Contemporary practices in nursing education call for reform that actively engages both teachers and students. Advances in science and technology have changed the way health care is practiced. Previously, faculty could teach content and feel confident that students who learned it would be able to provide competent nursing care. However, cognitive gain and skill acquisition, although necessary, are no longer sufficient to prepare students for current practice. They need to be able to think quickly, make connections, identify patterns and relationships, and continually question and seek understanding (Young, Hayden-Miles, & Brown, 2009).
Nurse educators need to teach students to learn ways to understand their increasingly complex world. Gadamer (1900/2003) posited that hermeneutics is a dialogic and practical activity that allows for understanding to occur through interpretation. Hermeneutics is a philosophical position and an approach to inquiry that provides teachers, students, and researchers with a means to understand others in their everyday lives.
This article presents how Gadamer’s (1900/2003) hermeneutic circle of understanding and Heidegger’s (1927/1962) interpretive phenomenology can be applied to nursing education through interpretation of the visual arts. Narrative pedagogy is discussed as an approach to teaching that helps students to critically think and understand through interpretation and dialogical exchanges (Diekelmann & Diekelmann, 2009).
The Hermeneutic Circle
Individuals view their world differently depending on their age, cultural background, life experiences, and interests. Heidegger (1927/1962) suggested that everyone comes to interpret and understand a phenomenon through an a priori understanding that is believed to arise from one’s everyday involvement in the world. Gadamer (1900/2003) contended that our background, or “horizon,” takes the form of prejudice or pre-understanding that is not a barrier, but rather an opening for new understanding. Gadamer (1900/2003) used the “fusion of horizons” (p. 306) as a concept to describe how understanding occurs when a connection is made between the self and the horizons of others.
Understanding is never complete; it is a neverending circle that occurs when the horizons of past and present fuse with the self and others. By interpreting the parts in relation to the whole of the context and the whole to the parts, a circle of understanding comes about. Dialogue leads to the formation of commonalities between horizons of the self and the other. As horizons fuse with one another, prejudices or pre-understandings can be overcome that make new understanding possible. This hermeneutic circle is fundamental to all understanding and is the way that meaning becomes intelligible.
Hermeneutics and Narrative Pedagogy
Nurse educators can use Gadamer’s hermeneutic circle as a basis for a meaningful exchange between teachers and students. The hermeneutic circle offers teachers and students a means to exchange thoughts and ideas about the ways that students learn and how teachers can teach more effectively. The benefits of using the interpretive process have been identified by Diekelmann and Scheckel (2004) and by Ironside (2006), who make a pressing call for pedagogical reform. Diekelmann (2003) conducted a multi-site study of reform using narrative pedagogy. Teachers identified how they wanted to embark on substantive reform. Breakdown occurred when traditional teaching strategies no longer helped in the teaching-learning process. Hermeneutic research showed that content-laden coursework, textual memorization, lectures, and repetitive assignments created problems in student learning. Boredom occurred when students were forced to learn textual data passively. However, these breakdowns became significant opportunities for pedagogical change (Diekelmann & Scheckel, 2004).
Diekelmann and Diekelmann (2009) asserted that narratives, or stories, provide an endless and open opportunity for learning and teaching; wisdom is gained through dialogical experiences as students and teachers converse with one another through “converging conversations” (p. 187). Narrative pedagogy does not look to eliminate traditional pedagogies because they are necessary, although inadequate, to prepare students for current nursing practice. Ironside (2006) claimed that narrative pedagogy helps students and teachers to think, to challenge their assumptions, and to interpret situations from multiple perspectives. Hermeneutic research findings show that focusing attention on thinking and interpreting provides communal experiences that cultivate wisdom, challenge preconceptions, and envision new possibilities for providing care. Documentation of students’ experiences in courses in which narrative pedagogy was enacted offered teachers research-based evidence to guide their pedagogical decisions.
Hermeneutic phenomenology is the foundation of narrative pedagogy. Humans shape and are shaped by their empirical and dialogical experiences. Through narratives, pre-understandings are brought forward, shared practices are derived, and understanding occurs through interpretations that are never final (Gadamer, 1988). Narratives offer an opportunity for discourse that opens up new possibilities for student-centered learning. The teacher’s engagement and active participation with students makes coursework more interesting and compelling. Teachers call students into conversations, and students can respond in their unique ways to gain understanding.
Narrative pedagogy has been enacted at Farmingdale State College in Farmingdale, New York, in health sciences programs, such as nursing (LPN, AS, BS), dental hygiene (AS, BS), and Med Lab Tech (AS), where students write narratives about their personal and clinical experiences and share them in class. Reading, writing, thinking, and dialogue are core practices of narrative pedagogy. Necessary content appears in the written stories, and students’ thinking about the meaning and significance of the stories is elicited. Narrative pedagogy emphasizes how students and teachers learn and experience thinking in actual situations. In doing so, students develop the high-level thinking skills that are required to ensure patient safety in complex health care environments.
Students and teachers actively participate in classes by sharing narratives about their experiences, which serve as a means to dialogue about and discuss nursing practice. Merely sharing stories in class, while often beneficial to students, is not narrative pedagogy. Narrative assignments are written prior to class and require much thinking. Students are directed to provide as much detail as possible when writing their narratives so those who are listening can “see” the experience that is being related. Many students described well-written narratives as painting a picture of the experiences being told.
In preclinical courses, students write about their personal experiences with concepts that are foundational to nursing practice, such as caring, ethics, communication, thinking, and health. For example, students are asked to write about an experience in which they cared for someone or received care from someone or about an experience with ethical or unethical behavior. As students read their stories, their classmates are asked to think about what stands out for them in the stories and the faculty member helps them make connections between these concepts and nursing practice. Students in narrative classes develop the skills of listening, identifying the significant parts of stories, and thinking that are so necessary for practicing in the current health care environment. As students progress through the program, they write narratives about their clinical experiences caring for patients.
Students have been given the opportunity to select a film or a piece of artwork, poetry, or literature that expresses something significant about their clinical experiences. The “Use of Force” by William Carlos Williams (2007) was read to dental hygiene students as they grappled with the feelings of providing care to patients with severe spasms due to cerebral palsy. The educator questions the students to stimulate hermeneutic dialectic or the art of questioning even further about their experiences to move the conversation to the art of thinking to evoke a richer understanding (Diekelmann & Diekelmann, 2009). Questioning, one of the Concernful Practices of Narrative Pedagogy, is different from asking questions. According to Young et al. (2009):
Questions require specific answers and once an answer is provided, thinking (about that particular issue) tends to end. The practice of questioning is to raise questions to explore meaning and provoke thinking rather than to obtain answers and close down on thinking. Questioning moves from focusing on a single correct answer to considering the complexity of nursing practice and the multiple interpretations and meanings of experience. Questioning cultivates thinking in a different way, about issues that students and teachers may not have thought about before. At times multiple answers arise; at times no answer at all, just persistent thinking and questioning.
This engaged openness brings about students’ matters of concern that call for educators to listen, attend, interpret, and invite them into further questioning to make meaning visible. The ensuing dialogues emphasize how students and teachers learn and experience thinking in actual clinical situations. Rather than ask students what care they provided to patients, faculty initially ask them what they were thinking as they prepared to provide care to their patients.
Narrative pedagogy embraces all pedagogies and can be enacted with a multitude of styles and strategies. Narrative pedagogy is a good fit for programs and educational styles in which self-reflection is expected. For example, in problem-based learning, where students solve problems and collectively work together through reflective processes, narratives are especially helpful to foster student expression resulting in active engagement with practice.
In classrooms with large numbers of students where lecture is often performed, the interpretive process can be used as a strategy to make lectures interesting and meaningful. Students can work on their interpretations in small groups. Self-reflection and uncovering thoughts leads to a fuller understanding of individuals as they exist in their world, thereby helping students to become respectful of the other’s point of view. Students often say, “I never thought of it that way before.” Narratives bring forth sensitivities as students identify their individual values and beliefs.
Enhancing Nursing Education Through Teaching and Learning with Art
The visual arts that appeal to the sense of sight are nonverbal narratives that are commentaries on the world. Through the lens of the viewer, art can be interpreted and meanings can be understood through symbols and images that are points of connection, unification, and belonging (Gadamer, 1900/2003). Works of art, such as a paintings, drawings, photographs, or sculptures, are entities that exist in the world as a visual text. Although it may be argued that art is a fixed reality, the story in the artwork is contained within symbols, images, and configurations that provoke thoughts and ideas, which stimulate dialogue. Narratives in artwork are contextually situated in an everchanging reality. Art calls for viewers to listen attentively and think about what is openly expressed or hidden from view and to bring this knowledge to spoken language (Swenson & Sims, 2003). Shared understanding between the artist and the viewer provides valuable information about values, conflicts, and beliefs.
Emphasis is placed on allowing feelings, thoughts, and ideas to flow as the viewer reflects on the art forms. The dialogue involves viewing the parts in relation to the whole and the whole in relation to the parts, which recruits our attention to search for significance. Cowlings (2006) described dialoguing as questioning the tension, the familiar and the strangeness, the distinctions and similarities, and the darkness and the light that lie within the artwork to derive meaning.
Teachers can guide students as they contemplate and hold open what is problematic. Together they seek new understandings in the learning encounter that can illuminate new possibilities for practice. They can interpret and critically think about the concepts, ideas, and situations expressed in a piece of art, and they can learn together through their reactions and interpretations.
Art is a means for teachers and students to gain an understanding of themselves in relation to their patients, cultures, communities, and world. Gadamer (1900/2003) suggested that our experience with art is a self-understanding. He stated that “Self-understanding always occurs through understanding something other than the self, and includes the unity and integrity of the other” (p. 97). As the viewer interprets art, a transformation occurs and something new evolves.
Sharing stories that arise through contemplating art can help students develop a greater insight, appreciation, and empathy for one another and for nursing practice as a whole. Engaging in art interpretation can enhance students’ awareness of the aesthetic knowledge needed to develop into caring professionals (Carper, 1978). Aesthetic knowing is unique to the moment and arises from an embodied grasp of the person and the work of art. Bringing forth intuitive possibilities provides for multiple perceptions and communal appreciation that shapes the future (Benner, 1984).
Chinn (1994) claimed that aesthetic knowledge is derived through criticism that occurs through thoughtful reflection and shared dialogue within the context of the group. Criticism is “the process by which the aesthetic pattern of knowing become visible and is shown to be plausible” (p. 25). Eisner (1985) suggested that criticism is the public art of disclosing and teaching others to provide a vivid rendering of what others can learn. The critic’s task is to see, not just to look. The critic who is a connoisser must be able to perceive what is subtle and unapparent to the naïve eye within one’s given practice and enable others to see the qualities in experiences.
Teachers encourage students to view art by thinking creatively and critically and relating their thoughts and ideas to praxis. Because students differ in cultural, social, and historical backgrounds, multiple interpretations result. Variations may cause one student to share and understand a story derived from the art and not another (Vezeau, 1994). Students also may view art negatively, which can provoke issues and discussions of the meaning behind the interpretation, allowing teachers the opportunity to discern meaning that may be different from others.
Teaching Learning Activities
Meaningful information is gleaned through art interpretation, which offers nurse educators ways to teach students about useful findings, practical interventions, and alternative methods of inquiry. Teachers need to be conscious of calling their own ideas into question and listening to others with openness that invites a trusting dialogue as students engage in interpretation (Swenson & Sims, 2003). Practical teaching-learning methods teachers can use to help students to develop aesthetic ways of knowing are presented below.
Journaling with Art
Journaling is a learning tool that helps students understand their feelings and ideas. By using reflective journaling (Heimstra, 2001), students can try to make sense of what they are attempting to understand by writing or drawing to clarify their feelings, beliefs, and thoughts. Journal sharing expands understanding through disseminating ideas and thoughts about experiences (Brown, Kirkpatrick, Mangum, & Avery, 2008). Journaling using art is a way that students can gain even more insight into the self. Students can draw their own experiences as they react to situations that arise in their day-to-day lives. Johns (2002) encouraged self-reflection as the means for students to convey their own patterns of interactions to understand their way of relating to others. As students gain more self-knowledge, they can develop a greater appreciation of the whole of their practice with patients.
The seminar in all levels of nursing education provides opportunities for critical thinking and discourse using art, during which ideas can be collectively exchanged, thought about, and openly discussed for learning. Paintings, pictures, and other art forms can be viewed and related to ethics, values, commitments, and professional ideologies in nursing. Through the act of criticizing and making ideas public in verbal, written, and artistic forms, scholars can teach and enlighten others to learn through a deeper method (Chinn, 1994).
Nursing History in Photographs
History has a profound impact when taught with photographs. For example, photographs of Florence Nightingale and Mary Seacole offer a way to discuss nursing’s role during wartime and to contrast the influential and political differences between the two historical figures (Lundy & Bender, 2009). Stories of these professional nurses will help students understand the impact nurses have on health care and the practice of the nursing professions. Sharing their own personal experiences may help students relate history to their own experiences as nurses today in comparison to what nursing was like in the past.
Health and Illness in Paintings
Visiting art museums with nursing students provides enriched experiences that offer a way to look at fundamental and poignant concerns of people. For example, The Scream by Edvard Munch (1893) reveals the complexities of emotions of frustration, fear, and rage. Body images in artwork can be contrasted, compared, and assessed (Pardue, 2006). Students can share their stories and engage in open discussions or written narratives about health promotion.
Community and Artistic Expressions
Art enables collaboration with groups in the community to discover and learn about values, beliefs, and aesthetics. For example, at the Henry Street Settlement in New York City the art museum provides an interesting view of how the community values the art of its children. Graffiti on buildings also offers an opening to share how subcultures live and how their everyday lives relate to community nursing practice. Jaret, Kasmauski, and Salmon (2008) offer an array of photographs of nurses’ commitment to caring globally in “Nurse: A World of Care.”
Cultural and Religious Art Forms
Cultural symbols and images contain the stories of cultures that can be articulated. A culture is comprised of members who share common experiences, thoughts, actions, activities, and expressions (Benner & Wrubel, 1989). Hidden skills, practices, and linguistic meanings in the culture are pervasive and make our world intelligible to us. According to Heidegger (1927/1962), meanings are embedded within social practices, language, cultural conventions, and historical understanding. Understanding meanings occurs within the context of the whole (Heidegger, 1927/1962). Benner (1984) stated that understanding common meanings embedded in our experiences provides knowledge that forms the basis for theory and practice.
Gadamer (1900/2003) stated that culture is a process of formation that is always preserving and becoming. Pre-understandings have important significance for the human sciences in understanding cultural differences. As horizons fuse, individuals and groups encounter the other. However, discourse of the otherness has an inherent risk that may perpetuate cultural differences, discrimination, and selective labeling.
Teachers must safeguard against cultural essentialism (Jagger, 2000), which views cultures as preset by historical and biological background. Educators need to protect against generalizations of a culture’s beliefs, values, ideologies, ethnocentrism, and racism that promote sharp oppositions. Narrative pedagogy is not free of the danger of repeating issues of racial, ethnic, and religious discrimination into different discourses. However, despite the risks involved in the discourse, it is still possible to participate in acquiring a deeper understanding of another culture (Jagger, 2000).
Art reflects beliefs and values that are embodied within symbols and images in paintings, drawings, sculpture, and other art forms. Teachers use paintings and art forms in discussions about subcultures and religious practices. Pesut (2008) addressed the difficulties in engaging in religious and spiritual discourse. Definitions and concepts of religion, spirituality, and faith in nursing literature are ambiguous and confusing, and practice is not clearly defined.
Religious intolerance may be closely tied into cultural beliefs and values, which can have grave consequences for those who do not have the same set of beliefs. Gadamer’s (1900/2003) circle of understanding presents limitations if individuals idealize their own religion as superior and are not open to understanding the other. However, dialogical exchanges of the concepts can be differentiated and discussed openly without bias if teachers safeguard against prejudice and engage in constructive debate that avoids marginalizing others (Pesut, 2008).
Narrative pedagogy is a way for teachers and students to understand human experiences and the life world of people, including their cultures and communities. To be effective, narrative pedagogy requires faculty to move from a teaching environment to a learning environment and from a focus on content to a focus on clinical practice. However, the shift that is often most unsettling for faculty is that from a controlled learning environment, where the teacher controls how, when, and what is taught, to an unpredictable learning environment, in which discussions arise that faculty do not expect and for which they may feel unprepared. In addition, research by Capone (2010) found that although narrative pedagogy was effective with all learning styles, dental hygiene students who were active learners were less likely to prefer it because they did not like to write stories.
The hermeneutic circle strengthens our means of understanding through art, and art provides a deep understanding that has application for practice. Educators are responsible for teaching students by using multiple methods that will enhance textual knowledge and assist them to think critically. Today, students seek to become engaged in an action-oriented world where visual connections are becoming increasingly used to convey information. Art provides a refreshing way to enlighten students to gain access to others, make connections, and gain a deeper understanding and appreciation for multiple perspectives and levels of knowledge.
- Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.
- Benner, P. & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness. Reading, MA: Addison Wesley.
- Brown, S.M., Kirkpatrick, M.K., Magnum, D. & Avery, J. (2008). A review of narrative pedagogy strategies to transform traditional nursing education. Journal of Nursing Education, 47, 283–286. doi:10.3928/01484834-20080601-01 [CrossRef]
- Capone, M. (2010). The perceptions of dental hygiene students in regard to the use of narrative pedagogy in a dental hygiene curriculum. Unpublished dissertation.
- Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1, 13–28.
- Chinn, P. (1994). Developing a method for aesthetic knowing in nursing. In Chinn, P.L. & Watson, J. (Eds.), Art and aesthetics in nursing (pp. 19–40). New York, NY: National League for Nursing Press.
- Cowlings, W. (2006). Editorial. Journal of Holistic Nursing, 24(1), 3–4. doi:10.1177/0898010105284735 [CrossRef]
- Diekelmann, N. (2003). Distance desktop faculty development in the new pedagogies for community-based care (Final Research Report). Madison, WI: University of Wisconsin-Madison, School of Nursing.
- Diekelmann, N.L. & Diekelmann, J. (2009). Schooling learning teaching: Toward a narrative pedagogy. Madison, WI: University of Wisconsin Press.
- Diekelmann, N. & Scheckel, M. (2004). Leaving the safe harbor of competency-based and outcomes education: Re-thinking practice education. Journal of Nursing Education, 43, 385–388.
- Eisner, E. (1985). The art of educational evaluation: A personal view. Philadelphia, PA: Palmer Press.
- Gadamer, H.G. (1900/2003). Truth and method (2nd ed.). ( Weinsheimer, J. & Marshall, D.G., Rev. ed.). New York, NY: Continuum. (Original work published in 1960).
- Gadamer, H.G. (1988). On the circle of understanding. In Connolly, J.M. & Keutner, T. (Eds.), Hermeneutics versus sciences?: Essays by H.-G. Gadamer, E.K. Specht, W. Stegmuller (pp. 68–78). Notre Dame, IN: University of Notre Dame.
- Heidegger, M. (1927/1962). Being and time. (, Trans.). New York, NY: Harper & Row. (Original work published in 1927).
- Heimstra, R. (2001). Uses and benefits of journal writing. New Directions for Adult and Continuing Education, 90, 19–26. doi:10.1002/ace.17 [CrossRef]
- Ironside, P.M. (2006). Reforming nursing education using narrative pedagogy: Learning and practicing interpretive thinking. Journal of Advanced Nursing, 55, 478–486. doi:10.1111/j.1365-2648.2006.03938.x [CrossRef]
- Jagger, A.M. (2000). Globalizing feminist ethics. In Narayan, U. & Harding, S. (Eds.), Decentering the center: Philosophy for a multicultural, post colonial, feminist world (pp. 1–25). Bloomington, IN: Indiana University Press.
- Jaret, P., Kasmauski, K. & Salmon, M. (2008). Nurse: A world of care. Atlanta, GA: Emory University.
- Johns, C. (2002). Guided reflection: Advancing practice. London, UK: Blackwell Science.
- Lundy, S.K. & Bender, K.W. (2009). History of community health and public health nursing. In Lundy, S.K. & Janes, S. (Eds.), Community health nursing: Caring for the public’s health (2nd ed., pp. 62–99). Sudbury, MA: Jones & Bartlett.
- Munch, E. Artist. . (1893). The Scream [Painting]. Oslo, Norway: Munch Museum.
- Pardue, K.T. (2006). Blending aesthetics and empirics: Teaching health assessment in an art gallery. Journal of Nursing Education, 44, 334–337.
- Pesut, B. (2008). Spirituality and spiritual care in nursing fundamentals textbooks. Journal of Nursing Education, 47, 167–173. doi:10.3928/01484834-20080401-05 [CrossRef]
- Swenson, M.M. & Sims, S.L. (2003). Listening to learn. [Monograph] In Diekelmann, N.L. (Ed.), Teaching the practitioners of care: New pedagogies for the health professions. (vol. 2, pp. 186–231). Madison, WI: University of Wisconsin Press.
- Vezeau, T.M. (1994). Narrative in nursing practice and education. In Chinn, P.L. & Watson, J. (Eds.), Art and aesthetics in nursing (pp. 41–66). New York, NY: National League for Nursing Press.
- Williams, W.C. (2007). The use of force. In Bishop, M. (Ed.), Single scene short stories (pp. 235–238). Layton, UT: Gibbs Smith.
- Young, P., Hayden-Miles, M. & Brown, P. (2009). Narrative pedagogy. In Caputi, L. (Ed.), Teaching nursing: The art and science (vol. 5, pp. 804–836). Glen Ellyn, IL: College of DuPage Press.