The profession of nursing is both a science and an art. The science of nursing pertains to the cognitive knowledge required to understand human physiology and technical skills required to safely perform procedures. The art of nursing concerns the interpersonal skills required to view individuals holistically and address psychosocial needs. Scholars and educators suggest that new pedagogical practices are needed to educate nurses who will embrace both the science and art of nursing (Rieger, Chernomas, McMillan, Morin, & Demczuk, 2016). Arts-based learning (ABL) is an innovative approach that educators can use to facilitate learning both the art and science of nursing.
ABL for nursing education proposed by Rieger and Chernomas (2013) is a teaching strategy that purposefully engages students with an art form to enhance learning of another subject. This may include creating original art or responding to another person's art. A key component to ABL is reflective observation, which requires the learner to think critically about the relationship with the art form and subject matter, as well as the individual's learning. Through the process of reflective observation and engagement in the art form, students actively participate and are constructors of knowledge. Active participation is particularly helpful and necessary when teaching and learning complex abstract concepts (Jack, 2015; Rieger & Chernomas, 2013; Rieger et al., 2016). The use of ABL pedagogies in nursing education has been explored to some degree, and diverse strategies have been used (McGarry & Aubeeluck, 2013).
In their recent synthesis of literature, Rieger et al. (2016) identified outcomes of arts-based pedagogies in nursing education, some of which include increased (a) student engagement and enhanced empathy, (b) self and cultural awareness, and (c) observational skills. Other research findings indicate that ABL helps students to become more emotionally aware, learn about themselves, and value the perspectives of others (Bailey & Davis, 2011; Idczak, 2007; Jack, 2012, 2015; Nguyen, Miranda, Lapum, & Donald, 2016). In addition, arts-based pedagogies may facilitate professional development and engender learning communities (Rieger & Chernomas, 2013).
In light of these outcomes and findings, the clinical setting is an appropriate learning environment to implement ABL in nursing education. Reflective writing has been studied as an ABL strategy in relation to clinical experiences (Mahlanze & Sibiya, 2017; Silvia, Valerio, & Lorenza, 2013). Coleman and Willis (2015) studied nursing student perceptions of both reflective writing and poetry writing. They found that students particularly enjoyed the creative expression with poetry and it provided an opportunity for them to deeply empathize with patients. In a study by Bailey and Davis (2011), nursing students selected an artistic work during clinical postconference to reflect a particular patient care experience. The researchers found that students expressed increased awareness of holistic care and a greater recognition of their own emotions.
Research on clinical postconference has often centered on enhancing critical thinking skills. Although many faculty believe that questioning during clinical postconference can positively influence critical thinking skills, research on this strategy has indicated that the majority of questions asked were at a low cognitive level, with focus being placed on tasks or facts (Hsu, 2007; Rossignol, 2000), which does not facilitate reflective practice. Benner, Sutphen, Leonard, and Day (2010) advocated for the preservation of clinical post-conference as a time for reflection and as a way to solidify the clinical learning experience, but there is little empirical data to support how the time should be spent or on effective teaching strategies to accomplish this goal. Clinical postconference is an ideal time for faculty to implement creative, student-centered teaching approaches, such as ABL, to assist students in maximizing their learning opportunities in the clinical setting. Engaging in ABL in the clinical setting near patient care experiences allows students to recall specific details of the clinical day to holistically reflect on the clinical experience. The two-fold purpose of this study was (a) to understand student perspectives of ABL activities in clinical postconference, and (b) to explore the effect of ABL pedagogies during clinical postconference on nursing students' perceptions of their own clinical practice.
Consistent with the purpose of this study, a qualitative research design was used. Qualitative research allows for in-depth explorations of participants' perspectives and the meaning they have constructed from phenomena leading to an uncovering of themes on the basis of participants' experiences (Merriam, 1998). We designed our study to meet the critical attributes of ABL as proposed by Rieger and Chernomas (2013) that include (a) designating a time and setting for the active learning experience, (b) integrating an art form with another discipline to promote learning, and (c) having active participation from the learners. Institutional review board approval was obtained from the authors' institution, where the study was conducted.
Setting and Sample
Study participants included 29 junior and senior nursing students in a baccalaureate-degree program at a midsize private college. The students were enrolled in either a chronic or an acute medical–surgical nursing course. Most of the participants were female (93%) and Caucasian (83%), ranging in age between 20 and 23 years. During the 1-hour clinical postconference, the authors engaged students in six different ABL activities over the course of the semester. Activities were designed specifically to assist students in reflecting on their clinical experiences. The ABL activities included (a) drawing, (b) painting, (c) collage, (d) poetry, (e) reflective writing, and (f) music. After this series of activities was completed, students were asked to write a reflective paper based on their experiences with the ABL activities in clinical postconference. Each of the 29 students in the study completed the reflective paper, which included the following questions:
- What activity did you find to be the most meaningful? Why?
- How did participating in arts-based learning activities contribute to perceptions of your own nursing practice?
- How do you see the relationship between arts-based learning and nursing practice?
- Compare and contrast how you perceive your nursing practice now, in comparison with your nursing practice prior to this semester.
Data Collection and Analysis
Data were gathered over the course of two semesters. The research team consisted of two main researchers and one research consultant. At the conclusion of the fall semester, 14 reflective papers were collected and deidentified. To establish validity and reliability (Creswell, 2009; Patton, 2002), each of the three researchers received and read a copy of all the reflective papers. Papers were then evenly distributed at random to each researcher for independent in-depth analysis. Consistent with an inductive analysis (Patton, 2002), the researchers independently read and reread the reflective papers looking for common phrases and concepts. Common phrases were identified in the original papers and then transcribed verbatim to electronic files, grouping similar phrases and concepts. When each researcher finished coding the data, a meeting to discuss the findings took place. Each researcher shared her findings and emerging themes for comparison (Patton, 2002). During the first meeting, researchers found that students had similar comments and concepts, indicating common themes. At the conclusion of the spring semester, the same process was followed and 15 reflective papers were collected and distributed. When each researcher finished coding the data, a meeting took place to discuss and compare each researcher's findings. During this discussion, it became clear that data saturation had been reached as students' reflections from the spring semester echoed reflections from the fall semester and no new themes emerged (Guest, Bunce, & Johnson, 2006). At the conclusion of the meeting, agreement was reached regarding the main themes. Cross checking took place when each researcher returned to the data, reexamining all the data for accurate representation of students' comments and any missed themes (Creswell, 2009; Patton, 2002). The two main researchers (S.L.L., C.L.P.) met weekly for 5 weeks to share progress toward cross-checking and coding themes. Files were dated and saved electronically to create documentation of each step in the process and establish dependability (Creswell, 2009; Patton, 2002). In addition, three-member checks were conducted, and each participant stated that the themes accurately reflected the student perceptions. A final meeting took place with all three researchers to finalize the themes, which are discussed in the Results section of this article.
Students wrote thoughtful responses in their reflective papers, which demonstrated the construction of knowledge regarding nursing practice in several ways. Student reflection of the postclinical conference ABL experience revealed four main themes: (a) Developing New Perspectives, (b) Appreciating the Patient Experience, (c) Reflecting on Feelings and Growth, and (d) recognizing the Value of ABL. Each theme is discussed in detail using the students' written comments.
Developing New Perspectives. Through participating in ABL, students frequently noted that they began to view nursing differently (29 instances). These new perspectives were articulated in two distinct ways. First, students expressed a deeper, more complex understanding of their practice:
- Trying to represent my day in a collage or trying to paint my patient's emotion…it gave me a deeper understanding of what nursing is.
- Prior to this semester, I viewed my nursing practice as just simple, I would go in, complete my activities for the day…. Now I think about it in a more complex way and think more out of the box when it comes to my nursing care.
Second, students began to see the creative aspects of nursing and the unique attributes each nurse brings to the profession:
- Nursing can become so rigid and formulaic that you miss the creative, more artistic part.… These activities helped bridge the gap between these two worlds of nursing.
- Before this semester, I kept telling myself I wanted to follow a nurse for a day to experience exactly how I was supposed to be caring for patients…. I realized that there is no specific way to care for a patient, and that there is no right way to be a nurse.
Another student stated, “Just as every piece of art is different, so is every nurse.”
Appreciating the Patient Experience. Students also discussed how engaging with the arts gave them a new appreciation for what patients experience (21 instances). This appreciation manifested in two distinct ways. First, participating in the ABL appeared to facilitate a greater sense of empathy among students, as they provided examples of their enhanced awareness for what the patient must feel:
[Painting] helped me reflect specifically on one of my patient's feelings…. Reflecting on his disabilities and how much his life had changed became more real to me after painting it.
Another student expressed;
I placed him under a dark cloud to illustrate him being lost on an island. On the other side was his wife calling out to him.... Many times as caregivers we see the patient in the position that they're in, but we don't think what's going on in their heads, what they're feeling.
Second, students discussed how often the small tasks they performed seemed to have a great effect on patients:
- Writing this out helped me realize the small tasks I perform for the patients that might mean the most to them.
- The collage made me remember…that sometimes the smallest things can make the biggest differences in our patients' lives.
Reflecting on Feelings and Growth. Students reported that participating in ABL created opportunities to reflect on their personal development as nurses (19 instances). Students described the importance of reflection to their personal growth:
This semester I realized a lot about myself, about the person I want to become, and more importantly, about the kind of nurse I want to become.
Second, students expressed increased feelings of confidence:
- At the beginning of the semester…I did not feel confident in my ability…. I now feel more comfortable going to clinical.
- Due to arts-based activities, confidence in my nursing skills has increased dramatically.
Recognizing the Value of ABL. Students also described how art can be a powerful and valuable strategy in the learning process (17 instances). Several students shared that engaging in the ABL activities lowered their stress level:
- Going to postconference to do art was really calming compared to past semesters…. After a clinical day, students don't want to be drilled, they want to feel like their feelings about the care they gave matters.
- After being on a hospital floor for 8+ hours, the last thing I wanted to do was have another boring conversation about my patient(s). Instead, I was able to express my thoughts and feelings…through art, which had the dual purpose of relaxation and sharing information about my patient to my classmates for learning.
In addition, students shared that participating in the ABL activities helped them recognize the importance of teamwork in nursing practice:
- The arts helped me to develop a bond with my classmates…. I became closer to some classmates that I barely spoke to before.
- We were able to build trust with each other, give comfort, and receive comfort from those who understand how stressful and long days can be in the hospital.
Our findings suggest that by participating in clinical post-conference ABL activities, students developed new perspectives of nursing and a deeper appreciation for the patient experience. Students also indicated that they began to embrace the arts as a tool for both learning and reflection. We believe that the juxtaposition of these findings highlights three significant contributions to the literature, each providing specific implications for consideration by both nurse educators and researchers.
First, we believe that this research offers new insight into the development of empathy. It is unclear whether specific emotional capacities can be taught, but we believe that by creating opportunities for students to imagine what another person feels and to explore these perspectives, that emotions can be evoked, and empathy can be encouraged and perhaps developed. Students in our study frequently discussed imagining how their patients thought, some indicating that they had never thought about what it was be like to be a patient before. This is particularly important as it suggests that as educators, we cannot assume that students automatically exhibit empathy. Rather, faculty must remember that we play an instrumental role in assisting students as they make meaning from their clinical experiences and that we need to be aware of how we may inadvertently emphasize the scientific and technical aspects of care to the detriment of developing empathy. Therefore, we encourage educators to strive to create environments that foster understanding of others' perspectives to promote views of caring that go beyond technical skills (Rolfe, 2014). In addition, we encourage further research to explore additional pedagogies that may facilitate empathy particularly in the postclinical setting.
Secondly, according to the literature, reflection in ABL can help students learn about themselves, promote emotional awareness, and value another person's perspective (Bailey & Davis, 2011; Idczak, 2007; Jack, 2012, 2015; Nguyen et al., 2016). This study's findings support these assertions and highlight the critical role of reflection when implementing ABL activities. More specifically, students in this study pointed out that the ABL allowed them the time to reflect on aspects of practice they had not been given the opportunity to consider before. Students thought that time for reflection created an awareness of their own learning and professional growth. Important to note is that although each ABL activity incorporated time for reflection, the summative reflection allowed students to think about all of the activities as a whole and connect thoughts about their nursing practice. Students were then able to write about perceptions of their nursing practice in a rather in-depth manner and internalize what they learned. Thus, faculty who incorporate ABL may consider including not only reflection for each activity, but also a summative reflection. Implications for research include encouraging faculty researchers to investigate the role of reflection in ABL, as well as how other pedagogical strategies may promote reflection during postclinical conference.
Third, this research highlights how ABL can be used specifically in clinical postconference to solidify learning. The purpose of postclinical conference is to review the clinical day, with common pedagogical practices being student reports, the posing of critical thinking questions, or faculty sharing personal knowledge and expertise of a particular topic (Hsu, 2007; Rossignol, 2000). According to the students in our study, they are often exhausted at the end of the clinical day and view these common practices as “drilling.” In turn, they admitted rarely paying attention during past postclinical conferences. On the contrary, students remarked that ABL was stress relieving and held their attention during learning about their patients, themselves, and their peers. In addition, our data support the notion that students want to discuss their feelings and emotions in the learning environment (Jack, 2012) because they stated that being able to reflect and share with others made them feel that the care they provided “really mattered.” We suggest that educators consider the ways in which they approach postclinical conference activities and encourage them to create an environment that seeks to alleviate stress and promote reflection, team building, and learning. Furthermore, we encourage additional research to focus on clinical postconference to investigate other pedagogies that may facilitate learning, the development of empathy, or broaden students' views of nursing.
This study was conducted at one baccalaureate program. Although participation and assignments were not graded, students were aware that we were conducting a research study, which could have influenced their positive statements about the integration of ABL strategies.
Our findings support various outcomes proposed in Rieger's and Chermomas's (2013) conceptual analysis of ABL for nursing education. The development and implementation of arts-based pedagogies in clinical postconference have tremendous potential to facilitate empathy, teamwork, and reflective practices among nursing students. In this study, ABL provided a learning strategy that fostered participation and deepened student thinking regarding clinical learning experiences, as well as contributed to their personal development as nurses. This study highlights one way to implement ABL into clinical teaching for nurse educators.
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