By Bella Madden, School of Healthcare Practice, University of Bedfordshire
The following reflection articulates the genesis and development of my approach to Higher Education generally and midwifery education specifically over twenty years of teaching. It draws on the impact of my own experiences in HE as a student; the parallels between clinical and teaching practice, and the influence of a handful of key thinkers and texts that have helped me to elucidate the values that underpin my teaching practice. This is presented here as an explanation for the case studies that will follow which illustrate how the humanities can be integrated into classroom teaching in healthcare in ways that will deepen learning. What follows is an explanation for why I think this is important.
Keywords: holistic; interdisciplinary; pedagogy; reflection; emancipatory; critical.
I remember an A level history session. We were discussing Marxism, I think, and in response to a question I can’t remember, I answered: ‘Well, there have to be workers in factories, don’t there?’ The lecturer looked at me – direct eye contact – and enquired ‘Do there?’ That’s it. All I remember. It was a simple question, gently put, rhetorical, but it struck home with deadly accuracy. It was personally put in a public space, and it floored me. I went home, for some reason picked up George Orwell’s The Road to Wigan Pier (2001), and pursued the question further. I still haven’t come up with an answer – but that wasn’t the point. What had been nudged into the open for me was my own ‘world view’. It made me see, for the first time, that I had a world view, and that I made assumptions about how the world ‘worked’. It made me think about other assumptions that might follow on from this one, and so on. Later on, I had to wonder whether I liked, or wanted to keep, my world view.
The moment described is the start of a process of revelation, which I presume is why it stays so vivid in my recall. I felt liberated – but from what?
Although I could not articulate it clearly at the time, it was liberation from unconscious prior assumptions about how the world works; liberation from my own responses to those assumptions; liberation to use and understand other ways of seeing the world and choose those that I preferred and to re-choose as well; and ultimately, liberation to build my own intellectual identity. All this was the legacy of my own education and something I valued highly – I still do. Pirsig (1974) later helped me articulate this liberation through his discussion of ‘the knife’ that we wield when we carve up the world in order to understand it – and his poetic analysis of our individual and collective ‘knives’ helps me still to understand the nature of this ‘aha’ moment:
The application of this knife, the division of the world into parts…is something everybody does. We take a handful of sand from the endless landscape of awareness around us and call this handful of sand the world. Once we have the handful of sand, the world of which we are conscious, a process of discrimination goes to work on it. This is the knife. It is necessary to see that part of the landscape, inseparable from it, which must be understood, is a figure in the middle of it sorting sand into piles.’ (Pirsig, 1974, pp.85-86)
Twenty years ago, therefore, I entered the teaching profession as a midwifery lecturer in a new university. Asked to present my educational approach at interview, I stated:
‘The use of stories facilitates critical reflection on midwifery practice, which is truly woman-centred. Critical reflection is emancipatory, releasing practice from constraints and transforming it.’
However, emancipatory outcomes are relatively easy to build into the study of pedagogy or social science – those disciplines being steeped in the study of knowledge itself and run through with a collective reflexivity. How, as a new university lecturer of midwifery, could I ensure our midwifery students received at least an echo of this? How is this achieved within an educational context that is highly vocational and with students who may not be used to the idea of ‘playing with ideas’ as an activity worthwhile in and of itself, and why should this level of reflexivity be desirable here?
Learning how to be a midwife is a great deal more than the acquisition of technical knowledge and clinical skills. It is emotional, physical and political work: an art, a craft and a science. It involves connecting with women and their families at significant crisis points in their lives. It uses all of you. If students are to survive the rigours of their work and thrive, they need a strong sense of their own professional and personal identity; a deep capability for empathetic communication and a well-developed yet critical self-belief to avoid long term burnout (McAllister and McKinnon 2009). They must be able to investigate their world and the world of their clients in ways that allow them both to connect with and advocate for the people they serve. In order to achieve this they must be able to listen to others and to their own responses to others.
The importance of listening to women’s stories of care had been embedded into my practice through the experience of running and researching a listening, or debriefing (as it was called at the time) service for women who wanted to talk through their midwifery care. The resulting thesis was less an analysis of the issues raised by the women I visited, but more an examination of the politics of listening itself as I grappled with what I could and should do with the stories of childbirth and midwifery care that women had given to me (Madden 2002a; 2002b). Discussing the implications of this research for midwifery education I concluded:
‘The fundamental need is to develop a holistic approach to students, just as we expect them to approach clients. Reflective practice, formally built into the modular structure of curricula, could provide the opportunity to trace the personal narrative of each student in their process of becoming a midwife.. (and) just as we acknowledge and accept the political nature of our midwifery practice, so we must also embrace the political aspects of our teaching practice.’ (Madden, unpublished MSc Thesis 2002)
Just as I want a student’s educational experience to be liberating (of discipline boundaries; of self-identity; of affect), I want it to enable them to see the world of their practice and the people for whom they care as more than the sum of their parts, as I have articulated before:
When you ask healthcare professionals to tell you what ‘holistic care’ means they tend to give you a list: physical, emotional, social, psychological… etc. This is still a collection of bits – just more bits than the one from which you may have started. I want students to consider more than the midwifery knowledge they leave with – more than the application of their skills. I want them to leave the classroom with bigger ideas and feel part of those ideas. Holistic care is not just a conglomeration of all those bits that you put together – it’s not paint by numbers – it’s a different picture. It’s not thinking ‘mind’ and ‘body’ – it’s thinking beyond mind and body. There are all sorts of reasons why this is important for their practice but essentially it’s about offering them a strong vision of care that allows them to ask intelligent, wide-reaching questions about their clients as well as their work. (Cf. Mathew 2016 p.18).
Our current midwifery curriculum states: ‘As health is more than a biological condition, so learning is more than the acquisition of information. The social context of women and their families requires recognition and respect, as does that of our students. As tutors we cannot just be concerned with what a student can demonstrate that they know, but how they apply that knowledge and what the experience of acquiring that knowledge and skill is for them…as educators and students we all learn from each other, and create the midwifery profession and therefore the experiences of women undergoing maternity care, just as the profession creates and sustains us. We are active agents in this process of professional development and take responsibility for it… student’s stories provide us with the context of effective teaching and learning.’ (University of Bedfordshire, 2012, p.33)
This is a consciously value-laden approach to education which seeks both the identification and articulation of student experiences and values as a ‘good thing’ in the interests of self-knowledge and which comes itself from a position that uses student experience as a resource for learning and for change.
What drives all of this is an ethic of care (McLellan 2014), interpreted as a need to attend to relationships of power: between professional and client; teacher and student; professional and professional, in order that care may release the voices and the needs of those most vulnerable. Education must therefore liberate the student’s story. It must role model in student/teacher relations a self-conscious use of power which it expects students to be mindful of in their own professional relations with women and their families.
Valuing these approaches (a transformative, liberating education; interdisciplinarity and holism; respectful and democratic classroom relationships)asserts that education is not only about getting people into their chosen careers, or even only about fostering deep, lifelong learning, but also creating a societal force for tolerance, understanding and change. Indeed, that is clearly what our midwifery vision states. Furthermore, because we also work within a widening participation organisation, we are explicitly elevating these values from the start – they are a ‘given good’ for us.
Freire (1972) speaks of the ‘ontological vocation to be more fully human’, warning that a truly liberating education must not seek to replace one dogma (the banking approach to education for example) with another, but must actively seeks ways to release rather than impose knowing. I interpret this to mean that deep understanding and knowing ‘emerges’ from the inside out, with the help of a skilled teacher-facilitator and is owned by the student throughout. This is hard labour on the part of both the student and the teacher, and involves a keen attention to the power balance of relationships within the classroom between teacher and taught. It must also be an honest relationship. As long as teachers assess; inhabit the front of the classroom and lecture hall; can call for silence and control access to the educational space, then there will always be a significant imbalance of power between teacher and student. However, we can mitigate this by attending to our own authenticity and maintaining what I call a ‘plumb line’ between our beliefs and practices. If we believe in an education that has the potential to liberate individual voices, then our practice must reflect that in the way we relate to students in terms of our communication styles; our expectations of them and our responses to challenge and difference. We must seek to subvert our own certainties.
One way of releasing student voices is to encourage students to use poetry – their own or the work of others – to help them reflect and to enable students to examine how they feel about their practice and their developing sense of themselves as midwives. I ask them to attend to affect – as well as skill, knowledge and attitude. Zull (2004) cites the growing neurological evidence that deep learning must involve emotion as well as thinking and doing – that learning itself changes the very structure of the brain and that the way we feel about and in our learning, is an essential aspect of this. Students I have worked with who have used poetry to help them express and analyse ideas and even structure assignments, support this:
‘I really found poetry helpful with my assessment. It made me really think about how women in a new and vulnerable situation would be feeling, and that us as the health care provider may not stop and think about her feelings and think about her as an individual.’
Another student puts it like this:
‘Humanities in health care may be the missing piece in the academic jigsaw. This is where I think poetry fits.…I was musing on it all last night and I realised that when you get 'socialised' into midwifery, in a way, you are kind of emotionally trapped…. Writing in this way or reading in this way shares so much of the experience and it suddenly feels as though something has 'clicked'. It is an amazing way of coping with what the job throws at you!’
Similarly, the use of collage has helped students reflect on their course and articulate their personal philosophy for midwifery practice. The idea of having a personal practice philosophy is a difficult one for many students, and the connections between experience, their responses to experience, and values and beliefs about ‘good’ or ‘desirable’ practice can be hard to make. However, turning experience and feeling about experience into a picture provides students with a directly accessible representation of often complex and contradictory feelings. Student feedback is overwhelmingly positive for the use of visual art in this way:
‘I loved the art work session which was a great way of expressing our reflections in a creative way. It was great fun and something different.’
‘I really enjoyed the drama day and art/craft – even though I thought I would hate it. Found what I wrote was interesting but not sure how I came to produce it.’
The use of poetry, art and drama will form the basis of case studies that will further illustrate the principles and approaches I have articulated here.
I have a mantra in the classroom stolen from a long-forgotten DVD which asserts that ‘it takes a lot of self-discipline to be a free spirit’. Education, perhaps particularly vocationally oriented education, must equip people with a way to consciously know themselves and make themselves within their practice. To do that it must attend to the whole human and cross the artificial boundaries that have come to demarcate knowledge, experience and learning.
Freire P (1972) Pedagogy of the oppressed. London: Penguin Books.
McAllister M McKinnon J (2009) The importance of teaching and learning resilience in the health discipline: A critical review of the literature. Nurse Education Today 29, 371-379.
McLellan J (2014) Claiming an Ethic of Care for midwifery. Nursing Ethics 21:7 803-811.
Madden I (2001) Hidden Agendas: Using reflection to explore and conceptualise the midwife/woman relationship during postnatal debriefing. MSc Thesis for Research and Evaluation, University of Luton.
Madden I (2002a) Midwifery Debriefing: in whose best interest? British Journal of Midwifery 10:10 631-634.
Madden (2002b) Working with Women Following Traumatic Childbirth. IN Johns 2002 Guided Reflection: Advancing Practice. Oxford: Blackwell Science.
Mathew D (2016) The Care Factory. Newcastle: Cambridge Scholars Press.
Orwell G. (2001) The Road to Wigan Pier. London: Penguin.
Pirsig R (1974) Zen and the Art of Motorcycle Maintenance: An Inquiry into Values. London: The Bodley Head.
University of Bedfordshire (2012) Faculty of Health and Social Sciences Department of Community Services Midwifery Curriculum Document.
Zull J (2004) The Art of Changing the Brain. Educational Leadership 62:1 68-72.