Modern healthcare is founded on the essential tenet of caring. Since nursing and midwifery education moved away from traditional, apprentice-style training into higher education, there have been questions raised as to whether the ability to care is innate, or is a skill that can be acquired in clinical practice (Barnett, 2008; Phipps et al, 2015). The concept of the 6Cs of good practice (care, compassion, communication, competence, courage and commitment) were introduced by NHS England (Cummings, 2012) in order to improve the quality of care for patients following examples of appalling care in the Mid-Staffordshire NHS Foundation Trust. Phipps et al (2015: 333) suggest that:
‘Caring occurs when communication is good, mutual respect is nurtured and decision-making about care is shared.’
Power (2015: 654) has noted that safe and effective care in practice is often:
‘Informed by evidence-based guidelines, developed and implemented by the National Institute for Health and Care Excellence, based on hierarchies of evidence, with meta-analyses and systematic reviews being identified as the “gold standard.”’
This approach can, however, fail to acknowledge the ‘art of midwifery’, where a constructivist paradigm of experiential, intuitive and tacit knowledge is used by reflective practitioners to provide high-quality care. Constructivist approaches in education advocate student-centred rather than instructor-led teaching and learning. This study uses Mayer's (2004) concept of guided discovery, where the tutor gives the student tools to explore the subject matter. The approach taken by this cross-disciplinary team is rooted in this paradigm. The tool provided was the 23-minute creative documentary, The Golden Window (Patel and Jackson, 2014).
The Golden Window was screened during a module on complex health needs of mothers and babies during which students had learned about prematurity and critically sick neonates, and the associated bio-psychosocial care for families. Within the safe environment of the cinema and classroom, The Golden Window provided a lens into the neonatal intensive care unit (NICU) environment that consolidated the theory, and brought an element of the experience of NICU to facilitate personal preparation for a challenging placement area. Within the midwifery curriculum, there is an emphasis on the effect of care on families through reflection on practice. In this case, The Golden Window afforded the students an opportunity to nurture their intuitive and reflective skills alongside new knowledge to refine their clinical, perceptual, and observational skills to recognise and address parental cues (Leap, 2000; Cox 2002; Power, 2015).
The Film
The Golden Window is a creative documentary, shot within 72 hours at the Rosie Hospital NICU at Addenbrookes Hospital, Cambridge. The central storyline follows the medical-induced cooling of ‘Baby J’ after a traumatic birth, and interweaves interviews with key staff and parents on the ward. The director, Dr Shreepali Patel, and neonatal consultant, Dr Topun Austin, made the film as a research project exploring collaboration between art and science. This significantly placed the film outside the broadcast commissioning and finance process, which broadly encourages highly dramatised television programme formats, such as 24 Hours in A&E (Channel 4) and One Born Every Minute (ITV). The film was not intended to be an informational piece, detailing clinical practice in NICU. Rather, the filmmakers (Patel and Jackson, 2014) took a poetic approach, placing the baby and parent's experiences at the centre of the film (Figures 1–3). Through film-making techniques of camera placement, detailed close-ups, shallow focus, enhanced sound design the film creates something close to the baby's point of view as a way of introducing NICU to the viewer (Figures 1–3). The film also captures contradictory and unanticipated emotions that NICU generates, incorporating the candid and immediate thoughts of parents and staff as they experience this world that the parents refer to as the ‘bubble world’. From the close-up intensity of the senses, to the very direct interviews, The Golden Window created an immersive filmic experience while also maintaining a fundamental ‘truth’ of these 72 hours in NICU.
The film was made through mutual and collaborative dialogue between the academic film-making team, the staff working in NICU (specifically Dr Austin and his team), and parents looking after their babies in the unit. All procedures were performed in compliance with relevant laws and institutional guidelines, and were approved by the appropriate institutional committee. The main idea behind the filming was to come to the unit for a few days and ‘see what happened’.
‘Filmmakers, cameramen and sound engineers went about their business in a much more unobtrusive way. Parents, doctors and nurses were invited into a little ‘film booth’ to speak directly to Shreepali [Patel]… One only has to see the parents to realise how this approach allowed them to open up in a really powerful way’
This intimate opportunity to open up to someone not directly related to the care of their babies, combined with the immediacy of the circumstances (the interviews were also shot in the 72 hours) allowed parents to candidly highlight their experience of NICU and to tell their stories. Riessman (2008) writes that filmic storytelling performs several functions, including a cathartic process of talking to someone who is not a patient or caregiver, but there just to observe and listen. Clandinin and Rosiek (2007) argue that filmed testimonies represent an interpretation of an event or series of events as seen by those individuals, which may be quite different to people working in the same environment, and this theory is played out in The Golden Window, showing the multiplicity of experience in NICU. The three principal testimony-based stories in The Golden Window are from parents: a father, who lost two of his triplets, talks about the ‘one cuddle a day’ he is allowed, and how he differentiates between the ‘good bleeps’ and ‘bad bleeps’ of the machines; a mother (Figure 3) who realised that it is only other parents with direct experience of ‘this bubble world of NICU who really understand’; and another mother whose baby was ‘whisked away’ at birth, and despite still being in shock, is able to articulate her feelings. Collectively these interviews suggest an experience that is almost abstract and imperceptible for those ‘outside’ of this physical space (the ‘bubble world’) of NICU.
The research nature of the production and the environment of NICU itself facilitated a responsive approach to the filmmaking process as well as the structure of the film. What emerged during the actual filmmaking process was the very real tension between science and emotion, where a ‘bleep’ on the machines meant something different to a parent, nurse or doctor.
‘Often the parents felt hopeless in the face of all the machines. However, it became increasingly clear that the emotionally-led instincts of touching and talking to the baby by parents were equally as important in the healing process’
For the filmmakers, this complex mix of science and emotion seemed best evoked by interweaving some aspects of traditional documentary storytelling with a more immersive cinematic experience. The use of heightened sound, macro lenses and movement were all designed to pull the viewer into the ‘bubble world’, to try and convey this world that the parents inhabited through feeling and emotion.
This type of creative and immersive filmmaking allows familiar processes and environments to be reframed. The Golden Window asks doctors, nurses and midwives to re-evaluate and reflect on the world they feel they know well and reframe their assumptions. For those who have yet to experience this world such as the student midwives, the film frames unexpected, nuanced and alternate experiences that can then feed into their actual experience in NICU and builds on the theory received in the classroom.
Screening the film
The Golden Window was screened to midwifery students at the Cambridge Arts Picturehouse. The filmmakers were interested in the students' response to the creative techniques used, and in their viewing experience. The midwifery education team wanted to evaluate if seeing the film made any difference in preparing the students for clinical placement.
This process was considered as an evaluation of teaching and learning. The screening was optional and the students were given the choice as to whether they contributed to pre-and post-screening comments. Students gave verbal consent for their comments to be used in a publication about the experience of screening this film as part of their curriculum. Obtaining comments from the students was in line with other teaching evaluations to which they were exposed. Following the screening, the students were asked to anonymously evaluate their cinematic experience of watching the film; whether the creative techniques used in filmmaking helped them to understand the NICU environment; and what emotional elements they may have perceived from the film. There was also a group discussion about the key issues that the students identified from the viewing. This primarily focused on parental reaction rather than the technicality of the filmmaking. Within the remainder of the module teaching, and during guided reflection sessions in placement, students had the opportunity to reflect on the screening in relation to their personal experiences in placement, with the help of the tutors.
Following their NICU placements, some students provided anonymous comments on the effect of The Golden Window on their learning, in line with usual module evaluation sessions.
Post-screening student response
The response by the students to seeing the film was overwhelmingly positive. Comments such as: ‘gripping’, ‘never lost interest’, ‘effective as if you're seeing and hearing everything as the baby being taken to NICU’, ‘felt a sense of anticipation and foreboding’ suggested that this creative approach was very powerful in drawing students into the ‘bubble world’, and giving them a sense of what it might be like for the parents and babies.
Students noted the effect that staff could have on families in NICU, and learned:
‘How to talk to parents in similar situations and take into account their feelings and that it is an abnormal environment for them’
‘An insight into some of the emotions of the parents in NICU and some of the amazing techniques that can be used to help babies that previously may not have lived or would have been very unwell long-term.’
Students reported feelings of empathy, gaining ‘a better understanding and appreciation of parents' experiences’, and said that the film was ‘powerful and humbling, it reminded me why I'm doing this job’. It also helped them to consider the impact of their choice of words, to take into account ‘the fear of the parents and the perspective of the baby’ and to ‘talk to the parents, absorb what is happening, understand that it is a highly charged environment with positive and negative outcomes’.
The feedback suggests that the students all took different things away from the cinema experience and several of them wanted to watch it again on their own, to have time to reflect on what they had seen. Some wanted to satisfy themselves that their initial response was accurate and they had ‘noticed all the important bits.’ In some cases, they wanted to watch it again because they felt emotionally overwhelmed by the impression it had left on them.
Post-placement student response
Further feedback was gathered from the students after their NICU placement. The Golden Window enabled students to be less intimidated by the NICU environment:
‘I went to NICU after the screening of [The Golden Window] and I felt prepared for the type of environment I walked into.’
‘It helped to make the environment more familiar.’
‘The film made me realise how much of an overwhelming experience it might be for parents and how frightened they are of a) what is happening or might happen with their baby, b) how frightening the environment is to them—especially machines and noises.’
Students reported the film enabled them to take a more active role in care provision and supported their understanding of the whole NICU experience. The film encouraged empathy and compassion for the parents and the baby, with student commenting:
‘As a student midwife on NICU, the hardest thing is to understand what's wrong with the baby and all the complex procedures they've undergone prior to meeting them.’
Students commented that the film also informed their knowledge of NICU, saying:
‘Due to the sensitive nature of NICU, when parents are present it is, understandably, inappropriate to ask your mentor to explain the condition and the treatment the patient has received. I had no knowledge of head cooling prior to seeing’
Another student commented:
‘I realised the huge benefit of seeing [The Golden Window] when I accompanied a family to an MRI [magnetic resonance imaging] scan to assess the impact of head cooling after birth. I immediately understood the rationale for everything we did that day in NICU, having seen the film.
The film gave them confidence to talk to parents and improved communication; and gave students ‘an insight into what the family had been through, which made it easier […] to make conversation with them.’ Other students commented:
‘[The Golden Window] enabled me to be a more active part of their care, rather than merely observing.’
‘Making conversation with families is extremely daunting on NICU, so I was very grateful to have seen the film.’
‘Supporting parents was the aspect I enjoyed most about my NICU placement.’
‘It has impacted on my experience on NICU in terms of communicating with parents and reassuring them and supporting both of them.’
Students were also able to see beyond the practice placement documentation aspects:
‘I felt that it allowed me to take more out of the placement than just clinical skills.’
Post-screening response from midwifery educators
The art and science of midwifery is embedded within the education of student midwives as part of the holistic provision of care. There are a number of ways of delivering this to parents and babies that encompass the bio-psychosocial model of care (Downe, 1998; Power, 2015), and midwifery education and practice needs to ensure students are properly prepared to do this. The Golden Window is one example of how different forms of media, art and technology can produce a teaching tool to create simulation of the NICU setting, combined with service user perspective. However, The Golden Window was a different experience to more straightforward audiovisual material used in teaching because of the immersive and poetic representation of the NICU world. This experience encouraged the students to consider the complexity of social, emotional, spiritual and physical needs of families in their care.
The Golden Window gives midwifery educators a unique chance to enable students to explore the views and feelings of the parents within a safe environment, free from the constraint of the potential for saying or doing the ‘wrong thing’. For midwifery, The Golden Window can bring a strong visual impression of the environment. Students can start to appreciate the audio sensations before entering the unit for placement, and can then consider how stressed parents may react to the sounds. They can use this knowledge to prepare parents antenatally or in birth settings before the first visit. Additionally, the midwifery educators felt that it helped students develop the knowledge and skills to support parents whose babies are being cared for in NICU because they are aware of the multiplicity of responses possible.
The Golden Window emphasises the importance of empathy, which is the essence of midwifery care. Students watching The Golden Window can ‘feel’ that empathy when they hear the voices of the parents, nurses and doctors, and this will prepare them for their experiences on NICU as well as helping them to start considering what it means to empathise. One student mentioned the effect and importance of noise and light, as the film helped her feel powerfully what it might be like to be that baby. Midwifery students unsure of empathy may therefore understand it from watching The Golden Window and improve their holistic care through this educational approach.
The midwifery team feel that using The Golden Window as a teaching and learning tool to facilitate the students' reflective ability had the potential to increase their confidence to use intuition and enhance their clinical decision-making. This has the potential to impact every clinical area that they work in and serves to ensure that every care episode is maximised to meet the holistic needs of the mother and her family. The team originally felt that they should show the film at the beginning of the second year, when students were due to complete their NICU placement. However, due to the positive results discussed above, the film will now be shown earlier in the degree course, as it raises many broader issues about this core holistic element to care provision.
Conclusion
Art and creative media have the capability to communicate, educate and inspire people in the most powerful ways (Patel and Toulson, 2013). They can enhance the viewer's intellectual and emotional response to a complex environment, allowing for critical reflection. Indeed, human beings are made up of mind, body and spirit, working seamlessly together with faculties such as logical thinking, imagination and feelings (Knudsen, 2008). As such, all these faculties should be considered as part of the pedagogic approach to the learning process of student midwives.
It should be noted that the making a transition between an instructor to a facilitator model of education requires ‘commitment and self-reflection on the part of the educator’ (Haith-Cooper, 2003), which the team embraced with this particular exercise. Both the film and midwifery teams saw this as a unique opportunity to harness the potential of working with other disciplines to enhance their own educational practices. It was hoped that the students would also embrace this new and exciting way of teaching across the two disciplines and take this experience forward into the next stage of their midwifery practice. The aim of the midwifery course is to prepare students for practice and using interesting and varied forms of learning enhances this process.
The Golden Window appeared to be a very effective tool in supporting the experiential learning of the student midwives by bringing a heightened sense of reality of NICU before they arrived. It also sowed the seeds of self-reflection for those with experience of NICU to see their environment through the eyes of the patients and the carers (as evidenced by feedback from evaluative exercise). Such an intuitive approach supports an iterative process from expert knowledge, recognition and reflection to inform future practice (Power, 2015) and facilitates a discussion of ‘clinical perception’ (Leap, 2000) where practitioners automatically use perceptual observation to notice overt and covert clues from women, parents, and patients, which they can then compare to their stored knowledge.