The effectiveness and experience of arts-based pedagogy among undergraduate nursing students: a comprehensive systematic review protocol

Centers conducting the review University of Manitoba and the Queen's Joanna Briggs Collaboration for Patient Safety: a Collaborating Center of the Joanna Briggs Institute Review question/objective The objective of this review is to synthesize the best available evidence on the effectiveness and experiences of arts-based pedagogy for nursing students in undergraduate nursing education. The specific review questions are: Is arts-based pedagogy more effective than non-arts based pedagogy for enhancing competencies and learning behaviors in undergraduate nursing students? What are nursing students' experiences of arts-based pedagogy in undergraduate nursing education? Background Well-educated nurses are key to the health of populations, and teaching strategies are needed which prepare nurses to be critical thinkers, creative problem solvers and effective communicators.1,2 Educators are tasked with developing approaches to effectively teach critical content for nursing, however, some argue that the traditional lecture is inadequate to teach many of these complex concepts.3,4 There is a call for a change towards student-centered and concept-based curricula in order to prepare future nurses to be critical and creative thinkers who are capable of meeting the present healthcare demands.1,2,5 Teaching strategies which emphasize learning processes, focus on students, and incorporate active learning are needed. In recent years, there has also been a growing interest in broadening pedagogical practices in order to develop nurses who embrace both the art and science of nursing.6,7 While scientific knowledge is important to inform effective nursing practice, the interpersonal and caring aspects of the nurse-client relationship also require knowledge about the human aspects of health and illness to guide practice.8,9 Thus, some educators have forged an alliance between the arts and essential nursing subjects in order to both address current curriculum needs,2,5,10 and develop learner competencies essential to excellent healthcare.2 A number of key organizations including the World Health Organization, the National League for Nursing, and the Lancet Commission, are recommending health care education reform,1,11–14 and some scholars view the arts as having pedagogical potential to promote humanistic healthcare.1,10 Although the founder of modern nursing, Florence Nightingale, viewed nursing as a holistic endeavor,15 positivism as the predominant philosophy of science in the twentieth century, and the focus on technology in healthcare, has eroded the value placed on the art of nursing.15–18 However, some nursing scholars posit that nursing education cannot just rely on the sciences, but that pluralistic pedagogical approaches are needed which also draw from the arts and humanities to develop well-rounded professionals who are sensitive to the human experiences of health and illness.6,8,19 The arts can develop certain habits of the mind that are vital to healthcare, 20,21 and can be a source of illumination for nursing students. 19 A clinical textbook can provide information about signs and symptoms, but an artistic piece can embody how the symptoms feel to the patient and express difficult emotions.18 Hence, a well-rounded education is essential for nursing practice which frequently demands practitioners to navigate emotionally and ethically complex clinical situations for which there are no straightforward textbook answers.8 This perspective is congruent with Carper's seminal work, 22 in which she presented four diverse, yet integrated, ways of knowing that form the epistemological basis of the nursing profession: empirics, ethics, aesthetics and personal.16,17,23 Carper's ways of knowing have evolved over time, and nursing scholars have proposed additional ways of knowing such as unknowing,24 emancipatory,25 and socio-political knowing. 26 Arts-based pedagogy (ABP) also holds significant potential to address these expanded conceptualizations of Carper's original work. Arts-based pedagogy (ABP) is a teaching methodology in which an art form is integrated with another subject matter in order to impact student learning. 27–29 ABP results in arts-based learning (ABL),10 which is when a student learns about a subject through either creating original art, responding to other's art, or performing art. Using ABP in nursing education encompasses an arts integration approach,30–32 in contrast to teaching art as a distinct subject, as students learn about nursing subjects through either creating art or responding to another's art.10 Arts-integration is defined as “an approach to teaching in which students construct and demonstrate understanding through an art form. Students engage in a creative process which connects an art form and another subject area…”. 33(p.1) Learning in, with and through the arts, is a widely accepted pedagogical strategy in the discipline of education,31,32 and there are several educational theoretical perspectives which provide support for this approach. The underlying philosophy for ABP can be found in the writings of John Dewey, 34,35 an American philosopher, who posited that education should focus on individual growth, the social aspects of learning and active learning experiences.34,36 He also argued that school subjects should not be taught in isolation and that the arts should be integrated into the common experience.35,37,38 More recently constructivist theory has provided a theoretical basis for ABP.39 Constructivist educators assert that meaning is constructed through engagement with the world, experiential learning activities, and social interactions.21,40 If knowledge is viewed as socially constructed, then inventive ways to engage students, enhance participation, promote dialogue, and facilitate reflection are valued, 41,42 and ABP addresses these constructivist learning objectives. Further, Gardner's Theory of Multiple Intelligences43 is widely used to support ABP.21 According to this perspective, there are numerous intelligences which humans use to learn, but in academia there is a focus on the verbal and logical forms. Through the use of artistic mediums, additional aspects of intelligence are engaged as the arts use diverse ways of communicating.21 Moreover, Davis posits that there are five unique features of the arts,44,45 and ten specific learning outcomes which occur because of these unique features that make the arts powerful pedagogically. These features include that the arts produce a tangible product resulting in imagination and agency, focus on emotion resulting in expression and empathy, privilege ambiguity resulting in interpretation and respect, embrace a process orientation resulting in inquiry and reflection and facilitate connection resulting in engagement and responsibility.44,45 Many of these outcomes are also important in nursing education. Indeed, there are numerous reported outcomes of ABP in nursing education. Several nursing educators have published their ABP initiatives and discussed notable impacts on students' learning and learners' behavior towards learning.2,8,10,46–56 Furthermore, researchers have found that integrating the arts into nursing education engaged learners,47 developed new ways of thinking,19,47,57 increased self-awareness,47,57 integrated thinking and feeling,57,58 fostered student empathy,47,52 enhanced cultural awareness,47,50 fostered transformational learning,57,59 and increased observational skills.53 In nursing education, the arts have been integrated with a broad array of nursing topics. One nursing educator developed an assignment in which undergraduate students created an artistic expression about a clinical experience with a client.2 This educator reports that the assignment fostered students' awareness of the humanistic aspects of nursing care and developed students' empathy for both clients and classmates. Other educators infused a psychosocial nursing course with art, literature, music, and film, in order to enhance nursing students' learning about mental illness.47 A qualitative investigation of the students' experiences revealed that integrating the arts into the course increased students' understanding and engagement, and fostered empathy, self-understanding, and cultural awareness. Thus, nursing educators assert that the arts can facilitate reflection, engage today's multi-literate healthcare students and promote meaningful student learning in nursing education. Scholars also report on their experiences of resistance to arts integration in nursing education.1,2,19,47 They write about how some are dismayed by this seemingly unlikely amalgamation of disparate disciplines and question the impact of ABP on nursing students' learning.9 There are several reported reasons for this hesitancy to embrace ABP, such as: the explosion of scientific knowledge and the pressure to incorporate this type of knowledge into the curriculum,2,8,60 the dominance of the scientific model within nursing education,9 the need to prepare students for registration exams,2 lack of educational preparation to teach with the arts,2 nursing students' focus on learning nursing skills, 8,61 and lack of student interest.47 Thus, it is imperative to consider both the student experiences of ABP and the effectiveness of ABP with undergraduate nursing students in order to inform this discourse. There is an emerging body of research about ABP in nursing education; however, this work represents a diverse group of primary studies which have not been systematically examined. In order to confirm that no other systematic reviews have been published about ABP or ABL in nursing education, a preliminary literature search was conducted. The following electronic databases were searched and no current or planned review was found about this topic: Joanna Briggs Library of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO International Register of Systematic Reviews, CINAHL, ERIC, PubMed and Scopus. The grey literature was also searched, however no systematic review about ABP or ABL in nursing education was found in the grey literature. This lack of scholarly work is consistent with the general lack of robust research for nursing education,62–64 despite the fact that evidence is needed to inform nursing education practice and current curriculum reform.63,65,66 This proposed systematic review could provide a comprehensive review of the current research evidence about the experiences and effectiveness of ABP in order to facilitate evidence-informed teaching practice, support curriculum reform and inform future research. The purpose of this comprehensive systematic review is to synthesize the best available evidence on the effectiveness and experiences of arts-based pedagogy for undergraduate nursing students in nursing education.

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