The primary purpose of undergraduate, pre-registration nursing education is to prepare students to practice as registered nurses [1-3]. Thus, the nursing curriculum evolves to reflect the dynamic nature of clinical environments and ultimately to produce competent nurses fit for practice at the point of registration [4, 5]. A significant debate continues in relation to the separation of theory and clinical practice `the practice gap’, with ongoing concern as to the practical clinical relevance of some nursing theory and teaching to preparing the qualified professional [6-8] argues for the importance of holistic nursing and to better achieve students’ need to be educated holistically; suggest that historically there was perhaps a tendency towards an over structured curriculum and categorization; the current focus would not necessarily negate `fixed information’ but with more of an emphasis on integration better reflecting the need to prepare students for social, political and clinical situations that are complex, moralistic and unpredictable discuss some of the barriers to student centered learning which include addressing traditional silos of knowledge and expertise in a teacher led approach [9-11]. The 2010 Nursing and Midwifery Council Standards for Preregistration Nursing and Midwifery Education focus the need for an integrated model of learning reflective of both the physical but also the psychosocial reality and living environment of patients and clients. As a result, The School of Nursing in Queens University Belfast sought to incorporate service users into curriculum development, assessment and teaching in the undergraduate programme. The initiative involving partnership with the WAVE organization and the engagement as co-educators with citizen trainers sought to help narrow or close that practice gap. Whilst previously the impact of this model of teaching had been very positively evaluated by Nursing and Midwifery students [12] evaluation of the teaching and learning from a user and carer perspective with citizen trainers as co-educators had not been evaluated. For educators in the health professions, the evaluation of learning takes on a dimension in terms of helping to ensure the efficacy of a teaching programme, and reflects in the development of competence and professional standards within graduates [13].  Evidence from a previous evaluative study [12] suggests students were engaged and experienced deep learning due to the innovative pedagogical approach of face-to-face interaction within small groups and within a safe environment [14]. This phase of the evaluation will seeks to investigate why citizen trainers choose to participte, to understand the experience of teaching and to evaluate the process from the citizen trainers as co-educators perspective. Secondly to engage their experience and ideas of adaptations and improvements to the teaching and learning programme and emphasis the contribution of service user and career representatives to enable students to understand key concepts at a meaningful level [15]. Which might not be achieved in traditional teaching settings.

The Troubles’ in Northern Ireland took place over an extended period with civil conflict particularly marked from the mid to late 1960’s. The Troubles probably resulted in the immediate death of some 3,800 people with estimates in excess of 40,000 having suffered severe injury. In addition, an indeterminate number of the citizenry suffered significant and ongoing psychological and subclinical symptoms as a consequence of the extremes of civil unrest. The legacy of ‘The Troubles’ is further reflected in disproportionately high levels of antisocial behavior, family dysfunction, drug and alcohol dependency within the province [16]. WAVE, as an organization, was formed in the early 1990s and is a cross community voluntary organization offering care and support to anyone bereaved, suffering trauma or injury as a result of the violent civil conflict. Following the signing of the Good Friday Agreement in 1998, the ‘conflict’ related incidents have significantly diminished. As most of the student nurses were born after this time they are less likely to understand what the impact ‘the troubles’ had on society in Northern Ireland. A significant number of patients and clients that current nursing students will be attending to in the course of their nursing and midwifery training or subsequent to qualification, may present with primary or secondary conditions associated with their experiences of the conflict. Many of the students will be drawn from social and geographical areas previously impacted by ‘The Troubles’. Therefore, a joint educative initiative between the School of Nursing and Midwifery at Queen’s University Belfast and WAVE was established to better inform nursing and midwifery students of the skills, knowledge and context required in working with those who have experienced trauma directly or indirectly as a result of the Northern Ireland conflict. As co-educators, WAVE delivered a core lecture (augmented by online material), which was then followed by tutorials with nursing and midwifery students. The tutorials were substantially led by those who had been involved with, and experienced loss and trauma as a result of the conflict (Health Service users) and provided an opportunity to share their experience and their recollection of personal interactions with medical and nursing professionals. This approach is relatively unique in that it involves many of those directly involved and injured by “The Troubles” as “citizen trainers” and clearly reflects the School’s policy of progressively engaging with users and careers of health services as co-educators to students. The potential benefits of such a co-educative approach is reflected in other studies [17] The Health Foundation [18]. Delivery of this teaching by WAVE forms part of the final phase of first year teaching in the Health and Wellbeing module. This module addresses the context of health; the anatomy and physiology of the body and human health (Life Sciences) but also the psychological, social, health education and public health dimensions of nursing and midwifery and the context of care. A paper which evaluated the Wave teaching initiative from the students’ perspective found the students rated the teaching extremely highly [12]  however there was a plethora of anecdotal evidence reported by the citizen trainers themselves that they enjoyed and reaped benefit from engaging with the students during this initiative. The aim of this research was to capture these benefits and potential costs to the citizen trainers when engaging in the teaching initiative.

Taking saline solutions and hydration

Studies carried out in the late 1970s show that drinking a liter of balanced saline solution can lead to an increase in plasma volume of up to 400 ml for a period of at least 4 hours. The extracellular fluid is mainly made up of 0.9% NaCl (sodium chloride) dissolved in water or a normal saline solution. If an individual is given a normal saline solution intramuscularly or by ingestion (as in the case of astronauts) the volume is distributed mainly through the extracellular compartments. Since the volume of the plasma constitutes a small part of the extracellular fluid, it retains a small part of the saline solution. The rest goes to fill the interstitial spaces of the tissues. Possibly a part of the fluid can enter the cells and a part can escape. Studies conducted in the mid-1980s found that this time-increasing plasma volume technique could be used by Shuttle astronauts to reduce orthostatic intolerance before landing.

Anti-Ag suits

Although all possible countermeasures are adopted in orbit to have good vascular conditioning upon returning to earth, inevitably, orthostatic intolerance, even if in a reduced form, always occurs. In the critical period of return and landing, the astronauts of the Shuttle (and of any other space aircraft) must wear anti-G suits. In fact, some more fragile parts of the body, for example the neck joints, can be affected by the stresses deriving from the high acceleration values, and also some internal organs such as the abdominal ones, can undergo displacements, because they are poorly supported anatomically. More than the value of the accelerations, their duration is important. In modern military supersonic aircraft the pilot can in fact be subjected to accelerations of up to 20 g, but this happens only for fractions of a second, as when ejected from the seat with a parachute. These particular garments automatically inflate as the acceleration undergone by the astronaut increases to prevent the stagnation of fluids in the lower extremities of the body and can also, through an abdominal bladder, help maintain adequate venous return to the heart. With this suit, therefore, the pilot's or astronaut's body is compressed in the intestines, thighs and legs, preventing blood from accumulating in the lower extremities of the body.

To explore the potential costs and benefits to service users (citizen trainers) disabled by civil conflict of engaging in a coordinated teaching and learning initiative with nursing and midwifery students.

Objectives

• To investigate why these individuals, participate as citizen trainers
• To investigate and evaluate their experiences during the process
• To investigate the impact of their participation on them as individuals.

The researchers will undertake qualitative methods of evaluation. After in-depth consideration and given the sensitive nature of their experiences it was decided a combination of semi-structured interviews and focus groups would be most methodologically sound technique to answer the research questions and to provide a more crystallised approach in depth of evaluation [19]. Those who participated were offered the choice of a one to one interview with a researcher or to be part of a focus group. Both formats used open ended questions and carefully used prompts to provide detailed and descriptive responses from the participants [20]. However, these questions were based in pre prepared and planned discussion themes to help keep to time limitations and to ensure the discussions stayed broadly on tract. The focus groups and interviews took place immediately after teaching for convenience and to allow the citizen trainers thoughts about teaching to be fresh and in a location away from the teaching rooms to provide a neutral and comfortable environment.

All participants involved in interviews will be recruited by purposeful sampling. The Wave Trauma Centre supports and trains Citizen Trainers who have provided face to face teaching in the undergraduate nursing and midwifery programme. All those involved with the programme were invited to participate via email and written letter explaining the purpose and requirements of the research, and were offered to either be part of a focus group or engage in a one to one interview. A total of 17 agreed to participate with most choosing to join a focus group and two individuals opting for one to one interview.

Ethical consent was sought and approved within the university context and all those who took part were fully informed and consented with the opportunity to withdraw at any stage assured. All ethical considerations were addressed including confidentiality, data security and anonymity were strictly upheld. Measures were put in place to provide support for both students and citizen trainers in the event of stress arising after engaging in the activities. Researchers engaged in reflexivity at all stages of the process and were mindful that participants on one hand would feel comfortable with researchers who are familiar to them. However, as the principle researcher is also the coordinator of the teaching programme it was felt their involvement in the focus group or interviews may lead to the participants feeling obliged to speak positively about the experience and so did not take part.

All interviews were taped recorded and transcribed verbatim. Audio recordings and full transcripts were stored in a safe and confidential environment and are available for independent inspection. Data was recorded, transcribed and analyzed using a coding thematic content analysis framework [21], with patterns of views, meanings and feelings discussed by the interviewees and organized in a way that provided meaning to the text using phenomenological thematic content analysis [22, 23]. At each stage the data was interrogated by other colleagues involved in the initiative but not with the data collection to assess accuracy and promote interrater reliability and rigor [24].

Aim 1: Why do citizen trainers participate in the partnership? With regards to why citizen trainers participate in teaching two key themes emerged: to educate students about their existence as victims and survivors and to provide information about how to best help them and others. Each session started by simply asking why these individuals decided to participate as citizen trainers and what was their role. In every discussion the desire to help educate a new generation and give information in a meaningful way was strongly expressed [25]. Citizen trainers all felt that they could better explain the impact of their trauma and the impact it had and significantly still has on their lives if they could personally tell their story and discuss with students directly rather than students learning from books or didactic teaching. This certainly seems to be a correct assumption as in previous work students had reported how meeting actual victims and survivors made a significant personal impact and made their plight very real [26]. When asked why this was important to the citizen trainers responses revealed a deeply held conviction that the legacy of the troubles still exists in Northern Ireland and shouldn’t be forgotten. “Doing this validates my story, I’m still here still struggling”, “a just want recognition from society that I’m a victim too, it didn’t happen to me but I’m still a victim”. Some individuals expressed a desire to educate a new generation that victims and survivors still exist and that they need special consideration in health care more than ever. One citizen trainer commented “I don’t want extra care or attention I just want the new nurses to understand why I am the way I am”, another said “to raise awareness, yes the country may be at peace now and these youngsters won’t know about all that went on but we still exist, we still live with it every day”. A large number of bereaved and injured individuals are now in advancing years needing more and more health care interventions. One commented “while my injury was done in the past my disability is still very much in my present”, “yeah me too, I was ok for years just got on with it but now I’m getting older I’m finding it harder to cope on my own’, “I had to have more surgery recently and the staff hadn’t a clue how to talk to me about how I was injured, they wouldn’t have been so uncomfortable if it was a car crash or something” [27]. The discussion then moved to a desire to not only highlight their own particular trauma but to educate the students about how the troubles are still impacting many others, “there’s a ripple effect throughout families and communities”, “alcohol, drugs, post-traumatic stress syndrome are seen in young folk caused by trauma caused by the violence which are only coming up in folk now!”, “there’s trans generational trauma, children being impacted by their parents experiences who new nurses need to know about and understand”. All participants in this particular discussion then agreed that an important aspect of their role is to highlight the need for signposting by nurses “it was only in the hospital that a nurse realized I was still distressed; it was her that suggested I got help”. “I hope the new nurses after hearing about me will pick up any others out there that haven’t got help and know what to do, it upsets me to think they’re suffering alone”, “correct, if it helps just one person in the future then the whole thing was worth it wasn’t it?. Another very understandable theme for participating was to keep memories alive. One bereaved citizen trainer said “by doing this I feel he’s still doing good, its keeping him alive’, “yeah I know what you mean, I feel good knowing my dad isn’t forgotten completely and he’d be proud I was doing something positive instead of being taken over with bitterness”. One group summarized their belief that their role was to “educate and raise awareness, it’s not to scare or traumatize them (the students)”, “the health service is being left to deal with the legacy of the past but the younger generation of its workers have no idea why its occurring. Hopefully after meeting them they understand why, and why it’s important they know!”. [28]. The interviewer than asked all groups was it important that it was student nurses they were engaging with and both groups seems to think this was significant “oh yes, I’m so grateful to the nurses so it’s nice to give back”, “doctors might fix you up in surgery or give you pills or whatever but its nurses who fix you up mentally or should I say notice when you’re not doing well mentally”. “you take it for granted that nurses will be sympathetic and want to help but unless they know and understand what went on how can they?”, “everything we’re talking about here, being able to talk to us, picking up others who need help, getting us help that’s like a nurse’s job isn’t it?”.

Aim 2: Citizen Trainer’s evaluation and experience of teaching. Emerging themes were that of its positive affect on the students and the belief that the initiative should be extended and developed both in nursing and other fields. With regards to their evaluation of the teaching and asking them to reflect on the process and how they evaluated the teaching participants overall thought it was positive. “ack they’re lovely, I wouldn’t say they enjoy it but they’re always so attentive and interested”, “you can tell it works because their questions at the end are good…I mean deep they get it!”, “I’ve had times when the next class is trying to get in and they’re still talking to me out the door and down the road”. One participant noted how deeply the engagement can affect students “one girl sat with her arms folded and looked out the window I though she didn’t care, then I saw tears in her eyes and realised actually she was moved more than anyone else in the room”. This again echo’s comments made by students in previous research when they reported that actually meeting and engaging with citizen trainers evoked deep understanding and learning as opposed to just hearing about it third hand. There were some suggestions for improvement “I never feel there’s enough time, we only scratch the surface”, “I would like another session later on in their time as students to see if they had come across anyone like me and if it made a difference”. Another negative experience that was reported was an incident when one trainer found a session uncomfortable when another citizen trainer used the tutorial as “a counselling session…. he went on and on, poor fella just wasn’t ready he shouldn’t have been allowed to come, he wasn’t there to help he was there to give off”. This highlighted the need to ensure citizen trainers are well prepared and have a good understanding of the purpose and boundaries of the sessions and to ensure they are mentally robust enough to deal with the situation. There was a belief with all groups that this type of training could and should be extended to other health care professionals and civil servants. There were several comments about General Practitioners, Physiotherapists, Police and social workers being unaware of their difficulties. “it’s a pity doctors and the like don’t do this true because my doctor has no insight whatsoever”, “I wish in fact this could be a conversation in the wider society, people who work with people need to know about the impact of trauma generally and why a person needs help or understanding”, “not just Northern Ireland, what about other communities and their traumas they’ll have all these problems too, their teachers should think about their students learning too”. When asked if they felt as if there was partnership between the staff, students and citizen trainer’s participants responded emphatically yes. “Oh yes, right from day one I felt valued and respected both by tutors and the students’, “I really appreciate how everyone listened and were really into it”. There was some discussion about the possibility of a new structure whereby students could read the citizen trainers background stories before coming to class thus leaving more time for questions and most agreed this would be good however all believed that it was the face to face interaction which had the impact and that couldn’t be replied.

Aim 3: Lastly the participants were asked to comment and discuss on the impact of engaging as citizen trainers had on them as individuals. Participants reported that the process did take its toll on them but overall it was a positive experience for them. One reported that the night before they found it difficult to sleep as they were nervous, while another said they were physically sick with nerves the first time but that it got easier with time. A number revealed that the process was physically and mentally exhausting and spoke of how listening to fellow trainer’s stories was emotional [29]. Many reported that reliving their experiences reopened wounds time and time again which was difficult for them and all agreed that it can be an emotional and distressing process some times more than others, “it can be draining I’m exhausted afterwards”, “my wife says I’m quiet and brood after, I didn’t realise but I suppose I do its raw again”. A common theme was how the citizen trainers had developed coping mechanisms, such as seeking family support, debriefing with colleagues after teaching on the way home, going for a long walk to “wind down” while another did admit to drinking alcohol after to numb the feelings it had evoked. One said “speaking for them (their deceased loved one) gives me the strength to do it”. Another theme was the worry of the responsibility of teaching. “I didn’t want to come across as self-righteous”, “we weren’t there to scare them but I've to get the point across, I worry sometimes I haven’t gone far enough then other times too far”, “it’s a big responsibility, I’m representing him (loved one) myself all of us (those affected by the troubles…. I worry I’m doing it ok”, “yeah I think that you can’t be too graphic but you have to tell the truth that’s the whole point of this isn’t it?”. [30]. It would seem then that there is a significant cost to citizen trainers to participate in teaching which must be anticipated and arrangements made to allow for de-briefing after each session. However, it was apparent from all the interviews that overall citizen trainers despite this emotional cost believed there were positive outcomes from teaching with many reporting feelings of a need to do something positive. One reported “I’m glad to help, it gives the dead a voice”, another reported “the acknowledgement of my trauma helps me personally, I feel as if I’m validated”, “it helps me personally every time, it works both ways what I give I get back and more”, “it’s done me more good than counselling, yeah really worthwhile”, “I feel I’m keeping their memory alive that feels nice I’m proud of that”. One citizen trainer became emotional when he spoke of his personal growth and development, “I was floating, drifting, this is brilliant WAVE reduces my isolation and I found my voice, when they said about going to Uni I though me? It’s the best thing ever happened to me I’m more confident now yeah I’m great thanks”.

If nurses and midwives are to adequately respond to the existing and future needs of victims/survivors of the conflict in Northern Ireland it is essential that they gain cultural competence by addressing issues of sectarianism within their training context [31]. From the volunteer’s point of view, there is clearly a benefit in having nursing professionals with a knowledge and understanding of the effect of the conflict on health in a broad context of different communities in Northern Ireland.  Benefits are also evident in terms of appreciating the impact on the health of individuals who are victims and survivors of the violence of this past. However, when embarking on such an initiative with users and carers, citizen trainers etc. one must be mindful that although it would seem the process does have benefits for those involved there is a significant cost in terms of stress at the time and an emotional cost to them personally [32]. All of those involved must be respectful, ensure there is robust preparations and anticipate for potential negative emotions and ensure they are addressed adequately.

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