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Teaching and Learning Forum 2008 [ Refereed papers ]
Using the emotion of art to build cohesion, collaboration and empathy between student nurses

Caroline Nilson
School of Nursing
Murdoch University

Art therapy is used as a tool for personal growth and greater self-understanding. Art enhances communication between individuals, groups and professional teams and is an effective tool to explore change.

In 2006, I developed and coordinated a third year Bachelor of Nursing unit on Maternal and Newborn Health Care. The first cohort of the Bachelor of Nursing students was entering their final year. Being a small group, having shared two years together, one would have thought that they would be supportive and cohesive. However to the contrary, the group was fragmented, insular and remote, with little demonstration of compassion or empathy for one another. Knowing that the ability to communicate and collaborate is essential to working well within the interdisciplinary health team, the group needed to evolve from being distant individuals with a student mindset to a model of engagement.

The project describes the changes in the dynamics of the group and personal growth of the students as a result of using art therapy as an assessable component in the unit. The students were required to develop an artwork, which reflected their interpretations, emotions and feelings about the process of pregnancy, childbirth and parenting. Not only did the activity develop an overwhelming change of individual appreciation for one another, but the marked change in their attitudes and development toward professional accountability was noted by lecturers and unit coordinators who taught the students in their following and final semester.


Developing a model of student engagement

Art therapy is a form of psychotherapy where creative expression using various media such as, painting drawing and sculpture allows for safe expression of emotions. Art enhances communication between individuals, groups and professional teams and is an effective tool to explore change. It enhances individual understanding of feelings of self-awareness, self-confidence and self-esteem and increases engagement and integration. Art bonds groups, encourages acts of generosity by increasing the sense of give and take and increases cooperation and respect for others (Everitt & Hamilton, 2003; Keyes, 1995; Macrorie, 1980). Tallarico (as cited in Macrorie, 1980) says that:
Art is native to all of us and we have the need and the capability of expression. Art comes from the whole reality of interior life. One person has more ability in expressing this interior life than others, but all of us have some (p.46).
One of the most important nursing graduate attributes and a competency listed in the Australian Nursing and Midwifery Council National Competency Standards for Registered Nurses is the ability to communicate and collaborate within the interdisciplinary health team. ANMC (2005) Standards, list five domains of which Collaborative and Therapeutic Practice is one. This relates to the establishing, sustaining and conclusion of professional relationships with groups and individuals. The ability to "care for" clients, co-workers and others is also an essential attribute for the graduate nurse. Caring is a universal phenomenon, the expression of which varies among cultures. It is central to the nursing profession. To provide therapeutic nursing care, the student acquires the knowledge of caring values, beliefs, and practices which support communication, promote adaptation, reduce stress, and meet psychosocial needs of the patient. 'Caring for' others begins with caring about self and other nurses. Caring is learned, by experiencing caring practices among faculty and students, which cultivates sensitivity to self and others. The student should learn the basic constructs of caring including but not limited to comfort, compassion, concern, empathy, helping behaviours, nurturance, support, involvement, and sharing. Gardner & Wheeler, 1981 (as cited in Wikstrom, 2001) suggests that 'the most common nursing behaviours reported in nursing literature are, availability and communication; giving information and explanation' (p.26). Griffin, 1983 (as cited in Wikstrom, 2001) describes caring as an interpersonal process in which liking and compassion are important. Ford, 1981 (as cited in Wikstrom, 2001) states that a 'nurses' caring behaviour is defined in terms of listening, helping and showing respect' (p.26), and Burnard, 1998 (as cited in Wikstrom, 2001) found that 'students regard being non-judgemental, empathic and a good listener, and understanding, as important characteristics of counsellors' (p.26).

Richard Florida (2006) asks, 'what then, is the role of colleges and universities in the creative age?' He suggests that 'a stimulating intellectual environment creates the capacity to innovate and in turn creates regional success.' The creative sector, which includes arts, culture and knowledge-based professions like law, finance, health care and education, has replaced natural resources and physical capital as the predominant driver of economic growth (Florida, 2006). Dr. Florida (as cited in deLisle, 2005) states that 'creative environments...allow for more holistic living...recreational activities are crucial to self-knowledge and self-expression.' The objectives of the project initiated in 2006, were to use art as a method of building cohesion, collaboration, empathy and caring between the first cohort of Murdoch University undergraduate nursing students going into their third and final year. As the lack of 'student engagement' was only identified at the end of the second year, time restraints were a major consideration in developing the project. Consequently, the project became an assessable component of a third year unit.

The assignment

In 2006, the Murdoch University School of Nursing was still in its infancy and the facilities were limited and certainly did not have provision for art workshops. With emphasis on the benefits of reciprocal learning opportunities between schools and tertiary education, it was agreed that the art sessions would be conducted using the facilities of a local high school.

The artwork was an assessable piece of the Maternal and Newborn Health Care unit, the students were required to create an art piece, research an artist who inspired the development of their piece and finally deliver a five minute electronic presentation to their group. The project was run over three weeks offering a two-hour art workshop per week, to each group. Attendance at the workshops was compulsory. The art teacher from the high school conducted all the workshops, providing technical assistance for the students while the unit co-ordinator assisted in the distribution of supplies provided by the university and generally encouraged the students as they completed the activity.

While one of the major objectives of the artwork was to enhance cohesion, collaboration and empathy between the students, it was also necessary to provide the students with a background understanding of how art has portrayed pregnancy, childbirth and parenting over the centuries, thus giving them a base to develop their assignment. During the first workshop the history of art, with a focus on maternal and newborn, was introduced. Various artists, using a large number of different styles, colours, textures and emotive intentions were discussed. A brief biography of each artist was given and examples of their works shown. Largely the students worked on their art pieces at home, and the main purpose of the second workshop, was for the students to bring their piece's to class and obtain help from the art teacher if required. Interestingly, this was the session when the students began to show a progression in their enthusiasm and become excited as new thoughts and ideas emerged and students excitedly discussed their own and others' productions. Clarke and Millmuth (1982) explain the 'importance of comparing perceptions, thoughts and feelings with peers as an important feed back mechanism, particularly as they have gained credibility for discussing significant issues' (p. 25). The final workshop was to facilitate presentation of the students work. The marks were allocated to the appropriateness of the artist selection and the link leading to the development of their art piece, rather than the finished artwork, understanding that the students were not studying art. However, Wikstrom (2000) states that 'feelings and experiences communicated through a work of art are not necessarily beautiful, but nevertheless compel our attention ... in this perspective art can be regarded as a natural ally to nursing' (p.97).

Knowing that the students had put a great deal of time and effort into the assignment it was decided to display the art, which would give the students a sense of achievement. Everitt and Hamilton (2003) point out that:

Having been creative, you take away with you something tangible - it could be an object it could be a feeling. And the importance of your work contributing to a display or exhibition should not be minimised' (p. 51).
The Murdoch University School of Nursing is uniquely situated on a co-located campus, together with TAFE and the Mandurah Senior Campus. With an emphasis on reciprocal learning the three institutions share one main library where the student's art pieces were displayed for two weeks. The library manager, who enthusiastically assisted in the preparation of the display, reported that:
One of the great advantages of a shared library is the diverse displays that we have during the year. These displays have a wide audience as Murdoch University, Challenger TAFE and Mandurah Senior College students and staff enter the library and view them. This was apparent when the third year nursing students completed an assignment during their Maternity unit and the resulting two and three dimensional presentations were displayed in the library. The display mid year was originally scheduled for 2 to 3 weeks, but there were numerous requests for it to remain due to the great interest from all sectors of the campus. Students and staff would stand in front of the display and discuss different presentations. We found that many asked for explanations of some of the exhibits and were intrigued by the background stories, origins and/or the methods used to interpret these stories. The library has asked for a repeat assignment and a resulting display for 2007.

Findings

Measures were conducted using two methods. The students completed a simple questionnaire (Fig.1), given to them a week after the completion of the assignment, and the unit co-ordinator reviewed a short paragraph, which was included at the end of the students' presentation. The student was required to link the emotive and reflective/perceptive intention of their art piece, to reflect their understanding of the holistic connection required between the nurse and the woman when providing care to her and the family during the childbearing process.

A weakness in the methodology was that of the 45 students who participated in the assignment only 30 students completed the questionnaire, due to non-attendance at the lecture. This could lead to an over-representation of students who positively responded to the assignment.

Art assignment questionnaire image file

Figure 1: An example of the questionnaire

Results of the questionnaire

In analysing the results to Question 1, 7 students indicated a response of 4 and above reflecting an initial positive attitude to the assignment, 6 students indicated a response of 3 reflecting an indifferent response and the remainder indicated a response of 2 or less reflecting an initial negative attitude. Generally the responses to Question 2 were positive. 27 students reflected a positive and enjoyable experience. However three students recorded negative comments, stated as follows.
When I first learned I would be doing art as a part of my nursing degree, I was horrified - yet another task outside my comfort zone. I felt asking a man to produce an artwork on feelings and emotion of pregnancy was too much. I question the relevance of art in nursing and feel my time would've been better spent elsewhere.

Not having any interest in doing this and not having a clue what to do, especially with no artistic ability.

At first, I was really pessimistic about this project. I thought it was too 'airy-fairy' and could not see the relevance.

The responses to Question 3 were once again extremely positive, with only 2 students recording a negative response and 1 student omitting the question. The positive responses of the groups, revealed an overwhelming sense of 'connectedness' to their fellow students. This was reported as follows.
I cried, I was so moved, inspired and proud of my peers for sharing of themselves, their vulnerability, depth, love and life experiences. I loved it! I conclude that in 1st year we all seemed aware of each other's short comings, second year we were all focused on surviving and this year we are choosing to focus upon each others positive aspects and strengths. The art has helped us bond.

After listening to my peers I realised how different people react. It was definitely an emotional journey and we allowed ourselves to share a piece of our hearts with our peers.

For me personally I was able to see others as feeling human beings rather than just students and academics. It changed us all as a group and made everyone realise that we all have a caring, emotional and sensitive side.

By the end of the assignment I felt closer to and more bonded to the group than any other exercise had ever made me feel. The descriptions people gave really made the artwork meaningful - everyone seemed to have such a special feeling about their work.

It made me feel closer to the other students as we all shared something emotional and special. This had not been a close group until we shared our stories / feelings.

I'll be the first to admit that I took the 'mickey' out of the whole art concept from the start! My initial opinion was that I couldn't believe we were doing something so frivolous and thought it was a waste of time in our final year. I also couldn't understand what this had to do with becoming a nurse. I couldn't have been more WRONG! After viewing everyone's individual art pieces and hearing their interpretations everything seemed to fall into place. This has made me appreciate how diverse our own personal opinions; experiences and viewpoints really are when it comes to maternal and newborn health issues. It takes this kind of holistic collaboration and group effort to provide quality of care and innovation in future clinical practice.

Finally, 27 students recorded a score of 4 and above for Question 4, reflecting a positive response regarding the relevance of the assignment in the Maternal and Newborn Health Care unit. Only 3 students recoded 3 and below, indicating an indifferent or negative response.

Holistic connection between nurse and woman

The emotive and reflective exercise of linking the student's art piece to their own personal understanding of holistic care, was designed to embed a sensitivity that is central to 'being with woman' during her childbearing experience. The student would then apply this in the clinical setting while on placement. While some of the students were able to draw on personal experiences others only had a perceived connection. However, both groups were able to express a deep holistic understanding of their artwork. A student with previous childbearing experience discussed her painting, and explained that:
The image is intended to project focus and serenity. The woman appears suspended in time, entirely alone; there is no-one and nothing within that moment. It is a deeply spiritual connection within oneself, an existence entirely with the birthing. The woman harnesses this energy and accepts, rather than fights the pain and works with her body to create life.
A student with no previous experience of childbearing discussed her piece (handmade quilt) explaining that:
The white squares within the quilt contain images to symbolise my perception of the journey through pregnancy. The hands of the couple to me symbolise the love, emotional, spiritual and physical connection ... the egg symbolises conception ... the splash of water represents the rupture of membranes and the assistance given by the midwife ... the small footprint leaving an impression depicts the beginning of the journey from newborn through the lifespan.
Wikstrom (2001) explains that 'a painting moves a person into the future, or it picks up memories from the past' (p.29). When the students allowed themselves to be inspired by creating their own artwork, they took a mental walk, perceiving the feeling in what was depicted. The students without previous childbearing experience were able to go beyond their immediate experience, because they felt present in the events represented in their art.

Discussion

According to Carl Rogers, 1959 (cited in Sommers-Flanagan, 2007) 'openness to learning from new experiences is considered one of the greatest indicators of optimal functioning' (p.121). Having continued to expand on her father's theory based on the person-centered tradition (encouraging students to be their own teachers and evaluators), Natalie Rogers, 2003 (cited in Sommers-Flanagan, 2007) states that 'rigidity impairs learning. This is why rigidity is considered the antithesis of psychological health' (p.124). In student nurse education, creativity is reported as important and many examples show that this is the case. Bruderle and Valiga 1994 (as cited in Wikstrom, 2001) argue for 'creative teaching strategies in nursing using humanities, because they stretch the imagination and are inspiring' (p. 30). Koithan 1994 (as cited in Wikstrom, 2001) believes 'that innovative teaching methods emphasise creative awareness and reasoning' (p. 30), and Smyth 1996 (as cited in Wikstrom, 2001) argues that 'in order to offer creative care, the arts are influential forces that invite students to step outside their normal frames of reference, challenging their attitudes and standpoints' (p 30).

Rogers, 2003 (cited in Sommers-Flanagan, 2007) suggests that art is much more effective than words to deal with some very difficult emotions, and explains:

With expressive art, we are concerned as much about the process as we are the product. And it is not a product to go on a wall or in a museum. It could be, but that isn't the intent. The intent is to peel away the layers of defence and find our true nature (p. 123).
The results were interpreted in relation to and in context of experiential learning. The advantage of using the art studio at the school placed the student in a non-clinical environment, positioning the student to 'absorb' the art culture displayed around the room. Clarke and Willmuth (1982) discuss group dynamics and student interactions in their study:
Usually three or four students form small groups while some students work individually. Initially there is chatter and nervous laughter. This is soon replaced by a conspicuous quiet, as students become engrossed (p. 25).
The students were asked to explore the works of various artists and reflect on their representations of the childbearing process, drawing on theoretical knowledge as they conceptualised and interpreted the significance of the works. They gathered ideas, explored colours, shapes, textures and mediums, which required imagination. The art teacher encouraged them to 'scribble' on large pieces of butcher's paper, noting their ideas, thoughts, colour considerations and mediums. She frequently stated ''the bolder the better'' and encouraged them to "take up the whole page, explore!" Macrorie (1980) suggests:
Disuse of our pictorial cells probably produces cancer of the brush-holding muscles, decay of the visualising circuits, arthritis of the sculpting fingers, and makes us a little less human. If we relax and keep our vision clear, we can convey to students the truth that all people who create must develop their doodlings (p.47).
The students spent time reflecting, listening, discussing and debating with their peers, as they worked through the assignment. They became active learners during this phase, developing their own teaching-learning strategies and enhancing their problem solving skills while stimulating latent or dormant cognitive skills. Some students reported difficulties and frustrations while working with various mediums and were given encouragement and suggestions by peers, others spoke of the assignment as the 'family project', describing the delegation of cutting, gluing and pasting. Walsh et al (2004) reports the benefits of 'activities in which family members participate in art-making projects, promoting feelings of well being' (p. 215).

When presenting their assignments the students reported verbally and with written reports. This drew on subjective experience and reflection as well as theoretical knowledge. People develop interpersonal skills through feedback and reflection, as it cultivates insight (Wikstrom 2000). The key words that would describe the overwhelming response by the students to their peer's presentations would be: recognition, inspiration, appreciation, understanding, connectedness, compassion and responsibility. From an evaluation conference report Everitt and Hamilton (2003) wrote this about creativity:

Creativity is about problem solving. It brings with it success. It is connected with inspiration and understanding things better. When you are creative together, you feel part of a team. It puts new meaning on partnership and working with others. It bonds us together, it makes us part of a family. Creativity is about development and personal (deeper) well-being. What also makes you feel good is working through the process from beginning to the middle and through to the outcome. It's about having a sense of purpose, being appreciated by others and being engaged (p. 50).
When reading the comments recorded by the students on the questionnaire, it can be agreed that the objectives of the project were absolutely met. The explanations recorded in the emotive and reflective exercise were additional to the original objectives and consequently this justifies a further study while the students are placed on clinical rotation. This will explore the connection of their expectations linked to their provision of holistic care while engaging with a childbearing family.

Price et al (2007) reports that:

By changing the approach to nursing education to include aesthetic knowledge, educators can begin to promote a more balanced health system that allows patients, family members, and healthcare professionals to explore expressions of illness as they make meaning from their life experiences (p.157).
Price et al (2007) continued to explore blending art and science and concluded that:

A goal in nursing education should be to empower students to learn creativity and creative thinking as essential elements of clinical practice. The use of art forms communicates openness to individual expression, fostering awareness of, and respect for the uniqueness of each individual (p.159).

What is already known on this topic

What this study adds

Changes of individual appreciation for one another and changes in their attitudes and development toward professional accountability were noted by lectures who taught the students in the semester following the art assignment. This is a record of the noted change.
As a Head of School and Program Chair for the Bachelor of Nursing, I was pleased with the positive change in group cohesiveness that I observed in the first student cohort as an outcome from them participating in the art assessment in the Maternal and Newborn Health Care unit of study. This unit was taken in the first half of 3rd Year and to that point the group culture reflected typically what is seen of students sharing the same units of study in their learning journey to course completion. The students came together as a collection of students who, at the best of times, had little appreciation for the personal stories of those they were sharing the journey with. The art assessment changed that. Students looked on their fellow students as colleagues and related in a more meaningful and supportive manner. The group developed a positive personality that included empathy, tolerance and understanding and this was very evident in a final semester unit on Indigenous Culture and Health Care that I taught. Student's usual zone of comfort was challenged by the content of that unit; however, the group displayed empathy to one another and a level of cohesiveness that I had not previously witnessed. Given the strength of change in the students from the art assessment, I admire the Maternal and Newborn Health Care Unit Coordinator's influential role in that process.

Conclusion

'Caring for' is written into the definition of the MUSON Bachelor of Nursing Conceptual Framework, as being a major building block for the development of a student nurse progressing through the curriculum to become a registered nurse. The art assignment was instrumental in kindling this instinct and lighting the 'eternal flame of caring' essential to the context of the nursing process. An art experience establishes feelings of equality within groups and between people and health professionals, so incorporating an art assignment into a nursing unit, encouraged students to develop a sense of deep connection with their peers, consolidating the vital nursing graduate attributes of empathy, trust and respect and dignity for all. Understanding that registered nurses need to act as patient advocates, communication skills, problem solving skills and an empathetic approach is required to achieve the most important function, that being the central issue of the nurse-patient relationship. The art assignment enhanced these skills and demonstrated to the students how vital the role of collaboration and communication is to establish therapeutic cooperation.

References

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Author: Caroline Nilson is a registered nurse with a diploma in midwifery. Caroline qualified as a registered nurse in Zimbabwe, studied in England to gain her midwifery diploma and then attended Curtin University to obtain a Bachelor degree. She is currently upgrading her midwifery qualification to a bachelor degree and will begin her Masters by Research in 2008. Caroline is the coordinator of two units in the Bachelor of Nursing program at Murdoch University. Email: c.nilson@murdoch.edu.au

Please cite as: Nilson, C. (2008). Using the emotion of art to build cohesion, collaboration and empathy between student nurses. In Preparing for the graduate of 2015. Proceedings of the 17th Annual Teaching Learning Forum, 30-31 January 2008. Perth: Curtin University of Technology. http://otl.curtin.edu.au/tlf/tlf2008/refereed/nilson.html

Copyright 2008 Caroline Nilson. The author assigns to the TL Forum and not for profit educational institutions a non-exclusive licence to reproduce this article for personal use or for institutional teaching and learning purposes, in any format (including website mirrors), provided that the article is used and cited in accordance with the usual academic conventions.


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