This paper describes our philosophy about teaching and learning in a master's degree program preparing family nurse practitioners (FNPs). As we developed this new major, the following factors influenced our curriculum choices: (1) Belief that the family is the unit of care, not merely the context for care provided to individuals; (2) Conviction that adult learners in professional programs are self-motivated and independent; (3) Commitment to building connecting conversations involving learners, teachers, patients, families, preceptors, and others (including both professional and popular literature); and (4) Love of stories as a means of reconstructing and interpreting experience.
Our university prepares FNPs during a 42-credit hour major in the master's degree program. Most students, because they are part-time, require three years to complete the work. Their preparation includes nursing research, theories, policy and practice, legal and ethical issues, advanced practice roles, pathophysiology, pharmacology, family theory, physical and community assessment, and independent research. In addition, they take clinical courses in primary health care of children, women, adults, and families.
Previously in our school, and continuing in most schools of nursing, teaching strategies included primarily lecture presentations, class discussion and seminar courses, research papers, case studies, and clinical practice. These traditional approaches to teaching have replaced the earlier, more medical, apprenticeship model. Nurse practitioner education, though making good progress away from the medical model, still clings to traditional educational design. This reluctance to abandon conventional didactic and clinical education may be because of the requirements for national certification by comprehensive examination. Many programs "teach to the test" to ensure success for their graduates on the examinations. Unfortunately, this content-driven approach may have stifled creativity and innovation in nurse practitioner education and made teachers slaves to the textbook and the review manual. All this just when the clinical and political content is changing far more rapidly than teachers can ever anticipate. We wanted another way.
The authors of this paper have been frustrated with the "received view" of education in nursing, in which the teacher is seen as the expert, the student is expected to learn what the teacher believes is important, and testing of learning is mainly the paper-and-pencil "objective" examination. Learning is mostly passive, receptive, teacher-directed. We are aware that the curriculum revolution has moved us beyond Tylerian behavioral approaches to teaching and learning. However, we still find predominant teaching strategies are inadequate to prepare nurse practitioner students for the subtleties and nuance of care in the real clinical world. The focus on "knowing the content," and lack of attention to context and meaning, fools students into thinking that they can learn it all, or that all of it can be taught in one program. Traditional teaching may reduce practitioners to a recipe approach to care, as does heavy reliance on protocols in both academic and clinical settings.
All of these concerns led to our search for a more interactive, reflective, and interpretive approach to teaching and learning for nurse practitioners. We have used various modifications of conventional case study analysis (RyanWenger & Lee, 1997) and Practice-Based Learning (Barrows, 1994). We have also included computer-mediated case study analysis in our FNP courses. We find all these to be relatively satisfactory approaches because they promote active learning with emphasis on clinical reasoning. A summary of the characteristics of these three strategies for knowing about nursing is given in the Table.
Nevertheless, we wanted an even more interpretive, context-situated source for student inductive learning. We have taken these learning strategies Usted previously, added concepts from narrative and interpretive pedagogy (Diekelmann, 1995), and have developed a narrativecentered curriculum for FNP study. We have used this approach for several years; the first class to complete the curriculum currently is involved in a qualitative, narrative evaluation of their educational experiences using these combined methods. Narrative-centered curriculum depends on a convergence of several conventional and nontraditional learning designs. The primary ways we enable students to learn in the narrative-centered curriculum include minimal dependence on didactic approaches (i.e., lecture, objective testing, directed class discussion of cases). However, we do rely heavily on the nonconventional learning designs outlined in the following sections.
Using simple vignettes and complex cases to teach has been a familiar approach in medical, law, business, and nursing education for many years. There is a long tradition of the use of cases and commentaries in teaching. We have used it in the nurse practitioner majors for at least 20 years, sometimes just to illustrate the practical application of a concept, and sometimes as part of the "stem" for a series of test questions. Usually, students receive the full case description and respond to specific questions intended to focus attention on particular details of the situation. Students may respond in writing, or in a class discussion led by the teacher. Students are responsible for knowing the answers to the questions. Students also develop their own case study write-ups, based on their clinical practice experiences. Other schools of nursing use a more elaborate clinical reasoning approach called Case Study Analysis (Ryan-Wenger & Lee, 1997). Our understanding of cases is that context is provided for students, but only as much as the presenter thinks is necessary to understand the problem(s), not necessarily reflecting the meaning of the experience for the client, family, and practitioner. The intent of the case is to enable students to narrow their focus using diagnostic reasoning to define and solve identified clinical problems. The expectation is that students will apply knowledge of content to a particular situation after analyzing the problems and determining the available interventions. Not only will they apply the content but also plan solutions to clinical problems, patient education, and follow-up. Rarely is interpretation called for, either regarding meaning for the patient/family or for the care provider.
Barrows & Pickell (1991) developed case-based learning even further, terming it problem-based learning (PBL). (We prefer the 1994 terminology, practice-based learning, since so often an encounter with a client or family involves not problems, but strengths and challenges). PBL represents an entirely inductive and prospective approach to clinical problem-solving. It emphasizes a clinical context for learning, developing skills in working with a group, and encouraging self-directed study. Small groups of students meet with a faculty facilitator (a "tutor") two to three times per week. Faculty members do not teach in the conventional sense. Instead, they facilitate discussion and direct students toward instructional materials to meet identified learning issues/needs. A series of cases focus on learning the basic clinical science required to understand patient problems. Students then work independently on learning issues before the next meeting, at which time the new information is discussed and refined in the context of the case. Schools of nursing in the United States have experimented with PBL in some courses, and some schools, (primarily in Australia) have committed to it as a way of organizing curricula. At Indiana University, we have gradually introduced PBL and diagnostic reasoning into the FNP curriculum; now this design is evident in all courses core to the FNP major. We maintain that PBL and case study analysis, especially in combination, are excellent means by which to develop sound clinical knowledge.
Developed by Diekelmann (1995), narrative and interpretive pedagogy challenges traditional thinking about teaching and learning in nursing. Diekelmann's work is embedded in interpretive phenomenology and hermeneutics, as explicated by Benner (1994), among others. "Narrative pedagogy is not a specific pedagogy or curricular model, but rather an approach that enables the converging conversations of all pedagogies" (personal communication, Diekelmann, 1997). With Benner (1994) she sees the scholarship of teaching and learning as ". . . cycles of understanding, interpretation, and critique" (p. 116). This approach supports the development of innovative and hermeneutic teaching strategies that promote reading, writing, thinking, and dialogue to connect teachers and learners in a way that promotes the learning needs of the student and enables learners to achieve their own goals. Not just a teaching or learning method, narrative pedagogy creates a place in the curriculum where active, interpretive learning can be called forth, using the best of both conventional and new designs for learning. Many theoretical perspectives come into the uses of narrative in this pedagogy: postmodernism, feminism, critical social theory, phenomenology, and hermeneutics, as well as traditional cognitive and critical thinking strategies. Diekelmann (1995) and Ironside (1997) propose that reading, writing, thinking, and dialogue are not separate skills, and that interpretive pedagogy allows the convergence of these scholarly practices. Narratives may be stories about client's lives, about preceptors or other providers, about the learning situation, or about encounters between teachers and learners. Narratives also may be stories of clinical experiences of students and preceptors. Any text related to life experiences (e.g., having and raising children, illness and recovery, self-caring) may be used for interpretation including films, novels and other fiction, poetry, and photographs.
Comparison of Learning Approaches in the Narrative-Centered Curriculum
COMBINING NONCONVENTIONAL TEACHING STRATEGIES
What is lacking in case study analysis and practicebased learning is the opportunity for reflective imagining about the meaning of the interaction between client and practitioner, the "putting yourself in another's shoes to consider what the illness means to them." Benner, Tanner & Chesla (1996) speak to these differences as well. They suggest two kinds of knowing in clinical encounters- clinical knowledge (ontic, technological knowledge) and caring knowledge (phenomenological, interpretive, narrativebased knowledge). The addition of narrative to case study analysis and PBL makes our FNP curriculum unique in its approach to combining the ontic and the interpretive, the content and the expressive interpretation of the content.
This narrative-centered curriculum uses narrative pedagogy concepts to gather the best ideas from case study analysis and practice-based learning, and adds mindful, guided attention to meaning through the interpretation of connecting conversations between and among nurses, clients, families, and other health care providers. Using narrative pedagogy frees us to bring together nonconventional learning and the more didactic, ontic, and technological learning necessary to ensure competence in the highly skilled advanced nursing practice required by FNP educational requirements. Differing pedagogies, both conventional and innovative, are brought together in the narrative-centered curriculum. In the places where case study analysis, practice-based learning and narrative come together, they sometimes overlap, and the narrative-centered curriculum creates an opening for the client and the family to tell the story from their own point of view, making room for them in the process. Students practice being quiet enough to hear the many voices represented in the story, to hear all the parts of the conversation. Centering the curriculum on the narrative enables the learner to see the patient as the expert about their own life experience and its meaning.
Narrative is used to reconstruct a full experience- not just one limited to finding and solving problems. The curriculum mandates an approach that goes beyond simple reflexivity to interpretation of experiences in advanced nursing practice, encouraging learners to consider the meaning of their own experiences as students and practitioners. Through conversation and interpretation of text, the narrative-centered curriculum provides a tangible way to develop caring knowledge, even while learners concentrate on the content critical to their future practice as FNPs. According to Applebee (1996), "... a curriculum provides domains for conversation, and the conversations that take place within those domains are the primary means of teaching and learning" (p. 37). We shift the focus of the work to conversations about practice and problemsolving, and away from content-as-content. However, we do not abandon structure, planning for and organizing content, and evaluating the curriculum. For example, our clinical evaluation tool (a checklist used by students, preceptors, and faculty), is based on Brykczynski's (1985) domains of advanced nursing practice.
Teachers function as guiding partners in the learning process, presenting appropriate materials, resources, consultations, skills, and experiences that lead to the next stages of learning (personal communication, Siegfried, 1997). Teachers also are evaluators of quality. This role highlights the inherent imbalance of power in teacherlearner relationships; nevertheless, our feminist principles compel us to seek an emancipatory atmosphere in the classroom and clinical practice settings.
We believe the primary resource for a teacher of nurses is one's own experience of being a nurse and experiencing nursing education; hence, our requirement that teachers and students have a current practice background. Teachers use the students' lively interest and lack of knowledge, the drive to want to know more, as the impetus for learning. Learners have the opportunity and power to make choices, to work both independently and in a team, and to pursue a topic to its logical conclusion. Students are given credit for what they already know, and no one is reprimanded for not knowing. Because there is such a mix of student skill and ability (ranging from students two years past the BSN to post-MSN students who are already nurse practitioners in another specialty area), teachers in this major cannot present the content at any one level; students identify what they need to learn. The narrative-centered curriculum respects the incoming experience and skills of students; the content arises out of the clinical and scholarly experiences of the students. It appreciates and celebrates the lived experiences of students, preceptors, clients, and families.
Students build further expertise in diagnostic reasoning by applying PBL and case study analysis to content knowledge in particular and focused clinical situations; case study analysis and PBL are adjunct to the narrativecentered curriculum. While maintaining the focus on narrative in the curriculum, we still help learners analyze subjective and objective data, differentiate possible diagnoses, and make diagnostic decisions based on pattern recognition (Barrows, 1994). We use a variety of textbooks to assist in classifying the patterns of health or illness, to determine the type of clinical problem, and to develop a plan of care. But expert nursing practice is more than simply the application of content to situation; the expert recognizes and integrates the unique meaning in every clinical encounter. Meaning is always individual and always exclusively available in the client and family story (Benner, Tanner & Chesla, 1996).
EXAMPLES OF NARRATIVE IN CURRICULUM
Families Tell Their Story
We invited Diane and Nancy and their adopted daughter, Emily, to attend our FNP class. Emily was adopted in India, and had multiple congenital problems, including a heart condition and cerebral palsy. Diane and Nancy described their experiences with the health care system, including ambiguity about the original diagnoses. The narrative provided to the class included Diane's story, !fancy's interaction with Emily during the visit, Emily's activity and verbal engagement with the class members and faculty, and a demonstration of a developmental assessment of Emily by a faculty member. During the class, students asked questions of the three family members, and after the visit, the class analyzed and interpreted the meaning of these multiple stories. The class learned the difficulties of international adoption, living in nontraditional families, caring for a multihandicapped child, managing insurance and social work complexities, and maintaining a two-career professional relationship. If the students had seen Emily in a clinic situation, they would have concentrated, quite naturally, on her individual problems and would have missed the richness of the meaning of her presence in the family. The narrative is not problem-focused, but family-focused, and is the story of themselves as a family, the meaning of the relationships within the family, and an understanding of the ways of health and illness in family life. Narrative is the place where knowledge and understanding come together to construct meaning.
Student Clinical Presentations and Paradigm Clinical Case Studies
Students choose a situation from their clinical experience that demonstrates critical thinking and diagnostic reasoning. In addition to the written case analysis, students reflect on the meaning of the experience of providing care, imagine themselves in the client's situation and environment, and are encouraged to "imagine" the meaning of the illness and care encounter for the client and family. Reading these interpretations aloud in class stimulates conversations focused on the learners as nurses, nurse practitioners, parents, and human beings.
Interpretation of Clinical Stories
Students beginning a new clinical course write two stories: the first, shared on the first day of class, describes the experience they bring to the course; the second, written at the end of the course, describes the experience that the course brought to them. Faculty members model how to interpret stories; teachers offer interpretations of their own stories and the stories shared by the students. Students read their own interpretations, read the interpretations of others, and reflect on interpretations in the literature. Students must eventually reach a level of comfort with various ways of viewing the world. Teaching text interpretation is very difficult; teachers must model interpretive practice for students by providing prolific feedback to students regarding every interpretive effort. Teachers also model interpretive practices by doing and sharing their own perspectives and interpretations of texts. Students also learn to interpret through guided exercises of "creative imagining" during which they imagine what it might be like to be "in the patient's shoes," or in the place of the preceptor, or from the viewpoint of the parent of an ill child.
Using Narrative in Research
FNP students design and conduct an independent clinical research project. In past years, students have participated in ongoing faculty research projects, including several phenomenological studies. In a project, students worked with a research team, other students, and a faculty member interviewing participants and interpreting transcribed conversations. Students interpreted their own texts, but also read across the group of texts to refine meanings and to expand their individual perspectives. In the future, students will use the texts created by their clinical stories as the basis of a hermeneutic interpretation across the texts accumulated over several clinical experiences. The interpretations may help students understand the meaning of their participation in advanced practice, their collaborative work, or their family involvement.
Participation in interpretive research also provides FNP students with an important opportunity to re-evaluate their world view in their own clinical practice. At the end of the research experience, students describe how making time for connecting conversations with patients about the illness experience becomes, for them as advanced practice nurses, a hallmark of excellent care. They appreciate the value of an interpretive interaction, in addition to their more clinically-focused "patient history." The process of doing interpretive research results in an enrichment of their own practice base and transforms the way they interact with clients and families (Sloan & Swenson, 1998).
Evluation and Modifications of the Narrative Experience
Students graduating in the first class of FNPs responded in various ways to this new learning situation. Overall, they liked the narrative approach and recognized how their educational experience in a narrative-centered curriculum differed from more conventional programs. One student commented, The independence of what to study and how to learn was a breath of fresh air." Another said, "I loved the interactions with the other students, and both the formal and informal case presentations." Probably our favorite comment was this: "Now that I know about how to listen to stories, I'll never again think of the patient as just a problem to be solved." A young graduate student wrote: "It took me a while to learn how to learn this way, but I probably will never find lectures that helpful again." Some students felt that they did more research and studying than with traditional lecture. As professional nurses and expert clinical thinkers, they liked the narrative case studies because of the experiential nature of this approach. They learn best through experience, and appreciated the opportunity to share what they already knew while learning from colleagues experienced in other specialty areas.
Not every student is comfortable with the narrativecentered approach. Some feel anxious at not being able to identify important content through lectures. For example. "I would say that initially, it (the curriculum) was conflictuel [sic], and I had a hard time. I'm one of those scientific people who has to have facts and outlines and things like that. And to learn by telling stories was difficult for me . . ."Yet this same student goes on to say, "I'd like [to see] storytelling stay as a part of it. I think it was a real helpful part in terms of knowing patients. . . and [building] the partnership between a patient and a provider, that I think medical models simply forget or can't seem to grasp. I think that stories should stay there. But I would like to see more actual presentations of certain specific maladies, for instance like a short, small lecture on the differential diagnosis of anemia and how you would treat that."
If success is measured by passing national certification examinations and by gaining employment as a family nurse practitioner, then these graduates have all succeeded. However, not everyone likes the experience of the narrative-centered curriculum. Student responses, both positive and negative, have been strong. No one is neutral; neither are they bored.
We learn as we go, responding to midcourse and final course evaluations and program evaluations by graduates. We learned that most students still want some kind of lecture, somehow. We learned that they are fearful that they might not really learn it if they are not tested. We were worried that they might not have the test-taking skills necessary to successfully pass certification examinations. We tried various ways of testing, including practice multiple-choice exams, take-home exams, and oral examinations focused on a standardized patient.
We learned that it is hard NOT to lecture. We want to ensure that the students know the essential content and we want them to "look good" in clinical practice and as graduates. We want students to know the boundaries of what is critical knowledge for advanced practice nursing. As a compromise, we offer "mini-lectures" in the form of a consultation, but only after the client story has been analyzed, researched, and interpreted by the class. We encourage students to ask for consultations, and to invite experts to provide short presentations on focused topics identified by the students. Consultants come from within our own faculty, from other schools in the university, or from students' clinical practices.
Diekelmann (personal communication, 1997) has noted that the stories of teachers and the stories of students are more alike than different. We have noted that the more we reveal to our students about what we are trying to accomplish with the narrative-centered curriculum, the more receptive they become. We try to be transparent in our teaching, always keeping students informed about what we have planned, and the reasons behind decisions we make regarding their educational experiences. We tell prospective students that the teaching approaches in the FNP major are different from most they have experienced in academia. We describe the learning opportunities in detail. We suggest that applicants who know they need structure (or those that are not sufficiently self-disciplined, or those who lack writing skills) might prefer the more conventional experiences offered in other majors in the school. Before the first course in the narrative-centered curriculum, we send a letter to students explaining how classes will be conducted and outlining what will be expected of them in the classroom.
To help with the transition to active learning, we take time at the beginning of every course to review principles of self-directed learning, team learning, and inductive, interpretive approaches. On the first day of class, students come with a written story, based in their own personal experience, to share with the class and to offer for interpretation. We explain that we will practice learning to listen to the story, hearing all the voices, and that teachers will participate in the same ways as students do.
Another effort to make our teaching understandable to students is demonstrated in a brief discussion following every class session. This is a "time out," when teachers and students evaluate the teaching and learning that occurred that day. The worries and concerns of each can be shared, and similarities and differences discussed. We openly talk about what went well during the class, what was frustrating, what to fix. Teachers and students have an equal voice in this evaluation.
We have included other nurse practitioner teachers in different aspects of all the courses, and many of them have asked to teach with us again. Gradually, we hope that other majors in our school will use various features of this approach as they become more comfortable with combining conventional and nontraditional teaching philosophies, and as they see its potential for preparing advanced practice nurses.
Narrative has power in teaching and learning. This narrative-centered curriculum is a combination of triedand-true (albeit nonconventional) approaches (case study analysis and PBL) with a teaching philosophy anchored in narrative pedagogy and interpretive research. We are learning to use it effectively, and we think it holds promise for nurse practitioner education as we continue to leave the medical model and search for our unique role as health care providers to clients and famüies. Narrative centered curriculum encompasses the entire educational experience of nurse practitioner students, and enables them to graduate with excellent clinical reasoning skills while maintaining their commitment to individualized care in the context of clinical stories.
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- Sloan, R. S., & Swenson, M. M. (1998). The phenomenon of phenomenology: Connecting education, research, and nursing practice. Prepared for presentation at the Chicago Institute for Nursing Education.
Comparison of Learning Approaches in the Narrative-Centered Curriculum