Enhancing Nursing Students' Clinical Experiences Using Aesthetics

Enhancing Nursing Students’ Clinical Experiences Using Aesthetics ROBIN

LADONNA NORTHINGTON, DNS, RN, BC, CCRN,* WILKERSON, PHD, RN, BC,* WANDA FISHER, PHD, C, RN,* LAURA SCHENK, PHD, C, RN, NNP*

Traditional nursing education is based strongly in empiric knowledge. However, just as important as empiric knowledge is aesthetic knowledge. Nursing involves multiple ways of knowing, and as such, educational institutions have a responsibility to assist students in gaining knowledge in nontraditonal ways. This article describes an assignment implemented in a pediatric course in a baccalaureate nursing program. Books and movies were used in a an undergraduate nursing course to help students gain insight into illness and disability from the client and family perspective. The students in the course were required to reflect on the meaning of the movie/book and the influence the book/movie had on the student. Based on student responses, this assignment was successful in meeting the objectives originally proposed. The books and movies provided a beginning introduction to, and an appreciation for, client and family experiences. Students were helped to understand illness, abuse, disability, and/or death from the client and/or family perspective. (Index words: Aesthetics; Ways of knowing; Nursing education; Alternative educational strategy) J Prof Nurs 21:66 – 71, 2005. A 2005 Elsevier Inc. All rights reserved.

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ISTORICALLY, THE NURSING scholars have stressed the importance of a holistic approach to both nursing care and nursing education. As the nurse becomes enmeshed in the profession, knowledge, and understanding are gained through multiple ways of knowing (Carper, 1978; Koithan, 1996). Nursing, in an effort to have a scientific basis,

*University of Mississippi School of Nursing, Jackson, MS. Address correspondence and reprint requests to Dr. Northington: University of Mississippi School of Nursing, 2500 North State Street, Jackson, Mississippi 39216. 8755-7223/$30.00 n 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.profnurs.2004.11.007 66

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has based much of the curriculum on empirics. There has not been documented evidence supporting the acknowledgment of personal knowing and its influence on nursing care, practice, or education. In education, there is often still a lack of opportunity for students to experience aesthetic knowing. To offer students the most benefit, all patterns of knowing must be included in the educational process. The purpose of this article is to describe the implementation of an aesthetic experience assignment in a pediatric clinical course in a baccalaureate nursing program. The assignment for this pediatric nursing course was an attempt to expand on the students’ life experiences and provide an opportunity for reflection. This would in turn broaden the educational scope of learning for the student to include aesthetic knowing. Review of the Literature

A review of the literature reveals only a few articles devoted to the implementation or evaluation of an aesthetic experience in nursing education (Hautman, 1997; Micheal, Candela, & Mitchell, 2002). Hautman (1997) incorporated an aesthetic project into a graduate nursing theory course. The intent of the assignment was to make several concepts (such as suffering and hardiness) more real for the students. The author did not discuss the results. Micheal et al. (2002) implemented an aesthetic project for undergraduate senior nursing students that involved clients who were chronically ill. The author reported that 66% of the students felt the project was positive. The students either changed the care for their client or the client’s care was affected positively in some other way. The review of literature related to aesthetic experiences in nursing education points to the need for the further research in this area.

Journal of Professional Nursing, Vol 21, No 1 (January–February), 2005: pp 66–71

ENHANCING NURSING STUDENTS’ CLINICAL EXPERIENCES USING AESTHETICS

Aesthetics Assignment

The changing health-care environment, including increased technological support and resources, combined with the increased acuity of patients and the new generation of students, makes it imperative that new ways of learning be incorporated with the traditional methods of teaching. Nursing students must begin to learn early the importance of the person within the client and the people supporting the client. There must be a growing tolerance and appreciation for all the factors influencing the experience of clients. In the clinical settings, students are limited to the diagnoses and illnesses of the patients admitted to the institution in which they have their clinical rotations. Those students fortunate enough to be in a medical center setting may experience pediatric clients with a variety of disabilities and long-term illnesses. There might even be occasions to deal with abuse/ neglect and death. However, there are a great number of students who graduate from a nursing program with no exposure to these circumstances. Nonetheless, students must understand early in their education that a person is influenced by past experiences, family backgrounds, socioeconomic status, religious and cultural beliefs, and experiences with illness within their own family or community. Additionally, students need to understand what it is like to be a family member or client with a longterm illness or disability, because most students have never experienced these situations themselves. Thoughts, emotions, and feelings are an integral part of and greatly influence the illness and healing process. If students are unable to experience this type of learning process directly, then it must be incorporated into the learning process in some other format. Indeed, with all the technical information that students must learn to nurse, how can aesthetics be incorporated? The objective of the assignment was to help the students understand experiences with illness, abuse, disability, and/or death from the client and/or family perspective. The goal was that raising the students’ awareness and understanding would effect a positive influence on care delivery. For the purpose of this assignment, the arts were used to operationalize aesthetics, providing a way for the students to better understand the meaning of the situation to the client and family. The faculty developed a list of movies and books that related to the experience of childhood illness, death, disability,

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and/or family struggles (see Table 1). Students were required to read a book(s) and/or watch a movie(s) of their choice (based on a point system) in their pediatric clinical rotation. After completion, the students were required to write a synopsis of the move or book and respond to several questions related to the experience. The questions included: How did the movie/book change you? How do you anticipate or how has the movie/book affected your practice as a nurse? Would you recommend the movie/ book to other health-care professionals? These questions were designed to challenge the students to reflect upon experiences from the client/family perspective and to delineate what influence the various types of scenarios presented in the books/ movies might have on the students’ delivery of nursing care. The faculty reflected on comments made by the students to evaluate the success of the objectives of the assignment. The faculty was attempting to validate if their objectives of the assignment had been met. Additionally, the faculty wanted to determine whether the student could project how the scenarios might influence their nursing care in the future. Many of the books/movies generated conversations in postconference sessions and on the clinical units. When questioned informally about the assignment, the students evaluated the experience as positive overall. Because the books and movies were being read or seen with a specific purpose in mind, the student’s perspective was different than it might have been if the exercise had been strictly recreational. Based on the overall comments from the students, the faculty accomplished the objectives for the assignment. The books and movie list were chosen based on the following: whether the book/movie presented a situation that would relate to the objective, conversations with students in the previous semester, the style of writing, faculty perceptions, and the subject matter. The most popular books chosen by students were: A Child Called bIt Q (Pelzer, 1995), The Lost Boy (Pelzer, 1997), Bethy and the Mouse (Bakely, 1997), The Midwife’s Apprentice (Cushman, 1995), and Death Be Not Proud (Gunther, 1949). The first book deals with a child’s survival of abuse (age 4–12 years); the second book is the survival of the same child (age 12–18 years) and the experience of foster care; the third book is a father’s account of having a child with a microcephaly and Down’s syndrome; the fourth book is a story about an orphan who is determined to survive and succeed; and the

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TABLE 1.

TABLE 1. (Continued ) List for aesthetic readings

List for aesthetic readings

Bakely, D. (1997). Bethy and the mouse: A father remembers his children with disabilities. Cambridge, MA: Brookline. Berube, M. (1996). Life as we know it: A father, a family, and an exceptional child. New York: Random House. Bornbeck, E. (1989). I want to grow hair, I want to grow up, I want to go to Boise: Children surviving cancer. New York: Harper & Row. Buck, P. S. (1950). The child who never grew. Bethesda, MD: Woodbine House. Buscaglia, L. (1982). The fall of Freddie the leaf. Thorofare, NJ: Charles B. Slack. Byars, B. (1970). The summer of the swans. New York: Puffin. Callanan, M., & Kelley, P. (1992). Final gifts: Understanding the special awareness, needs, and communications of the dying. New York: Poseidon. Coman, C. (1995). What Jamie saw. Arden, NC: Front Street. Creech, R. (1992). Reflections from a unicorn. Greenville, NC: R. C. Publishing. Cushman, K. (1994). Catherine called Birdy. New York: Harper Trophy Book. Curhman, K. (1995). The midwife’s apprentice. New York: Clarion Books. Fleming, V. (1993). Be good to Eddie Lee. New York: Philomel Books. Fox, M. (1985). Wilfrid Gordon McDonald Partridge. Brooklyn, NY: Kane/Miller Book. Fuller, C., & Jones, L. T. (1997). Extraordinary kids: Maturing and championing your child with special needs. Colorado Springs, CO: Focus on the Family. Gans, L. (1997). Sisters, brothers, and disability. Minneapolis, MN: Fairview Press. Gunther, J. (1949). Death be not proud. New York: Harper Perennial. Hughes, S. (1990). Ryan: A mother’s story of her hyperaction/Tourette syndrome child. Duarte, CA: Hope Press. Hughes, I. (1995). A prayer for children. New York: William Morrow. Jansen, L., & Caldwell, L. (1998). My sister is special. Cincinnati, OH: Standard Publishing. Johnson, C., & Crowder, J. (1994). Autism: From tragedy to triumph. Boston: Branden Books. Johnson, J., Johnson, S. M., & Williams, B. (1981). Why mine? For parents whose child is seriously ill. Omaha, NE: Centering. Kephart, B. (1998). A slant of sun: One child’s courage. New York: W. W. Norton. Kisor, H. (1990). What’s that pig outdoors? A memoir of deafness. New York: Penguin. Kraus, R. (1971). Leo the late bloomer. New York: Harper Festival. Kupfer, F. (1998). Before and after Zachariah: A family story about a different kind of courage. Chicago: Academy Chicago Publishers. Lucado, M. (1997). You are special. Wheaton, IL: Crossway Books. MacLellan, S. (1998). Amanda’s gift. Health Awareness Communications. Marsh, J. (Ed.) (1994). From the heart: On being the mother of a child with special needs. Bethesda, MD: Woodbine House. Meyer, D. (Ed.) (1995). Uncommon fathers: Reflecting on raising a child with a disability. Bethesda, MD: Woodbine House. Meyer, D. (Ed.) (1997). Views from our shoes: Growing up with a brother or sister with special needs. Bethesda, MD: Woodbine House.

Miller, S. (1990). Family pictures. New York: HarperCollins. Naseef, R. (1997). Special children, challenged parents: The struggles and rewards of raising a child with a disability. Secaucus, NJ: Carol Publishing. Noble, V. (1993). Down is up for Aaron Eagle: A mother’s spiritual journey with Down syndrome. New York: HarperCollins. Pace, J. (1997). A will to live: A diary of transplant kid. Tupelo: Fawn Grove Publications. Paulus, T. (1972). Hope for the flowers. New York: Newman. Peck, M. S. (1992). The friendly snowflake: A fable of faith, love and family. Atlanta: Turner. Peck, R. (1978). Something for Joey. New York: Bantam Books. Pelzer, D. (1995). A child called bit.Q Deerfield Beach, FL: Health Communications. Pelzer, D. (1997). The lost boy. Deerfield Beach, FL: Health Communications. Sacks, O. (1984). A leg to stand on. New York: Harper Perennial. Sacks, O. (1995). An anthropologist on Mars. New York: Random House. Seabrook, E. (1997). Cabbages and kings. New York: Viking. Silverstein, S. (1964). The giving tree. New York: Harper & Row. Simons, R. (1987). After the tears: Parents talk about raising a child with a disability. San Diego: Harcourt Brace. Spradley, T., & Spradley, J. (1987). Deaf like me. Washington, DC: Galludet University Press. Stalling, G., & Cook, S. (1997). Another season. Boston: Little, Brown. Stehil, A. (Ed.) (1995). Dancing in the rain. Wetport, CT: Georgiana Organization. Thompson, M. (1992). My brother Matthew. Rockville, MD: Woodbine House. Voigt, C. (1986). Izzy, Willy-Nilly. New York: Aladdin Paperbacks. Movies

Elephant Man (1980) Lorenzo’s Oil (1992) Marvin’s Room (1996) Mask (1985) Mr. Holland’s Opus (1995) My Left Foot (1989) Patch Adams (1999) Rain Man (1988) Simon Burch (1998) Ulee’s Gold (1997) What’s Eating Gilbert Grape (1993) Wide Awake (1998) The Other Sister (1999) Behind the Mask Molly

fifth book is a father’s account of his son’s battle with a brain tumor. BOOKS

A Child Called bIt Q

This story was enlightening for many of the students. There were comments about the brealityQ of such occurrences. The students stated that the

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book evoked feelings of depression, fear, anger, shock, horror, heartbreak, repulsion, being appalled, and sadness. Some of the students felt compassion directed toward the child. Many students remarked on the appreciation, gratefulness, and thankfulness they felt in their own lives for having a loving family. The students believed this story would influence them to be more cognizant of the signs of possible abuse and the importance of documentation (in the story, a school nurse was largely responsible for rescuing the child from his situation) and intervention. The students also commented that this story would help them to develop and increased awareness and sensitivity. The Lost Boy

Many of the students who read the first book were eager to read this one. Despite the feelings generated by the first book, the students stated ba need to know the rest of the story.Q This book helped them to understand the collaboration and cooperation required of personnel in service-oriented organizations that are designed to help children. One of the biggest realities for the students was the feelings the author discussed. Not only were there emotional scars from the abuse, but also the foster-care environment generated an entirely different set of feelings and emotions (e.g., unworthiness, instability, discrimination). To realize that these children are not bimmediately betterQ when removed from the abuse was a new reality for the students. Many of the students discussed the importance of bcaringQ and how it made a difference in the life of this child. Caring was as an integral part of this child’s survival. Therefore, the students viewed caring as a valuable part of their future nursing care. Bethy and the Mouse

This story is a father’s account of what positive influences his children had on him. The students gained a different perspective in viewing children with cognitive disabilities. Before reading the books, many of the students had preconceived ideas about persons with developmental disabilities. These included viewing these individuals as being challenges and life burdens and eliciting feelings of pity for the person and family members. This story helped students appreciate the uniqueness of children with special needs, the bnormalcyQ within developmental delays, as well as the use of coping and adapting skills. A very important awareness for the students was to

understand the need and reward of early intervention for these children. The Midwife’s Apprentice

This story was different from the previous books in that it was fiction and set in medieval times. The child in this story was an orphan, who was taken in by an apprentice. Although not mistreated, she was not treated well. Nonetheless, the child struggled to survive and learned the skills of the apprentice by observation. In time, circumstances presented themselves such that the child could demonstrate what she knew and could do (delivering babies). The students gleaned concepts from this story such as caring, perseverance, persistence, and not to judge ability based on appearance. Also importantly, it helped increase the students’ awareness of being confident in their own clinical abilities, despite their reluctance to admit competence. Death Be Not Proud

The students described this story as being one of strength, courage, determination, and the will to survive. During the time of this story, many of the treatment options available to this child were experimental and new, so the child and family had faith and belief, which allowed the child to live each day to the fullest. The students’ were inspired by the attempts of the child and family to be bnormalQ under circumstances that might dictate otherwise. The students were reflective of how often life and health are taken for granted and that when thinking about this story, it helped them to be more appreciative for life. This story also helped the students to understand the importance of hope, despite overwhelming odds. MOVIES

The movies most often chosen by our students included Patch Adams, What’s Eating Gilbert Grape?, Simon Birch, and The Other Sister. Patch Adams

In discussing the influence of this movie, the students described the importance of holistic care (physical and mental care) and of caring for the person, not the disease/illness. The connection between a bhappy mental stateQ and physical recovery became a reality for them. In responding to the clients with whom they are interacting, the students described the importance of listening, touching, laugh-

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ing, and communicating in whatever manner causes the client to respond. Caring was deemed as something that was innate and genuine and could not be forced. The students commented that nursing dictates a concern about the plight of others and the desire to make things better with knowledge, skills, and compassion. The students discussed how this movie gave them a renewed hope in the health-care professions and made them want to make an impression on their patients by bbeing thereQ to lessen whatever stressors they could in the client’s situation. What’s Eating Gilbert Grape?

The students discussed this movie in terms of the responsibilities inherent in caring for a child with a mental disability. More so, the students elaborated on the stress within a family system and the influence of the disability on the various other family members. Additionally, the students discussed the influence of role reversal (children taking on adult responsibilities when adults are absent or abandon the adult caregiving role), which raised an awareness of the enormous responsibility that is encompassed in caregiving. The students felt the movie made them more aware of the need to have patience, good assessment and communication skills, and knowledge of resource and referral systems. Simon Birch

This movie evoked a lot of discussion around bias. In this movie, the child is teased and ridiculed about the manifestations of his disability. Students could relate to that type of behavior, some confessing to having participated in such behaviors in the past. There was a realization regarding the pain and sadness that teasing, laughing, and joking can cause to another human being. The students stated that this movie was full of a belief in faith and the purpose of all life, whether that life was perfect or not. This movie also raised an awareness of the importance of love and friendship. The students discussed an increased need to develop an understanding of the feelings of others and learning to understand the needs of an individual with a disability. The students discussed this movie as influencing their nursing careers by developing a desire to learn to treat everybody as they would want to be treated (fairly). The Other Sister

This movie sparked discussions around social acceptance, individual growth, and developing inde-

pendence. Additionally, it raised the awareness that people with disabilities have the same wants and desires as those without disabilities. The students also discussed the effect on family relationships when one sibling has a disability, the need to encourage the development of maximal potential of a person despite the presence of a disability, and the role of family and health-care providers in accepting this growth. This movie helped the students raise awareness of their own behaviors toward people with disabilities and provided them with a desire to change those negative behaviors. The students wanted to be more receptive, a better advocate and to be able to treat all people fairly.

Conclusion

As faculty members, it was enlightening to read these student comments, which were similar in nature. As pediatric faculty, we continually strive to increase the students awareness that nursing is much more than skills. In fact, learning skills may well be the easiest part of nursing. Learning human behavior and response is often difficult, because of the varied influences (both from the client and nurse). Assignments such as this one, which can be done at the students’ leisure (but before the end of the semester), allows time to integrate and reflect on potential clinical situations/encounters. It gives the student an opportunity to think about their reactions to possible scenarios before having to intervene in a real setting. This reflection may include mental rehearsal of ways to communicate, behave, and/or respond and allow the student to assess their actions and begin to incorporate other possible approaches. This assignment also helped students better understand the client and the family perspective and what it is really like to experience situations and events, many of which the student might never otherwise experience. Many of the concepts and values of the philosophy of the school of nursing (caring, compassion, listening, communicating, collaborating, advocating) were discovered by the students as they worked through this assignment in conjunction with their clinical assignments. One of the roles of faculty in mentoring students into the profession of nursing, whether through didactic instruction or clinical experiences, is to help them understand that each client and client situation is unique. An understanding of the circumstances surrounding a client and family will give the nurse a better appreciation of how to intervene and connect with the client and family. This information

ENHANCING NURSING STUDENTS’ CLINICAL EXPERIENCES USING AESTHETICS

can only be gleamed from continuous assessment and observations, open and honest communication, and a listening ear. Learning to listen to bwhat is not saidQ is just as important as bwhat is said.Q These books and movies helped the students to place in perspective some of the experiences of clients and families both for which they provide care and for those the student may not have an opportunity to provide care for during nursing school. Based on student responses, this assignment was successful in meeting the objectives originally proposed. The books and movies provided a beginning

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introduction to and an appreciation for client and family experiences. Students were helped to understand illness, abuse, disability, and/or death from the client and/or family perspective. Based on the positive feedback by the students, and the fact that the objectives that had been delineated were met, the aesthetics assignment will continue to be a part of the pediatric course. Additional books and movies will be added as identified. The activity provided valuable insight for the student as well as for the faculty. Both in the short and long run, the student will be a better nurse for the experience.

References Bakely, D. (1997). Bethy and the mouse: A father remembers his children with disabilities. Cambridge, MA: Brookline Books. Carper, B. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1, 13- 23. Cushman, K. (1995). The midwife’s apprentice. New York: Clarion Books. Gunther, J. (1949). Death be not proud. New York: Harper Perennial. Hautman, M. (1997). Integrating theory and esthetics in a graduate nursing theory course. Nurse Educator, 22, 18, 23, 28.

Koithan, M. (1996). Aesthetics in nursing practice and education. Issues in Mental Health Nursing, 17, 529- 539. Micheal, S., Candela, L., & Mitchell, S. (2002). Aesthetic knowing: Understanding the experience of chronic illness. Nurse Educator, 27, 25 -27. Pelzer, D. (1995). A child called bit Q. Deerfield Beach, FL: Health Communications. Pelzer, D. (1997). The lost boy. Deerfield Beach, FL: Health Communications.