title: Effectiveness and experience of arts-based pedagogy among undergraduate nursing students: a mixed methods systematic review.
abstract: To develop well rounded professional nurses, educators need diverse pedagogical approaches. There is growing interest in arts-based pedagogy (ABP) as the arts can facilitate reflection, create meaning and engage healthcare students. However, the emerging body of research about ABP needs to be systematically examined.
  
  
  
  To synthesize the best available evidence on the effectiveness of ABP in enhancing competencies and learning behaviors in undergraduate nursing education and to explore nursing students' experiences with art-based pedagogy.
  
  
  
  The review considered studies that included participants who are undergraduate nursing students.
  
  
  
  The qualitative (QL) component considered studies investigating nursing students' experiences of ABP, and the quantitative (QN) component considered studies evaluating the effectiveness of ABP in undergraduate nursing education.
  
  
  
  The QL component considered QL studies including designs such as phenomenology, grounded theory, ethnography, action research and feminist research. The QN component considered studies that examined the effectiveness of ABP including designs such as randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, case series, individual case reports and descriptive cross-sectional studies.
  
  
  
  The following QN outcomes of ABP were assessed: knowledge acquisition, level of empathy, attitudes toward others, emotional states, reflective practice, self-transcendence, cognitive/ethical maturity, learning behaviors and students' perspectives of ABP.
  
  
  
  An extensive three-step search strategy was conducted for primary research studies published between January 1, 1994 and April 7, 2015. The strategy included searching CINAHL, MEDLINE, ERIC, PsycINFO, Academic Search Complete, Arts and Humanities Citation Index, Art Full Text, Scopus, ProQuest Dissertations and Theses, A&I, and gray literature. Only studies published in English were included.
  
  
  
  Two reviewers assessed all studies for methodological quality using appropriate critical appraisal checklists from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) or the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).
  
  
  
  Data were extracted from included articles using the standardized data extraction tool from JBI-QARI or JBI-MAStARI.
  
  
  
  Qualitative studies were pooled through a meta-synthesis. Data from the QN studies were combined using a narrative synthesis as a meta-analysis was not possible. The researchers used a segregated mixed methods approach to integrate the QL and QN components.
  
  
  
  Twenty-one QL studies of high methodological quality were included. The two synthesized findings revealed that art forms could create meaning and inspire learning in undergraduate nursing education and that ABP can develop important learner outcomes/competencies for professional nursing. These synthesized findings received a moderate ConQual rating. Fifteen experimental/quasi-experimental studies of moderate methodological quality were included. The narrative synthesis suggested that ABP improved nursing students' knowledge acquisition, level of empathy, attitude toward others, emotional states, level of reflective practice, learning behaviors and aspects of cognitive/ethical maturity. In five cross-sectional studies, the majority of students had a positive perspective of ABP. When the QL and QN findings were interpreted as a whole, ABP appeared to facilitate learning in the cognitive and affective domains and may be especially useful in addressing the affective domain.
  
  
  
  Nurse educators should consider using ABP as students found that this approach offered a meaningful way of learning and resulted in the development of important competencies for professional nursing. The QN studies provide a very low level of evidence that ABP improved students' knowledge acquisition, level of empathy, attitude toward others, emotional states, level of reflective practice, learning behaviors and aspects of cognitive/ethical maturity. Although the QN findings can inform future research, the evidence is not robust enough to demonstrate improved outcomes.
authors.affiliation: 1College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada 2Health Sciences Centre, Winnipeg, Canada 3Faculty of Education, University of Manitoba, Winnipeg, Canada 4Elizabeth Dafoe Library, University of Manitoba, Winnipeg, Canada.
authors.forename: Kendra L
authors.initials: KL
authors.lastname: Rieger
authors.forename: Wanda M
authors.initials: WM
authors.lastname: Chernomas
authors.forename: Diana E
authors.initials: DE
authors.lastname: McMillan
authors.forename: Francine L
authors.initials: FL
authors.lastname: Morin
authors.forename: Lisa
authors.initials: L
authors.lastname: Demczuk
mesh_terms: D001154:Art; D004506:Education, Nursing / Q000379:methods*; D006801:Humans; D013338:Students, Nursing / Q000523:psychology*; D013663:Teaching