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Teachers as researchers: a narrative pedagogical approach to transforming a graduate family and health promotion course.

RESEARCH

ABSTRACT Scholarship of teaching in nursing is illustrated by describing the development, implementation, evaluation, and revision of a family and health promotion course for graduate family nurse practitioner students. A narrative pedagogical approach that combines conventional pedagogy with action research is used. The work, an example of curriculum as dialogue, illustrates how teachers can incorporate research, evaluation, and reflection into their daily teaching practice. Given adequate support, these evaluation and research activities could constitute part of the scholarship of teaching, and, as such, would warrant allocation of time in faculty workloads and formal acknowledgment in annual performance evaluations and promotion and tenure decisions. The importance of increasing the clinical relevance of the scholarship of teaching in a practice discipline such as nursing is also emphasized.

Key Words Scholarship of Teaching and Learning--Narrative Pedagogy--Clinically Relevant Teaching--Action Research--Course Evaluation--Faculty Evaluation

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THE OVERRIDING EMPHASIS IN ACADEMIC HEALTH SCIENCE CENTERS ON RESEARCH AND CLINICAL ACTIVITIES THAT GENERATE REVENUE HAS RESULTED IN DECREASED TIME AND RESOURCES FOR FACULTY TO CONTINUE TO DEVELOP AS TEACHERS (WATSON, 2003; WHITCOMB, 2002). As a result of the nurse faculty shortage and heavy teaching workloads, faculty have little time to devote to enhancing their teaching skills and improving their courses (Yordy, 2006). In a recent national survey, faculty reported they had insufficient time or opportunities to devote to reflecting on teaching or discussing the scholarship of teaching (Benner, Sutphen, Leonard, & Day, 2010).

Although faculty are expected to respond to teaching and course evaluations by improving their teaching and revising their courses based on analysis and interpretation of qualitative data, in the form of student comments, and quantitative data, these everyday activities of being a teacher are scarcely recognized as evaluation research. This article describes a narrative pedagogical approach to developing, implementing, evaluating, and revising a family and health promotion course for graduate family nurse practitioner (FNP) students. The author, an experienced interpretive phenomenology teacher and researcher, combined aspects of conventional pedagogy with both formal and informal action research approaches in listening and responding to students. This work constitutes an exemplar of curriculum as dialogue (Diekelmann, 2003) and teachers as researchers (Kincheloe, 2003).

The Scholarship of Teaching and Learning For many years, the scholarship of teaching and learning for nurse faculty has been complicated by dichotomous perspectives on research versus teaching and teaching versus practice. Research has traditionally been the primary basis of promotion and tenure decisions in academia. Boyer's (1990) ground-breaking publication, Scholarship Reconsidered, produced an expanded perspective of scholarship in academia that has been well received in academic circles and has been applied in both nursing (Brown et al., 1995) and medicine (Simpson & Fincher, 1999). Riley, Beal, Levi, and McCausland (2002) proposed revisioning the scholarship of teaching for nursing as a practice discipline to prepare practitioners for lifelong learning.

Since the National League for Nursing Curriculum Revolution of the 1980s (Bevis, 1988), there has been considerable attention to the need for new approaches to nursing education. Yet, nurse faculty tend to employ conventional pedagogical approaches based on outcomes and/or competencies that emphasize covering content (Diekelmann, 2002). Benner et al. (2010) point to a major shift from concern about the education-practice gap to concern about the practice-education gap. These researchers report that conventional approaches to covering content in educating nurses are becoming increasingly unable to keep pace with new knowledge generated from research and advancing technology. Alternative interpretive pedagogies, such as critical, feminist, phenomenological, and postmodern approaches to learning-teaching and schooling, may be used alongside other approaches, including conventional pedagogies, to enhance learning and reform teaching practices and curricula (Diekelmann, Ironside, & Harlow, 2003).

The major thrust of the course revision process described in this article was the need to increase relevance for evidence-based practice. The article describes a situation-specific narrative pedagogical approach. As defined by Ironside (2001), narrative pedagogy is not a particular strategy to be implemented, but instead arises uniquely in each situation from reflection, interpretation, and dialogue between and among teachers and students.

Teachers as Action Researchers The literature regarding the origins of teachers as action researchers includes such well-known scholars as Dewey (1929), Lewin, (1946), Corey (1953), Polanyi (1958), Friere (1970), and, more recently, Giroux (1988; 2006) and Kincheloe (2003). Dewey viewed inquiry into pedagogical problems as an important role for teachers. Following World War II, Corey (1953) led an action research movement in education at Teachers College. He felt that teachers could reform curriculum practice by applying findings from their own inquiries. However, by the late 1950s, a separation had developed between science and practice, and reliance on experts for curriculum changes became more common (McKernan, 1988).

Polanyi (1958) viewed knowing as an act wherein the knower uses the self as an instrument of understanding and searching. Friere (1970) said that rather than being "bank accounts" for deposits from teachers, students need to be active participants in a mutual teaching and learning process. Giroux (1988) saw teachers as transformative intellectuals who consider students to be active agents and engage them in dialogue to promote self-understanding and emancipation.

Kincheloe (2003) viewed listening to students as a way to apply research to the pursuit of good teaching. He explained that teaching can be considered a form of research that attempts to understand the process of translating educational values into daily practice. Further, he observed that for practice to be informed, theoretical ideas need to be understood in terms of their relationship to the lived world, not simply as objects of abstract contemplation.

The Project In my teaching, I follow a narrative pedagogical approach to curriculum as dialogue (Diekelmann, 2003). Diekelmann explained that dialogue between teachers and students involves practicing community interpretive scholarship or "putting our heads together." I strive to remain open to feedback from students, referred to as formative or process evaluation in conventional pedagogy. Summative or product evaluation takes place once the course is completed. The feedback from both types of evaluation prompts reflection on what went well and ought to be continued and what did not go so well and needs improvement.

Although I typically engage in conventional evaluation research and informal action research during my everyday activities of being a teacher, a number of issues prompted the need to add a more formal action research component for this graduate-level FNP program. Specifically, there were ongoing questions about what family and health promotion content and skills need to be included in the program and how to actively engage students in learning. In listening and responding to our graduate FNP students over the years, it became increasingly apparent that there are discrepancies between current practice realities and health care needs for the future. Our students acquired clinical experience in the current illness care system, which is focused on individuals, episodic treatment, and cost effectiveness. Our challenge was to inspire their interest in, and commitment to, holistic, relationship-centered and family-focused care that integrates illness prevention and health promotion along with diagnosis and treatment of diseases in the context of daily life (Allan, Stanley, Crabtree, Werner, & Swenson, 2005; Institute of Medicine, 2001; Tresolini, 1994).

There was a discrepancy between faculty goals and student goals. Faculty in the program considered content and skills for working with families and advanced health promotion as essential learning for FNPs. Students, on the other hand, were primarily interested in learning about diseases and their treatment and were resistant to more nursing-focused content, such as family assessment and intervention and enhancing communication skills. They did not see this knowledge valued in the health care settings where they worked as nurses, and they viewed it as repetitive of their undergraduate education.

Over a period of several years, my FNP faculty colleagues and I engaged in an informal narrative pedagogical process of trying out a variety of ways to include this material in the FNP clinical management course sequence. Initially, family and health promotion content and skills were incorporated into the first clinical management course. Following student objections that they wanted more focus on disease, we revised the first course and interspersed the different components of family and health promotion throughout the three-course clinical sequence. These changes were associated with difficulties in scheduling and keeping track of the family and health promotion learning activities, as well as a general loss of emphasis on these topics.

To address these issues, we then placed all family and health promotion material together in the last clinical course. Even as we did this, we realized that it was counterintuitive to place this foundational learning at the end of the clinical sequence. To develop a holistic family perspective for their practice, students really needed it at the start of the program.

This combined narrative pedagogical, conventional evaluation, and informal action research process was followed for several years as learning activities were developed, implemented, and revised. During this time, the FNP faculty benefited from a continuing education program about curriculum as dialogue offered by Diekelmann, and the course coordinator participated in Diekelmann's (2003) faculty development initiative, a distance education program. We gradually realized that we had been caught up in a reactive process, moving content around in response to feedback from students, instead of engaging in a more reasoned approach to evaluating feedback over time, from more than one group of students.

The FNP faculty then engaged in a critical reflective process about trying to prepare students to think family instead of or in addition to individual; health promotion and illness prevention in addition to treatment of illness; and relationship-centered care instead of provider-centered care. We reaffirmed our belief in the necessity of this foundational learning to facilitate student learning of new ways of thinking and decided to create a separate, two-credit course for it, to be offered in conjunction with the first clinical management course. After teaching the course for two years with mixed feedback from students, I decided it was time to add a more formal action research component to evaluate the course and developed an evaluation research protocol, which was approved by the university Committee on Human Research.

The Research METHOD The project involved a combination of conventional pedagogy with action research and narrative pedagogy. Action research constitutes a way to systematically investigate problems and carefully develop specific plans to address them (Stringer, 1999); it is a family of research approaches rather than a single methodology (Chenail, St. George, & Wulff, 2007). Action researchers are insiders who conduct research to change aspects of their own world (Waterman, Tillen, Dieson, & de Koning, 2001). While both qualitative and quantitative data may be collected, action research is generally considered part of the qualitative research tradition because it focuses on "understanding specific and local phenomena in context, privileging the words/language used by participants, and proceeding thoroughly and systematically" (Chenail et al., pp. 450-451).

The purposes of action research are to stimulate change and to involve stakeholders in the change process. It is participatory and founded on democratic principles, "seek[ing] to empower those who are part of the process to act on their own behalf to solve real world problems" (Speciale, 2007, p. 327). Action research is also dynamic; data collection and analysis may continue in a cyclical fashion.

The basic elements of the action research model include planning, acting, observing, and reflecting. This project incorporated Kincheloe's (2003) teacher as researcher perspective derived from Stringer's (1999) community-based action research. This is the approach most frequently applied by practitioners such as educators, therapists, social workers, or nurses in solving everyday problems. It provides teachers an opportunity to understand how they and their students experience the educational process and can move both teachers and students into new avenues of thinking. It also fits well with narrative pedagogy, which involves planning co-equally for process as well as content; creating new partnerships between and among students, teachers, and others; and making learning rather than teaching the central activity (Diekelmann, 2003).

Action research can lead to more effective nursing education outcomes by virtue of sharing power and developing collaborative action plans (Speciale, 2007). The planning phase of this project involved preparing the protocol for the institutional review board. The acting phase involved reviewing literature, contacting faculty colleagues at two other universities, reviewing feedback from prior students, meeting with the FNP faculty, and presenting at a teaching conference for feedback from other faculty. The observing and reflecting phase involved studying and considering all the ideas and material collected.

The planning and acting phases occurred again with the development of proposals for changing the course and meeting with three current students who had completed the course. Their feedback on the proposed revisions was discussed with FNP faculty and refinements were made. Aspects of scientific merit incorporated into the project included triangulation of information from multiple data sources, peer examination, and member checking (Krefting, 1991).

ANALYSIS In 2005, the newly developed two-credit course for teaching family and health promotion knowledge and skills to FNP graduate students was offered for the first time. Student evaluations of the course averaged 4.5 on a 5-point scale. The second time the course was offered, in 2006, there was a disappointing mean of 3.4 on student evaluations. Because the evaluations were so low, the course coordinator considered the situation critical, warranting more than the usual course revision procedures. This was when the teacher as researcher transitioned from the ongoing narrative pedagogical plus informal action research and conventional evaluation process to initiating a more formal action research project. The goal was to thoroughly review problems with the course and collaborate with others to find solutions.

Comments from students constituted the qualitative data. Student comments in 2005 were all positive except for two: "the course could be completely web-based" and "I don't feel like I learned very much from this course. I feel like it was not applicable for being a FNP." In 2006, alongside positive comments, there were several negative comments: five about the family-of-origin paper; three about preferring a web-based course; one about the course being a rehash of undergraduate material; and one about its lacking clinical relevance.

REVISIONS Based on feedback from students and faculty colleagues from another university, the family-of-origin written assignment was eliminated. This learning activity, while highly valued by our FNP faculty (and some students) for stimulating self-reflection about family concepts and processes and preparing students for more effective communication with patients and their families, had become increasingly unpopular with students over the years.

A completely new assignment was developed that incorporated aspects of family assessment integrated with examination of selected leading health indicators in students' own families. It was designed to enable students to develop insight into the influences of the family on the formation of personal health practices, to analyze stability and transitions in these practices over time, and to reflect on implications for practice. This assignment required narrative self-reflection similar in some ways to the family-of-origin paper, but the context was more practical, less emotionally charged, and more readily translated into practice.

Several changes were instituted to help students grasp the clinical relevance of family and health promotion knowledge and skills for their future practice. For example, instead of faculty providing the primary care competencies for FNPs from the National Organization of Nurse Practitioner Faculties, students were asked to retrieve them from the organization's website, and then discuss them as a group and reflect on their relevance for practice. This active learning was designed to enable students to see for themselves that implementing these competencies in practice would require the incorporation of family and health promotion skills and knowledge.

Another change to increase clinical relevance involved replacing the terminology of basic health habits (Breslow & Enstrom, 1980) with the language of leading health indicators from the clinical preventive services literature and Healthy People 2010. These lifestyle indicators were selected on the basis of their potential to motivate action, the availability of data to measure progress, and their importance as public health issues. They were used to make course assignments more practical, action-oriented, and evidence-based.

The book The Way We Never Were (Coontz, 1992) had been used to prompt students to analyze changes in traditional family values and family health policy over time. Students had mixed reactions to this book, which they found more theoretical than practical. Through discussions with faculty and students, it was determined that the policy course provided sufficient exposure to family health policy and students really needed more emphasis on clinical ethics. Fadiman's (1998) powerful The Spirit Catches You and You Fall Down was then incorporated as a reading assignment. It includes narrative learning from the humanities and encourages reflection on, and analysis of, cultural, ethical, and moral issues in family health care. The book has the potential to refocus students on the holistic, human aspects of families experiencing illness and establishing relationships with providers, and it counterbalances the economic and instrumental loci students are more accustomed to encountering in health care settings (Rashotte, 2005). The assignment is especially effective for changing the paternalistic "do as I say," provider-centered compliance perspective to a more open and responsive patient/family-centered perspective characterized by cultural humility rather than cultural competence on the part of providers (Tervalon & Murray-Garcia, 1998). The assignment continues to be supported by positive feedback from students.

Results These more active and clinically relevant approaches to teaching and learning produced a complete refraining of the course. Now students were pointing out the importance of assessing the whole family and showed enthusiasm for evidence-based behavioral interventions that demonstrated effectiveness. The combined research approach used here led to a transformation from a teacher-centered course to a student-centered course; from passive to active learning; and from more abstract thinking to more practical and clinically relevant ideas and assignments.

The next time the course was offered the course evaluation mean was a very satisfactory 4.7, with just one negative comment about too much work for two credits. The formal action research project ended with a coincidental change from a face-to-face course with web support to a completely online course, which was implemented as part of the school's transition to more online courses. This change, which was not part of the action research project, was welcomed by faculty as it had been supported by comments on course evaluations over several years.

Subsequent evaluation data have continued to be positive with means of 4.89 reported in 2008, 4.1 in 2009, 4.29 in 2010, 4.32 in 2011, and 3.95 in 2012. In 2008, there were two student comments about the course workload being too heavy and one suggestion for consolidating assignments from individual to group projects. In 2009, two assignments were changed from individual to group projects, and there were six comments about the workload being too much for the number of credits. There were also negative comments about the self-health appraisal assignment: three in 2010, two in 2011, and seven in 2012. In 2012, with a major increase in enrollment from 20 to almost 50 students, there were 10 negative comments regarding the workload from this group of students.

Decreases in the evaluation means in 2009 and 2012, dissatisfaction with the self-health appraisal assignment, and comments about the heavy course workload for the past few years led to the decision to remove the individual health appraisal assignment in order to make the workload more manageable for both students and faculty. Thus, the dynamic combined narrative pedagogical, conventional evaluation, and informal action research process continues in cyclic fashion as the course coordinator responds to evaluation feedback from students, reviews the literature, and communicates with faculty.

Conclusion Faculty engage in conventional evaluation research along with informal action research approaches to evaluate and revise courses. However, these activities are not readily recognized as research or scholarship. The combined narrative pedagogical, conventional evaluation, and action research project described here is an exemplar of the practice of teachers as researchers. It also constitutes an effective approach to enhancing the clinical relevance of the scholarship of teaching. Teachers are expected to engage in ongoing analysis and synthesis of both quantitative and qualitative evaluation data to evaluate and continually improve their courses, teaching skills, learner outcomes, and overall curriculum. These examples of the scholarship of teaching constitute integral components of the practice of teaching that need to be promoted by support from administration and acknowledged in tenure and promotion criteria and decisions.

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Karen A. Brykczynski, DNSc, RN, FNP-BC, FAANP, FAAN, is a professor, University of Texas Medical Branch School of Nursing, Galveston. For more information, contact her at kbrykczy@utmb.edu or Karenski18@att.net.
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Author:Brykczynski, Karen A.
Publication:Nursing Education Perspectives
Geographic Code:1U2NY
Date:Jul 1, 2012
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