Finding inventive ways to teach nursing rests with teachers. Although it is risky, inventive strategies can be both exciting and, if planned well, can be inspiring. In courses such as mental health, in which important concepts are difficult to envisage or imagine, innovative strategies are needed. However, teachers often feel it is not worth taking a risk, although students have shown to prefer innovative assignments as a fairer or engaging means of evaluating student learning.1 Studies have shown that, compared with traditional modes, innovative "left-brain" assessments allow students to think "outside the box."2 The purpose of this article is to explain how an art-based teaching assessment was used in an undergraduate nursing course on mental health.
Art-based Teaching Assessment
Art-based assessments can create new opportunities for dialogue and inject fun into learning. Such an innovative approach not only can improve student learning but also can help students reach their individual potential.3,4 Through artwork, expression of creativity in auditory, visual, or performing artifacts depicting the author's imagination and skills occurs, and an intended message is conveyed. This creativity is closely aligned to nursing as it allows for the aesthetic expression of feelings, emotions, and meaning. Carper5 was the first to identify aesthetic expression as a significant way of knowing. A systematic review by Reiger et al1 emphasized that aesthetics formed the foundations from which other ways of knowing can be developed. Nurses through art can build on self-awareness and appreciation of human responses.6
Art also allows for the presentation of an idea or object in an original way using critical thinking and reflections. The creativeness involved in artwork is interpreted as the ability in redefining problems, analyzing solutions, overcoming obstacles, tolerating ambiguity, and maintaining perspective.7,8 Lindstrom9 suggested that students' creativity gives life to the students' work, allows for decisions to be made about their work, and highlights their strengths and weaknesses. More importantly, art-based pedagogy supports the notion that humans use numerous intelligences to learn.7 Therefore, the medium of artwork engages additional intelligences and allows for diverse ways of communicating. These attributes are important in nursing education.
Recent articles report on artwork in teaching nursing students. Moorman and Hensel10 explained how visual thinking strategies were used to improve skills in observation and communication. In that teaching method, nursing students, assisted by a facilitator, discussed pieces of artwork in an art museum. Students were then encouraged to draw relevance to situations in clinical practice. In another teaching strategy, Lapum and St-Amant11 used visual images as teaching tools in the classroom to prompt reflections and clinical reasoning. In a study by Buxton,12 drama was used to simulate nurse-patient interaction in regard to a mental health condition within the classroom setting. Students evaluated the various drama presentations favorably and reported that they helped decrease their fears and discomfort and built confidence about dealing with emotional distress experienced by mental health patients.
Another study by de Guzman et al13 used a selection of films to examine the essence of caring in geriatric nursing. Through content analysis and appreciative inquiry, a model was developed comprising of 3 themes (carer, caring, cared for), which gave rise to the nexus between living, learning, and loving as essentials to geriatric nursing. Frei et al14 integrated an art education program into a nursing course to improve empathy and communication skills. Their findings showed that students developed an increased awareness of human responses to ill health and disease.
These studies, however, did not use artwork in assessments. Essentially, few or no studies have used artwork as part of an assessment strategy. One study by Emmanuel et al2 used mask design as part of an assessment strategy for first-year nursing students studying communications. Further work by the author highlights how this strategy can be effective when teaching mental health nursing.
Assessment Activity
A total of 143 second-year nursing students enrolled in a mental health nursing course participated in this assessment activity. Course content included various ways individuals and groups respond to emotional and social trauma, such as those occurring in acute mental disorder, life crisis, and social disharmony. The course was composed of face-to-face weekly lectures and tutorials. It had 2 written assessments, followed by 2 weeks of clinical placement in a mental health facility or service. The teaching team involved 3 teachers overseeing class groups of 20 to 24 students. In preparation for each weekly tutorial, students were expected to attend a lecture and complete relevant readings. Each weekly tutorial involved focusing on new ways of thinking, incorporating thinking and feeling, integrating self-awareness, fostering therapeutic communication skills, and increasing observations skills. To achieve this learning, artworks were used to illustrate an imagined scenario. Within these scenarios, learning activities were embedded to promote reflections and clinical reasoning. Over time, the complexity of tutorial content increased.
The assessment involved asking students to first imagine what it would be like to spend a day in the life of a person with a mental health condition and illustrate these imaginings through artwork on a standard-sized poster. Second, in a related written essay, students analyzed and evaluated the emotional and social trauma experienced as conveyed in the artwork. Finally, students examined how the condition interfered with life in the mainstream, followed by a discussion on the person's needs during recovery.
As part of the tutorials leading to the assessment, students were obliged to consider the realities of people with mental health condition. This prompted students before coming to class to investigate the literature on this topic. Students were encouraged to discuss in groups their investigations, examine their view of the world, acknowledge their own limitations, and share their perceptions with colleagues. At regular intervals, students were also introduced to samples of artwork depicting various narratives. On these occasions, students were prompted to respond to different questions such as "What is being illustrated?", "Whose life is being portrayed?", "What must it be like for that person?," and "How is this connected/linked to the social world, health services, and nursing?".
With learning to make connections between real-life scenarios and artwork, the next challenge was introduced. Students were asked to create and express their conceptualization of what it would be like to spend a day in the life of a person with a mental health condition, through their own artwork. With this activity, students had to think and feel what it must be like to be in such a life situation. As new concepts from the course content were covered, reshaping and reformulating of their drafts of artwork took place. Students were also persuaded to work in groups and critique each other's artwork. Tutorial activities also covered the purpose of the related written work. Analysis and clinical reasoning of the imaginings conveyed in the artwork were sought. Essentially, students needed to make links between messages conveyed in the artwork, course content, the social world, and nursing practice.
This approach in assessment was daunting yet exciting for the teaching team. Our concerns, however, had a short life-span as students delved into preparation for the assessment with vigor and enthusiasm. Overall, the artwork presented as posters demonstrated a high level of creativity. Artwork featured painting, drawings (colored, black and white), and collages of images. An example of 1 student's artwork is displayed in Figure, Supplemental Digital Content 1, http://links.lww.com/NE/A291, illustrating a day in the life of someone given a diagnosis of schizophrenia. The student highlights with bright colors a recreational scene on the beach. People (sunbathers and swimmers) in the scene seem oblivious to the plight of the person with schizophrenia swimming in the deep. For him,
Everyday life is like being swallowed up by something more powerful than him. His world feels unstable with no firm ground beneath his feet. The more he tries to surface, the deeper into the water he gets. His thoughts tell him he should try and join the others and swim within the flags for safety.
In another example, the student uses pastel colors to depict a "normal day" for a mother with postnatal depression (see Figure, Supplemental Digital Content 2, http://links.lww.com/NE/A292). The images tell a story of personal daily struggles. The student wrote:
Becoming a new mum is like taking a roller coaster ride. Her day is usually one of demands and challenges, which is overwhelming. She tries to cope[horizontal ellipsis]too much pressure from all around. The physical exhaustion does not help.
The associated written work built on important points conveyed in the artwork. It provided a necessary conversation between the student and the teacher about the new learning experience. In this conversation, the student provided a personal dialogue and interpretation of 1 day in the life of someone with a mental health condition. From this, there developed a sensitivity and humanity that cannot be easily taught. At the same time, there was integration and analysis of the literature. Clinical reasoning, derived from both the artwork and written work, showed appreciation of students' newly acquired knowledge and relevance to nursing practice.
To evaluate this innovative assessment strategy, we measured the extent of student learning using Bigg's15 SOLO taxonomy. Results showed predominantly higher-order thinking at multistructural level and higher. Essentially, this suggested that students were able to demonstrate strong levels of analysis, evaluation, synthesis, and creation.
Many students looked forward to the nonconventional assessment, although a few complained that they were not creative enough and therefore felt disadvantaged. One teacher stated that "once the students got into it, there was no stopping them." Several students reported that the assessment had engaged them at a personal level in a profound way. As 1 student commented, "I was very apprehensive about mental health nursing. Now I can't wait for my clinical placement." For the teachers, taking this art-based approach in assessment was more time consuming and challenging than other forms of assessment. However, they felt that student enthusiasm and positive feedback made their teaching worthwhile. Above all, the learning experience prepared students for their forthcoming clinical placement in a mental health setting.
Conclusions
The use of creative assessment approaches that incorporate art shows much promise for nursing education. If used more frequently, these approaches can broaden the range of learning experiences for students. For teachers who are hesitant about using these teaching strategies, linking up with other educators within their own or other schools who share similar interests may prove beneficial. Interest groups among the faculty can increase one's creativity about assessment redesign and give confidence to teachers when implementing a change in assessment methods in nursing courses. Art-based assessment in courses such as mental health nursing enables students to better understand the human experience and allows faculty to interpret how students might interact and provide care for those with mental health illness.
References