Preparing nurses to meet the demands of contemporary health care contexts poses an enormous challenge for nurse educators. Increased acuity rates in hospital and community settings, increasing biomedical knowledge and technology, the trend toward specialized care, globalization, cultural diversity, and the way in which corporatization of health care is shaping allocation of resources are just a few of the factors that have served to make the everyday practice of nursing a complex and incredibly challenging affair. As the landscapes of practice have become more complex and varied, the types and range of knowledge and actions needed for competent practice have grown. Nurses are routinely faced with practice situations in which little is straightforward. What patients want and need, the resources or lack of resources available to meet those needs, and how to ultimately be effective in promoting health is variable and uncertain.
In their thoughtful and thought-provoking discussion about nursing education past and present, Diekelmann, Ironside, and Gunn (2005) contended that given the realities of the current milieu, conventional approaches to nursing education are no longer viable—a “revolution” in the way we approach education is required. These authors suggested that both individually and collectively, it is time for educators to look anew at what we are doing and “gather together to think about new possibilities for nursing education” (p. 75). The discussion in this article is offered in the spirit of that call.
Our own contemplations about the challenges of nursing education have led us to take a careful look at the way we are orienting our work—and in particular at the epistemological orientation that governs our work. Most often, education is epistemologically oriented and revolves around “knowing” and “covering the content.” Within epistemologically oriented education, the “subject” under study is considered to be the specific content that students need to learn, such as nursing theory, anatomy, and pathophysiology. Given the overwhelming amount of content and the realities of health care milieus, the limitations of such an epistemologically oriented approach have become increasingly evident. For example, as Diekelmann et al. (2005) contended, “covering” and “delivering” the overwhelming amount of available content while ensuring students have the opportunity to integrate that content into practice has become virtually impossible. In addition, it is clear that knowing content does not necessarily translate into competent action at the bedside (Hartrick Doane & Varcoe, 2008).
As we have begun to question what we are revolving our teaching around, we have purposefully begun to reorient our work toward ontology. With an ontological orientation, the “subject” of education becomes the student as a developing person and nurse. The ontology of the student (i.e., his or her way of being a nurse) becomes the primary focus. Similar to the description of formation set forth by Benner, Sutphen, Leonard, and Day (2010), we have oriented the educative process toward students’ personal and professional transformation. This ontological turn shifts the relationship between epistemology and ontology in such a way that epistemology is put to the service of ontology (Dall’Alba & Barnacle, 2005; Thomson, 2001). Knowing and knowledge development is oriented around moving the student from “acting like a nurse to being a nurse” (Benner et al., 2010, p. 176). The focus of study for both students and teacher becomes that of enhancing and evolving students’ ways of being so they become responsive, knowledgeable, ethical, competent nurses.
The Ontological Turn
Drawing on the work of Heidegger, Dall’Alba and Barnacle (2007) described the essential link between education and ontology, emphasizing the way in which our approach to education is reflected in how we treat ontology. Certainly, the link between education and ontology has been an embedded feature of nursing education since its inception. There has been a strong emphasis on providing learning opportunities that support students to become safe, competent practitioners. Yet in taking a close look at the actual structure of the educative process, it is also possible to see an epistemological orientation dominating. For example, most often curriculum is organized and structured around knowledge (theory and content) and the translation of that knowledge into practice (knowing-in-action). Overall, the educative process revolves around epistemology—around “knowing in order to do.”
Dall’Alba and Barnacle (2007) purported educational approaches that foreground knowledge tend to “render irrelevant or invisible the necessary commitment, openness, wonder, or passion that are integral to learning, or to taking action more broadly” (p. 681). Inspired by Dall’Alba and Barnacle’s compelling argument for an ontological turn in higher education, we have begun to explore how our approach to nursing education might shift if nursing education were to take an ontological turn—if the educative process was oriented ontologically and epistemology was explicitly put to the service of ontology. With the goal of providing learning opportunities and an educative process that can support students to develop confident and competent practice within the shifting, complex terrain of contemporary health care milieus, we consider what is referred to in nursing curricula as interpersonal communication, communication skills, and relational practice to explore an ontological turn and what it might mean to shift the relationship between epistemology and ontology. Such a shift seems to be resonant of the question Tanner (2004, p. 3) posed in an editorial: “What if one of education’s aims was for students to make sense for themselves what life means and how that shows itself everyday in nursing practice?”
Contextualizing Knowledge: Looking Through a Relational Lens
Dall’Alba and Barnacle (2007) described that with an ontological orientation:
Knowing is not reducible to thought or the discursive. Instead, knowing is always situated within a personal, social, historical and cultural setting, and thus transforms from the merely intellectual to something inhabited and enacted: a way of thinking, making and acting. Indeed a way of being.
Thus, an ontological turn in education explicitly emphasizes and illuminates the way in which knowledge and knowing are inherently related to subjectivity and context (Barnett, 2000
; Dall’Alba & Barnacle, 2007
; Thomson, 2001
As we have approached knowledge development and knowing ontologically—with the goal of enhancing informed, responsive nursing action—a relational lens has been central. Approaching education through a relational lens, we are “always assuming and looking for how people, situations, contexts, environments, and processes are integrally connecting and shaping each other” (Hartrick Doane & Varcoe, 2005a, p. 51). This relational lens highlights the way in which meaning, interpretation, and the knowledge translation process are being shaped by who the student is in any given moment and where he or she is located, that is, how the student in context is being, knowing, and acting.
To illustrate what an ontological turn might look like in practical terms, we use the learning and teaching of interpersonal communication and relational practice within nursing as an example. Our choice of “content” area has been influenced by several recent experiences that have highlighted just how central communication and interpersonal comportment is to every aspect of nursing practice. Our own experiences that inspired this choice include a firsthand experience as a patient, experiences of family and friends during recent hospitalizations, experiences as both teachers and learners, and experiences we have had through formal research we have undertaken. Collectively, the experiences have highlighted the integral “whole” of interpersonal comportment and competent, safe nursing practice—how interpersonal comportment in many ways determines, potentiates, and contravenes effective, safe, responsive nursing practice. At the same time, the experiences have highlighted how the teaching-learning of interpersonal communication can become mis-educative when knowledge and content are not translated ontologically. To illustrate, we share one teaching experience:
In following up with Angie, a student who had just completed a shift in a postpartum practice area, there was distress in her voice. Angie spoke of caring for a woman who had given birth to a stillborn baby in the hours just before her shift began. She described how she had started the shift with a clear set of the tasks to meet the woman’s postpartum physical needs. However, as the day went on and the physical needs had been addressed, she became less and less clear about how to be with her patient. I asked Angie about how she had spent her time with the woman after the main tasks had been done. She described how she had tidied up the room, responded to requests to contact family members, managed visitors, coordinated a time for the social worker to come, and basically just tried to be responsive and resourceful, quietly moving about the room with the intent to unobtrusively attend to the woman’s needs. Interestingly, in describing all of this, Angie concluded that she had been ineffective as a nurse, stating “I didn’t know what to say to her.”
In response, I asked what “knowing the right thing to say” might offer to the woman—how that might make her nursing more effective? Angie told me that her goal was to provide comfort so she could ease her patient’s pain. Having taken the communication course that had focused on behavioral skillfulness, Angie was translating effective nursing as “knowing what to say.” Moreover, she deemed her responsive actions as less valuable than having the right words of comfort to offer her patient.
In response, I began where Angie was—in her ontological struggle to enact her caring in words. I suggested that we consider various things she might have said to ease the woman’s pain. It quickly became clear that there were no words that would really be able to ease the woman’s pain following the death of her baby. In gaining that awareness, we were inspired to consider whether there were perhaps other responsive and effective ways of caring for her, of offering comfort during this incredibly painful time. As we explored those possibilities, Angie began to see that she had in fact enacted some of those forms in the nursing care she had been providing. This exploration opened up the space to consider the interrelationship between responsive, competent nursing care, interpersonal communication, and relational comportment.
This story illustrates the complex process of knowledge translation. It highlights the way in which meaning, interpretation, subjectivity, and context are integrally related, and how broader ideologies, norms, discourses, and educational practices shape and influence knowing-in-action—and ultimately the face-to-face interactions between students and patients. For example, although communication content taught in discrete courses (such as verbal behavioral skills) can certainly support responsive and competent nursing care, what is crucial (whether in the classroom or clinical learning) is how that content and knowledge support the ongoing development of the learner’s relational comportment and subsequent action.
Having had the experience of “learning” through earlier communication coursework that encompassed verbal skillfulness, the student in the story equated and evaluated her skillful relational comportment with “knowing the right thing to say.” Fortunately, the student was open about her “ineffectiveness,” and the teacher was able to open the space and opportunity for the student to examine that knowledge ontologically. Similar to Tanner’s (2004) suggestion of a teacher acting as a mentor and guide, the teacher asked the student how she had been with the woman and what her experience was. At the same time, the teacher listened carefully for the interpersonal and communicative “sensibilities” that were informing the student. In so doing, the teacher intentionally put epistemology at the service of ontology. For example, the sensibility that skillful relational comportment rests on verbal interaction and knowing the right thing to say was scrutinized in light of the particular situation and the student’s actions. Inquiring into what, why, how, how better, ought, and ought not of the student’s relational comportment in the particular situation, the student was able to explore other possibilities of relational know-how and comportment. As Benner et al. (2010) have described, this involvement of “asking what the students are paying attention to and how they understand what they are seeing” (p. 187) is crucial to their ongoing formation.
This relational transaction in learning has been described eloquently by John Dewey (1938). Dewey, one of the most influential writers on education, whose work has been the foundation for many of the contemporary approaches to experiential learning, emphasized that learning always arises through the relational transactions and interactions occurring within and between the learner and his or her world. Dewey described the organic connection between education and experience. As a moving force, each learning experience “teaches” students something, and the learning that students experience in one situation is taken into future situations, affecting subsequent experiences and subsequent learning (Dewey, 1938). Thus, according to Dewey, experience is both the means and goal of good education.
Within the vignette above, it is possible to see this organic process of one experience (learning communication content) shaping future experiences (learning in clinical practice). Moreover, it is possible to see what Dewey (1938) described as mis-educative experiences. Dewey (1938) emphasized that not all experiences are genuinely or equally educative. What determines whether the educative experience is “good” is what the experience and learning moves us toward and into as people. For example, some experiences are what Dewey (1938) termed “mis-educative” in that they arrest or distort growth, or may engender callousness and lack of sensitivity and responsiveness. At other times, experiences may be disconnected from one another so that a learning connection does not occur.
Returning once again to the vignette above, it is possible to see the mis-educative potential of the situation and how our well-intended efforts as educators can become “mis-educative.” The student had learned to equate skillful interpersonal comportment with verbal techniques she had learned in class. This epistemologically oriented learning was in some ways inadvertently limiting her interpersonal comportment. It is when ontological learning and knowing are obscured by epistemology that the potential for mis-educative learning is heightened. Thus, Dewey (1938) emphasized the importance of enlisting the available surroundings in the learning process and centering learning in people rather than content. Regardless of what is happening in the surroundings (e.g., excellent or poor role modeling, effective or ineffective communication strategies, and good or poor health care), those surroundings offer raw educational material that can and must (given the potential for mis-educative experiences) be used to create what Dewey (1938) termed “worthwhile” learning experiences.
An Ontological Orientation
We chose the vignette above because it offers a simple, everyday example of good clinical teaching that many educators probably enact daily. At the same time, it illustrates the subtle yet profound significance of an ontological orientation and how vital it is to: 1) orient teaching toward people, experiences, and action; 2) intentionally enlist the surroundings within which students are living and practicing to contextually locate learning in complex places (Dewey, 1938); and 3) intentionally put teaching and “knowing” at the service of ontological development and learning.
Orienting Toward People, Experiences, and Action
An ontological orientation in education focuses on people, experiences, and action. Because action is fundamentally ontological, Ricoeur (1991) contended that understanding, including interpretation and translation, is not simply a mode of knowing but is a way of being and way of relating. “Rather than treating knowledge as information that can be accumulated within a (disembodied) mind, learning becomes understood as development of…ways-of-being” (Dall’Alba & Barnacle, 2007, p. 683).
Taking an ontological turn very intentionally puts epistemology at the service of being and becoming a responsive, knowledgeable, and skillful practitioner. Although existing theory, research, and skill-based knowledge is still central to the learning process, a fundamental distinction with ontologically oriented pedagogy is the way in which ontological motivation shapes teaching and learning. Ontologically, the learner as subject does not so much follow or apply knowledge as respond to the possibilities any knowledge implies. The learner does not act from:
behind the text…but in front of it, at that which the work unfolds, discovers, reveals. Henceforth, to understand is to understand oneself in front of the text…[it is a matter of] exposing ourselves to the text and receiving from it an enlarged self… corresponding in the most suitable way to the world proposed.
For example, students most often are required to complete course readings prior to class and are expected to come to class or the clinical experience prepared to show that they “know” the material from the readings (they are directed to stand behind the text). In many instances, students are quizzed, either through questioning or through written tests, so that teachers can determine whether students know the content within the readings. When one orients teaching ontologically, students are invited to stand in front of the text. Interpersonal relationships are understood and approached as sites where nursing identity, values, knowledge, policies, and goals are translated into action at the ontological level. Students are supported to become skillful practitioners who are self-initiating, self-correcting, and self-evaluating within the complexities, challenges, and competing obligations of each practice moment (Baxter Magolda, 2004; Hartrick Doane & Varcoe, 2005a).
For example, a postclinical conference might invite students to “stand in front of the text” by considering textbook sections in light of their experiences that day—to question how (and how not) the knowledge within the text was relevant to their particular experience, how they engaged or did not engage, and how the patient responded. In this way, the assigned textbook reading becomes a resource for further inquiry—inquiry motivated by the students’ own ontology, questions, insights, experiences, and ontological motivation (e.g., the motivation to give good care to a patient in a particular circumstance). Ontologically as a learner, the student does not so much follow or apply knowledge as respond to the possibilities the knowledge implies. In this way, learning is “cast as continuous invention and exploration, produced through the relations among consciousness, identity, action and interaction, objects and structural dynamics” (Fenwick, 2003, p. 131).
This ontological process rests on inviting students to be fully engaged as individuals, to take up knowledge as a verb, and to be knowers in an active living sense. The crucial conceptual shift of an ontologically oriented learning is from “a learning subject to the larger collective, to the systems of culture, history, social relations and nature in which everyday bodies, subjectivities and lives are enacted” (Fenwick, 2003, p. 131). The learning strategy becomes that of inquiring into one’s way-of-being and how the proscribed intelligibility including knowledge, ideology, and normative practices and structures are shaping, limiting, and enhancing action. It is comparable to Parker Palmer’s (1998) proposal that as teachers, we teach who we are, indicating how each teaching moment is an enactment of self in relation with others.
Within the domain of communication education, the focus shifts from asking students to apply concepts of communication, such as therapeutic use of questions, paraphrasing, self-disclosure, and interviewing skills (van Servellen, 2009), to creating opportunities for students to acknowledge and enlist existing knowledge and sensibilities while simultaneously examining one’s way-of-being (including the knowledge and sensibility informing that way-of-being). Similar to shifting the lens of the camera, the content and skill acquisition necessary for “competence” in communication moves to the background, and at the focal center is the embodied ontology of the student.
Facilitating Learning in Complex Spaces
In reviewing communication education in nursing, Chant, Jenkinson, Randle, and Russell (2002) described a number of problems and barriers including significant differences in the behaviors, strategies, and attributes considered to constitute communication content. They also described the lack of attention given to the impact of social context and the hidden curriculum within that context. Following their in-depth study of communication education in England, Chant et al. (2002) concluded that overall, what is required is better integration of the individual and the social domains.
Brown (2008) found similar patterns in nursing practice when researching interpersonal spaces of maternal-infant care. Although the women receiving care in Brown’s study were attuned to the way in which their health care experiences and interactions with health care providers were shaped by the differing people, policies, contexts, and normative practices within the health care milieu, the nurses in the study framed and understood those interactions on the basis of individualist, decontextualized understandings of relationships. Even though the influence of the contextual backdrop on the face-to-face moments of care was strikingly evident during the research, the nurses did not tune into or locate their individual practice within the larger context of the health care milieu. The nurses described and acted as though the interpersonal care and the communication strategies required for achieving therapeutic ends resided solely within themselves.
The findings from these two studies are not necessarily surprising. Decontextualized neutrality is central to Western neoliberal ideology in which individualist assumptions and values neglect the ways in which individuals are formed through social contexts and enact the values and norms of those contexts—how they quite literally come to embody the contexts in which they learn and practice (Browne, 2001; Hartrick Doane, 2002; Hartrick Doane & Varcoe, 2008; Kymlicka, 1989; McGregor, 2001). Although neoliberalism and its impact on nursing knowledge and practice has received a fair bit of attention and critique throughout the past decade, its legacy continues to be felt in nursing education and nursing practice. For example, communication and interpersonal practice often continues to be taught within the confines of an individualist perspective that focuses on the nurse-patient relationship and communication skills outside of the ideologies and norms of the larger health care context. Relational concepts such as trust, empathy, and respect are neither conceptually nor practically linked to issues of social justice, equity, ethics, or safe, competent practice (Hartrick Doane & Varcoe, 2005a, 2005b, 2007, 2008).
The impact of this individualist approach to communication education and the significant implications it has for the enactment of nursing care was highlighted in Brown’s (2008) research. The nurses often did not see how contextual norms and limitations were shaping or constraining their interpersonal practice. Moreover, they tended to view their relationships and interpersonal care functionally as opposed to experientially, seeing them as “neutral” means to an end. However, Brown’s (2008) research revealed that the relationships were anything but neutral both in terms of experiential impact and health outcomes. The women poignantly described how it was often the words not said by nurses that sent the most powerful message; it was in what was not said that several women felt erased and dismissed in terms of their own capacity to carry their high-risk pregnancy to term. Moreover, the forms of communication, both verbal and nonverbal, created situations that had tangible (and often negative) physiological and psychological effects on the women’s health capacities and health outcomes.
From experiences such as those described in Brown’s (2008) research and studies that confirm how patients’ experiences of communication impact particular health outcomes (Haynes, MacDonald, Garg, & Montague, 2002), the question of how to educate nurses to understand therapeutic communication and interpersonal comportment as being about more than individual interaction and behavioral skillfulness (Brown, 2008) is vital. It requires that, as Fenwick (2003) suggested, we “accept the moment of experiential learning as occurring in action, within and among bodies…the mind’s insight is after all only a late ‘catching up’ to what the body has already learned in the interactive moment of experience” (p. 131). It requires being in and experiencing the non-neutrality of interpersonal spaces (Brown, 2008) to move beyond decontextualized, disembodied notions of communication competence.
Putting Knowledge and Teaching at the Service of Ontological Development and Learning
In essence, an ontological turn contextualizes knowing and action, and simultaneously orients teaching toward students as learning beings. In other words, the subject under study shifts from communication content to the student as becoming person. As such, every decision, whether it be related to which content, readings, learning activities, or assignments to include in the curriculum, is made within the context of how it will support learning and becoming. Although most educators probably would say we already do that, and often we do, when we have looked carefully at our own work, it is often possible to see subtle ways an epistemological orientation and emphasis on content are undermining that learning focus.
For example, Dall’Alba and Barnacle (2007) explained that when we focus on content and knowledge rather than learning, learning is often treated as a given and as unproblematic. Yet, as illustrated in the vignette regarding the student Angie, an emphasis on knowledge and knowing (e.g., covering the content of communication skills) translated for her into a potentially mis-educative experience—she translated skillful relational comportment into “knowing the right thing to say.” Although valuable knowledge of how to enhance interpersonal comportment was offered, it actually created a “learning” concern. Not only was the knowledge the student had learned limiting her practice, it set her up to understand and evaluate her own relational comportment in a limited way. Although the student had learned communication skills, she did not “know” how to integrate and localize that knowledge within the nursing situation.
This reflects Dall’Alba and Barnacle’s (2007) contention that when knowledge and skills are taught in a decontextualized manner, the difficult task of integrating knowledge into practice often falls to the students. The relevance of the knowledge is implied and assumed rather than explicitly addressed. At the same time, methods of evaluating students’ knowledge most often focus on testing acquisition of content separate from their being responsive, effective, and safe practitioners. Moreover, “not knowing” how to translate content into action (as in the vignette described earlier) may be viewed as signifying the student’s lack of communication competence.
When one takes an ontological orientation to the teaching-learning process, students’ non-knowing becomes the impetus for ongoing inquiry and learning, and the educational emphasis shifts to supporting students as they grapple with how to be responsive and effective in particular situations. Valuing students’ reflections on moments where they “did and did not know” implies we are open to their continual inquiry into how to best know, be, or do in any given moment. For example, a shift from creating assignments that test the quantity of knowledge students may or may not possess (i.e., multiple-choice questions where students are required to select the “right” thing to say to a patient) toward evaluation strategies designed to highlight the complexity of interpersonal comportment might be one way to facilitate the contextual translation of knowledge into action. Asking students to generate strategies for being with patients based on their insight and knowledge while in the midst of clinical practice could provide opportunities to bring together their experiences from practice and their learning about communication theories and skills. In this way, students are invited to learn how interpersonal moments are shaped by multiple contextual forces and to simultaneously question and imagine possibilities for effective communication within their own nursing comportment.
Overall, putting epistemology at the service of ontology puts teaching at the service of learning and involves teaching students to become practitioners who continually scrutinize themselves and their surroundings, including the knowledge and sensibilities they are drawing on to enact themselves as knowledgeable, compassionate, and competent nurses. It also means that as educators, we need to be comfortable with moments in which students are “under way” in terms of developing their comportment and inquiry skills. For example, when students do not have the answer to our questions or are struggling to determine how to best proceed, we might consider such moments of uncertainty and not knowing as prime opportunities for ontological development. We might enlist the experiential impetus to more explicitly guide them to question further, inquire into and seek out resources, read existing knowledge, invite class discussions, and generate new questions.
Imagine that Angie returns to her clinical placement experience the following week. Once again she finds herself in the midst of caring for another woman whose needs may only be evident by Angie’s capacity to tune in to the woman’s gestures, her movements, her physical discomfort following a cesarean section, and her interactions with her infant and her family. Imagine during the clinical postconference that Angie recounts the way she reasoned out the postpartum caregiving priorities through an ontological lens—asking herself how she might be with this woman. Recalling her experience in practice the previous week, she recounts how she presenced within the current situation and engaged in a self-inquiry process observing herself in action—paying attention to how she was interacting with the woman; what leads she was following or not following; what contextual forces and ideologies were pressing in on her; what past experiences, readings, and class discussions she was drawing on; how at times she knew just what to say and at other times she did not; and what she ultimately learned about herself and about nursing.
Such an ontological turn in education might involve a shift in our own approach as educators—that of tuning into and intentionally looking at how we were living and enacting knowledge within our educational practices and how that is supporting or contravening ontological learning and development. An ontological turn requires that we take an inquiry stance, constantly scrutinizing our educative actions to see what theories and truths are governing our own interpretations and approaches with students. Are we fully and explicitly using existing experiences (both classroom and clinical) to support the learning and development of skillful nursing comportment? How might our assignments and approaches to assigned readings better support Dewey’s (1938) compelling connection between experience and learning? How might we more intentionally create experiences that explicitly address the ontological process of knowing-in-action? What linkages between ontology and epistemology do we need to more explicitly create? How can important communicative concepts such as questioning, listening, and reflecting be learned contextually? Finally, how, at the fundamental level, might we support the being that makes any responsive knowing-in-action possible?
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