Authors
- Rieger, Kendra RN, BN
- Chernomas, Wanda RN, PhD
- McMillan, Diana RN, PhD
- Morin, Francine PhD
- Demczuk, Lisa MA, MLS
Abstract
Centers conducting the review: University of Manitoba and the Queen's Joanna Briggs Collaboration for Patient Safety: a Collaborating Center of the Joanna Briggs Institute
Review question/objective: The objective of this review is to synthesize the best available evidence on the effectiveness and experiences of arts-based pedagogy for nursing students in undergraduate nursing education.
The specific review questions are:
Is arts-based pedagogy more effective than non-arts based pedagogy for enhancing competencies and learning behaviors in undergraduate nursing students?
What are nursing students' experiences of arts-based pedagogy in undergraduate nursing education?
Background: Well-educated nurses are key to the health of populations, and teaching strategies are needed which prepare nurses to be critical thinkers, creative problem solvers and effective communicators.1,2 Educators are tasked with developing approaches to effectively teach critical content for nursing, however, some argue that the traditional lecture is inadequate to teach many of these complex concepts.3,4 There is a call for a change towards student-centered and concept-based curricula in order to prepare future nurses to be critical and creative thinkers who are capable of meeting the present healthcare demands.1,2,5 Teaching strategies which emphasize learning processes, focus on students, and incorporate active learning are needed. In recent years, there has also been a growing interest in broadening pedagogical practices in order to develop nurses who embrace both the art and science of nursing.6,7 While scientific knowledge is important to inform effective nursing practice, the interpersonal and caring aspects of the nurse-client relationship also require knowledge about the human aspects of health and illness to guide practice.8,9 Thus, some educators have forged an alliance between the arts and essential nursing subjects in order to both address current curriculum needs,2,5,10 and develop learner competencies essential to excellent healthcare.2
A number of key organizations including the World Health Organization, the National League for Nursing, and the Lancet Commission, are recommending health care education reform,1,11-14 and some scholars view the arts as having pedagogical potential to promote humanistic healthcare.1,10 Although the founder of modern nursing, Florence Nightingale, viewed nursing as a holistic endeavor,15 positivism as the predominant philosophy of science in the twentieth century, and the focus on technology in healthcare, has eroded the value placed on the art of nursing.15-18 However, some nursing scholars posit that nursing education cannot just rely on the sciences, but that pluralistic pedagogical approaches are needed which also draw from the arts and humanities to develop well-rounded professionals who are sensitive to the human experiences of health and illness.6,8,19 The arts can develop certain habits of the mind that are vital to healthcare, 20,21 and can be a source of illumination for nursing students. 19 A clinical textbook can provide information about signs and symptoms, but an artistic piece can embody how the symptoms feel to the patient and express difficult emotions.18 Hence, a well-rounded education is essential for nursing practice which frequently demands practitioners to navigate emotionally and ethically complex clinical situations for which there are no straightforward textbook answers.8 This perspective is congruent with Carper's seminal work, 22 in which she presented four diverse, yet integrated, ways of knowing that form the epistemological basis of the nursing profession: empirics, ethics, aesthetics and personal.16,17,23 Carper's ways of knowing have evolved over time, and nursing scholars have proposed additional ways of knowing such as unknowing,24 emancipatory,25 and socio-political knowing. 26 Arts-based pedagogy (ABP) also holds significant potential to address these expanded conceptualizations of Carper's original work.
Arts-based pedagogy (ABP) is a teaching methodology in which an art form is integrated with another subject matter in order to impact student learning. 27-29 ABP results in arts-based learning (ABL),10 which is when a student learns about a subject through either creating original art, responding to other's art, or performing art. Using ABP in nursing education encompasses an arts integration approach,30-32 in contrast to teaching art as a distinct subject, as students learn about nursing subjects through either creating art or responding to another's art.10 Arts-integration is defined as "an approach to teaching in which students construct and demonstrate understanding through an art form. Students engage in a creative process which connects an art form and another subject area[horizontal ellipsis]". 33(p.1)
Learning in, with and through the arts, is a widely accepted pedagogical strategy in the discipline of education,31,32 and there are several educational theoretical perspectives which provide support for this approach. The underlying philosophy for ABP can be found in the writings of John Dewey, 34,35 an American philosopher, who posited that education should focus on individual growth, the social aspects of learning and active learning experiences.34,36 He also argued that school subjects should not be taught in isolation and that the arts should be integrated into the common experience.35,37,38 More recently constructivist theory has provided a theoretical basis for ABP.39 Constructivist educators assert that meaning is constructed through engagement with the world, experiential learning activities, and social interactions.21,40 If knowledge is viewed as socially constructed, then inventive ways to engage students, enhance participation, promote dialogue, and facilitate reflection are valued, 41,42 and ABP addresses these constructivist learning objectives. Further, Gardner's Theory of Multiple Intelligences43 is widely used to support ABP.21 According to this perspective, there are numerous intelligences which humans use to learn, but in academia there is a focus on the verbal and logical forms. Through the use of artistic mediums, additional aspects of intelligence are engaged as the arts use diverse ways of communicating.21 Moreover, Davis posits that there are five unique features of the arts,44,45 and ten specific learning outcomes which occur because of these unique features that make the arts powerful pedagogically. These features include that the arts produce a tangible product resulting in imagination and agency, focus on emotion resulting in expression and empathy, privilege ambiguity resulting in interpretation and respect, embrace a process orientation resulting in inquiry and reflection and facilitate connection resulting in engagement and responsibility.44,45 Many of these outcomes are also important in nursing education.
Indeed, there are numerous reported outcomes of ABP in nursing education. Several nursing educators have published their ABP initiatives and discussed notable impacts on students' learning and learners' behavior towards learning.2,8,10,46-56 Furthermore, researchers have found that integrating the arts into nursing education engaged learners,47 developed new ways of thinking,19,47,57 increased self-awareness,47,57 integrated thinking and feeling,57,58 fostered student empathy,47,52 enhanced cultural awareness,47,50 fostered transformational learning,57,59 and increased observational skills.53 In nursing education, the arts have been integrated with a broad array of nursing topics. One nursing educator developed an assignment in which undergraduate students created an artistic expression about a clinical experience with a client.2 This educator reports that the assignment fostered students' awareness of the humanistic aspects of nursing care and developed students' empathy for both clients and classmates. Other educators infused a psychosocial nursing course with art, literature, music, and film, in order to enhance nursing students' learning about mental illness.47 A qualitative investigation of the students' experiences revealed that integrating the arts into the course increased students' understanding and engagement, and fostered empathy, self-understanding, and cultural awareness. Thus, nursing educators assert that the arts can facilitate reflection, engage today's multi-literate healthcare students and promote meaningful student learning in nursing education.
Scholars also report on their experiences of resistance to arts integration in nursing education.1,2,19,47 They write about how some are dismayed by this seemingly unlikely amalgamation of disparate disciplines and question the impact of ABP on nursing students' learning.9 There are several reported reasons for this hesitancy to embrace ABP, such as: the explosion of scientific knowledge and the pressure to incorporate this type of knowledge into the curriculum,2,8,60 the dominance of the scientific model within nursing education,9 the need to prepare students for registration exams,2 lack of educational preparation to teach with the arts,2 nursing students' focus on learning nursing skills, 8,61 and lack of student interest.47
Thus, it is imperative to consider both the student experiences of ABP and the effectiveness of ABP with undergraduate nursing students in order to inform this discourse. There is an emerging body of research about ABP in nursing education; however, this work represents a diverse group of primary studies which have not been systematically examined. In order to confirm that no other systematic reviews have been published about ABP or ABL in nursing education, a preliminary literature search was conducted. The following electronic databases were searched and no current or planned review was found about this topic: Joanna Briggs Library of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO International Register of Systematic Reviews, CINAHL, ERIC, PubMed and Scopus. The grey literature was also searched, however no systematic review about ABP or ABL in nursing education was found in the grey literature. This lack of scholarly work is consistent with the general lack of robust research for nursing education,62-64 despite the fact that evidence is needed to inform nursing education practice and current curriculum reform.63,65,66 This proposed systematic review could provide a comprehensive review of the current research evidence about the experiences and effectiveness of ABP in order to facilitate evidence-informed teaching practice, support curriculum reform and inform future research. The purpose of this comprehensive systematic review is to synthesize the best available evidence on the effectiveness and experiences of arts-based pedagogy for undergraduate nursing students in nursing education.
Article Content
Inclusion criteria
Types of participants
The quantitative component of this review will consider studies that include undergraduate nursing students who are in education programs leading to registered nursing or registered psychiatric nursing, regardless of their year of study in the nursing program.
The qualitative component of this review will consider studies that include undergraduate nursing students who are in education programs leading to registered nursing or registered psychiatric nursing, regardless of their year of study in the nursing program.
The textual component of this review will consider publications that report an educator's or expert's opinion regarding the impact (including experiences) of ABP with undergraduate nursing students who are in education programs leading to registered nursing or registered psychiatric nursing.
Types of intervention(s)/phenomena of interest
The quantitative component of the review will consider studies that evaluate arts-based pedagogy in undergraduate nursing education.
The qualitative component of this review will consider studies that investigate undergraduate nursing students' experiences of arts-based pedagogy.
The textual component of this review will consider publications that describe the impact (including experiences) of arts-based pedagogy with undergraduate nursing students.
Arts-based pedagogy will be defined as a teaching methodology in which an art form is integrated with another subject matter in order to impact student learning.27-29 Therefore, undergraduate nursing students must engage in artistic processes in which they actively participate by either responding to works of art, creating works of art, and/or performing artistic works, and this process must connect a nursing subject with the art form. The "arts" will refer to activities in the creative arts as opposed to the broad study of human activity. The arts activities may include, but will not be limited to, art forms such as murals, poetry, sculpture, dance, theatre, drama, drawings, masks, music, stories, quilts and film. The nursing subject, which is integrated with the art form, will not be specified or limited in this exploratory review.
Types of outcomes
This review will look at the impact of ABP on competencies and learning behaviors in undergraduate nursing students. Competencies are defined as the "ability to meet complex demands, by drawing on and mobilising psychosocial resources (including skills and attitudes) in a particular context", 67(p.4) and involve a "mobilisation of cognitive and practical skills, creative abilities and other psychosocial resources such as attitudes, motivation and values".67(p.5) Within professional nursing, it is acknowledged that competencies are "the integrated knowledge, skills, abilities, and judgment required to practice nursing safely and ethically".68(p14) Furthermore, learning behaviors are academic enablers that make learning possible,69 such as student participation, concentration, engagement, focus and listening.
These outcomes (competencies and learning behaviors) could also be conceptualized as representing various domains of learning. Educational theorists posit that learning can be viewed as having three broad domains: cognitive, affective and psychomotor.70-75 The cognitive domain encapsulates the development of knowledge and understanding,70,71,73-75 and could include outcomes such as improvement in knowledge about a particular subject. The affective domain encompasses the learners' emotions, attitudes, motivations, and values,72,74,75 and could include outcomes such as empathy and engagement with learning. The psychomotor domain represents the development of physical and motor skills,74-76 and could include outcomes such as the development of clinical and assessment skills. ABP may impact nursing students' in a number of learning domains,70 and might facilitate the development of one domain more so than others.
Thus, the quantitative portion of this review will consider studies that include outcomes which may include, but will not be limited to, the impact of arts-based pedagogy on students' competencies and learning behaviors in the following areas:
- alteration in level of empathy
- improvement in observational skills
- students' engagement with the learning experience
- increased motivation to learn
- decreased anxiety
- satisfaction or evaluation ratings of their learning experience
- altered attitude towards nursing care/practice
- demonstrated improvement in knowledge of the subject matter
As this project is an exploratory review, a better understanding of the outcomes to be measured will come with a more extensive review of the literature.
Types of studies
The quantitative component of the review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.
The quantitative component of the review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion.
The qualitative component of the review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
In the absence of research studies, other text such as opinion papers and reports will be considered. If the literature search retrieves textual papers, they will be shifted over to the textual component of the review.
The textual component of the review will consider expert opinion, discussion papers, position papers and other text.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of CINAHL, MEDLINE, and the Arts and Humanities Citation Index will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article.
A second search using all identified keywords and index terms will then be undertaken across all included databases.
Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published from 1994 to March 2014 will be considered for inclusion in this review. This date was selected as a number of early studies about this topic were noted within this timeframe. The review will only include studies published in English. However, in order to provide the broader picture of all available literature on this topic and notable international trends, we will tally (but not translate) the non-English literature.
The databases to be searched include:
CINAHL
MEDLINE
ERIC
PsycINFO
Academic Search Complete
Arts and Humanities Citation Index
Art Full Text
Scopus
Proquest Dissertations and Theses: A&I
The search for unpublished studies will include:
Conference proceedings, dissertations, relevant websites and grey literature.
Initial search terms to be used will be:
Terms related to the arts, including: art, arts, arts-based, visual art, creative arts
Terms related to teaching and learning, including: pedagogy, education, learning, instruction, teaching, inquiry, curriculum, course
Terms related to undergraduate nursing students, including: nursing students, undergraduate nursing, baccalaureate nurses.
These terms will be searched in all listed databases.
Assessment of methodological quality
Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data collection
Quantitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Textual data will be extracted from papers included in the review using the standardized data extraction tool from JBI-NOTARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Quantitative papers will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorizing these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form.
In the discussion section of the planned review, the results from the quantitative, qualitative, and textual analysis will be examined together in a narrative format.
Conflicts of interest
There are no conflicts of interest to declare.
Acknowledgements
This systematic review is supported by a research award from the Manitoba Centre for Nursing and Health Research at the College of Nursing, University of Manitoba.
Kendra Rieger is the recipient of a Manitoba Health Research Council Studentship Award (September 2013 - April 2014) and a Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Doctoral Graduate Scholarship (May 2014 - April 2017) which provide support for her doctoral education and research. This review may contribute to a Doctorate of Nursing degree for Kendra Rieger.
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Appendix I: Appraisal instruments
MAStARI appraisal instrument
QARI appraisal instrument
Appendix II: Data extraction instruments
MAStARI data extraction instrument
QARI data extraction instrument[Context Link]
Keywords: arts; arts-based; pedagogy; teaching; learning; nursing students; undergraduate