Nurse faculty continue to lament about the failure of students to read text assignments, but the majority of assignments in nursing programs continue to rely on readings from textbooks. The literature references various factors related to why students are not engaged in textbooks, and it is hypothesized that the problem is the textbook itself (Hattenberg & Steffy, 2013; Macmillan Learning, 2016). Textbooks are often written using numerous words, challenging novice learners to identify the main ideas, think deeply about key concepts, and integrate existing and new theoretical and conceptual models into their learning and decision-making.

Innovative methods are needed to help nursing students navigate complex, multidimensional, nuanced decision-making situations. Nurses will remain underprepared to negotiate the subtleties of their new roles without innovative and diverse learning practice activities (Benner et al., 2010; Institute for Healthcare Improvement, n.d.; National Council of State Boards of Nursing, 2019). Our goal in developing a course for baccalaureate nursing students using authentic literature as a textbook was to understand students' experiences of engaging with the material and attaining course outcomes, specifically the formation of clinical nursing judgment.

Arts-based pedagogy (ABP) is an innovative teaching-learning strategy that combines a specific subject and an art form (Rieger et al., 2015). In this instance, nursing is the subject, and the art form is authentic literature. This type of teaching-learning approach supports students' immersion in the contextualized and lived human experiences of others, promoting both affective and cognitive learning (Rieger et al., 2015) with the potential to expose students to ethical dilemmas and injustices not previously encountered. Using authentic literature via ABP can also provide students the opportunity to analyze human experience in a new context, as well as contemplate nursing's ethical and justice-driven mandates. This article reports the results of a study that explored students' perceptions of using authentic literature as the textbook for a nursing theory class focused on professional role development.

METHOD

This descriptive study used an online survey to explore a holistic perspective of students' experience using authentic literature. The target course, Nursing Theory and Knowledge, was taken by all first-semester upper-division baccalaureate nursing students. Small Great Things by Jodi Picoult (2015) was selected to replace the traditional course textbook. The novel is loosely based on a true story where the characters experience racism and social, political, and ethical issues. The issues have relevant application to experiences and decisions students will confront in today's health care environment.

Faculty reviewed the text to ensure appropriateness of scope, sequence, and alignment with course outcomes. Controversies in the novel were used as probes to enhance students' decision-making skills. The context presented via the novel prompted students to think critically about their own assumptions and beliefs and how they would shape their own decisions, comparing them to decisions made by characters in the novel. In addition, sections of the American Nurses Association (ANA) Scope and Standards of Practice (ANA, 2015b) and the ANA Code of Ethics (ANA, 2015a) were assigned to support students' decision-making in alignment with professional expectations.

In preparation for each class, students completed a reading guide requiring them to summarize key events and identify implications for nursing and society. During each class, students were divided into small groups for peer-led discussions. Each small group had a weekly designated peer facilitator (facilitators rotated throughout the semester) who was charged with informally presenting the assigned nurse theorist. The other students were charged with weaving the essence of the authentic literature and relevant ANA readings into the discussion. For example, groups were asked a faculty-developed probing question about how stereotyping and hierarchy negatively impacted the characters in the novel. The facilitator for the week examined the question through the lens of a specific nursing theorist, and the other students incorporated the nursing theory and ANA standards and ethics into the dilemma. At the end of each class, all students joined together for a Socratic seminar. Probing questions asked by faculty promoted grappling with ethical and social justice issues, leading to deeper analysis and critical thinking on the part of students.

Following the course, students were invited to respond to a faculty-developed online survey. No incentives were offered for participation. A Likert-style 5-point rating scale, with anchors of strongly disagree (1) to strongly agree (5), allowed students to express intensity of agreement with particular statements. Five statements focused on students' achievement of course outcomes via engagement with the novel; a sixth question asked students about the efficacy of using authentic literature as part of the course. The survey prompted students to include narrative comments about their experiences. The study team analyzed the Likert data using descriptive statistics and the narrative comments using thematic analysis (Raskind et al., 2019).

RESULTS

Of the 230 eligible students, 156 students (67.8 percent) completed the survey. Respondents identified predominantly as white (68 percent) and female (88 percent). Students reported the teaching methods used in this course helped them: 1) integrate nursing's ways of knowing with professional values (92.2 percent); 2) describe the four domains of nursing using selected nursing theorists in practice situations (87.8 percent); 3) examine the relationship between nursing and contemporary society through economic, political, and ethical perspectives within the health care system (93.2 percent); 4) perform a spiritual assessment and discuss spiritual concerns as they pertain to nursing (74.4 percent); and 5) describe the profession of nursing, including its role, history, and legal scope, as well as ethical practice (90.2 percent). Reported percentages reflect the total percentage of students who responded either strongly agree or agree on Items 1 to 5. The final Likert scale question asked if the book should be used as the primary textbook in subsequent semesters. The majority of students (96 percent) either agreed or strongly agreed that it should remain a part of the course in the future.

Three key themes presented via students' narrative comments about the use of the selected novel in this class: 1) it helped students examine the full nursing role; 2) it supported reflective practice, which was key to helping students develop their critical thinking; and 3) it provided a tangible platform students could use to apply nursing theory and support clinical judgment in their practice.

In the first theme, students identified that reading and discussing Small Great Things helped them examine the nursing role beyond the technical aspects of nursing practice. The novel required students to "examine the social constructs of our society and the nurse-patient relationship," fostering in students moral awareness and an aptitude for ethical practice. Students reported that reading the authentic literature enhanced their understanding of societal constructs, lending to the "importance of acknowledging privileges and inherent biases that exist in our world" that can influence the provision of nursing care and health outcomes.

In the second theme, students identified that reading and discussing Small Great Things supported reflective practice, preparing them for their future professional role. The novel offered a "real-world" look at "the challenges" they may face as nurses and promoted anticipatory and reflective thinking about "what I would do in that situation." Students stated that discussions about the book with peers supported their learning and made them aware of alternative viewpoints. They reported that this "helped them think outside the box," supporting the development of their critical thinking and clinical judgment.

In the third theme, students reported that incorporating authentic literature into the course provided an accessible platform for applying nursing theory and ethical dilemmas to practice. This helped students "understand how theory can be incorporated into nursing practice" by "anchoring abstract concepts" in the dilemmas of "real-life experience." The integration of the authentic literature supported students' critical thinking and clinical judgment, giving them opportunity to test multiple nursing theories across diverse contextual fields. Testing out different lenses and viewpoints forced students to be flexible in their thinking, humble in their knowing, fearless in their questioning, and intentional in their decision-making. These are desirable attributes of professional nurses that potentiate the provision of safe, high-quality nursing care.

CONCLUSION

Using authentic literature as an ABP is a an innovative way to support students' development of clinical judgment. To promote students' transition to practice, faculty should examine their use of traditional textbooks and if/how they enhance prospective nurses' everyday decisional practices. Where traditional texts do not meet the mark, the integration of an ABP approach is a creative way to provide a context within the classroom for students' learning in their journey toward becoming professional nurses.

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