The unpredictable and volatile economic context, ever-changing demography, explosion of technology, and rapid disruptive health delivery models are only a few of the factors characterizing the constant flux permeating the health care system. Nurse leaders and educators have responded by modifying and adapting curricula, adding other and higher academic degrees, and embracing new learning platforms and approaches. Yet, these educational initiatives continue to lag behind societal changes and result in corrective and reactive measures, rather than reflective and proactive transformations.
It is becoming necessary to shift the focus to the development of the individual student’s capacity to face the world’s complexity and remain truthful to the original intent of learning, namely, uncovering the nature of humans, society, and nursing practice. Some renowned nurse educators and educational leaders (Benner, Stephen, Leonard, & Day, 2010; Caputi, 2018; Carper, 1978; Doane & Brown, 2011; Forneris & Fey, 2018; Ironside, 2004; Tanner, 2004, 2006) pioneered the departure from a learning emphasis on what nurses do to what nurses become. To supplement attitudes that are by-products of knowledge and skills acquisition, they have proposed others that can be acquired through new relationships, teaching strategies, and content foci.
RELATIONSHIPS, STRATEGIES, CONTENT FOCI
To develop reflective practitioners who use metacognition to make meaning of their experiences, nursing educators are encouraged to redesign their learning-teaching approach. The educator joins the learner to co-create knowledge (Diekelmann, 2005; Diekelmann & Lampe, 2004; Eppich, Rethans, Teunissen, & Dornan, 2016; Levy, Thomas, Drago, & Rex, 2013). Forneris and Fey (2018) provide a structure composed of context, content, and course and recommend practical guidance to foster the constant dialogue between educators and learners and capture the learner’s unique thought processes and the rationales guiding their actions.
Doane and Brown (2011) concede that the defeat of current nursing education is rooted in its epistemological focus or what to know, in lieu of an ontological orientation that primarily focuses on developing the learner as a nurse. In this context, students are not slaves of knowledge. The authors propose strategies for nursing students to develop responsible, ethical, and competent attitudes toward filtering, synthesizing, adapting, and recreating knowledge to apply as they see fit. They also propose that nurses cultivate flexibility and receptiveness to change, uncertainty, and instability.
Tanner (2004) supported Ironside’s (2004) proposition that nurse educators shift the focus of learning from imparting content to a more wholistic paradigm of engaging students in pondering the meaning of life and creating places for thinking about the meanings of the content being learned. In 2006, Tanner took the next logical step in her clinical judgment model, illustrating the stages of thinking as noticing, interpreting, responding, and reflecting.
To foster deliberate, responsible, and thoughtful critical thinking essential for nurses to be effective in their role, the Caputi model for teaching (Caputi, 2018) illustrates how clinical reasoning lies at the symbiotic point of the thinking stages (Tanner, 2006), the continuum of nursing experiences (Benner, 1984), and the acquisition of skills and strategies to develop critical thinking. Carper (1978) contends that it is aesthetic knowing that equips the nurse with the intellectual curiosity needed to become a certain kind of person who does certain kinds of things. In 2010, Benner et al. called for radical transformation of nursing education, reiterating the significance of aesthetic knowing in the nurse’s development of clinical and moral imagination. In this climate of knowledge explosion, they recommended the cultivation of students’ sense of saliency.
Doane and Brown (2011) concur that placing epistemology at the service of ontology calls for aesthetic elevation, development of human intuition, and recovery of one’s aptitudes. For example, a nurse educator can engage learners in the discussion of a case study and challenge them, based on the pathophysiology of the case, to deduct the aims of its management. With the boundaries of preexisting epistemological narratives removed, learners cease to be mere knowledge consumers and become partakers free to imagine, think their own thoughts, discover alternative perspectives, and create new paths.
ONTOLOGICAL ORIENTATION MODEL FOR RN-BSN EDUCATION
Epistemology refers to the nature of knowledge and ontology focuses on the nature of the learner’s development. The former targets “how” we know, and the latter targets “who” knows (Boersema, 2008; Dewitt, 2018). To enact and expand fundamental ontological principles, an RN-to-BSN program located in the mid-Atlantic region gives learners a place to translate and transcend their epistemological acquisition into human experiences and actions uniquely tailored to specific individuals and practice settings. Changed from a generic baccalaureate to an RN-to-BSN degree in 1997, this program equips learners with competencies that can ignite the habit of observing, inquiring, discovering, and creating projects to change patient outcomes. Program enrollment varies from 25 to 50 students and is managed by three full-time faculty and up to three adjunct faculty members. The curriculum, distributed within three semesters, was revised in 2015. Five stages of the ontological-driven learning process are enlisted in three interrelated courses in the program of study as exposure, inquiry, discovery, reflection, and evaluation.
The modules inserted in the first-semester RN transition (RN-to-BSN) course expose the students to multiple ways of knowing and the process of knowledge development as theory, research, and practice. To foster the ontological learning approach, faculty select several grand and middle-range theorists for learners to label, compare, and contrast. They assign learners to research and identify other works produced by the theorists. For example, learners discover that Florence Nightingale was a keen statistician who created the modern circular histogram to convince the British government to improve sanitation in its military hospitals during the Crimean War.
Learners also deduce personal traits contributing to the theorists’ ability to create. They notice the necessity of being patient and knowing that what is created is not always readily usable. They become familiar with Rogers’ pandimensionality theory, which was not readily understood because Rogers was ahead of her time (Johnson & Webber, 2015). They also become familiar with Leininger’s transcultural movement, which was dismissed until it became necessary for the health care system to heed the cultural diversity of their clients, patients, and families to support positive health outcomes (Alligood, 2014; Faucet, 2013; Johnson & Webber, 2015).
Such practices are designed to strengthen the students’ epistemological capital, initiate their ontological journey, and ignite their dormant creative spirit. They also provide students the opportunities to verify the plurality of venues for entering the cycle of knowledge and discovering how creativity, in lieu of being exclusively the province of a few individual geniuses to create a specific intervention for a specific domain, can be a basic everyday, everyone, everywhere human capacity.
The second stage, which is inserted in the second semester course, focuses on professional nursing issues. At this point, faculty assign learners to observe their community and workplace and note how people live and interact with their technological and natural environments. The goal is to identify a particular health issue worth confronting and resolving. Students have the choice of working individually or in groups of two or three.
To translate and transcend their epistemological acquisition during their observation, the learners assess the environmental context of the health issue to identify the root cause of its occurrence or perpetuation. They then search and appraise six or more interventions known to be effective to resolve the health issue. During this stage, learners demonstrate their ontological orientation by extracting or modifying the known interventions to reach what is applicable in the present context. Weighing the strengths and weaknesses of evidence exposes learners to the dynamism and complementarity of knowledge. Learners liberate themselves from the status quo and cultivate tolerance for ambiguity and uncertainty. Appraising divergent thinking and interventions leads to the habit of reinvention and the creation of new ideas.
Discovery and Evaluation
According to Ricoeur (1991), action is the primary ontological principle. Learners complete their liberal arts, humanities, and fundamental nursing courses before entering the third and final semester of the program. Drawing from their epistemological acquisition and artistic skills, they design projects to tackle the health issue observed during the second semester. The most common projects are: a) apps of best ways for adults living independently to obtain accurate blood pressure; b) pathways of best approach for home health care nurses to assemble adequate and appropriate supplies for sterile dressing changes; c) algorithms for the safest method to transfer an acutely ill patient from one facility to another; and d) posters as an effective approach to increase water intake in demented older adults.
To improve and refine their project before submitting their final product for grading, students are encouraged to submit it to classmates and faculty, soliciting feedback and recommendations. At the end of the semester, students invite friends, family members, students, and faculty of other departments to the oral presentation of their project. Analytic grading rubrics provided to attendees are averaged to assign a final grade.
Initiated in the second semester, learners maintain an ongoing journal to reflect on the knowledge, skills, meanings, values, and experiences used and acquired during the process of creating their project. By reading students’ journals, faculty capture their ontological growth. Some students comment on the degree of humility, persistence, endurance, openness, and receptiveness they have acquired or mustered to revisit and refine their project. They concede to the need to be lifelong learners, for each new knowledge acquired and each new answer to a burning question introduces them to a new set of questions and uncertainties. They also express their intention to increase their chance of employment by inserting their projects into their portfolios.
Nurse educators must exchange learning pedagogies limiting learners in favor of strategies that allow them to observe transformational leaders, expert clinicians, and exceptional managers. The American Association of Colleges of Nursing (2008) acknowledges that the forces influencing health care systems and patients’ health outcomes call for new ways of thinking and providing health care. The solution lies at the crossroads of nurse educators acquiring teaching skills, nursing judgment, personal values, and a spirit of inquiry (National League for Nursing, 2017). In this order of learning process, the line between captain and disciples, and teachers and learners is purposely blurred for patients’ better health outcomes and for nurses to apply liberal arts and other nursing competencies and creatively place their translation of current evidence into their practice.
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