Helping students grow intellectually, become socially responsible citizens, and develop a professional value system are important parts of nursing education (AACN, 2008). As nurses, we espouse values such as The National League for Nursing's (NLN, 2016) core values of caring, diversity, integrity, and excellence. Nurse educators have a responsibility to help students examine their beliefs and values to develop competencies in the affective domain, such as compassion, a professional ethic, and altruism, that are essential to the practice of nursing (AACN, 2008; Barbezat & Bush, 2014). Contemplative activities can be used to help students develop affective competencies. These practices have been used throughout the ages across cultures and religions, and increasing evidence demonstrates the benefit of using these activities in nursing education (Hansel & Laux, 2014; Poorman, Mastrovish, Liberto, & Gerwick, 2010; Rajagopal, Pugazhanthi, & George, 2012; Ratanasiripong, Rark, Ratanasiripong, & Kathalae, 2015; Walker & Mann, 2016).
Many types of contemplative activities exist, but a common thread in all of them is that they require students to think deeply and reflectively (Barbezat & Bush, 2014). In academic settings, contemplative activities promoting reflection have been used in many different contexts to accomplish a wide range of learning outcomes. The tree of contemplative practices (Figure) was developed to illustrate the variety of activities that can be used academically (The Center for Contemplative Mind in Society, 2016).
The tree of contemplative practices. Copyright 2016 by The Center for Contemplative Mind in Society (http://www.contemplativemind.org/tree). Reprinted with permission.
The roots of the tree are formed by two intentions that are considered foundational to contemplative practice. Although many contemplative activities are derived from religious and cultural practices, approaching practices from an inquiry context rather than a spiritual context may be helpful in educational settings (Barbezat & Bush, 2014). Keeping activities rooted in awareness and communion and connection allows for secular use of many traditional contemplative activities (The Center for Contemplative Mind in Society, 2016). Faculty may be familiar with promoting awareness through reflective activities. Contemplative activities can also promote communion and connection with other individuals and communities. This type of connection can be difficult to foster using traditional classroom and clinical activities, and this is an area where contemplative activities are particularly useful.
The tree of contemplative practices groups similar contemplative activities together on tree branches. The tree is not meant to be a comprehensive or exhaustive list of all contemplative activities, but rather displays the range of potential activities that might be introduced in the classroom. Although all the activities promote contemplation, each different activity can also be used to meet other outcomes. For example, several activities relieve stress and help students focus, whereas others help students think creatively and some activities promote development of morals and ethics (Barbezat & Bush, 2014; The Center for Contemplative Mind in Society, 2016).
Some reflective activities have been a mainstay of nursing education, but the type of activities used in the classroom is expanding. Journaling is a beneficial reflective tool used in nursing programs, and descriptions and evaluations of this practice have at least a 20-year history in nursing literature (Davies, 1995; Kobert, 1995). Contemplative activities, such as meditation and centering, have been used with nursing students to decrease stress and anxiety and to foster coping (Poorman et al., 2010; Rajagopal et al., 2012; Ratanasiripong et al., 2015; Walker & Mann, 2016). Rees (2013) found that reflective activities helped students understand the complexities and emotional challenges of nursing. Rees (2013) also found that students learned more about themselves and identified attributes needed by successful nurses. Pedagogical strategies that incorporate elements from the arts and humanities can help students to explore their feelings prior to encountering difficult clinical issues (Dwyer & Hunter Revell, 2015). Contemplative activities can accomplish a variety of course outcomes that can be difficult to facilitate and can be valuable.
Selection of Class Activities
Several factors guide the selection of activities to use in class. Faculty must be familiar with the roots of practices, and although many contemplative activities are rooted in religious traditions, secular activities are best suited for the classroom. The teacher should be familiar with practices before introducing them in class and should have a good deal of experience personally using the practice (Barbezat & Bush, 2014). The activities will be more authentic and the teacher will be able to identify potential problems with activities prior to use in the classroom. The activities selected for use in the author's classes required no prior experience or training for the students. Because the activities are reflective and influential, it is important to recognize that some students may need time and an opportunity to discuss activities with the teacher or other students. Another essential element is allowing students to opt out of any activity that may be in conflict with their belief system or may evoke a strong emotional reaction for personal reasons (Barbezat & Bush, 2014). Although students will rarely need assistance processing these experiences, it is wise to proactively identify support resources should the need for them arise.
Several activities used in class will be discussed. These activities were selected for several reasons. First, the teacher had experience using the activities personally, as well as in other practice settings. For example, for decades, the teacher had taught and used guided imagery for childbirth preparation. Some activities were chosen based on availability, such as the art exhibits displayed during the academic year and vigils held on campus.
Additional contemplative activities that were not used in class but have the potential to be used in class or clinical settings with students will also be discussed. These activities were not used in class because of less teacher experience with the activities and due to logistics associated with using the activities. For example, yoga is a widely used contemplative activity, but time, space, and mats were not available to facilitate this activity effectively during this class. The Association for the Contemplative Mind in Higher Education provides helpful resources for faculty interested in implementing contemplative activities into courses (The Center for the Contemplative Mind in Society, 2016).
Description of Classes and Contemplative Activities
Contemplative activities including meditation, guided imagery, and journaling were used successfully in a senior-level capstone course the previous year. The activities were positively evaluated by students and faculty. The subsequent year, contemplative activities were introduced earlier and more frequently in two required senior-level courses. Forty to 45 students were enrolled in each course. The first course was a maternal/child nursing course offered in the fall semester. The second course was a synthesis course offered in the final spring semester of the program. The same group of students were enrolled in both courses. Institutional review board approval was obtained, and students consented to allow their course submissions to be analyzed and published.
An important element of being a successful nurse working in women's health is to understand the key issues affecting women. Students may not get many opportunities to participate in vigils unless a catastrophic tragedy occurs in their region. Many communities offer annual vigils to highlight violence against women. Activities such as this give faculty an opportunity to role model community involvement and activism. An annual event is held on the author's campus to raise awareness and to remember a young university employee and a student who were both kidnapped, raped, and assaulted by the same individual. One was murdered and the other escaped. Their stories are told through a docudrama movie. Following the film viewing, all interested students, faculty, and community members meet in a large open green space in the middle of campus. Comments from university officials and guests are shared followed by a single file silent walk across campus in the dark. This vigil is profoundly moving and gives students a much richer understanding of the issues of violence against women than can be accomplished in a typical classroom session.
Scheduling conflicts with clinical courses made attending the walk difficult for some students. Attendance at the event was optional, and 25% (n = 11) of the class participated in this event. Students were asked to write a brief reflection about the experience. Key themes in student reflections were community and awareness. Student thoughts included statements such as, “Walking as part of the hundreds in complete silence would be eerie and uncomfortable for most, but to me I felt connected to all of those people.” Another commented:
I have a new perspective on what has been going on around me after attending last night's event. I will no long stay in my sheltered little world while others are suffering. I will be a light for those who are in the constant darkness of violence.
Generative contemplative activities were used in the course to encourage students to explore their thoughts and express feelings. Incorporating art into nursing education is a way to allow for multiple interpretations of abstract concepts (Rieger & Chernomas, 2013). Two student art exhibits, one in the fall semester and one in the spring semester, supplemented class assignments. The first exhibit was titled No One Sits Next to the Black Girl on the Bus. This was an autobiographical exhibit in which race and family were infused in a mixed-media display (Cooper, 2014). Students were instructed to visit and experience the exhibit. All of the students in the course attended this event. They were asked to express their feelings and attitude about this exhibit in a brief one- to two-paragraph paper. Nursing students were also asked how the exhibit might inform patient care. They were asked to discuss nursing care considerations for the young woman depicted through the exhibit. One student commented:
I was immediately saddened and humbled. I know firsthand how children can be, but I have never endured discrimination based on my skin color as the artist had…. Cruelty and discrimination affect each person differently, and it was very moving to see the artist express her feelings through these pieces.
Another student stated:
If I had this young woman as a patient, there would be several considerations for nursing care. She has had a history of fragmented relationships, so I feel as though it would be important to establish a therapeutic relationship and to build rapport with her. It is within this construct of the relationship that I would provide support and encouragement to her because from what I saw and read during the exhibit, it seemed that she did not have that in her life.
Students were given the opportunity to attend another student art exhibit the following semester, titled Imaginary Places. This exhibit focused on proprioception and was composed of light-emitting sculptures displayed in a dark room (University News, 2015). Students were asked to attend and experience the exhibit and reflect on how it related to nursing; however, attendance was optional. Student comments included:
While staring into the installments, for a moment I felt as if I could climb down into the spaces that were created, only to quickly regain my sense of reality and remember it was only an illusion…. I wanted to see what was behind the side of the bending tunnel wall and how far down the ladders into the ground actually went. I wanted to walk into the stairwell that I, for some reason, felt confident would light up more and more as I continued through the dark hole. This feeling can reflect the journey one takes into the profession of nursing, especially during nursing school, when there is still a confidence inside us all that cannot be explained, because from our perspective, all we see and all we know are merely the first few steps, and then nothing but darkness. However, the excitement and curiosity we all feel while beginning this adventure in our lives is something that pushes us to want to continue down the unknown stairwell, or climb that seemingly never ending ladder…. But the journey through the darkness, which we believe will eventually flood with light, is what fuels our passions and what is ultimately most important.
In a previous capstone course, journaling was used to help students capture their thoughts about the profession and the ways in which they were evolving as professionals. Traditional paper-and-pen journals were used, the journals remained each student's private property, and journal entries were not read by the faculty member. All of the class participated in journaling, but only half of the class felt journaling was beneficial and only one third said they would use journaling again in the future.
A slightly different approach was taken the following year. Digital portfolios (i.e., e-portfolios) were used instead of journals. E-portfolios have been used as a way for students to showcase their work and to document growth and competence (Green, Wyllie, & Jackson, 2014). E-portfolios are used at the author's university to document learning and to create a positive, professional digital presence ( https://aportfolio.appstate.edu/). Designing a portfolio gave students the opportunity to reflect on learning throughout the program and creatively showcase some of the work they had done. This was a required, graded project, and students could choose to submit their portfolio for a university award.
The grading guidelines incorporated nursing program outcomes and the university e-portfolio award criteria. Students were asked to include artifacts that documented their best work or exemplars related to program outcomes, such as engagement in evidence-based practice and dissemination of health information. Students were expected to reflect and make clear connections between their experiences and what they learned from them. Although the guidelines were specific, students had latitude in terms of the content they added to the portfolio. They could include narratives describing what they learned or evidence, such as papers or other documents, that demonstrated mastery of each outcome. The design of the portfolio in terms of ease of navigation, organization, and visual appeal was also graded. Adherence to ethical and legal standards, including authenticity and privacy were expectations in this project. Students could choose whether they wanted to enter the university- wide portfolio competition. They could also determine privacy settings and who had access to the portfolio. Students produced stellar portfolios, and three of the top 10 portfolios for the university came from this class.
A future goal is to implement e-portfolios near the beginning of the program. Andrews and Cole (2015) recommended using e-portfolios as a scaffolded assignment. Early in the program, students could learn the technical aspects of entering content and gain familiarity with the portfolio software. As they progress through the nursing program, they can identify work that fulfills program outcomes. Near the end of the program, they can reflect more creatively on their entire experience and better describe how and what they have learned throughout the program. An additional benefit of e-portfolios is that with student permission, collected content can be used for program evaluation purposes.
Several types of stillness activities were used in both classes. Simple breathing exercises were introduced in the maternal/child course in the context of prepared childbirth. Breathing exercises have been used extensively for pain management and focus during labor. Students were asked to sit comfortably with both feet grounded on the floor, with their hands resting on their laps. They were instructed to close their eyes, inhale slowly, and exhale slowly. They were asked to continue to focus solely on breathing for several minutes. The exercise finished with another one to two deep breaths.
Body scan meditations were used in class as a means to destress and to help students focus on class. Body scan meditations are a form of progressive relaxation of each part of the body, working from feet to head, with 15 to 30 seconds of focus on feet, knees, hips, abdomen, chest, arms, shoulders, neck, and head. This exercise also began and ended with deep breaths. Short meditations were also used in the synthesis class. These included focused breathing activities, but also included guided imagery. Students imagined events such as passing the NCLEX and graduation. They were also led through a guided imagery experience in which they created the sights, sounds, and smells of a place of relaxation. They could then revisit this imaginary place whenever they felt the need to relax and refresh. Students quickly embraced these activities, and many came to class asking to “breathe.” These practices gave students tools they can use in the future for stress relief.
Relational activities include dialogue, deep listening, storytelling, and council circle. Storytelling can be used to describe clinical scenarios, express feelings and emotions in unique and powerful ways, and set the stage for reflective thinking and complex problem solving (Edwards, 2014; Wheeler, Butell, Epeneter, Langford, & Taylor, 2016). Clinical stories with identifying information removed were shared throughout both courses as relevant to class content. The students met for a preclinical conference in a lobby dedicated to author Maya Angelou, and her stories and poems were read in class, particularly to highlight women's issues (Angelou, 2015). Stories, myths, and legends highlighting common women's concerns have been used as a component of therapy for disordered eating and eating disorders (Johnston, 1996). Some of these stories were also read and shared in the maternal/child course.
A relational activity not used in class but potentially beneficial for nursing education is council circle. This activity has its origins in Native American cultures and involves respectful and thoughtful dialogue in a group setting. The group sits in a circle to discuss a topic of concern. An object such as a piece of art or a symbolic object is passed around the group. The person holding the object has the floor to speak. The speaker should express thoughts succinctly while the rest of the group listens quietly. This process gives everyone the opportunity to be heard without allowing anyone to monopolize the discussion (The Center for Contemplative Mind in Society, 2017). Although this activity was not used in this class, it may be an activity that would be useful in postconference situations or in small classes. A form of council circle was used in faculty meetings in one of the author's former work settings. The process gave everyone the opportunity to speak if they wanted to and helped promote active listening by nonspeakers.
Movement activities were not used in class primarily due to logistic issues. The physical layout of the classroom did not allow for the room adaptation necessary for activities such as yoga, dance, or labyrinth walking. Some of these activities, such as yoga, have been used in nursing education, and others, such as labyrinth walking, are emerging as pedagogical activities.
Labyrinth walking has been used for centuries; however, this activity has not been widely used in nursing education. Nurses have used labyrinth walking as a metaphor for RNs returning to school to complete BSN degrees and for the research process (Diaconis, 2010; Munro, 2010). Labyrinth walking has been used as an intervention by nurse researchers (Zucker & Sharma, 2012). Labyrinths are located at medical centers, parks, and churches throughout the world. Recently, they have been included in medical facility designs and in patient care, including cancer and Alzheimer's treatment (The Labyrinth Society, 2016). Labyrinths have been also been used in school settings (Michels, Maxwell, & Chang, 2010). Although a labyrinth was not used in class, a canvas labyrinth is available on campus and has been used by faculty and students. Introducing this activity in class may be best accomplished by coordinating the activity with a Certified Labyrinth Facilitator.
Ritual and Cyclical
Ritual and cyclical activities often include the use of sacred space, culturally or religiously based ceremonies and traditions, and retreats. Creating a sacred space was not conducted in class, but introducing students to this concept may be important for future practice. Nurses have created sacred spaces in hospital environments, such the operating department, in labor and delivery suites, and in outpatient settings (Ayers-Gould, 2000; Roseman, 2016; Schmock, Breckenridge, & Benedict, 2009). The basic tenet is to create a space that will promote healing and the authentic use of self with patients. This practice is based on respecting patients and their needs and creating a space that allows for comfort and cultural and religious expression within the confines of traditional hospital and outpatient settings.