Phase 1: perspective sharing and collaboration building

Opening to a juxtaposition of perspectives: possibilities for an international perspective of health humanities

Through the discussions and written reflection we agreed that the Health Humanities ‘holds space’ for dialogue between health and biomedical research and practice on the one hand, and the humanities, arts and social sciences on the other. Since these respective ways of thinking have developed from quite different paradigms, languages, traditions and norms, a core activity in health humanities education is the constant work of ‘translation’. This work is of course necessary for all involved in bridging the disciplinary divides. Alternatively, we recognised that it is easy to get into a narrow mindset when only engaging with local partners in designing health humanities education, because potentially challenging issues such as assessment and interdisciplinary practice need a broad perspective. Important elements of the international perspectives included open meaningful dialogue reflecting on different perspectives, which we found offered more diversity in social, cultural, geopolitical, and humanities contexts for our study [20].

Health humanities from a more global perspective

A common thread signposted was that holism or having a holistic outlook is relevant to many perspectives around health humanities education. Our collaboration also led us to formulate pathways to navigate the tension between localisation and the dominant modes of health humanities dialogue. We suggest that international collaborations and networks may be the way forward for others in the field too [20].

There was also an impetus within the group, particularly from the perspective of low and middle income countries, to consider how health humanities can be utilised to bring advocacy into health professions education [24]. An activist approach is needed to confront global health issues such as poverty, climate change, educational and health inequalities and ethical issues such as the rise of technology in health care [20]. An international outlook on the Health Humanities can unpack approaches to these problems which are both complex and interconnected, and which benefit from international comparison and sharing (see Table 2).

Table 2 International view point for health humanities education

Phase 2: evidence gathering

The literature search, which covered a 5 year period (2015-2020), identified 8621 publications with 24 articles meeting the criteria for inclusion. Over half of these were published in North America (n = 13); the remaining were based in England, Ireland, Australia, India, New Zealand, Spain and Sweden. Only the one from India was not from a high income country [25]. Many reported health humanities curricula focused on developing students’ capacity for perspective, reflexivity, self-reflection and person-centred approaches to communication however learning outcomes were not consistently described. The primary finding of the review was that at present, there is an absence of a consistent framework for health humanities learning, teaching and assessment, and hence, little capacity for systematic evaluation within or across curricula. The findings recommended the need to articulate a more systematically realised and empirically informed set of core capabilities for health humanities that can be adapted for local educational contexts. The value of core capabilities for developing health humanities curriculum within a programme was reported as being able to more systematically develop integrated learning activities that can achieve some of the higher-order educational outcomes and more accurately and systematically evaluate whether these core capabilities are being achieved and thereby inform the development of a curriculum framework [2].

Phase 3: curriculum and evaluation framework for the health humanities

For health humanities curricula to become integrated as core, some key antecedents and facilitators for success require consideration [26]. These include the external influences that may be outside of course coordinators’ control but can impact successful curriculum implementation. For example, the AAMC states that it strongly endorses all medical schools to offer some medical humanities-focused learning [27]. Similarly, the Health Professions Council of South Africa stipulates a key competency as being a patient/client-centred approach [28]. Likewise, academics in programs of healthcare management are calling for a dialogue surrounding the utility of humanities to broaden the scope of required competencies of their accrediting bodies [25]. This recognition and validation by an external or accrediting body acts as evidence in supporting the validity of health humanities education and is useful when looking to obtain support from local leadership and inspire engagement from within an institution. The development of the curriculum and evaluation framework recognised this need for some impetus or inspiration when proposing the introduction of a Health Humanities curriculum. The design of the framework focused on some key aspects of curriculum design as summarised in Table 3 [29], to develop the InspirE5 model of curriculum design for Health Humanities.

Table 3 InspirE5 model of curriculum design for Health Humanities

Environment: learning and political facilitators and barriers to be aware of

When introducing health humanities teaching, it is helpful to be aware of the curriculum model or models informing the overall educational program, and array of instructional methods used (problem-based learning, interprofessional, integrated community-based learning, etc.), as well as recognized gaps, to identify opportunities for interweaving humanities offerings and helping learners appreciate connections with other aspects of the curriculum [30, 31]. Others have also emphasised the need for this unifying perspective in curriculum design that focuses upon construction and maintenance of a particular learning climate [7, 31]. Imperative for success is having academic staff who are confident to apply innovative teaching strategies or inspire others and make the most of opportunistic curriculum innovation and can be the pioneers or the champions. We recognised that bringing health humanities teachers and researchers together in a collaborative way such as at health professions education conferences and through networks may support faculty and curriculum development. It is also important to recognise that health humanities can be perceived as competing with other disciplines in what is typically a time and resource poor environment. Finding ways to work within an existing curriculum can make it easier for the learning experience to be integrated rather than stand alone and makes it easier to prevent competition or obstruction but does require appropriate faculty development. Our collective experience and findings of the scoping review [2] suggests that persistence of supporting people who are strengths-based with a collaborative orientation, can successfully combat individualistic academic norms. Tapping into areas of possible student dissatisfaction with the biomedical model of education or the learning environment can act as the impetus or inspiration for curriculum renewal and inclusion of health humanities.

Expectations: graduate capabilities that are clearly articulated for all

The research group determined to focus on graduate capability, rather than competence as better preparing health professionals to respond to the challenges of working in the contemporary international health sector [32]. Capability is the ability to adapt to change, generate new knowledge, and continuously improve performance [28], whereas competence-based approaches are less dynamic, focus on the current state, having the knowledge and skills necessary to perform a job [32, 33]. Capability embeds the integration and adaptation of knowledge, skills and personal qualities through scaffolded learning that enables generation of new knowledge and adaptation to change and uncertainty [33, 34]. We propose graduate capabilities that align with learning and teaching strategies and topics commonly reported in health humanities literature, as outlined in Table 4.

Table 4 Suggested Graduate Capabilities of Health Humanities Curriculum for Health Professions Education

Experience: learning and teaching experiences

The interdisciplinary nature of health humanities sees learning occurring at multiple intersections between a range of humanities disciplines and the health and medical sciences. The humanities disciplines frequently referred to in published studies include philosophy, sociology, literature, visual arts, music, narrative and performing arts and less frequently but equally valuably, history (in context and place, for example China, Africa, Australia) and anthropology [2]. This current work identified how health humanities teaching strategies are being applied to emergent issues for health professions education such as management of high stress work environments and burnout for health professionals, responses to the COVID-19 pandemic and the utility of technology for healthcare. From our collective experience and review of the literature the common content topics being taught as part of health humanities curricula can be summarised as depicted in Table 5.

Table 5 Common content covered in health humanities education

Health humanities focused education is reported to enable students, through engaging learning and assessment experiences that are predominantly in face to face settings, to create a learning environment that encourages students to reflect, critique and consider their personal values and beliefs. The teaching methods encountered are most often small group in nature, whether delivered in online or face-to-face modes, and involve sharing of thought and reflections in dialogue with peers and mentors. This learning commonly aims to enhance the future health professionals’ capability for self-reflection, advocacy, empathy, leadership, followership, scholarship and person centred communication [2, 8, 20, 21].

Evidence: guiding principles for assessment of health humanities and assessment strategies

Through discussion and review of the literature, the project team identified three apparent guiding principles surrounding the assessment of student learning in health humanities. Firstly, the approaches to assessment often expected the students to engage in the act of creation to demonstrate achievement of a health humanities capability. This creation was often a written piece (essay, narrative, story, and reflection) or an object (concept plan, drawing, picture, sculpture, painting) or a performance (art, music, theatre) and sometimes included the application of technology (blog, podcast, video). Secondly there was always an engagement with the object created through reflection and the articulation of reflective thought. Finally, the assessment commonly explored values and beliefs of the students. This was sometimes to identify values or to understand the presented values and beliefs and thereby enhance capacity for divergent perspectives. On other occasions the assessment focused on shifts in values towards professionally accepted standards. The assessment of achievement of the graduate capability utilised critical evidence synthesis, self- assessments, peer assessment, direct observation of performance and work integrated assessment of professional practice rather than objective, measurement based assessments. Assignments were more frequently used than examinations.

Enhancement: program evaluation of student and teachers learning experiences

Responsive evaluation is an approach that places importance on quality improvement and the representation of quality in a program rather than just the educational outcomes achieved [26]. When compared to other evaluation approaches, it draws attention to program activity, program uniqueness, and the social plurality of the people running a program [35]. This responsive approach is applicable to summative and formative evaluations and allows for flexibility and ambiguity. Formative evaluation is useful when staff need help monitoring a program and when problems are difficult to identify and articulate. Summative evaluation is useful when audiences want to understand the activities, strengths and shortcoming of a program [35]. In responsive evaluation, data is gathered around the processes and activity of a program using quantitative and qualitative methods. We chose a responsive model to curriculum evaluation of health humanities programs because of this recognised capacity for tolerance of ambiguity. That is, we recognised that internationally, health humanities education programs in the health professions are often not mainstream programs, there can be a lack of clarity about success indicators, they are usually collaborative and multidisciplinary, making their implementation complex and sometimes ad-hoc in nature, resulting in an absence of consensus of purpose and method amongst stakeholders [36]. Based on Kirkpatrick’s levels of evaluation [37], the scoping review of health humanities and other systematic reviews, and informed by other published evaluation matrices, we designed the evaluation matrix depicted in Table 6 for use by educators of health humanities in health professions education [38].

Table 6 Enhancement: evaluation matrix for health humanities curricula in health professions education (Adapted from Gibson et al., 2008) [38]

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