Journal of Nursing Education

Nursing Education: Caring, Dialogue, and Practice

Nancy Diekelmann, PhD, RN, FAAN

Abstract

A Personal Journey

As a student of the Ws, I found that many of my college teachers misused their power. Feeling frightened and controlled, I put great effort into giving them what they wanted. Trying to psych them out, even the good ones, made me feel manipulative and inauthentic. In 1970, after practicing in psychiatric nursing and serving 2 years in the Peace Corps, I returned to graduate school. I took nursing education courses so I could teach and have my summers off.

Behavioral education and instructional technology were in their heyday. My first teaching job was in a diploma school, a part of the NLN Open Curriculum Project, where we gave the students great freedom in how they met our objectives. Next, in university teaching, I realized that what mattered most was not being explicit about learning expectations, but rather having time to talk to students in ways that encouraged thinking. In my doctoral study in Education in the late 1970's, I encountered criticism of behavioral education and the Tylerian approach to curriculum. I learned humanistic education was but another attempt to recast the power relationships between teachers and students by defining learning as a psychological event. I continued to explore alternatives. Coursework introduced me to the work of Apple (1979, 1982, 1986), Heidegger (1962, 1971, 1977), and Habermas (1973, 1981). Apple (1979) showed me that though we intend the opposite, our practices in teaching reproduce the very inequities we seek to change in society. Since language shapes and is shaped by our experiences, I realized how important, the language of nursing was to education and practice.

In 1984, Patricia Benner (From Novice to Expert) described an approach and view of nursing practice that allowed me to recast my earlier work in nursing education: specifically that nurses do not teach as teachers teach; their teaching is informed by their practice of nursing. After reading Heideggerian texts and using Heideggerian hermenéutica, I discovered a new approach: Nursing Education as Caring, Dialogue, and Practice. In 1986, 1 supported the move of the Society for Research in Nursing Education to become an official forum of the NLN, an alliance which brings educational researchers in contact with teachers and administrators. When I was asked to help plan the 1987 Nurse Educator Conference, my position was that we needed a revolution.

For me, the curriculum revolution is conversations among students, teachers, and clinicians as we seek to transform health care, and the institutions in which we practice nursing, teaching, and research. In our conversations, we both shape, and are shaped by our language. This experience of the language of nursing, is one that we all share.

This revolution is about the HOW of our speaking. That is, how do we listen to each other and what do we hear? How can we let our understandings and our personal experiences guide us in our struggle to transform the world? How can we speak and listen to the voices of inequity and oppression that we seek to overcome? How do we let our understanding of what it is to be human and our knowledge of the necessity of human connectedness guide our practices in nursing, teaching, and research? Through these conversations we can expand our practices toward the openness of a future of possibilities. Three of the conversations that are central to a revolution in nursing education are: caring, dialogue, and practice.

This revolution is, therefore, about creating communities of care that empower and liberate us. It is about a form of resoluteness in which we enter the clearing struggling to transform our cultural practices. As…

A Personal Journey

As a student of the Ws, I found that many of my college teachers misused their power. Feeling frightened and controlled, I put great effort into giving them what they wanted. Trying to psych them out, even the good ones, made me feel manipulative and inauthentic. In 1970, after practicing in psychiatric nursing and serving 2 years in the Peace Corps, I returned to graduate school. I took nursing education courses so I could teach and have my summers off.

Behavioral education and instructional technology were in their heyday. My first teaching job was in a diploma school, a part of the NLN Open Curriculum Project, where we gave the students great freedom in how they met our objectives. Next, in university teaching, I realized that what mattered most was not being explicit about learning expectations, but rather having time to talk to students in ways that encouraged thinking. In my doctoral study in Education in the late 1970's, I encountered criticism of behavioral education and the Tylerian approach to curriculum. I learned humanistic education was but another attempt to recast the power relationships between teachers and students by defining learning as a psychological event. I continued to explore alternatives. Coursework introduced me to the work of Apple (1979, 1982, 1986), Heidegger (1962, 1971, 1977), and Habermas (1973, 1981). Apple (1979) showed me that though we intend the opposite, our practices in teaching reproduce the very inequities we seek to change in society. Since language shapes and is shaped by our experiences, I realized how important, the language of nursing was to education and practice.

In 1984, Patricia Benner (From Novice to Expert) described an approach and view of nursing practice that allowed me to recast my earlier work in nursing education: specifically that nurses do not teach as teachers teach; their teaching is informed by their practice of nursing. After reading Heideggerian texts and using Heideggerian hermenéutica, I discovered a new approach: Nursing Education as Caring, Dialogue, and Practice. In 1986, 1 supported the move of the Society for Research in Nursing Education to become an official forum of the NLN, an alliance which brings educational researchers in contact with teachers and administrators. When I was asked to help plan the 1987 Nurse Educator Conference, my position was that we needed a revolution.

For me, the curriculum revolution is conversations among students, teachers, and clinicians as we seek to transform health care, and the institutions in which we practice nursing, teaching, and research. In our conversations, we both shape, and are shaped by our language. This experience of the language of nursing, is one that we all share.

This revolution is about the HOW of our speaking. That is, how do we listen to each other and what do we hear? How can we let our understandings and our personal experiences guide us in our struggle to transform the world? How can we speak and listen to the voices of inequity and oppression that we seek to overcome? How do we let our understanding of what it is to be human and our knowledge of the necessity of human connectedness guide our practices in nursing, teaching, and research? Through these conversations we can expand our practices toward the openness of a future of possibilities. Three of the conversations that are central to a revolution in nursing education are: caring, dialogue, and practice.

This revolution is, therefore, about creating communities of care that empower and liberate us. It is about a form of resoluteness in which we enter the clearing struggling to transform our cultural practices. As nurses, grounded in a cultural practice of caring that values human connectedness, we see clearly the present political and economic threats to our country and the world.

Creating Communities of Care

A common commitment of nurses is to care. Whether we provide nursing care, teach students, or conduct research, we conduct our practices in caring ways. This ethic of care and responsibility is shared by all nurses. I know of no one in our profession who would advocate practicing uncaringly. The issue is comportment. How do we go about creating communities within which we practice, teach, and conduct research that are caring?

It seems ironic that we work hard to create caring environments for our patients but not for ourselves as clinicians, teachers, and students. The issue is how can we create caring communities, not because we like or dislike each other's personalities, but because we are nurses. What are the practices in our nursing cultures that serve to make caring impossible? What are the issues of power and the distribution of resources that perpetuate a competitive, alienating, uncaring culture (Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985; Heidegger 1977; Taylor, 1989). We can begin by reflecting on the times that we do come together. Are most of our conversations about what is wrong? Do we dwell in the language of deficit? Is there a language of possibility that we can use in our meetings with one another? How do we see and learn the context from which the other speaks?

Dialogue

Our conversations need to be dialogues in which we hold mirrors up which reflect and call one another forth. Dialogue is engaged listening, seeking to understand, and being open to all possibilities. By being fully engaged in the situation, through dialogue, we seek to get the story "right." Reflecting and probing, we search for words that disclose and bear witness to our understanding. Dialogue is central to nursing education and the revolution.

The legacy of behavioral education is deeply ingrained (Bevis and Watson, 1989; Dreyfus, 1984; Giroux 1988a, 1988b; Kliebard, 1977). It shapes our language as well as our thinking about teaching. Through the dialogue of hermeneutic inquiry we must try to bare the meanings embedded in our language of nursing education in order to reveal this commitment to behaviorism and humanism. By explicating the hidden assumptions in our language, new conversations emerge (Weiler, 1988). For example, we often discuss course objectives and organizing content throughout the curriculum. Through an examination of our language, we could begin to challenge what function is served by this practice.

By constantly talking about organizing the content into courses and the courses into a curriculum, we: 1) begin to believe that this is necessary or else none of us would know how, what, or when to teach; 2) argue over the best and most effective and efficient way to teach as if we would know it when we see it; and 3) organize to organize, forgetting to challenge where this important practice of organizing comes from (Diekelmann, Allen, & Tanner, 1989).

Discussions about schooling, such as selecting and sequencing knowledge, the role of experience and the policies, and the practices that organize our schools, are ever present. We need these important discussions, but when they become our central and exclusive conversations, than other, perhaps more important, issues are ignored, devalued, or covered over.

The challenge of future conversations will be to determine how we spend our time together. Do these times help us to get to know each other? Do we discuss the dilemmas of teaching? Do we talk with clinicians and students about their experiences? We need to create a dialogue that does not perpetuate the disenfranchisement of clinicians and students in discussions about how they experience and participate in teaching and learning practices. The sharing of our histories and our struggles to create and recreate communities of care will shift our conversations from the curriculum as a roadmap or pieces of a puzzle, to how we live out our lives as students, teachers, and clinicians in the context of schooling.

New possibilities for curriculum and instruction will emerge that are grounded in the day to day experiences of clinicians, students, and teachers. We must uncover and create a pedagogy rich in diversity, responsibilities, and problems. It should be based in care, and reflective of language and dialogue and attuned to the nature of nursing practice. My view of the curriculum is not totalizing. It embraces all approaches through a critical examination of practice, and argues that there are hidden backgrounds to our practices; not everything about them can be objectified, made explicit, decontextualized, totalized, or brought wholly under our control. (Diekelmann, Allen, & Tanner, 1989).

How we approach the way in which "Being" shows up for us is, I suggest, the ongoing act of learning. It is this sense of the relational context of the world that is our history. Learning focuses meanings is already scattered throughout our culture in people's language and practices. Education publicly displays the serious issues in practice. Through dialogue we make and are made by our history.

Also through dialogue we can reflect on how we speak through our writing. Our literature in nursing could be enriched by becoming more personal and complex and speaking to our day-to-day lives. We need to make our stories of practice, teaching, and research visible for ourselves; and share them with our students and colleagues.

The decision of what to publish is central to this revolution. Traditionally, this has been decided by the audience and the profits to be made. We need a nursing press, such as the NLN Press, for nurses, and run by nurses, to handle small vanguard books that speak to special groups and cultures. We could use profits to fund such voices as our nursing poets, historians, and students' essays. Our dialogues need to be public and to reflect the plurality of our lived experiences.

Each year, the NLN Nurse Educator Conference brings us together to share new possibilities and our day-to-day experiences as students, teachers, and clinicians. The Council for the Society for Research in Nursing Education is committed to preserving the practice of research in teaching at a time when we seek innovation. We must be diligent in our efforts to restore funding for research in nursing education. Currently, new researchers, many doctorally prepared in education, cannot risk developing research careers in nursing education, where they may not be able to obtain funding, publish, or receive tenure. We must join and attend these meetings where, through dialogue, we can explore new approaches to schooling.

The Practice of Teaching

In creating communities of care, teachers can speak about their practice of teaching. If teaching is a practice, then there are skills to be learned and expertise to be developed over time. Conversations about getting started in practice would begin to unveil the nature of novice teaching practice.

One faculty person discusses concerns about going into teaching:

First You Act Like a Teacher- Then You Are One

I knew I was a good nurse and I have always liked teaching... As a nurse, I found time to do a lot of teaching with my patients and somehow I wasn't bothered by the student nurses when they are around. . .1 was selected to be a preceptor. . .But I don't know how to write an objective - I mean in the proper form and everything. We had a course in graduate school on teaching, but the only thing I remember is clinical has to be observable and measurable. ... I have been teaching for over a year and I am still really nervous about being a clinical instructor. There is a lot of theory and stuff you don't use when you practice what you have to learn. I know nursing, but whether I'm able to teach it still remains to be seen! I've seen new teachers get in trouble trying to care for patients instead of teaching the students. . . I'll be honest with you, most of the time I am pretending that I know what Fm doing when I teach.

We don't leave nursing and go into teaching. We think we do, because we first take on the new skills and rules of teaching promulgated by education. We attempt to use these strategies to enhance cognitive gain, and we initially work in education, not nursing practice. But once we are experienced and proficient in our skills, we allow our nursing practice to enter our practice of teaching (Diekelmann, 1988c, 1989, in press).

If we develop expertise in teaching as we do in nursing, then central to our successful entry into the practice of teaching is the back-up and guidance that novices need when they are still rule-governed and lacking in the experience needed to read complex situations of learning.

Another way we can create our communities of care is to talk about the support and back-up we provide for each other. When and how do we ask for help? How do we share the common dilemmas of teaching, such as a failing student, or deciding not only what content to include but what to leave out? How do we welcome novice teachers? How do we provide back-up for experienced faculty?

One teacher recalls being new and receiving back-up in a caring way:

Having Trouble Teaching

My first semester teaching was a disaster. I was a new PhD and all nervous about getting my dissertation published and a grant written. . . I did things like change how I graded in the middle of the course. I went from a fixed scale to grading on the curve. . . I had students petitioning the Dean about my course and before long it was all over the school that I was having trouble teaching. Luckily, the woman in the next office rescued me and said, you don't know how to teach. It's just like in nursing where you go by the book and make a lot of mistakes and the other nurses protect the patient from you and make sure you don't get into too much trouble. Well, this teacher really saved me. She offered to help me, and when I didn't seek her out enough she started to talk to me every week before I would lecture. She would say, "Why are you going to teach that? They wuT only remember three things in an hour. Write them on the board and use the rest of your time talking to them." She'd show up in my classroom and once when I was passing papers back and trying to field questions about the exam, she arrived and just took over. Somehow she got me through that first semester.

Experienced teachers need back-up too. Often, experienced teachers provide back-up through sharing their experiences. These can be used as anticipatory guidance for less experienced teachers. In addition, experienced teachers maintain their skills and expertise by continually being involved with their practice of teaching (Benner, 1984; Benner & Tanner, 1987; Benner & Wrubel, 1989; Dreyfus, Dreyfus & Benner, 1990).

This teacher describes how she realized there was a dissonance between her intention to be caring and how the students experienced her:

A Slap in the Face

I was helping a senior student care for a very ill COPD patient and things started to happen rapidly. I knew the student was getting overwhelmed. I said, "Let me help." I encouraged her to stay and watch while I worked with the physician, the patient, and the family. It was touch and go but finally things turned around. As we left and were walking down the hall, we talked about what happened. [I was] thinking that as soon as she had expressed her feelings of fright and being overwhelmed, that I would begin to go over everything carefully with her as I usually do, she could learn from this situation, you know, point out for her the things I was seeing [in] it - she said something I shall never forget. She said, "You are the most caring person I have ever seen. You helped the patient, the family, and even the doctor. If only you would care about us, like you do them!" It was like a slap in the face for me, because you see I thought I was! . . .that is, I sure thought I was a caring teacher!

This teacher describes the striking discrepancy between her intentions and how students experienced her. Through reflecting on her own experience, new insights into her teaching practice emerged.

Discussions with experienced teachers unveil the practical knowledge of teaching. The times that matter, times of break down or when things go well, could become the center of our conversations. An expert teacher tells of one such time:

I Passed

A woman with a very low GPA who had repeated two of our courses, arrived in my office with two kids, both under the age of 3, in tow. She asked me to help her learn drug calculations. As the kids were running around and playing in my long office, we went over her problems. I worked so hard to try and figure out how to help her. Finally, I realized and I wrote a series of rules. I knew it would help. Our students are so caring and they work so hard. But they have all had such bad high schools. As she left, I asked, 'You taking the bus, it's snowing hard?" She said she was on her way to work at a nursing home and is dropping the kids off at her mother's. This student has no phone. I know where she lives and her mother fives, and I know where she works. Sometimes it makes me mad when teachers accuse the students of being lazy. This woman spent 4 hours just getting to and from school so she could have her questions answered. But guess what? I saw her 2 days later and she told me, "I passed!" "God be praised," I said!

Teachers report how important to their practices it is to have times where they made a difference, so as to sustain them during more frustrating and difficult times. As in nursing, central to the practice of teaching are these times of making a difference.

A constitutive pattern has emerged from my hermeneutical research on the lived experiences of teachers: teaeheras-learner/learner-as-teacher. (Diekelmann, 1988b, In Press). Traditionally, teachers have been viewed as information givers or facilitators of learning. This constitutive pattern offers a new perspective for us to consider. The teacher-as-learner is not a new role for the teacher, it has always existed as a way of "being- with" Students. It is comportment in which teachers attune themselves to the creation and recreation of meaning among their students. Students do not teach the teacher information. The teacher-as-learner is teachers continually teaching in ways that maintain them as learners. Teachers-aslearners reflect on how their students are learning, and bring difficult questions that have meaning for them into their teaching. Others explore the nature of thinking with a view of nursing as a way of thinking. There are many paths to thinking, nursing is one of them (Rather, 1990).

This pattern describes how learning occurs as ontology, which is distinguished from epistemology (Bruns, 1989). The teacher becomes an explorer of meaning and significance with students; that is, they all attain hermeneutical, not simply solipsistic, understandings of their experiences.

When teachers are learners, they are in the world through their continual rebirth of the struggle to understand. The primordial state of teaching, that which comes before teaching as information-giving, facilitating learning, or evaluating, is teaching-as-learning. Teachers-aslearners are always open to new possibilities, constantly transforming and being transformed. Learning becomes teaching. Learning is hearing. It is not merely listening but hearing, in the sense of dialogue and meaning. Schooling is the struggle to transform through explication and understanding (Diekelmann, 1988a, In Press).

This approach to teaching is dwelling as a moving into nearness such that the conditions for the possibility for anything to show up become unveiled. Teaching is what we are always moving near. It is seeking for and Being that understands that which is on the one hand close and so familiar, and on the other hand, the abyss of nearness (Heidegger, 1962, 1971). In this way, the conversations of the lived experiences of teachers, students, and clinicians is not a study of teaching, but rather of learning. This is the nature of teaching in nursing; teaching as ontology, not epistemology.

The Nursing Curriculum-As-Lived

In our preoccupation with the nursing curriculum we stand in danger of losing something crucial - clarity of vision. Surrounded by the artifacts of education - objectives, courses, tests - we tend to lose sight, literally as well as metaphorically, of the rhythms of teaching, the nature of learning in teaching, and our lives with students. We think more and more of a mechanistic construct called the Nursing Curriculum that orders our world of courses, content, and experiences. We dwell less in the meanings of our day-to-day experiences of teachers-as -learners and learners-as-teacherB.

We also tend to lose sight of the moral significance of our practice of teaching. Our daily lived-experiences are heavily overridden by the artifacts and constructs of Education. Covered over is the phenomenon that we all dwell in the world learningly. It is impossible not to do so. We dwell in a world of meanings in which, as selfinterpreting beings, we at once shape, and are shaped by, the worlds in which we inhabit. To recapture the moral sense of teaching and its relationship to learning, and even to the world of artifacts, it is necessary to reflect hermeneutically on our lived experiences.

The Rhythms of Teaching

This has been a transformative year for me. Beginning with a series of faculty seminars to discuss knowledge development, I experienced a new way to "Be" with my faculty colleagues. These seminars were a time together devoid of school problems and discussions of resources that are so divisive. Beginning with a buffet luncheon, we easily moved into reading texts together. Taking turns at beginning the discussions, we experienced rich conversations. The issues of power and commitment to our research approaches that often acted divisively to keep us from working together, all fell by the wayside on that day. I could see my colleagues, not as particular personalities but rather as intellectually gifted persons who were seeking to understand a difficult text with me. As we struggled together in these seminars, we experienced content as conversation. Students who attended shared their excitement of seeing and participating with their teachers-as-learners. I realized that what matters to us all, whether assistant professor, professor, clinical instructor, or student, is the embracing and cherishing of learning. This seminar made visible how important it is for us to critique HOW we spend our time together. We need to dialogue about creating experiences for ourselves that are engaging, empowering, and meaningful. I now realize how the meetings we plan each semester are a part of the rhythms of teaching and the communities we build.

The Nature of Learning in Teaching

This summer, I offered a 2-week Nursing Institute for Heideggerian Hermeneutical Studies. Participants included clinical scholars, masters and doctoral students, nurse teachers, assistant professors, and professors. The experience of studying together and participating in each other's interpretative research approaches helped me to understand the important links between grounded theorists and hermeneutical researchers: Heideggerian, critical, and analytical. Most meaningful to me was a new understanding of the nature of learning in nursing. To prepare for this intensive Institute, I had to clear my desk of all correspondence, course work, and commitments because I knew that for 2 weeks I would be busy day and night. What that meant however, was that each evening I could go home and study intensely. On the last day of the Institute, thinking I would need to rest, I instead found myself, excited, energized, and full of thoughts I needed to write. The urgency to write sustains me still. Clearly Institutes where we can study and conduct our research together are important ways for teachers to dwell together learningly.

I am a member of a subset of nurse teachers, nurse academics who exist in research universities. This year, I will conclude a hermeneutica! study of nurse academics to unveil the hidden meanings of our practice. In my interviews with nurse academics, I am beginning to understand the centrality of learning, rather than teaching or research to our academic lives. This understanding provides a way to examine how the university has come to separate learning from teaching and research. Learning as primary, with teaching and research being special kinds of learning, is a new way to approach academic life.

Because of the accomplishments of past nursing scholars, I feel at-home, welcomed, and an equal member of the academic community. I do not feel that I have to defend nursing education, practice, or research. I am not at-home however in the practices that I am reproducing as a member of the academic community. I think that the tenure process is dehumanizing and oppressive. Our work lives at the university have left no time for learning, discovery, or creativity - the very things that mean the most to me as a nursing academic. For me, the future includes feminist scholarship in which I want to show my academic colleagues in other departments and schools that there is another way to practice teaching and research that is more connected while still embracing excellence. These new approaches are not evident. And in discovering these, we will be wrong a lot of times before we begin to get it right. But I am convinced that through dialogue we can create a new future for everyone in the university that is not driven solely by power and competition, but rather with a sense of community and a commitment to care, and responsibility. Our future will be to bring these two ways together. Academic life is ready for this transformation.

Our Lives With Students

Using hermeneutic inquiry in my classroom has opened up a view of practice in our lives with students that was never available to me before. When studying a particular content area, I ask students to write their related experiences - paradigm cases. Students write their experiences as students or nurses, ones they will never forget because it taught them about what it means to. . . . My life has been enriched by conversations that emerge when we use class time to read these stories together. Approaches to learning that are informed by Heideggerian phenomenology have allowed me to think in new ways about who I am.

Transforming Awaiting Into Anticipation

I do not seek to prove a point but to evoke and to share a vision based on the pioneering work of Martin Heidegger. Thus my primary tool is dialogue, not argument. I seek to lay forth an invitation to look and to see, not to develop a doctrine. Wanting not to instruct but to point, I hope to recall what we have forgotten.

It will be difficult for us to arrive at a stance, one that criticizes itself and does not have before it the new approach. It will be even more difficult to maintain this stance, since we exist in a culture that we eventually want to get outside of and overcome. Heidegger (1966) calls this position of openness "serene waiting" (Gelassenheit). For me, this is the nature of the curriculum revolution. It is not waiting in the sense of passivity, or supporting the status quo of depersonalizing or prejudicial practices (Gadamer, 1975). Rather it is resolute, involving ourselves in all the understandings provided by our culture, in the context of practice, through dialogue, transforming awaiting into anticipation.

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