Lessons From Literature: Caring, Interpretation, and Dialogue

Student nurses in dialogues with hypothetical patients regarding paintings

As early as the work by Lichtwark (1902) arts were used as a pedagogical tool. His aim was to teach children to `see' through careful observations of works of art. The pedagogy employed in health care education must continually be questioned and expanded. Student nurses must be prepared for nursing practice that continually changes, meaning that alternative concepts in nurse education must be considered. Thus, visual art dialogues in student nurses' education could be a valuable teaching/learning complement to theoretical knowledge. The aim of this study is to investigate the ways in which student nurses intended to conduct a dialogue with a patient using a painting as a starting point. The study was conducted in the students' second year at a university college of health sciences in Sweden. In all, 50 students (47 female and three male) participated. The students had previously received a short introduction to art perception of some of the museums' paintings by the curator. This included observation and reflection on specific works of art. When they had studied several works of art at the museum they were asked to select one work of art from a series of 12 paintings that they thought might be used as a conversation tool with patients. The selection of these paintings was performed on basis of methods in psychological and art scientific research into aesthetic reactions to and perception of art tendencies. Analysis of the students' comments on how the dialogue with the patient would develop revealed comments of five qualitatively different types: activating memories, presenting knowledge, existential aspects/meaning of life, emotional reactions and concrete aspects.

‘The Demolition of a Man’: Lessons From holocaust literature for the teaching of nursing ethics

The events of the Holocaust of European Jews (and others) by the Nazi state between 1939 and 1945 deserve to be remembered and studied by the nursing profession. By approaching literary texts written by Holocaust ‘survivors’ from an interpersonal dimension, a reading of such works can develop an ‘ethic of responsibility’. By focusing on such themes as rationality, duty, witness and the virtues, potential lessons for nurses working with people in a variety of settings can be drawn. Implications for the teaching of nursing ethics are made in the areas of the virtues, relationships, professional ethics and the moral community of nursing.

Restoring the Patient's Voice

Reflective and insightful autobiographical accounts of illness not only illuminate fundamental disruptions in selfhood and continuity of life that accompany illness, but authors of such accounts also maintain that narration is an important way to make sense of an illness episode, to restore personhood and connectedness, and to reclaim the illness experience from the medical metanarrative. That witnessing and helping to order illness narratives can be a caring/healing nursing practice modality with significant healing potential is supported both by narrative theory and by nursing's theoretical and philosophical legacy. The challenge for the nurse guided by narrative ideas is to give primacy to the patient's voice, to listen for meaning rather than for facts, and to provide a relationship enabling the evolution of the patient's story.

Using Poetry Writing and Sharing to Promote Student Empathy and Caring

A poetry writing activity revealed both empathy and caring among nursing students. Using course readings to identify a topic, students created and shared their poems in an online format. The poems and students' reactions concur with existing literature that poetry writing and sharing reveals empathy and caring. Suggestions for using a poetry writing activity in nursing education are included.

Reading Ella: Using Literary Patients to Enhance Nursing Students’ Reflective Thinking in the Classroom

This action research study was designed to explore, in-depth, how 70 senior nursing students experienced an assignment that involved reading and reflecting on a short story, Ella, and the educator’s experience during the process. Four sources of data were collected: student reflections, field notes, a classroom process recording by an expert educator/observer, and a focus group interview. Four themes emerged: (1) student reflections revealed their inner, often hidden landscapes; (2) Ella prompted clarification of the past and/or triggered future projective thinking; (3) Ella clarified difficult-to-teach concepts; and (4) the interface between students’ thoughts and teacher responses provided a platform of connectivity. I propose that reading well-written stories may enhance students’ clinical reasoning skills and ethical comportment within the confines of a classroom. In addition, when students are introduced to literary patients like Ella, they can dwell with the characters at a more peaceful pace which, in itself, may encourage reflectivity.

School nurse book clubs: an innovative strategy for lifelong learning

Recognizing the ongoing need for continuing education for school nurses, the authors discuss the use of school nurse book clubs as an innovative lifelong-learning strategy. Current research supports the use of literature in nursing education. This article discusses the benefits of book club participation for school nurses and includes suggested fiction and nonfiction books that can be used to enhance nursing knowledge and practice. Through reading and discussion, school nurses can increase their knowledge of nursing history and current health care issues, thus becoming better prepared to address challenging issues that arise in practice. In addition, the use of literature as a learning strategy allows school nurses to broaden their understanding of unique cultural factors that influence the health beliefs and practices of students and their families. Book club participation can also assist school nurses in honing leadership and communication skills and becoming energized to become better advocates for children and families.

Storytelling as an educational strategy for midwifery students

This article describes the use of purposive storytelling as a creative teaching strategy in the nurse-midwifery education program at San Diego State University and the University of California, San Diego. Student evaluations over a 4-year period showed overwhelming support for the inclusion of storytelling into a weekly didactic midwifery course. Benefits, such as increased cognitive learning, enhanced role transition, and emotional clarification were identified in the students' comments. The students' comments further supported the efficacy of incorporating storytelling into midwifery education. A review of the literature confirms the growing popularity of storytelling in both health care and education, and a conceptual framework is also provided. Further research is needed to examine the benefits of this worthwhile technique in promoting learning, stimulating interest, and facilitating the development of critical thinking.

Culture and ageing: reflections on the arts and nursing

AIM; In this paper, we focus on ageing as an area in which nursing, society and the humanities can be profitably conjoined. We illustrate our argument with three case studies of ageing: in painting, opera and ballet.

BACKGROUND

There has been a recent spectacular increase in papers devoted to the relatively new field of the medical humanities. We argue for a similar renaissance in thinking about the connections between the arts and nursing.

DISCUSSION

First, we consider the paintings of J.M.W. Turner (1775-1851) as examples of loss, ageing and death. Second, we draw upon Leos Janácek's opera 'The Makropulos Case' (1926) as a focus for debate about human mortality. Third, we review some ethnographic research on the balletic body as an example of cultures of youthful ageing.

CONCLUSION

A focus on the embodiment of vulnerability is a productive catalyst for research on the intimate connections between self and society, biology and culture, and reason and emotion. Such a research agenda would be the hallmark of a holistic approach to the arts and nursing.

Using the arts and humanities to support learning about loss, suffering and death

In this article, the benefits of using the arts and humanities as teaching and learning strategies are explored. Their contribution to undergraduate nursing curricula, as a means of promoting a deeper understanding of the experiences of loss, suffering and death, cannot be undervalued. They need to be present equally alongside the physical and social sciences in nursing curricula. More than ever, is the need for all undergraduate nursing students to participate in self-reflection of these experiences, in order that they may meet the needs of their patients and families adequately, in a range of healthcare settings.

This new house: Building knowledge through online learning

The purpose of this study was to understand from baccalaureate-degree nursing students the experience of virtual learning in nursing and to understand how online education enhanced and detracted from learning. Three in-depth, focus-group interviews were conducted with a total of 27 baccalaureate nursing students. Hermeneutic phenomenology was employed to analyze the narrative data. Seven themes were identified from the data. The first theme was "making the framework": (1) providing flexibility; (2) enabling students through observing, guiding, and modeling; (3) faculty as facilitators; and (4) questioning as method. The second theme was "building incredible dialogue": (1) having great discussions, (2) sharing ideas/knowledge, and (3) not being inhibited. The third theme was "critical thinking--the 3-D effect": (1) sitting with the words, (2) using references/research, (3) seeing a variety of perspectives, (4) critiquing self and others, and (5) using selective language. The fourth theme was "personal and professional growth": (1) being connected, (2) feeling valued and respected, and (3) having intimate relationships. The fifth theme, representing the outcomes for online courses, was "more comprehensive learning": (1) deeper understanding and (2) better retention of knowledge. The sixth theme was "being overwhelmed", and the seventh theme was "being frustrated". As a result of this study, an understanding of the phenomenon of online learning was developed. The findings provide direction for future development of the pedagogy of distance learning.

Teaching Cultural Competence Using an Exemplar from Literary Journalism

Fadiman's work of literary journalism, The Spirit Catches You and You Fall Down, was used as a case study to teach transcultural and other nursing concepts to undergraduate nursing students. Campinha-Bacote's model of cultural competence was used to organize transcultural nursing concepts in the course. Before and after the course, students completed assessments consisting of two cultural attitude questionnaires and a paper describing a personal experience with adherence and failure to adhere by a Mexican American client. After reading Fadiman's book and completing several short writing assignments examining key course concepts, student scores on the questionnaires were mostly unchanged. However, students demonstrated growth in cultural awareness and skill in their "after" papers. Results suggest that valid, reliable tools are needed to detect changes in cultural competence. Qualitative data suggest that students can begin the process of becoming culturally competent through the creative use of literature in nursing education.

Instilling the value of reading literature through student-led book discussion groups

With the desire to instill the value of lifelong reading, nursing faculty and a librarian developed a student-led book discussion group as an innovative teaching strategy for a senior seminar course. Inclusion of the librarian was unique and influenced the shape and rigor of the assignment. In this assignment, students chose one of the faculty-selected books, researched its author(s), read relevant professional book reviews, and developed questions for their peer discussion groups. Student and faculty responses were positive and clearly demonstrated the benefits of this assignment for students' personal development and professional growth.

Storytelling as a Teaching Technique

For centuries storytelling has been used a powerful communication vehicle. It is also useful in nursing education to enhance self-esteem, develop critical thinking, model behaviors, and to teach cultural sensitivity and communication skills. The authors discuss the use of storytelling in the nursing literature and in a nursing course.

Literary Pedagogy in Nursing: A Theory-Based Perspective

Using fictional and autobiographical literature in nursing education is a primary way of understanding patients' lived experiences and fostering development of essential relational and reflective thinking skills. Application of literary theory to this pedagogic practice can expand conceptualization of teaching goals, inform specific teaching strategies, and potentially contribute to socially consequential educational outcomes. This article describes a theoretical schema that focuses on pedagogical goals in terms of the three related skills (i.e., reading, interpretation, criticism) of textual competence.

Advancing nursing scholarship through the interpretation of imaginative literature: ancestral connectedness and the survival of the sufferer

Imaginative literature has played an important role in nursing practice and education since the time of Florence Nightingale. Used primarily as an exemplar, however, its potential has not been realized fully by nurses. This article addresses the use of imaginative literature in scholarly inquiry. Often considered the aegis of literary critics and philosophers, the formal discipline of literary criticism enables the nurse to identify concepts and to generate theoretic explanations about human phenomena. The relationship between the ancestor and the survival of the sufferer is illustrated using Morrison's literary and cultural paradigm applied to selected novels. Implications for practice are identified.

Masterworks of art and chronic illness experiences in the elderly

AIM

This article presents findings of a qualitative study, conducted between 1997 and 2000, to investigate the plausibility of integrating masterworks of art with care of the chronically ill elderly, and to analyse perceptions about chronic illness among three groups: registered nurses, nursing students, and the elderly.

BACKGROUND AND SIGNIFICANCE

Statistically the incidence of chronic illness increases in the elderly. Although pathophysiology of chronic illness is increasingly understood, few studies explore the experience of living with chronicity from the perspective of the elderly. Understanding and intervening appropriately for the elderly with chronic illness may contribute significantly to improving quality of life for this growing population.

ETHICAL ISSUES AND APPROVAL

The study was approved through an Institutional Review Board. Facility permission and participant informed consent were obtained. Anonymity and confidentiality were protected.

DESIGN

Using hermeneutic phenomenology and masterworks of art as a centre point for dialogue, the investigators explored the perceptions of nurses, students, and the elderly about living with a chronic illness. A purposive sample of 65 participants made up seven focus groups with which group interviews were conducted. Themes were explicated and analysed from audiotaped interviews until data saturation was reached.

FINDINGS

Content analysis of focus group interviews revealed themes of social isolation, inevitable role change, and inertia-movement. Only the elderly acknowledged hope and a steadfast refusal to give up, while nurses and students viewed chronicity more negatively. Themes of social isolation and role change are consistent with other studies of the elderly. A paradox of inertia-movement in the chronically ill elderly has not been reported in the nursing literature.

CONCLUSIONS

Paradoxical tension of inertia-movement in the chronically ill elderly appears to be linked to the broader concept of energy in nursing science, and to Parse's theory of human becoming. Masterworks of art can generate energy exchange between the elderly and caregivers, providing a plausible catalyst for meaningful interventions that transcend age and practice settings.

Understanding mental health through reading selected literature sources: an evaluation

The increasing use of the humanities in nurse education provides an alternative means of facilitating students' understanding of health issues. In part, this contributes to a critique of rationalist-technological approaches to education where knowledge is reduced to abstract, discernable and measured units. A more communal approach to education recognises the place of interpretation as part of learning and, within this, the significance of dialogue, identity, tradition, attachment and partnership. The reading of works of literature is one way in which the reader interprets texts in a multiplicity of ways in order to more fully understand the 'real' world. Mental health offers particular opportunities for literary descriptions. The evaluation of a learning unit within a mental health nursing branch programme where students read a number of works of literature is outlined. Results indicate a variety of student responses to use of such an approach. The authors assert the usefulness of these approaches in encouraging deeper understanding of complex issues faced in mental health nursing practice. At the same time, however, careful consideration is given to the place of such approaches within the overall philosophy of a curriculum programme.

Northern Ireland--state of the arts? An evaluation of the use of the arts in teaching caring

In recent years, nursing literature has shown a growing interest in the use of the arts as a teaching medium in nurse education. This interest has been further fostered by the advent of the curriculum revolution, which has underlined the need for nurse educationalists to attempt more innovative teaching strategies in helping their students develop caring skills. However, little has been done to establish the extent to which this medium is actually being used by teachers. The authors report on a survey which was carried out across Northern Ireland to gather evidence on the use of this strategy from teachers of nursing, midwifery and health visiting.

Work of art dialogues: an educational technique by which students discover personal knowledge of empathy

The visual art programme was an approach used to facilitate students' discovery of personal knowledge of empathy. The research programme constituted the first phase of an existing theory course in empathy. It involved a visual-verbal-writing process in which a reproduction of Edvard Munch's The Sick Child was studied and interpreted with a focus on personal knowledge of empathy. Data were collected from two university colleges of health sciences in Sweden during a period of 4 years (1995-1998). Student nurses (n = 428) in the undergraduate programme served as the study population. In the first stage, the students worked alone on written reports. Then, in small-groups, they discussed whether the picture facilitated the discovery of a personal knowledge of empathy. The results showed that the visual art programme stimulated the students to discuss and write about empathy. The ambiguity in the painting and the relaxed study situation was favourable to the students' discovery of their personal knowledge of empathy.

Works of art: a complement to theoretical knowledge when teaching nursing care

Visual art dialogues were used in student nurses' education as a teaching and learning complement to theoretical knowledge of nursing care. An intervention group as well as a control group discussed what was characteristic of good nursing care. The control group was used to control for the effects of visual art dialogues in the intervention group. The study was undertaken at two university colleges of health sciences in Sweden. Data were collected from student nurses (n = 267) during their first year of study. The Wheel Questionnaire was used in the intervention group and control group. It measured three aspects of student nurses' perception of nursing situations: structure, the extent of emotional involvement, and motivation. The results showed statistical differences (one way ANOVA) between the intervention group in which visual art dialogues were implemented and the control group. Students in the intervention group, compared to the control group, were more structured, motivated and emotionally balanced when they expressed the elements most typical of good nursing care. They showed personal readiness in caring situations.

The political role of illness narratives

Cultural criticism is used to describe the political role of autobiographical illness narratives or pathographies. In expressing the subjective experience of illness, authors of pathographies illuminate ideological differences between patient and health care cultures, reveal the dominance of health care ideologies, and explicate patients' moral and political claims. The contributions of these literary works to nursing practice provide direction for relational restructuring. Gadow's concept of the relational narrative is proposed as a way to restore patient subjectivity and agency and establish the dialogue necessary for cultural pluralism in nursing and health care.

Data analysis method for evaluating dialogic learning

The purpose of this paper is to introduce a new method of analysing and evaluating dialogic learning. Dialogic learning offers possibilities that have not previously been found in nursing or nursing education, although some nursing researchers have lately become interested in dialogic nursing interaction between nurses and patients. The stages of analysis of dialogic learning have been illustrated by using an example. The data for this illustration were collected by video-taping a planning process where students for a Master's degree (qualifying them to be nursing instructors in Finland) plan, implement and evaluate a course for nursing students, on the care of terminally ill patients. However, it is possible to use this method of analysis for other dialogic learning situations both in nursing practice (for example, collaborative meetings between experts and patients) and in nursing education (for example, collaborative learning situations). The focus of this method of analysis concentrates on various situations where participants in interaction see the object of discussion from various points of view. This method of analysis helps the participants in the interaction to develop their interactional skills both through an awareness of their own views, and through understanding the other participants' various views in a particular nursing situation.

Integrating the creative arts into a midwifery curriculum: a teaching innovation report

The practice of midwifery has long been recognized as both art and science. However, educational programmes for midwifery are most often undertaken within an academic health sciences environment, and tend to be based on knowledge derived from the sciences (e.g. life sciences, biomedical sciences, behavioural sciences and social sciences). These scientific perspectives, while essential to the preparatory and on-going education of midwives, do not necessarily fully prepare midwives to fulfil their practice roles. This paper reports a teaching innovation aimed at facilitating student exploration of fundamental, complex and ethereal concepts which are essential to the effective and skillful practice of midwifery. Through the exploration of the arts and humanities, students were encouraged to engage with concepts such as 'caring', 'empathy', 'suffering', 'motherhood', 'pain', 'love', 'attachment', 'health' and 'illness'. Students were also encouraged to explore cultural and social symbols pertaining to parenthood and family life. Evaluation revealed that students valued the course, and that they gained insights which assisted them to develop understanding of key concepts. Implications for practice and education are drawn from this paper.

Seeking balance to dialectic tensions in teaching through philosophic inquiry

PURPOSE

To propose a plausible means of cultural criticism of nursing's educational environment for preparing new nurses by exploring epistemological tensions and their consequences from the perspective of educators.

DESIGN

Naturalistic, qualitative, philosophic.

METHOD

Six nurse educators teaching in a university-based traditional BSN program were interviewed in one southeastern state of the United States about their experience as creative, innovative teachers during 1991.

FINDINGS

Three major themes were reflections of the positivist work culture of teaching, reconciliation of tensions, and repercussions from personal choices. Educators reconcile dialectic tension by suppression, subordination, or equilibrium and are influenced by their sense of tension and willingness to be risk takers.

CONCLUSIONS

Philosophical conflicts are inherent in nursing when commitments to empirical knowledge and personal meaning are both valued. A plausible means for moving beyond this tension is to increase awareness of the dynamics and consequences that occur when perspectives seem contradictory. Schools of nursing socialize future nurses. Calling into question the context in which the professional nursing culture is transmitted and reproduced is necessary if nurses of the future are to be in the forefront of changing health care.

Balancing the curriculum: promoting aesthetic knowledge in nursing

The view of nursing as both art and science is widely held within the profession; however, this belief is not reflected in nurse education where the artistic aspects of nursing practice continue to be overshadowed by the emphasis on the scientific, the technical and the objective. It is suggested that nursing knowledge can be considered within four fundamental types or patterns of knowledge: empirical, aesthetic, personal and moral, each interrelated and interlinked, with aesthetic knowledge argued to encompass the art of nursing. Nursing's dual identity as an art and science arguably requires a balance within the curriculum, therefore the promotion and acquisition of aesthetic knowledge seems a desirable aim. The development of strategies specifically designed to develop and incorporate such knowledge across the curriculum and to make it explicit presents a challenge for all nurse educators. This paper will examine aesthetic knowledge as essential to the art of nursing, and will consider the application of literature as a method through which this knowledge may be attained. The use of literature is suggested as facilitating an awareness of human predicaments universal to all, thus enabling the nurse to develop qualities of caring, empathy and compassion, indicated to be components of nursing's art form.

The reflective clinician

As students struggle to determine what is important in their lives and to incorporate nursing into their existence, they are encouraged to share their thoughts and explore new insights in a nursing/humanities course, The Reflective Clinician. The authors describe the rationale for placing humanities in a nursing curriculum and describe strategies and content to be included in the course. Student narratives of their perceptions of the course are offered for illustration and to give examples of growth experienced by the participants.

Storytelling. An approach to client-centered care

Storytelling as a communication technique influences listeners in a powerful way. The rebirth of storytelling, an old art form, is evident in nursing education programs. This approach enhances the learner's sensitivity to the illness experience. Stories relating to clinical situations use examples that address chronic illnesses, humanity, death, dying, and advance directives. Well-chosen stories have the ability to motivate, inspire, teach, or enhance the human sensitivity skills needed by interdisciplinary healthcare providers.

The use of poetry to test nursing knowledge

The traditional testing process often is static and intimidating to students and encourages multiple guessing or rote recall of information. To avoid these problems and encourage student creativity and critical thinking, the author developed a test that solely uses poetry. In this article, she discusses the use of poetry to test nursing knowledge.

Reclaiming 'Big Nurse': a feminist critique of Ken Kesey's portrayal of Nurse Ratched in One Flew Over the Cuckoo's Nest

Nurse Ratched or 'Big Nurse' in Ken Kesey's counter-culture novel One Flew Over the Cuckoo's Nest is one of popular culture's most arresting and memorable images of the nurse. She is, however, deemed to be remarkable primarily for her malice and authoritarianism. This paper argues that such a purely realist reading fails to fully appreciate the significance of the character of Nurse Ratched. A feminist critique of the novel contends that the importance of 'Big Nurse' is less related to how realistic/unrealistic or good/bad she is as a nurse. Nurse Ratched is important because she exemplifies all that traditional masculinity abhors in women, and particularly in strong women in positions of power and influence. This paper explores the stereotype of 'Big Nurse' and argues that Kesey's vision of her ultimate 'conquest' is not a progressive allegory of 'individual freedom', but a reactionary misogyny which would deny women any function other than that of sexual trophy.