATE COLLEGE RESEARCH APPROVAL

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128 APPENDIX C LONG TERM CARE ROTAT ION -SUMMARY OF EXPERIENC E Based on your experience and knowledge working with the ACES framework, create a digital story about a resident you cared for during your long term care rotations. (You may use the questions listed below as a guide.) Introduction 1. Introduce your resident. Individualized Aging 1 aging? 2. What is the baseline functional and cognitive status of this resident? What data/evidence is used to support this? Is there a conflict between what is baseline and what is perceived by the resident and/or caregiver? Complexity of Care 1. What multiple co existing acute and chronic conditions may generate tension between immediate and long term needs of your resident? 2. What concerns did you have in th e relation to the complexity of your resident did you have? Vulnerabilities During Life Transitions 1. What are the resident and/or family expectations of outcomes of care? uality of life? 5. What are the resident and/or caregivers understanding of patient safety concerns? 6. What were the risks and benefits of the safety concerns?

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129 Resources to help you create your digital story: http://www.patricklowenthal.com/digitalstory/tie/jobaids/ppt+digitalstory.pdf download.microsoft.com/documents/australia/education/photo_story_3.pdf http://digitalstorytelling.coe.uh.edu/getting_started.html http://digitalstorytelling.coe.uh.edu/photostory.html http://digital stories.wikispaces.com/01+Powerpo int+into+Photostory

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130 APPENDIX C ACES FRAMEWORK RUBRIC

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131 0 1 2 3 Individualized Aging Demonstrates no components of the following key concepts: Assessment of function Assessment of cognitive function Atypical presentation of pain and management of pain Assessment of geriatric syndromes Assessment of sexuality Assessment of violence and elder mistreatment Demonstrates 1 2 components of the following key concepts: Assessment of function Assessment of cognitive function Atypical presentation of pain and management of pain Assessment of geriatric syndromes Assessment of sexuality Assessment of violence and elder mistreatment Demonstrates 3 5 components of the following key concepts: Assessment of function Assessment of cognitive fu nction Atypical presentation of pain and management of pain Assessment of geriatric syndromes Assessment of sexuality Assessment of violence and elder mistreatment Demonstrates > 5 components of the following key concepts: Assessment of function Assessmen t of cognitive function Atypical presentation of pain and management of pain Assessment of geriatric syndromes Assessment of sexuality Assessment of violence and elder mistreatment Complexity of Care Demonstrates no components of the following key concepts: Geriatric syndromes Oral hydration Infection Poly pharmacy Depression Dementia Acute vs. chronic disease process Demonstrates 1 2 components of the following key concepts: Geriatric syndromes Oral hydration Infection Poly pharmacy Depression Dementia Acute vs. chronic disease process Demonstrates 3 5 components of the following key concepts: Geriatric syndromes Oral hydration Infection Poly pharmacy Depression Dementia Acute vs. chronic disease process Demonstrates >5components of the followin g key concepts: Geriatric syndromes Oral hydration Infection Poly pharmacy Depression Dementia Acute vs. chronic disease process Vulnerabilities During Life Transitions Demonstrates no components of the following key concepts: Health care decision making Palliative care Iatrogenesis Frailty Advocacy Environment of care Demonstrates 1 2 components of the following key concepts: Health care decision making Palliative care Iatrogenesis Frailty Advocacy Environment of care Demonstrates 3 5 components of the following key concepts: Health care decision making Palliative care Iatrogenesis Frailty Advocacy Environment of care Demonstrates >5 components of the following key concepts: Health care decision making Palliative care Iatrogenesis Frailty Advocacy Environment of care

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132 Defining Characteristics ACES Knowledge Domains Individualized aging Assessment of function Activities of daily living o Bathing, eating, dressing, hygiene, transferring, mobility, toileting Independent activities of daily living o Housekeeping, cooking, laundry, shopping, finances transportation Age related changes o Physiologic changes by system Nutrition o Weight, BMI, labs, 24 hour dietary intake, supplements/calorie intake, mealtime difficulties, oral health Sensory chang es o Loss, deprivation, aides, assistive devices, balance and movement. Assessment of cognitive function Executive function, short term memory impairment, long term memory impairment, orientation, sequencing, adaptive capabilities apathy, mild cognitive im pairment, onset of symptoms, impact on functioning Learning needs o Cognition, language, style Substance misuse o Prescription and non prescription medications, recreational drugs, alcohol use, tobacco use Atypical presentation of pain and management of pain Knowledge of pain, use of pharmacologic and non pharmacologic agents Assessment of geriatric syndromes Sleep Disorders, Problems with Eating or Feeding, Pain, Incontinence, Confusion, Evidence of Falls, Skin Breakdown Assessment of sexuality Influence of m edications, normality, desire and mechanics, intimacy, sexually transmitted infections, orientation Assessment of violence and elder mistreatment Abuse and neglect o Physical o Psychological o Financial o Verbal Complexity of Care Geriatric syndromes Presence of Sleep Disorders, Problems with Eating or Feeding, Pain, Incontinence, Confusion, Evidence of Falls, Skin Breakdown Hydration status Dehydration Constipation Medication toxicity Fluid overload/CHF Infection Increased risk Atypical presentation Poly pharmacy Medication reconciliation

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133 Financial implications Depression Lethality assessment Social isolation Treatment Atypical presentation Dementia Types Behavioral concerns Treatment Client/family education Caregiver burden Acute vs. chronic disease process Identify differences Vulnerabilities During Life Transitions Health care decision making HIPPA Patient wishes and expectations Belief systems/religion/spiritual Culture considerations o generational, ethnic, racial considerations Advance directives Risks and benefits of expectations Palliative care Hospice End of life decisions Iatrogenesis Cascade disease pattern Frailty Needs assistance with ADLs Dependent on others for care Generalized weakness Weight loss Advocacy Who and how Environment of care Legal/ethical considerations Resources o Access to care o Financial Safety Interdisciplinary collaborative care

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142 BIOGRAPHICAL SKETCH Kellie Bassell graduated in 1983 from Boston College where she earned her BSN. She earned her MSN in 2004 from Florida Atl antic University and received her Ed.S. from the University of Florida in 2009. She received her Doctor of Education from the University of Florida in the summer of 2013. Kellie has worked at Palm Beach State College in Lake Worth, FL since 2002, in the Re gistered Nursing program. Currently, she is the Director of Nursing Previously, she was Department Chair of the Nursing program from 2007 2008 and Interim Program Director for Nursing, from January 2008 August 2008. One of her respon sibilities has been to develop the nursing courses into multiple formats including web component, web hybr id and online. From 2005 2008, she taught Medical/Surgical Nursing (both didactic and clinical), Human Growth and Development in the on line format; (a course she developed ), and lecture and clinical to 1st semester Fundamentals students, in the e vening/weekend program in a hybrid format. ntegrating educational technology into nursing education across the curriculum, academi c nursing leadership and healthcare needs of the older adult.