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Enlightenment, empowerment and emancipation: the case for critical pedagogy in nurse education
Enlightenment, empowerment and emancipation: the case for critical pedagogy in nurse education Jane Harden
Jane Harden RN, DPSN, CertEd, BSc(Hons), Senior Lecturer, Faculty of Health, Social Work and Education, University of Northumbria, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK (Requests for offprints toJH) Manuscript accepted 8 December 1994 Nurse EducationToday(1996) 16, 32-37
This paper explores the notion that nurse education is a political activity which is value laden and has multiple social meaning. As long as teachers continue to pursue liberal and andragogical theories of learning, students will fail to develop a critical consciousness. The implications are vast as nursing prepares to enter the next millennium: notions such as the reflective practitioner and the knowledgeable doer feature highly on the profession's educational agenda, both of which implicitly require critical thinking skills. By using Habermas' definition of 'critique' as a framework and Paulo Freire's concept of 'conscientisation' as an educational model, it is argued that nurse teachers can expose the oppressive structures which confine and limit the nursing experience. Only then, when our oppression, both as women and nurses has been recognised, and a critical consciousness achieved, can true humanistic care be given. Through the development of emancipatory nursing actions can the profession stop colluding with the social structures which keep many people and groups in oppressive conditions. We should, in short, be teaching for 'peaceful revolution'. © 1996PearsonProfessionalLtd
INTRODUCTION Developing critical consciousness in students should be a quintessential part of the nurse teacher's role, and yet we are constrained by our own educational philosophy: the notion of andragogy. The major assumption which underpins andragogy is that adult learners, through their own backgrounds and rich life experiences are driven by a desire to become self-directed, independent and autonomous in their learning careers. However according to Thompson (1987) everyday living as experienced by the majority is characterised by a naive, pre-reflective adherence to 'established' versions of the life world. The consequence of this is that 'factual' or doxic, patterns o f living are never challenged, and the question of legitimacy is never raised, because the social world is presented and accepted as a natural phenomenon. For too long nurse education has submerged its students in a situation in which critical awareness and response are practically impossible. By embracing andragogy we have become both the oppressor and the oppressed at one and the same time. Paulo Freire (1972) has described a 'culture of silence' which exists among the oppressed. He came to realise that lethargy and ignorance were the direct product of the whole situation o f economic, social and political domination and o f the paternalism - o f which they were victims. For the purpose of this paper I shall apply Freire's model of education to the vocational career of nursing, and argue that unless we teach for emancipation, the concepts o f the knowledgeable doer and the reflective practitioner will never be realised. I am not going to offer the reader a critique o f andragogy, as this has already been done in the excellent article by Philip Darbyshire (1993). Rather I shall develop further his argument, and present a case o f need for a critical pedagogy in the education of our future nurses. Pedagogy has been defined by Lusted (1986) as: The transformation of consciousness that takes place in the intersection of three agencies - the teacher, the learner and the knowledge they together produce. Whilst critical pedagogy is, according to Luke & Gore (1992), centred on hope, liberation and equality, with agency and raised consciousness at centre stage, albeit with structural constraints acknowledged. It is theoretically grounded in the Frankfurt School o f Sociology, Gramsci's notion of hegemony and Freire's educational practice and concept o f conscientisation. Taken together, negative critique, counter hegemonic practices and conscientisation
Enlightenment, empowerment and emancipation: the case for critical pedagogy in nurse education 33
provide a powerful agenda for emancipatory education. But how do we translate such weighty abstract theory into nurse education? More importantly, perhaps, is why should we?
ARE WE NOT ALREADY
FREE?
It is the premise of this paper is that nurses can be viewed as an oppressed group, a view supported by the fact that nurses lack autonomy, accountability and control over their own profession. Yet nursing is by far the largest occupational group within the sphere ofhealthcare, so why is it so powerless? For me history of the domination o f nursing is inextricably linked to that of the domination and oppression of women. Marriner (1978) has suggested that leadership is lacking in the nursing profession because the persons attracted to it have certain characteristics, low self-esteem lacking initiative and submissiveness for example. Because nursing continues to be perceived as a subservient, non-autonomous, rigid, stifling and non-creative occupation it will continue to appeal to people who possess those traits, and to w h o m self-actualisation and responsibility are threatening prospects. W o m e n who seek exciting, autonomous and creative careers will go elsewhere. Jo-Anne Ashley (1976) in her seminal work,
Hospitals, Paternalism and the Role of the Nurse, describes that hospital managers and physicians have benefited from control over, and exploitation of, nursing. The reason for dominance is based on the fact that both these patriarchal professions need nurses. Dingwall et al (1988) have traced the beginning of the domination (or colonisation as Roberts (1983) prefers to describe it) of nursing by others and found that it occurred in the late part of the last century when care o f the sick became institutionalised. This also coincided with the emergence of the new dominant professions, particularly medicine, which used its new found power to sanction attacks on what it deemed to be unsuitable behaviour, whether by their patients, nurses or society as a whole. Many nurses have internalised the values of doctors, and developed a 'mini-medical' knowledge base in the vain hope that if they can attain the characteristics of the powerful, they too will become powerful (Roberts 1983), and perhaps even achieve the nursing equivalent o f the Holy Grail, professional status. Freire (1972) pointed out that the major characteristics of oppressed group behaviour stems from the ability of dominant groups to identify their norms and values as the 'right' ones in society and from their initiad power to enforce
them. In most cases of oppression, the dominant group looks and acts differently from the subordinate group (white coat or mufti versus uniform). The characteristics of the subordinate group become negatively valued, which over time contribute to the maintenance of the status quo. The tendency is for the subordinate group, as well as the oppressor, to internalise these norms and to believe that to be like the oppressor will lead to power and control. Lewin (1983) has described how individuals with certain expectations and goals see belonging to the subordinate group as an impediment to achieving their ambitions. The result is 'assimilation'. People who are successful become known as 'marginal' because they do not belong to either group, but rather are on the fringes of their own group and unable to be a full member of the dominant group. Hedin (1986, 1987) has described this process ofinternalisation and attempt at being marginal as leading to certain personality characteristics: self-hatred and low self-esteem. These attributes can be easily understood by the realisation that to want to be more like the dominant culture, the subordinates must reject their own characteristics. These attributes combine to create what Carmichael & Hamilton (1983) have described as submissive-aggression syndrome. The oppressed person, when able to feel aggressive against the oppressor, is not able to directly express it. Although there may be much complaining within the oppressed group, selfhatred and low self-esteem create submissiveness when confronted with the powerful figure. Fanon (1983) reports that aggression in oppressed people may be vented in an even more self-destructive way. 'Horizontal violence' or conflict within the oppressed group is a result of being unable to revolt against the dominant group rather than, as is often interpreted, a characteristic inherent in oppressed groups. This trait is more than obvious amongst nurses, education versus service; ward staffversus nurse managers; day-staff versus night-staff and so on. Many in the profession find the whole concept o f oppression difficult to accept, and the suggestion is often met with hostility. Domination is, however, most complete when it is not even recognised, suggests Freire. The watershed for nursing must surely be the introduction of the Project 2000 diploma course with nurse education moving from the hospital, the domain o f the physician, into higher education, where nurses will have increased control. But as Lynaugh (1980) points out, since the paternalistic model of education, widely assumed as correct has been operating since the turn of the century, nurses, like other women, do not see the need for a
34 NurseEducationToday 'university education'. Our history, as both nurses and women, has brought us to this juncture. Freire (1972) has described education as suffering from 'narration sickness', the teacher talks about reality as if it were motionless, static, compartmentalised and predictable, or alternatively, expounds on a topic completely alien to the existential experience of the students. Thus, narration turns students into 'containers' to be filled by the teacher. The more completely the receptacle is filled, the better the teacher. The more meekly the receptacles permit themselves to be filled, the better the students. Nurse education, argue Holloway & Penson (1987) has followed this model for years, little more than social control, it has been the vehicle by which the status quo has been maintained. The 'banking system' as Freire calls it positively holds students back, as the more they work at storing the deposits entrusted to them, the less they develop the critical consciousness to transform the world. The ethos of Project 2000 is to encourage the development and growth o f the 'knowledgeable doer'. Implicit in this is the raising of critical consciousness. The notion o f reflective practice, now high on the nursing agenda, is an aspect of emancipatory education, and has a critical component also (Miller 1992). So in what Freire has described as problem-posing education, students need to develop their power to perceive critically the way they exist in the world, with which, and in which they find themselves; they come to see the world not as a static reality, but rather as a reality in transformation.
BREAKING THE C H A I N S T H A T B I N D US According to Habermas (1979) social critique is most useful in liberating people and aggregates from domination, but it must be aimed at the fundamental structures and ideologies o f social systems. The fundamental structures of a society include: • the kinds of work and wages that are available and to w h o m • the meaning ofprivatised, unpaid work and who does it • assumptions about what constitutes a family • access to education • images of women, racial minority groups and gay people in the media • the availability of health care • the profit motive of capitalist economies and the distribution of wealth • law and law enforcement. Such social structures define how privilege, exploitation and powerlessness are distributed
among persons and groups in the society. Racism, sexism, ageism, heterosexism and classism are some of the fundamental dogmatic ideologies that are internalised in social structures and thus operate in unexamined ways. Introducing student nurses to critique and its associated concepts as defined by Critical Theory, is a useful lens through which to view health and health care.
Critical Theory Critical Theory refers to a series o f ideas that emerged in Frankfurt in the 1920s. These ideas were based on critical Marxist self-understanding and Hegelian dialectics that stressed the principles o f contradiction, change and movement. There are two basic features o f dialectical analysis: 1. There is not a simple one-way cause and effect relationship among the various parts o f the social world. For the dialectical thinker social influences never simply flow in one direction as they do for cause-andeffect thinkers. To the dialectician one factor may have an effect on another, but it is just as likely that the latter will have a simultaneous effect on the former. This kind of social thinking does not mean that the dialectician never considers causal relationships in the social world. It does mean that when dialectic thinkers talk about causality, they are always attuned to reciprocal relationships among social factors, as well as to the dialectical totality o f social life in which they are embedded. 2. In dialectical analysis social values are not separate from social facts. The dialectic thinker believes that not only is it impossible to keep values out o f the study o f the social world, but it is also undesirable, as it produces a dispassionate, inhuman sociology that has little to offer people in search o f answers to the problems they confront. Facts and values are inevitably intertwined, with the result that the study o f social phenomena is value-laden. Critical theorists, according to Stevens (1989), are concerned about interpreting 20th century history, their basic belief was that no aspect of social phenomena may be comprehended unless it is related to the historical whole and to the structural context in which it is situated. The primary goals o f these theorists were to break the grip o f closed systems o f thought and to counter the unreflective affirmarion o f society (Thompson 1987). Habermas (1979) places critical theory within a framework o f scientific knowledge. He distinguishes types of scientific knowledge
Enlightenment, empowerment and emancipation: the case for critical pedagogyin nurse education 35 by examining critically the interests they serve. His categories of knowledge are: 1. empirical/analytical knowledge, which serves the interest in technical control of the environment 2. historical/hermeneutic knowledge, which has a practical interest in understanding individuals subjective experiences 3. critical theory, which is interested in liberating people from unacknowledged circumstances of domination and transforming constraining conditions. Habermas does not question the validity of the first two forms of knowledge, but he does demand that they realign their self-perceptions in relation to each other and to the critique of domination (Thompson & Held 1982). Stevens (1989) argues that two of these epistemologic categories, empirical/analytical knowledge and historical/hermeneutic knowledge, are becoming better established in nursing, whereas critique and analyses of how domination affects health and health care are still in their infancy.
U n d e r p i n n i n g concepts 1. Oppression and domination are used interchangeably to indicate unequal power relations embedded in basic structures and functions of society: oppression, which inheres in the social structuring of life limitations that are not equally experienced across groups, is the systematic abbreviation of possibility by which dominated people are constrained in their quest for human potential. 2. Liberation is freedom from the coercion and constraint of oppressive social structures; the particular freedom of individuals is understood within a social and collective context. 3. Dogma or ideology is a dominant, authoritative system of ideas whose underlying assumptions and premises have not been sufficiently examined or challenged. 4. Critique is a process that consists of several components: (a) oppositional thinking that unveils and debunks oppressive ideology by explaining the implicit rules and assumptions of the historical, cultural and political context; (b) reflection upon the conditions that make uncoerced knowledge and action possible; (c) analysis of the constraints upon communication and human action; and (d) dialogue. • 5. Dialogue is mutual interaction that raises collective consciousness by clarifying, affirming and integrating the historical, social, political and economic experiences of communities.
6. Conscientisation is learning to perceive social, political and economic contradictions and conceiving of ways to take action against oppressive contradictions. 7. Action is informed, deliberate, meamngfnl behaviour and verbalisation by those experiencing oppression that seeks to bring about social change; it is based on critical insights, reflection and dialogue. (Stevens 1989)
E m a n c i p a t o r y teaching We must accept that teaching is a political activity, and be aware that everything we teach is value-laden and that neutrality is a myth. Chally (1992) has argued that nurse teachers have failed to instil vision, meaning and trust in their students, as learning that occurs must be measurable and is outcome-based. Through an obsession with the know-that form of learning, students are being prevented from learning how to challenge and critique. Andragogy reinforces the blind pursuit of facts, as the social value of knowledge (particularly of a scientific nature) is immense. In short, student nurses are being prevented from learning how to learn due to both internal and external factors. Emancipation requires teaching practices that are liberating, but it also requires commitment from the learner. As Bevis & Murray (1990) have stated, that while lecturing does not teach how to critique, or how to come to our own meanings, it does provide information that can be used to raise consciousness, to alter perceptions and to shape criticism. Students must learn to construe their own meanings, through their own frames of reference, and teachers must resist the temptation to control, validate or interpret the perceived meaning. This raising of consciousness lea& to enlightenment regarding the mythical, religious, scientific, practical and political interpretations of the world (Habermas 1979). Wheeler & Chinn (1989) describe the power of nurturing that respects individual circumstances and life experiences, but as Chally (1992) argues, most germane to education is the power that results from knowledge. She offers five tools of empowerment to actualise a shared vision. They are: • Positive self-concept, teachers who feel positive about themselves are better equipped to meet the needs of others; • Creativity, ideas are generated, new ways of doing things are developed and alternatives imagined; • Resources, as well as funds, space and materials, teachers are also a vital resource.
36
NurseEducationToday It is our responsibility to keep updated within our field o f expertise; • Information, being 'in the k n o w ' regarding data and technical knowledge, but also being aware that political intelligence is another information tool o f empowerment; • Support, which can be given in a number o f ways, from written feedback to a smile. Empowering students results from teaching methods characterised by commitment, caring and interaction. As such they are in keeping with the goals o f feminist pedagogy, which is itself critical in nature (Luke & Gore 1992). Hezekiah (1993) cites an atmosphere o f mutual respect and trust, shared leadership, cooperative structures, integration o f cognitive and affective learning and action as being fundamental to educating nurses (or women). As teachers we must exposure the reality o f the structures that oppress them and give them the tools o f k n o w ledge whereby they can critically reflect on their condition, in a climate o f mutual trust, collaboration and respect. Thompson (1987) tells us that critical scholarship in nurse teaching is a sign that we are responding sensitively and intelligently to nurse's own historical experiences. W h y is our own history o f oppression, both as w o m e n and nurses, relevant to our clients, and what can an understanding o f it offer in terms o f patient care? Kendall (1992) calls for nurses to recognise the reality that health, education and social problems are inextricably linked. For too long nursing has been involved with helping clients adapt to their oppression, and a model o f emancipatory nursing action is called for. Emancipatory nursing actions include taking gender, race and class considerations seriously, conceiving all social structures as containing an interplay of contradictory forces and, attempting to understand the factors that make people define social reality the way they do. Promoting an environment where nurses can communicate freely may be thought of as revolutionary considering the setting where most nurses are employed: hospitals. Long considered bastions o f patriarchal bureaucracy and control, the hierarchical communication systems have been designed to enforce the status quo, but it is not only nurse education which is quitting the hospital setting. Legislative changes to the National Health Service have brought about a huge shift to community-based programmes o f care. As a profession we need to be in on the ground floor o f these changes. The practitioners o f t o m o r r o w needs to be involved in the pursuit o f radical change through the constant questioning and critiquing o f unacceptable conditions in which certain people and groups in our society are forced to live.
CONCLUSION There is a world o f difference between consciousness raising and the development o f critical consciousness, which is inherent within Freire's notion o f conscientisation. Kenway & Modra (1992) claim that while powerful and o f lasting value, consciousness can be engaged in such a way as not to be articulated with action. For example a nurse may have developed a heightened awareness o f a female client as a victim o f domestic violence, but may still feel powerless to resolve or change the situation. In other words, consciousness raising can so easily become the reflection without action that Freire calls 'wishful thinking'. In what Darbyshire (1993) calls the new orthodoxy o f andragogy, limitations and constraints are self-evident, and it is worth bearing Griffin's (1982) words in mind that theory at frst invigorating slowly builds a prison for the mind. Andragogy has become ideology, and is a step away from dogma. W h a t we must also acknowledge that so-called 'liberal' teaching strategies are not the answer either. Although more 'right on', these are surely just as confining. Raising consciousness in our students is only taking them halfway there, for we are also imbuing them with feelings o f helplessness and powerlessness, being aware that their clients may be victims o f racism, sexism or ageism is just not enough. Nurse teachers have a responsibility not only to the nursing profession, but to everyone in our society whose voice cannot be heard. It's time to get radical: be subversive, and teach for peaceful revolution.
REFERENCES
AshleyJ 1976 Hospitals,paternalismand the role of the nurse. Teachers College Press, New York Bevis EO, MurrayJP 1990 The essence of the curriculum: emancipatoryteaching.Journal of Nursing Education 29 (7): 326-331 Carmichael S, Hamilton C 1983 In: Roberts SJ fed) Oppressed group behaviour: implicationsfor nursing. Advancesin Nursing Science 5 (7): 21-30 Chally PS 1992 Empowerment through teaching.Journal of Nursing Education 31 (3): 117-i20 DarbyshireP 1993 In defence of pedagogy: a critique of the notion ofandragogy. Nurse Education Today 13: 328-335 DingwaliIK et al 1988 An introduction to the social history of nursing. Roufledge, Chapman & Hall, London Fanon F 1983 In: Roberts SJ fed) Oppressed~oup behaviour: implicationsfor nursing. Advancesin Nursing Science5 (7): 21-30 Freire P 1972 Pedagogy of the oppressed(Bergman1KarnosM trans.). Penguin, Harmon&worth Griffin D 1992 In: Miller MA fed) Outcomes evaluation: measuring criticalthinking.Journal of Advanced Nursing 17 (12): 1401-1407
Enlightenment, empowerment and emancipation: the case for critical pedagogy in nurse education
Habermas J 1979 Communication and the evolution of society (McCarthy T trans.). Beacon Press, Boston Hedin BA 1986 A case study of oppressed group behaviour in nurses. Image 18 (2): 53-57 Hedin BA 1987 Nursing education and social constraints: an in-depth analysis. International Journal of Nursing Studies 24 (3): 261-270 HezekiahJ 1993 Feminist pedagogy: a framework for nursing education? Journal of Nursing Education 32 (2): 53-57 Holloway I, PensonJ 1987 Nurse education as a form of social control. Nurse Education Today 7:235-241 Kendall P 1992 Fighting back: promoting emancipatory nursing actions. Advances in Nursing Science 15 (2): 1-15 KenwayJ, Modra H 1992 Feminist pedagogies and emancipator'/possibilities. In: Luke C, GoreJ (eds) Feminisms and critical pedagogy. Rontledge, Chapman & Hall, London Lewin K 1983 In: Roberts SJ (ed) Oppressed group behaviour: implications for nursing. Advances in Nursing Science 5 (7): 21-30 Luke C, Gore J (eds) 1992 Feminisms and critical pedagogy. P,.outledge, Chapman & Hall, London
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Lusted D 1986 Why pedagogy? Screen 27 (5): 2-14 LynhaughJ 1980 The entry into practice conflict - how we got there, and what will happen next. American Journal of Nursing 80:266-270 Marriner A 1978 Theories of leadership. Nursing Leadership 1 (3): 13-17 Miller MA 1992 Outcomes evaluation: measm-ing critical thinking. Journal of Advanced Nursing 17 (12): 1401-1407 Roberts SJ 1983 Oppressed group behaviour: implications for nursing. Advances in Nursing Science 5 (7): 21-30 Stevens PE 1989 A critical social reconcepmalisation of environment in nursing: implications for methodology. Advances in Nursing Science 11 (4): 56-68 ThompsonJL 1987 Critical scholarship: tile critique of domination in nursing. Advances in Nursing Science 5 (2): 17-25 ThompsonJB, Held D (eds) 1982 Habermas: critical debates. MIT Press, Cambridge, USA Wheeler CE, Chinn PL 1989 Peace and power: A handbook of feminist process, 2nd edn. NLN, New York
Jane Harden RN, DPSN, CertEd, BSc(Hons), Senior Lecturer, Faculty of Health, Social Work and Education, University of Northumbria, Freeman Hospital, Newcastle upon Tyne NE7 7DN, UK (Requests for offprints toJH) Manuscript accepted 8 December 1994 Nurse EducationToday(1996) 16, 32-37
This paper explores the notion that nurse education is a political activity which is value laden and has multiple social meaning. As long as teachers continue to pursue liberal and andragogical theories of learning, students will fail to develop a critical consciousness. The implications are vast as nursing prepares to enter the next millennium: notions such as the reflective practitioner and the knowledgeable doer feature highly on the profession's educational agenda, both of which implicitly require critical thinking skills. By using Habermas' definition of 'critique' as a framework and Paulo Freire's concept of 'conscientisation' as an educational model, it is argued that nurse teachers can expose the oppressive structures which confine and limit the nursing experience. Only then, when our oppression, both as women and nurses has been recognised, and a critical consciousness achieved, can true humanistic care be given. Through the development of emancipatory nursing actions can the profession stop colluding with the social structures which keep many people and groups in oppressive conditions. We should, in short, be teaching for 'peaceful revolution'. © 1996PearsonProfessionalLtd
INTRODUCTION Developing critical consciousness in students should be a quintessential part of the nurse teacher's role, and yet we are constrained by our own educational philosophy: the notion of andragogy. The major assumption which underpins andragogy is that adult learners, through their own backgrounds and rich life experiences are driven by a desire to become self-directed, independent and autonomous in their learning careers. However according to Thompson (1987) everyday living as experienced by the majority is characterised by a naive, pre-reflective adherence to 'established' versions of the life world. The consequence of this is that 'factual' or doxic, patterns o f living are never challenged, and the question of legitimacy is never raised, because the social world is presented and accepted as a natural phenomenon. For too long nurse education has submerged its students in a situation in which critical awareness and response are practically impossible. By embracing andragogy we have become both the oppressor and the oppressed at one and the same time. Paulo Freire (1972) has described a 'culture of silence' which exists among the oppressed. He came to realise that lethargy and ignorance were the direct product of the whole situation o f economic, social and political domination and o f the paternalism - o f which they were victims. For the purpose of this paper I shall apply Freire's model of education to the vocational career of nursing, and argue that unless we teach for emancipation, the concepts o f the knowledgeable doer and the reflective practitioner will never be realised. I am not going to offer the reader a critique o f andragogy, as this has already been done in the excellent article by Philip Darbyshire (1993). Rather I shall develop further his argument, and present a case o f need for a critical pedagogy in the education of our future nurses. Pedagogy has been defined by Lusted (1986) as: The transformation of consciousness that takes place in the intersection of three agencies - the teacher, the learner and the knowledge they together produce. Whilst critical pedagogy is, according to Luke & Gore (1992), centred on hope, liberation and equality, with agency and raised consciousness at centre stage, albeit with structural constraints acknowledged. It is theoretically grounded in the Frankfurt School o f Sociology, Gramsci's notion of hegemony and Freire's educational practice and concept o f conscientisation. Taken together, negative critique, counter hegemonic practices and conscientisation
Enlightenment, empowerment and emancipation: the case for critical pedagogy in nurse education 33
provide a powerful agenda for emancipatory education. But how do we translate such weighty abstract theory into nurse education? More importantly, perhaps, is why should we?
ARE WE NOT ALREADY
FREE?
It is the premise of this paper is that nurses can be viewed as an oppressed group, a view supported by the fact that nurses lack autonomy, accountability and control over their own profession. Yet nursing is by far the largest occupational group within the sphere ofhealthcare, so why is it so powerless? For me history of the domination o f nursing is inextricably linked to that of the domination and oppression of women. Marriner (1978) has suggested that leadership is lacking in the nursing profession because the persons attracted to it have certain characteristics, low self-esteem lacking initiative and submissiveness for example. Because nursing continues to be perceived as a subservient, non-autonomous, rigid, stifling and non-creative occupation it will continue to appeal to people who possess those traits, and to w h o m self-actualisation and responsibility are threatening prospects. W o m e n who seek exciting, autonomous and creative careers will go elsewhere. Jo-Anne Ashley (1976) in her seminal work,
Hospitals, Paternalism and the Role of the Nurse, describes that hospital managers and physicians have benefited from control over, and exploitation of, nursing. The reason for dominance is based on the fact that both these patriarchal professions need nurses. Dingwall et al (1988) have traced the beginning of the domination (or colonisation as Roberts (1983) prefers to describe it) of nursing by others and found that it occurred in the late part of the last century when care o f the sick became institutionalised. This also coincided with the emergence of the new dominant professions, particularly medicine, which used its new found power to sanction attacks on what it deemed to be unsuitable behaviour, whether by their patients, nurses or society as a whole. Many nurses have internalised the values of doctors, and developed a 'mini-medical' knowledge base in the vain hope that if they can attain the characteristics of the powerful, they too will become powerful (Roberts 1983), and perhaps even achieve the nursing equivalent o f the Holy Grail, professional status. Freire (1972) pointed out that the major characteristics of oppressed group behaviour stems from the ability of dominant groups to identify their norms and values as the 'right' ones in society and from their initiad power to enforce
them. In most cases of oppression, the dominant group looks and acts differently from the subordinate group (white coat or mufti versus uniform). The characteristics of the subordinate group become negatively valued, which over time contribute to the maintenance of the status quo. The tendency is for the subordinate group, as well as the oppressor, to internalise these norms and to believe that to be like the oppressor will lead to power and control. Lewin (1983) has described how individuals with certain expectations and goals see belonging to the subordinate group as an impediment to achieving their ambitions. The result is 'assimilation'. People who are successful become known as 'marginal' because they do not belong to either group, but rather are on the fringes of their own group and unable to be a full member of the dominant group. Hedin (1986, 1987) has described this process ofinternalisation and attempt at being marginal as leading to certain personality characteristics: self-hatred and low self-esteem. These attributes can be easily understood by the realisation that to want to be more like the dominant culture, the subordinates must reject their own characteristics. These attributes combine to create what Carmichael & Hamilton (1983) have described as submissive-aggression syndrome. The oppressed person, when able to feel aggressive against the oppressor, is not able to directly express it. Although there may be much complaining within the oppressed group, selfhatred and low self-esteem create submissiveness when confronted with the powerful figure. Fanon (1983) reports that aggression in oppressed people may be vented in an even more self-destructive way. 'Horizontal violence' or conflict within the oppressed group is a result of being unable to revolt against the dominant group rather than, as is often interpreted, a characteristic inherent in oppressed groups. This trait is more than obvious amongst nurses, education versus service; ward staffversus nurse managers; day-staff versus night-staff and so on. Many in the profession find the whole concept o f oppression difficult to accept, and the suggestion is often met with hostility. Domination is, however, most complete when it is not even recognised, suggests Freire. The watershed for nursing must surely be the introduction of the Project 2000 diploma course with nurse education moving from the hospital, the domain o f the physician, into higher education, where nurses will have increased control. But as Lynaugh (1980) points out, since the paternalistic model of education, widely assumed as correct has been operating since the turn of the century, nurses, like other women, do not see the need for a
34 NurseEducationToday 'university education'. Our history, as both nurses and women, has brought us to this juncture. Freire (1972) has described education as suffering from 'narration sickness', the teacher talks about reality as if it were motionless, static, compartmentalised and predictable, or alternatively, expounds on a topic completely alien to the existential experience of the students. Thus, narration turns students into 'containers' to be filled by the teacher. The more completely the receptacle is filled, the better the teacher. The more meekly the receptacles permit themselves to be filled, the better the students. Nurse education, argue Holloway & Penson (1987) has followed this model for years, little more than social control, it has been the vehicle by which the status quo has been maintained. The 'banking system' as Freire calls it positively holds students back, as the more they work at storing the deposits entrusted to them, the less they develop the critical consciousness to transform the world. The ethos of Project 2000 is to encourage the development and growth o f the 'knowledgeable doer'. Implicit in this is the raising of critical consciousness. The notion o f reflective practice, now high on the nursing agenda, is an aspect of emancipatory education, and has a critical component also (Miller 1992). So in what Freire has described as problem-posing education, students need to develop their power to perceive critically the way they exist in the world, with which, and in which they find themselves; they come to see the world not as a static reality, but rather as a reality in transformation.
BREAKING THE C H A I N S T H A T B I N D US According to Habermas (1979) social critique is most useful in liberating people and aggregates from domination, but it must be aimed at the fundamental structures and ideologies o f social systems. The fundamental structures of a society include: • the kinds of work and wages that are available and to w h o m • the meaning ofprivatised, unpaid work and who does it • assumptions about what constitutes a family • access to education • images of women, racial minority groups and gay people in the media • the availability of health care • the profit motive of capitalist economies and the distribution of wealth • law and law enforcement. Such social structures define how privilege, exploitation and powerlessness are distributed
among persons and groups in the society. Racism, sexism, ageism, heterosexism and classism are some of the fundamental dogmatic ideologies that are internalised in social structures and thus operate in unexamined ways. Introducing student nurses to critique and its associated concepts as defined by Critical Theory, is a useful lens through which to view health and health care.
Critical Theory Critical Theory refers to a series o f ideas that emerged in Frankfurt in the 1920s. These ideas were based on critical Marxist self-understanding and Hegelian dialectics that stressed the principles o f contradiction, change and movement. There are two basic features o f dialectical analysis: 1. There is not a simple one-way cause and effect relationship among the various parts o f the social world. For the dialectical thinker social influences never simply flow in one direction as they do for cause-andeffect thinkers. To the dialectician one factor may have an effect on another, but it is just as likely that the latter will have a simultaneous effect on the former. This kind of social thinking does not mean that the dialectician never considers causal relationships in the social world. It does mean that when dialectic thinkers talk about causality, they are always attuned to reciprocal relationships among social factors, as well as to the dialectical totality o f social life in which they are embedded. 2. In dialectical analysis social values are not separate from social facts. The dialectic thinker believes that not only is it impossible to keep values out o f the study o f the social world, but it is also undesirable, as it produces a dispassionate, inhuman sociology that has little to offer people in search o f answers to the problems they confront. Facts and values are inevitably intertwined, with the result that the study o f social phenomena is value-laden. Critical theorists, according to Stevens (1989), are concerned about interpreting 20th century history, their basic belief was that no aspect of social phenomena may be comprehended unless it is related to the historical whole and to the structural context in which it is situated. The primary goals o f these theorists were to break the grip o f closed systems o f thought and to counter the unreflective affirmarion o f society (Thompson 1987). Habermas (1979) places critical theory within a framework o f scientific knowledge. He distinguishes types of scientific knowledge
Enlightenment, empowerment and emancipation: the case for critical pedagogyin nurse education 35 by examining critically the interests they serve. His categories of knowledge are: 1. empirical/analytical knowledge, which serves the interest in technical control of the environment 2. historical/hermeneutic knowledge, which has a practical interest in understanding individuals subjective experiences 3. critical theory, which is interested in liberating people from unacknowledged circumstances of domination and transforming constraining conditions. Habermas does not question the validity of the first two forms of knowledge, but he does demand that they realign their self-perceptions in relation to each other and to the critique of domination (Thompson & Held 1982). Stevens (1989) argues that two of these epistemologic categories, empirical/analytical knowledge and historical/hermeneutic knowledge, are becoming better established in nursing, whereas critique and analyses of how domination affects health and health care are still in their infancy.
U n d e r p i n n i n g concepts 1. Oppression and domination are used interchangeably to indicate unequal power relations embedded in basic structures and functions of society: oppression, which inheres in the social structuring of life limitations that are not equally experienced across groups, is the systematic abbreviation of possibility by which dominated people are constrained in their quest for human potential. 2. Liberation is freedom from the coercion and constraint of oppressive social structures; the particular freedom of individuals is understood within a social and collective context. 3. Dogma or ideology is a dominant, authoritative system of ideas whose underlying assumptions and premises have not been sufficiently examined or challenged. 4. Critique is a process that consists of several components: (a) oppositional thinking that unveils and debunks oppressive ideology by explaining the implicit rules and assumptions of the historical, cultural and political context; (b) reflection upon the conditions that make uncoerced knowledge and action possible; (c) analysis of the constraints upon communication and human action; and (d) dialogue. • 5. Dialogue is mutual interaction that raises collective consciousness by clarifying, affirming and integrating the historical, social, political and economic experiences of communities.
6. Conscientisation is learning to perceive social, political and economic contradictions and conceiving of ways to take action against oppressive contradictions. 7. Action is informed, deliberate, meamngfnl behaviour and verbalisation by those experiencing oppression that seeks to bring about social change; it is based on critical insights, reflection and dialogue. (Stevens 1989)
E m a n c i p a t o r y teaching We must accept that teaching is a political activity, and be aware that everything we teach is value-laden and that neutrality is a myth. Chally (1992) has argued that nurse teachers have failed to instil vision, meaning and trust in their students, as learning that occurs must be measurable and is outcome-based. Through an obsession with the know-that form of learning, students are being prevented from learning how to challenge and critique. Andragogy reinforces the blind pursuit of facts, as the social value of knowledge (particularly of a scientific nature) is immense. In short, student nurses are being prevented from learning how to learn due to both internal and external factors. Emancipation requires teaching practices that are liberating, but it also requires commitment from the learner. As Bevis & Murray (1990) have stated, that while lecturing does not teach how to critique, or how to come to our own meanings, it does provide information that can be used to raise consciousness, to alter perceptions and to shape criticism. Students must learn to construe their own meanings, through their own frames of reference, and teachers must resist the temptation to control, validate or interpret the perceived meaning. This raising of consciousness lea& to enlightenment regarding the mythical, religious, scientific, practical and political interpretations of the world (Habermas 1979). Wheeler & Chinn (1989) describe the power of nurturing that respects individual circumstances and life experiences, but as Chally (1992) argues, most germane to education is the power that results from knowledge. She offers five tools of empowerment to actualise a shared vision. They are: • Positive self-concept, teachers who feel positive about themselves are better equipped to meet the needs of others; • Creativity, ideas are generated, new ways of doing things are developed and alternatives imagined; • Resources, as well as funds, space and materials, teachers are also a vital resource.
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NurseEducationToday It is our responsibility to keep updated within our field o f expertise; • Information, being 'in the k n o w ' regarding data and technical knowledge, but also being aware that political intelligence is another information tool o f empowerment; • Support, which can be given in a number o f ways, from written feedback to a smile. Empowering students results from teaching methods characterised by commitment, caring and interaction. As such they are in keeping with the goals o f feminist pedagogy, which is itself critical in nature (Luke & Gore 1992). Hezekiah (1993) cites an atmosphere o f mutual respect and trust, shared leadership, cooperative structures, integration o f cognitive and affective learning and action as being fundamental to educating nurses (or women). As teachers we must exposure the reality o f the structures that oppress them and give them the tools o f k n o w ledge whereby they can critically reflect on their condition, in a climate o f mutual trust, collaboration and respect. Thompson (1987) tells us that critical scholarship in nurse teaching is a sign that we are responding sensitively and intelligently to nurse's own historical experiences. W h y is our own history o f oppression, both as w o m e n and nurses, relevant to our clients, and what can an understanding o f it offer in terms o f patient care? Kendall (1992) calls for nurses to recognise the reality that health, education and social problems are inextricably linked. For too long nursing has been involved with helping clients adapt to their oppression, and a model o f emancipatory nursing action is called for. Emancipatory nursing actions include taking gender, race and class considerations seriously, conceiving all social structures as containing an interplay of contradictory forces and, attempting to understand the factors that make people define social reality the way they do. Promoting an environment where nurses can communicate freely may be thought of as revolutionary considering the setting where most nurses are employed: hospitals. Long considered bastions o f patriarchal bureaucracy and control, the hierarchical communication systems have been designed to enforce the status quo, but it is not only nurse education which is quitting the hospital setting. Legislative changes to the National Health Service have brought about a huge shift to community-based programmes o f care. As a profession we need to be in on the ground floor o f these changes. The practitioners o f t o m o r r o w needs to be involved in the pursuit o f radical change through the constant questioning and critiquing o f unacceptable conditions in which certain people and groups in our society are forced to live.
CONCLUSION There is a world o f difference between consciousness raising and the development o f critical consciousness, which is inherent within Freire's notion o f conscientisation. Kenway & Modra (1992) claim that while powerful and o f lasting value, consciousness can be engaged in such a way as not to be articulated with action. For example a nurse may have developed a heightened awareness o f a female client as a victim o f domestic violence, but may still feel powerless to resolve or change the situation. In other words, consciousness raising can so easily become the reflection without action that Freire calls 'wishful thinking'. In what Darbyshire (1993) calls the new orthodoxy o f andragogy, limitations and constraints are self-evident, and it is worth bearing Griffin's (1982) words in mind that theory at frst invigorating slowly builds a prison for the mind. Andragogy has become ideology, and is a step away from dogma. W h a t we must also acknowledge that so-called 'liberal' teaching strategies are not the answer either. Although more 'right on', these are surely just as confining. Raising consciousness in our students is only taking them halfway there, for we are also imbuing them with feelings o f helplessness and powerlessness, being aware that their clients may be victims o f racism, sexism or ageism is just not enough. Nurse teachers have a responsibility not only to the nursing profession, but to everyone in our society whose voice cannot be heard. It's time to get radical: be subversive, and teach for peaceful revolution.
REFERENCES
AshleyJ 1976 Hospitals,paternalismand the role of the nurse. Teachers College Press, New York Bevis EO, MurrayJP 1990 The essence of the curriculum: emancipatoryteaching.Journal of Nursing Education 29 (7): 326-331 Carmichael S, Hamilton C 1983 In: Roberts SJ fed) Oppressed group behaviour: implicationsfor nursing. Advancesin Nursing Science 5 (7): 21-30 Chally PS 1992 Empowerment through teaching.Journal of Nursing Education 31 (3): 117-i20 DarbyshireP 1993 In defence of pedagogy: a critique of the notion ofandragogy. Nurse Education Today 13: 328-335 DingwaliIK et al 1988 An introduction to the social history of nursing. Roufledge, Chapman & Hall, London Fanon F 1983 In: Roberts SJ fed) Oppressed~oup behaviour: implicationsfor nursing. Advancesin Nursing Science5 (7): 21-30 Freire P 1972 Pedagogy of the oppressed(Bergman1KarnosM trans.). Penguin, Harmon&worth Griffin D 1992 In: Miller MA fed) Outcomes evaluation: measuring criticalthinking.Journal of Advanced Nursing 17 (12): 1401-1407
Enlightenment, empowerment and emancipation: the case for critical pedagogy in nurse education
Habermas J 1979 Communication and the evolution of society (McCarthy T trans.). Beacon Press, Boston Hedin BA 1986 A case study of oppressed group behaviour in nurses. Image 18 (2): 53-57 Hedin BA 1987 Nursing education and social constraints: an in-depth analysis. International Journal of Nursing Studies 24 (3): 261-270 HezekiahJ 1993 Feminist pedagogy: a framework for nursing education? Journal of Nursing Education 32 (2): 53-57 Holloway I, PensonJ 1987 Nurse education as a form of social control. Nurse Education Today 7:235-241 Kendall P 1992 Fighting back: promoting emancipatory nursing actions. Advances in Nursing Science 15 (2): 1-15 KenwayJ, Modra H 1992 Feminist pedagogies and emancipator'/possibilities. In: Luke C, GoreJ (eds) Feminisms and critical pedagogy. Rontledge, Chapman & Hall, London Lewin K 1983 In: Roberts SJ (ed) Oppressed group behaviour: implications for nursing. Advances in Nursing Science 5 (7): 21-30 Luke C, Gore J (eds) 1992 Feminisms and critical pedagogy. P,.outledge, Chapman & Hall, London
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Lusted D 1986 Why pedagogy? Screen 27 (5): 2-14 LynhaughJ 1980 The entry into practice conflict - how we got there, and what will happen next. American Journal of Nursing 80:266-270 Marriner A 1978 Theories of leadership. Nursing Leadership 1 (3): 13-17 Miller MA 1992 Outcomes evaluation: measm-ing critical thinking. Journal of Advanced Nursing 17 (12): 1401-1407 Roberts SJ 1983 Oppressed group behaviour: implications for nursing. Advances in Nursing Science 5 (7): 21-30 Stevens PE 1989 A critical social reconcepmalisation of environment in nursing: implications for methodology. Advances in Nursing Science 11 (4): 56-68 ThompsonJL 1987 Critical scholarship: tile critique of domination in nursing. Advances in Nursing Science 5 (2): 17-25 ThompsonJB, Held D (eds) 1982 Habermas: critical debates. MIT Press, Cambridge, USA Wheeler CE, Chinn PL 1989 Peace and power: A handbook of feminist process, 2nd edn. NLN, New York