According to Linda Honan, a professor emerita at Yale University School of Nursing, quite a lot. Honan, PhD, MSN, CNS-BC, RN, ANEF, FAAN, is well-known in nursing academia for using creative, novel teaching strategies to help students evaluate the whole patient. Her research reveals that diagnostic observations can be significantly improved by training nursing students in the visual examinations of art, aural training with music, creative writing, and more.
Honan carries this philosophy through in her newly released version of Medical-Surgical Nursing: Focus on Clinical Judgment, now in its 3rd Edition. She imparts “pearls of wisdom” educators can glean from her long teaching career, challenging educators to look for ways to creatively demonstrate concepts based on her research working in collaboration with art and music experts. This approach activates a range of senses to create space for students to practice the skill of observation, using clustering to see, hear, and express what may — or may not — be going on with patients.
Quoting the early childhood educator Maria Montessori, she emphasizes to educators that “you just can't say observe. You have to give them (students) the curriculum with which they need to observe.”
A picture tells a thousand words
Honan and her collaborators first went public on her novel teaching approach in 2009, reporting the effects of an art museum experience on the observational skills of nursing students in “Looking is not seeing: using art to improve observational skills.” The project was based on a truth that most educators can agree with — “Our experience is that students' vision is naturally limited, particularly when you put them in a high-stress environment. There is no higher stress than putting a neophyte into a clinical situation. Patients come in with multisystem problems. There's polypharmacy. And technology has increased exponentially.” She says this can be overwhelming, especially when instructors ask students open-ended questions such as, “Tell me what you see.”
To help expand the nursing students' vision, Honan turned to the Yale Center for British Art, where she met and worked with Linda Friedlaender, who is its Head of Education. “Linda introduced me to the use of art to improve clinical observation,” says Honan, adding that the School of Dermatology used the approach at the time. However, unlike Dermatology, which sought a narrow focus, Honan wanted to open the lens up wide.
“I wanted the patient's body to be seen as a piece of artwork where everything was observed,” she explains. The hope was that observations on what students were seeing or what was absent would prompt options based on what they thought was happening with the patient.
Honan and Friedlaender tested their hypothesis by exposing half of a class of students to select paintings with “a rich visual inventory,” the rest of the curriculum remaining the same for both groups. Along with providing “lots to observe,” they purposely selected pieces with visual elements that didn't seem to belong in the painting's story. “That's how it plays out in clinical practice,” Honan says. “Too often, we think that the patient's diagnosis is only in a pre-ordained area of specialty,” however, “in nursing, we are looking at the whole body,” which can include multiple issues.
Students who visited the museum spent three hours with a trained art docent, doing “deep seeing.” The docents challenged them to verbalize what they saw, being as objective as possible. This included things like identifying the color of a dress, its texture, and why they characterized the details in a certain way. No subjective interpretation was allowed. The museum group also observed 13 objective physical examination findings using photos of patients with specific disease processes, which offered a differential diagnosis versus just one thing.
Honan and Friedlaender found that the students with the museum experience averaged an additional differential diagnosis versus the control group. “That's important,” she says, “because we don't want students going down a pre-ordained line” on what is happening. “We need that net to be wide when it comes to making a list of potential problems for your patient.”
The sound of music
Once it was clear that the “visual” approach worked, Honan next moved to sound, focusing on the heart, lungs, and bowel sounds, which she calls “your body's music.” She enlisted the help of Tom Duffy, a professor of Music at Yale University, to help train students to make a differential diagnosis based on what they were hearing. “When Duffy listened to all these sounds, as a musician, they all made sense because he thought of them in terms of rhythm and tone and whether a sound is louder or softer in amplitude. To him, it was music; to me, it was pathology.”
Honan taught Duffy how to hear things like a systolic heart murmur, which he synthesized, in effect creating a fake heart. He also created “masking” to help students hear beyond other sounds, like a person's stomach growling, eventually synthesizing the heart, lung, and bowel sounds altogether. “In that cacophony of noise,” they would ask students to pick out the sounds of the various organs and make out any abnormalities.
Ultimately, Honan and Duffy tested students on 25 different heart, lung, and bowel sounds. They initially tested half of a class, and the students “absolutely loved it,” she says. The control group eventually “rebelled,” so they gave them the interventions too. “Now it is part of the Yale curriculum for nurses and first-year medical and physician's assistant students.”
The power of touch
In Honan's final intervention, she also worked with Yale's Department of Engineering on identifying issues based on touch. “I noticed that students didn't know how to check pedal pulses or posterior ribs. They would either go in too hard or too soft. I worked with engineering to create a device that the students named the beatbox.'' It had a pulsation that would never be found in a human being, but they could put their fingers on this device, turn the machine up or down, and feel what was normal, weaker than normal, or barely palpable.
Express yourself
Along with activating the senses, Honan also challenged students to journal their resulting feelings and experiences. “I wanted them to remember how hard this is,” she explains, “because sometimes we forget, and it is important to look back to see what the struggle was like.” She adds that it gives you “compassion 20 years from now for people who are struggling.”
The journaling resulted in a “treasure trove” of stories that Honan says were ultimately about “the process of becoming a nurse, teaching nursing, what works or doesn't work in the curriculum, and what the real barriers are.” When she shared them with Catherine Gilliss, PhD, RN, FAAN, who is now Dean of the School of Nursing at the University of California, she urged Honan to “give voice” to them. This led to a fundraising effort, with Honan creating the Yale School of Nursing Creative Writing Award, an endowment at the Yale School of Nursing which recognizes nursing students for one of three significant student awards.
The big takeaway for educators, says Honan, is that all of these approaches can help simplify key concepts so students think in an interdisciplinary way, which helps to build clinical judgment skills. “We delude ourselves into thinking if we can stand up and wax eloquently,” she explains, adding, “The best educators work really hard to break down complex biochemical processes into something so simple it becomes elegant.” To this point, she urges nursing educators to “create a database of common sense curriculum that works and stop getting caught in the false narrative that somehow you are better if you sound smarter. To me, the smartest people value simplicity.”
Check out the latest edition of Medical-Surgical Nursing: Focus on Clinical Judgment.
