Embedding the Humanities into Nursing Education

Abstract

Humanistic education in nursing began in the 1980s. At that time, nursing education emphasized the human being and regarded each person as a unique individual with potential. However, modern developments in medical technologies and changes in the health-care environment have led to a trend toward dehumanization of the healthcare industry. Various developments, particularly in genetics, have raised issues related to human dignity, value, and ethics. The development of a humanized care model based on both scientific principles and a humanistic ideal has become an urgent issue in today’s professional nursing education environment. A humanistic education in the nursing profession will allow nurses to develop a broader perspective, to cultivate insight, to understand and to feel the unique experience of patients, and to look at problems from multiple perspectives, especially in complex situations. The challenge of today’s nursing education is using multiple teaching strategies to improve humanistic cultivation of humanities education in the nursing profession.

1. Introduction

In addition to the COVID-19 pandemic severely affecting healthcare services worldwide, the innovation of high-tech and precision medical resources in the twenty-first century has also greatly improved. This improvement and innovation will also change the future medical care environment and trends [1]. Moreover, the nursing profession in this new era of information and biotechnology development has been affected by technological developments and is bound to continue to be affected by ever-changing scientific and technological achievements, of which genetics raises issues related to human dignity, values, and ethics [2]. Rapid changes in medical technologies have resulted in dehumanization of the healthcare industry [2]. Although compassion is a core value of the nursing profession, the decline of compassion in the broader medical environment has led to a similar decline in this core value in the nursing profession. The nursing profession will face unprecedented challenges if nurses cannot embody empathy and compassion when caring for patients [3]. How to develop and provide a humanized care model based on science and humanities has become an urgent issue in today’s professional nursing education [4, 5, 6].

The value of humanistic education to the nursing profession is to provide an affective experience of humanity, care, and esthetic appreciation; to develop broader perspectives; to cultivate insight; to help nurses understand and feel the unique experience of patients; and to look at problems from multiple perspectives, especially in complex life situations. The challenge of today’s nursing education is how to use multiple teaching strategies to improve humanistic cultivation in the nursing profession’s humanities education. However, modern nursing education focuses on acquiring professional knowledge and ignores cultivating a humanist spirit. In order to help nurses, adapt to the rapidly changing medical environment and express professional and humanistic caring, the six Es framework (Example, Explanation, Exhortation, Environment, Experience, and Expectation) should be promoted in humanistic-nursing education [3, 6].

2. The meaning of “Humane” or the “Humanities”

In Confucian thought, the term “humane” connotes benevolence, righteousness, morality, and etiquette. These characteristics regulate the relationships between “people and themselves,” “people and others,” “people and society,” “people and nature,” and “people and the supernatural.” Compared with the East’s Confucian humanistic thinking, the West was very eager to get rid of the bondage of God during the Renaissance, develop humanism, and establish thinking with “people” as the central concept. At that time, it followed the example of ancient Greece and Rome, focusing on the Seven Liberal Arts (grammar, rhetoric, dialectic, arithmetic, geometry, astronomy, and music), and advocating liberal education [7].

From the perspective of historical development, this can be called “humanistic education.” After the Renaissance and the Reformation, the core value of humanism, with people at the core, remained unchanged. Comparing the aforementioned connotations of the “humanities” and “humaneness’ in the East and the West, humanistic thought in the East is influenced by mainstream Confucianism, emphasizing the “interpersonal norms of benevolence, righteousness, morality, etiquette, and ethics.” By contrast, Western humanities take “people as the main body of thinking” and centers on people as the thing to be valued. In short, humanity includes three aspects. The first aspect refers to human thinking, which involves respecting oneself and the value of human life. The second aspect refers to the viewpoint of inter-subjectivity between human beings, emphasizing that people should respect each other. The third aspect refers to the establishment of a harmonious relationship between people and society [7].

Humanitas in Latin means humanity and upbringing. Humanistic care is the exercise of the humanistic spirit and having a humanistic spirit is having the ability to become attached to others and to have the courage to love and care for people. It includes the ability to be inspired to change thoughts or behaviors and to connect with others and make them feel the power and mystery of life [8]. Humanistic literacy regulates relationships between people of various ethnic groups, cultures, genders, and beliefs. Humanistic literacy can make up for aspects that science cannot cover, including encouraging critical reflection on technology, preventing overspecialization, and arresting tendencies toward dehumanization. Humanities and social sciences can include literature, art, philosophy, history, sociology, ethics, etc. Literature and the arts provide opportunities for individuals to describe their feelings and observations to understand suffering, the situations of others, and the essence of human nature. It can also heighten insight into other people’s responsibilities and improve the core competencies of caring, such as observation and analysis, empathy, self-awareness, and reflection [9, 10]. Throughout history, nurses have established their profession’s position and role in society and confirmed the value of their contributions. Sociology helps to understand the nursing profession’s place in a cultural and social context and the effect of culture on healthcare behaviors [11]. Ethical inquiry helps nurses cultivate their moral sensitivities and become practitioners of reasonable care [12]. When the humanities and social sciences are integrated into professional teaching, the improvement of humanistic literacy will naturally give rise to a uniformity in the actions of nursing staff and realize the purpose of humanistic education [13].

3. Importance of humanities education in nursing

Humanities are one of nursing’s professional competencies. Nurses must have a human touch to ensure the physical and mental well-being of patients. In the process of patient care, nurses must have humanistic literacy to see the human side of the patient; reflecting and implementing humane care are the basis for the physical and mental healing of patients and is one of the nursing profession’s core values. Therefore, a lack of compassion in nursing education may lead to clinical care being dominated by a conception of patients as mere objects to be subjected to medical instruments and procedures without any voice of their own [3]. Therefore, nursing staff must develop the ability to be aware of the unique experiences of patients [14]. In addition to teaching professional knowledge, nursing education should cultivate compassion to assist nurses to be empathetic [15, 16]. When nurses face the humanistic needs of care recipients, they use their emotional awareness and reflection to develop a sense of themselves and their patients’ life stories. It is necessary to activate the energy of humanistic nursing care through systematic teaching strategies [17, 18] to enhance nurses’ cultivation of humanism in their own lives and express the humanistic spirit of caring, concern, and compassion in nursing [8, 19].

Calman pointed out that allowing nursing students to experience other people’s life experiences can increase their own sensitivity to others’ suffering [20, 21, 22, 23]. Reflecting on their own and their patients’ life stories can help nurses to be more compassionate. Through empathy and reflection, nursing students can enhance their understanding of patients’ life experiences, promote empathy, and improve their literacy to face complex situations [9, 10, 24, 25, 26]. Then, nursing students can internalize the characteristics of humanistic care. William Osler, the father of American medicine, believed that a good doctor must possess the humanistic qualities of the 3Hs: humility, humanity, and humor. These three humanistic qualities align with society’s expectations for humanistic medical care [27]. Humanistic care is a core value of the nursing profession. A qualified nurse must be able to empathize with patients and understand their unique life experiences. Only a compassionate nurse can care for patients and provide humane care [28]. The nurses that impress patients the most are those who are respectful, empathetic, caring, professional, sensitive, and enthusiastic [3].

Through qualitative in-depth interviews, Yeh found that for the nursing profession, the essence of nursing humanities includes caring, respect, enthusiasm, and professional sensitivity. Among these, “caring” is the most important humanistic-nursing characteristic, which refers to having “empathy” or “sympathy” and being able to “show compassion from the heart.” In addition to caring, respect is essential in the nursing profession because respect is the process of interaction; respect can correct an indifferent attitude and show self-discipline and politeness. Furthermore, a qualified nurse must possess professionalism sensitivity. In addition to having professional knowledge and skills, nurses also need to observe keenly, synchronize with patients, be emotionally present, understand, and interpret the patient’s body language and nonverbal meanings, and help solve the patient’s problems in a timely manner. At that point, the beauty of nursing humanities will also be fully displayed [29].

The development of the nursing profession should focus on humanistic education and be committed to caring for the whole human being. Nursing professionals must empathize with patients to help them. Understanding a sick “person” goes beyond reading instruments and performing routines; it involves perceiving a truly complete and living “person” with pain, expectations, and anxieties. In addition to the scientific and objective understanding of “disease,” the understanding of “human beings” must rely on subjective life experience and feelings, putting oneself in the shoes of others, empathizing with them, and treating patients professionally and confidently with humanity and wisdom. Therefore, the meaning and substance of humanities are emphasizing human dignity and value, and the “human being” is the main body of scientific knowledge [3].

4. Teaching strategies in humanities education

The nursing profession needs to strengthen the knowledge and depth of humanities education. To encourage compassion among nursing staff, Ryan’s 6Es (Example, Explanation, Exhortation, Environment, Experience, Expectation) should be used as the framework [30] for education in school and work environments to deepen the humanistic essence of nursing education (Figure 1). The 6Es include role modeling (Example), inspiration (Explanation), exhortation, and encouragement (Exhortation), the shaping of the environment (Environment), reflection on experiences (Experience), and self-expectation (Expectation). Since the deepening of humanistic cultivation focuses on affective education, the use of 6Es in the cultivation of nursing humanistic essence aims to emphasize the recognition of intrinsic value, which internalizes the essence of human nature to the characteristics of nurses, and then engages the humanistic spirit [3, 6]. The 6Es involve the following: (1) Example: The humanistic connotation of nursing education must subtly implement humanistic care into nursing practice. Therefore, it is encouraged to use real figures in life as learning models so students can learn from example, (2) Explanation: Education should not be dogmatic or only require rote memorization. Instead, educators should encourage dialog, discussions of values, and reflection on why the nursing profession should be compassionate, what the core values are, and how nurses can implement and practice compassionate behaviors, (3) Exhortation: A compassionate spirit should be practiced through a variety of activities, such as video, story, and experience, (4) Environment: Compassionate and ethical values should be promoted on campus, (5) Experience: Experiential-learning activities should be arranged for nurses to practice providing compassionate care, and (6) Expectation: Nurses should be encouraged to set humanistic care goals to motivate themselves and continually pursue growth [3, 6].

Figure 1.

Framework of humanistic-nursing education.

Derbyshire pointed out that, in addition to using the 6Es teaching strategy, we can improve the inner awareness of nursing staff and discover our shared humanity through reading literary works, such as biographies, novels, and works on history and philosophy [31]. Literary descriptions of human life experiences can help caregivers feel and appreciate other people’s life stories, including experiences involving illness, pain, anxiety, and the loss of function. When cultivated in literature and art, nursing staff can enrich their values through inner imagination, esthetic appreciation, and experience with care. In particular, the affective experience at the perceptual level can help nurses better implement the ideals of humanistic care [32]. Through the experience of reading literature and the observation of art, nursing staff can improve their observational skills; through the appreciation of music and drama, nurses can express their thoughts and feelings; through values clarification, identification of ethical values, and moral reflection, nurses can enhance their understanding of patients’ life experience and enrich the nursing curriculum. Through narrative medicine, by listening to the life stories described by patients, nurses can understand diseases from the perspectives of patients [33, 34, 35]. Self-awareness and reflection stimulate nursing staffs’ empathy, motivates them to learn, cultivates humanistic qualities, and brings humanity back to medical education [5, 9, 10, 36].

This study identified that intergenerational narrative inquiry can effectively improve the quality of humanistic care in nursing students [37]. Nursing students can change patients’ perspectives on chronic diseases by understanding life stories of the elderly, inspiring students with a humanistic attitude, and deepening students’ self-awareness. Through empathetic understanding, communication between generations can improve, which generate more positive attitudes toward the elderly from the students [37]. It helps nursing students to understand patients and illuminate the intricacy of specific phenomena and the paradigms that shape peoples’ experiences [38]. Therefore, the storytelling process is a fundamental element of the narrative approach, as it provides the opportunity for reflective dialog [39], which allows for the acquisition and transfer of tacit knowledge [40, 41]. Each generation has different beliefs and memories, affected by different social background factors, and a generation gap is unavoidable [42], especially for younger nursing professionals [43, 44, 45]. Therefore, it is necessary to promote awareness and insight for different generations of nursing students, to enable the students to integrate previous learning and life experience, stimulate learning motivation, and establish intergenerational relationships. Through understanding patients’ perspectives, nursing professionals learn to respect the emotional experience and exercise the empathetic side of human nature when caring for patients suffering from disease [16, 46].

5. Teaching plan design of nursing humanities

In order to deepen the humanistic care of nursing students, nursing education should be dedicated to improving humanistic qualities, helping nursing students to develop the ability to understand and feel the unique experience of patients, so that they can provide “patient-centered” humanized care in medical situations with humanistic caring skills. Especially in clinical practice, when facing the needs of patients, nursing staff must perceive and reflect on their own emotions through teaching, and develop a vision of seeing themselves and seeing the suffering of patients, which is the driving force behind professional care. In order to inspire students to have such reflections, we take students as the focus and discuss issues such as how to develop humanistic qualities of nursing students. Through group discussion and independent learning activities, students place their subjectivity in classrooms and clinical fields, think about the knowledge of nursing and humanities, and then enlighten the practice of humanistic actions. This is a student-centered perspective on humanistic cultivation and the design and practice of nursing humanistic teaching programs, which can better meet the needs of nursing education and clinical practice.

5.1 The design process of the nursing humanities teaching program

Since the humanistic spirit emphasizes the ability of empathy, it must be based on one’s own life experience and generate a common understanding between people. Therefore, the design concept of the nursing humanities teaching program is to explore the students’ self-growth experience and regional environment as the starting point for the cultivation of nursing humanities. Therefore, the design of the “Nursing Humanities” teaching program starts with students as the main body. First, let students talk about their own experiences, understand the inner structure of people, and stack up their unique inner spirit and world meaning. Finally, the students reflect on their own humanistic nursing care. Each nursing student brings their own life growth memory and integrates the humanistic elements in this course, initiating and shaping the students’ outline to become modern humanistic care nurses.

The design process of the nursing humanities teaching program [29] includes the following: (1) Recruit 19 students who voluntarily participate in the group. Through group discussion dialog, reflection on homework, learning experience, and teacher participation in action and reflection, we constructed the core concepts and connotations of the nursing humanities teaching program. It includes three core concepts: life resilience generated through connections between people and the land, recognizing people’s spiritual value from narration and stories, and modern nursing role models, (2) Constructing evaluation tools for nursing humanistic teaching programs, including the assessment of nursing humanistic practice, thematic study sheet, clinical practice experience narrative and reflection form, and peer quality assessment, as the evaluation tools of this teaching program, (3) In the fourth grade of the university’s nursing department, the elective course “Nursing Humanities” is offered. There are three classes in total, with 61, 32, and 60 students taking the courses. Among them, 32 elective students are nursing students with clinical work experience, and (4) In the course of nursing humanities, through the narration of the nursing students’ life experience, humanistic activity experience, and the process of critical reflection, with teaching strategies such as group discussion, dialog, and self-reflection, it can increase the breadth and depth of humanistic care, help nursing students have the ability to understand and feel the unique experience of patients, and provide students with clues to reflect on their future nursing careers.

5.2 Nursing humanities teaching program

The framework of the nursing humanities teaching program [3] is based on the life experience of nursing students themselves as the starting point of humanistic inspiration; second, they discuss the meaning of nursing humanities and the analysis of clinical nursing images. Then through the narration of the story, added humanistic elements, including the nourishment of humanistic images to explore the media material of the life value story (The Memory Keeper’s Daughter), let students reflect on and experience the value of being human again. It is not only about a biological science viewpoint but also a rich humanistic and social context. Guided by the media mentioned above, nursing students can imagine people’s helplessness, fear, and weakness in different situations and their limitations and blind spots. When students can see the context behind the incident, it is an essential humanistic ability and the basis of empathy or compassion. When students can see the context behind the incident, it is an essential humanistic ability and the basis of empathy or compassion.

In addition, we also arrange “life story sharing by care recipients” and “caregivers’ experiences in practicing humanistic care.” Because the narration and the story have the power of moving resonance, nursing students recognize the value of people through storytelling. Therefore, with a series of storytelling learning, international volunteers are invited to share their personal life beliefs and traveler stories of international service. Through the videos and photos of the stories, the students realize that the work of helping others can range from clinical work to cross-border. This sharing activated the enthusiasm and confidence of the students, and it turns out that the field of nursing work can be a humanistic care action without borders.

At the end of the course, the nursing students reviewed their clinical experience, reflected on their humanistic care, and explored their understanding of humanistic care; to think about how to practice humanistic care, make the nursing process more humane, give full play to the spirit of humanistic care, and make nursing work an art of caring for people. In the reflection on the process of the teaching plan, nursing students mentioned their worries about the future practice environment, and burnout is also a notable problem. Nurses need to be respected and cared for, considering their limitations and vulnerabilities. How the humanistic quality becomes a nutrient and turns around to nourish nurses, enrich each other’s life, become an internal motivation, or plant humanistic seeds in the heart, is a direction worth exploring in the future. It is also an essential purpose of this teaching plan design. We believe that “putting yourself in the shoes” in the teaching program of nursing humanities is not a realistic and achievable goal; just as it is difficult for us to understand the world of “autistic” patients, we must infer the patient’s feelings from their reactions. Only through teaching program design, good use of media materials, dialog and discussion, and experience reflection, nursing students can be trained to have multiple thinking and deep awareness and be prepared for their future careers. This is the feasible teaching plan for the nursing humanities course.

6. Nursing professional development trends and humanistic education

Nursing professional development has been influenced by the specialization and institutionalization of the health care system. With the division of medical specialties, patient care has become oriented to disease diagnosis and biomedical treatment. Professional care is often provided according to physician order, neglecting that human beings not only have bodies but also minds and spirits. The patient care often generalizes and decontextualizes the essence of the nursing profession.

To counterbalance this situation, nursing professional development should place more emphasis on humanistic education. Nursing professors must have humanistic qualities, including tolerance, appreciation, and a respectful and caring attitude.

The key to the development of nursing students’ humanistic care ability is teachers possessing the competence to implement humanities education in their own instruction. Therefore, the key to the success or failure of humanities education is ensuring, through the professional development process, that nursing professors have this competence [47]. Only professional teachers that have humanistic qualities and practice the essence of nursing humanities can serve as role models, naturally influencing their students as they implement humanistic care in clinical practice [19].

Ideal humanities education teachers would have both professional nursing as well as humanities and social sciences training. The lack of teachers with this training creates a challenge for nursing professional development. The authors suggest that humanities and professional teachers should work together to open nursing courses. Teachers should be able to identify with humanistic qualities, teaching as much by example as by through their words, allowing students to recognize the necessity of humanistic literacy [48].

To reiterate, promotion of humanities education and the cultivation of humanities teachers must be achieved in order to improve the humanistic cultivation of nursing staff. This is the key element that must be implemented in the process of nursing professional development [3].

7. Conclusion

A humanistic education in the nursing profession will allow nursing students to provide an affective experience of humanity, care, and esthetic appreciation, to develop a broader perspective, to cultivate insight, to understand and feel the unique experience of patients, and to look at problems from multiple perspectives, especially in complex situations. The challenge of today’s nursing education is using multiple teaching strategies to improve humanistic cultivation in the humanities education in the nursing profession. We recommend actively advocating the use of 6E as a teaching strategy framework to promote humanistic nursing education and integrating the experience of literature and artistic esthetics to enhance the affective experience of nursing staff at the perceptual level. At the same time, through self-awareness and reflection, nursing staff can strengthen deep empathy and keen observation ability, improve humanistic quality, and practice the humanistic spirit in professional nursing, which promotes the nursing process to be more humane.

Conflict of interest

The author declares no conflicts of interest.

Funding

These researches were funded by the Taiwan National Science Council (Grant Number NSC99-2511-S-255-001-MY2, NSC102-2511-S-255-004-MY2) and Chang Gung Memorial Hospital.

The data that support the findings of these studies are available on request from the Principal Investigator, M.-Y.Y.

The data are not publicly available due to their containing information that could compromise the privacy of research participants.