Linking liberal & professional learning in nursing education.

THE SPIRIT OF THE HUMANITIES has been present in the delivery of nursing care since its beginning. But it was not until the turn of the twentieth century that nursing educators mandated that nursing education would include distinct courses from the liberal arts and sciences. From this time period, nursing faculty have relied on the expertise of the liberal arts and sciences faculty to teach and enlighten nursing students taking courses in their disciplines. This viewpoint is mainly rooted in the philosophical belief that learning in the liberal arts and sciences is essential to prepare critically thoughtful, reflective, humanistic professional nurses. Contributions of the various liberal education courses have provided a powerful and enriching antidote to the mechanistic and reductionistic methods that have historically prevailed in both medical and nursing education.

However, despite the belief that liberal learning is a necessary component of the professional nursing student's education, the scientific focus has held prominence in nursing education (Valiga and Bruderle 1997). In the twenty-first century, thoughtful linking of liberal learning to professional nursing education takes on renewed urgency.

As early as the 1970s, nursing education literature asserted that when the liberal arts are taught in discrete curricular courses, the connections between these courses and the learning needs of the professional nurse remain unrecognized. In an effort to address this disconnect between liberal learning and professional nursing courses, some general and nursing educators have argued that efforts should be directed at methods to integrate liberal learning within nursing courses (Newell 1989; Valiga and Bruderle 1997).

A new century poses daunting challenges that stem from myriad factors such as scientific advancements, growing clinical knowledge, expanding technology, increased client diversity, market-driven policies, ethical and justice issues, and global awareness. Integration of the humanities has been described as one curricular approach that supports the growth of critical thinking within a humanistic perspective as well as the personal and professional development of the nursing student. Expanding societal and health care complexities demands that professional nursing education be tailored to prepare nursing students as informed, responsible, democratic citizens as well as empowered, competent, compassionate professional nurses.

Given the multitude of conflicting influences, the value of liberal learning continues to hold promise as the best preparation for students to meet the challenges imposed by these competing variables. The literature in higher education has recommended the adoption of interdisciplinary approaches to guide curricula that foster integration (AAC & U 2002; Dressel 1978). The Association of American Colleges and Universities' Greater Expectations urges all university and college faculty, administrators, and stakeholders in higher education to engage in thoughtful planning as to how their institutions can reinvigorate the mission of liberal education for all students. Several effective plans have been described in the literature. Crucial to the achievement of liberal learning goals is not just the content, but also how the content is delivered (AAC & U 2002; Darbyshire 1995). In the discussion of how the content is handled, the significance of a critically reflective educator joined with varied teaching-strategy expertise warrants attention (Brookfield 1987; Paul 1993).

Over the past thirty years some nursing educators have described the implementation of their ideas concerning integrating the humanities components of the liberal arts within their nursing courses. In reviewing the literature, some positive anecdotal evidence on the educational value of including such learning activities has been found. However, research on measuring the achievement of the liberal learning goals linked to these humanities strategies is lacking.

Humanities integration in baccalaureate nursing education

The purpose of the study described here was to examine the current nature of the integration of the humanities learning activities within nursing courses in baccalaureate nursing education. In addition, nursing faculty perceptions on the achievement of the goals related to these humanities learning activities were explored. Furthermore, faculty views regarding motivation for integrating with the humanities as well as the perceived obstacles were examined.

A humanities learning activity was defined as one developed from the disciplines of history, literature, religion, philosophy, architecture, or the fine arts including music, painting, sculpture, drama, or film. This learning activity consisted of distinct concepts, teaching/learning strategies, and evaluation methods. Kolb's model of experiential learning, which claims that the process of learning involves the development of certain specific abilities, provided the theoretical foundation for this study (Kolb 1984). In this model, learning is initiated through a concrete personal experience. The development of reflective/observation abilities in response to this stimulus aims to generate multiple perspectives within the student. Next, students, either independently or through the guidance of the faculty, are asked to create a "working theory" resulting from their reflective process. The final set of abilities involves the student translation of their reflective thinking into problem solving.

A specific example that illustrates humanities integration involved an assignment for freshman nursing students to view the film And the Band Played On. They were asked to view the film prior to the didactic classroom presentation on the basics of the science of epidemiology. And the Band Played On chronicles the epidemiology of the AIDS virus within the United States through the eyes of an American scientist. After watching and reflecting on the film, students wrote reaction papers describing their overall response to the film as well as discussing the social, moral, political, and economic factors that impacted the evolution of the AIDS virus in this country. The quality of the reaction papers and class discussion provided overwhelming positive evidence that this assignment effectively engaged students. A scientific textbook is sorely incapable of providing the engagement and integrative scope of understanding that this film was able to engender, as the students reflected on the human and social complexities of disease.

Survey methodology

The research design was the case study method. The selected sample was generated from twelve out of thirty-five generic, accredited baccalaureate nursing programs in the Philadelphia area. These institutions included public/private institutions classified as Baccalaureate College General, Masters Colleges, University 1, and Research University, Intensive/Extensive. Data collection involved two main sources: 1) document examination of all the nursing course syllabi for presence of humanities learning activities; 2) follow-up interviews with faculty who had integrated the humanities learning activities within their nursing courses.

Survey results

The examination of the syllabi demonstrated that there was a modest occurrence of the integration of the humanities learning activities within nursing courses in baccalaureate nursing education with a mean of 12.33 per institution. However, caution must be taken in interpreting this mean since in three of the twelve institutions, 75 percent of the humanities activities occurred in elective, not required courses. Furthermore, a pattern in the frequency of humanities occurrences within certain levels of courses and nursing specialties emerged. Introductory courses exhibited the largest number of humanities occurrences, followed by the nursing courses in the specialties of psychiatric, community, and pediatric/maternal nursing. These four areas demonstrated statistically more frequent humanities occurrences at a significant level (p<.05). The medical surgical nursing courses had the lowest number of humanities occurrences.

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Relative to most frequently named concepts, leadership and diversity were the most prevalent concepts at 14 occurrences, followed by nursing history and grieving (each at 12), professionalism (10), and incidents for caring (9). In regard to teaching/learning strategies, film and subsequent discussion was the most employed (83 activities) followed by the use of literature (38). The most frequent evaluation technique was the discussion method, used in 58 activities.

The second main data source, faculty interview responses, provided an accurate validation of what was stated in a particular course syllabus. Additionally, the interviewed faculty were asked the following question: what are the expected student outcomes as perceived by the nursing faculty associated with these nursing concepts (critical thinking, humanistic perspective, personal and professional development)? Other questions uncovered faculty motivations and obstacles to integration with the humanities and views on the critical thinking process.

The 23 interviewees were asked to rate on a scale of 1 to 5 (1 the smallest, to 5 the largest) their perception on the effectiveness of the humanities learning activities in achieving the identified student outcomes, as well as to share supporting comments for their ratings. For critical thinking, a mean score of 4.31 was indicated; for humanistic perspective 4.81; for personal development a 4.20, and for professional development a mean score of 4.16 was obtained. Thus, the humanities learning activities, according to the interviewed faculty, were perceived to be highly effective in the achievement of the student outcomes as noted.

About critical thinking (mean 4.31), faculty commented that some students, have difficulty "standing outside of themselves" and are quick to offer an opinion. They noted that incorporating a living case study story was a highly effective way to guard against this tendency and foster a more analytical and holistic approach to thinking. The affective or humanistic perspective student outcome (mean 4.81) was realized as students interacted with the issues and related to the characters in the films or in the literature.

As communicated in the faculty interviews, these strategies were effective in critical examination of (student) value systems, or, as one faculty member wrote, "breaking through the belief systems that students bring to college and increased awareness of how their own values influence their thinking." In an example involving the assignment to view the film The Color Purple, the student sees the many challenges faced by an African American family. In a class discussion it appeared that this film fostered reflection on racial issues, engendering empathy for the characters in the story.

In terms of personal development (mean 4.20), faculty commented that the majority of students view their college goal as solely enabling them to "get a good job," rather than as an experience that may assist them to grow as a person. Mitch Albom's book Tuesdays with Morrie was the basis for an assignment that effectively generated introspection on the importance of authentic relationships. Concerning professional development (mean 4.16), the majority of the faculty who were interviewed were involved in introductory courses. A popular strategy was an assignment to read Suzanne Gordon's Life Support: Three Nurses on the Front Lines (1997), a book which engagingly portrays the concepts of leadership, professionalism, and caring.

The nursing faculty's discovery of the motivation that initially generated this humanities integration contributed significant understanding. Several described their motivation as the "power to engage the student, bringing a broader focus to the learning process." Also, the use of alternative approaches to learning guards against the "one size fits all mentality." Interviewees emphasized that their purposes were not to develop nursing students as experts in film or literary criticism. Rather, the collective goal was to enhance the thinking and practice of the nurse through engagement in these alternative approaches. Furthermore, these integrative activities were not expected to serve as a substitute for the inclusion of liberal education courses. Respect for the expertise of the liberal education faculty and their associated distinct courses was conveyed.

Faculty discussed the highly effective way that an appropriate film illustrates a concept and stimulates different student learning styles. Since today's students have grown up within a peer culture of electronic violence, indifference and apathy may prevail. Thus, one challenge in viewing these films is to create learning activities that penetrate this possible numbness. Several faculty emphasized the necessity for faculty to create well-conceived discussion questions to drive the critical thinking process. Thoughtful reflection, guided by a humanistic educator, can serve to ready the student for addressing the unscripted problems that will surface in real practice and can contribute to the development of enlightened humanistic professionals.

The main reasons cited for lack of or decreased humanities integration in nursing courses involve the lack of preparation of nursing faculty as educators, the content-driven nature of faculty, the time-consuming aspects of developing these alternative strategies, and beliefs that "the core curriculum should take care of the liberal arts." Additionally, external standardized tests, although recognized as needed to ensure knowledge competence, impose restrictive assessment pressure. Furthermore, these tests fail to capture requisite qualities of a compassionate student and inhibit pedagogical innovations.

Where do we go from here?

Several areas for faculty development and recommendations to both higher education and nursing education have emerged from this study. The study findings confirm that there are some nursing educators who are utilizing elements of humanities learning activities, primarily in the introductory courses. A plausible explanation stems from the decreased amount of nursing content in these courses compared to upper-division courses.

Concerning the increased integration trend in the nursing specialties of psychiatric, community, and pediatric-maternal courses, a possible interpretation is that in these specialties the complexity of providing care to these patients is recognized. Consequently, humanities learning activities may be effective in assisting students to grasp a holistic view of the many variables. In contrast, the medical-surgical specialty had the lowest number of humanities occurrences, possibly because of the heavy nursing content related to this nursing specialty. The view seems to be that there is not ample time to include integrative activities.

Nursing faculty interview responses indicated that the humanities learning activities were perceived to be highly effective in the achievement of the identified student outcomes. Recommendations from this study include increasing interdisciplinary dialogue that promotes faculty awareness of this value through faculty development programs. Furthermore, administrative leadership is needed to support faculty in "trying out" innovative teaching/learning strategies joined with the message that these strategies "do work." Since both the literature review and this study prove that how the content is delivered is as crucial to its effectiveness, continued development for the faculty as effective educators is recommended. Faculty need to value the importance of connecting liberal to professional learning, serving as role models in this endeavor.

This form of connected education has the capacity to develop integrative thinkers with humanistic perspectives equipped to address the complexities of the twenty-first century.

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WORKS CITED

Association of American Colleges and Universities (AAC & U). 2002. Greater expectations: A new vision for learning as a nation goes to college. Washington, DC: Association of American Colleges and Universities.

Brookfield, S. 1987. Developing critical thinkers. San Francisco, CA: Jossey-Bass.

Darbyshire, P. 1995. Lessons from literature: Caring, interpretation, and dialogue. Journal of Nursing Education 34 (5): 211-12.

Dressel, P. 1978. Liberal education: Developing the characteristics of a liberally educated person. Liberal Education 65: 313-22.

Gordon, S. 1997. Life support: Three nurses on the front lines. Boston, MA: Little Brown.

Kolb, D. 1984. Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall.

Newell, L. 1989. The healing arts and the liberal arts in concert. In R. A. Armour and B. S. Fuhrmann, eds. Integrating liberal learning and professional education. New Directions for Teaching and Learning, no. 40. San Francisco, CA: Jossey-Bass, 67-76.

Paul, R. 1993. Critical thinking: How to prepare students for a rapidly changing world. Santa Rosa, CA: Foundation for Critical Thinking.

Valiga, T., and E. Bruderle. 1997. Using the arts and humanities to teach nursing. New York, NY: Springer.

MARY L. HERMANN is associate professor of nursing at Gwynedd-Mercy College.