Much has been written about the poor image and status of nursing in North America. In particular, Kalisch and Kalisch (1983a, 1983b, 1983c) have written extensively on this issue. In Pakistan, this image is compounded because it is a patriarchal society where the vast majority of women are illiterate, and maternal and child-health problems abound. Moreover, the tenets of Islam are interpreted from a male perspective, which further limits choices and decision-making by women, and prescribe appropriate female behavior and apparel. Nursing is viewed as improper and unsuitable for good Muslim women. The Aga Khan, Imam of the Ismailis, a subgroup of Shia Muslims, in his attempt to elevate the standards of health care and nursing in Pakistan, was instrumental in starting a nursing diploma program at the Aga Khan University in 1980. A two-year postdiploma program leading to the Bachelor of Science in Nursing (BScN) commenced in 1988 with the first class graduating in November 1990. The intent of the program is to provide leadership in nursing education, administration, and primary health care.
The course in which I participated and subsequently coordinated along with two other colleagues was a three-credit course taught weekly to first-year post-RN BScN students. There were 22 students in the first year that I co- taught and 15 in the year I coordinated the course. These small numbers lent themselves to experimentation with a variety of teaching strategies other than the traditional lecture method.
In the course we explored the social forces and issues faced by nurses (primarily female) in Pakistan. We focused on the concepts of power/powerlessness, conflict resolution, change process, interpersonal relations, assertiveness, critical thinking and decision-making, group dynamics, image, status, role of nursing, and social obligations and responsibilities of nurses as citizens of Pakistan. Many of these concepts, which are central to feminist thinking, provided the medium for consciousness-raising for the students as individuals and as a group. They critically examined the issues - in light of their roles as women in their own society, in nursing's relationship with medicine, and in the larger social system in Pakistan. We used the small-group process and a variety of adult education practices.
A feminist approach is used in this article to describe and to analyze the content and process of the course.
Feminist Theory and Nursing
Laird (1988), in critiquing proposals of the Carnegie Forum's Task Force and the Holmes Group on Teaching as a Profession, made a powerful argument to challenge those concerned with transforming teacher education (considered a "woman's true profession") to consider the promise of feminist pedagogy for educating schoolteachers. In her examination of the historically conceived slogan attributed to teaching as a "woman's true profession" much of what she had to say with regard to teaching as a profession has direct application and relevance to nursing because nursing, like teaching, has also been considered a "woman's true profession" and is still primarily female.
Laird (1988) analyzed the contradictory and ambiguous theses found in the slogan "woman's true profession" and argued for «conceptualizing teaching. Similarly, it can be argued that feminist theory and feminist pedagogical practices hold considerable promise for reconceptualizing nursing practice and education.
It has been posited that feminist theory, as a world view of women, brings to nursing the underpinnings for a conceptual framework in women's health (Andrist, 1986). While many nursing theorists and leaders have stressed the importance of nursing as a science and promoted the development of a scientific knowledge base, increasingly, there are those who challenge that point of view as inadequate to address nursing issues and concerns (Beatón & Tinkle, 1983; Silva & Rothbart, 1984). In particular, Hagell (1989) convincingly used a sociological perspective and feminist theory to argue that nursing is not grounded in empirico-analytic science and its methodology, but rather evolves from the lived experiences of nurses as women and as nurses involved in caring relationships with their clients.
The Charleston Faculty Practice Group (1986), which began as a support group for nursing faculty, used feminist methods to review the process that led to the writing of an article describing a model for faculty practice and the creation of an environment in which collaborative, collégial relationships could flourish. They noted that feminist "ideas were useful in viewing the struggle over issues of leadership, authorship, credit, power, participation, and responsibility experienced by group members" (p. 29).
Feminist theory is not a comprehensive cohesive approach or viewpoint. There are a variety of descriptions, explanations, and analyses of women's experiences that purport to be feminist theory. One might argue whether a monolithic ideology is even useful or desirable. There are proponents of Marxist feminism, liberal feminism, socialist feminism, existentiahst feminism, radical feminism, and psychoanalytic feminism, to name a few. Despite these varying perspectives, each perspective or theory attempts "to describe women's oppression, to explain its causes and consequences, and to prescribe strategies for women's liberation" (Tong, 1989, p. 1). Keohane, Rosaldo, and Gelpi (1982) stated that the construction of women's experiences has never been adequate because men, rather than women, have described and explained women's experiences.
At the outset I should state that I find it extremely difficult to locate myself unequivocally on the spectrum of feminist thought and to assign myself any one feminist label. But I have felt comfortable with experimenting in practice with strategies that go beyond the traditional classroom didactic method, and to seek alternatives to the student-teacher dichotomy (Ruth, 1990).
Andrist (1986) challenged nursing to refocus its graduate curriculum toward feminist theory and practice and offered cogent arguments for doing so. She suggested that nurses could ally with feminist activists in recognizing and analyzing the institutionalized power relationships in the medical care system and further reconstruct "women's experience through research and clinical practice to move toward feminist praxis, to empower women towards self-determination in health and health care" (p. 67).
Andrist's (1986) challenge can, in fact, be taken up at the undergraduate level in nursing. Nursing as a caring relationship can provide unique and manifold opportunities for teachers to be innovative and less didactic. Yet much undergraduate and diploma-nursing classroom teaching consists of lectures with the nursing teacher seen as the authority figure.
Feminist pedagogical practices
A few feminists (Bunch, 1983; Mclntosh, 1983; Rosser, 1986) have written about the ways in which they attempted to include feminist processes and content in their teaching. Wheeler and Chinn (1984) described feminist process as "based on a balance between unity within the group and conflict between individuals" (p. 12). Their focus was on group process rather than on content and they provided alternatives to the traditional way of viewing group process and dynamics. Rich (1985) addressed standards relative to feminist pedagogy and suggested that female teachers needed to keep their standards high while supporting risk-taking because self-respect often came only when exacting standards had been met. Rosser (1986), in particular, outlined in a systematic manner her feminist pedagogical methods for teaching science and health from a feminist perspective. She used the process goals suggested by Schniedewind in her chapter, entitled "Feminist Values: Guidelines for Teaching Methodology in Women's Studies" (1983). These goals could be implemented with different strategies dependent upon the teacher, students, course content, and level. The five basic process goals for classroom interaction described were: development of an atmosphere of mutual respect, trust, and community in the classroom; shared leadership; cooperative structures; integration of cognitive and affective learning; and action (cited in Rosser, 1986). These process goals will form the framework for an analysis of the content and process of the course.
Five Basic Feminist Process Goals
Atmosphere of mutual respect, trust, and community
Building an atmosphere of mutual respect, trust, and community requires an environment that promotes treating students as adults with their own learning needs and where the teacher is seen as a partner in the learning enterprise. How was such a climate created in the post-RN BScN program at the Aga Khan University? It involved both the physical and the psychological environment. The physical environment was planned to make the students feel at ease. It consisted of three small rooms with chairs around a table rather than the traditional classroom style. The psychological climate was one that allowed the students to feel accepted, respected, and supported. Faculty and students addressed each other by first names, not a norm in the culture where the teacher- student relationship is more formal.
A strategy suggested by Schniedewind (1983) to promote such an atmosphere was to devote some class time throughout the semester to dealing with process skills. This was achieved by using group process to examine the process skills, thus providing students with an opportunity to develop an awareness of themselves and how they related with others in the group. The concept of group dynamics was discussed and students consciously took turns in assuming various task and maintenance roles that all members needed to perform for group growth and development. They assumed such roles as leader, clarifier, timekeeper, summarizer, and coordinator. In a risk-free environment, they had the opportunity to practice and to gain skill in any or all of these various roles. The process of self, peer, and group feedback was conducted weekly as an inherent part of the course. This small-group format increased their basic skill of working in groups and helped them to learn and to practice new and alternate ways of behaving. Schniedewind has advocated such approaches, as they "offer women a means for giving positive or constructively critical feedback to each other in a supportive way . . . are easy to learn, can be shared among peers and between students and instructor, and are very effective in producing an honest classroom atmosphere" (p. 263).
Rosser (1986), as well, has noted that because of the power differential, faculty-student and student-student interactions were important factors in establishing an atmosphere of trust, mutual respect, and community. Paulo Friere (1974), renowned for his revolutionary ideas about education, posited that "the class is not a class in the traditional sense, but a meeting-place where knowledge is sought and not where it is transmitted" (p. 148).
Rosser ( 1986) suggested that leadership could be shared by the development and use of process skills as well as by sharing authority that is traditionally held by the teacher. In our classes the weekly feedback and the assessment of the group's progress facilitated sharing the leadership. Although students were hesitant to give feedback to the faculty member who served as facilitator, with encouragement they did so. It was seen as a learning process for all members of the group. Initially, students constantly looked to the facilitator for encouragement, recognition, and direction. They struggled with accepting their own leadership. About mid-semester they became more selfassured, had norms established, and were more comfortable with each other. Increasingly, the facilitator functioned as a group member. Student-student interaction was the norm as the facilitator took an observer or participatory group role. This process is well-documented by Prière (1970) who pointed out that the practice of problem-posing education demanded resolution of the teacher-student contradiction. He argued that:
. . . through dialogue, the teacher-of-the-students and the students-of-the-teacher cease to exist and a new term emerges: teacher-student with students-teachers . . . They become jointly responsible for a process in which they all grow. In this process, arguments based on authority are no longer valid . . . authority must be on the side of freedom, not against it (p. 67).
In our group, students shared their experiences and were rich resources for each other. Mezirow (1981) suggested that learners who were used to the traditional teacher dominance in a learning situation could be helped to examine the implicit assumptions by being placed in a situation where the teacher refused to play the authority role and became a resource person. A further example of shared leadership was the co-teaching by faculty facilitators. Each of the three facilitators shared the responsibility for organizing certain sessions. The entire group of students and facilitators sometimes met for one hour together to either view a videotape or to interact with an invited guest facilitator; and in the next two hours students assumed the leadership role in their small groups.
Schniedewind (1983) indicated that "an activity has a cooperative goal structure when an individual can complete it successfully if, and only i£ all others with whom she is linked do likewise. The group sinks or swims together" (p. 266). In our classes, games were played to enhance students' problem-solving skills and to let them experience the need and benefit of a group working cooperatively to solve problems. Individual and group assignments and exercises on decision-making were given and the students were free to decide whether to complete them. In class, the exercises formed the basis for an exploration of the styles of group decision-making, and the role of the individual and the group in the decision-making process. This was achieved through an observer chosen among themselves and through self-analysis of their feelings and perceptions of the role they played in the decision-making process. Students explored the power dimensions of their work situation and the use of their own power, and identified power sources for nurses in their own institutions and in Pakistan. Course evaluation was a cooperative endeavor. Self, peer, and facilitator evaluation comprised half of the final evaluation and the other half consisted of a scholarly paper that was criterionreferenced.
Integration of cognitive and affective learning
Rosser (1986) observed that "since feminism is premised on valuing each woman's personal experience and recognizing that the personal is political, integration of cognitive and affective learning is basic to most women's studies" (p. 114). As well, Mezirow (1981) suggested that conceptual learning must be integrated with emotional and aesthetic experience, as critical reflexivity was fostered when a premium was placed on personalizing what was learned by applying insights gained to one's own life. His Highness, The Aga Khan, in speaking about nursing and the role of science at a convocation address, noted:
Science is a wonderfully powerful tool. But science is only the beginning, in the new age we are entering. My hope is that in Islamic Pakistan, The Aga Khan University and Hospital can make progress in developing new models. Islam does not perceive the world as two separate domains of mind and spirit, science and belief Science and the search for knowledge are an expression of man's [woman's] designated role in the universe, but they do not define that role totally. Surely there is no more worthy area in which East and West can work to bond these two aspects of man's [woman's] understanding, than in the field of health science that our graduates enter. (Cited in yearbook, 1987, p. 5).
Our course was a preliminary step toward the Aga Khan's vision, because it was a blending of knowledge and beliefs, thoughts and feelings. Ideas from the West about feminism and the role of women and nursing were critically examined with recognition and awareness of Pakistani culture and beliefs. In the first session, a Pakistani social worker who is a political and feminist activist was the large-group facilitator. She explored with them the social structures and forces in Pakistani society that hindered the development of women. Examples of such structures included the male interpretation of the Qur*an and the various laws that have evolved from such interpretation - for example, The Hudood Ordinance 1979, which covers, among other things, adultery and rape. At the legal level, it prescribes that there must be four Muslim male adults as eyewitnesses and excludes the testimony of women altogether (Mumtaz & Shaheed, 1987, p. 100).
Students were shown a videotape of the actual results of such an ordinance on the lives of women in Pakistan who had been jailed for being raped; they heard the experiences of these women as they shared their oppression and powerlessness in a system designed for male dominance. Students struggled with their feelings and thoughts to determine ways and means to confront and deal with these oppressive structures within their society.
The multifaceted dimensions of women's roles and nursing as a profession were the focus of another session. Much personal inner conflict occurred, as together we experienced the sense of "powerlessness" that we have as women and nurses in attempting to deal with these embedded religious/political structures, yet students thought of creative ways to deal with these issues. Friere (1970) asserted that the humanist revolutionary educator's efforts "must coincide with that of the students to engage in critical thinking, and the quest for mutual humanization ... to achieve this, he [she] must be partner of the students in his [her] relations with them* (p. 62).
Time was allotted at the end of each session for verbal feedback from students about their individual thoughts and feelings regarding their learning, their role in the group, and that of their peers. These opportunities helped them to integrate the concepts under discussion with their feelings about these issues in real-life situations in their society. Ruth (1990) observed that in feminist classrooms there were two factors not typical in traditional classrooms: "an acceptance of, and even emphasis on, the personal-affective element in learning; and a warm, human relationship among persons in the class, students and teacher" (p. 13).
A final goal of the feminist process is action-oriented field work. This involves students on a personal level with the material they are learning. Friere (1974) has emphasized and demonstrated the need for action as "praxis" if learners are to transform their world.
There were several ways in which action on the part of students took place. For example, they explored the power dimensions of their work situations and identified power sources within themselves and within other nurses in their work environment. They did role-playing and observed power-oriented individuals to learn more about assertive, aggressive, and passive behaviors. To understand the role of nursing in terms of its image and status in their society, the students collected data from a cross-section of the public through interviewing professionals and lay people on their perception of nurses and nursing. Game-playing was another way to learn new concepts. In looking at the change process, apart from any discussion of theories of change, they worked in small groups to identify general categories of societal change that influenced nursing and how they might be able to bring about changes in their work settings. The final session was dedicated to professional accountability. Through creative problem-solving, students, in small groups, demonstrated pictorial representations of how they saw themselves bringing about change in the nursing profession in Pakistan.
Feminist pedagogy views issues from a female perspective and is most applicable for nursing education. Educating women (nurses) to the reality of the structures that oppress them and giving them the tools of knowledge whereby they can consciously reflect on their condition, in a climate of mutual respect, collaboration, and trust, help them to take constructive action to change their lives.
This reflective analysis and description of one nursing course demonstrated the attempt to take an initial step in that direction. Hopefully, this information will add to the pool of data available on theorizing feminist pedagogy. Further research will be needed to determine whether these teaching strategies will empower nurses in Pakistan to take action for the betterment of health care in their institutions and in their country.
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