The arts as a catalyst for learning with undergraduate nursing students: findings from a constructivist grounded theory study

ABSTRACT

Background: There is a growing interest in arts-based pedagogy (ABP) to promote the wide range of competencies needed for professional nursing. The aim of this study was to develop a theoretical understanding of how students learn through ABP in undergraduate nursing education.

Methodology and Methods: We used a constructivist grounded theory methodology which incorporated art-elicitation interviews. Thirty nursing students and eight nurse educators shared about their ABP experiences. Data were analyzed with grounded theory procedures.

Results: The arts as a catalyst for learning emerged as the core category and elucidates how the unique quality of the arts created powerful pedagogical processes for many students. When students engaged with these processes, they resulted in surprising and transformative learning outcomes for professional nursing.

Conclusions: These findings provide insight into why and how students learned through ABP, and can inform the effective implementation of ABP into healthcare education.

KEYWORDS:

• Arts
• arts-based pedagogy
• learning
• nursing students
• grounded theory

Background

Well-educated nurses need more than scientific knowledge and technical skills (Carper, 1978; Pavill, 2011). Entry-level practitioners must possess an extensive range of competencies to navigate complex practice situations: challenging clinical problems demand creative approaches, working together intensively with others requires collaborative skills, and the promotion of well-being demands emotional intelligence. A variety of educational approaches are needed to develop these and other critical capabilities. However, it is challenging to teach the wide array of required competencies within a content-focused curriculum (Hermann, 2004). This is sometimes due to pedagogical approach, and numerous nurse educators have begun incorporating the arts with the belief that new pedagogical perspectives can foster these essential competencies (Rieger, Chernomas, McMillan, Morin, & Demczuk, 2016). Arts-based pedagogy (ABP) is a teaching approach in which an art form is integrated with another subject matter to foster meaningful student learning (Rieger & Chernomas, 2013). Students learn about another subject through engaging in artistic processes by either responding to works of art, creating works of art, or performing artistic works.

There is a growing body of research evidence about the impact of ABP in nursing education. ABP seems to alter both the learning process and the learning product (Rieger et al., 2016). There are numerous reported positive outcomes such as self-awareness (Mahar, Iwasiw, & Evans, 2012), awareness of others (Jack, 2012), empathy (Casey, 2009), cultural sensitivity (Newcomb, Cagle, & Walker, 2006), reflection (Jack, 2012), and deeper understanding (Mahar et al., 2012). The emerging body of research suggests that ABP has a meaningful impact on nursing students’ development as professionals (Rieger et al., 2016). Educators also write of how ABP is sometimes met with resistance or seen as extraneous in an over-saturated nursing curriculum (Darbyshire, 1994; Pavill, 2011). Students may resent having to complete an assignment which is not tested on registration examinations (Pavill, 2011) and is seen as irrelevant for developing practical nursing skills (Casey, 2009).

To further inform this discourse, there is a need for a theoretical understanding of how nursing students learn through the process of ABP and the impact of this process. Whilst numerous authors have investigated ABP, none of them theorised the learning processes of students (Rieger et al., 2016). This understanding can guide the continued development and implementation of this innovative approach and inform discourses about the arts and learning in healthcare education.

Theoretical perspectives

Symbolic interactionism and transformative learning theory guided this study. Symbolic interactionism is a theoretical perspective that explains how human action is based on the individual’s meaning of a situation (Blumer, 1969). These meanings are constructed through a process of social interactions, which occur through the use of symbols, and personal interpretations of those interactions. This theory guided our inquiry about the participants’ meaning of ABP and factors that influenced this meaning. Transformative learning theory is an adult learning theory that explains the way adults make sense of experience to better guide future action (Mezirow, 2009). It provided a theoretical perspective for exploring the learning processes of students with ABP. As constructivists, we acknowledge that we also brought our own perspectives as educators in higher education to this work (Charmaz, 2014). As well, the primary researcher (KR) was a doctoral candidate and the co-authors were her PhD committee members.

Research approach

Methodology

Our research question was: how do nursing students learn through ABP in undergraduate nursing education? To elucidate the students’ learning process with ABP, we chose a constructivist grounded theory (CGT) methodology (Charmaz, 2014; Rieger, 2018). Grounded theory emerged from symbolic interactionism and provides flexible guidelines for developing a theory about a social process that is grounded in the data. Recently, Charmaz (2014) proposed CGT, which takes a constructivist view. It assumes that data are a co-construction between the researcher and participants. As a theoretical understanding about a practice issue was desired, rather than a highly abstracted theory, this purpose fit well with CGT.

Participants and setting

Participants were nursing students (n = 30) and educators (n = 8) in a mid-western Canadian baccalaureate nursing program. Inclusion criteria included: willingness to participate, experience with reflecting on nursing practice through ABP in an undergraduate nursing course, and the ability to speak and read/write English. Participants were recruited in-class (students) and by mail/email (students and educators) from two multi-sectioned courses (Supplemental File 1). The first was a third-year community course in which the students developed an arts-based reflection about a community clinical experience, and shared it in a group seminar. The second was a third-year issues, politics, and policy course in which students created a photo essay with a small group to reflect on a local social justice issue, and shared it in a class presentation. Recruitment from both ABP experiences provided rich information that contributed to and challenged the emerging theory (Charmaz, 2014). The response rates were 25% for students and 80% for educators. As students completed both assignments, some chose to volunteer twice (n = 4); thus, 34 student interviews were conducted. We used purposive and theoretical sampling. Eleven students were interviewed during purposive sampling. Theoretical sampling commenced once theoretical categories were identified and included interviewing students (n = 23) with a revised interview guide and interviewing their educators (n = 8). Our main research focus was the students’ perspective of their learning process; thus, this report primarily highlights student quotes. The educator data was used to confirm and explicate our developing GT of how the students reported learning through ABP. Data collection stopped when theoretical saturation occurred.

In total, 19 students shared their perspectives about the creative reflection and 15 about the photo essay. The majority of the student participants were under the age of 35 (66.6%), female (93.3%), and white (80.0%) (Table 1). Students rated the value of the ABP assignment out of 100, with higher scores reflecting greater perceived value, and 44.1% rated it as 76 or higher, 35.3% between 51–75, and 20.6% as 50 or lower. Ethical approval was obtained from the relevant institutional ethics review boards, and informed consent was obtained before data collection. To ameliorate the power differential between the researchers/educators and students, an intermediary conducted the recruitment procedures and only students who were no longer being taught by the research team were recruited.

Table 1. Participant demographics

Characteristic	n (%)
Student Participants (n = 30)
Age range (years)
20–24	8 (26.7)
25–29	8 (26.7)
30–34	4 (13.3)
35–39	7 (23.3)
40 and above	3 (10.0)
Gender
Female	28 (93.3)
Male	2 (6.7)
Ethnicity
White	24 (80.0)
Asian	1 (3.3)
Metis	4 (13.4)
Other	1 (3.3)
Number of arts-based assignment in the nursing program (n = 34)
1	7 (20.6)
2	15 (44.1)
3	5 (14.7)
4 or more	7 (20.6)
Value of the assignment total (n = 34) out of 100
0–25	4 (11.8)
26–50	3 (8.8)
51–75	12 (35.3)
76–100	15 (44.1)
Value of the creative reflection (n = 19) out of 100
0–25	2 (10.5)
26–50	3 (15.8)
51–75	5 (26.3)
76–100	9 (47.4)
Value of the photo essay (n = 15) out of 100
0–25	2 (13.3)
26–50	0 (0.0)
51–75	7 (46.7)
76–100	6 (40.0)
Educator Participants (n = 8)
Age range (years)
Under 29	0 (0.0)
30–34	1 (12.5)
35–39	1 (12.5)
40–44	0 (0.0)
45–49	2 (25.0)
50–54	2 (25.0)
55 and above	2 (25.0)
Gender
Female	8 (100)
Male	0 (0.0)
Ethnicity
White	8 (100)
Other	0 (0.0)
Years in the nursing profession
0–9	0 (0.0)
10–19	3 (37.5)
20–29	3 (37.5)
30 and above	2 (25.0)
Years as a nurse educator
0–4	1 (12.5)
5–9	3 (37.5)
10–14	3 (37.5)
15 and above	1 (12.5)

Data generation

Data were collected from February to December 2015. Socio-demographic information was collected to describe participant characteristics and promote transferability of the findings. One in-depth, semi-structured interview was held with all participants to gather rich narrative descriptions. The average interview duration was 47 minutes for nursing students and 63 minutes for educators, and interviews were digitally recorded and transcribed verbatim. The first author (KR) conducted the interviews in a convenient and private location of the participants’ choosing. Most students (94%) brought pictures of their assignment (or their actual work) to the interview where they were used for photo/art elicitation (Harper, 2002). Exemplars of interview questions included: “Can you describe your overall experience of participating in this assignment?” and “How did you go about creating this assignment?” Descriptive field notes were written about the interview context and the interviewer’s perceptions of the conversation.

Data analysis

Socio-demographic data were analyzed with descriptive statistics and other data with CGT analysis methods (Charmaz, 2014). Data were managed with ATLAS.ti. Although 15 participants requested a transcript review (Polit & Beck, 2012), no participants made any changes. Coding, constant comparison, and memo-writing began early with the first few interviews. Two phases of coding were utilized: initial coding involved studying fragments of data and labeling them with codes, and focused coding categorized large amounts of data by using the most analytically significant codes from the line-by-line coding. After 11 interviews were analyzed, an emergent, focused coding framework was developed and used to code all following interviews. New participants’ data were compared to focused codes from previous participants, and their data were added to the framework. During focused coding, the codes became increasingly conceptual and explicated, and certain incisive focused codes were elevated to abstract categories. Theoretical integration began during focused coding and was achieved through coding, constant comparison, memo-writing, and diagramming a visual representation of the emerging GT (Charmaz, 2014). Two researchers conducted the coding and analysis (KR, WC), and two confirmed the emerging analysis and audited analytical decisions (DM, FM).

Numerous strategies were used to enhance methodological rigour (Charmaz, 2014; Lincoln & Guba, 1985). To gain an in-depth understanding, the researchers engaged in prolonged engagement with the study topic and persistent observation with in-depth interviews and photo/art-elicitation (Polit & Beck, 2012). The primary investigator taught in the same nursing program in which the study was conducted; however, she wrote reflective memos and engaged in reflexive dialogue about her influence on the research process during consultations with her supervisor. Careful documentation of the constant comparison process and key analytical decisions occurred through memo-writing. Data (student and educator) and method (interviews and photo/art elicitation) triangulation were both used. Theoretical sampling enabled us to check our initial interpretations with future participants and to search for confirming/disconfirming evidence. Lastly, the consolidated criteria for reporting qualitative research (Tong, Sainsbury, & Craig, 2007) guided this report.

Results

In this study, students expressed that their main concern was how to create art and authentically learn through this creative process in nursing education, and the nurse educator participants confirmed this finding. To their surprise, many students reported experiencing the arts as a catalyst for learning. When students engaged with ABP the arts acted as a catalyst, or an event that impacts change, with that change being learning. To learn through the arts, students described navigating a creative learning process with different phases. However, there was variation in the students’ experiences and notable enabling and restraining factors influencing students’ engagement with this learning process. Although some students did not find meaning in the ABP experience, most students reported learning to be a nurse through ABP (see Figure 1 for the GT). In this paper, we report on the core category, experiencing the arts as a catalyst for learning, and the category that encompasses its resultant outcomes, learning to be a nurse through ABP (Table 2). A description of the other two categories are reported elsewhere (Rieger, Chernomas, McMillan, & Morin, n.d.).

Table 2. Categories and sub-categories described in this paper

Category	Sub-category
Experiencing the Arts as a Catalyst for Learning (core category)	Musings through mediums
	Connecting emotionally with learning
	Leaving the comfort of my computer
	Realizing my perspective, your perspective
	Creating unique pedagogical places
	Making it personal
Learning to be a Nurse through Arts-based Pedagogy	Authentic reflections and revelations
	Making connections
	Transformations of perspectives
	Deeper understanding of others
	Developing unique nursing skills
	Inspired towards advocacy
	Negligible, unimportant, or no learning

Figure 1. Experiencing the arts as a catalyst for learning

Experiencing the arts as a catalyst for learning

Participants described how the arts were a unique catalyst for learning in nursing education because of their distinct features as ways of knowing and expressing. The six sub-categories explain how these features created important pedagogical processes for many students.

Musings through mediums

ABP enabled students to muse through different mediums than they normally would – artistic ones. The arts offered ways of seeing and expressing that transformed the way clinical experiences and social justice issues were viewed. Students explained how representing their thoughts within artistic mediums demanded that they think conceptually to match a concept and an art form in a meaningful way. As one student said, “It’s supposed to be a symbol of what you’re trying to say.” This process involved deeper thinking to understand what would fit well with an art form: “…it’s not creating something that isn’t there. But it kind of helps you dig for what is there.” Using the lens of the arts privileged certain aspects of experiences, such as the relational side of nursing. Musings through mediums also fostered an iterative inquiry into the experience. One student expressed it as a conversation with her painting: “And this is just me and my reflection. This is me and my board. We both are sitting and just kind of talking to each other.”

Connecting emotionally with learning

ABP enabled the self-expression of emotions and an emotional connection to the subject, which engaged students. The arts provided an affective language to process and express difficult or hidden emotions. One student visited the same high school which she attended as an adolescent, where she had struggled with feelings of belonging as an Indigenous child adopted by a white family. She shared: “When I came back there, I felt like I had a place…But I wasn’t the same person I was when I was there so many years ago.” She had an “epiphany moment” when processing this emotional journey (Figure 2): “I think I was stuck and I was lost. And I don’t feel lost anymore…and writing this poem made me figure that out.” Students explained that this level of emotional expression was a unique experience within the nursing program:

Figure 2. Student poetry for the creative reflection

We don’t talk enough about our feelings in this program…I guarantee you every single student in this program has cried at one point…and I think we need to talk about it more…And I think this assignment was.

Participants also described how the arts helped students to connect emotionally with a clinical situation. One student described how taking photographs for the photo essay deepened her appreciation to genuinely empathize: “It’s one thing to research it because you don’t identify with it…you don’t really empathize with them until you see them.” The emotions involved in creating art could also be draining as one student explained: “If you’re truly being creative…it weighs on you….it’s hard. You’re taking basically a piece of yourself and putting it out there.” Many students still valued this deep emotional work, as one reflected: “I want to walk out of here remembering specific things that meant a lot to me and that will change me emotionally…And this poem and that experience would be one I would say.” (Figure 3)

Figure 3. Student poetry for the creative reflection

Leaving the comfort of my computer

ABP required that students leave their computers and connect with other learners, clients, populations, practitioners, and agencies in their communities. These relationships became a living curriculum. One student said about taking pictures of a social justice topic for the photo essay (Figures 4 and 5): “It made it real, getting out of the classroom, talking and interacting with others had a huge impact; the photos representing these interactions”. The photo essay involved interactive group work, and in the creative reflection, students especially connected with their learning community through sharing at seminar presentations. Some that did not enjoy ABP itself, still highly valued these relational connections.

Figure 4. Student photograph for the photo essay

Figure 5. Student photograph for the photo essay

Realizing my perspective, your perspective

The arts elicited multiple perspectives about a topic, and encouraged students to express their own thoughts, to consider another’s perspective, and to acknowledge the reality of multiple valid interpretations. Students got to “learn how everybody sees that issue.” An educator explained how group work facilitated discourse: “the ones who work collaboratively, there’s a lot of discussion on what is the best thing to put on those photos.” Group presentations also unveiled different perspectives of clinical learning experiences. In one seminar, three people reflected on the same clinical encounter and one student noted: “It was the same visit but…she pulled something out of that, different than what I pulled out of it.” Students found that there was not always a right viewpoint with the arts, and that “the person receiving it can also have their own interpretation.”

Creating unique pedagogical places

ABP opened up unique pedagogical places. It created a space in which students could pause and reflect within a busy curriculum. Representing concepts with art demanded time for contemplation and creativity. One student compared ABP to previous reflections: “I never really stopped to pause …so I think doing this reflection made me pause and look back.” Participants also described how ABP democratized the classroom through creating a unique place for diverse learners to flourish and shine. One student shared: “This assignment was very special to me because, because of my English, sometimes I’m not able to put my thoughts into words but I was able to put my thoughts into pictures. And I think they were powerful.” One educator noted:

there’s a whole other group of students that … have a lot of creativity. And…for them to be able to express it in a different way than writing the exam, I think it’s great … some of these other students that were maybe just average were able to shine.

Some students described ABP as a fun space, and one said: “In the nursing school…everybody’s grading you on every little thing. And it’s just, it’s intimidating…so it’s nice to have a little bit of fun too. I mean you’re still learning but…it’s a fun learning.”

Making it personal

Students highly valued the personal nature of ABP, which cultivated deeply meaningful learning. They discussed how they expressed personal thoughts, connected to a personal interest, explored a personal struggle, engaged in personal self-care, and told or heard a personal story. One student said, “I did this because I had to do it but by the end I felt like there was more meaning to it because I was able to add my own…personal touch to it.” Students were also able to incorporate parts of their personal lives into their nursing education through selecting an art form or topic that previously held meaning for them. One student explained, “I had an awesome time actually doing this just because I love painting and… during my nursing years, I really didn’t have enough time to do it.” Some students found that expressing artistically helped them to care for themselves:

…it calms me down and, I’m just so passionate about it and I just kind of forget all of my problems and I just concentrate on that… I took time and I was like in my room, listening to music…it’s relaxing…it just didn’t feel like what my other assignments were like.

ABP also situated social justice issues in a personal story which helped students to “put a face to those people that you are writing about.”

Learning to be a nurse through arts-based pedagogy

In their reflections, participants shared about the valuable learning for professional nursing that arose from their ABP experiences. The learning elicited by the unique qualities of the arts was more about a way of being as a nurse than about an effective transfer of content. In contrast, some students questioned whether ABP resulted in meaningful learning. The following seven sub-categories speak to the variation in the students’ learning.

Authentic reflections and revelations

Students described authentically reflecting and revealing the insights generated to others. Some participants discussed how the nuances of multiple artistic modalities enabled them to develop a richer understanding of the experience, and to reflect at deeper levels. An educator observed that: “It wasn’t just a surface reflection. It was many layers.” Through having an authentic experience, some students came to value reflection more. One student shared (Figure 6): “Self-observation…is an important piece to overcoming challenges…This is my reflection. My self-observation. Art.” Some found that through art forms, they were able to share with their learning community on a deeper level than they had previously (Figure 2): “I think that when I read this poem people understood what it felt like to be me for a minute.”

Figure 6. Student art work for the creative reflection

Making connections

Through ABP, students were able to make meaningful connections between concepts and real life. Students had to take photographs of social justice issues in their own community for the photo essay, and this connection increased the relevance and their understanding of the issue. Students described how they learned about community resources and agencies through the experiential community engagement with ABP, and made connections with their nursing practice. ABP also helped previous content to become more vivid. One student described this learning when taking photos: “You can’t deny it when you see it… we were out there. It was minus 50. We saw it. And it really solidified, I think, our learning in that way.” So it was not the impact of this one assignment, but of how ABP illuminated content from other courses. Some students also made new connections between the arts and the nursing profession, as they started to see the value of the arts for their professional growth.

Transformations of perspectives

Students talked about changes in perspectives that would impact their future nursing practice. One student said, “This whole thing was just…an eye-opener.” Through both assignments, students’ personal assumptions were challenged as they realized and revised some of their own judgmental thoughts towards others. Students discussed how they were able to visualize the contextual factors influencing the individual and their vulnerability to healthcare inequities. One student shared:

You read about African refugees and what they go through and the trauma and, you know, their living conditions and all of that. And you just see it on paper…but going out and taking the pictures and talking to the people that have experienced it…it’s totally different. (Figures 4 and 5)

Students also described changing perceptions about the value of creativity within nursing. Those who felt a sense of accomplishment about their assignment, especially after doubting if they were creative enough, reported a transformed sense of their own creative self-efficacy (Tierney & Farmer, 2002). One student shared:

And I do not see myself as an artistic person…This assignment, which asked me to tap into my creative side terrified me because I lack confidence that the creative side of me even exists… However, I discovered that with the right tools and supports, even I can create something beautiful…I am capable of more than I ever thought possible.

Deeper understanding of others

Students reported imagining what it was like to be another through the arts. One student described how role-playing to take pictures for a photo essay about discrimination fostered a deeper understanding of others: “I think it kind of puts you in those shoes” (Figure 7). Another explained why this understanding is important: “Thinking about the person as a whole instead of just the IV [intravenous] that you have to start or the medication that they have to have, can help you build that relationship with your client.” Presentations also increased students’ understanding of others in their learning community, as they learned about their peers’ creativity or interests. One student recalled: “One of my friends played the guitar and sang. And I remember thinking, you can play the guitar? We’ve been friends for three years. What do you mean you can play the guitar?”

Figure 7. Student photograph for the photo essay

Developing unique nursing skills

ABP resulted in developing important nursing skills that are challenging to foster through traditional educational approaches. These skills included: presenting through creative means, creative abilities, collaborating with a group, empathy, interpersonal skills, cultural competence, creative self-care, and interpretation of an ambiguous situation. One student discussed developing collaborative skills through creating together:

It’s a valuable skill. You have to learn how to work with people and sometimes you’re going to get the short end of the stick and someone’s going to bail on you and it’s going to suck and you just kind of have to eat it. But that in and of itself is kind of a life lesson.

Students described how they learned to present creatively and that “there’s different ways of getting your point across.” One student reflected: “I learned how to make a photo essay…it kind of packed a little bit more punch than if I just stood up there and read a research paper to the class.”

Inspired towards advocacy

Participants discussed how the photo essay inspired them to advocate about social justice issues in the future. One student said it “instills the sadness in you that, you know, something needs to be done and makes you want to make change.” Another shared that:

I had no idea how rich nursing actually was until I got here. It’s not just about putting that bandage on so to speak. And I don’t want to downplay any of…what we’ve learnt practically as nurses do. But what I’m recognizing is that nurses can be far, far more than that. And, to be political advocates.

Negligible, not important, or no learning

In contrast, when a student did not engage with the ABP assignment, it seemed to result in less effort, less engagement, and an inauthentic assignment. Some students reported negligible, unimportant learning, or no learning, or that their learning was not worth the stress of the assignment. One student said (Figure 8): “What am I learning from this? That you like to cross stitch…Like we didn’t learn anything.” Another student shared candidly, “it’s really hard to say …what I really learned from it. I don’t really think I learned a lot of anything if I’m being completely honest.” This group of students either felt that they experienced very little to no learning, or that they did not need the art form to reflect or learn.

Figure 8. Student art work for the creative reflection

Discussion

Our study is the first to develop a theoretical understanding of how and why students learn through ABP. Our findings revealed that the arts bring unique qualities to nursing education and foster alternative meaning making processes for many students. The arts encourage students to consider aesthetic and holistic aspects of nursing practice, and provide illuminating symbolic languages for deep internal reflection and meaningful conversations with others (Blumer, 1969). One reason that the arts may be an enlightening lens in nursing is that they privilege the affective aspects of experiences (Eisner, 2002). Nurses often experience difficult emotions in their practice which is intertwined with illness, suffering, and grief. The potential of the arts to provide a fitting container for these deep and often hidden emotions is important (Lapum, Yau, Church, Ruttonsha, & David, 2015). An emotional connection to learning may also enhance the students’ memory and engagement. In a review about the interaction of emotions and cognition, the researcher found that emotions can enhance the formation and recollection of episodic memory, and draw the learner’s attention to what is essential (Phelps, 2006).

Another possible explanation for the ability of the arts to foster learning is that they offer multiple modes for understanding. In this study, students represented their understandings through multiple modalities, such as various art forms, text, and verbal reflections, and described musing through different mediums. Drawing on multimedia learning theories, multiple representations can engage learners, create a more comprehensive mental model, and enhance learning (Ayres, 2015). Groff’s (2013) theory, Wholemindedness: The Theory of Cognitive Processing Systems, highlights that integrating multiple processing systems (i.e. visual-object, visual-spacial, and verbal) are critical to students’ holistic development. She argues that because the arts draw on diverse processing systems, they should be “a central modality and mechanism” (Groff, 2013, p. 34) for of all learners.

Our findings also highlight that ABP incorporates multiple ways of knowing. Although there has been a tendency for the elevation of the rational way of knowing, scholars argue that professional nursing is based on diverse ways of knowing: empirical, aesthetic, personal, ethical, and emancipatory (Carper, 1978; Chinn & Kramer, 2018). Aesthetic inquiry refers to knowing through an aesthetic experience (Archibald, 2012), and is defined as “a method of knowing that implies an ability to appreciate and comprehend the elements of an art form” (Price et al., 2007, p. 155). Nursing scholars refer to aesthetic inquiry as a way to develop important nursing knowledge about the meaning of a lived experience and the relational narratives of nursing practice (Archibald, 2012; Doane & Varcoe, 2007; Price et al., 2007).

Although the arts have valuable pedagogical qualities, a fundamental question is: what is worthwhile learning in nursing education? When one looks at the students’ learning, there are outcomes which are significant to the development of professional nurses, but which may not be testable on exams. Some educators are calling for this ontological turn in nursing education. While education that is epistemologically oriented focuses on covering key content, an ontological orientation focuses on the “the student as a developing person and nurse” and “explicitly emphasizes and illuminates the way in which knowledge and knowing are inherently related to subjectivity and context” (Doane & Brown, 2011, p. 22). Thus, epistemology serves the ontological focus on students’ transformations towards professional ways of being (Doane & Brown, 2011). In our study, it became apparent that ABP could support an ontological pedagogical approach.

Our participants indicated that ABP offers a meaningful alternative to written reflections, and reflection is a crucial competency within professional nursing (Scanlan & Chernomas, 1997). The arts enable the grasping of concepts and experiences through the process of transforming them into a tangible product which can be touched, viewed, or heard; thus, allowing for a deeper, different, and more thorough reflection (Eisner, 2002). Students also reported that their perspectives became more inclusive, discriminating, and open (Mezirow, 2009). The arts can be a catalyst for transformative experiences because they tap into unconscious knowledge, bring experiences into public view for reflection, and create insights not readily accessible through technical-rational academic activities (Butterwick & Lawrence, 2009).

One interesting finding was that ABP developed students’ creative abilities and creative self-efficacy (Tierney & Farmer, 2002). This type of learning was unusual in the nursing program; yet, everyday creativity is an essential competency for solving problems in nursing practice and research (Carper, 1978; Fasnacht, 2003). Conducting research is also an intensively creative process and nurse researchers need to be inventive when designing and enacting studies. Conformist education can cause a loss of creativity (Fasnacht, 2003), and in one study, nursing students’ creativity scores decreased by the end of their program (Sullivan, 1987). There is a need to cultivate creativity in nursing students (Fasnacht, 2003), and ABP can address this pedagogical concern.

An important, but somewhat concerning, finding was that some students reported negligible, unimportant, or no learning. This finding is also evident in the measurement of the students’ value of ABP experiences (Table 1): seven students (20.6%) rated the assignment between 0 and 50 out of 100. The students’ creative learning process, the factors influencing students’ negative experiences of ABP, and the implications for educators are reported in another paper (Rieger et al., n.d.).

Implications

Overall ABP resulted in meaningful learning for professional life, and some students suggested that it should be integrated throughout the nursing program. This experiential and student-centered approach can meet many recent demands for nursing curriculum change (Oermann, 2015). Nurse educators should consider ABP when planning courses and administrators could strategically layer ABP experiences into the curriculum. There is a wide range of novel activities to choose from, as evidenced in the breadth of work reviewed in our systematic review (Rieger et al., 2016).

There may be places in the nursing curriculum in which ABP may be especially useful. Nurse educators could use ABP to incorporate a critical pedagogical perspective that challenges students’ preconceived assumptions. Study participants suggested that ABP could elicit personal sharing to build the learning community. Additionally, ABP could reinforce previously introduced concepts with an approach that incorporates the affective domain of learning. Another participant suggestion was to have an arts-based option for written reflections in order to democratize the learning process.

Educators should also expect that a proportion of students will respond in a negative way to ABP, and provide appropriate alternatives and supports. A good entry point may be an assignment with more guidelines and in which everyone works within the same modality; thus, decreasing the risk-taking aspect. Educators should also consider the importance of formative feedback, the value of students working with a partner or smaller groups when taking their first steps in creative projects, and the appropriate provision of guidance for graded assignments to decrease anxiety.

Limitations and future research

A limitation of this study is that this study involved 30 students, and is not known why other students did not volunteer for the study or how they experienced ABP. Further, we used one retrospective interview to elucidate a process, and key junctures may not be remembered well. Further research is needed to determine how this grounded theory is applicable in other settings. This study could be replicated with different types of ABP experiences, including non-evaluated ABP and in multi-disciplinary contexts. Analyzing students’ artwork and conducting multiple interviews at critical junctures could also expand this theory. To enhance our understanding of facilitating ABP, additional research is needed from the nurse educator perspective. Experimental or quasi-experimental studies are warranted to investigate the effectiveness of ABP on the learning outcomes described by our participants.

Conclusion

The arts have unique characteristics which foster meaningful ways of knowing and expressing in undergraduate nursing education. ABP demonstrates promise to provide fresh pedagogical perspectives that result in important learning for the development of professional nurses. The arts have a place in nursing education. As Eisner (1998) writes,

The arts inform as well as stimulate; they challenge as well as satisfy. Their location is not limited to galleries, concert halls and theatres. Their home can be found wherever humans choose to have attentive and vital intercourse with life itself (p. 56).

Acknowledgments

Kendra Rieger was the recipient of a Manitoba Health Research Council Studentship Award (September 2013–April 2014), a Canadian Institutes of Health Research Frederick Banting and Charles Best Canada Graduate Scholarships Doctoral Award (May 2014–April 2017), a Sir Gordon Wu Graduate Student Scholarship (2014–2017), and a Manitoba Centre for Nursing and Health Research Graduate Student Research Grant which provided support for her doctoral work.

We would like to acknowledge Mr. Patrick Faucher from the Centre for Healthcare Innovation who developed our visual diagram and Dr. Marilyn Macdonald for her review and feedback on an earlier version of this work.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed here.

Additional information

Funding

This work was supported by the Canadian Institutes of Health Research [Frederick Banting and Charles Best Canada Graduate Scholarships Doctoral Award];University of Manitoba [Sir Gordon Wu Graduate Student Scholarship];Manitoba Centre for Nursing and Health Research [Faculty of Nursing Endowment Fund Graduate Student Research Grant];Manitoba Health Research Council [Manitoba Health Research Council Studentship Award].