N U R S I N G E D U C AT I O N P E R S P E C T I V E S N O V E M B E R / D E C E M B E R 2 0 0 4
ALL THE VOICES IN THE R OOM
Integrating Humanities in Nursing Education
R O B Y N L . S M I T H , M I C H E L L E B A I L E Y, S H A R O N K AY H Y D O , M A R G R E T L E P P,
S Y LV I A M E W S , S U S A N T I M M ,
T
AND
CECELIA ZORN
he humanities, the branches of knowledge that address the state
or quality of being human and living authentically (1), have been
called the language of the soul (2). Integrating the humanities in
nursing education reinforces the balance between the art and science of nursing (1) and inspires and strengthens all the voices in
the room. Through images, symbols, and sounds, nursing students give voice to their appreciation for universal truths and the
uniqueness of the individual experience. • This article describes
the integration of the humanities into a graduate nursing education
course. Participatory action research (PAR), a form of action research
that places prime importance on collaboration with participants by
including them as co-researchers throughout the entire process (3), was
used to link the humanities with a deeper level of teaching and learning.
Two faculty and five graduate students collaborated to implement this
research method. THIS ARTICLE ADDRESSES THE PLANNING, ACTION,
REFLECTION, AND EVALUATION COMPONENTS OF THE EXPERIENCE.
ABSTRACT
Participatory action research was used to link the humanities with a deeper level of teaching and learn-
ing. Planning, action, reflection, and evaluation steps were collaboratively implemented by two nurse faculty researchers
and five graduate nursing education students in a midsized, comprehensive, public midwestern university. Planning
involved a literature review of the use of humanities in nursing education. Action entailed an essay assignment and an
artwork-exhibition workshop. Written appraisal of the workshop provided data that were analyzed phenomenographically in the reflection step. Two categories, with descriptive subcategories, emerged: “Feelings” and “Learning Evaluation.” Implications for nursing education leading to the generation of practical knowledge are discussed.
2 7 8 Nursing Education Perspectives
H U M A N I T I E S I N N U R S I N G E D U C AT I O N
Planning Action research, used frequently in practice settings,
can be highly effective in education. Essentially, action research
involves taking action to improve practice and systematically
studying the effects of the action taken. Problems are described,
possible solutions are identified and implemented, and the
process and outcome of change are evaluated (6). The goal is to
generate practical knowledge relating directly to the problems
specific to a setting. Practitioners are then able to learn about
their practice in that setting and implement change to improve
their practice.
The planning step of action research involves data generation
(4). To that end, the participants reviewed the literature to examine support for integrating humanities in nursing education and
how such integration has already been accomplished.
T H E N E E D F O R H U M A N I T I E S I N N U R S I N G E D U C AT I O N
Although recent technological advancements have strengthened
the science of health care, the art of health care is poorly recognized and underutilized (2). Valiga and Bruderle (1) stated that the
humanities enable a balance in presenting the science and art of
nursing in nursing education and contend, as do others, that failure
to teach the humanities constitutes a disservice to students (5-12).
The understanding that teaching modalities integrating the
humanities expand one’s appreciation of the human experience
aligns with the American Nurses Association’s statement that
nursing needs to attend to “the full range of human experiences
and responses” (13, p. 6). It is consistent with the consumer
demand for humanistic health care. According to Barry, humanizing health care is dependent on understanding human experience, and must begin with teaching nursing through the “lens of
caring” (14, p. 28).
A lens of caring requires nurses to use personal, empirical,
ethical, and aesthetic ways of knowing (15). This affects and
influences how nurses generate knowledge. “Aesthetic expressions are guides to the essence of human experiences in health
and illness” (9, p. 529). Through these expressions, students
experience other ways of knowing. Educators have a responsibility to teach in a way that honors the multiple ways of knowing that
nurses bring to their caring practice.
HOW THE HUMANITIES ARE INTEGRATED INTO NURSING
Several nurse educators have creatively integrated
the humanities into their teaching methods, using aesthetic activities to teach the concept of caring. Barry (14) illustrated the importance of nurturing the wholeness of others through caring by having nursing students create a quilt. Students’ individual aesthetic
representations were sewn together into an interrelated whole in
which the stitches represented the connections between nurse and
client. Beckerman (5) used reflective self-inquiry aided by differ-
EDUCATION
ent works of art to explore the inner feelings and experiences of
caring with nursing students.
Works of art have also been used by some nurse educators to
enhance learning. After viewing selected works of art depicting
illness, disease, and the human condition at an art museum (8),
students formulated nursing diagnoses. They felt inspired and
free to express their interpretations of assessment data and
described finding this experience more powerful than learning
from a textbook.
Similarly, Wikström has used art to complement theoretical
knowledge of nursing care and develop an understanding of interpersonal relations between the nurse and the nursed (16). With
beginning nursing students, Wikström used art to create a safe
environment for the discovery of personal knowing of empathy (17).
Photography, a form of visual art, has been used to enhance
personal knowing by inspiring introspective discussions surrounding nursing care. Photographs have offered students new
perspectives of the world (18) and “the chance to experience
visually what can be difficult to articulate in words” (19, p. 276).
Other forms of the humanities have been effectively integrated
into teaching methods. De Montigny (7) explored nursing students’ individual and family beliefs, values, and aspirations
through puppet shows, crossword puzzles, poems, and collages.
Schaefer (20) and Olson (21) used reflection and writing activities
to increase students’ aesthetic knowledge about previously experienced caring situations. Winland-Brown (12) used literature to
teach students about caring for the critically ill. After students
graduated and were in practice, they reported that they continued
to reflect on this experience.
In the early 1990s, Bruderle and Valiga (22) questioned
whether the majority of faculty adequately apply the humanities
into their daily education practice despite acknowledging their
value. Later, in 2001, Andrews (23) expressed concern that
advanced practice nurses are embracing the medical model in
their practice, rather than holistic nursing values, and questioned
whether integrating the humanities in graduate education would
deter this tendency.
It is clear from this literature review that integration of the
humanities has inspired the voices of some students and strengthened the voices of others. This integration has increased students’
ability to see the client holistically, enhanced knowledge about
self, increased sensitivity to the voices of others, enhanced the
discovery of knowledge, and facilitated alternative ways of knowing. In addition, while there has been some integration of the
humanities in nursing education, the need continues. There is
support for using a wider variety of approaches to blend the
humanities with nursing and to expand this integration to graduNovember / December 2004 Vol. 2 5 N o . 6 2 7 9
H U M A N I T I E S I N N U R S I N G E D U C AT I O N
ate education (9). The data generated in this first phase of the
PAR process supported implementation of our project.
Action The action step in PAR involves the actual implementa-
tion of the new idea or change. The primary emphasis is to learn
through action (4).
PA RTICIPANTS AND SETTING Five students enrolled in a
master’s degree program in nursing and two doctorally prepared
faculty participated in the project at a midsized, comprehensive
public university. The faculty were a professor from the University
of Wisconsin-Eau Claire and a visiting professor from the University College of Health Sciences in Borås, Sweden, who had
experience using drama as a pedagogical strategy.
The course was the first of two nursing education graduate
classes. After verbal information was provided about the project,
the students gave written consent to use their appraised data for
research. Drama activities were focused on the educational use of
art and based on the assumption that drama is both a method and
a subject that, seen from a holistic perspective, integrates thoughts,
feelings, and actions. O’Toole and Lepp (24) defined drama as the
dynamic embodiment of events involving human beings and a valuable tool for intellectual and emotional growth.
WRITING SESSION The project began with the following
assignment on a take-home essay exam: “Select one artwork
(painting, sculpture, poem, movie, short story, novel, play, weaving, piece of music, etc.). Describe how the artwork you selected
illustrates your current conceptualization of ‘education’ and ‘educator.’ It is hoped that your current conceptualization reflects who
you are, as well as the literature you’ve been reviewing.” Students
had several weeks to complete their response.
ART EXHIBITION WORKSHOP After the exams were read and
returned to the students, one student suggested that all of the art
and students’ reflection be shared in class. Although this was not
part of the original plan, an art exhibition workshop was conducted
that, in essence, was a drama activity. Each artwork was displayed
on its own table in the classroom — a poem copied in a student’s
handwriting, a vase, a needlework wallhanging, a description of an
outdoor scene, and a child’s pencil drawing. With soft music playing in the background, the students and faculty silently moved from
table to table to view each piece. The silence provided for reflection and privacy and helped create a safe space.
The third step involved a discussion about each piece of art.
Everyone present, except the “owner” of the art, spoke about the
meaning it had for them, its connection with education, and how
they felt about the art. The owner did not participate or indicate any
reactions to the comments made by others. Questions included,
2 8 0 Nursing Education Perspectives
Who is the owner? Is it old or new? Is it produced by a child or
adult, male or female? From what culture is the piece of art? After
a brainstorming session, the owner told her story about the art and
its connection with educator and education.
Three additional steps ensued. First, the participants and one
of the course faculty discussed, in pairs, the experience of taking
part in the exhibition and how this pedagogical strategy might be
used in nursing education. Second, everyone sat together in a circle without tables to summarize the remarks and observations
they made when they paired off to discuss the experience.
Finally, at the conclusion of the workshop, the students were
asked to write anonymous responses to two questions: What were
your feelings related to participating in the program? What did
you learn? The responses were transcribed verbatim and analyzed according to the principles of phenomenography (25,26).
Reflection The reflection step in action research occurs during
the implementation of the new ideas. It provides insight into the
process of implementation and the effect that change has on the
key players (4). In an effort to examine the implementation
process and its influence on the students, a phenomenographic
analysis of written data was conducted. Phenomenography is concerned with people’s qualitatively different conceptions of the
experienced world (25,27) and emphasizes conceptions as central
to describing knowledge (26). The ultimate goal is to describe the
different ways people make sense of, experience, and understand
phenomena in the world around them.
Feelings and learning are the two main categories that
emerged from the data analysis. Descriptive subcategories were
also found. The meanings of the two categories, organized into
subcategories, are elucidated by quotations from the students.
(Fictional student names are used.)
Category: Feelings
Subcategory:“Feeling uncomfortable meeting the unknown” This sub-
category reflects negative feelings related to the beginning of the
workshop. One student described the discomfort she experienced walking around the classroom without talking while looking
at the art. The same student expressed feelings of uncertainty
about what was going to happen “as there were no clear objectives and our learning was what we made it” (Lisa). A second
student expressed feeling nervous about her specific piece of
art: “I felt nervous that others wouldn’t like that or that mine
wouldn’t be as good as others” (Kaye). Another student felt
“sneaky” holding back her reaction to what others were saying
about her artwork.
H U M A N I T I E S I N N U R S I N G E D U C AT I O N
E
ducators must ask a basic question: “How can we
position ourselves as less masters of truth and justice
and more as creators of a space where those directly
involved can act and speak on their own behalf?”
Subcategory:“Feeling enjoyment in participating” Students expressed
positive feelings about participating in the exhibition and the
sharing of artwork, using phrases such as “highly enjoyable and
insightful,” “fun and exciting,” and “delighted and surprised.”
Lisa stated, “As the exercise transpired, I began to enjoy learning about the differences in the artwork.” Another said: “I am not
an artist and to have a piece of art that I chose be considered
worth any discussion was an exhilarating feeling” (Charlotte).
Subcategory: “Feeling excited about sharing thoughts” This
subcategory illustrates the excitement and uniqueness of discussing ideas centered on the selected art. Kaye felt excited to
see the works her peers selected and honored to “hear the inside
scoop.” Another expressed curiosity about how others used art to
reveal their thinking: “I was very interested in viewing my peers’
favorite artwork that illustrated their conceptualization of education and educator” (Jennie).
Subcategory: “Feeling of duality while being in focus” This
subcategory emerged from the students’ expressions of both positive and negative feelings. For example, Charlotte described
being more nervous than usual but feeling empowered: “When it
was time for me to talk I was more nervous than is the norm for
me; but to have this very personal part of myself revealed and
accepted as good was empowering.” Similarly, Jennie wrote,
“Even though I was uncomfortable to be in the limelight, I felt
valued and respected as I shared.”
Category: Learning
Subcategory: “Learning a teaching-learning strategy” Various
phrases were used to describe the experience as a learning strategy,
including “an exercise in aesthetic knowing” (Charlotte), and “a
fun way to learn or teach others” (Kaye). Jennie used the terms
“creativity and freedom” to express what she learned: “The art
show was an example of how to use art as a way of incorporating
creativity and freedom in the curriculum effectively, respectfully,
and holistically.” Lisa wrote of learning about human diversity and
related the experience to a demonstration of nonbehavioristic/
humanistic education: “I also learned about diversity, not diversity related to culture so much but human diversity. Just that all
people are different and see things differently. That people come
from all different backgrounds that influence how they experience
things. This exercise demonstrated this very effectively. I think it
may have been a demonstration of nonbehavioristic/humanistic
education. We went into it with very little rules and no clear objectives and our learning was what we made it.”
Another student, Rose, expressed how connecting learning to
art was educational for her: “What was really educational was to
connect it [art] with ‘education’ and ‘teaching-learning
process’….It took me another step deeper into the artwork.” Kaye
related that she was “challenged and stimulated” by the brainstorming used at the beginning of the exhibition. Lisa stated she
never thought of brainstorming as a learning strategy but found it
to be a different and unique way to present a learning experience.
She further explained: “I liked the brainstorming and the rules
associated with brainstorming — especially that nothing that is
said is related to right or wrong. This makes people feel safe.”
Subcategory: “Learning about connection” This subcategory
includes statements that underscore how students learned about
connection to the group and to the unique individual. Rose stated,
“I felt a connection to the group [trust] and to each individual as
they presented their art.”
Connections with others may illuminate the way that human
beings are similar, yet unique. Charlotte stated poignantly, “I
learned that we all have similar things and yet, at the same time,
very unique ways of looking at what is beautiful.”
November / December 2004 Vol. 2 5 N o . 6 2 8 1
H U M A N I T I E S I N N U R S I N G E D U C AT I O N
Subcategory: “Learning about myself and others” One student
said that she was encouraged to learn about herself. Another,
Rose, described how she opened herself to see what others did not
see: “As we went from table to table in our class last week, I
reflected on what I learned prior, how to open myself to see what
others may not see.” The students were able to learn more about
each person in the room and were awakened to how differently
each one viewed the same thing. “Most of all, it shows me how
there are so many ways to view one thing no matter what it is. We
interpret/perceive differently from others. That should be
respected” (Rose).
Learning about peers through art adds an intimate quality.
Referring to a classmate who shared a poem “that revealed a personal inner struggle resulting in self-discovery” and another’s
“love for nature,” Jennie stated, “I was able to learn about my
own favorite artwork; things I hadn’t thought about in relation to
it. This brought about more appreciation, value, and understanding for the artist.”
Evaluation The evaluation step of PAR, which begins when the
implementation step is concluded, leads to practical knowledge
generation. “Practitioners learn about their practice and about
themselves within a setting and also learn to implement change to
improve their own practice” (4, p. 252). Action research may
include a report written by the co-researchers that is not a “prescription for action,” but a “springboard for dialogue” (4, p. 262).
Educators must ask a basic question: “How can we position ourselves as less masters of truth and justice and more as creators of a
space where those directly involved can act and speak on their own
behalf?” (28, p. 137). Schneider asks, how many students think
that art is “made by upper-class men, writing their views of the
human experience?” and how many want “desperately to sound
like them?” (29, p. xv). It is only in this notion of creation, in which
climate, structure, and dialogue are safely and carefully designed
(30) that students find their own voice and “articulate what they
may have hesitated to say in another context” (18, p. 54).
Schneider maintains that “art belongs to the people…it
belongs to those who ‘stand here ironing,’ to those who clean city
streets, to those who work in front of computer screens, as well as
to those who read in the ivy halls” (29, p. xv). If that is so, surely
it belongs to the thousands of students who learn and experience
nursing caring and practice in the most daily and ordinary and
elegant ways. Educators must respect and honor students’ voices
and art no more nor less than than they honor the assigned scholarly literature.
The first implication that emerged as practical knowledge from
2 8 2 Nursing Education Perspectives
this project is the recognition that students and faculty may feel
uncomfortable in meeting the unknown and, if these feelings prevent forward movement, no further learning or development will
occur. Students voiced that part of the discomfort was related to
being in focus. Yet, to have one’s own voice (i.e., being in focus)
is essential.
A second source of discomfort may be the call to “witness what
was important to other persons” (18, p. 53). A paradox emerges:
There is a sense of joy, perhaps of freedom, that is apparent with
voice, focus, and witness, but it is also accompanied by some hesitancy and discomfort. Perhaps faculty need to help themselves
and their students identify and describe feelings of discomfort so
that the pain will not be immobilizing.
A second implication is confidence in knowing that once students feel that they are participating, they will also feel enjoyment. That is, actively sharing their conceptualizations about
education and the educator role in a safe environment created a
feeling of excitement that served as the foundation for related
scholarly activities. Finally, this project supported the connection between learning and feelings. It may be that learning cannot be separated from feelings. To isolate them in our classrooms
and clinical teaching may be a barrier to personal and professional growth.
If nurses are expected to integrate humanities with their nursing practice, they must experience and practice a connection in
their education, and that connection extends beyond the four
walls of the nursing classroom. For example, could nursing students and faculty join with theater students to voice what it means
to despair, hope, lose cognition, or become a parent? How might
this experience affect everyone involved and how might it be used
in future research? Could such an experience help faculty identify
how students use linking, connections, and patterning to develop
different ways of knowing?
Linking, connecting, and patterning help educators shift from
a focus on teaching to a focus on learning, away from an isolated
teaching strategy to an emphasis on a broader understanding of
the world. Palmer (31) reminded educators that when teaching is
divided from learning, the result is teachers who talk but do not
listen, and students who listen but do not talk. He maintained that
technique is what teachers use until the real teacher arrives and
concluded that good learning does not begin until the real-life
teacher joins with the real life of the student.
The students’ voices in this research have echoed Palmer’s
belief that “to educate is to guide students on an inner journey
toward more truthful ways of seeing and being in the world” (31,
p. 6). If humanities are the language of the soul, they can be used
H U M A N I T I E S I N N U R S I N G E D U C AT I O N
on this inner journey to learn more about what it means to be
human. It is desired that these evaluative thoughts serve to
launch further spirited discussions and changes in the way education is conceptualized.
NLN
NLN
About the Authors Robyn L. Smith, BSN, RN, is an assistant
researcher at the School of Nursing, University of Wisconsin-Eau
Claire, and a critical care nurse at Luther Hospital, Eau Claire.
Michelle Bailey, BSN, RN, is a public health nurse, Burnette County,
Department of Health and Human Services, Siren, Wisconsin.
Sharon Kay Hydo, BSN, RN, is a medical-surgical nurse, Sacred
Heart Hospital, Eau Claire, and a clinical instructor, School of
Nursing, University of Wisconsin-Eau Claire. Margret Lepp, PhD,
RN, is an assistant professor, University College of Health Sciences,
Borås, Sweden. Sylvia Mews, BSN, RN, is a palliative care nurse,
St. Joseph Hospital, Marshfield, Wisconsin. Susan Timm, BSN,
RN, is a patient safety specialist, Luther Hospital, Eau Claire.
CeCelia Zorn, PhD, RN, is a professor, School of Nursing, University of Wisconsin-Eau Claire. Robyn L. Smith, Michelle Bailey,
Sharon Kay Hydo, Sylvia Mews, and Susan Timm are students in
the master’s program at the School of Nursing, University of Wisconsin-Eau Claire, preparing for the role of educator. For more
information, contact Dr. Zorn at [email protected].
Key Words Humanities – Pedagogy – Nursing Education – Participatory
Action Research – Phenomenography – Reflection
References
gallery. Journal of Nursing Scholarship, 32(1), 197-199.
1.Valiga,T. M., & Bruderle, E. R. (1997). Using art and
humanities to teach nursing. New York: Springer
Publishing.
12.Winland-Brown, J. E. (1996). Can caring for critically ill patients be taught by reading a novel?
Nurse Educator, 21(5), 23-27.
2. American Association of Colleges of Nurses
(2002). Peaceful death: Recommended competencies
and curricular guidelines for end-of-life care. Washington, DC: Author.
13. American Nurses Association. (1995). Nursing’s
social policy statement. Washington, DC: Author.
3. Argyris, C., & Schon, D. (1991). Participatory
action research and action science compared: A
commentary. In W. F. Whyte (Ed.), Participatory
action research (pp. 85-96). Newbury Park, CA:
Sage.
4. Streubert, H., & Carpenter, D. (Eds.) (1999). Qualitative research in nursing: Advancing the humanistic
imperative (2nd ed.). Philadelphia: Lippincott.
5. Beckerman, A. (1994). A personal journal of caring through esthetic knowing. Advances in Nursing
Science, 17(1), 71-79.
6. Brodersen, L. D. (2001). Creatively capturing
care: Poetry and knowledge in nursing. International Journal for Human Caring, 6(1), 33-41.
22. Bruderle, E. R., & Valiga,T. M. (1994). Integrating
the arts and humanities into nursing education. In
P. L. Chinn & J.Watson (Eds.), Art and Aesthetics in
Nursing (pp. 117-144). New York: National League
for Nursing.
14. Barry, C. D. (2001). Creating a quilt: An aesthetic expression of caring for nursing students.
International Journal for Human Caring, 6(1), 25-29.
23. Andrews, J. L. (2001). Role of the advanced
practice nurse. In D. Robinson & C. P. Kish (Eds.),
Core concepts in advanced practice nursing. St. Louis:
Mosby.
15. Carper, B. (1978). Fundamental patterns of
knowing in nursing. Advances in Nursing Science,
1(1), 13-23.
24. O’Toole J., & Lepp M. (2000). Drama for life: Stories of adult learning and empowerment. Brisbane,
Australia: PlayLab.
16. Wikström, B. (2001). Works of art: A complement to theoretical knowledge when teaching
nursing care. Journal of Clinical Nursing, 10(1), 2532.
25. Lepp, M., & Ringsberg, K. C. (2002). Phenomenography: A qualitative research approach. In L.
R-M. Hallberg (Ed.), Qualitative methods in public
health research (pp. 105-135). Lund, Sweden: Student litteratur.
17.Wikström, B. (2001).Work of art dialogues: An
educational technique by which students discover
personal knowledge of empathy. International Journal of Nursing Practice, 7(24), 24-29.
26. Marton, F. (1986). Phenomenography: A
research approach to investigating different understandings of reality. Journal of Thought, 21(3), 28-49.
18. Killion, C. M. (2001). Understanding cultural
aspects of health through photography. Nursing
Outlook, 49, 50-54.
27. Svensson, L. (1997). Theoretical foundations of
phenomenography. Higher Education Research and
Development, 16(2), 159-171.
8. Inskeep, S. J., & Lisko, S.A. (2001).Teaching strategies: Alternative clinical nursing experience in an
art gallery. Nurse Educator, 26, 117-119.
19. Darbyshire, P. (1993). Understanding caring
through photography. In N. L. Diekelmann & M. L.
Rather (Eds.), Transforming RN education: Dialogue
and debate (pp. 275-90). New York: National
League for Nursing.
28. Lather, P. (1991). Getting smart: Feminist research
and pedagogy with/in the postmodern. New York:
Routledge.
9. Koithan, M. S. (1996). Aesthetics in nursing practice and education. Issues in Mental Health Nursing,
17, 529-539.
20. Schaefer, K. (2002). Reflections on caring narratives: Enhancing patterns of knowing. Nursing Education Perspectives, 23, 286-293.
10. Tsakiridou, C. A. (1999). Aesthetic expression.
International Journal for Human Caring, 3(1), 43-49.
21. Olson, T. (2002). Poems, patients, and psychosocial nursing. Journal of Psychosocial Nursing
and Mental Health Services, 40(2), 46-53.
7. De Montigny, F. (1998). Using art to stimulate
thinking in a family nursing clinical practicum. Journal of Family Nursing, 4(4), 358-366.
11.Wikström, B. (2000). Nursing education at an art
29. Schneider, P. (1993). The writer as an artist:A new
approach to writing alone and with others. Los Angeles: Lowell House.
30. Lepp, M., & Zorn, C. R.. (2002). Life circle: Creating safe space for educational empowerment.
Journal of Nursing Education, 41, 383-385.
31. Palmer, P. J. (1998). The courage to teach: Exploring the inner landscape of a teacher’s life. San Francisco: Jossey-Bass.
November / December 2004 Vol. 2 5 N o . 6 2 8 3
Copyright of Nursing Education Perspectives is the property of National League for Nursing and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.