An online community board (CB) was created for undergraduate nursing students to enhance teaching, learning, and student engagement in end-of-life (EOL) care across the curriculum. An asynchronous online venue is a helpful supplement to didactic and clinical teaching-learning of EOL care content. This is especially true as faculty increasingly try to get more curricular content into existing timeframes, often at the expense of individual sharing and processing of experiences. The CB allows me to facilitate students' learning related to my teaching of EOL content across the generic undergraduate curriculum in ways that I was previously unable to do given the limited amount of class time devoted to any one topic.

Fostering Teaching-Learning

The End of Life Nursing Education Consortium (ELNEC) Supercore training program, developed by the City of Hope and the American Association of Colleges in Nursing, is fully integrated into our generic baccalaureate program.1 In various core courses, one lecture is dedicated to ELNEC content each semester; however, the time allocated for EOL lectures is discontinuous and there is little time for student engagement. With the creation of the CB, students continue to be engaged in teaching-learning of EOL care over the entire program. For each of 8 EOL lectures held over 2 years, students are required to post a minimum of one related reflection on the associated course discussion forum. Notably, many students choose to post more than 1 reflection and also respond to one another during the term.

The CB bridges gaps between didactic and clinical learning when students, such as the one quoted below, choose to share their experiences of death and dying with the rest of the class, giving those who do not have similar experiences the chance to learn from them:

We had a patient who died&... being do not resuscitate/do not intubate, it wasn't as if [death] came suddenly. His wife was crying, his kids were crying, social workers were trying to contact family members...just a whole lot of things all at once. I didn't process the death at first; we all had patients to take care of...but then our instructor had us in the room...to help prep the body. Then bam, you're staring at a body who is still, completely still, incapable of doing anything, and who a few hours ago, was alive. His heart was beating, impulses were firing, blood was flowing, and now it's still... I've been to wakes and funerals, too many, but I'd never seen how death is handled in a hospital. It felt cold. It was as if the aide did so many; it became mechanical. I understand the body is heavy but I just thought it could've been done a little more gently ...we helped bind his hands, feet and jaw together, he was tagged and then put into a bag. That was weird, I helped put a human into a bag, put him onto a cart, rode down on a freight elevator with him and rolled him into the morgue, into a big refrigerator. and being with a dead body, well, it isn't as scary as I once thought it'd be. It's just really quiet. And that's the sad part. The quiet.

In addition to the discussion boards, students are able to access a plethora of materials related to EOL care. Using an online platform, such as Blackboard, files on the CB can include not only written-word files and PowerPoint presentations but also animation, video, and audio files, along with wikis and external links for the students to explore, thus enabling students to expand upon the relationship between EOL topics presented in the lecture classes and their clinical and personal experiences.

Student Engagement: A Community of Caring

Having taught EOL nursing care for more than a decade, I realize that there can be no constructive discussion about death and dying without considering life and living; one must readily acknowledge that "death" does not make appointments. During any given term, there are students who experience the death of a loved one or have a loved one who is dying. Since its inception, the EOL Nursing CB has had one discussion forum for the express purpose of providing a space for students to share personal feelings related to death, dying, and bereavement. This is the only forum on which posts and discussion are optional rather than required. However, it is this forum that gets the most use.

In just 1 year, there have been 276 student postings on this particular discussion forum concerning death and dying experiences. Notably, 16 students shared personal experiences of a loved one's death while in nursing school, 73 students relayed previous experiences with loved one's deaths, and 7 students shared experiences of patients dying in the hospital clinical practicum. An additional 4 students also noted anticipation of a loved one's impending death. In this communal rendering of experiences, all undergraduate generic students are availed the opportunity to learn from one another.

The very personal and often heart-wrenching disclosure of the students provides a valuable lesson for faculty as well as students. Although it is most obvious to one teaching death and dying content specifically, almost all faculty discuss content with potential serious and sometimes fatal outcomes. The odds are high that at least 1 student in every class taught has experienced those outcomes with a friend or family member. Having a CB invites those students who normally might not do so to share their suffering in a caring, safe environment.

The compassion that has emerged in cyberspace on the CB has been humbling, inspiring, and palpable. One year after its inception, there have been more than 850 student posts on the various forums. Students are learning from each other how to provide support to those who are grieving, and as they progress through the program, they find that the online CB offers an opportunity to discuss death and dying topics, which are many times deemed taboo in their social circles with family and friends. This, then, is a first step in overcoming death denial, an ongoing problem that exists in society and, unfortunately, in healthcare as well.

Initial feedback from students regarding use of the CB was requested and obtained via e-mail (86% response rate), and it has been impressive. Students stated that the CB offers them a place to express themselves freely on life and death topics without feeling intimidated or scared that someone is going to judge them. Many noted that it was easy to access the CB and share thoughts/reflections as they arose in an atmosphere that was refreshingly available, all the time. One student wrote, "Every time I feel...like kind of confused or scared about something related to death or life itself, my best friend is the discussion board!"

The creation of a CB for teaching EOL nursing content has facilitated peer relationship building and peer-to-peer teaching-learning. It also had the additional benefit of fostering grief-healing and an overall community of caring while students progressed through the nursing program, augmenting an understanding of EOL care that they could not get with lectures alone.

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