Interrogating education of the heart

This paper reports students’ responses to a curriculum focused on integrating critical approaches, and evidence-based knowledge, with an education of the heart pedagogy. A focus group was conducted with 12 student representatives from a large first year undergraduate sociology of health and illness topic taught to a number of health professional students. Discussion centred on student views and feelings about the emotional or lived experience components of the topic portrayed through films, plays and poetry as well as the arts-based assessment exercise. Student responses indicate that they found the artsbased portrayals of the lived experience insightful for developing their own theory of care, but this was tempered by feelings of insecurity in completing these forms of assessment in the competitive environment where grades are important for achieving transfer to their


Introduction
Where students are seriously engaged, all education potentially results in change, although this does not mean all students are transformed (Mezirow & Associates, 2000).As Mezirow notes, students participate in three possible learning processes: one where knowledge is transmitted to them (analogous to Freire's, 1993, concept of banking knowledge), a second where they engage in knowledge transactions through experiential engagement, and a third that is transformative.
Proponents of transformative education argue that it results in the student engaging in a deep shift in perspective.This may be a rational, emotional or social change (Cranton & Taylor, 2012).Our focus in this article is on these latter two forms of education-the transactional and transformative-in the context of teaching first year health sciences students.
Increasingly, universities are attempting to offer first year undergraduate students choice in professional outcomes.This is motivated by three pragmatic factors.The first is awareness that not all young people mature at the same pace or achieve the necessary high scores to get into their first program of choice; a number require additional time and a second chance pathway facilitates this.
Secondly, universities market their courses aware that not all school leavers know what profession they wish to pursue; they require time to taste and see.Thirdly, and to meet this recent trend, programs of study are structured to include early generic courses that allow students to get a feel for the field, before committing to a specific profession.This is an attractive, but dubious, marketing strategy for finite places, creating a highly competitive first year for university students, who must now get very high grades to transfer to their desired program of study.Added to this, institutions face demands to ensure the production of work-ready graduates who understand and comply with applicable regulatory frameworks.In the case of tertiary education for health professions, the aim is to produce novice practitioners who can demonstrate the desired specified competencies and compliance with ethical practice.
Many students who seek a career in health do so from an existing individual orientation towards caring and social justice for their patients or clients.Instead of assuming that students need to change and transform, or that our role is to critically engage them in a revision of their values and practices, the aim of our teaching is to deepen their meaning perspective (Mezirow, 1978), rather than change it.We refer to this "deepening" as education of the heart. 1 Drawing specifically on the theories informing mythopoesis or education of the heart as outlined by MacDonald (1981), Heron (2007) and Heron and Reason (2008), we have developed a teaching approach that seeks to integrate evidence-based knowledge of health policy with critical theory and an education of the heart.This paper draws on two theoretical underpinnings of our curriculum approach and then reports on student evaluation of our endeavours and their responses to our stated aims.As we demonstrate, there is a tension between the student's desire for choice as well as an expectation of a high grade, and our model of transformative education of the heart.

Theoretical underpinnings: MacDonald's three approaches to curriculum
MacDonald proposed three approaches to knowledge: the evidence, the critical and the imaginal (Bradbeer, 1998).In the health sciences, there is a strong argument for evidence-based, practical and critical knowledge (Habermas, 1972;Van Manen, 1991), bolstered by instruction in the rigours of ethical and professional behaviour.The scientific or evidence-based approach is clearly present in the topic content of health professional courses.It includes the current scientific knowledge on illness processes, and the social patterns of disease, as well as the skills needed to gather this information using evidence-based medicine (EBM) processes.
The second approach to curriculum outlined by MacDonald (1981) is the critical, including related theory.Teachers and their students need to be able to step outside the scientific and rational forms of knowledge and examine the way they and their patients are subject to forms of cultural and societal power, including the power of particular forms of scientific knowledge.This can be as simple as the underlying ideology informing policies in domains such as those shaping addiction or aged care, what constitutes national health priorities for research funding, or the impact of funding mechanisms on practice.The critical approach allows the novice health professional to situate their own practice within our culture and society, and understand whose interests are being served (Habermas, 1972).The danger of critical theory is in its nihilism on the one hand, and its unrealistic and arrogant attempts at emancipation on the other.Both should be avoided.Our approach is to see the reflexive aspects of critical theory as involving "the process of critically assessing the content, processes and premise of our efforts to interpret and give meaning to an experience" (Mezirow, as cited in Wang & King, 2006, para 28) and to discern what pragmatic actions are possible.For health professionals, any response is also governed by codes of ethics and professional boundaries.
We seek to extend this concept of critical reflexivity to a dwelling with the experience.Critical reflexivity engages the intellect and will to action, while dwelling with the experience resides in the soul and leads to acceptance and potentially to a deepening of the professional self.This is the mythopoetic, or MacDonald's (1981) third theoretical approach to curriculumsometimes referred to as the lived experience, the practical, or the imaginal.Shifting from seeing curriculum as the collection of facts, skills, or even critical knowledge, it engages the student and teacher in the process of being human.A mythopoetical approach requires the organisation of knowledge in such a way that the ontological questions are elicited, or emerge.The mythopoetic curriculum is not so much a set of knowledges, but rather a way of presenting the curriculum content so that the student and teacher come to a deeper understanding of what it is to be human within a particular social and cultural context.An essential component of this is an understanding of the lived experience.This goes beyond an ordinary understanding of practical as practice or even exchanges of experiences, to include quality, feeling, symbols, emotions and desires.All these are brought into focus in the reflection on the practical.Importantly, this imaginal understanding must be grounded in the socio-cultural possibilities for practice.Core to our curriculum therefore are the policies and frameworks for clinical practice, for example, the policy of harm minimisation for drug and sex education.These policies can be subject to critical examination, but they also provide the social and cultural boundaries of practice.
One useful way for creating imaginal forms of educational exchange is through the use of art forms such as film, drama, poetry, or painting.These aesthetic forms create metaphors, symbols, and imagery for taking knowledge beyond mere facts into the heart, or for taking seriously the lived experience of others.They provide opportunity for heartfelt thinking "that helps illustrate for the student what it means to be open to the puzzle of existence" (Bradbeer, 1998, p. 45).Our approach centres on the student's role as health professional and their relationship to the other as patient, highlighting the lived experience of both.It asks the student health professional to enter into the lived experience of the heart of the patient and in doing so to reflect on their own transformation.For first year students, this link to their professional futures may have special resonance by confirming or sustaining their initial choice of vocation, and building a foundation for later study.The role of the teacher is not only to provide opportunity for the student to take seriously the lived experience of patients, but also to ensure that the care students will eventually provide to patients is shaped by the student having a thorough knowledge of policy, the scientific evidence, critical insights, and highly developed technical clinical skills.Such acts of professional care illuminate and enrich the meaning of being human, making the educational process not so much transformative as deepening.

Heron's Ways of Knowing
A similar typology has been formulated more recently by Heron and Reason (2008) who argue for "four ways of knowing that go beyond the positivist oriented academia" (p. 1).These four modes are experiential knowing, presentational knowing, propositional knowing and practical knowing."A knower participates in the known, articulates and shapes a world in at least four interdependent ways" (Heron & Reason, 1997, p. 3).They argue that knowing will become more valid if the four ways are congruent with each other: if our knowing is grounded in our experience, expressed through our images and stories, understood through theories which make sense to us, and expressed in worthwhile action in our lives (Heron & Reason, 2008, p. 1).Heron and Reason (1997) propose a cycle of cooperative inquiry that moves through these ways of knowing: collaboration to "define the questions to be explored and the methodology for that exploration (propositional knowing)"; skill to "apply the methodology into the world of their practice (practical knowing)"; which in turn "leads to new forms of encounter with their world (experiential knowing)"; and then "find(ing) ways to represent this experience in significant patterns (presentational knowing) which feeds in to a revised propositional understanding of the originating questions" (p.3).
In subsequent work on spiritual inquiry, Heron (2007,) suggests that "the totality of ways of knowing … involves knowing how, knowing that, knowing as, and knowing with -practical, conceptual, imaginal and affective ways of knowing."This terminology remains consistent with earlier work in relation to practical knowing ("knowing how"), but equates propositional knowing with "conceptual knowing" ("knowing that"), experiential knowing with "imaginal knowing" ("knowing as"), and presentational knowing with "affective knowing" ("knowing with") (pp.16-17).

Developing our curriculum: Drawing threads together
Drawing upon the ideas of MacDonald (1981), Heron (2007) and Heron and Reason (1997;2008), we argue that a solid curriculum requires the integration of the scientific, the critical, and practical forms of knowledge.It is not sufficient to teach scientific facts, rather the facts must be embedded in practice, and in turn this practice must be grounded in human meaning including the critical.Human meaning resides in the imaginal, in our understandings of what it means to be human and how this might be expressed.Our pedagogy requires that students are given space to travel through a process where they encounter evidence-based knowledge, critical theory and then, imaginal knowledge as an emotional response to various content and media as it is evoked (Willis & Leiman, in press).Students are invited to consider how this knowledge shapes their own identity as a professional in practice.Some students will uncover a dissonance between their core myths, the lived experience of others, and the empirical knowledge of the practical area.This allows them to assess the effectiveness of policy responses, and how these fit with their future identity as professionals working in the field, or the demands this dissonance may place on them.For other students, it is an opportunity to align their own core values with the boundaries that policy or practice guidelines impose.Our curriculum thus uses the critical approach to illuminate core myths, rather than to critically tear them down.It asks: What is the message or the meaning behind this myth?(Holland & Garman, 2008).In doing so, we seek a curriculum that achieves understanding of one's perspective, rather than necessarily a perspective transformation (Mezirow & Associates, 2000).

Theory in practice
The topic, Health Practitioner Practice 2, is taught to approximately 400 first year students enrolled in a range of degree programs.The topic takes a "sociology of health policy" approach and is divided between firstly, a focus on population groups at risk of institutionalisation or victims of failures in deinstitutionalisation-the frail elderly, those with mental illness or a disability, and Indigenous Australians; and secondly, major contemporary public health issuesobesity, nutrition and physical exercise, alcohol and other drugs and sexual health-that risk falling victim to the medicalisation of deviance or everyday life.The format follows a typical weekly lecture and tutorial workshop model with a onehour lecture and tutorials running for two hours across the 12 weeks with classes up to 30 students.The topic is primarily taught by casual staff, many of whom have taught it for two or more years.Workshops begin with the tutor leading discussions focussed on assigned sociology of policy and practice readings and lecture content chosen to reflect the various forms of knowledge discussed above.They include qualitative accounts of the lived experience, critical accounts of policy success or failure, and evidence-based knowledge.In the second hour, students do a class presentation in which they select and show a visual medium, and lead subsequent class discussion.This is usually a popular Hollywood film and up to 40 minutes is spent on this activity.Class reflection on the film dwells on the lived experience of the characters, rather than attempting any critical analysis or solutions.The point here is to provide time for students to dwell with the phenomenological account of the suffering of the patient, or the experience of caring for this population, which in many instances is difficult emotional work.
There are three pieces of assessment: a systematic literature review requiring students to address evidence-based research, a class presentation, and an artsbased assignment.The latter two pieces assess evocative responses from students.The arts-based assignment asks students to produce a painting, poem, poster, visual medium, music lyrics or piece of sculpture that portrays the lived experience of one of the policy areas covered, along with a 500-800 word theoretical summary of what is being portrayed.Although students may or may not be gifted at painting or writing music, high grades can still be obtained if the written reflection captures the spirit and intent of the assessment.While a majority of students have reacted positively to the topic, it has not been clear whether students either experience the pedagogy of the heart in the way we imagine, or perceive the differences in knowledge.Gaining insight into how students receive and interact with the various forms of knowledge is an important step in our approach.Our attempt to evaluate this is outlined below.

Methodology
In 2011, approximately 400 students were enrolled in the topic with around one third hoping to transfer to another degree, such as paramedic or dietetics, or needing to maintain a GPA of 5 to retain their place in medicine, physiotherapy or occupational therapy.Two of the authors (Abery and Willis) were among the twelve teaching staff.Once the semester had finished, grades had been submitted to the Exam Board, and following the granting of ethics approval, students elected as class representatives in each of the 19 classes (17 internal, and 2 external) were invited to participate in a focus group facilitated by the third author (Leiman), who works in another school.Prior to the focus group, participants were sent an email asking them to read an article written by Willis (2010).This paper outlined the intention behind designing a teaching process which integrated the lived experience with evidence-based knowledge and policy along with critical analysis.Twelve students attended this 90-minute focus group session conducted by Leiman.The discussion was audiotaped.Students were asked to reflect on the particular pedagogical approach used in the topic and, through the use of semi-structured questions, to elicit their views and perceptions of: • the use of films as a mechanism for conveying the lived experience of the patient or population group under discussion; • the use of arts-based forms of assessment as a mechanism for illuminating education of the heart; and • how the knowledge gained from the film and arts-based activities resonated with theoretical information presented in readings and lectures to inform or change existing perceptions of future professional practice.
Analysis of the transcripts was initially conducted by author Abery.These themes were then verified by authors Willis and Leiman.

Thematic discussion
Emerging themes included:

Successful insight into the lived experience
Overall, responses from students (shown below in italics) to the use of films and the arts-based assignment in eliciting an understanding of the lived experience were very positive.Using a visual medium (film) allowed students to easily engage with the patients and carers, and led to a memorable experience that facilitated their understanding of the issues portrayed.Students found it easy to immerse themselves in the situations depicted and recognised the impact not only on individual population groups-disabled, aged, Indigenous and those suffering from various mental illnesses for example-and how they dealt with their illness or situation, but also on those around them: families, friends and health care professionals and how it affects every part of their life … every aspect.Some students were previously unaware of the overall impact and consequences of living with illness or the adverse circumstances, as reflected in their comments: Oh my God this is what people are living through -it's awful.
Using films consolidated their learning experience.These insights lead easily to critical and theoretical understanding.For example, in the film The Black Balloon (Ayre-Smith et al., 2008), the realities of deinstitutionalisation and the feminisation of care, as well as the impact on siblings in families that have a child with a disability were portrayed.The film illustrated how policy is lived out, and in discussion, students were able to flesh out their understanding of the lecture or readings: students felt it made more sense.

Challenging of existing knowledge/beliefs/development of new understanding/compassion
As a result of the insight gained into the lived experience, the focus group students identified that their existing knowledge, personal beliefs/values and preconceptions were changed or questioned, leading to new knowledge, understanding and compassion.They were able to appreciate the challenges and frustrations experienced by others and felt less judgmental: There tends to be a feeling of "Yes it's difficult" but why don't they make the best of it and get on with it?And then you look at all the stumbling blocks…it's not surprising that there's a level of despondency.There was also the realisation that in many cases the students' own circumstances were very different from those portrayed in the films: You sort of understand that it's difficult for these people; you begin to learn how every single little thing we take for granted … is really difficult.The films offered an opportunity for students to see the theory being put into practice and gain a greater understanding of the patient's perspective: It's one thing to know in a lecture that there's a disparity between different groups than when you're watching the films you're looking at it with a different perspective … because you're trying to put yourself in that situation.

Connection to future professional practice
The intended purpose of the curriculum is to allow students to immerse themselves in the lived experience.Given this, it was not difficult for them to make connections to the theory and evidence-based knowledge, and how this might impact on their future professional practice.The content of many films chosen highlighted broader issues such as the role of professionals in caring for particular population groups, and the challenges that some populations experience in accessing appropriate health care and services.Students were able to identify relationships between the readings and lectures from a more theoretical and policy basis.They could go on to make connections with how policy and the structure of the health care system might impact on, or impede not only these population groups but also their own future professional practice.Student comments highlighted the value in gaining this insight: You know this is real life and these are real people … I think it kind of bridges that gap between you as a student, the people you're going to be working with and the process of getting to that place… In the words of one student: You can look up a policy but you can't just dial up a feeling.
Importantly, we also wanted students to make the connection between their own professional vocation to care, and the boundaries that the evidence and policy provide.In taking this approach to the curriculum, we sought not only to provide a space for students to deepen their commitment to care, but also to do so employing the frameworks outlined by their own profession along with current Federal or State government policy.For example, a desire to assist individuals and families with a mental illness requires an orientation to care, but this care must be offered within the confines of professional practice and the policies of deinstitutionalisation and communitybased care (South Australia Department of Health, 2010).Added to this, a critical understanding is required.Deinstitutionalisation and communitybased care are not without flaws!There was little evidence that students were able to discern how policy and their critical analysis of this policy might shape their practice.It may be that it is too early in their education and training for this to occur given that in first year they have had little exposure to clinical practice.

Fear of not meeting academic standards through perceived unconventional means
One challenge arising out of the use of this pedagogy is assessment.The importance of, and anxieties connected with, achieving high grades came through in focus group responses.Formal academic input and outcomes such as essay writing and exams were perceived as having more value and acceptance than choosing a film to present to the class or the evocative arts-based production assignment.Some felt that the standard forms of assessment such as the writing of an essay provide more structure and that it is easier to understand expectations: You can't fake it with an essay and greater knowledge was assumed to be gained from essay writing.Students indicated that they saw formal written assessment as a more accepted format.Many students enrolled in the topic are high achievers or seek to achieve a high Grade Point Average in order to transfer into other degrees of their choice.While they enjoyed the opportunity of choosing a movie they thought evoked the lived experience and in being able to express their own emotions through the evocative arts-based assignment, they worried that the tutor would not interpret their work as they intended and that they would not achieve a high grade.Given the high quality of the artistic works submitted by students, these views are surprising.What appeared to be the issue of concern was their capacity to convey their intent through artistic content and some did not feel comfortable in relaying their own emotions: It would have been a good assignment because it really did make you think and it put you out of your comfort zone and it made you create all this work but trying to express emotion, but when -at the end of the day if we don't get a distinction you know we may or may not get into paramedics.
There was also concern that the assessor would not share or understand the message they were attempting to portray: It's hard though -if you're trying to get a point across to the person … that's hard because it doesn't mean putting any less effort in, and it doesn't mean that you don't get it.Inclusion of the written reflection supporting the art work alleviated some of this apprehension, but the issue remains a problematic, one of conflicting agendas: The art work is supposed to show that we felt it, but the written statement is really the part of it that's being marked maybe or not -I don't know.Considering the varying backgrounds and experiences of students and tutors within the topic, this uncertainty is not surprising.An ongoing challenge here is to allow students the opportunity to deepen their orientation to care through education of the heart whilst also ensuring that they feel confident that this medium of assessment will still support result driven academic expectations and demands: I have to get a GPA of five and higher so I have to maintain that and I really love the assignment and as soon as I looked at the weightage (sic) that the assignment had, I started to panic….What has emerged as clearly important is an ongoing responsibility to provide clear guidance and a solid understanding of the pedagogy to tutors, and to ensure consistency across the marking and grading process.

Interrogating the pedagogy
Our pedagogy exposes first year students to some of the "realities" of the lived experience at the same time they are reading the clinical evidence and the policy imperatives intended to shape institutional and societal responses to these issues.Four forms of knowledge (evidence-based, critical, the practical lived experience and evocative) are brought together in classroom activities.These activities draw on MacDonald (1981), Heron andReason (1997, 2008) and Mezirow's (Mezirow & Associates, 2000) schema, including Mezirow's later developments that incorporated emotions and spirituality (Baumgartner, 2012).We have also drawn heavily on Mezirow's concepts of transformative knowledge, but modified it to suit our beliefs that transformative education does not require a radical shift.It is sufficient that students have opportunity for deepening their existing caring values and beliefs, gaining an insight into the ideas behind their beliefs, and beginning to understand what is appropriate and possible in the practical world of professional practice.Our research has provided some evidence that the use of various art forms such as films and evocative exercises such as the writing of poems meant that some students experienced what Mezirow (1978) coined as perspective transformation.This is directly linked to Mezirow (1978), MacDonald's (1981) and Heron and Reason's (2008) critical forms of pedagogy.Student responses indicated that they came to "see" the social, cultural and political barriers that some population groups experience.This experience allowed them to go beyond empathy, to see that social structures such as inequalities in gender, class or ethnicity raise additional impediments to health access.
Our approach, although successful in deepening student's empathy, did not necessarily assist them to understand how that empathy is played out in the professional context.Even though students exhibited some connections with their future profession, the way in which these lived experiences might impact on their future practice was not evident.The focus group discussions showed that students imagined themselves as paramedics, nurses, doctors or physiotherapists, but this did not lead to them to sharing any reflections they may have had on how their compassion and care might have been actioned.This may be an impossible aim, given that the topic is offered in first year when students have few opportunities for even simulated practice.As discussed above, our intention in bringing together a sociology of practice with policy and imaginal forms of knowledge was to provide a framework for students to deepen their professional vocation to care within the pragmatic boundaries of the possible.This includes the professional boundaries that govern patient-practitioner relationships.Professional practice is not the same as charity, or being a good neighbour or friend.There is clearly room for more development of the theory at this point.
The fear surrounding assessment, suggests tensions between "getting a good grade" and deepening the knowledge.Whilst students understood and engaged in the intent of the topic, and enjoyed the artsbased forms of assessment, this did not mean they were comfortable with our approach, the assignment topics or for that matter our assessment of their work.The students' agenda (using their first year of study to transfer to their course of choice, or retain the place they have already achieved) is instrumental and pragmatic.They preferred the predictability of an essay or exam.In many other topics, this predictability is bolstered by having access to rubrics, and standardised approaches to assessment.Novel forms of assessment, such as producing a poem, produce anxiety and appear risky.Arts-based forms of assessment are assumed to favour those with creative talent.The idea that creative productions might be a more ready reflection of the heart is not necessarily appreciated or accepted.This is particularly so where the aim of the assessment appears nebulous and the language for talking about it vague.

Conclusion
One student in the focus group, having been asked to read some of the theoretical work informing our approach (Willis, 2010), commented that if he had known of our intent earlier, he might have collaborated more fully in it.While the introductory lecture did outline the four approaches to knowledge, this comment is a challenging observation.It opens up the teacher's intentions for closer scrutiny by students.It exposes the teacher's views to the student and defines what we understand as deep learning and transformation.Not all students may accept that education includes exploration of the deep feelings of the heart and may resist.Our pedagogical approach also challenges a number of assumptions about what is required in teaching in this first year context and how this is to be achieved.
In attempting to evaluate our approach, the most profound question for us is whether or not such transformative learning can be assessed at all.In arriving at this point, and reflecting on student responses to the assessment of their evocative art-work, we return again to the critical role played by the teacher.Teachers must take care to understand exactly what it is they are doing as they seek to teach using this pedagogy, to think carefully about the journey they are inviting students to begin, and how knowledge might shape students' future identity as professionals in practice.
Providing space for students to deepen their meaning perspective makes similar demands on teachers who believe that this is the role of education, as teachers seek to align their core values with the boundaries that current curriculum paradigms impose.