Arts and Humanities to Teach Civility in Health Professions

Incivility

Defined by Clark (2017) as “rude or disruptive behavior which may result in psychological or physiological distress for the people involved” (p. 121), incivility negatively affects health-care professionals ‘well-being and the workplace environment (American Nurses Association [ANA], 2015a). Examples of incivility in health care include behaviors such as arm-crossing, eye-rolling, disparaging remarks, refusing to assist others, failing to intervene on another's behalf, withholding vital information, and intimidation (ANA, 2015a; Clark, 2017). In an analysis of new graduate nurses, Laschinger (2011) found that 39% of first-year nurses and 51% of second-year nurses reported witnessing or experiencing incivility, and that this negative behavior was a significant predictor of job dissatisfaction and job turnover (Laschinger, 2011). In examining the direct and indirect effects of incivility on patient safety outcomes, incivility had a direct effect on both nurse-assessed quality of care and the frequency of reported adverse events, with physician incivility having the strongest effect (Laschinger, 2014).

Nurses are obligated to practice compassion and respect for others, to preserve wholeness of character and integrity, and to maintain an ethical work environment (ANA, 2015b). If any of these values are lacking, the potential for incivility increases (Clark, 2017). The Center for American Nurses (2008) addressed the need for the development and implementation of nursing curricula that specifically educate nursing students on the incidence of and steps to eradicate uncivil workplace behaviors. Civility is defined as “a compilation of positive behaviors and attributes that influence communication, interpersonal relationships, learning, and patient outcomes” (Woodworth, 2016, p. 201); scholars in this field maintain that it is the responsibility of health professions educators to model civility and to integrate civility, professionalism, and ethical practice into curricula (Clark, 2017; De Gagne et al., 2016).

Health professions education must encourage students to embody the ideals of respect and civility, empower them to uphold these values, and embrace creativity and innovative learning opportunities. One such creative avenue is use of the arts and humanities to teach civility in health professions education.

The Arts and Humanities

In 1934, American philosopher John Dewey described art as an intensified ordinary experience that could provide a foundation for learning in education and provide multiple ways of viewing the world and those in it (in Rieger & Chernomas, 2013). Integration of the arts in education enabled the incorporation of the cognitive and affective domains of learning and was one of the many developments that led to more progressive educational theories such as constructivism (Rieger & Chernomas, 2013).

Humanities was defined by Smith et al. (2004) as the “branches of knowledge that address the state or quality of being human and living authentically” (p. 278). Medical humanities is the interdisciplinary field that explores the contexts, experiences, and conceptual issues in health care that focus on the human experiences of medicine (Chiavaroli, 2017). The inclusion of medical humanities encourages health-care providers to retain humanistic attitudes and improve the quality of patient care (Goodwin & Machin, 2016).

Knowing and Becoming

The purpose of higher education curricula is to go beyond providing knowledge and teaching skills to students, and connect knowing with becoming (Barnett, 2009). Barnett posited that “the connection between knowing and being/becoming requires a thinking through of the kinds of human being that we want our students to become” (p. 440). In 1978, nursing theorist Barbara Carper identified the four pillars of knowing in nursing: empirics, ethics, personal meaning, and esthetics (Carper, 1978). Carper's esthetic way of knowing referred to the ability of nurses to perceive deeper meaning in human experiences (Cloutier et al., 2007). The art of nursing is more than just an action on behalf of the nurse; it is an understanding of what is significant to the patient, and an empathic understanding of their condition that is reflected in the care that the nurse provides (Carper, 1978).

Created to categorize education objectives for knowledge, attitudes, and skills, Bloom's taxonomy consists of the cognitive, affective, and psychomotor domains of learning (Krathwohl et al., 1973). The affective domain addresses a person's ability to perceive, attend to, and respond to phenomena in the world around them (Krathwohl et al., 1973). The attention to this domain is especially important for teaching health professions students how to manage emotional interactions with others, and how to listen to and respect individuals (Muzyk et al., 2017). Valiga (2014) argued that through the affective domain of learning students explore their values, beliefs, and humility by critically thinking about what guides their actions. Concepts such as incivility could be addressed through this domain by enabling students to understand their values regarding the respect of others, encourage them to actively listen to others ‘experiences, and explore their own emotions within the context of nursing care.

Arts and Humanities as a Pedagogical Tool

Rieger and Chernomas (2013) defined the term arts-based learning (ABL) as a creative strategy that engages learners in understanding multiple perspectives while simultaneously connecting the cognitive and affective domains of learning. ABL is not simply adding art appreciation classes to the curriculum, but a tool that facilitates learning. Kinsella and Bidinosti (2016) further organized arts-based approaches into the categories visual, verbal, and performative.

Visual approaches to ABL include traditional visual art media such as drawing, painting, photography, film, video, sculpture, collage, posters, and mask-making (Kinsella & Bidinosti, 2016). Works of art representing disease and the human condition were studied to formulate nursing diagnoses (Smith et al., 2004). Guided discussions in art galleries promoted observation and listening skills, respect for the

Effective communication, respectful interaction, and appreciating the interests of others are the essential ingredients for building a culture of civility in nursing education.

Verbal approaches to ABL include media such as literary fiction, narrative prose, poetry, creative writing, and zines (Kinsella & Bidinosri, 2016). The End-of-Life Nursing Education Consortium (ELNEC) utilized poetry and narratives to remind nurses that illness is a profound human experience, and to encourage them to reflect on their meaningful work (Ferrell et al., 2010). A medical university in Jerusalem used poetry to facilitate insights into patient experiences (Muszkat et al., 2010).

Performing art approaches to ABL include theater, music, dance, and the spoken word (Kinsella & Bidinosri, 2016). A medical school used a role-play workshop taught by a theater skills tutor to enhance students ‘abilities to connect with their patients and improve their observation, listening, and other interpersonal skills. Participants in the workshop reported significantly higher empathy scores than the control group, as well as significantly better objective structured clinical examination performance (Lim et al., 2011). Clinical humanities were incorporated into the curriculum of a school of nursing to gain insight into the patient experiences of health, illness, and suffering (Yu, 2014). At another university, students reflectively observed illustrated narratives to understand patient experiences of uncertainty. The narratives personalized the concepts and helped them understand others ‘perspectives (Nguyen et al., 2016).

Learning Outcomes

Kinsella and Bidinosti (2016) found that health-care professions students reported personal and emotional growth, greater awareness of personal values and beliefs, increased perception, deeper levels of reflection, and a greater appreciation for creativity and empathy after engaging in ABL experiences. Incorporating the arts into medical education provided new approaches to learning, increased creativity in practice, challenged assumptions and beliefs, and improved the “social performance” of medicine (Lake et al., 2015, p. 769). Hierarchies between co-learners declined, while supportive relationships grew during arts-based education (Haidet et al., 2016). Moreover, when nursing and medical students together studied literature, ethics, history, and spirituality, they became aware of their own values as well as those shared by practitioners in other disciplines; they appreciated the different perspectives and practices while feeling unified by the common goal of ensuring patients ‘well-being (Dellasega et al., 2007).

Teaching Civility with the Arts and Humanities

While a review of the literature on teaching civility in health professions did not yield any studies utilizing the arts and humanities as a pedagogical tool, the concept of using these disciplines to do just that is quite old. Humanists of the Renaissance viewed civility as a virtue that needed to be cultivated (Hank-ins, 2018). They encouraged civility to be part of an educated person's self-concept, and reinforced that concept through literature, history, theater, arts, and music. The liberal disciplines or the “good arts” were the instruction and training for how to make one more fully human (Hankins, 2018, p. 113).

Effective communication, respectful interaction, and appreciating the interests of others are the essential ingredients for building a culture of civility in nursing education (Clark & Carnosso, 2008). Using the arts and humanities as a creative pedagogical tool to engage cognitive and affective learning, educators could empower students to think through situations, consider others ‘experiences, and reflect on the implications for their own practice. ABL could foster collaboration and civility among the disciplines as they find common ground in improving interprofessional collaboration and patient outcomes. De Gagne and colleagues (2018) argued that it is important for health professions students to be aware of the negative impact of incivility and to be equipped with strategies to prevent or resolve incidents of incivility. Understanding the personal experiences of those experiencing incivility and recognizing the negative impact incivility has on others could also be facilitated through ABL.

Barriers to Using the Arts and Humanities

While there is support in the literature for the inclusion of arts and humanities into health professions education, these disciplines are not widely integrated into current health professions education curricula (Dennhardt et al., 2016; Haidet et al., 2016). Haidet et al. (2016) recognized that the inclusion of an arts-based pedagogy was dependent on the instructor and was rarely a part of the curriculum design, mostly due to the lack of a conceptual framework. Chiavaroli (2017) argued that the absence of humanities in medical education was largely due to the lack of demonstrated and reported outcomes, making it difficult to prove that the results were applicable in clinical practice. Likewise, some ABL activities were not viewed positively by students because it pushed their comfort levels and required them to embrace creativity and exploration (Nguyen et al., 2016). Instructors also may be hesitant to incorporate ABL due to its time-consuming nature and the advance planning needed (Nguyen etal.,2016).

Conclusion

Incivility negatively impacts the health-care work environment and can lead to negative patient outcomes. Nurses have an obligation to practice with compassion and respect; therefore prelicensure education should address incivility. Nurse educators can use the arts and humanities as a creative pedagogical tool to provide interdisciplinary education on incivility in order to prepare health professions students to improve the culture of civility in health care.