“Nursing is an art.” – Florence Nightingale
If nursing is an art, then perhaps the arts have lessons to offer nurses. At least, this notion is behind a recent spate of programs that seek to use art and art museums to teach practice skills to nurses (Frei, Alvarez, & Alexander, 2010; Inskeep & Lisko, 2001; Pellico, Friedlaender, & Fennie, 2009; Wikstrom, 2000). The growth of visual arts in nursing education has, in many senses, paralleled the use of art education in medical schools (Bardes, Gillers, & Herman, 2001; Dolev, Friedlaender, & Braverman, 2001; Naghshineh et al., 2008; Schaff, Isken, & Tager, 2011). Despite the fact that nurses and physicians work as teams in the clinical setting, only one program has had both professionals engage in art education together (Klugman, Peel, & Beckmann-Mendez, 2011).
Assessing the value of using art as an educational modality in nursing education is a challenge. Although new programs incorporating the fine arts and humanities in nursing education are still evolving, these programs vary widely in their scope and focus. Some studies used student self-evaluations, often through indicating agreement or disagreement with a statement, using a Likert scale about what they learned and whether they enjoyed the experience (Bardes et al., 2001; Frei et al., 2010; Schaff et al., 2011). However, most evaluations asked students to give free responses to reflect on their feelings, empathy, and the experience (Pellico et al., 2009; Schaff et al., 2011; Wikstrom, 2000, 2001, 2011).
All of the programs report an improvement in some aspect of student learning or performance. Studies of nursing students in art education programs have focused on developing an increased awareness of emotion (in the form of empathy) (Bardes et al., 2001; Freeman & Bays, 2007; Moorman, 2013; Wikstrom, 2001; Wikstrom & Sviden, 2005). Both nursing and medical programs showed that students developed an increased comfort with ambiguity (Klugman et al., 2011; Moorman, 2013; Schaff et al., 2011). All programs reported that students were better able to observe details in art (Dolev et al., 2001; Klugman et al., 2011; Naghshineh et al., 2008; Wikstrom, 2000). However, fewer efforts demonstrated that this skill would translate from works of art to patients. Several programs had students observe pictures of patient faces and found that their ability to clinically observe improved as well (Bardes et al., 2001; Dolev et al., 2001; Hoshiko, 1985; Inskeep & Lisko, 2001; Pellico et al., 2009).
In 2011, the authors published an evaluation of a pilot program, called Art Rounds (Klugman et al., 2011). This curriculum consisted of three weekly visits to the McNay Art Museum in San Antonio, Texas, where nursing (both undergraduate and graduate) and medical students were introduced to the Visual Thinking Strategies (VTS) system for learning to observe art. After offering this experience twice, the Art Rounds enrichment program was approved as a 16-week, for-credit elective in both the schools of nursing and medicine. Art Rounds consisted of nine sessions: four 2.5-hour–long sessions at the McNay Art Museum and five 2-hour meetings on the campus of the University of Texas Health Science Center at San Antonio. Museum educators used VTS to teach the students to focus on their observations. VTS asks three questions: What do you see? What do you see that makes you think that? and What more do you see? (Reilly, Ring, & Duke, 2005). The VTS system asks students to repeatedly answer the same three questions as they continue to make observations. In addition, the VTS facilitator will rephrase what a speaker said to demonstrate understanding, deep listening, and reflecting back to the student for further thought.
The students were divided into two groups to ensure proportional representation of both disciplines in each group. The museum educators guided the students to visit two works of art in the gallery and applied the VTS technique. At the fourth Art Rounds museum session, students performed the VTS process on a live human model. In the previous version of this program, it was noted that students had a greater skill increase around pieces of art than around images of live patients. Thus, in this iteration, it was decided to have students apply VTS to a live model to help make the application of this method to real people more apparent. Split into two groups, the students spent 30 minutes observing each of two models, one male and one female. Each model had make-up applied to simulate certain skin conditions, such as a classic lupus butterfly rash, a removed tattoo, and a suspicious mole. For the first 20 minutes, the models did not speak, and students were guided through the VTS process by the museum educators. For the final 10 minutes of the session, students could ask questions of the live models, who had been provided with case-based scripted scenario answers. At the end of the session, the students and models debriefed on the experience of using VTS on a live person.
Students attended five sessions at the University of Texas Health Science Center at San Antonio campus. The purpose of these sessions was to demonstrate the applicability of observation through a variety of disciplines, understanding the role the arts can play in understanding patient experiences, and how images in nursing and medicine are constructed similarly to images in art (e.g., perspective, time sense, light, and shadow). The first session was taught by a studio art instructor, who introduced students to the practice of drawing. A second session was taught by a music educator, who taught about careful listening, as well as how music affects how we see things. The third lecture was by a radiologist presenting on the use of observation in the many technologies used to peer into the human body. The fourth session was with a dermatologist, who displayed photographs of patients with various skin conditions and explained how observation is the key to diagnosis. In the final session, students displayed their final project—creating a unique piece of art inspired by their art patient. This exercise was meant to teach a student that as much consideration and reflection goes into creating art as is necessary to understand it.
In addition, students undertook various formative assignments. The formative assignments were intended to reinforce the lessons from the didactic sessions by giving students additional practice in the aims of the program. Grading was on a complete/did not complete basis for these assignments. Students were divided into pairs—ideally one student from each discipline where possible—and assigned to an “art patient,” that is, a piece of art that the students would visit each time they came to the museum. The students would write blogs about their art patient after each visit, similar to keeping records. Each student was also assigned a second piece of art that reflected a human image. The student had to list three potential differential diagnoses that the person depicted in the art may have had and offer reasons supporting the diagnoses.
To evaluate the effects of the semester-long program, students took the same pre- and postassessment examinations that had been given in the initial 3-week offering: a variation of Budner’s Tolerance of Ambiguity Scale (Geller, Tambor, Chase, & Holtzman, 1993) and the Communication Skills Attitude Scale (CSAS) (Budner, 1962; Rees, Sheard, & Davies, 2002). In another section of both tests, students gave free-response answers to the question “What do you see?” for three works of art and for three headshots of dermatologic patients (images used with permission), including examples of lupus, rosacea, alopecia, and thyroid goiter.
Scores were calculated for the standardized tests according to their instructions. For the free-response answers, word counts were done in Microsoft® Word 2011. One person (C.M.K.) counted the number of observations made by the students, with random verification conducted by a second person (D.B.-M.). As in the authors’ previous study, a single observation was defined as “a single factual declaration about an image” (Klugman et al., 2011, p. 1268). A code book was developed to reflect the themes students wrote about in their free response (art language, diagnosis, emotion, evidence, medial language, narrative, storytelling). One person (C.M.K.) coded each student’s free-response essay.
Using SPSS® Statistics (version 20.0.0) and R (version 2.15.1), the pretest and posttest were analyzed with paired t tests and 95% confidence intervals. The results of the standardized tests were compared to sex and discipline using the Wilcoxon signed rank test. Significance was defined as p = 0.05 or less.
A total of 19 students participated in the Art Rounds course. Twelve students were women, seven were men; 12 were medical students and seven were nursing students. Of the nursing students, five were graduate students and two were undergraduate students.
The differences between the CSAS (p = 0.55) and ambiguous (p = 0.325) pretest and posttest scores were not significant, and these scores showed no significant variations according to sex or discipline. Overall, the differences in the number of words and the number of observations were highly significant for both art images (p = 0.000) and patient photos (p = 0.000). This significance did not vary by discipline (art, p = 0.034; patients, p = 0.47). However, female participants made more significant increases than male participants in the number of words used to describe art (p = 0.003) and patient photographs (p = 0.004), and in the number of observations made for art (p = 0.02) and patient photographs (p = 0.01).
The students also showed significant changes in the appearance of themes in their free responses for pretest and posttest images. The students discussed emotion less (p = 0.000) and made more medical observations (p = 0.013) when describing the art and patient images in the posttest. In addition, they told fewer personal narratives (p = 0.042) and patient stories (p = 0.025) in the posttest.
In the students’ free responses to the posttest question, “What did you learn as a result of the Art Rounds experience,” three themes were evident. The students explained the importance of communication and collaboration (seven of 19 students), the benefits of patience (six students), and the consequences of jumping to conclusions (seven students).
One of the goals of the VTS program is to teach students to spend a considerable amount of time just looking at an image and then noting observations about it. The learner is dissuaded from making stories or interpretations about the art and to focus instead on the details. This approach is similar to teaching students not to make assumptions about their patients before entering the clinical room. Rather than focusing on certain attributes of a patient (such as their personal hygiene or the condition of their clothing) and making assumptions, this program encourages students to consider the broader context, as well as the smaller details, which can easily be overlooked when a clinician has a preconceived notion based on singular details.
Similar to previous studies (Dolev et. al, 2001; Pellico et al., 2009), after the semester-long course, students dramatically increased the number of observations they made when looking at both art and patient pictures. Furthermore, students used significantly more words when describing both types of images. Although comparable changes were seen in the 3-week version of this program, the results from the semester-long course were even more significant. In the 3-week program, students improved more in their observations about the artistic image, whereas in the longer course, students demonstrated increases with both the artistic images and the patient images during the posttest. This equivalent change was attributed to the use of the live models during the fourth session at the McNay Art Museum. Instead of assuming that students would translate the art skill to a patient, the model exercise was explicit in having students use VTS on a human being, providing a direct application of VTS in a more clinical context.
Improvements in the number of words and observations were also correlated with the sex of the student. Female students, in general, made larger gains than male students. One explanation is that female students used fewer words at the start of the program and learned to be comfortable with expressing themselves and having confidence in their ideas. The increase in number of words around art is also correlated with discipline, and given that most of the nursing students were women, it is possible that the results of sex and discipline influence one another. Given that no other study has compared nursing and medical students to help in understanding whether using techniques for visualizing fine art, such as VTS, would translate from viewing an art piece to inspecting a patient, more research in this area will need to be done.
The examination of students’ free responses showed that four thematic codes changed in distribution from the pretest to the posttest. The theme of emotion denoted where a student attributed emotions to the figure in the image. In the posttest, students discussed emotion much less. This finding is in direct contradiction to other programs that found students gaining a deeper emotional understanding of people (Bardes et al., 2001; Freeman & Bays, 2007; Wikstrom, 2001; Wikstrom & Sviden, 2005). All of the previous studies that found increased emotion focused solely on nursing students. However, the interdisciplinary nature may have changed the group dynamic that moved away from emotional aspects being identified. Another possibility for the difference may be attributed to the method of instruction used, namely VTS, because it requires participants to specifically say what they see and use evidence from the image to support their answers.
Students increased their use of medical or scientific terms in describing the images, applying more clinical language in observing the images. The study by Naghshineh et al. (2008) found that students used more art language after the program, but their course focused on teaching art terminology to students. By not teaching art appreciation but rather focusing on a clinically transferable skill, students may fuse the abilities learned in this course with those they are currently developing in clinical experiences. Also, because this program takes place over 3.5 months, it is possible that students have learned more clinical reasoning and terminology over the semester than would have occurred in a shorter program.
The theme of “narrative” is when the student relates the image to her or his own personal experience. Thus, in looking at the image, the student becomes slightly less likely after this course to say, “This patient reminds me of my sister.” The VTS emphasis on observation and not interpretation may explain that students move away from identifying with the image, understanding it from their own context, or trying to construct a story about it. By not creating stories and interpretations, the students are allowing the image, and perhaps someday the patient, to tell his or her own story. On the negative side, by translating the skill of art observation to human beings explicitly in this program, are we training nurses and physicians to objectify their patients? Most of the programs cited in this article have been relatively short term in duration. The long-term program may reveal that there is a dose–response, resulting in the opposite of the desired effect.
Several limitations to this evaluation exist. Given the small number of students at a single health science institution, these results are not generalizable. However, one must remember that this is an evaluation of an education program and not a research project. This evaluation demonstrates that students can be effectively taught visual observation skills through the use of art. Students become more adept at observation and move away from making assumptions about art and about patients. Simply, they learn to see more.
However, it is also evident that the context of that education matters greatly. Using VTS, the authors of the current study encouraged students to use observations, not interpretations, stories, or emotion. As a result, students relied on what they knew and developed their clinical gaze.
This evaluation demonstrates that students can be effectively taught visual observation skills through the use of art. Students become more adept at observation and move away from making assumptions about art and about patients. Simply, they learn to see more. The lesson is that context matters.
Art is a powerful tool for teaching nursing students how to be skilled clinicians. As educators, we need to be aware of how we are using art and what we want the students to get out of the experience. As this evaluation proves, students do listen to us, for better and for worse.
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