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Integrating the humanities in the education of health professionals: implications for search and retrieval of information
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Integrating the humanities in the education of health professionals: implications for search and retrieval of information Robert G. Polson and Elizabeth S. Farmer
Robert G. Polson MA, DipLib, ALA, MSc, Assistant Information Officer, Highland Health Sciences Library, University of Stirling, Highland Campus, Old Perth Road, Inverness IV2 3FG. Elizabeth S. Farmer RGN, SCM, DN, PhD, Senior Lecturer, University of Stirling, Department of Nursing & Midwifery, Highland Campus, Old Perth Road, Inverness IV2 3FG. Tel.:;44(0) 1463 705269; Fax: ;44(0) 1463 713471. (Requests for offprints to RP) Manuscript accepted: 22 January 2002
This article examines the increasing use of the humanities in the education of health professionals and posits that the approach may be of use in teaching health professionals information search and retrieval skills. However little evidence exists to support the educational effectiveness of using the humanities. This lack of evidence raises concerns about the costs of financing this approach to learning. These costs include the issue of copyright which cannot be ignored. While the humanities might provide a more attractive approach to teaching information search and retrieval skills, further research is needed to justify the costs of this approach to learning in more general terms and urgent attention to copyright issues is needed. © 2002, Elsevier Science Ltd. All rights reserved.
Introduction Since Calman et al. (1988) described their short course on the liberal arts in medicine a range of papers and books have outlined the usefulness of this approach within the medical curriculum. For example, Charon et al. (1995), McLellan and Jones (1996), Greenhalgh and Hurwitz (1998). Meakin and Kirklin (2000), Skelton et al. (2000a,b) cover general aspects, whilst writers such as Jones (1997) and Kutz (2000) consider specific works, respectively, Gabriel Garcia Marquez’ Love in a Time of Cholera, and the Biblical Book of Job. The use of the humanities in the fields of nursing and the professions allied to medicine has developed more slowly (Robb & Murray 1992, Styles & Moccia 1993, Chinn & Watson 1994, Darbyshire 1994, 1999, Valiga & Bruderle 1997, Koch 1998, Murray 1998, Grindle & Dallat 2001, McKie & Gass 2001). This article considers the use of the arts
© 2002, Elsevier Science Ltd. All rights reserved. doi10.1054/nepr.2002.0046, available online at http://www.idealibrary.com on
and humanities in the education of nurses and other health professionals with particular emphasis on some of the problems involved with this approach to learning.
Value of the humanities in professional education? The use of the humanities in medicine is rooted in the perceived need to restore the therapeutic element in the doctor–patient relationship allegedly made worse by the effects of the marketplace economy in health care and the advent of evidence-based medicine (Macnaughton 2000). Key factors in this disruption, also affecting nursing, are identified as the rapid throughput of patients and the consequent interruption in the continuity of care. Additionally, the holistic health movement, especially in nursing, may
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have triggered the increasing attention given in the medical curriculum to patients’ experiences of illness (Dingwall & Allen 2001), and to the use of the liberal arts in bridging the gap in understanding these experiences. The changing discourses in nursing and medicine towards a more holistic perspective and, specifically, the emphasis on ethical and moral issues has also focused attention on the role of narrative in constructing meaning and there is pressure for this to be integrated with evidence-based practice (Rolfe 1998). Narrative knowledge arises from the process of exchanging stories, and of making sense of the detail presented; multiple interpretations are possible as each listener draws meaning from a variable pattern of detail emerging from this form of social interaction (Alterio 1999). The strength of narrative is that it is able to capture meaning within context, thus permitting discussion and understanding of a situation even though the person may not be familiar with the specific situation. Poetry and literature present archetypal stories, stories that are recognizable but at the same time different in each person’s experience. The pedagogical imperative underpinning this approach to learning is located in complexity science and postmodern theory in the context of which ‘sense-making’ and ‘knowing’ is local, transient and fractal, leaving space for other emerging realities, understandings, and ‘not-knowing’. Boundaries in the student/teacher relationship are legitimized by beliefs about the nature of learning and the role of education. Through entering the learning process as co-creators of knowledge, teachers participate in a selforganizing learning process where change and creativity are possible in a process of doubleloop learning through which theories in action are created and evaluated (Argyris & Schön 1974). The issues that emerge from this approach to learning include the skills and knowledge needed to facilitate the process, the resource implications and their relationship to educational outcomes. Concerns about the skills and knowledge needed for reflective learning within a narrative pedagogy have been extensively addressed elsewhere (see Boud & Walker 1998, Ellis & Bochner 2000, Ruch 2000, for example). This article considers
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the resource implications in light of scant evidence of the effectiveness of this form of learning for health professionals.
Evidence-base In the context of the education of health professionals evidence of learning through the humanities is sparse. The early work initiated by Calman et al. (1988) aimed to broaden the life experiences of students and thus enabling them to gain insights into the feelings and attitudes of others. No formal educational evaluations were recorded during this study, but overall it was noted that staff and students taking part found participating in the course useful. Charon et al. (1995) produced a study that attempted to measure educational outcomes in a more formal manner. They posited a five-point rationale for using the humanities:
Providing students with lessons about the lives and experiences of sick people Helping students realize their power as health professionals Helping students understand patients’ stories Opening up exploration of narrative ethics Combination of the above widens medical experience (Charon et al. 1995, p. 600).
This study used the course evaluations of the students, post-course interviews, and questionnaires to measure educational outcomes. Assessments of students’ work were included in the study and apparently indicated improved understandings of patients’ experiences, ethical problems and clinical knowledge. The researchers concluded that longitudinal research was needed to follow the medical students beyond the point of qualification to study how narrative knowledge and skills impacted on their clinical practice throughout their subsequent careers. Darbyshire (1994) described the creation of a course for student nurses entitled: Understanding Caring Through Arts and Humanities. No formal course evaluations were made, but Darbyshire claimed that through the use of dialogue in a Heideggerian hermeneutic tradition he was able to: ‘ … gain a deeper understanding of the lived experiences of the
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study participants and where possible to disclose new possibilities.’ (Darbyshire 1994, p. 860). He concluded that students became more aware of patients’ needs and experiences through study of the arts and humanities with participants making comments such as ‘I think that something like the kind of readings we did on … [mastectomy] really gave a lot of insight.’ (Darbyshire 1994, p. 861). Murray (1998) used the five-point model suggested by Charon et al. (1995) to evaluate the effectiveness of an arts and humanities course with students in the professions allied to medicine. The results indicated three areas where the programme had been useful: enhanced skills in communicating purpose of treatments to patients, helping participants develop their own views on controversial issues of practice, and increasing sensitivity to patients’ and carers’ views of illnesses. Meakin & Kirklin (2000) considered the value of the humanities against the framework of the 1993 General Medical Council Tomorrow’s Doctors report (General Medical Council 1993) which recommended the development of special study modules. They recommended that one such module should consider the study of humanities on grounds of providing insight into patients’ experiences of illness and health care. However, they emphasize that these special studies modules should be subjected to the same rigorous evaluation as other medical education courses. This view is supported by Skelton et al. (2000a,b) who argue that study of the humanities can begin to broaden medical education by emphasizing the value of approaches such as qualitative research and holistic assessment. However, they stress that a more rigorous approach to measuring the educational effectiveness of humanities as an area of study is needed. Whether the study of the humanities by health professionals has value, or not, apparently depends upon one’s view of science and what constitutes evidence in the context of particular views held. While this situation may be acceptable to individuals, rising educational costs will ultimately require more rigorous evaluation of educational (Davies 1999) and clinical benefits. The need for increased rigour becomes more evident when the costs of
© 2002, Elsevier Science Ltd. All rights reserved.
accessing material for courses of this nature are considered.
Information search and retrieval In a culture of evidence-based practice, one important aspect of education for all health professionals is the acquisition of skills to retrieve, process and use information for best practice. This has led to a review of clinical education and to the recommendation that all health professionals should be able to:
Locate specified on-line health-related information Apply the basic concepts of query languages Undertake searches and access relevant sites, and relevant health-related databases (Severs & Pearson 1999, pp. 16–23).
The report also notes that ‘providers should utilise approaches that make learning opportunities accessible, interesting, appropriate and relevant to learners’ (Severs & Pearson 1999, p. 27). Traditionally, librarians have taught information retrieval and processing skills in nursing and medicine. The perspective of the librarians and information technology experts is, inevitably, very different from those of health professionals and this was alleged to be a significant barrier to the effective transfer of skills and knowledge (Kirby et al. 1998) for information search and retrieval. Consequently, it is argued that information skills teaching will be more effective if it embraces user perspectives, rather than those of librarians and other information technology personnel (Kuhlthau 1991, Keefer 1993, Dervin 1997). Informal observation of student nurses at work in a computer laboratory environment suggests that they can easily seek out information requiring fairly complex searches; for example, accessing information about the best new car to buy, or information about their favourite football team or pop group. However, if the same people are presented with an educational task, such as compiling an annotated bibliography and preparing a critical review of the information on accountability in nursing, they seem to have great difficulty knowing how to do this. This situation suggests that the problem is not simply a lack
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of cognitive knowledge and skill required in searching for and using information, but may have more to do with context and motivation. This issue is at the heart of information behaviour and retrieval research. Earlier in this paper poetry and literature were described as archetypal stories, stories that are recognizable but at the same time different in each person’s experience (Alterio 1999). Information behaviour research highlights the need for system developers to share the language of users. Textual use case specification in natural language is seen as a way in which a deeper understanding of information needs and use can be achieved by system developers. As Urquhart (2001) has noted: ‘There are subtleties of meaning and interpretations of situations which need to be considered, and there are likely to be many differences between “formal rules”, and what people actually do, and between what they think they are expected to do, and what they would prefer to do’. Thus the arts and humanities may provide a shared language where none exists, for example, in a set of new recruits to nursing, or when new concepts are being introduced at various points in the education of nurses and other health professionals.
Resources and copyright issues The increasing use of problem-based learning, narrative, and story in the educational preparation of health professionals may offer a window of opportunity for enhancing the capacity of staff to use information technology in ways that are engaging and meaningful. However, this is not necessarily an argument for using the humanities in nursing or in the education of other health professionals especially when there is a copyright minefield to negotiate in order to access and use relevant material. As noted earlier a difficulty with humanities courses would appear to be justifying them in terms of educational outcomes. However, there are other considerations, key amongst which is the fact that material needed for humanities courses is bound by copyright. Copyright is a legal concept protecting the right of the author to: ‘… make a living from creativity.’
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(International Federation of Phonographic Industries, Undated.) Copyright covers all media types including: books, maps, videos and designs (Copyright Licensing Agency 2000, p. 2). Copyright also straddles time and international boundaries and is constantly under review (Parliament 1998, European Parliament 2001). Infringement of copyright can be expensive, for example the Copyright Licensing Agency (2000, p. 2) cites cases where a Local Authority and a school have faced heavy fines and legal costs. Thus, in developing humanities courses the issue of copyright has to be taken seriously. This is apparently not so easy to do. The editor of the Literature, Arts and Medicine Database (http://endeavor.med.nyu.edu/lit-med/ lit-med-db/topview.html) when asked how she would use a set of resources replied: ‘Copyright issues are indeed tricky and in many cases have not been clearly addressed or solved. I really do not know how to advise you. … ’ (Aull, pers. comm.). None of the recent texts on the use of humanities (e.g.: Greenhalgh & Hurwitz 1998, Kirklin & Richardson 2001) addresses the problem, possibly because of a combination of lack of knowledge of the situation and the complexity of the issues (Woods et al. 1999). Ignoring the issue is not an option. The vast, sprawling global resource, the Internet, offers both access to material suitable for inclusion in humanities courses and also a distribution media for them. It also adds to the access and copyright dilemmas. From an access point of view there are treasuries of works of art (for example; http://www.tate.org.uk), books (http://onlinebooks.library.upenn. edu/), poetry (http://www.library.utoronto. ca/utel/) and music (http://mp3.com) all of which clearly state what is permissible regarding copyright – this is mostly fairly restrictive. For example the Tate Gallery prohibits any form of reproduction of material within its Internet site (Tate Gallery, Undated). Software tools such as WebCT (Morss 1999) allow, indeed encourage, learning in depth by providing resources such as links to relevant Internet sites. When integrated, the range of sites above, for example, offers the chance to deliver tailored humanities courses. However the Internet by its nature is ever-changing
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which means that the location of a resource can be altered at any time without notice. It can be argued, therefore, that rather than relying on links to transient external sites material could be downloaded and mounted on the Internet as part of a customized WebCT site. In addition to this the Internet with peripheral technology allows sound media to be transferred from vinyl, tape or CD-ROM into MP3 format. The implications of this regarding copyright are immense with copyright clearance required for each piece of work included in the site. Some work has been done on this but to date is restricted to the media of electronic journals and texts (Rowlinson 2000). Clearly, there are cost implications both for the students and the institution. There may be a need for students and institutional libraries to purchase copies of the texts to be used. As discussed above if partial sections of texts are to be used there are copyright regulations that apply to making copies of sections of texts, artwork (slides and images), or film and television programmes. Initiatives such as the Higher Education Resources ON-demand (HERON) project may eventually provide a way to do this (Rowlinson 2000). Additionally the development of online modules using tools like WebCT (Morss 1999) in developing humanities modules could involve substantial costs, but may be costeffective in terms of distance learning.
Conclusions Humanities courses would appear to offer useful ways of developing a wide range of professional skills relating to aspects of caring. In an age of evidence-based practice the humanities appear to be a potentially useful educational resource to teach information search and retrieval skills. However it has been noted that there are problems with measuring educational benefits. There are additional problems with such courses that include elements of copyright clearance, with its associated costs in terms of money, time and the costs of developing electronic versions of the images, texts and sound files. Further studies of these all factors may be useful from the point of view of the Campbell Collaboration (Boruch et al. 1999) which aims
© 2002, Elsevier Science Ltd. All rights reserved.
to do for evidence-based education what the Cochrane Collaboration claims to do for evidence-based medical and nursing practice. References Alterio M 1999 Using formalised storytelling as a professional development tool. Paper presented at the SEDA/SRHE Conference, Research and Practice in Educational Developments; exploring the links. April 1999, Grantham: United Kingdom Argyris C, Schön D 1974 Theory in practice: increasing professional effectiveness. Jossey-Bass: San Francisco Boruch R, Petrosino A, Chalmers I 1999 The Campbell Collaboration: a proposal for systematic, multi-national, and continuous reviews of evidence: background paper for the meeting at the School of Public Policy, University College London, 15/16 July 1999. Campbell Collaboration Secretariat: Philadelphia Boud D, Walker D 1998 Promoting reflection on professional courses: the challenge of context. Studies in Higher Education 23(2):191–206 Calman KC et al. 1988 Literature and medicine: a short course for medical students. Medical Education 22:265–269 Charon R et al. 1995 Literature and medicine: contributions to clinical practice. Annals of Internal Medicine 122:599–606 Chinn PL, Watson J (eds) 1994 Art and asthetics in nursing. National League for Nursing: New York Copyright Licensing Agency 2000 Copyright concerns: a pocket directory of organisations involved in the administration of copyright and rights in performances. Copyright Licensing Agency: London Darbyshire P 1994 Understanding caring through arts and humanities: a medical/nursing humanities approach to promoting alternative experiences of thinking and learning. Journal of Advanced Nursing 19:856–863 Darbyshire P 1999 Nursing, art and science: revisiting the Two Cultures. International Journal of Nursing Practice 5:123–131 Davies P 1999 What is evidence-based education? British Journal of Educational Studies 47(2):108–121 Dervin B 1997 Using sense-making self interviews as a primary assignment for undergraduates in senior level reading courses. http://communication.sbs.ohiostate.edu/sense-making/prac/pdervin97class.html Ohio State University, School of Journalism and Communication, Columbus. Last accessed 8/2/2001 Dingwall R, Allen D 2001 The implications of healthcare reforms for the profession of nursing. Nursing Inquiry 8(2):64–74 Ellis C, Bochner A 2000 Autoethnography, personal narrative, reflexivity: researcher as subject. In: Denzin N, Lincoln Y (eds) Handbook of Qualitative Research. Sage: Thousand Oaks, CA European Parliament 2001 Directive 2001/29/EC of the European Parliament and of the Council of May 2001 on the harmonisation of certain aspects of copyright and related rights in the information society. European Parliament: Brussels
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General Medical Council 1993 Tomorrow’s doctors: recommendations on undergraduate medical education. General Medical Council: London Greenhalgh T, Hurwitz B (eds) 1998 Narrative based medicine: dialogue and discourse in clinical practice. BMJ Books: London Grindle NC, Dallat J 2001 Northern Ireland – state of the arts? An evaluation of the use of the arts in teaching caring. Nurse Education Today 21(3):189–196 International Federation of Phonographic Industries Undated What is copyright? http://www.ifpi.org/copyrightcreativity/what_is_ copyright html International Federation of Phonographic Industries, London. Last Accessed 10 Sept 2001 Jones AH 1997 Garcia Marquez’ Love in a time of cholera. Lancet 350:1169–1172 Keefer J 1993 The hungry rats syndrome: library anxiety, information literacy, and the academic reference process. RQ 32(3):333–339 Kirby J, Liddiard L, Moore K 1998 Empowering the information user: new ways into user education. Library Association Publishing: London Kirklin D, Richardson R (eds) 2001 Medical humanities: a practical introduction. Royal College of Physicians of London: London Koch T 1998 Story telling: is it really research? Journal of Advanced Nursing 28:1182–1190 Kuhlthau CC 1991 Inside the search process: information seeking from the user’s perspective. Journal of the American Society for Information Science 42(5):361–371 Kutz I 2000 Job and his ‘doctors’: bedside wisdom in the book of Job. British Medical Journal 321:1613–1615 McKie A, Gass JP 2001 Understanding mental health through reading selected literature sources: an evaluation. Nurse Education Today 21(3):201–208 McLellan MF, Jones, AH 1996 Why literature and medicine? Lancet 348:109–111 Macnaughton J 2000 The humanities in medical education: context, outcomes and structures. Journal of Medical Ethics: Medical Humanities 26(1):23–30 Meakin R, Kirklin D 2000 Humanities special studies modules: making better doctors or just happier ones? Journal of Medical Ethics: Medical Humanities 26(1):49–50 Morss DA 1999 A study of student perspectives on Web-based learning: WebCT in the classroom. Internet
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Research: Electronic Networking Applications and Policy 9(5):393–408 Murray R 1998 Measurement of effect of participation in a medical humanities group on the practice of physiotherapists. Physiotherapy 84:473–479 Parliament 1998 Copyright, Designs and Patents Act: Chapter 48. HMSO: London Robb AJP, Murray R 1992 Medical humanities in nursing: thought provoking? Journal of Advanced Nursing 17:1182–1187 Rolfe G 1998 Expanding nursing knowledge. ButterworthHeinemann: Oxford Rowlinson C 2000 Supporting learning through ondemand and electronic reserve services. Collection Building 19(2):56–60 Ruch G 2000 Self and social work: towards an integrated model of learning. Journal of Social Work Practice 14(2):99–112 Severs M, Pearson C 1999 Learning to manage health information: a theme for clinical education. NHS Executive, Enabling People Programme: Bristol Skelton JR, Thomas CP, Macleod JAA 2000a Teaching literature and medicine to medical students, part I: the beginning. Lancet 356:1920–1922 Skelton JR, Thomas CP, Macleod JAA 2000b Teaching literature and medicine to medical students, part II: why literature and medicine? Lancet 356:2001–2003 Styles MM, Moccia P (eds) 1993 On nursing: a literary celebration: an anthology. National League for Nursing: New York Tate Gallery Undated Copyright notice. http://www.tate.org.uk/home/copyright.htm Tate Gallery, London. Last accessed 13/9/2001 Urquhart C 2001 Bridging information requirements and information needs assessment: do scenarios and vignettes provide a link? Information Research 6(2). http://informationr.net/ir/6-2/paper102a.html (last accessed 16/1/2002) Valiga TM, Bruder ER 1997 Using the arts and humanities to teach nursing: a creative approach. Springer, New York Woods A, Coles AM, Dickson K 1999 Copyright awareness and training for textile design protection. Journal of European industrial training 23(7):329–334
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Integrating the humanities in the education of health professionals: implications for search and retrieval of information Robert G. Polson and Elizabeth S. Farmer
Robert G. Polson MA, DipLib, ALA, MSc, Assistant Information Officer, Highland Health Sciences Library, University of Stirling, Highland Campus, Old Perth Road, Inverness IV2 3FG. Elizabeth S. Farmer RGN, SCM, DN, PhD, Senior Lecturer, University of Stirling, Department of Nursing & Midwifery, Highland Campus, Old Perth Road, Inverness IV2 3FG. Tel.:;44(0) 1463 705269; Fax: ;44(0) 1463 713471. (Requests for offprints to RP) Manuscript accepted: 22 January 2002
This article examines the increasing use of the humanities in the education of health professionals and posits that the approach may be of use in teaching health professionals information search and retrieval skills. However little evidence exists to support the educational effectiveness of using the humanities. This lack of evidence raises concerns about the costs of financing this approach to learning. These costs include the issue of copyright which cannot be ignored. While the humanities might provide a more attractive approach to teaching information search and retrieval skills, further research is needed to justify the costs of this approach to learning in more general terms and urgent attention to copyright issues is needed. © 2002, Elsevier Science Ltd. All rights reserved.
Introduction Since Calman et al. (1988) described their short course on the liberal arts in medicine a range of papers and books have outlined the usefulness of this approach within the medical curriculum. For example, Charon et al. (1995), McLellan and Jones (1996), Greenhalgh and Hurwitz (1998). Meakin and Kirklin (2000), Skelton et al. (2000a,b) cover general aspects, whilst writers such as Jones (1997) and Kutz (2000) consider specific works, respectively, Gabriel Garcia Marquez’ Love in a Time of Cholera, and the Biblical Book of Job. The use of the humanities in the fields of nursing and the professions allied to medicine has developed more slowly (Robb & Murray 1992, Styles & Moccia 1993, Chinn & Watson 1994, Darbyshire 1994, 1999, Valiga & Bruderle 1997, Koch 1998, Murray 1998, Grindle & Dallat 2001, McKie & Gass 2001). This article considers the use of the arts
© 2002, Elsevier Science Ltd. All rights reserved. doi10.1054/nepr.2002.0046, available online at http://www.idealibrary.com on
and humanities in the education of nurses and other health professionals with particular emphasis on some of the problems involved with this approach to learning.
Value of the humanities in professional education? The use of the humanities in medicine is rooted in the perceived need to restore the therapeutic element in the doctor–patient relationship allegedly made worse by the effects of the marketplace economy in health care and the advent of evidence-based medicine (Macnaughton 2000). Key factors in this disruption, also affecting nursing, are identified as the rapid throughput of patients and the consequent interruption in the continuity of care. Additionally, the holistic health movement, especially in nursing, may
Nurse Education in Practice (2002) 2, 49–54
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have triggered the increasing attention given in the medical curriculum to patients’ experiences of illness (Dingwall & Allen 2001), and to the use of the liberal arts in bridging the gap in understanding these experiences. The changing discourses in nursing and medicine towards a more holistic perspective and, specifically, the emphasis on ethical and moral issues has also focused attention on the role of narrative in constructing meaning and there is pressure for this to be integrated with evidence-based practice (Rolfe 1998). Narrative knowledge arises from the process of exchanging stories, and of making sense of the detail presented; multiple interpretations are possible as each listener draws meaning from a variable pattern of detail emerging from this form of social interaction (Alterio 1999). The strength of narrative is that it is able to capture meaning within context, thus permitting discussion and understanding of a situation even though the person may not be familiar with the specific situation. Poetry and literature present archetypal stories, stories that are recognizable but at the same time different in each person’s experience. The pedagogical imperative underpinning this approach to learning is located in complexity science and postmodern theory in the context of which ‘sense-making’ and ‘knowing’ is local, transient and fractal, leaving space for other emerging realities, understandings, and ‘not-knowing’. Boundaries in the student/teacher relationship are legitimized by beliefs about the nature of learning and the role of education. Through entering the learning process as co-creators of knowledge, teachers participate in a selforganizing learning process where change and creativity are possible in a process of doubleloop learning through which theories in action are created and evaluated (Argyris & Schön 1974). The issues that emerge from this approach to learning include the skills and knowledge needed to facilitate the process, the resource implications and their relationship to educational outcomes. Concerns about the skills and knowledge needed for reflective learning within a narrative pedagogy have been extensively addressed elsewhere (see Boud & Walker 1998, Ellis & Bochner 2000, Ruch 2000, for example). This article considers
50
Nurse Education in Practice (2002) 2, 49–54
the resource implications in light of scant evidence of the effectiveness of this form of learning for health professionals.
Evidence-base In the context of the education of health professionals evidence of learning through the humanities is sparse. The early work initiated by Calman et al. (1988) aimed to broaden the life experiences of students and thus enabling them to gain insights into the feelings and attitudes of others. No formal educational evaluations were recorded during this study, but overall it was noted that staff and students taking part found participating in the course useful. Charon et al. (1995) produced a study that attempted to measure educational outcomes in a more formal manner. They posited a five-point rationale for using the humanities:
Providing students with lessons about the lives and experiences of sick people Helping students realize their power as health professionals Helping students understand patients’ stories Opening up exploration of narrative ethics Combination of the above widens medical experience (Charon et al. 1995, p. 600).
This study used the course evaluations of the students, post-course interviews, and questionnaires to measure educational outcomes. Assessments of students’ work were included in the study and apparently indicated improved understandings of patients’ experiences, ethical problems and clinical knowledge. The researchers concluded that longitudinal research was needed to follow the medical students beyond the point of qualification to study how narrative knowledge and skills impacted on their clinical practice throughout their subsequent careers. Darbyshire (1994) described the creation of a course for student nurses entitled: Understanding Caring Through Arts and Humanities. No formal course evaluations were made, but Darbyshire claimed that through the use of dialogue in a Heideggerian hermeneutic tradition he was able to: ‘ … gain a deeper understanding of the lived experiences of the
© 2002, Elsevier Science Ltd. All rights reserved.
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study participants and where possible to disclose new possibilities.’ (Darbyshire 1994, p. 860). He concluded that students became more aware of patients’ needs and experiences through study of the arts and humanities with participants making comments such as ‘I think that something like the kind of readings we did on … [mastectomy] really gave a lot of insight.’ (Darbyshire 1994, p. 861). Murray (1998) used the five-point model suggested by Charon et al. (1995) to evaluate the effectiveness of an arts and humanities course with students in the professions allied to medicine. The results indicated three areas where the programme had been useful: enhanced skills in communicating purpose of treatments to patients, helping participants develop their own views on controversial issues of practice, and increasing sensitivity to patients’ and carers’ views of illnesses. Meakin & Kirklin (2000) considered the value of the humanities against the framework of the 1993 General Medical Council Tomorrow’s Doctors report (General Medical Council 1993) which recommended the development of special study modules. They recommended that one such module should consider the study of humanities on grounds of providing insight into patients’ experiences of illness and health care. However, they emphasize that these special studies modules should be subjected to the same rigorous evaluation as other medical education courses. This view is supported by Skelton et al. (2000a,b) who argue that study of the humanities can begin to broaden medical education by emphasizing the value of approaches such as qualitative research and holistic assessment. However, they stress that a more rigorous approach to measuring the educational effectiveness of humanities as an area of study is needed. Whether the study of the humanities by health professionals has value, or not, apparently depends upon one’s view of science and what constitutes evidence in the context of particular views held. While this situation may be acceptable to individuals, rising educational costs will ultimately require more rigorous evaluation of educational (Davies 1999) and clinical benefits. The need for increased rigour becomes more evident when the costs of
© 2002, Elsevier Science Ltd. All rights reserved.
accessing material for courses of this nature are considered.
Information search and retrieval In a culture of evidence-based practice, one important aspect of education for all health professionals is the acquisition of skills to retrieve, process and use information for best practice. This has led to a review of clinical education and to the recommendation that all health professionals should be able to:
Locate specified on-line health-related information Apply the basic concepts of query languages Undertake searches and access relevant sites, and relevant health-related databases (Severs & Pearson 1999, pp. 16–23).
The report also notes that ‘providers should utilise approaches that make learning opportunities accessible, interesting, appropriate and relevant to learners’ (Severs & Pearson 1999, p. 27). Traditionally, librarians have taught information retrieval and processing skills in nursing and medicine. The perspective of the librarians and information technology experts is, inevitably, very different from those of health professionals and this was alleged to be a significant barrier to the effective transfer of skills and knowledge (Kirby et al. 1998) for information search and retrieval. Consequently, it is argued that information skills teaching will be more effective if it embraces user perspectives, rather than those of librarians and other information technology personnel (Kuhlthau 1991, Keefer 1993, Dervin 1997). Informal observation of student nurses at work in a computer laboratory environment suggests that they can easily seek out information requiring fairly complex searches; for example, accessing information about the best new car to buy, or information about their favourite football team or pop group. However, if the same people are presented with an educational task, such as compiling an annotated bibliography and preparing a critical review of the information on accountability in nursing, they seem to have great difficulty knowing how to do this. This situation suggests that the problem is not simply a lack
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of cognitive knowledge and skill required in searching for and using information, but may have more to do with context and motivation. This issue is at the heart of information behaviour and retrieval research. Earlier in this paper poetry and literature were described as archetypal stories, stories that are recognizable but at the same time different in each person’s experience (Alterio 1999). Information behaviour research highlights the need for system developers to share the language of users. Textual use case specification in natural language is seen as a way in which a deeper understanding of information needs and use can be achieved by system developers. As Urquhart (2001) has noted: ‘There are subtleties of meaning and interpretations of situations which need to be considered, and there are likely to be many differences between “formal rules”, and what people actually do, and between what they think they are expected to do, and what they would prefer to do’. Thus the arts and humanities may provide a shared language where none exists, for example, in a set of new recruits to nursing, or when new concepts are being introduced at various points in the education of nurses and other health professionals.
Resources and copyright issues The increasing use of problem-based learning, narrative, and story in the educational preparation of health professionals may offer a window of opportunity for enhancing the capacity of staff to use information technology in ways that are engaging and meaningful. However, this is not necessarily an argument for using the humanities in nursing or in the education of other health professionals especially when there is a copyright minefield to negotiate in order to access and use relevant material. As noted earlier a difficulty with humanities courses would appear to be justifying them in terms of educational outcomes. However, there are other considerations, key amongst which is the fact that material needed for humanities courses is bound by copyright. Copyright is a legal concept protecting the right of the author to: ‘… make a living from creativity.’
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(International Federation of Phonographic Industries, Undated.) Copyright covers all media types including: books, maps, videos and designs (Copyright Licensing Agency 2000, p. 2). Copyright also straddles time and international boundaries and is constantly under review (Parliament 1998, European Parliament 2001). Infringement of copyright can be expensive, for example the Copyright Licensing Agency (2000, p. 2) cites cases where a Local Authority and a school have faced heavy fines and legal costs. Thus, in developing humanities courses the issue of copyright has to be taken seriously. This is apparently not so easy to do. The editor of the Literature, Arts and Medicine Database (http://endeavor.med.nyu.edu/lit-med/ lit-med-db/topview.html) when asked how she would use a set of resources replied: ‘Copyright issues are indeed tricky and in many cases have not been clearly addressed or solved. I really do not know how to advise you. … ’ (Aull, pers. comm.). None of the recent texts on the use of humanities (e.g.: Greenhalgh & Hurwitz 1998, Kirklin & Richardson 2001) addresses the problem, possibly because of a combination of lack of knowledge of the situation and the complexity of the issues (Woods et al. 1999). Ignoring the issue is not an option. The vast, sprawling global resource, the Internet, offers both access to material suitable for inclusion in humanities courses and also a distribution media for them. It also adds to the access and copyright dilemmas. From an access point of view there are treasuries of works of art (for example; http://www.tate.org.uk), books (http://onlinebooks.library.upenn. edu/), poetry (http://www.library.utoronto. ca/utel/) and music (http://mp3.com) all of which clearly state what is permissible regarding copyright – this is mostly fairly restrictive. For example the Tate Gallery prohibits any form of reproduction of material within its Internet site (Tate Gallery, Undated). Software tools such as WebCT (Morss 1999) allow, indeed encourage, learning in depth by providing resources such as links to relevant Internet sites. When integrated, the range of sites above, for example, offers the chance to deliver tailored humanities courses. However the Internet by its nature is ever-changing
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which means that the location of a resource can be altered at any time without notice. It can be argued, therefore, that rather than relying on links to transient external sites material could be downloaded and mounted on the Internet as part of a customized WebCT site. In addition to this the Internet with peripheral technology allows sound media to be transferred from vinyl, tape or CD-ROM into MP3 format. The implications of this regarding copyright are immense with copyright clearance required for each piece of work included in the site. Some work has been done on this but to date is restricted to the media of electronic journals and texts (Rowlinson 2000). Clearly, there are cost implications both for the students and the institution. There may be a need for students and institutional libraries to purchase copies of the texts to be used. As discussed above if partial sections of texts are to be used there are copyright regulations that apply to making copies of sections of texts, artwork (slides and images), or film and television programmes. Initiatives such as the Higher Education Resources ON-demand (HERON) project may eventually provide a way to do this (Rowlinson 2000). Additionally the development of online modules using tools like WebCT (Morss 1999) in developing humanities modules could involve substantial costs, but may be costeffective in terms of distance learning.
Conclusions Humanities courses would appear to offer useful ways of developing a wide range of professional skills relating to aspects of caring. In an age of evidence-based practice the humanities appear to be a potentially useful educational resource to teach information search and retrieval skills. However it has been noted that there are problems with measuring educational benefits. There are additional problems with such courses that include elements of copyright clearance, with its associated costs in terms of money, time and the costs of developing electronic versions of the images, texts and sound files. Further studies of these all factors may be useful from the point of view of the Campbell Collaboration (Boruch et al. 1999) which aims
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