Humanities and literature courses are typically part of the educational experiences of baccalaureate nurses in the United States, and educators maintain that effective practice include an art of nursing component. Currently, nursing education is dominated by theory, facts, technical skills (Chan, 2014; MacDonnell & Macdonald, 2011; Wright, 2006), and computer-based documentation systems that foster emotional distancing from patients (Dempsey, Wojciechowski, McConville, & Drain, 2014). Important aspects of nursing, such as social justice, advocacy (Lapum et al., 2012), and caring behaviors, might be lost in the process (Dempsey et al., 2014). Poetry might support empathy in nursing students to prepare them for roles as patient advocates who challenge social inequities in health care (Lapum et al., 2012; MacDonnell & Macdonald, 2011; Saunders & Kowalski, 2015).
Poetry has been used in some nursing education programs through poetry reading and writing exercises (Foster & Freeman, 2008; George & Aswegan, 2015; Jack, 2015; Kidd & Tusaie, 2004; Musckat, Yehuda, Moses, & Nararstek, 2010; Saunders & Kowalski, 2015). Poetry can shape one's thoughts, feelings, and experiences to develop new ways of thinking (Clansy, 2013; Jack, 2015; Kidd & Tusaie, 2004; Tetley, Dobson, Jack, Pearson, & Walker, 2016) and draw people to express themselves and their own vulnerabilities (Clansy, 2013). As stated by one educator, “I have certainly found that I regard a heartsink patient with more compassion and fellow feeling if a line or two of poetry that seems to describe his feelings floats into my mind” (Salinsky, 2007, p. 683).
Poetry might be an effective tool to develop the art of nursing in nursing students, also known as aesthetic knowing. Chinn and Kramer (2008) expanded on Carper's pattern of aesthetic knowing as “the dimension of knowing that connects with human experiences that are common but expressed and experienced uniquely in each instance.” (p. 150). The authors further asserted that aesthetic knowing “endows the experience with its aesthetic qualities and differentiates it from the impersonal performance of technical acts and routinized procedures” (Chinn & Kramer, 2008, p. 153). In other words, poetry in nursing education might shift the performance of routine acts in nursing to a personal and meaningful level that expands their perceptions of the experience allowing the art of nursing practice to unfold (Chinn & Kramer, 2008). However, evaluation strategies for aesthetic knowing are elusive and unknown.
Poetry has been used to evaluate student knowledge of course content (Peck, 1993; Smith, 1996) and reveal improved communication with patients (Roberts, 2010). Coleman and Willis (2015) found that nursing students preferred poetry writing over reflective writing because it allowed them to express their feelings at a deeper level and show compassion for patients. Overall, evidence exists to support using poetry in nursing education to support professional ideals such as compassion (Foster & Freeman, 2008; George & Aswegan, 2015; Jack, 2015; Kidd & Tusaie, 2004; Musckat et al., 2010; Saunders & Kowalski, 2015), and the American Association of Colleges of Nursing (2008, 2011) indicates empathy is an expected professional nursing value.
A consistent theme in health professions' education literature is positive viewpoints from students who have been exposed to poetry reading or writing. Medical students report a greater connection with fellow students, faculty, and staff through the sharing of poems (Rodriguez, Welch, & Edwards, 2012). Nursing students find freedom in expressing themselves through writing poetry (Coleman & Willis, 2015; Peck, 1993; Spencer, 2011; Wright, 2006). Others in nursing report feeling more confident following a poetry writing experience (Kidd & Tusaie, 2004). Finally, one report shows how nursing students, after hearing an instructor's poem on her own perceived oppression, opened up and shared their feelings on their own personal oppressions, which led to the development of a group poem (Lapum et al., 2012).
However, little research still remains on the use of poetry and uncertainty on how best to use it in nursing education (Chan, 2014; Jack, 2015). The purpose of this qualitative study is to gain graduate nursing students' perceptions of incorporating a poem into a final examination to evaluate learning in an advanced physical assessment course. In an earlier report, Smith (1996) used a poem about a woman who conveys multiple health issues as a means to evaluate knowledge of the assessment process among graduate nursing students. Students in that report (Smith, 1996) read the poem and answered assessment-related questions in a paper-and-pencil format within a 2-hour time frame in a classroom setting. For the purposes of the current qualitative study, one author (M.M.S.) administered the same poem used in the Smith (1996) report (Table 1), followed by six questions, also developed by the author of the current study, to meet the course's objectives (Table 2). Validating the use of poetry with course objectives is a recommended practice (Bruce & Tschanz, 2013). Because the course was taught 100% online, the examination was computer based, which also simulates current documentation practices. Further, students were afforded only 35 minutes to answer the questions in an effort to simulate the time afforded if this were a real patient encounter. In addition, students completed an 80-item comprehensive, multiple choice examination that had been traditionally used as the final examination for this course. All students completed the final examination on the same day, and the examinations were graded by the same author.
Poem Used in Final Examination
Questions Asked in the Final Examination as Related to the Poem
This qualitative study used an emergent design (Lincoln & Guba, 1985). This allowed the research to unfold based on the researcher's (S.L.K.) viewpoint while conducting the interviews. The study was approved by the institution's review board.
Recruitment and Data Collection
After the final examination grades were computed and posted for the students in the course, the study was announced at the course Web site. This was followed by individual e-mail communications to each student that explained the study with the attachment of the informed consent. Of the 11 students in the course, seven (63%) signed and returned consent forms and each underwent a private telephone interview conducted by the researcher. All interviews took place within 2 weeks of the final examination. Table 3 shows the questions that were asked of each participant in the interview. All interviews were tape-recorded. During the interviews, additional probing questions were asked to clarify emerging patterns or irregularities. Interviews lasted approximately 30 minutes each. By the seventh interview, informational redundancy was reached, as defined by Miles and Huberman (1994).
Questions Asked in the Study
The interviews were transcribed verbatim by the researcher, and confirmed with the audiotapes. A line-by-line method of analysis was used (Miles & Huberman, 1994). Multiple strategies were used in data analysis to include confirmability strategies and coding and recoding of emerging themes with segments of supportive testimonies and counting frequencies (Miles & Huberman, 1994). All authors of the current study agreed on the final themes at greater than 90%. Two of the authors (S.L.K., S.W.) had no affiliation with the course or the graduate nursing program. Five study participants volunteered to review the final themes approximately 4 months after the conclusion of the study, with 100% agreement.
Data were collected from seven participants all preparing for the role of Adult-Gerontology Clinical Nurse Specialist in an all online graduate nursing program. The average age of participants was 37 years, with a range of 28 to 56 years. All were women and were either married (58%), divorced (14%), widowed (14%), or single (14%). Participants were Caucasian (86%) or African American (14%). All were currently employed in nursing roles and had been in the graduate nursing program for one term to 2 years. All participants denied prior experience that used poetry to evaluate learning in a nursing course.
Three themes emerged from the data: Being There, Think More, and Feeling Rushed. The theme of Being There meant feeling like the woman in the poem was a real patient. One participant stated, “It would be like a real patient presenting to me, sharing their entire case.” The time frame was also meaningful. Another participant stated, “It kind of simulated…a patient you would have; you would have 20 minutes to get it done.” Participants also felt, in contrast to other methods of evaluation, that the poetry method was more in touch with real life. One participant stated, “It made the person in the case study an actual person to me versus just a list of the age, gender, and symptoms.” Feelings of concern for the woman in the poem were expressed. Another participant stated, “You felt bad for the patient instead of reading a clinical scenario. It's so objective in a clinical scenario, it was like the patient seemed kind of happy but was still really sick, so you kind of felt more for the patient.” One participant repeatedly used the word “she” when talking about the person in the poem, stating:
She has so many things wrong and she just didn't want anyone to know, she didn't want to bother with it. I just felt she was defeated because there were so many things that were wrong, so she was just doing the best she can do and saying she was fine.
Overall, participants felt they were in the presence of the woman in the poem and indicated feeling empathy for the patient.
Participants indicated they had to Think More with the poetry method. One stated, “I thought it was unique, it made me think more. I felt like I got more out of it than just a multiple choice test.” Participants may have been challenged to new ways of thinking. One participant described it this way, stating:
With the other portion [multiple choice], you have this, and you have to pick an answer, then you have that, and pick an answer. I do better in that because my brain's more black and white. Now, when you throw something more out there [the poem], it's kind of like the other side of your brain, ugh. I'm thinking I see the point, when someone comes in to see you, first time in a clinic or whatever, it's going to be vague, it's going to be a little like this and you're going to have to figure it out. It's a different way of looking at taking it from a poem and then developing a diagnosis, it made you think.
Some hints indicated that the type of poem mattered, with one participant stating, “There's a lot going on with this patient. I got to put this puzzle together.” Overall, the poem used in this study provoked thinking in a different way than traditionally used evaluation methods. It seemed to take participants out of their comfort zone, not only in thinking about what to do, but feeling concern for the patient and their ability to meet the patient's needs.
The final theme was Feeling Rushed. All participants voiced they would have liked “more time” but balanced this with the reality of time-constraints in health care. “I know you don't have a lot of time with patients in the real-world setting, but I just think maybe 10 more minutes would have been perfect.” Feeling rushed made some students more “nervous” or feel that they did “not have enough time to reflect back on all that's been learned in the course.” Participants found the 35-minute time limit challenging, but mostly for the purposes of doing well on the examination.
This is the first study to examine students' perceptions of incorporating a poem into a final examination to evaluate learning in an advanced physical assessment course. The poetry strategy was similar to an evaluation method described 2 decades ago (Smith, 1996). The study by Smith (1996), among other studies (Peck, 1993; Jack, 2015), supported the use of poetry to measure learning among nursing students. To the knowledge of the authors of the current study, this is also the first study to assess the use of poetry in graduate nursing education and in a course delivered 100% online. For these participants, Being There meant feeling as if they were with the patient to support Chan's (2013) suggestion that poems used in nursing education be similar to real-life case scenarios. The participants expressed concern and a desire to help her (i.e., the woman in the poem). This supports previous evidence that poetry can support the formation of empathy in nursing students (Foster & Freeman, 2008; George & Aswegan, 2015; Jack, 2015; Kidd & Tusaie, 2004; Musckat et al., 2010; Saunders & Kowalski, 2015) and possibly aesthetic knowing (Chinn & Kramer, 2008). Participants also confirmed the need to Think More as they attempted to pull together prior learning in the course, and it challenged them to think in a different way than in a multiple choice examination. This concurs with others who support the use of poetry in developing new ways of thinking (Clansy, 2013; Kidd & Tusaie, 2004; Peck, 1993; Rodriguez et al., 2012; Spencer, 2011; Wright, 2006). Feeling rushed simulated the time constraints when seeing patients and the desire to score well on the examination. Students' scores on the poetry portion of the examination were positive and congruent with overall course grades to demonstrate mastery of course objectives. Scores on the poetry portion of the examination ranged from 90% to 100% (mean = 94%). Students' overall course grades ranged from 91% to 96% (mean = 94%).
The findings support the use of poetry in nursing education because patients need providers who are stretched to think in different ways, be empathic, and take ordinary and routine nursing skills such as the “patient assessment” to deeper levels of meaning. Overall, poetry interpretation might enhance our grasp on the art of nursing through aesthetic learning (Chinn & Kramer, 2008). It is also encouraging that the students' perceptions in this study in an online course are consistent with the positive viewpoints of students from classroom settings, as reported in the literature. This supports the need for more research in the use of poetry in online delivery courses, as well.
In terms of pedagogy, the poem may have been well received by this group of students because of other instructional methods used during the course. Students completed an older adult assessment, and one student indicated that she felt prepared for the woman in the poem based on the students' work for that assignment. Also, caring practices were an expectation in the course, and with every patient assessment students had to document and demonstrate caring practices to the instructor (M.M.S.). The poem may have also been viewed positively because all students scored well on that portion of the examination. We cannot exclude that perceptions might have been different if scores had been lower on the poetry portion of the examination.
This sample was small and the results therefore are not generalizable. Four graduate students chose not to participate. We cannot exclude that their perceptions might have been different than the perceptions of those who did. However, of those who did participate, five participants volunteered 4 months after the study to review the final themes and all agreed unanimously that the results did capture their perceptions as stated. Larger sample size and the use of a mixed-methods design might be useful in future research. Variables such as compassion and empathy might be worthy of investigation. Allowing more time on the examination might be beneficial, too.
The incorporation of a poem into the final examination of an advanced physical assessment course was well-received by the Clinical Nurse Specialist students who participated in this qualitative study that explored their perceptions of this evaluation strategy. Two of the dominant themes, Being There and Think More, suggest aesthetic knowing, in that students were affected on a personal level in a meaningful way. The students also identified appropriate physical findings described in this poem but felt rushed (i.e., the third theme) when completing this portion of the final examination.
Aesthetic knowing is an important component of the art of nursing, and it is the authors' desire to produce graduates with an appreciation of the human experience, in addition to technical competence. This evaluation strategy might be one effective way to measure aesthetic knowing. The time allotment for this portion of the examination was based on a reasonable guess. The third theme, Feeling Rushed, suggests more time is appropriate. The intent is to replicate this study with future cohorts, and allowing slightly more time for this portion of the final examination is under consideration. The authors are also considering how to incorporate poetry into undergraduate nursing programs, recognizing that this is the time when students form attitudes and impressions about the art of nursing.
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Poem Used in Final Examination
|There is nothing whatever the matter with me,
I'm just as healthy as I can be.
I have arthritis in back and knees,
And when I talk, I talk with a wheeze.
My pulse is weak and my blood is thin,
But I'm awfully well for the shape I'm in.
My teeth eventually had to come out,
And my diet I hate to think about.
I'm overweight and I can't get thin,
But I'm awfully well for the shape I'm in.
I think my liver is out of whack,
I've got a pain high up in my back.
Sleep is denied me night after night,
And every mornin' I'm just a sight.
My memory is failing, my head's in a spin,
But I'm awfully well for the shape I'm in.
The moral of this story as the tale we unfold,
For you and me that are growing old,
It's better to say, “I'M FINE” with a grin,
Than to let folks know the real shape we're in.
Questions Asked in the Final Examination as Related to the Poem
Question 1: Identify three potential medical diagnoses and three potential nursing diagnoses the patient may have. Be exact. Place them in order of consideration from most serious to least serious.
Question 2: After reading the poem, what is one word that describes how you feel at this moment? Just be honest and write that one word. There is no right or wrong answer for this question.
Question 3: Pick one potential diagnosis from your answer to question 1 to assess further. The remaining questions pertain to this potential diagnosis only. What three additional questions would you ask to learn more about this potential diagnosis?
Question 4: Describe how you would care for the patient's comfort and safety during your physical assessment. Specifically, what special instructions/coaching of the patient or care would you implement when doing your assessment for the potential diagnosis you selected?
Question 5: Write out what data you would record in the O (Objective) section of your note on this potential diagnosis. Use most or all of the techniques as relevant to your potential diagnosis (e.g., inspection, percussion, palpation, and auscultation).
Question 6: Name one diagnostic/special test you would do or order to help confirm the diagnosis. In a sentence or two, indicate how this test would be helpful.
Questions Asked in the Study
How did the patient's story in the poem make you feel? (Explain)
How did that feeling affect your performance in completing that portion of the examination, if at all?
Did you feel differently when taking the poetry portion of the final examination, compared with the other part of the examination (i.e., multiple choice examination)? (Explain)
Which part of the examination (the multiple choice or the poetry) best reflects your learning in the course? (Explain)
Would you recommend the use of poetry to evaluate student knowledge of advanced assessment in the future? (Why or why not)
Is there anything else you wish to share about the poetry examination?