Pedagogical Evolution

Flower Like many other disciplines, nursing education has undergone a profound metamorphosis in recent decades. Traditionally, nursing students were educated using an apprenticeship model of instruction framed within a distinct biomedical, positivist, behaviourally-focused paradigm. As nursing education moved from an exclusive clinical setting into colleges and later university settings, a shift towards the humanities and a more holistic paradigm was adopted, though nursing education and culture still occurred within a deductive modernist framework. Remnants of this still exist, coupled with humanistic, critical social theory, and feminist-postcolonial lens to ultimately cultivate neophyte nurses who are empowered, engage in dialogue, reflection and praxis, and who provide care that is distinctly phenomenological, client-focused and salient to the individual client's health needs and situation

All Canadian nursing education now occurs within degree-granting configurations, where nursing students gain practical and theoretical experience in working with clients on various specialty units as well as in the community, including in-home care, clinic-based work, public schools and other community service areas (Hills, Lindsey, Chisamore, Bassett-Smith, Abbott, & Fournier-Chalmers, 1994; Storch & Gamroth, 2002). Students are enculturated to influence change, conduct both qualitative and quantitative research, to inquire in phenomenological ways, to advocate, to empower, and to develop empathy and respect for the unique lives, beings, and saliency of each unique client and their supportive families and circles. They are guided to apply a critical social lens to health care and question the way client experiences are governed by systematic and bureaucratic ideologies (Wilson-Thomas, 1995). As well, nursing education culture is influenced by the academic and organizational culture of the university or college it occurs in. As Holmes (2002) directs, "the central role that universities play in the concretization, legitimation, and reproduction of cultural norms, should be acknowledged. Their role is more usually one of social-regulation and stabilization rather than fundamental challenge or political action" (p. 73).

Ways of Knowing

Ways of KnowingNursing students are taught several different ways of knowing, including personal knowing, in order to holistically plan and provide comprehensive client care. "Personal knowing is the most problematic and difficult pattern to master and teach. It is the ability to see an event from the perspective of another and recognizing the other as a subject rather than as an object. Personal knowing is the discovery of self and others, which is arrived at through reflection, synthesis of perceptions, and connecting with what is known. It is captured through retrospective accounting of an interaction. The creative dimension of personal knowing is the process in which one becomes genuine, authentic, real and more whole" (Jacobs, 1998, p. 25).

Personal knowing is engrained through therapeutic reciprocity or the therapeutic use of self. This application of self promotes integrity and wholeness in personal encounters with clients and with other student and practicing nurses. By creatively blending personal knowing with empirical, aesthetic, ethical and socio-political knowledge (Carper, 1987), student nurses learn to perform within a therapeutic caring culture that is holistic and salient to the client's health condition and recovery. This "shows patients and their families that the nurse understands their world and can interpret some of their decisions and experiences in an enlightening context that will facilitate their growth and understanding of the difficult situation. Personal knowing is central to nursing since illness is radically subjective" (Holmes & Gastaldo, 2004, p. 28).

Culture Clash

The culture taught in nursing education, with professional ideals of autonomy, empowerment, and critical reflective practice clashes with the "highly bureaucratic institutions in the health care system" (Clare, 1993, p. 1034). As students gain experience within the clinical milieu, they often experience a discrepancy between the ideal culture taught in school, and the manifest culture experienced within the hospital and community care settings. "There is a cultural crossroads created when two or more cultures come into contact" (Blackford, 2003, p. 239) but this crossroads can become an area of contention, disillusion and distress, rather than an intersection of compatibility and congruence: sometimes to the point of "culture shock".

Fortunately, students are not mere passive recipients of socialization, they can actively construct and impact the world around them. Faculty spend a lot of time helping students recognize the constrictive institutional structures and influencing hegemonic forces that make the clinical setting a challenging place to provide holistic client care. They are also encouraged to question practice that is not grounded in an empowering, emancipatory culture, and to move beyond fear of the "eating our young" behaviour sometimes exhibited by practicing nurses. .

Development of Expertise

Expertise or tacit knowledge is a manifestation of an individual's experiential knowledge acquired over the life course. Adaptation of tacit knowledge to new situations requires that experts have well developed thinking and reflective skills. Reflectivity is associated with the expansion of an expert's horizon. "Thinking progresses through cycles where the tacit and silent components become intertwined with expert knowledge, activity, efficiency, and service" (Viitanen & Piiraienan, 2002, p. 180).

Benner In her landmark study, From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Patricia Benner (1984), described how nursing students are enculturated to develop what she calls "nursing connoisseurship," a hallmark of growing expertise within nursing culture. Students need to learn to recognize and describe "the context, meanings, characteristics, and outcomes of their connoisseurship" (p. 5). Benner applied Stuart and Hubert Dreyfus' (1980) model of skill acquisition to nursing, where students are seen as progressing through five levels of proficiency: novice, advanced beginner, competent, proficient and expert. As students move through these five stages, they learn to apply intuitive plus linear, calculative thinking to their work within the organizational culture.

As well as intuition, reflective or meditative thinking is very important for ideal nursing practice and culture. "Meditative thinking is, in many ways the opposite of calculative thinking. Instead of computing new results and possibilities, meditative thinking is more concerned with reflecting upon the meaning implicit in the experiences encountered in daily life - to examine reflectively our most immediate and personal experiences" (Severtsen, 2005, p. 2). Meditative thinking helps nursing students to learn about the culture and profession of nursing much more clearly than calculative thinking can. Student nurses primarily learn about the nursing culture and profession through the lived experience of the clinical practice that they are exposed to, rather than classroom experiences. Thus reflection on their experiences within the clinical milieu aids in self-initiated, deliberate enculturation into nursing culture.

Nursing education is often based on a model of transformatory learning and emancipatory action. Transformatory education encourages experiential freedom and the right to interpret the stimulus events in life as one chooses, adopting from the manifest culture what one will, and discerningly refraining from emulating the more base, less desirable aspects of manifest culture in the workplace (Freshwater, 2000). Part of the ideal culture of nursing is valuing the profession as a knowledgeable practice and supporting nursing students to cultivate an intention to nurse. According to Locsin (2002), the lens of the intention to nurse is the unifying concept underlying nursing practice and education. "Promoting nursing values, facilitating health, and inspiring a positive human health experience for those nursed are directions for nursing that reveal the intention to nurse. Intention to nurse is the dynamic that is expressed through the prevailing lens of being authentically present with the other in the moment" (p. 2).

Critical Pedagogy and Nursing

The choice to apply critical pedagogy to nursing allows both faculty and students to question the motives and tenets of these aforementioned overlapping cultures and the dynamics within and between them. As Giroux (2004) eloquently attested: "I believe that pedagogy represents both a mode of cultural production and a type of cultural criticism that is essential for questioning the conditions under which knowledge is produced, values affirmed, affective investments engaged, and subject positions put into place, negotiated, taken up, or refused. As a critical practice, pedagogy's role lies not only in changing how people think about themselves and their relationship to others and the world, but also in energizing students and others to engage in those struggles that further possibilities for living in a more just society" ( pp. 63 - 64).

Giroux (2004) supported further analysis of how the study of culture fits the notion of critical pedagogy by pointing out how this can contribute to our understanding of how culture deploys power and is shaped and organized within diverse systems of representation, production, consumption, and distribution. Particularly important to such work is an ongoing critical analysis of how symbolic and institutional forms of culture and power are mutually entangled in constructing diverse identities, modes of political agency, and the social world itself. Culture is partly defined as a circuit of power, ideologies, and values in which diverse images and sounds are produced and circulated, identities are constructed, inhabited, and discarded, agency is manifested in both individualized and social forms, and discourses are created, which make culture itself the object of inquiry and critical analyses. (pp. 59 - 60). Giroux is vehement in stressing that culture is "constitutive and political, not only reflecting larger forces but also constructing them....culture not only mediates history but shapes it" (p. 62). It is a virtual hotbed of both "contestation and accommodation, and it is increasingly characterized by the rise of mega-corporations and new technologies that are transforming the traditional spheres of the economy, industry, society, and everyday life" (p. 62).

The vision and mission of most nursing education programs go beyond preparing students for the workplace: the intent is to enculture students who can examine the flaws in the current bureaucratic modernist workplace and find fissures and cracks that encourage change and slow but sure transformation. Nursing faculty do not protect the borders of the curricula in order to perpetuate a "professionalized, gated community" (Giroux, 2006, p. 64) or "ivory tower' cloistered milieu, but to actually preserve the critical socially-conscious culture that can support nursing students to develop the knowledge, discernment, inner strength, vision, and social critical skills to bring a genuine client-centred health care system into reality. In fact, the teaching methods adopted by many contemporary nurse educators reflect the ideal espoused by Giroux (2006). They at least attempt to enact Giroux's warning that " is imperative that public intellectuals within and outside of the university defend higher education as a democratic public sphere, connect academic work to public life, and advance a notion of pedagogy that provides students with modes of individual and social agency that enable them to be both engaged citizens and active participants in the struggle for global democracy" (p. 66).

The critical pedagogy embraced within nursing education is enacted to "shift how students think about the issues affecting their lives and the world at large, potentially energizing them to seize such moments as possibilities for acting on the world and for engaging it as a matter of politics, power, and social justice" (p. 66). Many nursing faculty both support and are keenly aware that educational institutions which, as Giroux (2006) pointed out:

"By virtue of their privileged position, division of labor, and alleged dedication to freedom and democracy, have an obligation to draw upon those traditions and resources capable of providing a critical, liberal, and humanistic education to all students in order to prepare them not only for a society in which information and power have taken on new and potent dimensions but also for confronting the rise of a disturbing number of anti-democratic tendencies in the most powerful country of the world and elsewhere across the globe" (p. 71).

Nursing Education in the 21st Century

Although much more challenging to do when teaching within the clinical arena of the current health care system, the actual classroom pedagogy of nursing does support Giroux's prescription for 21st century higher education.

Rhizome"If higher education is to be a crucial sphere for creating citizens equipped to understand others, exercise their freedoms, and ask questions regarding the basic assumptions that govern democratic political life, academics will have to assume their responsibility as citizen-scholars, take critical positions, relate their work to larger social issues, offer students knowledge, debate, and dialogue about pressing social problems, and provide the conditions for students to have hope and believe that civic life not only matters but that they can make a difference in shaping it" (Giroux, 2006, p. 74).

Holmes and Gastaldo (2004) presented a metaphor for postmodern self-examination in nursing, using the notion of Rhizomatic Thought in contrast to traditional linear discourse or "Arborescence". They explained that the rhizome is open at both ends, and does not conform to historical linear thinking. Rather, it emerges and grows in simultaneous, multiple ways and represents the ideal cultural essence of nursing since all life is a process of assemblages, connections and interactions. Rhizomatic thought is postmodern in essence, and acknowledges, accepts and promotes multiple discourses within nursing, even if they compete with one another. It embodies in a particular type of discourse that challenges the status quo and regimes of truth that are taken for granted within the health care context, promotes alternative discourses and suggests paths toward "lines of flight" (resistance). Characterized by freedom, movement, and flux that serves to deconstruct historical nursing dogma, rhizomatic thought and discourse provides a means for nurses to examine their own mode of cultural being and governmentality within the current health care system and the wider context of society at large.

It is the responsibility of all nursing educators and leaders to shape nursing education and the nursing workplace into environments that support fledgling nursing leaders and practitioners of tomorrow. Through carefully determined pedagogy and curriculum, nurse educators can engage students in important ways: ways that will amply prepare students to shape and partake in the emerging primary health care system, a system founded on respect, understanding and a keen awareness of the social determinants of health. A system that will rely on nurses that know how to effectively lead change, and truly promote health, healing, and wellness in the diverse populations we serve. This site is dedicated to the provision of tools, resources, links to literature, and a collaborative approach to creating models, best practices, theory, praxis, and practice activities to support the evolution of nursing pedagogy for the 21st Century.


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