Introduction

This paper reports on an investigation into an arts-informed educational approach used over 5 years within an ethics course in a health sciences curriculum. The project was adopted in response to the proposition put forward in a number of reviews, that arts-informed approaches have the potential to enrich learning in health professions education but that more research into the topic is required (Ousager and Johannessen 2010; Perry et al. 2011; Rodenhauser et al. 2010; Staricoff 2004). Furthermore the study responds to a growing literature calling for more personalized and engaged approaches to ethics education in the health professions, and investigations into approaches that have the potential to foster humanistic, compassionate, caring, reflective, self-aware and socially responsive practitioners (Kinsella et al. 2015). A hermeneutic phenomenological investigation was undertaken to study 234 occupational therapy students’ written reflections on learning following engagement with an arts-based educational project.

Arts in health professional education

In recent years, arts-informed approaches to education have been proliferating in health professional education, as evidenced by many published reports in fields such as medicine (Kumagai and Wear 2014; Kumagai 2012), nursing (Casey 2009; Schwind et al. 2013; Schwind et al. 2014a, b), occupational therapy (Kinsella et al. in press; Kinsella et al. 2008), physical therapy (Caeiro et al. 2014), social work (Desyllas and Sinclair 2014; Walton 2012; Wehbi 2014), allied health (Blomqvist et al. 2007), paramedics (Milligan and Woodley 2009), psychology (Connor-Greene et al. 2005), dietetics (Lordly 2014), and health leadership (Hughes 2011).

Arts-informed approaches to health professional education

A variety of arts-informed (a term often used interchangeably with arts-based) approaches to health professional education have been reported in the literature. According to Desyllas and Sinclair (2014) what distinguishes arts-informed approaches to education “are the multiple (creative) ways of representing experiences and the different representational forms (medium) of expression that can effectively enhance the understanding of the human condition and experience” (p. 298). Further arts-informed approaches can be differentiated between approaches that engage students in observation of and reflection about the arts, and approaches that engage students in the actual creation of arts (Perry et al. 2011). Arts-informed approaches in health professional education have variously included: (a) visual approaches such as visual arts (Brett-MacLean 2007; Schreiner and Wolf Boronaro 2012) drawing (Lyon et al. 2013; Rabow et al. 2013), painting (Thompson et al. 2010; White et al. 2010), photography (Miller et al. 2014), film (Miller et al. 2014), video, sculpture (Lordly 2014), collage (Schwind et al. 2014a, b), posters (Wehbi 2014), mandelas (Mahar et al. 2012), mask-making (Lordly 2014); (b) verbal approaches such as literary fiction (Kinsella 2007), narrative prose (Caeiro et al. 2014), poetry (Collett and McLachlan 2006; Connor-Greene et al. 2005; Milligan and Woodley 2009), creative writing (Miller et al. 2014; Milligan and Woodley 2009; Schwind et al. 2013) zines (Desyllas and Sinclair 2014); and (c) performative approaches such as theatre (Skye et al. 2014), music (Milligan and Woodley 2009) dance (Thompson et al. 2010), and spoken word (Desyllas and Sinclair 2014).

Learning outcomes in arts-informed curricula

Various learning outcomes related to arts-informed approaches to health professional education have been reported in the literature. One frequently identified outcome is self-awareness. Through engagement with arts informed approaches students have been reported to experience personal growth (Miller et al. 2014, Smith et al. 2004), became more aware of their values and beliefs (Caeiro et al. 2014; Schreiner and Wolf Boronaro 2012), find expression for unresolved or hidden issues (Lordly 2014; Walton 2012), and begin to see how they present themselves to the world and interact with it (Hughes 2011; Rabow et al. 2013).

Emotional growth is another frequently reported outcome (Walton 2012, Lordly 2014; Mahar et al. 2012; Blomqvist et al. 2007). Students’ art activities have variously been reported to offer insight into emotional reactions to situations (Walton 2012), assist students to deal with ‘hidden-away’ situations (Lordly 2014), and to help students to “trust their feelings as a tool in their work” (Blomqvist et al. 2007, p. 91).

Further a number of studies point to deeper levels of reflection as a result of using an arts informed approach (Skye et al. 2014). Deeper levels of reflection in medical students were reported in ways that were said to parallel the interpretive skills needed in clinical practice (Casey 2009), and in ways that engendered students’ surprise at the depth of the insights apprehended (White et al. 2010).

A number of studies also point to arts informed approaches as  contributing to awareness of the link between personal and professional life. Arts-informed approaches have been reported to reveal student insights about life not being separate from practice (Schwind et al. 2013), to remind students “why they chose to study medicine in the first place” (Kearsley and Lobb 2014, p. 4), and to help student integrate their ‘personal’ self with their ‘professional’ self (Rabow et al. 2013).

Arts informed approaches have also been documented as creating opportunities for students to make links to future practice (Blomqvist et al. 2007; de la Croix et al. 2011; Caeiro et al. 2014; Hughes 2011; Kearsley and Lobb 2014; Lordly 2014; Mitchell and Hall 2007; Rabow et al. 2013; Schreiner and Wolf Boronaro 2012; Schwind et al. 2014a, b; Walton 2012; Wehbi 2014). Health care students were reported to gain insights into how they would like to practice in the future as a result of involvement in an array of types of artistic endeavours including performance activities (Wehbi 2014), or for instance through a piece of art such as poetry that linked to future practice (Schwind et al. 2014b).

The arts have also been reported to assist students to see in new ways (de la Croix et al. 2011; Smith et al. 2004). For instance, theatre and role-playing experiences were identified as helping students to think about clinical encounters in new ways (Skye et al. 2014). And, Desyllas and Sinclair (2014) report on the use of pictures as “liberating” for some students because as one student put it: “the picture can go places my words may not be able to” (p. 310).

Developing an appreciation for the value of creativity is another frequently cited outcome (Miller et al. 2014). Casey (2009, p. 78), for example, reported on the creative inquiry involved in a nursing humanities course: “It was about what you could bring out in yourself…like…it was your small idea and it was growing”. Similarly, White et al. (2010, p. 523), discussing an arts-informed interpretive project in a medical school, noted that “students often report surprise at the creative quality of the interpretive projects”. Robinson (2007) highlights how the process of engaging in art can lead to valuing creativity even amongst students who are initially skeptical.

Use of the arts in health professional education has also been linked to the development of empathy on the part of students, and to enhanced understanding of patient experiences (Blomqvist et al. 2007; Caeiro et al. 2014; Connor-Greene et al. 2005; McGarry and Aubeeluck 2013; Milligan and Woodley 2009; Robinson 2007; Skye et al. 2014; White et al. 2010). Casey (2009, p. 77) notes that using an art-making process to explore the situations of people receiving care enabled empathetic learning to take place amongst nursing students. Another project using interpretive art to represent the narrative accounts of patients’ reports on students increased understanding of the experience of illness from the patient’s perspective (White et al. 2010).

In short, there are a growing number of studies on arts-informed approaches to education in the health professions, and a number of recent papers that highlight a range of learning outcomes. Few of these studies however examine ‘learning outcomes’ related to arts-informed approaches as the central focus of the study, or in a systematic manner. Rather, the focus is often on one or two primary or targeted learning outcomes, for example the development of empathy, or the development of observational skills, or enhanced humanism. As Rodenhauser et al. (2010) point out in their review of medical schools across the US “although it is clear that many US medical schools are involving a variety of the arts in their instructional and extracurricular programs, approaches to integrating arts into their curricula vary widely. Of greater significance, however, is the observation that very few schools are formally evaluating these learning activities” (p. 237).

This suggests the need for research that specifically focuses on the analysis of learning outcomes related to arts-informed education in the health professions. Work that systematically examines students’ reflections on their phenomenological experience of arts-informed approaches to learning in health professions education has the potential to make an important contribution to the field.

Purpose

The purpose of this study was to investigate students’ reported learning experiences as a result of engagement with an arts-informed project in a health professions’ ethics course.

To this end, the study involved a phenomenological investigation of 234 occupational therapy students’ written reflections on learning. The research question was: What is the nature of the learning experiences reported by students who engaged in an artistic representation of ethical practice project as part of their health professions ethics education?

Methodology

This study adopted a hermeneutic phenomenological methodology (Benner 1994; Gadamer 1975; Heidegger 1927/2008; Laverty 2003; Smythe et al. 2008; Svenaeus 2000; Thomas and Pollio 2002; van Manen 1997). The aim of phenomenology according to Husserl, one of the founders, is to put our pre-understandings in abeyance and ‘return to the things themselves’ (Husserl 1907/1990; Park Lala and Kinsella 2011). Later phenomenologists (Heidegger 1927/2008; Gadamer 1975), questioned the possibility of bracketing out all pre-understandings, and instead emphasized the interpretive or ‘hermeneutic’ nature of understanding and the situatedness of interpretive activities (Crotty 2003; Kinsella 2006; Kinsella et al. 2015). Hermeneutic phenomenological research acknowledges that researchers are engaged in rendering interpretations of the materials collected and attempts to make such interpretations, and the approaches utilized as transparent as possible so that others may make reasoned judgments as to their potential value in other contexts.

The things themselves “are phenomena that present themselves immediately to us as conscious human beings” (Crotty 2003, p. 78). Phenomenology “requires us to engage with phenomena in our world and make sense of them directly and immediately” (Crotty 2003, p. 79), and to “place our usual understandings in abeyance and have a fresh look at things” (p. 80). The phenomena of interest in this study were the reported learning experiences afforded by engagement with an arts-informed project, as reported in students’ written reflections.

Participants

Ethics approval for the study was obtained from the University of Western Ontario, Research Ethics Board prior to commencement. The study occurred over 5 years in an Occupational Therapy Master’s level entry to practice program. 234 out of 244 eligible occupational therapy students participated: 45/48 in the first year of the study; 47/47 in the 2nd year; 46/48 in 3rd year; 50/51 in the 4th year; and 46/50 in the 5th and final year.

Description of the context

An arts-informed project was included within a health professions education course on Ethics and Professional Practice in Context. The course occurs in the second year of a two year program and covers a variety of topics including: ethical theories, ethical principles, ethical tensions, narrative ethics, ethics of care, moral agency, obstacles to moral reasoning, reflective deliberation, and ethically-based decision making.

The research team

The first author is a scholar with expertise in theories of reflective practice, ethics and health professions education, who has instructed the course described above, and used an arts-informed educational project within that course since 2004. She has used the arts as a means of engaging reflection in her own life, and is interested in the power of the arts to foster reflection and learning in professional education (Kinsella 2007, 2012; Kinsella and Vanstone 2010). The second author is an artist, designer and research associate who has worked in health care contexts using arts informed approaches to Veteran’s care, and on various arts-informed research projects.

Description of the project

Students were assigned a project which involved developing a representation of ethical practice using an arts-informed approach (Fig. 1). The instructions for the project were:

Fig. 1
figure 1

Arts-informed student projects

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According to David Seedhouse (1998) ethical actions stem from a person’s awareness that what she/he does is socially important; the task for anyone who wishes to be ethical in this sense is to first work out what ‘being ethical’ means. According to Seedhouse, since the founding question of ethics is how should I conduct my life in the presence of other lives? The ethical challenge – at any time and in any place – is to work out what commitment to living to make.

The purpose of this project is to engage in reflection on the question - What does ethical practice mean to me? Each response to this question will be unique. A range of possible mediums may be used to represent one’s ethical stance through artistic means. You may choose to develop a 3-D model, a piece of visual art such as a painting, collage, pen and ink drawing; literary works of art such as a collection of poetry, a dramatic performance or script, a short story. Be creative! Have fun with this!

This project is to be accompanied by:

  1. (a)

    A 3–5 page paper (double spaced) that makes explicit the intended meaning, significance and/or symbolism of the work, as well as insights garnered in the process of its construction.

  2. (b)

    A short (one paragraph) artist’s statement providing a brief overview of the project on a separate page.

  3. (c)

    A ½–1 page reflection on learning. What, if anything, did you learn through the process of completing this project? If you didn’t learn anything, why do you think that was case?

Data collection

As part of the project students were asked to write a ½–1 page reflection on learning related to participation in the arts-informed educational project. After the projects were graded and final grades submitted students were invited to participate in the study by permitting inclusion of their reflection on learning in the analysis. Two hundred and thirty-four written reflections (out of a possible 244) served as the data for the study.

Data analysis

Data analysis involved the use of hermeneutical phenomenological methods (Van Manen 1997), and was conducted by the first and second authors. Hermeneutics has a long history in textual interpretation, and is frequently defined as ‘the art of intepretation’; it is particularly suitable for the analysis of written texts (Ferraris 1996). Gadamer (1996) contends that hermeneutics is a universal activity; that the quest for ‘understanding’ (verstehen) is the link in all interpretation of any kind. Five characteristics of a hermeneutic approach (Kinsella 2006) that informed the current analysis were: (a) a quest to ‘understand’ rather than ‘explain’ the data, (b) acknowledgement that interpretation is a situated activity and an attempt to make the situatedness of the researchers and texts explicit, (c) recognition of the significance of language in interpretation, and an effort to ‘show’ the data (to the extent possible in limited space) rather than ‘tell’ it, (d) a view of inquiry as conversation between the researchers and the texts, and (e) an effort by the researchers to remain comfortable with ambiguity throughout the analysis process, resisting the urge to ‘impose’ themes on the data.

Given these dimensions, thematic analysis in hermeneutic phenomenological research is a dynamic process guided by: holistic analysis (reading for a sense of a whole), selective analysis (identifying important parts i.e. passages that elicit understanding) and detailed analysis (identification of meaningful words and phrases). Accordingly, all of the data were read to gain a sense of the whole, while bearing the research question in mind as an anchor for the analytic process. The emphasis in this analysis was on what students said about their experiences of learning through the use of the arts-informed project, as opposed to an analysis of ‘ethical insights’ which was undertaken separately, and is the focus of a distinct paper in progress. During this time, the researchers engaged in mind mapping (Buzan 2003), as a means to begin to track preliminary emergent themes (Tattersall et al. 2011). Mind mapping involves creating visual diagrams with thought bubbles for brainstorming key ideas/themes and drawing connections between them in a visual and nonlinear way. Next, the data were re-read, and the researchers began to look for ‘parts’ of the ‘whole’ through selective analysis and detailed analysis and the identification of passages, key words and phrases, that elicit understanding about what students were saying about their learning. The researchers continued to create mind maps and to identify emergent themes, meeting regularly to engage in dialogue about the findings. The researchers then iteratively collapsed and reworked the themes. Once both researchers were confident and in agreement that the themes represented the predominant ideas articulated in the data (those most frequently depicted in student reports), the second author returned to the transcripts and organized the data according to these predominant emergent themes. At this stage, 14-26 pages of data were compiled in support of each of the five themes presented in this paper. Due to space restrictions, these findings are markedly condensed in their representation in the following section.

Findings

Five overarching themes related to students’ self-reported learning outcomes were identified through the analysis (Table 1). Although the themes are presented separately here, they overlap and are intertwined such that many of the quotes and points could have been included within more than one theme. To preserve confidentiality, all names are pseudonyms.

Table 1 Themes and emergent insights
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Becoming aware of values

Many students wrote about how the project engaged them in a process of becoming aware of their values. For instance Lin wrote: “This artistic representation and reflection has opened my mind and expanded my awareness of my beliefs and values.” Casey offered a particular example: “I realized how strongly I feel about creating a therapeutic environment that is just and enables equal rights for all.” The importance of appreciating diverse values was also a prevalent topic. Alicia wrote: “Throughout this process I was able to better identify my own views on ethics, while developing an appreciation for the diverse perspectives held by others.”

Recognition of one’s background—including family, upbringing, religion, heritage, and culture—in shaping values was a prevalent theme. In Briana’s words: “Deep inside I have my own views and values that are probably a result of my upbringing and education”. Some students identified insights about how their values were shaped or challenged by exposure to other cultures. Anna wrote of being: “partly inspired by the values of my clients that were part of the Maori culture”; while Emily spoke of her changing values “Africa was an experience that changed me to the core. It changed how I will think of being an OT…how I will advocate for clients”.

A number of students wrote about the ways in which the project assisted them to articulate values they hadn’t previously put into words: “The process …helped me to put feelings into words. When it comes to ethical practice, I think I tacitly know how I think and feel, but this project enabled me to put it into words” (Amy). Many students discussed the process as challenging past assumptions and inviting new insights or interpretations—as transforming values. Lindsey noted “By looking deeply at this piece of art and myself, I was able to see past what I took for face value and see what else it could mean. I am grateful for having uncovered…a certain level of naivety.”

For some, awareness of values was linked to the negotiation of ethical dilemmas. For instance, Aesha shared that: “During this process, I realized just how much my approach to ethical dilemmas is a reflection of my own values and principles”. Links were also made between values and how these shape actions in professional practice. Kayla wrote: “I was able to reflect back on my own personal experiences and look at how my own morals, beliefs and values shaped my decision when dealing with conflicts”.

(Re) discovering creativity

A second major theme was discovering, and in many cases re-discovering creativity. Students variously expressed surprise to discover: the significance of the learning that occurred through creative engagement; creative aspects of themselves; therapeutic aspects of the creative process; and the link between creativity and development of insights.

Many students noted surprise at their learning through creative means. Debbie wrote: “What I learned from completing this project is that creativity can be a truly effective learning tool”. And Julie indicated surprise at the significance she discerned in the process: “I found more meaning than I intended and appreciated the fact that my painting can have significance to me in more than one way”. A commonly expressed view was how memorable it can be to use a creative medium. Monica noted that: “Without contest I feel that I am more likely to remember what I have learned in doing this project … In addition to the books and articles…that I have read, I now have a visual image ingrained in my mind…and it is something I will never forget.”

Discovering (or rediscovering) a creative side was also a prevalent topic. Although initially skeptical, Shelby articulated this idea: “Completing this assignment forced me to step outside of my comfort zone and delve into the world of artistry and creativity…without completing this assignment I would never have had the chance to prove to myself that I am able to be creative and inventive.” And Molly drew insights about creativity and connecting with oneself: “I finally had insight into the reasons why so many women love scrap-booking or quilting. It is a way to connect with your soul and bridge your inner feelings to something that is concrete.”

Many students wrote of discovering creative engagement as therapeutic, relaxing or enjoyable. As Molly stated: “These [creative] activities…can provide you with the outlet to express your desires, worries and stresses which is actually very…therapeutic. Creating this artistic representation was relaxing and enjoyable and allowed me the time to think and process information in a different way.” Some students indicated that the project awakened a desire to engage with creative arts in the future: “This project has also rekindled my desire to pursue creative arts. This had previously been a hobby of mine yet has been abandoned due to other commitments” (Gabrielle).

Students’ reflections about engagement with the creative project frequently pointed to the development of insights. Zoe indicated that “I learned that a creative medium can provide a liberating outlet…not only to others but also to myself. I found the creative process to be valuable… as a means of expressing my own understanding… but also as a means of enriching, expanding and consolidating this understanding”. Hailey speculated on the power of the creative process: “I think the reason I find art to be such a powerful tool for introspection is because I become so completely absorbed in the process that learning and growth is bound to occur. It provides me with the sense of flow that is so sought after in the field I have chosen to pursue.”

Valuing reflection

A third major theme was learning to value reflection. Amanda indicated surprise at this insight, “I learned the importance of reflecting, and to be honest, I never thought I would do such a thing.” Students variously wrote about valuing reflection as a means to understand the self, as it relates to ethical practice and ethical deliberation, as informing their future practice, and as a process facilitated through engagement with the arts.

Many students wrote of how they came to value reflection as a means to understand the self. Xia wrote: “reflection allows you to explore your true feelings and thoughts. It forces you to be aware of any uncomfortable feelings and thoughts and to analyze the reasons for these feelings. It encourages you to really become more aware of yourself by examining your values, beliefs, behaviours as well as your capacities, abilities and limitations in situations”.

The connection between reflection and ethical practice was also frequently highlighted. Jenna suggested reflection was necessary for ethical practice “I have learned that being ethical is not about following cookie cutter rules and guidelines…Being ethical is to continuously reflect on one’s actions. It may be to continuously reflect on what ethics means to us every day.”

The value of reflection for ethical decision-making was also frequently discussed. Taylor wrote that the process “validated the use of reflection in the exploration of ethical decision-making.” The value of reflection in negotiating the complexity of ethical practice also arose, Catlin noted, that: “Reflecting on this experience encouraged me to think deeply about how I felt… and how I can incorporate this [reflection] into my practice. I learned that while ethical practice is twisty and complicated I should not be intimidated because I have started to develop skills that will aid me in the future.”

A number of students noted new insights regarding the value of reflection for their future practices. Annika wrote “I hope that in practice I will have the chance to stop for a moment, take a breath and relate back to this time where reflection flows freely and is encouraged at all stages.” Amanda noted that: “This skill of reflecting is transferable…to various areas of practice, which will help me as a clinician.”

Further, recognition of the value of the arts as a means of reflection was frequently articulated. Rosella described her insight as follows:

I also learned that engaging in reflection is more than reading an article and writing down your thoughts after reflecting on it. Reflection can be in any form, even art. I found it was a deep reflective process - creating my art piece -…thinking about what to create, the process of creation, as well as reflecting on my piece after…

Eric, and others, suggested that the use of image and symbol, made the reflection memorable:

It made me reflect on an image and symbol, something that I can easily remember… a picture is worth a thousand words and therefore I can easily remember my thoughts and ideas…through that one visual representation.

Students frequently noted the depth of reflection afforded by the project. Nathan noted that the artistic medium offered a place for recursive processes of reflection “While I was creating the piece, it felt like a reflection within reflection. And when I performed the piece, there was a genuine nostalgic feeling that ‘here I am, reflecting yet again’.”

Deepening self-awareness

A dominant learning theme identified in the writings of participants was related to the ways that engaging with an arts based approach contributed to self-discovery and self-awareness, and the implications for who they are becoming as future health care practitioners. Comments such as “… I have learned a lot about myself in the process” (Megan); “I learned more about myself as a person” (Ko); “I take from this assignment a greater understanding of myself, and my own unique perspective” (Allie) were common. Students often used phrases such as ‘self-discovery’ ‘self appraisal’, ‘self analysis’, ‘self revealing’ to characterize their learning.

Insights relevant to becoming a therapist were frequently noted. Selena wrote: “This project forced me to look deeper into myself and examine what is important to me as a person and future occupational therapist.” Maia indicated: “This process… has allowed me to garner insight into who I am as a person, and as a professional.” Similarly, Beth wrote: “I learned a lot about my own personal beliefs and feelings when it comes to being a health care worker”.

A number of students described insights into specific personal characteristics relevant for their future professional practices. Michelle described becoming aware of her self-critical qualities: “I like things to be perfect and am constantly criticizing my artwork…I learned a lot about myself… This project highlighted my pessimism and perfectionism…[and] made me realize that I tend to think the worst of things that I am not good at, or unfamiliar with.”

A number of statements related to self-awareness encompassed insights about transformed perspectives of the self. Erika wrote: “I did not feel that I was a creative enough person to pull this off…Now I have more confidence that when I face things that are unfamiliar to me, I will be able to attempt them; and if the result is not exactly what I had hoped for, I can learn from the experience and build upon it in the future”.

Connections between personal experiences, and who students were becoming as professionals, were also frequently made. Rene noted that “This project took me on a personal journey through my past experiences”. Lily recounted connections between how her past experiences contributed to who she is, and how she will practice, as a therapist:

I have learned a great deal from this project. Before this I never thought about what has contributed to my ethical values and consequently what will frame and impact my future practice…each [experience] has nurtured me and allowed me to grow into who I am today. These experiences are part of me. Some…were life altering like the death of a loved one, while others provided me with only a small lesson of fairness. However, each had the potential to change me.

Imagining future practice

A final theme that emerged in the students’ writing was the theme of imagining future practices, particularly from the perspective of ethical practice. Repeatedly students wrote about imaginatively projecting themselves into their future practice in terms of the values they intend to bring, the actions they wish to take, and the type of practitioner they’d like to become. As Christa wrote: “This project gave me insight into what kind of healthcare professional I would like to be and how I would like to practice in the future.”

Katie wrote that the arts based project helped her to realize that “I am learning from each new experience I encounter, and I am storing the lessons I have learned so that I can apply them to future situations.” Hannah, noted that the piece of art she produced was representative of her past experiences, and helped her to reflect on implications for her future professional practice.

I realize that I intimately connect the image that I have sculpted with a relationship of caring. When I look at my sculpture I can relate what I see to my own experiences of friendship, experiences that I have had while on placement, experiences that I have had with my own family, and experiences that I have with complete strangers…I want to be able to extend my ethic of care to everyone that I come into contact with regardless of whether they are family or not.

A number of students came to insights about the dynamic nature of their professional practices generally, and ethical practice in particular. Sierra noted that “ethical practice is not a static phenomenon, we must continue to learn and grow, adding onto the layers of our knowledge and awareness”. For Anna, the symbol of a phoenix represented her insights into the changing and dynamic nature of her future practice “The phoenix rising is symbolic of my belief that my ethical practice will be reborn time and time again.” Selena wrote that “… my education on ethics and occupational therapy [practice] has just begun and is really never finished.” And Olivia summarized her learning as follows:

“I have developed the view that Occupational Therapy practice is not something that is ‘mastered’ but rather something that evolves as we gain new experiences, are exposed to new opportunities and learn new lessons…my future goal will be to remember this point and strive towards bettering myself as a practitioner by being open to new ideas and ways of thinking, and reflecting and learning from the experiences I am fortunate enough to have.”

Other students noted the importance of returning to core values as a means of anchoring ethical future practices. In Andrea’s words: “In order to be able to carry out my practice, I will indeed need to return again and again to the core values of caring for individuals that…will hopefully re-inspire me when all the red-tape and bureaucracy get in the way of giving all of my clients the best care possible.”

Discussion

This study contributes to the emergent body of knowledge reporting on the use of the arts in health professions education. The current findings highlight the potential of arts-informed research to foster students’ learning in the context of ethics education in the health professions with respect to: becoming aware of values, (re) discovering creativity, coming to value reflection in professional life, deepening self-awareness, and developing capacities to imagine future practices (Table 1). These results are highly consistent with those identified in the emergent literature on arts-informed education in the health professions, as well as responding to calls for more personalized and engaged approaches to ethics education. The findings make a unique contribution given that they are situated within the context of ethics education in the preparatory education of occupational therapists, the breadth of the sample, the engagement of students in the creation (as opposed to observation) of art, the focus on written reflections, and the analysis of learning outcomes (as opposed to a peripheral focus). The findings however seem to offer more of a moral overtone than those depicted in the broader literature, with an emphasis on the elucidation and enactment of ethical values permeating many of the themes; this is not surprising given the context of the study in ethics education. The findings offer support for the proposition that arts-informed approaches have the potential to add value to education in the health professions generally, and to ethics education in the health professions more specifically.

Imaginative approaches to education

In the context of health professions education, Bleakley et al. (2006) suggest that: “knowledge is often both taught and learned in insensitive and unimaginative ways” (p. 200). Ways that Davey (1999) suggests support an “epistemological prejudice” that marginalizes forms of knowledge rooted in the aesthetics of life, and which link to “the inner worlds of subjects” such as “interpretations, feelings and values” (p. 17). Similarly, in a call for arts-based educational approaches, Eisner has decried the ways in which we “expel the poetic from what can be known”, pointing to the power of the aesthetic to enrich our understandings (Eisner 2009, p. 8). The importance of imaginative and aesthetic approaches to education are further underlined by educational philosopher Maxine Greene who writes that:

the sense of possibility, of what might be, what ought to be, what is not yet–seems to be essential in moving the young to learn to learn. It may be nurtured… through aesthetic education, moving people by means of participation, to awaken to the wonders of authentic appreciation. (Greene 2008, p. 17).

The results of this study suggest that arts-informed approaches may have the potential to enrich and deepen approaches to health professions education in ways that engage the imaginative capacities of students.

The art of interpretation

It has been argued that health care practice is as much an interpretive practice as it is a science (Gabbay and Le May 2011; Montgomery 2006; Svenaeus 2000). Of note is the way that arts-informed approaches engage the interpretive capacities of students (Kumagai 2012). Interestingly, there are two main foci in the arts-informed approaches to education identified in the literature: those that involve responding to pieces of art and those that involve creating art. The current study focused on students’ creation of art, through an artistic representation of ethical practice, and the consequent interpretations about their learning.

Whether students are asked to respond to, or create art, the interpretive dimension to arts-informed educational approaches are striking in what they potentially offer to the development of students. The significance of interpretation for effective practice is underlined in Montgomery’s (2006) seminal book on ‘How Doctor’s think’, where she engages in a sustained examination of the interpretive nature of physicians’ practices. Her case studies demonstrate that while health care practitioners use science their practices are not exact sciences, rather she shows that health care practices (indeed all practice) are interpretive in nature and grounded in practical judgements in context.

The capacity of arts-informed approaches to foreground, and call forth the art of interpretation may well be instructive in preparing students for the interpretive nature of practice. Kumagai (2012, p. 5) for instance notes the expansive quality of arts-informed interpretation in medical education: “Through a call for interpretation, art and the conversations associated with its creation have the potential to move …beyond the Self. Through the ‘fusion of horizons’ that occurs between individuals and a work of art and between individuals and others, art broadens the horizon of each.”

Hermeneutic aesthetics and transformative understanding

A focus on interpretation brings hermeneutics, also known as “the art of interpretation as transformation” (Ferraris 1996), to the forefront of our understandings of practice. Davey (1999, p. 13) points out the “extraordinary power” of arts-informed interpretation for what he calls “hermeneutic aesthetics”, to … “electrify inanimate matter with concepts and ideas” in a way that allows us “to feel their presence”. According to Davey, hermeneutical aesthetics asks “what happens to us in our experience of art” (Davey 1999, p. 23), thus linking to the growth in self-awareness reported in the current study and in the literature.

For Davey (1999) “Hermeneutic aesthetics emphasizes that art works do not merely re-interpret and re-present subject matters but extend and alter their being” (p. 4), suggesting the potentially “transformative power of aesthetic understanding” (p. 23). He points out that “in hermeneutic thought, the notion of having something ‘brought to mind’ is connected with the idea of being able to ‘see beyond’ that which is immediately visible.” (Davey 1999, p. 11). This is interesting in light of the findings of the current study where participants were frequently seen to imaginatively project themselves into their future practices, and to reflect on the values they hope to embody, and the types of practitioners they hope to be, in their future professional lives.

New ways of knowing

Allen writes that “Art is a way of knowing what we actually believe” (1995, p. 3). One of the striking findings in this study was the capacity of arts based approaches to extend the perspectives of students to foster new ways of knowing, such that new insights, reflections and interpretations were frequently brought into view.

The power of the arts to foster new ways of knowing is a theme frequently identified in the education literature (Eisner 1998; Greene 1995, 2001; Kinsella 2007). In writing about an academic movement that advocates for arts-informed educational approaches Maxine Greene writes that “We are interested in openings, in unexplored possibilities…for us, education signifies an initiation into new ways of seeing, hearing, feeling, moving. It signifies the nurture of a special kind of reflectiveness and expressiveness, a reaching out for meanings, a learning to learn” (Greene 2001, p. 7).

A seminal writer in the field of arts and education, Elliot Eisner (2002) describes the process as follows: “Put as simply as I can, permission to use new tools and new forms of representation enables us to look for different things and to ask new questions” (p. 380).

Further, he points out that “Our linguistic capacities do not define the limits of our cognition” (Eisner 1998, p. 33), suggesting that engagement with the arts may unleash other dimensions of cognition, or other ways of knowing, beyond our linguistic sensibilities.

Deepening reflection

There have been many calls for reflective practice in health professional education (Kinsella et al. 2012; Mann et al. 2009), yet the potential of arts based approaches to foster reflection have only been touched on in the literature and are only recently being explored.

The famous educational philosopher John Dewey (1934) wrote of the potential of the arts to “touch the deeper levels of life” (p. 46); reflections on the deeper levels of life were revealed in students’ reflections within the current study. Davey further notes that “art achieves its proper provenance in the metaphoric translation and cross-wiring of ideas and sensible particulars” (1999, p. 23). Perhaps the power of the arts for reflective practice lies, at least in part, in the probing of the metaphoric meanings afforded, and the connection of ideas in new ways. Indeed, Lakoff and Johnson (1980), amongst others have noted the power of metaphor and symbol as a means of reflection and meaning making. Interestingly, the arts-informed educational approach appeared to provide a means for many students in this study to reflect deeply on their values in ways that move beyond purely linguistic understandings.

Heightening consciousness

One of the striking findings of the current study to us as educators is the capacity of the arts to bring tacit or transformative understandings to consciousness. Chinn and Watson (1994) have noted that “art is both feared and revered because it moves consciousness into realms not yet imagined and realities not predicted.” (p. 20). They note that art frequently “expresses what words usually fail to express” (p. 20).

And Eisner argues that the arts affect consciousness in a number of ways: “They refine our senses so that our ability to experience the world is made more complex and subtle; they promote the use of our imaginative capacities so that we can envision what we cannot actually see, taste, touch, hear and smell; they provide models through which we can experience the world in new ways; and they provide the materials and occasions for learning to grapple with problems that depend on arts related forms of thinking. They also celebrate the…noninstrumental aspects of human experience and provide the means through which meanings that are ineffable, but feelingful can be expressed.” (Eisner 2002, p. 19)

Hughes (2011), in a study of management leadership education, reported that the metaphors that emerged for students offered a way of knowing that could bring previously unconsciousness material to the surface. For instance, one student depicted an organization “as a windowless pyramid, expressing a lack of openness and a fearful secretive culture”: while the student was reportedly “surprised at this metaphor that emerged from his unconscious” (p. 88), he also recognized it as an appropriate depiction.

Recovering inner life

In speaking about the aims of aesthetic education, Greene (2001) suggests that it is integral to the development of persons, and should in no way be regarded as a ‘fringe undertaking’ or as a ‘frill’. She argues that such approaches may be seen as part of the effort to engage students in seeing “a greater coherence in the world” (p. 7). Greene writes:

Sometimes I think that what we want to make possible is the living of lyrical moments, moments at which human beings (freed to feel, to know, to imagine) suddenly understand their own lives in relation to all that surrounds. …People are constantly prevented from doing this. Their lives, even the things they are taught, are broken into fragments, categorized, compartmentalized (Greene 2001, p. 7).

Many of the themes reported in this study and in the literature speak to the power of the arts to assist health care learners in recovering a connection to their inner lives. The potential of the arts to foster: insights regarding the value of one’s own creativity, deep reflection, empathy, discernment of values, self-awareness, and to imagine how one wishes to act in the future all speak to the recovery of the inner life of the practitioner. In these technical rationalistic times, such a recovery may be more important to advances in health professions education than ever.

Limitations

A limitation of the study is that the students’ written reports on learning were rendered as part of an academic assignment. Students desire to acquire a good grade may have shaped students responses, and is a consideration in interpreting the reported findings. Secondly, the findings must be interpreted in context.

Conclusion

Recently, there have been numerous calls for arts informed approaches to education in general, and to education in the health professions specifically, yet research in the field is in the early stages. The current study highlights the potential of a particular arts-informed educational project to foster students’ learning with respect to becoming aware of values, (re) discovering creativity, coming to value reflection in professional life, deepening self-awareness, and developing capacities to imagine future practices. There appear to be a number of unique ways in which arts-informed approaches can contribute to health professions education including: activating imaginative engagement, fostering interpretive capacity, inspiring transformative understandings, offering new ways of knowing, deepening reflection, and heightening consciousness, while also enriching the inner life of practitioners. Innovative approaches are being used to introduce arts-informed practices in health professions curricula programs. While the integration of arts informed approaches are in the early stages and further research is clearly required, the findings point to the promise of arts-informed approaches for advancing health sciences education.