Texts are lazy machineries that ask someone to do part of their job.
- Umberto Eco (1979, p. 214)
The use of fictional and autobiographical literature has proliferated in nursing and medical education to teach understanding of the human experiences of health, illness, healing, death, and dying, and to teach competencies such as "the capacity to adopt others' perspectives, to follow the narrative thread to complex and chaotic stories, to tolerate ambiguity, and to recognize the multiple, often contradictory meaning of events" (Hunter, Charon, & Coulehan, 1995, p. 788). While this educational practice is prevalent, selecting teaching approaches is challenging because courses are process focused, rather than content focused; outcomes evaluation can be difficult; and guidelines for teaching strategies are elusive. However, "the best learning experiences and interpretive thinking around the reading of appropriate texts does not simply happen. Teachers, as active participants in this new learning, create the conditions and possibilities whereby nursing humanities can work" (Derbyshire, 1995, p. 214). This article describes literary pedagogy in nursing (defined as the use of fictional and autobiographical literature in nursing education), reviews literature regarding teaching strategies and educational outcomes, and demonstrates the use of literary theory as a base for teaching approaches.
Literary pedagogy was introduced to United States medical school curricula in 1972 (Charon et al., 1995) to help physicians develop skills in the human dimensions of medical practice. Its introduction into nursing education is more difficult to date. References to the use of literary works to teach nursing phenomena and therapeutics appear as early as the mid 1960s in anecdotal sources; recur throughout the following 2 decades (Bartol, 1986; delbrnyay, 1988; Donaldson, 1983; Germain, 1986; Siegel & Siegel, 1977; Wilson, 1974; Young-Mason, 1988a, 1988b); and emerge as a steady focus in the 1990s (Bartol & Richardson, 1998; Derbyshire, 1994, 1995; Giarratano, 1997; Robb & Murray, 1992; Smith, 1996; Stowe & Igo, 1996; Styles & Moccia, 1993; Winland-Brown, 1996; Younger, 1990; Young-Mason, 1997).
In nursing education, literary works are viewed as a rich source of knowledge (Bartol, 1986; Young-Mason, 1988a), and literary themes such as suffering, loss, and the search for meaning coincide with human experiences nurses witness daily. Derbyshire (1994) summarized three goals of literary pedagogy works in nursing as follows, "to come to a deeper appreciation of the complexity of human experience, human intersubjective responses to health, illness, disability and death. ..to develop participants' interpretive, critical and analytic abilities and to share these through mutual dialogue and critique. ..to create a community of learning" (p. 859).
For contemporary literary scholars, the primary goal of pedagogy is "something developed in the student by questioning the text rather than something transmitted from the text to the student" (Scholes, 1985, pp. 13-14). For literary scholars like Scholes (1985) and Callaghan and Dobyns (1996), this "something" is textual competence, with three interrelated skills- reading, interpretation, and criticism. This pedagogic goal relates to enabling students to change reading strategies from reading for information, key points, main ideas, or answers to taking authority for their own learning by reading reflectively, observing both their own reactions and the questions the work evokes, and by actively creating meaning.
Teaching strategies incorporating the use of fictional and autobiographical literature are addressed both in nursing and medical literature. At the most general level, consensus exists that exploration of associations and emotional responses elicited by a literary text is the critical pedagogical element. Literary pedagogy may be integrated into other courses or may be the focus of selective courses taught in small, ongoing groups. Classes can be organized by case, disease, or issues. The most frequently reported teaching approaches are common reading of fictional or autobiographical texts, oral presentations by students, and discussion. Brief lectures sometimes are employed, and written assignments often include journals, recording observations and reactions to texts, and brief critiques (Hunter et al., 1995).
Most nursing literature describes case examples of literary pedagogy. The few articles that address philosophicai or theoretical foundations for narrative pedagogy cite phénoménologie curriculum models, which emphasize the importance of experience and meaning (Derbyshire, 1995; Diekelmann, 1988, 1993; Nehls, 1995). Germain (1986) described use of a contemporary literary work to facilitate integration of aesthetic, personal, ethical, and empirical ways of knowing and specified a learning guide developed for this purpose. Styles and Moccia (1993) presented a literary anthology with the hope that it would "spark.. .infusing literature throughout the curriculum. ..to humanize and extend learning" (pp. 2-3). Giarratano (1997) detailed the use of short stories to supplement a traditional maternity nursing textbook; students were encouraged to compare literary portrayals with their own clinical experiences and "come to thenown opinions and understanding" (p. 130). Stowe and Igo (1996) offered criteria for selection of literary works and provided examples appropriate for specific nursing content, while Winland-Brown (1996) reported a study requiring students to read and write about the meaning of an autobiographical illness narrative. Smith (1996) delineated the use of poetry to teach health assessment and to encourage divergent thinking, as well as the critical thinking skills. Derbyshire (1995) described challenging "students' thinking and understanding of the lived experience of patients/clients in ways that more traditional scientific and behaviorist approaches to nursing education are unable to do" (p. 216) by structuring classes around literary readings. He stressed:
* Careful selection of readings and organization of content.
* Creation of conditions to maximize each participant's interpretation and contribution to discussion.
* Balancing textual study and interpretation with students' professional experiences and practices.
In the medical humanities literature, teaching approaches have been conceptualized as the ethical approach, focusing on moral reflection, and the aesthetic approach, emphasizing the literary skills of reading, writing, and interpretation (Jones, 1990). Coulehan (1995) suggested a third approach- the empathetic approach, focusing on students' ability to understand the experiences, feelings, and values of other people. While these approaches can overlap, each leads to distinctive seminars or courses.
The ethical approach, designed to encourage moral reflection, may include reading of texts selected to clarify particular ethical dilemmas, small-group discussion, role playing and other interactive techniques, and writing assignments. The aesthetic approach, emphasizing literary lessons (e.g., point of view, metaphorical structures, narrative stance, identification with characters), usually proceeds with close readings of chosen texts, enriched by discussions of the authors' biographies or of critical studies of the assigned works. Readers' responses to the texts are emphasized, capitalizing on the range of interpretations and linking interpretations with readers' own autobiographies and life experiences. The empathie approach is used to convey particular aspects of being a patient and emphasizes students' ability to understand the experiences, feelings, and values of other people.
Despite substantial literature regarding literary pedagogy in nursing and medical education and rich case examples of teaching, few articles refer to the use of literary theory in relation to teaching strategies. With the exception of Ayres and Poirier's (1996) description of reader-response theory in narrative analysis, explication of literary theory or literary criticism as a base for teaching approaches is notably lacking.
Regardless of the generally atheoretical approach to literary pedagogy, support for use of literary works in health professional education is evident in studies of educational outcomes. Using students' course evaluations, postcourse interviews and questionnaires, and faculty members' assessments, outcome studies have demonstrated that such courses improve students' understanding of patients' experiences, enrich their capacity for coping with ethical problems, or deepen their self-knowledge (Billings, Coles, Reiser, & Stoeckle, 1985; Caiman, Downie, Duthie, & Sweeney, 1988; Marshall & O'Keefe, 1994; Radwany & Adelson, 1987; Wilson & Blackwell, 1980). All studies assumed that literary knowledge alters methods of perception and understanding, with individual physicians attesting to skills accruing throughout a career of reading and writing and listening to their patients (Charon, 1993; Connelly, 1990; Coulehan, 1992; Quill & Frankel, 1994). However, these studies acknowledged that the ideal outcomes measure- the longitudinal effect of literary pedagogy on practice- merits further exploration (Hunter, 1995).
Learning outcomes claimed by nurse educators focus on relational capacities and on reflective thinking. For example. Younger (1990) asserted that literary works "may educate, support, and liberate the intuitive, connected knowledge of human responses," compassion, and understanding of our own stories (p. 42). Woodcock (1990) and Gadow (1990) cited sensitivity to complexity of character and situation, heightened awareness of self and others, ability to embrace contraries and ambiguities, and "seeing from the other's perspective'' as significant outcomes. Derbyshire (1994) found that a narrative course
stimulated participants to tell the narratives of their practice, developed their interpretive and critical understandings, highlighted ethical and professional concerns, illuminated numerous human lived experiences, taught us more about ourselves and our work, and generated new insights into previously taken-for-granted issues (p. 862).
In a later publication, Derbyshire (1995) stated that narratives not only promoted better understanding of patients'lived experiences but also challenged students to do closer and more sustained readings and made students aware of the "multiplicity of critical and interpretive approaches to understanding of the worlds of nursing, patients, clients, health, illness, disability, and the health care and sociopolitical systems within which they work" (p. 212). In addition, Winland-Brown (1996) cited empathy and caring outcomes and Giarratano (1997) found enriched abilities to identify ethical care, advocate for patients, and consider many possibilities for care.
On the assumption that interpretive reasoning closely parallels clinical reasoning, literary pedagogy also may contribute to clinical reasoning by developing skills in observation and interpretation, tolerance of uncertainties, formulation of responses to difficult situations, sensitivity to nuance, and ability to cope with complex situations (Hunter et al., 1995). For example, Lindesmith and McWieny (1994) and Sandelowski (1994) asserted that stories may expand diagnostic reasoning from a holistic perspective and enhance creativity and critical thinking. Further, by enabling understanding of a particular patient's illness experience and understanding of the patient as a person, narrative reasoning is claimed to help clinicians turn experience into practical knowledge and understanding (Benner, Tanner, & Chesla, 1996; Coles, 1989; Kleinman, 1988).
THEORETICAL PERSPECTIVES LN LTTERARy CRITICISM
While "nursing humanities in education should not become a pale substitute for English literature courses" and the purpose "is not to produce aesthetes or critics, but enhance nurses' professional thinking and practice by offering alternative approaches to reading, seeing, thinking, interpreting, and understanding" (Derbyshire, 1995, p. 214), consideration of literary theory can expand conceptual frameworks and practices used in teaching with fictional and autobiographical works and can extend the range of learning outcomes.
The insights of several eras of literary theory can be applied to literary pedagogy in nursing. One of the first major schools of literary criticism, formalism, assumed the content of a literary work is related to its form (i.e., what a work of literature is about- its content- is related to how it is constructed- its form) (Ryan, 1999). This critical approach focused on the internal organization of and the inherent meaning in the formal features of a text, such as narration, plot construction, imagery, and language in fiction, or use of rhyme, rhythm, and alliteration in poetry. Formalists transformed literary scholarship from an impressionistic approach to an analytic approach, focusing on how literary structure and dynamics operate together to create a unified artistic composition. Some critics maintain that the "close reading" strategy employed by the formalist approach is a necessary first step in any study of literature. That is, before a literary work can be studied from other perspectives, it first must be read analytically to encourage awareness of the unfolding of meaning through use of literary techniques.
Structuralism derived from formalism in the middle of the 20th century and analyzed literature on the model of modern linguistic theory. The structuralist approach emphasized order, structure, and rules and sought to describe the invariant structures of literature. It assumed the source of meaning in a literary work was neither the writer's nor the reader's experience but emanated from sets of relations governing language (e.g., oppositions, sequences of functions, syntactical rules). Structuralist critics focused attention on literary systematicity, or "how texts operate logically or systematically, what mechanisms produce meaning, what structures texts possess in themselves and in common with other texts, and how texts are made up of parts in relation to each other" (Ryan, 1999, p. 27). Like formalism, this approach was necessarily static and ahistorical in its attempt to introduce rigor and objectivity into literary theory and develop a science of literature (Seiden & Widdowson, 1993).
In the 1970s, structuralism was displaced by poststructuralism, a subset of the broader postmodernism. While formalism and structuralism emphasized order, structure, and rules, poststructurausm denied that any literary work possesses formal features or specific and preexisting meanings. Rather, it emphasized the ways language, psychology, and social life undermine the stable orders of meaning, identity, and truth structuralism sought to establish (Abrams, 1993). Poststructuraliste argued that meaning is elusive because unconscious, or linguistic or historical forces always are operating and cannot be mastered. According to Seiden and Widdowson (1993), "They set the text to work against itself and refuse to force it to mean one thing only" (p. 168). These changes in literary criticism led from the description of invariant structures of literature to concern with the "contingencies of identity, the undecidability of meaning, and the indeterminacy of the world" (Ryan, 1999, p. 67).
A fourth salient perspective, reader-response theory, is a form of poststructurausm. The decentering of the author or linguistics as the sole source of meaning in poststructuralism left the reader as the focal figure in literary theory. Reader-response theory is informed by many critical theories, but all aim to describe the reader's experience of a work or the reader's consciousness as produced by reading the work. Its fundamental tenet is that a literary work is converted into an activity on the part of the reader (i.e., texts have no properties of their own; they come into full being only when someone reads the words on the page and interprets the text). As Rosenblatt (1995), one of the founders of reader-response criticism, stated:
The reader, drawing on post linguistic and life experience, links the signs on the page with certain words, certain images of things, people, actions, scenes. The special meanings and., .the submerged associations that these words and images have for the individual reader will largely determine what the work communicates to him. The reader brings to the work personality traits, memories of past events, present needs, and preoccupations, a particular mood of the moment, and a particular physical condition. These and many other elements in a never-to-beduplicated combination determine his interfusion with the peculiar contribution of the text (p. 30).
In this way, readers "create" or "produce" the literary text as a response to their individual psychological and social backgrounds and, therefore, must become aware of their primary psychological responses to a text. Readerresponse criticism does not attempt to define what a literary work means but attempts to describe the effect of a literary work on an informed reader.
Scholes (1985), a scholar of semiotics, or the general science of signs as they function in human experience, maintained that the most recent literary theories have much to offer education. For Scholes, textual power (i.e., how a text has the power to select and to suppress, or to shape and present certain aspects of human experience) is the ultimate subject of pedagogy. Therefore, the goal of pedagogy is textual competence "to help our students unlock textual power and turn it to their own uses. We must help our students iato their own powers of textualization. We must help them to see that every poem, play and story is a text related to others" (Scholes, 1985, p. 20). To accomplish this, reading must be perceived "not simply as consumption but as a productive activity, the making of meaning, in which one is guided by the text one reads.. .but is not simply manipulated by it" (Scholes, 1985, p. 8). Therefore, teaching strategies must focus on ways for students to perform the productive activity of making meaning (i.e., to produce oral and written texts themselves).
These strategies can be conceptualized in terms of three related aspects of textual competence:
While each skill is incomplete by itself, and all skills merge, they are sufficiently distinguishable to be addressed separately. Engendering "new textualities" (Scholes, 1985, p. 24), the making of new texts by students, plays a central role in teaching approaches related to each skill, each of which can be defined by the textual activity it engenders. Reading produces "text with text"; interpretation produces "text upon text"; and criticism produces "test against text" (Scholes, 1985, p. 24).
According to Scholes (1985), reading is the primary activity. Reading and thinking with stories means joining with them, submitting to the text, reading for pleasure, and allowing our thoughts to adopt the story's logic and to imagine one's way into the story and grasp the personal meaning of narrated experiences (Callaghan & Dobyns, 1996). Younger (1990) described this process eloquently, addressing illness narratives:
A story calls forth the ability to identify with a character and vicariously experience illness. This vicarious experience may bridge gaps in the personal experience of the nurse.-.a story enables readers to participate in experiences in small doses of personal involvement, to become acquainted with suffering that is outside of their personal experience (p. 39).
While reading is largely an unconscious skill, it is based on knowledge of codes in a given text and its historical context. Ideally, readers share the author's codes and can process the text efficiently, filling in gaps without difficulty.
Interpretation is activated by the reader's experience of incompleteness, inconsistency, or incoherence. The gap between the reader and a literary work can be temporal (i.e., a different time), linguistic (i.e., different language conventions), or cultural (i.e., different customs, expectations, beliefs, and values) (Callaghan & Dobyns, 1996). Major goals of interpretation are becoming aware of assumptions readers use to fill in the gaps and reflecting on questions raised by the work, such as "What does that mean? How does that connect? Why does that seem important? So what?" (Callaghan & Dobyns, 1996, pp. 2627). In the process of reflection, the reader engages in abstraction, generalization, and thematization, moving from the level of specific events narrated to a more general level of social types and ethical values and to consideration of the meaning of a work.
Developing Textual Competence
Criticism is not rejection of ideas and values proposed by a text but involves questioning the values and themes developed in the text. It is founded on differentiation of the subjectivity of the critic from that of the author, which is an assertion of another textual power ageinst that of the primary text (Scholes, 1985, p. 40). Scholes (1985) asserted that criticism is not a matter of personal preference but of collective judgment. Readers are part of interpretive communities and, as critics, speak for these communities on issues of importance, invoking world views with social consequences. Therefore, criticism is ideologically based. It reflects carefully inculcated norms established by social groups and resistance of the text as critics recognize their own values.
THEORY-BASED TEACHING STRATEGHiS
Teaching toward development of textual competence addresses each of these skills and employs approaches derived from literary theories. The Table juxtaposes Scholes' (1986) three skills of textual competence with teaching goals and strategies related to each. Based on the fundamental assumption that the responsibility of educators is to develop ways for students to exercise judgment and create meaning by producing oral and written texts themselves, each teaching strategy is focused on creating a text.
For reading competence, Scholes (1985) suggested asking students to construct a scene from a text, including how they would summarize the story, rewrite the story from the point of view of another cherecter, retell it, or expend it. For example, for reading literary accounts of illness, nursing students may be asked to respond to questions such as, "What was this person's illness experience like?" and "How would the patient's family or nurse retell this story?" In essence, students produce a "text within text," (Scholes, 1985, p. 28), reflecting the world they have constructed by their reading. The text produced by students is "within" the text insofar as it accepts the original story.
The early stages of interpretation ere reflected in the beginning differentiation of the subjectivity of the reader from that of the author, and reader-response theory is helpful in this transition. Questions that encourage differentiation of the reader's and author's subjectivities and serve to surface the reader's own expectations and values include:
* What was your reaction to the work?
* How do you think your experiences and expectations affect these reactions?
* What is the work's intended authence, and how are you similar to or different from that authence?
Facilitating awareness of one's own reactions to a literary work is an essential aspect of the teaching process. However, Rosenblatt (1996) cautioned that recognition of one's own responses is a necessary, but not sufficient, condition to ensure literary insight, critical judgment, and ethical and social understanding. Self-awareness reflects engagement, some reflection, and establishes conditions for enlargement of responses. The function of the educator must surpass selecting appropriate works and listening to spontaneous comments in order to lead students to textual competence, which entails moving beyond initial reactions to discoveries about one's self, the literature, culture, and intellectual freedom.
In facilitating interpretation, Scholes (1985) maintained that educetors cen use formelist and structuralist theories and techniques, such as searching for repetitions and oppositions in the obvious text and asking about their meaning and symbolism. Questions helpful in applying formalist and structuralist techniques include (Callaghan & Dobyns, 1996, pp. 26-27):
* What relates to what (e.g., social setting and a character's actions)? What does that mean? Why does that seem important?
* What changes throughout the text (e.g., style, ideas, attitudes of characters)?
* What is the significance or value of the work as it contributes to your understanding of yourself and your world?
Because in interpretation readers move beyond the particulars of the verbal text to generalized themes and values, interpretation is dependent on cultural knowledge. Scholes (1985) asserted that to teach interpretation, educators must be prepared to teach the cultural text as well. For example, students reading fictional or autobiographical illness narratives may be asked to consider questions such as:
* What does the work tell us about what it is like to be ill? To suffer? To heal? To be cared about?
* What does the work communicate about illness as an ontological assault? About embodiment? About construction of meaning? About relationships?
In the process of interpretation, "text upon text" is produced. (Scholes, 1985, p. 31).
Teaching to the goal of criticism is grounded in helping students identify their own communities and speak for them on matters of importance to that group. To accomplish this goal, students can be assigned critical essays, writing a parody or any "countertext" (e.g., rewriting a selected portion of an illness narrative), essentially producing "text against text" (Scholes, 1985, p. 35). For example, in nursing, criticism derives from the professional discipline's value base, its theoretical heritage, and its practice wisdom. It is from this community base, formed by professional socialization, nursing's world views, and the social, political, and cultural stances of the profession, that the process of criticism occurs. In turn, this criticism has the potential to create shared knowledge and meanings that can inform professional nursing practice. Questions that may be helpful in learning criticism include:
* What does the work say about the concerns or roles of nurses?
* What questions or concerns of the nursing profession are being examined in this work?
* In what ways does the work challenge or affirm traditional assumptions about the role of nursing in society?
* What other works seem to address these concerns? How are they alike or different?
Because the ability to criticize is a function of critical maturity "earned by study and thought" (Scholes, 1985, p. 38), Scholes cautioned that students will not find criticism easy but that it can be facilitated by showing critics in action and encouraging students to produce their own critical texts based on recognition of their own values.
In progressing through the stages of reading, interpretation, and criticism, one moves from submission to textual authority in reading, through a sharing of textual power through interpretation, toward an assertion of another textual power against that of the primary text.
The importance of literary pedagogy in nursing education is that it may enhance development of reflective thinking and relational capacities, which are essential aspects of nursing practice. In particular, the textual competencies inherent in reading and beginning interpretation encourage development of relational skills, such as how to listen more fully, comprehend and empathize with the illness experience, establish caring relationships, and develop self-awareness.
However, to achieve the reflective thinking that is an integral part of professional practice, reflexivity and critique are essential, and the textual competencies of reading and beginning interpretation may not be adequate. As Scholes (1985) stated, if we simply engage intersubjectively with a text, "our reading will not be sufficiently other for us to interpret it and criticize it" (p. 39). Differentiating the reader's subjectivity from that of the author is a critical step toward textual competence and intellectual independence. Reflective thinking requires the ability to adopt new perspectives and critical and innovative thinking, encompassing the consideration of context in understanding phenomena and events; the ability to find meaningful connections among events and phenomena; the ability to organize knowledge; and selfreflexiveness (i.e., self-critique). Textual competencies inherent in interpretation and criticism foster such skills. They are facilitated by participation in communities of learners who share observations, question their own and each other's assertions, and search for common understandings, and by theoretically-based teaching approaches that invite learners to extend their reflections, interpretations, and critical questioning in ways that lead to discovery and new knowledge.
The full spectrum of textual competencies is necessary for the development of desired educational outcomes in nursing. The literary theory embedded in Scholes's (1985) schema offers a broad and theoretically coherent foundation for pedagogic practices, enabling nursing students to actualize their own powers of textualization.
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Developing Textual Competence