Introduction
The aim of this article is to propose ways in which the concept of difficulty could be used as an opportunity for learning in healthcare ethics education. Viewing difficulty as a stepping-off point for learning runs counter to the common reaction students have when they read something that confuses them. Difficulty is often viewed as a barrier and a source of frustration for students. To turn this attitude around, teaching and learning strategies must be employed to structure the encounter with difficulty so that students see it as a “promising place to begin.”Footnote 1 I argue that poetry is an excellent means to achieve the aim of thinking through difficulties because of its complexity and ambiguity, as well as its strangeness compared to the usual scientific texts healthcare students encounter in their programs of study.
My approach will be fourfold. First, I briefly examine the literature on difficulty with reading texts as a starting point for thinking and the process of interpretation. To set the stage for using poetry to unpack difficulty, I summarize the general rationale for, and benefits of, the inclusion of the humanities in healthcare education. Third, specific examples of teaching and learning strategies for turning difficulty into opportunities for learning are presented, including a version of the triple mark-up method and the difficulty paper.Footnote 2, Footnote 3 Both methods require students to: examine their individual process of working through difficulties, reflect on how they make sense of a difficult text, and share their process and interpretations in a collaborative manner with peers. Finally, I will turn my attention to the transference of this kind of personal and collaborative learning about difficulties to healthcare ethics education. I propose that teaching and learning strategies that focus on difficulty, when embedded throughout healthcare curricula, will enhance interpretive skills. Also, I argue that this approach to difficulty prepares students to engage novel difficulties in patient care. Furthermore, working with others to identify common difficulties could lead to improvement in interprofessional collaboration, particularly when dealing with ethical issues.
Difficulty as an Entrée to Learning
What do we mean by difficulty regarding a written text? There is considerable variability among scholars in English literature, literary theory, linguistics, communication, comparative literature, and composition regarding the meaning of difficulty as a concept or term.Footnote 4, Footnote 5, Footnote 6, Footnote 7, Footnote 8, Footnote 9, Footnote 10 Some argue that specific authors or types of literature, such as poetry, that rely on metaphor, complex language, or specific structures to achieve a variety of effects and meanings, are inherently difficult. The difficulty then becomes a condition or element of the author or text, not a result of the transaction between the reader and the text. How then do we explain differences in the difficulty of reading texts from different historical periods or even in the personal history of a reader? The text remains the same, it is the reader who changes and the “nuance of individual readings that breathes life and meaning into texts.”Footnote 11 Thus, for the purposes of this article, we will define difficulty as a concept that, “lives in the eye of the beholder; it may be based on the beholders’ estimate of the object as well as their estimate of their capacity to deal with that object in a fashion appropriate to a given situation.”Footnote 12 Put another way, the finding of meanings in the written word involves the text and what the reader brings to it in a sort of ‘transactional’ relationship.Footnote 13 The reader brings his or her past experiences of life and literature, memories, present preoccupations, sense of values, and aspirations to the relationship with a text.Footnote 14
A shift from the theoretical to the practical is in order at this preliminary point, as the overarching focus of this article is on teaching and learning. The purpose of any type of education is the transference of learning. What students learn today in healthcare education, for example, must be transferable to novel difficulties they will encounter in the future if what they learn is to have any lasting value. Understanding how one identifies and works through difficulty is a valuable transferable skill. The rest of the article focuses on the pedagogy of difficulty in healthcare ethics education using poetry to enhance interpretive and collaborative skills, mindful of the transactional relationship between the reader and the text.
Why a pedagogy of difficulty? I offer two reasons. The first has to do with the similarity of skills required to interpret a difficult text, the narrative of a complex patient, or the insights of a co-worker from a different discipline than one’s own. The aim of all healthcare, to assist patients in times of illness and suffering, is achieved in large part by interpreting the patient’s story, whether written or verbal, and working with others from diverse health professions to provide the necessary care. It is the process or means by which healthcare professionals carry out the purpose of healthcare. This leads to the second reason that a focus on difficulty makes sense in healthcare education. Difficulty ranges across the curriculum and thus exists in every type of healthcare profession and practice setting.Footnote 15 A brief example from the clinical setting will suffice here. Like the reader of a complicated text who blames the author for the reader’s struggle, health professionals often blame patients for difficulties that arise in their care, and react with avoidance or abandonment. In other words, they give up trying to work through the difficulty they have identified. Learning to read in ways that nurture flexibility of mind and perceptual skills such as thinking the thoughts of another, or temporarily adopting somebody else’s arguments, can be good preparation for encountering and working through ethical difficulties in healthcare practice.Footnote 16
A pedagogy of difficulty runs counter to the common belief in the United States that almost everything should be easy, including learning, and if it is not, something is wrong. Mariolina Rizzi Salvatori describes difficulty from the perspective of the student as “thinking that stops before coming to fruition.”Footnote 17 It is as if the student gets to a door and doesn’t know how to open it. Students often place difficulty outside of their abilities to negotiate, whether they locate it in the text, “the author is being deliberately obscure” or in themselves, “I just don’t get poetry.”Footnote 18 Specifically, from the perspective of the learner, difficulty is “whatever slows down or brings to a halt the physical activity of reading, leaving the reader mystified, wondering why, what, how.”Footnote 19 Understanding anything is an interpretive process in which students must engage the content actively.Footnote 20 To see difficulty as an opportunity for learning requires learners to reflect on the process they use to work through difficulty rather than move away from it.
Before students tackle difficulties, they must recognize them. The text offers students certain clues such as the sort of text it is, for example, a novel or a poem; visual elements such as formatting; and the presence of characters and incidents in the text. The student’s background and experiences also provide guides to new content. However, students might not appreciate that who they are and what they bring to the text are key factors in interpretation. What is needed are learning activities that push students beyond their tried and true methods of interpretation. Novel, difficult material that doesn’t immediately reveal itself encourages insights into how they formulate ideas, where they look for clues, and how they use comparable techniques of analysis. As a side note, teachers rarely provide students the opportunity to watch them work through a novel text, exposing and examining their mental processes as they interpret a text. Teachers may not even be aware of all the moves they make when engaging with a new text.
When students experience difficulties, a common reaction on the part of the teacher is to step in and clarify matters. The temptation to reduce frustration on the part of students is strong. However, overuse of prompts that break down confusing content often result in missed opportunities and unintended consequences such as: (1) moving learners away from the work as a whole and reducing it to parts; (2) shifting the identification of difficulties from students to the teachers who likely do not see eye-to-eye about what is causing difficulty;Footnote 21 and (3) missing the opportunity of the learning that results from grappling with incompleteness, confusion, and frustration.Footnote 22 Teachers need to strive for the sweet spot where the students have some scaffolding to prepare them for addressing difficulty but not so much that answers are predetermined by the teacher.
It is important to have a good individual sense of one’s abilities, tools, and approaches to difficulty; but that is not enough. Collaborating with peers to interpret a difficult text enriches interpretation and imagination. Collective inquiry is also a key element of successful interprofessional collaboration in healthcare. Working together reinforces what is communal about the way students think and the importance of the give-and-take in collaboration and interpretation.
Benefits of the Inclusion of Poetry in Healthcare Education
The general rationale for including the humanities—such as plays, films, novels, or poetry—in healthcare education is to humanize healthcare. Many claim the humanities “enhance empathy, perspective taking and openness to different view points, and … prompt reflection on self, others and the world.”Footnote 23 The health humanities thus serve as a counter balance to the objective, often sterile, world of healthcare in which patients and healthcare professionals live and work.Footnote 24, Footnote 25, Footnote 26, Footnote 27, Footnote 28, Footnote 29, Footnote 30
Some of the benefits of reading literature in healthcare education are evident in students’ reflective writing that reveals self-reported increases in tolerance for uncertainties, understanding of illness and suffering, grasping ethical issues, and clinically relevant self-knowledge.Footnote 31, Footnote 32 Others report increase in empathy, reflection on practice, and self-understanding.Footnote 33 Literature and poetry have often been used to highlight ethical issues in healthcare because they provide a richer, fuller context of the moral life that encourages students to take on different perspectives and appreciate the interconnections in our lives as well as the complexity of making decisions. In addition, literature such as poetry in healthcare education programs provides an environment for emotional exploration and expression of feelings.Footnote 34 Although these benefits can accrue from incorporating literature and poetry in healthcare ethics education, what I propose here is a different use of poetry, that is, to focus on developing habits to engage difficulty.
Why is poetry particularly suited to the task of working through difficult texts? First, poetry requires a different type of reading than healthcare students commonly encounter. When a student reads a pathophysiology textbook, the focus is on what will remain after the reading, that is, the facts or information that the student acquires from the text and must recall to successfully pass exams and competently care for patients. Louise Rosenblatt refers to this type of instrumental reading as “efferent” reading.Footnote 35 The heightened language and the novelty of the form of a poem requires different tools to get at the meaning. “Poetry inhabits a space where logic and clarity do not hold sway, where language opens up strange paths that defy all our intellectual classifications and attempts at possession.”Footnote 36 Also, students are likely to associate poetry with difficulty, further drawing attention to the reader’s experience.Footnote 37
To really understand poetry, the reader must pay attention to every word. Aesthetic reading, where the primary concern is what happens during the actual reading event, is necessary to fully experience a poem.Footnote 38 As an art form, poetry involves collecting details and scattered particulars into a coherent whole for assessing meaning.Footnote 39 The same could be said of collecting information from patients and making sense of the “scattered particulars” of patients’ lives to provide individualized care. The poet creates the coherent whole and the reader interprets the meaning.
Also, there are practical reasons for using poems rather than other types of literature. Poems are shorter than novels, or even short stories, so easily fit into the curriculum and allow for more than one reading.Footnote 40 Additionally, the potential of the impact of a poem, the emotional, hidden truths that are rarely discussed in ethics coursework, such as our shared vulnerability and morality, often emerge.
Strategies for Transforming Moments of Difficulty into Learning
Students come to new learning experiences with a system of knowledge developed from personal experiences and previous learning.Footnote 41 In designing any learning activity, the teacher must be clear about what he or she wants students to learn and recall, what the students already know, and the students’ beliefs about learning.Footnote 42
When a familiar context is presented to students, they generally use tools from that familiar experience to apply to the task. What that means is that healthcare students will approach material within a healthcare context based on their experiences in healthcare. If a novel context is presented, such as a poem, students may begin their analysis using the efferent reading tools they have used to make sense of clinical, healthcare texts. As we have established, efferent reading of a poem will not work to get at the meaning of a poem. This approach can quickly result in frustration for students. The middle ground in choosing poems for a learning activity in healthcare ethics education would be to use poems that have an underlying healthcare theme and a narrative line. Such poems provide students familiar clues, trouble them a bit, yet the form, images, language, and metaphors of such poems push them into new territory. Additionally, such learning activities should not be isolated experiences but included throughout a program of study. Transfer of knowledge to novel situations in the future is more likely if there is ample opportunity for repetition.Footnote 43 In healthcare education programs, there are many opportunities in didactic courses or clinical experiences to use poetry in this way. The following are two sample teaching strategies using poetry that focus on difficulties. The first is the triple mark-up method proposed by Newkirk and Heaney.Footnote 44 The second is the difficulty paper method initially proposed by Mariolina Rizzi SalvatoriFootnote 45 and further refined by Salvatori and Patricia Donahue.Footnote 46
Triple Mark-Up Method
The triple mark-up method makes visible to the student and others the various interpretive strategies used to make sense of a complex text, in this case a poem. The triple mark-up method requires students to read a poem a minimum of three times, which emphasizes the importance of multiple readings. If possible, the teacher and students should simultaneously encounter a poem for the first time.Footnote 47 This would entail courage on the part of the teacher and assistance from a colleague to choose a poem that is novel to the teacher as well as the students. In that way, the teacher would be on the same footing as his or her students regarding the novelty of the poem, although it is assumed that teachers bring a deeper and broader knowledge base and experience to the task. One might also eliminate the poet’s name so that readers can approach the work without biases about a poet’s reputation. On the first individual reading, teacher and students mark words, phrases, lines, whatever gave them difficulty. This step indicates to students that difficulties are expected in poetry. On each reading, a new color and/or way of marking the poem is used to indicate the progression through a total of three readings. In other words, the individual student’s process to make sense of the text is made visible. When the readers have worked out the difficulties they encountered to the best of their abilities, they write a short narrative account of their reading and use the mark-up as cues to their process. These accounts and the mark-ups are then shared in small groups or with the whole class depending on the number of students. It likely that some difficulties will remain unresolved and through sharing with others, light may be shed on a satisfactory interpretation, or perhaps not. The general process and exchange of the mark-ups and narrative accounts can be accomplished in a face-to-face classroom, or in the virtual online environment in an asynchronous discussion. The mark-ups can be scanned so that everyone can see their peers’ process of interpretation as it progressed through multiple readings.
The triple mark-up method places greater emphasis on the development of individual analysis and interpretation before sharing with others, to give students time to imagine and question their own methods and insights. Thus, there is room for encouraging students to have confidence in their abilities to work through a difficult text and recognize the successful strategies they employ, such as looking up complicated or unfamiliar words, using the title of the poem to get a sense of the meaning, exploring the relationship between images as well as disconnections, or listening to the sound or tone of the poem and the emotional reactions that are evoked.
Difficulty Paper
The difficulty paper is a simple yet effective method for capturing and unpacking difficulties in texts and other types of learning experiences. Basically, it asks students to identify some aspect of an assigned reading they found difficult or disorienting. A variety of questions can be used to prompt the students as to what the teacher means by difficulty, including: Where did this text surprise you and what did you expect it to do? Where did the text fail to meet your expectations? Where did you stop reading? What did you find confusing?Footnote 48 The second step asks students to describe in detail, in a two to three-page paper, why they experienced the text as difficult. This step in the difficulty paper process encourages students to view what stopped them in their reading in a fuller sense. As John Dewey noted in his model of problem solving, this is the stage where students begin to understand the parameters of the problem they encounter as follows, “The width of the ditch, the slipperiness of the banks, not the mere presence of the ditch, is the trouble. The difficulty is getting located and defined; it is becoming a true problem, something intellectual, not just an annoyance.”Footnote 49 Next, students turn in their individual difficulty paper before the class discussion, so they have no idea what their peers’ experiences were. The discussion that follows allows categorization of the types of difficulties the class encountered such as unfamiliar language, genre, theoretical difficulties, or simple miscomprehensions.Footnote 50 The difficulty paper can achieve at least three basic learning goals:
1) It can help students begin to reflect on how they read, and why, and on the kind of understanding their ways of reading can produce;
2) It can help students shape a position from which to speak, literally or virtually, in class discussion to engage the thoughts of others;
3) It can help students foreground, to begin to analyze, and to assess the intricate moves they must make as readers who transact and negotiate with a text.Footnote 51
A modified version of the difficulty paper has been incorporated in a graduate course, MHE 607 Practical Ethics in Health Care Settings in the Master of Science in Health Care Ethics (MSHCE) program at Creighton University.Footnote 52 The purpose of the course is to move students through the functions of institutional ethics committees, i.e., case review and consultation, policy development, and education in a variety of clinical contexts. Selected students’ insights, and thinking about difficulties from one assignment in the course are included here as well as basic instructions for the learning activity. In small groups, each student was assigned a poem with a healthcare theme and a narrative line.Footnote 53, Footnote 54, Footnote 55, Footnote 56, Footnote 57 Students were asked to reflect on the meaning of their assigned poem and how it compared to the way traditional ethics case studies present similar issues.Footnote 58 The written response, which was their initial discussion post, was limited to no more 500 words. The inclusion of a poem in the assignment caught some students off-guard, even though previous assignments in the same course included short stories. Also, the mere appearance of a poem caused some students immediate frustration because of unpleasant experiences with poetry in high school and non-healthcare courses in college.
After the initial response of their individual reading and reflection was posted, students could view what their peers wrote, so all responses were public. Without requiring the students to do so, almost all read each other’s poems. Although they were not specifically asked to focus on difficulties or their process of interpreting their assigned poem, they offered descriptions of their interpretation process and highlighted difficulties in their small group discussions. The following elements in the students’ writing indicate growth, at least on a formative basis, in their abilities to describe their process of interpretation, share insights from the perspectives of others and connect or transfer what they learned from the poems to clinical realities. The following are some markers of complicated thinking in the students’ initial posts:
Use of Complex Sentences and Images
In response to the poem, “Thanksgiving: Visiting My Brother on the Ward” by Peter Schmitt,Footnote 59 one student described images that arose from the poem that she interpreted to be an inpatient psychiatric unit. The image seemed so real that she felt she was there. She also reflected on her clinical experiences and misconceptions about what a psychiatric ward is like.
The words that were chosen to describe each scene and detail helped me to clearly picture a psychiatric hospital ward. Thinking about a psych ward in general gives us a combination of feelings and ideas in a single moment, but the use of the words in this poem made the images seem so real, as if I had been in the same ward before. I was able to imagine the windows and picture a room with a small bed. I think my visions of what the scene looks like are influenced by my experience on a psych unit in nursing school, where I had my misconceptions of those units changed.
Explanation of Their Thinking Process
Several students described how they tackled their poem to make sense out of it. This student read the poem “The Good You Do” by Anne Caston,Footnote 60 that involves a nurse who gives a cigarette to a dying patient. Exactly what the nurse offers to the patient is not included in the poem and confuses many students. By rereading the beginning of the poem, the student could interpret the ending.
It wasn’t until you stopped and contemplated the words and the meaning behind the nurse’s actions that you understood the meaning behind the poem. I actually had no idea what the nurse had given the patient, until I reached the end of the poem. In fact, I re-read the first part of the poem, because I thought I had missed something.
This comment is an excellent example of the student noting that elements of the poem “do not fuse with or relate to what precedes it, either emotionally or in terms of ‘sense.’” Footnote 61 The student traced her reading of the poem to look for clues as to what she might have read incorrectly, so she could make sense out of the poem as a whole.
Use of Phrases That Present Different Perspectives
Again, the poem by Peter SchmittFootnote 62 offered the students the opportunity to see a psychiatric ward from the perspective of the brother of the patient.
This poem is presented through the eyes of a visitor. As a health care employee reading this poem, a different perspective or understanding may be gained after seeing things from their point of view. We may have a set idea in our head after working with certain types of patients or in a medical setting for an extended time but hearing/seeing what another individual has to say may cause us to think differently or gain a different insight on the situation.
What is a normal environment for healthcare professionals is often an alien and frightening setting for patients, family members, or others.
Questions That Are Risky or Posit Unforeseen Possibilities
Few students reach this place in their interpretation of their assigned poem, that is, what are the limits of interpretation?
I have never thought how different writing styles can lead you on a different journey. I enjoy how poetry allows you to make it your own. You can input your own ideas, feelings, experiences into the poem and it may read different for everyone. This may be beneficial in ethical situations as it allows you to see a different perspective than the narrative that is being told to you. However, there is a need to be cautious because you could create something that really isn’t there.
This student’s insights into the limitations or problems with individual interpretations of a poem or a clinical encounter are unusual in the students’ responses to the poems. Yet, her comments are echoed in Jeffrey Bishop’s concerns about interpreting patients’ narratives, “A narrative understanding does not lead us to an all-encompassing notion of the realities that surround a particular case.”Footnote 63 The student recognized the nature of interpretation as one that remains open to change with the addition of different perspectives or reconsideration.
Aware of Themselves Thinking in Their Writing
The following general comments about reading poetry describe a process and the different interpretations that the same person can have returning to a text later.
Personally, when I read poetry, I have to go back and reread it a few times to get the gist of what the author is trying to express. Poetry is not meant to be read just once. Much like a work of art, it calls for the reader to study it, ruminate on it, leave, come back and reread it, and so on. A piece of art may look completely different to a person after they have looked at it once, and then come back to look at it again.
Differences Between Individual and Collaborative Inquiry
These two students reflected on the differences between their individual process and that of the group.
The emotions the nurse felt were easy to relate to, but I didn’t find the poem easy to follow. I read it over and over and still felt like I was missing information that you and the other members of the group picked up on! Your description was really helpful for me to read!
The second student wondered about the influence of a peer’s interpretation on her own after she read the poem “Let Me Breathe.”Footnote 64
I read this poem after I read your post. I found it interesting that my point of view was influenced by what you explained here. I am curious as to what I would have thought about the poem if I read it prior to reading your post. The intensity of the struggle to breathe almost took my breath away.
Application to Clinical Practice
Many students provided specific examples from their clinical encounters such as this reflection on the poem by Pam Mitchell.Footnote 65
I want to compare the idea of attention to this poem because as a health care professional, I sometimes find it challenging to remember why I do what I do. I fall into a routine, sometimes struggling to get through the day. As I read this poem, it makes me reflect not only on myself, but others I work with, too. What if we, as healthcare professionals, took into consideration what we truly go through every day?
Transference of Learning to Healthcare Settings
Exploring the challenges students have reading complex texts can offer insights into how healthcare students approach difficulties in clinical practice as well. One valuable lesson for healthcare students is how to tolerate the incompleteness of an interpretation. “Students need to come to understand that to read a text is never a terminal event like the placement of the last jigsaw piece. To learn this and be able to live with it and be satisfied with it is itself a solution.”Footnote 66 An additional problem in clinical settings is that healthcare professionals still tend to view problems of any sort from their individual, disciplinary, perspective rather than reflexively turning to the wealth of insights that colleagues from other disciplines possess. Although there is greater emphasis on interprofessional education and collaborative practice in the United States, it remains the exception rather than the rule.Footnote 67 The act of making difficulty public breaks down the distinct discourses of various health professions and emphasizes that students do not exist in a vacuum but are part of a community who often share common perceptions and experiences.Footnote 68 Interprofessional collaboration requires trust, tolerance of and need for different ‘readings’ of difficulties in the clinical setting. Thus, the ability to recognize and work through difficulties, on an individual and collective basis, could serve as an overarching competency in healthcare that bridges professional differences.
In summary, using poetry in healthcare ethics education to enhance interpretation and collaboration prepares learners to:
1) Reflect on their own thinking;
2) Identify where difficulties lie;
3) Actively engage with difficulties, not move away;
4) Believe that they will not be punished or left stranded to struggle on their own;
5) Analyze difficulties by offering specific language for doing so;
6) Hypothesize reasons for difficulty;
7) Collaborate with others to map out plans to come to terms with difficulty, even without a final interpretation;
8) Frame interpretation as a public, visible, and collaborative process;
9) Clarify that working with and through difficulties demands a level of trust among colleagues and acceptance of reciprocal responsibility.Footnote 69
It is important in healthcare to focus attention beyond the self to develop the ability to observe, listen, and attend to the perspectives of others, whether peers or patients. A pedagogy of difficulty is a promising method that should be further tested to evaluate what is learned and retained as it applies to real ethical issues encountered in clinical practice. Research should investigate what strategies would be most effective using poetry and other humanities in cross-disciplinary healthcare ethics education to maximize the contributions of difficulty to collaborative clinical practice. As Eleanor Milligan notes, “Ethics educators need to be open to any and all means that equip future health professionals for the inextricable moral work that lies ahead.”Footnote 70
