At the lower end of the ancient Canongate in Edinburgh there is a worn sandstone lintel over a small seventeenth-century doorway. Inscribed in Latin are the words: ‘Pax intrantibus, salus exeuntibus’ … Peace to those who are entering, and safety to those about to depart. This engraving serves as a reminder that there is a threshold which marks the demarcation between what lies within, that place of familiarity and relative security, and what lies beyond … a place that is unknown and sometimes frightening ~ Meyer, Land & Baillie (2010).
I deliberately titled my ‘Blog Educating Nurses … Transforming Lives’ as I believe that one of the most rewarding aspects of being an educator is guiding nursing students as they step across the threshold and embark on the journey of transformation from layperson to qualified health professional. During this process of transformative learning, disorientating dilemmas become a catalyst for growth and change (Mezirow, 2000), and students learn to question taken-for-granted ideas, attitudes, beliefs, habits of mind and feelings, as they begin to experience fundamental shifts in perspective. This transformation requires learning activities that challenge students to think more deeply and broadly, to question their assumptions and prejudices, and to see their world and the world of healthcare through a new lens.
One way of facilitating this transformation is through the deliberate integration of threshold concepts into our teaching. Meyer and Land (2003, p.1) describe threshold concepts as: “akin to a portal, opening up a new and previously inaccessible way of thinking about something … a transformed way of understanding, interpreting, or viewing something without which the learner cannot progress”. In nursing, typical examples of threshold concepts include person-centred care, stigma and compassion. In order to transition from lay person to professional nurse, students must experience a transformed way of viewing, understanding, or thinking about concepts such as these that are fundamental to nursing.
Although threshold concepts play a critical role in nursing education, they can be challenging to teach because they are often conceptually difficult, tacit, or ritualised. However, storytelling and narrative arts are evocative ways of facilitating understanding and aiding students’ journey of transformation.
One of the great powers of stories is that they invite us to walk in other people’s shoes for a while, and also reflect on our own situation (Stone & Levett-Jones, 2014). For nursing students, stories help to build a foundation of self-awareness by exploring their own experiences and those of others, and uncovering embedded meanings, values and beliefs (Crawley, 2007).
Who we are.
Where we have come from.
Where we are going . . . and
What we care about.
Stories give life!
Dana Winslow Atchley III, artist, storyteller and musician, 1941–2000
Examining and debating the contentious and complex issues imbedded in meaningful stories can be far more memorable than other more conventional approaches (Darbyshire, 1994). Stories can humanise healthcare experiences and prompt critical thinking and empathetic understandings. Although there are many creative ways to use stories, in this post I profile ‘The Reading Room’ (McAllister, Lasater, Stone & Levett-Jones, 2015), a paper that illustrates how the use of novels, memoirs and picture books can invite learners to enter into imagined worlds and enhance their understanding and internalisation of threshold concepts that are integral to nursing.
In the Reading Room Margaret McAllister (CQ University) describes her use of the Booker Prize winning novel The English Patient (Ondaatje, 1993), a romantic drama set in the mayhem of the allies’ liberation of Europe during World War II. Ondaatje evocatively describes the crumbling Italian villa that serves as a military hospital, where the bombed walls and rain soaked beds becomes a dangerous shelter where a man, burned beyond recognition in a plane crash, is slowly dying. He is being cared for by Hana, a young Canadian nurse, who has refused to be evacuated because she cannot abandon this patient to suffer and die alone.
Every four days she washes his black body, beginning at the destroyed feet. She wets a washcloth and holding it above his ankles squeezes the water onto him, looking up as he murmurs, seeing his smile.
Through guided engagement Margaret challenges students to discuss threshold concepts such as professional boundaries, dehumanisation and adversity. They learn to move from a state of discomfort and uncertainty, through the liminal state of unknowing, to one where they are able to articulate new values and ideas befitting the contemporary role of the nurse.
The Spirit Catches You and You Fall Down (Fadiman, 1997) is a true story that uses an ethnographic approach to illustrate the interface between two very disparate cultures, that of a Hmong family and the culture of Western healthcare. Kathie Lasater (Oregon Health & Science University) describes how she uses this book to facilitate online discussions with students.
Lia Lee is the 14th child of Hmong immigrants from Laos; she suffers years of seizures that eventually result in permanent brain damage. The book describes the fundamentally opposing views of Lia’s family and the health professionals about health and illness.
Your soul is like your shadow. Sometimes it just wanders off like a butterfly and that is when you are sad and that’s when you get sick, and if it comes back to you, that is when you are happy and well again” (Fadiman, 1997, p. 100).
The lessons from this complex story, although poignant and distressing, illustrate key threshold concepts for nursing – the importance of caring for people who are socially or culturally marginalised, regardless of personal or cultural biases, and how to suspend judgment and engage empathically with every person.
Teresa Stone (Yamaguchi University) describes how she seeks to tackle controversial and complex issues such as stigma, despair and loneliness through thoughtful debate about and reflection on picture books such as The Red Tree (Tan, 2001). Through the use of this picture book students examine depression through a series of visual images that profile a nameless, unhappy little girl set against a dark and foreboding backdrop. The recurring metaphor of hope is characterized by the image of a bright red leaf that flutters in the margins of Tan’s austere landscapes (Newmonic, 2014).
Picture books can be a way of exploring threshold concepts to promote holistic and humanistic approaches to learning in keeping with the philosophy and values of nursing. Students learn to reflect on personal values, appreciate complexity and unlearn stereotyped ideas. Using ‘The Red Tree’ leads students across a threshold from unfamiliar territory to a place of quiet deliberation. This approach allows them to be closely immersed in the emotions, dilemmas, disruptions, insights and puzzles presented, while at the same time remain at a safe distance.
The use of narratives resonates with educators who are interested in inspiring students to transition from their lay identity to one befitting a professional nurse. Literature can provide a vehicle for transformative learning and for enhancing students’ understanding and internalisation of threshold concepts that are integral to contemporary nursing. However, there are opponents to humanities-based learning in nursing; and crowded curricula along with a focus on procedural skills and knowledge can present challenges for educators. Nevertheless, making time for students to explore literature can awaken their imaginations and help them develop authentic understandings of what it means to be a nurse.
Darbyshire, P. (1994). Understanding caring through arts and humanities: A medical/nursing humanities approach to promoting alternative experiences of thinking and learning. Journal of Advanced Nursing. 19(5), 856-863.
Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus, & Giroux.
McAllister, M., Lasater, K., Stone, T. & Levett-Jones, T. (2015). The reading room: Exploring the use of literature as a strategy for integrating threshold concepts into nursing curricula. Nurse Education in Practice. 15(6), 549-555
Meyer, J. & Land, R. (2003). Threshold concepts and troublesome knowledge: Linkages to ways of thinking and practicing within the disciplines. ETL Project, Occasional Report 4, May 2003.
Meyer, J., Land, R. & Baillie, C. (2010). Threshold concepts and transformational learning. Roterdam: Sense
Mezirow J. (2000) Learning as transformation. Jossey-Bass, San Francisco.
Newmonic, D. The Red Tree. An Analysis of Shaun Tan’s Luminous Work of Art. Retrieved May 30, 2016 from http://www.speechlanguage-resources.com/the-red-tree.html
Ondaatje, M. (1993). The English patient. New York: Vintage Books.
Stone, T. & Levett-Jones, T. (2014). A comparison of three types of stimulus material in undergraduate mental health nursing education. Nurse Education Today. 34, 586-691
Tan, S. (2001). The red tree. Lothian Books, Sydney.