Teaching the Subject of Nursing—Academic Teaching Based on Dossey's Holistic Nursing Theory

Abstract

Introduction

Being a teacher of nursing education can be challenging. Nursing theories can guide clinical nurses in their work, but is it possible to apply a nursing theory in the context of academic teaching?

Purpose

To investigate if it is possible to apply Dossey's holistic nursing theory into the context of teaching the subject of nursing.

Conclusion

This article proposes that Dosseys holistic nursing theory could be applied in the context of nursing education.

Introduction and Purpose

The purpose of this article is to investigate whether it is possible to understand academic teaching more deeply by using Dossey's holistic nursing theory as a framework (Dossey, 2001; Dossey, 2013; Helming et al., 2021). Dossey is a United States-based professor of nursing who strives for a holistic view of the field of nursing.

Nursing is a core subject of the training courses for nurses and specialist nurses. Holistic nursing has its origins in holism and humanism. Dossey developed a holistic nursing theory in which Florence Nightingale's (1859) thoughts on nursing are central, as well as Wilber's holistic view of reality (Wilber, 1999). A sense of meaning runs like a common thread in Dossey's holistic nursing philosophy and in teaching aspiring nurses. In a previous study on the success factors of leaders in nursing (Garmy & Forsberg, 2020), the feeling of meaningfulness in doing good also emerged. Nurses could achieve this through a substantial dose of creativity, fighting spirit, networking, and room for recovery.

Discussion of Topic

Learning—The First Component

The foundation of nursing is health and health promotion; the first component of Dossey's theory is healing (Dossey, 2013). The concepts of healing and learning are closely related. Both are about a process; they are a transition (Meleis, 2010) that must take place from sick to healthy or from novice to expert (Benner, 2001). Nursing theorist Eriksson (Eriksson, 2002) starts from the concepts of “tending, playing and teaching” (p. 62). The term tending is about caring in a practical way, that is, to take care of and, for example, dress a wound. In a higher education pedagogical context, it could be considered appropriate when the teacher gives feedback on a student's text so the student understands what needs to be done to improve the text (Schartel, 2012). The teacher then tries to alternate between being very concrete and giving examples of how the text can be written by giving feedback on a more comprehensive level so the student can work on the text independently. However, this is often difficult because students are different and many of them feel stuck when they are provided with constructive feedback. This can be addressed by combining both verbal and written feedback while also telling the student that the teacher is available if they have more questions or think something is unclear. It is also good if the teacher is open to changing her/his mind if the students can provide logic and rationale. There is often more than one way that a finished product can look.

Play is about being present at the moment, being creative, and improvising. It means interaction with the student and is close to what is called relational pedagogy (Aspelin, 2014). It is also about daring to try. Nursing education requires the use of method rooms and simulation exercises where students can “play” nurses in a safe environment (Eyikara & Baykara, 2017).

Simulation exercises have been developed in nursing education in technically advanced moments but also in difficult conversations. It is common to have seminaries for teachers in higher education where the teachers try out ideas and think out loud together. By “testing” or “thinking out loud” (Rankine, 2019) in a permissive climate, teachers can collectively gain a deeper and broader understanding of complex phenomena. A teacher seminary recently had the theme “Kindness and Courage in Nursing.” Here, the conversation drifted in various exciting directions. Topics included the fact that kindness is a virtue, questioning what kindness really means, and the value of spearheading the needs of patients, students, colleagues, and ourselves.

Being genuinely kind may sometimes mean being uncomfortable and awkward, and this can require a great deal of courage. Aristotle (2011) spoke of the balance between cowardice, courage, and hubris. This is also a recurring topic of conversation in ethics groups in nursing undergraduate training. The nursing students themselves experience ethically difficult situations, and they observe how the supervising nurses and staff act in different situations. They mostly act as role models but sometimes also as discouraging examples. The students reflect wisely on how they can best stand up for their patients in their current and future roles as a nurse. It is necessary to sometimes question existing routines and strong people in the workplace, that is, to practice being uncomfortable.

The third concept in Eriksson's theory is teaching (Eriksson, 2002). It includes both the nurse's own learning and the ability to teach patients and relatives. It will be left for now because the intention of this entire text is that it should be about teaching and learning in different forms.

The MetaParadigm in Nursing—the Second Component

Nursing has four consensus concepts: person, health, environment, and nursing (Bender, 2018). Dossey (2013) also includes these concepts in her holistic nursing theory.

The first consensus concept is person (Dossey, 2013). Person-centeredness (McCormack et al., 2021) focuses on the person and that care should be given based on the individual's needs. In nursing care for children and young people, the terms child-centered or family-focused nursing is often used. Higher education pedagogy includes the concepts of student-centered teaching. These concepts enrich each other and are not in opposition.

The second consensus concept is health (Dossey, 2013). Health and learning are intimately connected. Several studies have shown a connection between students’ health and their school performance, for example, in the case of long-term pain (Ragnarsson et al., 2020) and sleep problems (Hedin et al., 2020).

The third consensus concept is the environment (Dossey, 2013). The teaching environment impacts learning. During the pandemic, nursing education had to quickly change teaching to a digital form, which had an impact on learning and academic achievement (Amir et al., 2022).

The fourth consensus concept is nursing (Dossey, 2013), but it is changed to teaching in this article to fit into a higher education pedagogical context. This fits nicely into Eriksson's concept of play that is described above. Teaching is based on co-creation. It goes without saying that this arises in the relationship between the teacher and the student. But co-creation also occurs on a larger level. Co-creating occurs in the teaching team when the teachers plan to teach and discuss learning and teaching with each other. Co-creating occurs on an organizational level when, for example, a scholar gives feedback on course plans in the role of a member of the course plan committee. Here, there is a dialog with program area managers, course managers, and student representative on the committee.

Teachers are often surprised when they realize that the best learning occurs when a person gets to teach (Biggs & Tang, 2011). This could provide an understanding of many scholars’ predilection for teaching because it offers a fantastic chance for their own learning. However, the realization could be painful for teachers when they understand that it is probably themselves who learn the most during their lectures and not those sitting in the audience. For those, who enjoy both lecturing and listening to lectures, it could not be an entirely easy medicine to take.

A solution could be to have a pragmatic view, which means that lectures can certainly have their place where they fit. It is a pleasant form of “entertainment,” but perhaps not the most effective and challenging for the students. Just as everything on the plate does not have to consist of healthy fibers, teaching can also consist of fast carbohydrates sometimes (if one were to dare to liken lectures to fast carbohydrates). At best, they can give a short-term kick, but then easily fall into oblivion. A paradox in student evaluations, however, is that courses with many lectures are often rated highly by students. This may be because students who are used to traditional classroom teaching feel secure with this form of teaching—this design places fewer demands on the students’ own learning.

Different Patterns of Knowledge—The Third Component

The third component of holistic nursing theory deals with the different domains of knowledge found in nursing: Personal, empirical, aesthetic, ethical, non-knowing, and sociopolitical (Dossey, 2013).

Personal knowledge can be developed through art, meditation, dance, music, stories, and other expressions in daily and professional life (Dossey, 2013). This is about the teacher her/himself, and the teachers’ personal development process. For example, culture is a big part of many scholars’ existence: reading fiction and poetry, listening to music and playing an instrument are times to allow oneself to be bathed in culture. But there is a challenging question about the actual utility of culture. Culture does not have to have an immediate benefit. Scholars will be better teachers if they have taken part in different stories—just like a clinician will be a better nurse if he/she can increase their understanding of different situations that their patients experience. One of the many ways to expand one's personal knowledge is to read fiction.

The third-year students in the nursing program had been given the task of preparing an ethics seminar by retrieving examples of ethically difficult situations they had read about in fiction or seen on film. They would then imagine how they themselves would have acted as nurses in the situation. The students brought examples from widely different sources—everything from the television show Grey's Anatomy to books where nurses who have become patients talk about their experiences. The students used the situations they had read or seen and then turned them into something deeply personal, but still with a protective factor because that was not their own story. During the meeting, the students were initially allowed to start from the story or film sequence that touched them. In the next stage, they had to share a situation they themselves experienced during their clinical practice and then link that experience to a scientific article. This was an advanced exercise, but the students managed it excellently.

One example was a student who took a story from a book about a nurse who was hospitalized for a long time after an accident. The nurse found the staff on the ward were invisible or, in the worst case, treated her disrespectfully. The student reflected on how important it is as a nurse to be visible to patients, to greet patients at the beginning of the shift, and to be treated respectfully even when stressed. The other students in the ethics group chipped in, and it became a lively conversation. In the next stage, the student recounted an incident at clinical practice where a patient did not want to accept the treatment that was offered. The supervisor listened to the patient and explored the patient's concerns. The care team could then partially adapt the care to the patient's wishes without jeopardizing patient safety. The student also referred to an article where nurses like to use a democratic leadership style; they try to gather requests and information from several different sides before making decisions (Moiden, 2002). The discussion concerned the concept of “window of compromise”, that is, the space that the patient has to negotiate (Gustavsson & Sandman, 2015). There was a fruitful discussion in the group about how, as a nurse, one can still be perceived as respectful by the patient even if the treatment itself can be somewhat unpleasant. The teacher can draw parallels to the relationship between student and teacher. It is with the teacher that a large part of the power resides, but there is also a window that is somewhat open for compromise.

Empirical knowledge includes scientific competence in education and clinical practice (Dossey, 2013). It is expressed through models and theories and can be integrated into evidence-based practice. Empiricism is experienced through observation, measurements, and verification. For a teacher, empirical knowledge is largely about subject expertise, for example, the teachers own research field.

Aesthetic knowledge in nursing focuses on exploring the experiences of meaning in life and an authentic presence (Dossey, 2013). Here, the nurse can facilitate the health-promotion process, which requires a combination of knowledge, experience, and intuition. With the help of aesthetic knowledge, the nurse can explore the experiences of life, health, illness, and death together with the patient. As a teacher of future nurses, it is important to support the students so they can remain in difficult situations when they face suffering and death.

Ethical knowledge in nursing is closely linked to acting morally right. In nursing, the focus is on behaviors and expressions as well as ethical and moral dilemmas (Dossey, 2013). The foundation is respect for the individual and family including a context that promotes communication and moral agency. As a teacher, one must equip the students so they can reflect on ethical dilemmas and their own positions. The article on the importance of formulating and expressing one's nursing philosophy (Garmy, 2020) is aimed at school nurses. The article argues that it is easier to stick to one's moral compass in difficult and stressful situations if one has formulated fundamental values and methods to use them. These are also recurring topics of conversation in the ethics group with undergraduate students, in clinical practice conversations with specialist nursing students, and during conversations in the college.

Non-knowing in nursing describes the ability to be present at the moment with a health-promoting purpose without having predetermined answers (Dossey, 2013). It includes authenticity, mindfulness, openness, wonder, and discovery of the self and the other in a subjective and intersubjective way. Not knowing offers new solutions and discovers new possibilities. School nurses often use Borup's model for health conversations (Borup, 2002), which is based on open reflection. The student and the school nurse think aloud together so the student can identify health-promoting solutions to the problem. This technique can be used when supervising undergraduates and doctoral students in their theses/studies, as well as in professional learning (Coward, 2022).

Teachers learn through experience there is a payoff in not being too quick to come up with solutions and presenting them. By letting the process take its time, and letting the solution come from within the patient/student/doctoral student, there can be new and exciting ideas as well as sustainable solutions. A student who has been involved in designing the purpose and method for the essay has greater endurance and capacity to handle the challenges the work inevitably entails. It is also important to have courage and good self-esteem to remain in the stage of not knowing. This stage can be perceived as provocative by students when the teacher does not come with readymade answers. There might not be any other solution to that problem than to stay put and put up with the students’ frustration (and sometimes also give a push along the way) (Thaler & Sunstein, 2009). Of course, it is also not sustainable to withhold knowledge. In the teacher role, there is a wish to share what you know. The problem for most teachers is not that they share too little. It would be good if teachers dared to stay in the not-knowing a little more often.

Socio-political knowledge is about the importance of the context in the form of social, economic, geographical, cultural, political, historical, and other key factors in practice and research (Dossey, 2013). For a teacher, socio-political knowledge is partly about being aware of socio-political factors that may have an impact on students’ learning. It is also about raising awareness of these aspects for future nurses and specialist nurses in their future professions. It is a challenge that many nurse educators and in the nursing profession largely consist of the same gender, ethnicity, and background. Studies show how racism and ignorance of socio-politics are common in nursing (Bell, 2021). Teachers, nurses, and citizens all have an extremely important task ahead to work for a democratic society without discrimination based on gender, ethnicity, sexual orientation, etc.

The Quadrants—The Fourth Component

In the fourth component, Dossey (2013) adapted a model by Wilber (1999) where reality is described from four perspectives that relate to each other. These are made visible through four quadrants that give a holistic picture of a person and/or a situation, see Figure 1. They include both internal and external aspects, as well as individual and collective aspects. The quadrants can be used in the teaching team when there is a need to discuss the development of an individual student or in a class. With the help of the quadrants, the teacher and students can discover where the problem lies and if there are other areas that are functioning well.

Figure 1.

In Dossey's fourth component, four quadrants are described that convey four perspectives on reality (Dossey, 2013).

The quadrants can be used when the students in the postgraduate nursing program analyze cases they encounter in their clinical practice. These can be a great help in identifying needs. It would also be possible to explore and utilize the quadrants in the context of mentoring new faculty members. It provides space for conversation and analysis of the teaching situation at the individual, group, and organizational level. This also considers both internal and external factors.

Comprehensive Picture—the Fifth Component

In Dossey's fifth component, the four quadrants are combined with all other components (Dossey, 2013). In this way, it is possible to get a more comprehensive picture that can facilitate reflection on the multifaceted everyday life in both nursing and higher education. Here is personal and professional maturity and competence development essential (Garmy et al., 2021).

Conclusions

Teaching nursing is a multifaceted pursuit including teaching theoretical and practical knowledge. By adding Dossey's holistic nursing theory to the customary literature on pedagogy in higher education, teachers in nursing are given tools to deal with phenomena in nursing education.