Keywords

Creativity; education; empathy; nursing students; poetry

Introduction

Becoming a nurse requires more than just learning facts and theories. The seminal work of Carper (1978) is a reminder that there are four fundamental patterns of knowing in nursing, empiric, aesthetic, ethical and personal, which are of equal importance. Emotional awareness, sensitivity towards others and relational caring lies at the core of nursing practice and ways in which these patterns can be developed are required. Some of the criticisms relating to nursing practice have been targeted at the educational preparation nurses receive, and more specifically the move to an all-degree profession at the point of registration. However, Rolfe (2014: 1459) suggests that even now nursing students are in fact „under-educated‟ and although well trained and able to think critically, they are lacking in imagination. He suggests the need for a more rounded education, one which incorporates issues and subjects which at first seem to have no relevance to nurse education, for example, the arts, humanities and philosophy. Theoretical and factual knowledge has clear value in nurse education but there is a requirement for approaches which encourage recognition of the uniqueness of another; an education which has empathy and understanding of the human condition at its heart. The purpose of this article is to explore one such approach. The work reports on an evaluation of the use of poetry writing and performance as a means of helping students identify and understand their feelings about important nursing issues such as communication, compassion and the therapeutic practice of nursing.

Background

There has been some interest in arts based approaches within nurse education. Creative art and collage has been used in the education of student nurses and midwives, (Hall & Mitchell, 2008, Jack 2012). Lillyman et al (2011) used storyboarding with student nurses to explore thoughts and feelings about nursing practice. The use of published material has been used to good effect for example, the consideration of children‟s stories to explore the meaning of ageing (Jack, 2013) and the reading of published poetry as a way to reduce anxiety and stress (Mohammadian et al, 2011). Crawley et al (2012: 45) describe books as a „rich resource‟ for educators when encouraging the development of emotional awareness, for example when exploring issues such as death and dying, and story extracts can be used to explore understanding of what it is to be human (Gallagher and McKie, 2010). Emmanuel et al (2010) used mask design as a form of assessment of therapeutic communication skills and found it an effective way to promote deeper levels of learning. Poetry has been described as a debatable term (Andrews, 1991) and various forms of poetry have been used across education, including social work, teacher education, medicine and nursing. For the purposes of this intervention, the importance is placed on the process of poetry writing and subsequent discussion, rather than the actual structure of the poem itself. Biley & Champney-Smith (2003) facilitated haiku writing workshops as part of a course on the use of arts in health care. Modern haiku is a form of Japanese poetry which is none rhyming and consists of patterns of five, seven and five syllables in the first second and third lines. Student nurses were asked to write haiku about an aspect of their clinical work or their nurse education. Findings revealed that the exercise had been an effective way to reflect on clinical practice, develop writing skills and expression of ideas. Threlfall (2013) explored the use of poems to reflect on prior learning with students enrolled on a Foundation Degree in Sports Coaching. This method replaced the formulation of a study skill action plan which explored their personal and professional development. Sixteen students were given 48 hours to produce poems which represented their action plans in a different way. The poems were collected and following a four week period, the students were interviewed and attended a focus group. The findings support the use of poetry as a way to reflect and the process was enjoyable, if at times frustrating for the students. Students felt empowered by the process as it helped them feel in control of their learning and some requested more creative learning methods in future lessons and assessments. Speare & Henshall (2014) used six published poems as a basis for discussion with seven further education student teachers enrolled on a Post Graduate Certificate in Education Programme. The discussion sessions were audio recorded and each participant was individually interviewed after the group session. The authors suggest that reading poetry can support reflection particularly on the motivation to teach and the reasons why student teachers choose the profession. The participants found the exercise therapeutic and encouraged a „stepping back‟ from practice in order to reflect on it critically. Foster & Freeman (2008) explored the use of published poetry with thirteen general practice registrars. The participants experienced two sessions; in the first, the facilitator chose the poems and in the second, the registrars made the choices. Six of the group then engaged in an individual semi structured interview which was analysed using interpretive phenomenological analysis. Findings revealed that the sessions had supported development of emotional awareness and encouraged them to consider alternative viewpoints thus increasing their understanding of others.

Methods

Students

A cohort of 42 first year nursing students enrolled on the BSc (Hones) Adult Nursing program at a Shahid Beheshti university were asked to participate in this exercise as part of the teaching for the module „Nursing in a Contemporary Society‟. Part of the module focus is on the development of emotional sensitivity, self-awareness and self-monitoring. Students explore theoretical concepts such as emotional intelligence and are encouraged to consider how to identify and understand their emotions and ways to manage their feelings effectively (Salovey & Mayer, 1990). Ethical approval was gained through the Faculty Ethics Committee at Shahid Beheshti University.

Approach

This session had previously been taught using a lecture style approach in which models of emotional intelligence such as those written by Goleman (1999) and Salovey & Mayer (1990) were examined and discussed within a large group. There was a focus on the need for students to identify and manage their feelings although little in the way of how this might be achieved. Critical reflection was identified as a way to explore feelings although this was considered from a theoretical rather than practical focus. Mindful of the shortcomings of this method a different approach was used which required the students to write a poem about their feelings. This decision was based on the success of other art based approaches adopted within the Department of Nursing in previous years. Input was sought from a creative writing lecturer from another department and interested nursing academics. Following this process the lesson was restructured and given a more student centred focus. The initial lesson was replaced by a one hour workshop where poetry was discussed as a method of exploring practice. Emphasis was given to the need to focus on the process of poetry writing rather than concentrate on the quality of the product, the poem itself. However input from the creative writing colleague gave examples of poetry styles which the students could utilize if they chose. The cohort was given directed study time to create their poem and then in small groups of ten – twelve they were required to read out their poem and listen to their colleagues reading theirs. Each group was facilitated by one lecturer with an interest in arts based approaches to teaching. The following direction was given to the students:

Write a poem of any length and style, with a focus on an important nursing issue e.g. compassion, communication or your therapeutic role as a nurse. Read the poem aloud to the small group and be able to discuss its meaning and how this relates to you as a nurse and to your practice. Due to the nature of the module it is important to promote a safe and supportive environment where students feel able to state their views and explore their feelings in front of their colleagues. This need is further emphasized when using arts as students can feel vulnerable and exposed particularly if they feel that their end product, in this case a poem, is substandard. Students need to feel safe enough to explore issues without too much educator prescription, which only serves to stifle individual creativity (Casey, 2009). To further encourage the students, they were informed that the lecturers involved would be writing their own poems, thereby exposing something of themselves to the small group. By doing this, the educator is a „co-discoverer‟ in the process rather than an information giver thereby encouraging a supportive and inquiry based approach (Koithan, 1996). Students using art based educational methods will need to get used to a different style of learning, one which is not as structured as they might have become used to. Using arts based approaches such as poetry teaches us that there is more than one solution to a particular problem (Eisner, 2002) and „diversity and variability are made central (p. 197). Much of the teaching in Year One of the undergraduate nursing program is anatomy based and students have been used to a didactic lecture style approach by the time they reach this module. Therefore the concept of using poetry to think about practice was discussed at the introductory session and referred to throughout the module. In doing this it was hoped that the students would already feel familiar with the concept when they were asked to produce creative work. During the follow up session, when the students were required to read their poems aloud, the chairs were arranged in a circle to promote an informal atmosphere. The educators provided chocolates to be shared during the session to further promote a relaxed and supportive atmosphere.

Analysis

The following three areas were analyzed to provide an understanding of the students learning experiences:

  1. Student written evaluations: students were asked three qualitative questions about their experience and the perceived benefit of poetry writing to explore their practice
  2. Qualitative follow up interviews: a purposive sample of three students were invited to an unstructured interview where they were asked to discuss their feelings about this method of teaching.
  3. Verbal feedback from four members of staff involved with the delivery of the teaching initiative.

Results

The students wrote poems which were diverse in content, meaning, style and length. Many students wrote about their experiences of patient death and their associated feelings. Many poems had a focus on communication and the importance of effective interaction with patients. Some students wrote about what it is like to be a student nurse and their commitment to completion of their nursing program. The evaluations were completed by 40 students on a voluntary basis. Sixty percent of students (n = 24) reported that the exercise had increased understanding of their chosen subject (Question: How well did the exercise increase your understanding of your chosen topic?). Comments included; „It helped me think more about emotions and how other people might feel‟, „It got me to consider the topic in more depth‟ and

„It made me think about compassion in different ways‟. Ten percent (n = 4) stated their initial reluctance to engage with the exercise with comments such as; „At first I thought it was a pointless exercise, but when doing it, it made me think‟. Thirty percent (n = 12) stated that it had not made any difference to their understanding. It is possible for this latter group that they might have been referring to understanding of the theoretical aspects of the topic which was not the primary concern of the exercise. Seventy percent of students (n = 30) stated that they had learned something about themselves through taking part in the exercise (Question: Did writing the poem help you to learn anything about yourself?). Comments included; „I learned about how I must come across to the patient‟, „It made me think about what I would want, if I was in hospital‟ and „I learned that things affect me a lot more than I think they do‟.

Sixty five percent of students (n = 26) stated that they had enjoyed the exercise as a learning activity, with many describing given time as an important factor (Question: How much did you enjoy the poetry writing exercise?). Comments included; „I enjoyed it as I had to sit back and have a quiet think‟, and „It was different and a more interesting way to learn‟. Twenty percent of students (n = 8) stated that they hadn‟t enjoyed it although some of these comments related to the end product rather than the process; „I felt quite stressed as I am no good at writing poems‟, „I didn‟t enjoy it as I don‟t like poetry‟. Some students reported it had value even though they did not enjoy doing it which comments such as; „I didn‟t enjoy it but I did look at nursing from a different angle which was good‟. Some students engaged with the process in a very meaningful way as evidenced by the following qualitative exemplars, taken from the interviews: „I was initially sceptical but then I heard the poems written by the rest of my cohort. As I listened to the works of people who I had shared lectures with, I began to understand not just their experiences, but how it had affected them, not only as a student nurse but on a personal level‟ (Student 1)

„Having my poem as a prop enabled me to discuss my feelings with others in the group in a very honest way and I probably wouldn’t have been brave enough to do that otherwise. Reflection is very valuable but some of the models don’t allow for much freedom. This poetry exercise allowed us to reflect without being restricted by a template. We are reflecting on things that are personal to us, so the process should be personal and individual too‟ (Student 2) „It helped me to clarify and validate what my thoughts and feelings were. When it is free and easy like this, you are left to explore the areas that might not be explored in the formula of a reflective piece. If you write a poem you have to explore these areas‟ (Student 3) Four lecturers were involved with the exercise and stated that the students had seemed engaged in the process and it had generated in depth discussion about the topics raised. The students found the session challenging and some were uncomfortable, particularly when reading out their poem. However some students stated that they were proud to have read their poem aloud and had viewed it as a positive challenge to themselves to do so. They felt that having to present their poem to their peers served as a good practice for their forthcoming assessment which has a presentation format. The session lead to deeper levels of reflection and there was a feeling of empathy in the group as each student read their poem.

Discussion

Results of this study seem to suggest that the writing and reading out of poetry might be an effective way for students to identify and explore their feelings about nursing practice. I suggest that there are multiple benefits to this approach. The poems written by the students might at first seem confusing and abstract and require the listener to concentrate in order to make sense of what it being said. However listening to others poems is a rehearsal for what student nurses will be expected to do in practice. This educational method emulates the often confusing nature of nursing practice, when faced with fragments of information which need to be pieced together to form a history. Charon (2007) suggests that sharing poems encourages nurses to follow narratives which helps them to be able to deal with the complicated nature of those they meet in practice. Group discussion of the poems encouraged the students to raise differing views on the subject matter presented in the work. Using poetry to reflect enables learners to develop „higher level‟ thinking skills and to view the world in different ways (Threlfall, 2013: 361). Openness to others perspectives, enriches the imagination and context for understanding ourselves and others in new ways. The data in this study suggests that poetry provides a way of slowing down the thinking process compared to other methods. This provides students with opportunities to consider multiple perspectives, thus avoiding stereotypical ways of thinking (Furman et al, 2008). Rolfe (2014: 1460) suggests the need for a broader educational experience for nurses, one which engages the student in subjects such as literature and the arts. This will support the development of the imagination rather than learning merely the science and the facts. Engaging with this poetry exercise reminds students that nursing is more than a technological process and there is a need to develop relational as well as transactional ways of being. Findings from this study suggest that engaging with poetry supports the development of empathy for another person. Hearing the poems of others helps us to explore the human condition and to feel what another is experiencing (Speared & Hen shall, 2014). When reading a poem out loud we become exposed and vulnerable, we are sharing our innermost thoughts and feelings. Writing poems enables us to free our imagination and express feelings and insights we might normally keep hidden. This is in stark contrast to traditional ways of teaching which might serve to inhibit creativity and imagination (Chan, 2013). Fostering confidence is important to student learning and further strategies for its development are required in undergraduate curricula in England (Roberts & Johnson, 2009). Reading and discussing poetry has been shown to increase self-esteem and self-exploration and might be effective in reducing anxiety and stress (Mohammadian et al, 2011). To increase students confidence it is important for the educator not to look for right or wrong answers but to respect all of the contributions offered (Gomez, 2007). The perceived lack of restriction involved in poetry writing gave a „freedom‟ not found in assignment writing or when engaging in traditional forms of reflection, for example, when using a reflective model. Poetry writing is a way of finding a voice not only for oneself but for those unable to speak (Fox, 1995). This is important in nursing practice, as a means to catharsis and closure on difficult experiences. However the value of poetry writing reaches further than the initial draft of the poem. It is the reworking and redrafting, in order to find the most appropriate words to capture the experience, memories and emotions, which brings further insight and understanding (Bolton, 1999). It is here that the true value of poetry writing lies. The poems seemed to act as the voice of „another‟ and one participant described her poem as a „prop‟. It is as if by having a different outlet, the students had the confidence to discuss feelings that they might have not usually done and this encouraged discussion of topics not normally explored. Fox (1995: xv) describes the way in which poems can become „containers‟ of feelings and when this occurs, the writer is able experience those feelings at a more conscious level. This is important for nurses as it is when they begin to be aware of their own feelings, they can begin to understand the feelings of others. Nurses need to be creative thinkers if they are to overcome problems and find solutions to challenges that nursing practice creates (Chan, 2013). If educators can support the development of creative thinking in undergraduate education, this prepares nurses for their future roles. Karpova et al, (2011) suggests that to develop creativity students need space to generate and try out their ideas. Poetry writing and performance is one such way as the poems are based on real life stories and offer multiple avenues for discussion and encouragement for the curious mind.

Limitations

Not all students felt they were creative enough to take part and some opted out. Some students concentrated on the structure of the poem and became concerned about length and the need for their poem to rhyme. This distracts the students from the process as a reflective activity and is a finding shared by similar studies (see Threlfall, 2013). However engaging in the task of writing a poem supports the development of writing skills, language and vocabulary (Wiseman, 2011) even if it does not encourage the reflective process. It is acknowledged that some individuals are much more creative than others and there needs to be a receptive environment if students are going to develop creative skills (Gomez, 2007). Lillyman et al (2011) suggest that all student centred teaching methods require careful planning and skilled facilitation, as educators need to incorporate their pastoral role into their formal teaching. Students need to feel safe and the educator needs to take on a nurturing role whilst encouraging the freedom that this style of learning affords. Creating such an environment might be difficult for lecturers who already feel challenged to meet the demands of their role in the current higher education setting.

Conclusion

In conclusion, it is important that teaching methods are developed which engage students‟ imagination and creativity if they are going to be prepared for future practice. There is a need to move beyond only the delivery of theoretical principles and engage students in deeper and more meaningful levels of learning. It is not a case of whether the arts and literature can be utilised in nurse education but more a question of how it can be done and the scope and extent of use. Based on this assertion, it is important that further nursing research is undertaken in order to explore the possibilities.