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“Attempting to say something without saying it …”: writing haiku in health care education
  1. F C Biley1,
  2. J Champney-Smith2
  1. 1University of Wales College of Medicine, Health Park, Cardiff, Wales, UK
  2. 2Cardiff and Vale NHS Trust and the University of Wales College of Medicine, Health Park, Cardiff, Wales, UK
  1. Correspondence to:
 F C Biley, Ty Dewi Sant, University of Wales College of Medicine, Heath Park, Cardiff, CF14 4XN Wales, UK;
 Biley{at}cf.ac.uk

Abstract

Over a number of years the authors have been running short haiku writing workshops and have been using haiku as an evaluation tool. This paper describes those experiences and uses the haiku generated in these workshops to illustrate how this poetic form can be used as—for example, part of the process of reflection, to explore emotional and practical issues related to clinical health care practice, to refine writing skills and precision and, it is hoped, to convey to others the essence of the experience of health care provision, education and, perhaps, health, illness, and disease.

  • poetry
  • haiku
  • art
  • health care evaluation
  • health care education
  • humanities

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In the context of today’s health care systems, where patients have more information about their health care needs, have a greater understanding of health care treatments and options, and often require personal and professional engagement with health care professionals, new approaches to health care education are required. Understanding patients’ lived experience of health care, disease, and illness is becoming increasingly important, and this understanding is being achieved in a number of ways. For example, Malterud considers that qualitative research offers ways in which to understand social events and their context that can lead “to a broader understanding of medical science” than can be obtained from controlled experiments.1 In addition to this qualitative shift, there appears to be an increasing interest being paid to the role that the arts and humanities can play in the contemporary education of health care professionals.

To this end, it has been stated that gaining an understanding of the aesthetics of nursing is a worthwhile endeavour which can reveal—for example, what constitutes good practice2; that illness narratives have the potential to inform health care practitioners about how to gain an insight into “the mundane world of disease and its treatment essential to an understanding of suffering”,3 and that employing popular literature in nursing education can have a humanising effect on the technological imperative.4 Such an approach may enable “the health care worker to transcend his or her necessarily limited perspectives and insight into illness”.5

But as Skelton et al point out (in the course of describing the development of a special study module in literature and medicine), the study of literature in the context of medicine is not new.6 Indeed, health care students may already implicitly have identified its importance. Hodgson and Thomson found that one group of medical students read not only for pleasure, but to gain an increased awareness of life issues and to stimulate an increased professional interest.7 A majority of the students considered that a medical humanities course should be an option on the medical curriculum.

There are numerous ways in which the arts and humanities can be integrated into health care education. Skelton et al chose to develop a list of required reading of relevant texts,6,8 Wilkström used Edvard Munch’s The Sick Child as the visual stimulus for the verbal and written exploration of individuals’ experience and personal understanding of the concept of empathy,9 and a variety of other works of art in order to explore constructions of nursing.10 Others have used creative writing,11 poetry writing,12 and poetry reading, which “gives us as direct access to the experience of illness as it is possible to get …[it] allows some glimpse of the nature of the experience”13 and is “able to provoke an image and an idea of something beyond …”.14 Even bearing this in mind, however, Little claims that it is doubtful whether reading poetry can enhance a clinician’s skills.13 Mangum, on the other hand, when reflecting on her course on “art, aging and the medical consumer” maintains that “reading literature about illness and suffering offers health care professionals insight and empathy, thereby fostering communication and care skills”,15 with Allen adding that poetry is like a “breath of fresh air in this emotionally rarefied atmosphere of scientific medicine”.16

We subscribe to this latter view, and have used haiku, a form of Japanese short poetry, in a variety of classroom and other educational and educational evaluation settings. There is some evidence for its use in health care education. For example, Schuster used haiku in order successfully to promote the creative expression of student nurses’ perceptions and feelings about aging.17 The students embraced the process, producing haiku that allowed them to understand many facets of aging, including loneliness, anger, and frustration, and reminiscence. In a similar way, Anthony used haiku writing to help junior nursing students to monitor their own professional development18 and poetry in general has been used to monitor the effectiveness of clinical instruction.19 Finally, Gustafson considered that writing haiku can be a form of creative verbal expression and increase sensitivity to a variety of health care topics, provide a medium with which to share moods and emotions, and be used as an evaluation of a learning activity.20

Modern haiku is a form of short non-rhyming Japanese poetry written using the metrical pattern of five, seven, and five syllables in the first, second, and third lines respectively. Most modern haiku contain a seasonal reference (kigo) that places the poem and “haiku event” in a seasonal context, and should aim to create some kind of verbal image or picture that “attempts to say something without saying it”,21 having also the potential to evoke deep feelings in a reader. In this form, haiku has existed only from the end of the 19th century when, as the opening component of a hokku (a longer form of Japanese poetry), it became detached from the main poem. Almost any single event can be the subject of a haiku poem, often the greatest impact being gained from common, everyday situations that may or may not be juxtaposed with something not usually associated with them.

WRITING HAIKU

Over a number of years the authors have been facilitating short haiku writing workshops in a variety of educational settings with a wide variety of undergraduate, pre- and postregistration and masters’ degree students in nursing. In addition, we have used haiku as an evaluation tool for nurses participating in workshops on a variety of subjects. Typically, the students and qualified nurses who have participated in these activities have had a background in adult or mental health nursing, but our teaching has also included others with a midwifery, community nursing, or health visiting background.

Typically, the haiku writing workshops form one component of a general course on the use of the arts and humanities in health care, and last for about one hour. In an atmosphere of informality, students are introduced to the subject of poetry in general, and, specifically, the rules and form of the haiku. The aims and objectives of using such a poetic form (as outlined above) are elaborated upon, often using poetry or previously generated haiku as an illustration of its potential. For example, if attempting to use haiku as a form of workshop evaluation, we would read an extract from a poem by Watson which evaluated her experience of working with a Native Australian tribe in Western Australia.14 The poem was written in an attempt to evaluate her work as a district nurse in a way that did justice to the spirituality of the people she had been working with.

The following is an excerpt from The Time and Sharing the Tears with the Wongi Tribe of Cundeelee22:

But listen to wisdom to time and my stories of late That have been told by the dreamtime and hold us awake If only we hear the children and chants in the night The stars in the heavens that show us what’s right The soul’s reawakening will come in the night If you listen to dreamtime before all goes quiet.

Students were then invited to form into small groups and create haiku that reflected some aspect of clinical work or was related to the process of nurse education. Small groups were chosen so that individuals would have initial support in achieving design and style. Content, however, was more often than not constructed by an individual working alone. Often, at this stage, a degree of understandable cynicism would be expressed; students were invited to set this aside and to attempt the exercise. The following haiku are examples generated from the workshops. The accompanying commentary is limited because if a haiku poem is to be regarded as successful its meaning should be inherent.

Walking down a path Chaos erupts, fire and brimstone The scarlet river of life (Fran, Dan, Helen, and Jon)

This poem attempts to describe issues related to student nurses’ initial experience of a clinical placement in an accident and emergency department.

Despite their initial reservations—questioning the exercise’s relevance in the learning and understanding of health care practice, or questioning whether they would possess the ability to write haiku—the participants quickly got into their stride, working in a cohesive, determined, and able fashion. The groups were comfortable enough to use the exercise for personal disclosure:

Alone on a moor Cold, bright wind, ring sparkling Will you marry me? (Pip, Sam, Jenny, and Ali) On the screen moving Sought, yet not wishing to be found. Home invaded. (Darren)

In the first poem one member of the group uses the opportunity to announce her recent engagement. In the second, a prospective father describes the feelings of seeing his child on an ultrasound scan. Perhaps not surprisingly, students often used the workshop to describe their feelings about academic work:

Lightning—my fingers Fly to save the work, before The C-drive dies (Paddy and Linda) A day in my life is like a rebirth in Spring research essay done (Vicki)

However, clinical experience and personal feelings about difficult clinical practice situations formed the basis of many poems:

Outside the sun shines inside, hand held tight, she cries too much to bear alone (Cheryl and Paddy) Baby born at night, no movement, no sign of life. Rain falls, the moon shines (Mary) Night of life and death A touch to wash the shadows Clear sun, future bright (Mike and Darshana) Chemotherapy The Rosy Periwinkle Poisons but gives life (Sian)

Some of the participants took the opportunity to comment on the profession of nursing itself:

Unseen like the wind Worked like the soil of the land Nursing. Don’t do it (Lisa, Alice, Helen, and Sarah)

It is perhaps not surprising that many other haiku poems were comments on participating in the process of education:

Switched on, drifting off Tell me how were your workshops? They change like the seasons (Adam) Learning all or nowt Sleeping, focused or in doubt Swirling fog of mind (Deb) Swimming up like trout Focused, pushed without a doubt Nearly home and dry (Kate)

Clinical issues were also addressed, however, as shown by the following poem:

Five weeks in a life One last to heaven above But I am still here (Sylvia)

One of the class tutors participating in the workshop offered an enigmatic effort on the trials of being a mental health lecturer:

Ravens dive earthward, Feathered missiles, squawking death. Friend water beckons. (Mike)

Despite initial reservations, many of the students undertook the exercise with enthusiasm. To close the workshops, individual haiku writers were encouraged to read their poems to the class, and this was followed by a discussion of the process and the outcomes of the experience. Generally, people enjoyed the experience and discovered that they were able to produce the very precise written images that are required when constructing haiku, finding the process particularly rewarding. The enjoyment of poems in the feedback sessions was apparent, often demonstrated by spontaneous applause. The value of the exercise as a method of reflecting on clinical practice led to lively debate. There was recognition that poetry had potential as such a conduit, though groups were divided as to how likely they were to use such a method. It was recognised that other forms of expression, such as music and painting, could have equal value in reflection on clinical situations. Some students, although enjoying the workshop, maintained that such expression of thoughts and feeling had little value. All students, however, felt they had achieved something in expressing their ideas and producing what was for the great majority their first written poem. As Jack put it:

reading it [Japanese poetry] will teach you how to distil thoughts and feelings into only a few lines and it is good training for anyone wanting to hone their writing skills.23

WRITING HAIKU AS AN EVALUATION EXERCISE

Haiku writing for the specific purpose of evaluating people’s experience of a workshop was used in two settings. The first was an all day workshop for a community alcohol team on working with people with a dual diagnosis of substance misuse and mental illness. As described above, participants were introduced to the process of haiku writing and invited to work in pairs writing a haiku to describe their aspirations and anticipations for the workshop. It was also agreed with participants that they would repeat the exercise at the end of the day, in the same pairs, describing their feelings about the workshop and whether their aspirations had been achieved.

Haiku from the first session seemed to say much about the exercise as people’s feelings about the day:

Early arrival, oppressive room, hear the rain, crave enlightenment Rain noises pass still cooler stuffy nose and head thoughts to take and think. Rushing through the rain change from home now expectant open to new growth.

The second session suggested that the day was gruelling, but left people thinking. Some scepticism as to the value of writing haiku remained:

Sore back, apathy, and more questions than answers Rain stop for weekend! Darkness creeping raindrops falling brain drained, thoughtful. Sat in a green room with a girl from the valleys we remain confused.

A second evaluation took place at the end of a workshop for participants at a national conference for community psychiatric nurses. The following workshop summary was formulated:

Psychiatric name, Mentally ill, drug of misuse, of no use at all Mental illness/drugs Dual diagnosis or not Who knows and who cares Helliwell will help Throw him in the canal quick Let’s start again now

The themes that emerged from the workshop concerned the inappropriateness of the label “dual diagnosis”, and the failure of social policy—exemplified by the reference to the UK government’s then “Drug Tsar” (Helliwell)—to deal with complex substance use and mental health problems.

CONCLUSION

The biopsychosocial model of health care often does not take account of an aesthetic or spiritual dimension. The use of poetry in modern health care as a means of gaining an insight into the experience of illness has value in addressing this deficit.12,13,16 In encouraging health and social care workers to reflect on practice, we found that haiku could offer a non-threatening form of poetry with which even a beginner could easily engage. Although initially sceptical, participants were enthused by their ability to produce written poetry, often for the first time, and they used the opportunity to reflect on clinical practice and, on occasion, their personal feelings. The use of haiku as a reflective tool suggests value in its application in a clinical supervision setting. As Birx affirms:

…Writing poetry is a way to develop and communicate the aesthetic knowledge of the discipline.24

It is important to recognise not only the holistic nature of health care delivery but also the holistic nature of health care education, as Adam, one of the workshop participants, suggests in the following, final haiku:

Here we are again College—is it relevant? Let’s ask owls not slugs (Adam)

Acknowledgments

The authors would like to express gratitude to all the participants who contributed to the workshops and who all willingly gave permission for their haiku to be reproduced here.

REFERENCES

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