Journal of Nursing Education

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A Critical Pedagogy for Family Nursing

Gwen Hartrick, RN, PhD

Abstract

ABSTRACT

Little consideration has been given to the philosophical tenets that underlie existing family nursing theory and practice and that ultimately influence the content and process of family nursing education. This article emphasizes the importance of students and faculty engaging in a critical analysis of family nursing theory and practice. A pedagogical approach that employs phenomenology, feminism, and critical social theory as observational lenses for examining the ontology and epistemology of family nursing is described.

While family nursing is coming to be recognized as an essential element of any nursing curriculum, family nursing pedagogy is in its infancy. Family nurse educators are currently working toward developing curricula and educative processes that will furnish students with a theoretical (scientific) base for family nursing practice and will provide them with opportunities to develop the practice skills they need to work with families (Hanson & Heims, 1992; Wright & Bell, 1989). However, little consideration has been given to examining the philosophical tenets that underlie existing family nursing theory and practice and that ultimately influence the content and process of family nursing education (Richards & Lansberry, 1995).

This article asserts that critical analysis of family nursing theory and practice is integral to family nursing pedagogy and must be a primary consideration in the advancement of family nursing education. The discussion is in two parts. Part I highlights the importance of a critical analysis of family nursing theory and practice including both ontological and epistemological inquiries. Part II describes a critical pedagogy of family nursing that addresses both ontology and epistemology.

Abstract

ABSTRACT

Little consideration has been given to the philosophical tenets that underlie existing family nursing theory and practice and that ultimately influence the content and process of family nursing education. This article emphasizes the importance of students and faculty engaging in a critical analysis of family nursing theory and practice. A pedagogical approach that employs phenomenology, feminism, and critical social theory as observational lenses for examining the ontology and epistemology of family nursing is described.

While family nursing is coming to be recognized as an essential element of any nursing curriculum, family nursing pedagogy is in its infancy. Family nurse educators are currently working toward developing curricula and educative processes that will furnish students with a theoretical (scientific) base for family nursing practice and will provide them with opportunities to develop the practice skills they need to work with families (Hanson & Heims, 1992; Wright & Bell, 1989). However, little consideration has been given to examining the philosophical tenets that underlie existing family nursing theory and practice and that ultimately influence the content and process of family nursing education (Richards & Lansberry, 1995).

This article asserts that critical analysis of family nursing theory and practice is integral to family nursing pedagogy and must be a primary consideration in the advancement of family nursing education. The discussion is in two parts. Part I highlights the importance of a critical analysis of family nursing theory and practice including both ontological and epistemological inquiries. Part II describes a critical pedagogy of family nursing that addresses both ontology and epistemology.

PART I: ENGAGLNG LN A CRITICAL ANALYSIS OF FAMILY NURSING

In a study that explored the philosophical and educational beliefs of graduate family nursing faculty, Richards and Lansberry (1995) discovered that there was a major discrepancy between the beliefs and world views espoused by faculty and the beliefs and world views underlying the family nursing models those faculty employed. For example, although most faculty believed in the simultaneity world view, the frameworks influencing their practice were derived from the totality world view. Within the simultaneity paradigm, family is viewed as an irreducible whole experiencing unique patterns of health. Family nursing based on this paradigm focuses on enhancing the awareness, meaning, and potential of families' health and healing patterns and experiences. In contrast, the totality paradigm emphasizes the individual in the context of family. In this paradigm, family nursing focuses on the diagnosis and treatment of health concerns (or deviations from norms) with the overall goal being the restoration of balance (Richards & Lansberry, 1995).

This discrepancy between espoused world views and world views in use implied that the models of practice faculty currently employed (and promulgated with students) were incongruent with the values and beliefs they advocated as family nurses. These findings accentuate the importance of engaging in a critical analysis of the philosophical tenets underlying family nursing theory and practice (Richards & Lansberry, 1995). It is only through such an analysis that we a) become aware of the congruence or lack of congruence between our values and our practices, b) ensure that we do not give contradictory messages to family nursing students, and c) are able to question the values and beliefs embedded within existing theories and practices and reimagine new possibilities.

The nature of an analysis of family nursing is also crucial. First, it is imperative that such an examination include both ontological and epistemological inquiries. Within nursing there has been an overriding tendency to focus on epistemological questions of knowledge, while ontological questions of reality, meaning, and being go unrecognized (Silva, Sorrell, and Sorrell, 1995). Ontological questions can reveal the aspects of family nursing that are often inexplicable, puzzling, or difficult to know. In this sense, these ontological questions lead us to the art of nursing (P. Chinn, personal communication, March 20, 1996). The second crucial aspect of a critical analysis is the personal/individual exploration that must be done by both students and faculty. Active participation by both provides a unique opportunity for students and faculty to question the taken-for-granteds embedded within their own personal perspectives and to expand their awareness to encompass other possibilities.

Family Nursing Ontology and Epistemology: A Dialectic

A critical examination of family nursing involves illuminating the dialectic between our knowing and being. Silva et al. (1995) maintain that the dominant philosophical thrust of modern nursing has been epistemologica!. In family nursing education, this epistemologica! emphasis is evident. For example, the teaching and learning of family nursing most often emphasizes the content and process of gaining knowledge of family nursing theory (in the classroom) and of families (in clinical settings). In particular, the end products of knowing are accentuated (e.g., what do students know about family theory and the family they are working with). The content includes the learning of discrete theories and information related to family, while the process of learning involves gathering information for the purpose of diagnosis (what more do I need to learn, what is this family's major health problem) and treatment (what will I do to learn what I need to know, how will I intervene with this family).

In contrast, ontological questions of family nursing are often hidden within epistemologica! questions. Silva et al. (1995) maintain that although the mixing together of epistemologica! and ontological questions is not itself an issue, the concern is that often nurses do not move beyond epistemological questions to illuminate the ontological questions that are essential to their practice. These ontological questions illuminate the "in-between" and the "beyond" of human experience (Silva et al., 1995). The inbetween and the beyond are the essential elements of existence that are not revealed through linear, action-oriented methods of knowing. Rather, these elements are brought to light through ontologica! questions that move us beyond "what do I know" to "how do I (as a person-inthe-world) make and find meaning in what I know." Ontological questions ask: What is the integral relationship between my knowing and my being?

The ontological questions of family nursing also move us beyond students and teachers as individual knowers to uncovering the relational nature of knowing in family nursing. Family nursing involves an ontology wherein our knowing is always relational. Therefore, our experiences and knowledge of anyone/anything is gained through our relationships with them/it. This acknowledgment of a relational ontology opens up vast possibilities for students and teachers to enhance their understanding and knowledge of families' health and healing experiences. Examples of ontological questions include: How do I/we (as student/teacher/family) find meaning in what we have heard, discovered, or learned? How is this meaning co-created? How do our differing ways of being influence each other and the meaning we co-create? As these ontological questions are considered, two-dimensional visions of families1 health and healing experiences can be transformed into multidimensional ones.

PART II: A CRITICAL PEDAGOGY FOR FAMILY NURSING

In preparation for the future, both nurses and nursing students must understand how to learn rather than how to hoard knowledge, how to critique rather than how to accept, how to expand rather than how to contract (Silva et al., 1995, p. 12).

During the past 8 years, the School of Nursing at The University of Victoria has collaborated with nine partner colleges and university colleges to develop a new and innovative curriculum focused on changing our direction in nursing education. This collaborative curriculum evolves from an emancipatory interest and is informed by phenomenological, feminist, and socially critical views of people, health and healing, nursing, and education. In particular, these three perspectives have shaped the teaching and learning of family nursing throughout our 4-year baccalaureate program. Together they have highlighted the significance of the ontology of family nursing and have provided a foundation that supports the examination of the ontology and epistemology of family nursing practice.

Specifically, phenomenology, feminism, and critical social theory serve as the differing lenses through which we are able to:

* Examine the meaning and relevance of family nursing epistemology and ontology for students, teachers, and the families we care for.

* Question the taken-for-granteds embedded within family nursing theory and practice.

* Transform both the personal and professional taken-for-granteds that influence and shape our family nursing practices.

Central to this critical analysis is the illumination and evolution of the personal world views that govern our ways of being and knowing as family nurses.

Family Nursing Pedagogy: A Process of Critical Analysis

Mancini & Semerai (1988) contend that we need a lens or foundation to help us know what we should observe if we are to take notice of something. Phenomenology, feminism, and critical social theory provide observational lenses for examining the ontology and epistemology of family nursing. Specifically, these lenses facilitate:

* The examination and critique of family nursing theory and practice.

* The illumination and evolution of students' and teachers' personal theories of family nursing.

* The re-imagining of alternate ways of being and knowing as family nurses.

While it could be argued that the philosophical foundations of these three observational lenses are somewhat incongruent, this possible incongruity can be considered a strength. In examining the ontology and epistemology of family nursing from the different philosophical orientations, our overall intent is to create opportunities where interpretations and realities can be questioned and examined. If there is divergence among these different views, learning can be further enhanced as students and faculty experience the multiple and possibly contradictory ways any family, theory, experience, or situation can be perceived.

A Phenomenologiecal Lens

Using a phenomenological lens, the experience of families, students, and faculty are in the foreground. In essence, phenomenology is discovery oriented (van Manen, 1990). The aim of phenomenology is to gain a greater understanding of the meaning of human experience as it is lived. Rather than focusing on the facts of a situation, phenomenology leads us to uncover the meaning those facts and the situation have for the people experiencing them. In the context of family nursing education, phenomenological questions are raised in regard to the meaning and significance of family and family health, the health and healing experiences of families, and student and faculty family nursing experiences.

By viewing the health and healing experiences of families through a phenomenological lens, we move away from seeking to discover "what is really going on in this family" to focusing on understanding the experience of the different family members and the multiple realities that coexist within the family (Hartrick & Lindsey, 1995). Together, students and faculty raise questions about the nature of family and family experiences in an effort to uncover the deeper meaning structures within them. Phenomenological questions may include:

* What is the experience of health and healing for each of the family members?

* What is the experience for the family as a whole?

* What is significant about this experience for each of the family members and for the family as a whole?

* What issues within the experience are of concern to the family members?

* What, for me (as nurse), is significant about this family's health and healing experience?

* How does this significance influence the way I am with this family?

By examining student and faculty family nursing experiences through a phenomenological lens, both ways of being and ways of knowing as family nurses are considered. From a phenomenological perspective, it is assumed that our knowing and being are inseparable and that both are influenced, enhanced, and constrained as a result of the situated and constituted nature of our being. Phenomenological (and ontological) questions such as: What, for you, is significant about what you have read in regard to family theory? What issues arising with your practicum family cause you concern? In what ways are these concerns similar to or different from the concerns of the family members? illuminate the integral relationship between ourselves as knowers and our "knowing" as family nurses.

A Critical Social Theory Lens

Using a critical social theory lens, the social structures that constrain and enhance family health and healing experiences, as well as the family nursing practices of students and faculty, are in the foreground. Overall, the focus of critical social theorists is to liberate people from unacknowledged circumstances of domination and to transform constraining conditions (Stevens, 1989). One of the central values of critical social theorists is a commitment to penetrate the world of objective appearances to expose the underlying social relationships that are often concealed. In the context of family nursing education, the objective appearances of family nursing are probed, including assumptions concerning the nature of family, the nature of health and healing, and the knowing/being/doing of family nursing. Underlying belief systems and ideologies are questioned and examined using family nursing experiences. Through this process the effects of ideology are illuminated. This provides an opportunity for families, students, and faculty to see beyond the taken-for-granted reality that may constrain them.

Stevens (1989) identifies six assumptions that underlie critical social theory. Family nursing content, process, and experiences are examined using these assumptions. They include:

* All research and theory are political.

* Oppressive structural relations that pervade our society are taken for granted and often remain unexamined.

* Mythical, religious, scientific, practical, and political interpretations and knowledge are open to question and critique.

* Social conditions are not natural or constant but rather are created by specific historical situations (reality is not a constant, but is created/constructed).

* Understanding the changing conditions of human suffering can be gained through an historical look at the development of oppression.

* Liberation from oppressive structures is essential for the expression of human potential, completion, and authenticity.

By examining the social structures and rules governing families and their health and healing experiences (as well as the science and practice of family nursing) the following are examples of questions that would be posed: Who is best served by those rules? How do history and tradition continue to impact this family? How do history and tradition influence me as a family nurse? How are our (student, teacher, family) interpretations of this familya experience/situation being influenced by societal taken-for-granteds?

A Feminist Lens

Overall, feminism is concerned with gender equality and focuses on the necessity of restructuring societal roles and relationships to create equal rights and power for both women and men (Sherwin, 1992). Viewing the health and healing experiences of families through a feminist lens provides an avenue for discovering both the subtlety and the power of the dominant culture to prescribe what is good for families and their health and healing experiences. Questions that may be raised from a feminist perspective include:

* What societal structures influence the power and privilege provided to each family member?

* What family structures influence the power and privilege provided to each family member?

* How do these power structures influence the health and healing resources available to this family?

* In what ways do prescribed gender roles influence the health and healing experiences of this family?

* In what ways could "power with" relationships promote health and healing in this family?

A feminist lens also allows students and faculty to become aware of the values and methods of the dominant culture that they have accepted and integrated as their own (Gray, 1994). This awareness fosters the ability to be clear about the ways family nurses conceptualize and practice family nursing. In addition, this awareness fosters the ability to see how experiences of gender are influenced by larger societal structures. Questions that may be raised for exploration include:

* How does our gender influence the way we undertake family nursing?

* How does our gender influence our place (and voice) in the larger health care arena?

* In what ways are gender differences relevant or irrelevant to our work as family nurses?

* How does gender influence how we work with specific family members?

* Are our expectations similar to or different from mothers and fathers in regard to their role in the health and healing of their family?

An Example

The following story is an actual experience of a teaching colleague. This story exemplifies how the different philosophical lenses of phenomenology, critical social theory, and feminism influence the pedagogical process.

During the nursing practice seminar, a student described a dilemma she was facing in working with her practicum family. The practicum focused on family health promotion and involved students working with a "healthy" family in the community. The family the student was working with consisted of a single mother and three school-aged children. During one of the student's visits, she accompanied the mother to the grocery store. While there, the student watched as the mother (who was on social assistance and, therefore, a very limited budget) filled her grocery cart with what the student described as "junk food." In seminar, the student expressed her feelings of both dismay and uncertainty about what she "should have done" and what she "needed to do now" to be a health-promoting nurse with this family. The student stated that her knowledge of nutrition and children's nutritional needs makes her cringe at the thought of the family eating the prepackaged, processed food she observed in the cart.

Together the students and teacher critically analyze this family nursing experience through the three lenses. It is not just the students who evolve their perspectives through such an exercise. Each time family nurse educators engage in this form of critical analysis, they gain a deeper understanding of the values and beliefs that both enhance and constrain them. As a result, they are able to expand the possibilities of their practice as both a family nurse practitioner and as a nurse educator (Hartrick, 1995).

Through a phenomenological lens, the analysis begins by asking: As nurses seeking to understand the experience of this mother and of the family, what questions would be important for us to ask? After identifying potential questions, we then consider the questions with regard to this family. For example, we may identify the numerous and differing concerns that may be guiding this mother. While we acknowledge that we can never know what this particular mother's experience is, the process of identifying various concerns provides an opportunity for each of us to hear possibilities we may not have considered given our situation. In addition to posing questions about the family's experience, we raise questions to understand the nurse's experience and her interpretations of the situation. For example, we may ask questions such as: What concerns are guiding the nurse? How does the nurse's situation influence what the nurse finds significant? How might these be similar to or different from the mother's and family's concerns?

Using a critical social theory lens, we raise questions about the social structures that influence this family and the family nursing experience. For example, we may identify questions such as: What cultural values led to this mother with three children being on such a limited income? What social structures support and perpetuate the family's inability to access needed resources? Belief systems and ideologies that guide our interpretation concerning the nature of family, the nature of health and healing, and the knowing/being/doing of family nursing theory and practice are questioned. For example, students often raise questions regarding how the economic power of the dairy and beef industries and advertising in the media ultimately influence our beliefs about nutrition.

Through a feminist lens, we consider the influence of gender and power on this family and family nursing experience. Typical questions we would raise include: How did gender influence this nurse's interpretation of the situation and of the mother? How did the cultural dictates surrounding women who are mothers influence the different people in the situation? What cultural values have led to the majority of economically disadvantaged single parents being women? Would each of us as nurses respond differently to this parent as a result of their/our gender?

Together phenomenology, critical social theory, and feminism provide powerful and often enlightening views of students,' faculty's, and families' taken-for-granteds. As the integral relationship between ontology and epistemology is examined, everyday elements of nursing practice and experiences are highlighted and questioned. Through this questioning process, students and faculty have the opportunity to re-imagine and transform both their practices and the theories that guide those practices.

CONCLUSION

Street (1991) describes how imagination can create the capacity to construct an image that contains the potentialities of nursing practice in the future. Street maintains that through a re-imagining process, nurses can "uncover their tacit ways of knowing by identifying and discarding traditions and nursing myths which have sustained them and begin to image themselves and their nursing care, in new ways" (1991, p. 2). As we continue in our quest to advance family nursing education, it is imperative that we move beyond the taken-for-granteds embedded within our current family nursing theory and practices. We must engage in critical analysis of both the ontology and epistemology of family nursing practice and education. The pedagogical process described in this article provides an example of how we might begin such a process.

REFERENCES

  • Gray, P. (1994). Nurses and power. In O. Strickland & D. Fiehman (Eds.), Nursing issues in the 1990s (pp. 522-523). Albany, NY: Delnar.
  • Hanson, S, & Heims, M. ( 1992). Family nursing curricula in U.S. schools of nursing. Journal of Nursing Education, 3UT), 303-308.
  • Hartrick, G. (1995). Part 1: Transforming family nursing theory: From mechanism to contextualism. Journal of Family Nursing, 1(2), 134-147.
  • Hartriek, G-, & Lindsey, L. (1995). Part 2: The lived experience of family: A contextual approach to family nursing practice. Journal of Family Nursing, 1(2), 148-170.
  • Mancini, F., & Sèmerai, A. (1988). Kelly & Popper: A con8tructivist view of knowledge. In F. Fransella & L. Tomas (Eds.), Experimenting with personal construct psychology (pp. 69-79). London: Routledge & Kegan Paul.
  • Richards, E., & Lansberry, C. (1995). A national survey of graduate family nursing educators. Journal of Family Nursing, 1(4), 382-396.
  • Sherwin, S. (1992). No longer patient: Feminist ethics and health care. Philadelphia: Temple University Press.
  • Suva, M.C., Sorrell, J.M., & Sorrell, CD. (1995). From Carper's patterns of knowing to ways of being. An ontological philosophical shift in nursing. Advances in Nursing Science, 18(1), 1-13.
  • Stevens, P. (1989). A critical social reconceptualization of environment in nursing: Implications for methodology. Advances in Nursing Science, 11(4), 56-68.
  • Street, A (1991). From image to action. Reflection in nursing practice. Victoria, Australia: Deakin University Press.
  • van Manen, M. (1990). Researching lived experience. London, Ontario: The Althouse Press.
  • Wright, L.M., & Bell, J.M. (1989). A survey of family nursing education in Canadian universities. Canadian Journal of Nursing Research, 21(93), 59-74.

10.3928/0148-4834-19980201-07

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