Judith Frei, RN, MS
The American Association of Colleges of Nursing 2008 document Essentials of Baccalaureate Education for Professional Nursing Practice describes the curricular elements for Baccalaureate Nursing Education.1 The very first essential asserts that a liberal education in the sciences and arts is foundational to professional nursing practice and directs faculty to include in the curriculum “ways of knowing” from both areas.2 Yet this very simple and concise two pages is subsequently overwhelmed by the following 30 pages explaining the remaining eight essentials of Leadership, Evidence-Based Practice, Informational Technology, Health Care Policy, Communication and Collaboration, Clinical Prevention and Population Health, Professionalism, and Baccalaureate Generalist Nursing Practice.
After reading the Essentials, and thinking about the sheer volume of information required in baccalaureate education, I am concerned that the “ways of knowing” from the arts and sciences are obscured by the other essentials. In this article, I argue that faculty not lose sight of the first essential and, further, that we develop innovative “ways of knowing” based on the sciences and the arts. "From the Grotesque to the Sublime" describes my efforts to incorporate the sciences and visual arts in nursing education using two very unusual academic settings: the morgue and the art museum.
Health Assessment, Pathophysiology, Pharmacology—the names might vary from college to college, but the courses are always there, early in the curriculum, instilling fear in most undergraduate students. Reading assignments are scientifically precise and factual, describing normal anatomy, common disease states, typical pharmacological treatment, and nursing management. The information is essential; however, many students struggle with the enormity of the information, which is provided devoid of practice. It is therefore the challenge of the nursing instructor to make this information more real for the students.
One experience that has helped my students ground their knowledge in reality has been to take them to the morgue to observe an autopsy. First of all, the popularity of the various television police dramas—the many iterations of Crime Scene Investigators (CSI) and Bones for example—almost guarantees an interested and enthusiastic audience. Secondly, the visual impact of seeing diseases, not from a photograph, but in situ, translates the textbook words on the page to the real thing. Two autopsies that my students observed highlight the benefit of adding direct observation to standard lecture and reading assignments.
During the first visit to the morgue, students witnessed side-by-side autopsies of a 90-year-old female who had fallen at home and a 45-year-old male who had collapsed at work. After a gross inspection of each heart, the pathologists dissected the coronary arteries. All the students had studied coronary artery disease and its management in class, but this experience was a real “way of knowing” moment. The coronary artery of the older woman was soft and compressible, whereas that of the younger man was round and stiff. When seen in cross section, the woman’s coronary artery was widely patent and the man’s almost completely occluded. The students, who had struggled in the classroom with concepts of blood flow and atherosclerotic coronary artery disease, understood its consequences when they then observed the 45-year-old’s friable and damaged myocardium, which was dependent on the occluded vessel.
On a subsequent visit to the pathology department of a major medical center, students had the opportunity to see cancer and micro-metastatic disease. In this experience, the students both inspected and palpated the patient’s lungs and liver. The primary lung tumor was amorphic in shape, four-to-five centimeters in size, dense in feel, and lighter in color than the surrounding healthy lung tissue. Alternately, while the liver was grossly healthy, its surface was splatter-painted with micro-metastatic disease. The importance of early detection, emphasized in every class with statistics, finally hit home: the students recognized the futility of the battle to save the patient’s life against an already well-established army of cancer cells prepared to assault the vital organs. As a result of these two experiences, students connected what they observed and touched at the morgue to their knowledge of pathophysiology, grounding their understanding in reality, and further developing their clinical skills of precise and controlled visual observation.
A visit to the art museum, like the one to the morgue, also has the potential to develop student assessment skills, albeit in a less direct manner. The Discerning Eye, a program developed by the Art Institute of Chicago and local nursing schools, uses works of art to develop systematic observational and analytical skills in students. Ground rules at the start of the tour are essential to its success: (a) Students must not read the label describing the work of art, (b) Students are instructed to observe and discuss the works of art from various perspectives (far and near, in the round), (c) Students are to describe the work of art without pointing, and finally (d) Language used to depict the work must be precise and non-judgmental and must not include adverbs (clearly, obviously) or adjectives (beautiful, pretty) that suggest bias. Selected works by the artists Bonnard, Goya, Monet, Rodin, and Dubuffet emphasized the following important nursing concepts: (a) First impression requires a follow-up of detail, (b) Power is expressed in physical positioning, (c) Subtle changes in shading and hue suggest chronological order, (d) Strength and sorrow can be expressed together in one figure, and (e) Beauty is not limited to youth.
One of the works that had a particular impact on my students was Pierre Bonnard’s Earthly Paradise.3 When students viewed this painting from a distance, most were initially distracted by the naked woman laying in the foreground. On closer inspection, students recognized the figure of a man standing next to a tree as well as the depiction of many animals. In analyzing the work, most students accurately read the pictorial narrative as representing the Garden of Eden. In clinical, we ask this same procedure of our students—that they go into a room, examine a patient, and discuss their findings afterward. But how many times do students miss important inspection findings because they are either overwhelmed by one piece of visual information, have not learned a systematic approach to visual inspection, or are so focused on auscultation that they forget to inspect carefully? The Discerning Eye correctly emphasizes the importance of careful inspection that is necessary for clinical nursing care.
Pierre Bonnard, French, 1867–1947
The Art Institute of Chicago
If a visit to an art museum is not possible because of time or logistical constraints, there are other ways to incorporate the visual arts into nursing education. Projecting an image of Felix Gonzales-Torres’ Untitled (Portrait of Ross in L.A.)4 could stimulate a nuanced discussion on HIV/AIDS. If the purpose of art is to “arouse the imagination of the viewer,”5 Gonzales-Torres’ conceptual piece does so with subtlety and force. The installation is composed of a large pile of brightly-colored, cellophane-wrapped, hard candies placed on the floor of the museum. The viewer is encouraged to take a piece of candy so that, over time, the “portrait” decreases in size and mass.
The seriousness and depth of the work is only realized after reading the artist’s accompanying explanation. The installation conceptually represents Ross, the artist’s partner who died of AIDS-related illness in 1991. Gonzales-Torres associates the sparkle and color of the wrappers and sweet taste of the candy to the joy and love that Ross brought to his life. The initial weight of the candy, 175 pounds, corresponds to Ross’ ideal weight before his illness, and the decreasing weight, as viewers take pieces of it, represents the wasting effects of AIDS. In a single work of conceptual art, Gonzales-Torres has revealed the emotional impact of joy and love within a relationship, a classic clinical manifestation of AIDS, and the heartbreak of death and dying. Nursing faculty ask students to develop emotional awareness and empathy as part of nursing practice. A discussion of Gonzales-Torres’ Untitled (Portrait of Ross in L.A.) provides a meaningful exercise to assist students with this objective.
Although the typical courses in the nursing curriculum offer knowledge and skills necessary to the development of professional practitioners, the exclusive emphasis on these traditional courses sacrifice innovative and memorable approaches to education. Perhaps we need to step back and consider ways in which the liberal education can provide experiences that will develop more thoughtful learners. Taking students from the Grotesque to the Sublime, as described here, provides experiences that connect nursing concepts to concrete observations. The educational process that this entails challenges students to synthesize knowledge from the sciences and arts in meaningful and productive ways.
"Thank you to Sarah Alvarez of the Art Institute of Chicago, and Michelle Alexander, of Rush University Medical Center, for their participation in and contribution to educational innovations."
1-2. American Association of Colleges of Nursing. (2008). Essentials of Baccalaureate Education for Professional Nursing Practice. American Association of Colleges of Nursing: Washington, D.C.
3. Bonnard, P. Earthly Paradise. The Art Institute of Chicago. http://www.artic.edu/aic/collections/artwork/144361
4. Gonzales-Torres, F. Untitled (Portrait of Ross). The Art Institute of Chicago. http://www.artic.edu/aic/collections/artwork/152961
5. Adams, L. S. (2007). The Making and Meaning of Art. Pearson Prentice Hall: New Jersey.
, RN, MS is an instructor at the Rush University College of Nursing. She also serves on the Advisory Committee for Hektoen's Nurses & the Humanities.