Enabling Narrative Pedagogy: Listening in Nursing Education

The role of the nurse has become considerably more demanding in the past twenty years through increased complexity of patient care within a rapidly changing health care environment. Research is needed to expand the pedagogical literacy of nurse educators and address the needs of students entering a complex health care system. Narrative Pedagogy was identified as a research-based nursing pedagogy and has been enabled in nursing education for over a decade. The Concernful Practices emerged from Narrative Pedagogy research, which helped identify what teachers, students, and clinicians considered meaningful in teaching. Listening was one of the Concernful Practices and became the focus of this study. This hermeneutic phenomenological study provided new understandings of the experience of listening in nursing education. The research question addressed " How do nurse educators who enable Narrative Pedagogy experience Listening: knowing and connecting? " One of the themes, Listening as Dialogue, emerged from the study and included ways nurse educators can open and interpret a dialogue, shift the way they think about teaching, and make connections with students.


Introduction
The landscape of health care delivery systems has changed dramatically in the past twenty years.Nurse educators are challenged with graduating students who are able to meet the diverse needs of patients, work collaboratively, and deliver safe, competent care in a complex health care system [1].Narrative Pedagogy (NP) is a research-based nursing pedagogy grounded in hermeneutic phenomenology [2]; when enabled, students and teachers collectively share and interpret experiences related to patient care.NP research draws attention to what is considered meaningful to teachers, students, and clinicians in nursing education and teachers have enabled NP for over ten years [3][4][5][6][7][8][9][10][11][12].NP is always present in the teaching and learning community of nursing, but the ways it is enabled varies depending on the site.To enable NP, nurse educators: (a) attend to the Concernful Practices; (b) publicly share and interpret experiences; and (c) engender community interpretive practices [10].The aim of this research study is to describe how nurse educators who enable NP experience Listening: Knowing and Connecting as one of the Concernful Practices.
The Concernful Practices (Box 1) are derived from over ten years of data; they emphasize how nursing education is experienced, with language focused on what teachers and students find meaningful in nursing education [3].The Concernful Practices are considered ontological, meaning they are built out of a phenomenological sense and way of being in the world.The Concernful Practices are always present in teaching and learning and are not considered positive or negative; they always already exist as possibility.The Concernful Practices provide faculty and students with a new way of talking about their experiences that exceeds (but includes) the common focus on content, objectives, or outcomes throughout nursing education [13].This study explored the experience of Listening: knowing and connecting as a phenomenological concern.This Concernful Practice was selected as a way to provide rich descriptions of listening and how faculty experience it.
The Concernful Practice of listening includes a description of knowing and connecting from a phenomenological sense [2].When teachers and students make connections through a learning experience, they invite a sharing of scholarly inquiry and an opportunity to interpret their experiences of patient care from multiple shared perspectives [13,14].The public sharing and interpretation of those experiences creates a communal experience between students and teachers, which is widely supported in the literature as an educational practice [2,15,16].The communal experience was neither teacher-centered nor student-centered, but rather teachers and students were learners together.Rossetti and Fox [16] indicated characteristics of successful teachers were those who continued to learn along with the students and continuously refreshed their knowledge.The communal experience draws on the knowledge already known and builds interpretive practices to envision new ways of thinking.Interpretive practices created in the teaching and learning environment demonstrate formation of new knowledge, which is socially constructed [17][18][19][20].The interpretative practices allow opportunities for the students and teachers to communally think through the contexts of patient care, furthering their current understandings.Vital to this, communal experience and interpretive practice is the Concernful Practice of Listening: knowing and connecting.

Methods
This hermeneutic phenomenological study is a multi-site, international study of nurse educators who enabled NP in their courses.The participants consisted of nine nurse educators and one midwifery educator.Following approval by the university Institutional Review Board, the investigator used unstructured interviews of the participants over a span of two years.To begin the interviews, the investigator asked participants to discuss how they became familiar with NP and enabled it in their own teaching practices.Following this description, the participants were invited to share their experiences with the Concernful Practice Listening: Knowing and Connecting.Specifically, participants were asked to relate those experiences in which listening stood out to them as important in teaching and learning.The investigator used prompts such as "go on" or "can you tell me more about that" encouraging participants to give as much detail as possible about their experiences.
The investigator coded data using MaxQDA and identified themes using a six-phase process derived from a combination of interpretative methodologies presented in the literature [21][22][23][24][25].Those phases included: naïve understanding, dwelling and releasement, initial interpretation, exemplars, paradigm cases, and themes.During all phases of analysis, several philosophical works including Gadamer [26] and Heidegger [27] were used in addition to literature related to nursing education and the notion of listening across the health professions literature.Pseudonyms were used for the names of participants to conceal their identity.Two themes were explicated in this study, one, Listening as Dialogue, is presented here.

Listening as Dialogue
The participants in this study described ways they attended to students in a collaborative manner when enabling NP.One of the participants, Heather, had been teaching in nursing education for several years.Heather described enabling NP in her everyday teaching practices and believed it created an environment where students felt they had a voice in their learning experiences.Heather shared: The students read an article; another classic from the 80's called White Privilege and the author lists out twenty-six items of privilege that she had identified as a white woman . . . the directions of the paper [were to] think of a role that you or one of the cultures you are a part of that grant you privilege and name that...So talking about privilege and power is a really sensitive issue.White people tend to say it wasn't something that I asked for; it isn't something that I want, and so I don't have it.Well, this past week in class a woman that . . .grew up in Kenya . . .was the first person to talk and that was the first time in three weeks that she's said more than a couple of sentences at a time . . .She [student] started talking and had a five-minute, almost a soliloquy about the difficult topic of power and privilege and how unless you are a person of a different color you don't understand that . . .

Interviewer: How did the students respond to her?
That was really interesting.There was silence a little bit afterwards . . . .And a student, sort of leaning [forward], very thoughtfully said, "Wow, I hadn't really thought about it like that before."And so when that student said that it really opened up a lot of other students started talking a lot, kind of the same thing, and it was a very rich discussion, very rich.
Heather maintained an open environment, in which she invited students to engage in a dialogue through the use of a predetermined assignment in which students were asked to critically examine themselves in the world ("white privilege and how their culture grants them privilege").During the ensuing dialogue, a previously reticent student speaks up, eloquently describing her experience as a person of color.Rather than calling out a debate or hostility, Heather finds this student's contribution elicits silence, during which time another student shares her surprise at the new perspective being shared-one she had previously not considered.This comment "opened up" a "very rich" discussion among students in the room.When asked how she experienced this exchange Heather shared: It gave me chills . . .and I mean, the really cool thing is when students nail it, they do the teaching and all I have to do is sit back, let it happen and just maybe ask a few questions or if I know who seems to be hesitant to speak up and has something to say and [while] not just calling on someone arbitrarily, but picking somebody out and saying, "Well, John, what do you think about that?How did what Susie said; what are you thinking about that?"And also then saying, "that's okay Amy you really don't have to say anything."You know if you get that sense that you've stepped in too far and somebody is not willing or able to speak up you just have to back out and do it in a respectful way so that then it maintains that safety, that sense of preserving students' personhood.
Heather described how moving she found the discussion ("it gave me chills").Importantly, Heather is not quiescent in the discussion she described, but rather she participates in the discussion by asking questions and inviting other students to contribute to the dialogue as it unfolds.Heather speaks with students in the shared dialogue and students similarly speak with each other and not just to her as the teacher, but as a person.Heather draws on the variety of perspectives students bring to the discussion and creates a sense of "safety" that "preserves students' personhood" as different perspectives are elicited and considered.In addition, Heather describes how this approach fostered students talking "a lot" in the sense that without her directing the discussion, students readily engaged in exploring the multifaceted experiences being shared by others.Through these discussions, together with her questions, students hone their interpretive practice are able to consider perspectives quite different from their own.
Embedded in Heather's account is an openness to exploring different perspectives, rather than having students reach consensus on one best or right perspective.In content-laden curricula that are common in nursing [14], it is often difficult for teachers to create time for discussions that engage students in listening to and considering perspectives different than their own and for sharing their thinking in ways that fosters knowing and connecting.Fostering such interpretive practices, however, can help students consider themselves as nurses, and those for whom they provide care in new ways [28].
That is not to say that the discussions, such as the one Heather fostered in her classroom, were always successful or transformative.For some participants, efforts to enable NP were difficult and uncomfortable and they worried they had "lost" students.Gina, a less experienced teacher, shared: . . .I could say when we cover a topic like fluid and electrolytes, I think it gets a little, I don't know, it gets a combination of boring, or I'm a little over their heads [students'], which I try not to be.I haven't figured out a way to present fluid and electrolytes without slides.We do a lot of definitions and we do case studies, but I go through the broad strokes about sodium and potassium, all of that with slides.And it's dry and it's boring.I think my stress levels are up because I know fluid and electrolytes, but I don't love them.I think because I don't love the content, it's just bad all around . . .it's palpable in the classroom and I lose them a little.
Interviewer: When you say you lose them a little, how do you determine that?When do you know you lost them?I think that when they're not engaged, like when I ask a question, no one raises their hand, or they are still continuing to talk to one another [while I'm presenting].I'll ask simple things, like what's the definition of hypokalemia; it's really just knowing suffixes and prefixes, things like that.I think they're simple; then again, it's based on thinking that the students are prepared for class.Have they done any reading or are we starting fresh?But usually it's when you ask a question and you kind of get a blank stare.[Or when there's] not a lot of participation because my classes are usually participative, I don't want to do all the talking, I want to hear what they have to say.So I do ask a lot of questions and try to engage what they know to bring it into the conversation.
Gina seeks to enable NP in her classroom, but invites dialogue focused on correctly answering the questions asked (i.e., what is the definition of . . .).These questions do not invite students' thinking or interpretation, but rather merely responding to questions with memorized content.Clearly, it is important for students to learn about fluid and electrolytes and nursing teachers spend a lot of time in their courses teaching physiological concepts such as these.Gina does describe noticing "blank stares" and that no one volunteers to answer a question she poses (by raising their hand), yet she attributes these responses to students' lack of preparation or lack of reading, rather that the nature of the questions she asks and the ways she might be inviting (or not) students' perspectives.That is, she describes wanting to "hear what students have to say" but only in response to questions she asks.
NP fosters communally (publicly) sharing and interpreting experiences in which teacher and students engage.It requires being with each other in a different way.Being-with is a way of co-understanding another's view of the world [29].Thought of in this way, neither a student or teacher dominate the dialogue, all must be in it together.
Listening as Dialogue was not merely an exchange of a conversation; it was centered on interpretive acts that accompany the experiences of teaching and learning.Jayna, a teacher who had enabled NP for several years shared: The woman [patient] had talked about how she was having screening for fetal abnormalities and she talked about if her baby did have an abnormality then she would consider terminating the pregnancy.So the students had been discussing this afterwards [in class] and one student said well, "that was just so out there because my family, my friends would never do that.If we had a baby with an abnormality, we would just have it and love it."So she [student] said, "I [student] was surprised at what she [woman] said and then I was surprised at how I was feeling.I [student] was surprised that I felt that way because I didn't think I would feel that way.I thought that whatever a woman did would be absolutely fine."So she [student] was actually able to verbalize through that dialogue and the reflection on the dialogue to actually realize something about herself and her own beliefs.I think anyone, any health professional, that's absolutely crucial, isn't it?Because you have to really acknowledge your own beliefs and okay, that's my belief system, that's my culture, that's the way my family does it, but others have different ways of dealing with these issues.As a professional, you have to acknowledge your own beliefs, put them to one side . . .I thought that was a really good thing to happen through dialogue and could all be verbalized and then hopefully when she goes into practice, she can just put that in the back of her mind.It's not going to come bubbling up again.In Jayna's experience of listening, she recognized how the dialogue surrounding a narrative allowed an opportunity to co-respond about biases.Jayna experienced listening by allowing time for interpretation of those thoughts and biases that were imperceptible prior to the discussion.The listening and co-responding to narrative accounts encouraged reflection on ways of being in the world and ways of being a nurse.The student was unlearning the previous ways she thought about having a baby with an abnormality and, through that interpretation, changed the way she thought about being a nurse.The narrative allowed the student to interpret this bias and Jayna experienced listening by attending to the dialogue as the student realized this on her own.Jayna described how she was listening to her students and through the narrative accounts, interpretation ensued.Jayna acknowledged how through examining those biases, "it's not going to come bubbling up again." The experience of listening in which the participants, at times, would experience a sense of not listening or a lack of connection may have been elicited for a variety of reasons.Gina and Heather both described experiences of listening or not listening that were uniquely distinct.For Heather, the dialogue was vibrant and students are engaged, which contrasted with Gina's situation with a lack of dialogue or connection.Even though the situations are different, Listening as Dialogue developed from the participants' experiences through the interpretation of connections and dialogue.Dialogue was not simply the conveying of experiences, but rather a way of co-understanding another's way of being in the world and related to the art of thinking [26,27].Important to dialogue was the co-understanding of another view to expand how the content was interpreted and understood.Listening as Dialogue and co-understanding occurs in various ways allowing for interpretive acts, regardless of pedagogical strategies used along with enabling NP.

Discussion
Patient care has changed dramatically in the past decade and approaches to teaching and learning need to respond to the complexity of this change in the current health care system.The findings of this study provide a different way of thinking about teaching and learning that extends traditional pedagogical approaches.The experience of listening described by Heather and Jayna furthered interpretative practices that enhanced how students could think through a situation from multiple perspectives and explore biases.When NP is enabled, it may be used alongside other approaches to teaching and learning and creates a way to publicly interpret experiences commonly experienced in patient care.The focus shifts away from the teacher as the purveyor of knowledge and towards a collective dialogue.The implications of this study offer nurse educators insight about opening a discussion and listening for ways that invite interpretative dialogue.
Silence on the part of the teacher creates an opening for dialogue to occur.Heather and Jayna listened to the experiences of students and allowed interpretation of the experiences to be explored.The power is shifted from the teacher as purveyor of knowledge to the communal experience of understanding.According to Heidegger [27], silence is an essential possibility for dialogue.Heather and Jayna invited dialogue through remaining silent, in contrast to Gina who continued to ask questions.The silence is an essential piece for allowing that communal dialogue to emerge.
When nurse educators learn to enable new pedagogies, like NP, it is a process to develop a different way of thinking about teaching and learning.Listening: knowing and connecting, as a Concernful Practice, is always already present in teaching and learning and the participants in this study experienced it through dialogue.For nurse educators to address this important finding, Listening as Dialogue can be the focus of ongoing faculty development while sharing how listening is attended to through dialogue.Small group sessions between nursing faculty can explore successes and challenges when they attempt to shift their way of thinking about teaching towards remaining open to a dialogue.During faculty development, nurse educators can discuss how listening appeared and consider the many possibilities that exist for opening a dialogue.Questions to ask during faculty development may include: "How was dialogue encouraged?", "How was interpretation experienced?", and "What were ways that dialogue and interpretation could have been encouraged?".These questions and more can help nurse educators explore the possibilities of how Listening as Dialogue may be experienced in a group discussion to further enable NP in teaching and learning.This study emphasizes how a research-based pedagogy, such as NP, can extend current practices in nursing education.
When nurse educators enable NP, they shift their teaching practices towards a communal experience.Noddings [29] identified how educators can shift the way they think about teaching towards a focus more on the student as a person.Heather, referred to this as "preserving the personhood" of the students.By attending to listening and responding to a dialogue, nurse educators are able to connect with how students are thinking about nursing care, address their understanding of the content, and help interpret how the content relates to the critical care of patients.The focus towards the student as a person allows nurse educators a way to attend to the dialogue at the moment and address the student's biases and decision-making processes in patient care at that time.

Conclusions
Nurse educators nationally and internationally have embraced NP as a researched-based way of teaching and learning.This research has implications for how nurse educators attend to teaching and learning in nursing education.The concluding statements are more of an opening to future endeavors, rather than an ending to a study.This research expands what is known about Listening: knowing and connecting as a Concernful Practice and the findings are applicable along-side other strategies and pedagogies.Nurse educators need the research-based knowledge of teaching and learning in order to provide the best possible outcomes in student learning.The findings of this study include the stepping-stones to further pedagogical insight in nursing education.