Generating ideas for the teaching of nursing's history in Australia

Developments in pedagogy of history of nursing 

In the early parts of the 20th century in the USA, when history enjoyed a status within education as being part of the ‘great tradition’ (Husbands, Kitson, & Pendry, 2003), learning nursing's history was an essential component in the curriculum. In 1917, the National League of Nursing Education recommended 15h of history of nursing learning in a nursing program (Lewenson, 2004). It was suggested this be taught with the use of photographs to make the past more interesting.

Twenty years later, the recommended hours increased to 30 and teaching strategies suggested were the use of maps and graphs, to show the sequence of related social and political movements, as well as reading assignments, class discussions, holding pageants and museums. After World War II, when few historical research studies were being conducted, the hours for history learning were reduced by half, and it was left up to faculty to decide which students might be interested in studying the subject and how it should be taught (Lewenson, 2004).

Then in the post war period another change was seen. In the developed world the technology boom began to have an effect both on nursing practice and, by association, the nursing curriculum. Nursing skills diversified and became more complex. Proponents of science, including those in nursing science, with their interests in technology, efficiency, standardisation and control, emphasised the development of procedural nursing skill proficiency. This technological determinism or ‘technophoria’ is a form of bureaucratic power that contributes to a technocratic health system (Willis, 1983). Technocratic discourse is characterised by the way it is represented as neutral, objective or scientific. It is presented as free of all interests and values except truth although it has a hegemonic function (McKenna & Graham, 2000).

Continued technological advances have now begun to spill over into management and education and this is influencing nursing education. Some theorists challenge and question the development of clinical management arguing that it has become the new technocratic orthodoxy (Belkin, 1997, Sharp, 2002, Syrett, 2003). There are concerns that computers and distance learning are disrupting opportunities to develop relationships, leading to loss of caring ‘know-how’ and cultural identity (Bowers, 2000). Furthermore, studies have identified reluctance by academics to teach values, morals, history and customs (Jenner, 1998, Miller, 2006). The recent Australian study also revealed an overwhelming sense amongst academics that history content was being marginalised by a growing preference for technical skill development and science-based courses to ensure graduates were ‘work-place ready’ and academics felt powerless to resist this technophoria (Madsen et al., 2009). This study found history content was as high as 120h but was frequently as low as 12 and in some instances not included at all.

Making space for history in the nursing curriculum 

Critics of the technological impact on nursing are emerging. Technocratic determinism in the health system constructs and perpetuates a kind of cultural zeitgeist (Held, 2002; Raine, 1998). Others argue that nursing education requires a rebalancing between the sciences and arts because of the loss of professional attributes, such as caring know-how, cultural identity, critical thinking and reflective practice. These professional attributes are best cultivated through the liberal arts, an important component of which is history (Chambers and Subera, 1997, Newby, 1991, Newby, 1979). However, reviews of Australian nursing education reveal a paucity of effective study tools, such as history, that enable students to understand professional issues, stimulate critical thinking and professional attributes to assist them to integrate into the workforce (Bellack, 2004, McAllister et al., 2006, Madsen et al., 2009).

Such deficiencies are not restricted to Australia. The marginalisation of history content in nursing is reported also in the UK and the USA. Indeed, over 20 years ago, Newby (1991) mapped out a plan to resolve problems of teaching nursing history in the UK, which are readily transferable to the Australian context, but not widely enacted. The plan does, however, provide a logical starting point for the improvement of teaching. It outlines the need to:

Towards transformative learning 

In devising quality teaching and learning material, it is also useful to reflect on levels and types of learning. Bloom's revised taxonomy of learning (Anderson et al., 2001) helpfully illustrates levels of cognitive learning and shows how teaching and learning can begin with a surface level that is concerned with students knowing and reciting things, on to understanding and through to a high level that is concerned with the student learning to analyse, evaluate and create new insights. This taxonomy is useful in guiding the development of both learning and assessment strategies, and can move teaching from a uni-directional, sender–receiver and transmission-based model (Shannon & Weaver, 1949), that tends to cultivate knowledge recall, to a model that is more collaborative and transactional, and where it is important for students to actively apply, critique and construct new ideas (Lieberman, 1995, Null, 2004). Reflecting on the taxonomy in terms of history of nursing can be useful in appraising and developing approaches that academic teachers may take to the learning process (see Figure 1).

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Figure 1. Bloom's taxonomy of learning.

Learning a set of historical dates, events, and figures of the collective past, the so-called ‘traditional content’ of history studies sits at the base of the taxonomy. This learning is useful for providing a snapshot of the big picture, providing chronological structure. It also prompts knowledge recall and is a basis for further knowledge development. As Wineburg (2000) argued, it reflects first-order level of history learning. When teaching stops with this first level learning, it has been heavily criticised by educationalists because it overlooks ambiguity and dilemmas and fails to teach students how to think critically about sources, how to find out answers to questions, and to become a producer rather than just a consumer of information (Tanner, 2003). Teaching this lower level learning about terminology and processes in nursing's history can be made more interesting, especially when conducted in small groups, by setting cross-words and quizzes that require collaborative learning and increase history vocabulary (Madsen, 2008).

A criticism of first-order learning relevant to nursing education is that students who only learn the functions and techniques of practice are unlikely to make much contribution to social change. Thus, nurses may become technically proficient, but professionally weak. Whilst it is a necessary component in nursing education, technique-dominated learning is not sufficient for skilled health professional practice. Indeed, there are many who argue that technical knowledge is inherently conservative (Gee and Lankshear, 1995, Habermas, 1972)—in nursing it may teach students client-assessment and treatment skills, but it is not good at engendering critical, imaginative and creative thinking.

When cultural and social problems commonly seen within health structures are not discussed within the relatively safe context of the classroom, students may remain ignorant of them until they have to experience them. When this happens events may be perceived as shocking, frustrating and overwhelming, and the nurse may lack problem solving strategies. Common problems include power inequities between clients and healthcare workers, ethical dilemmas such as enforced treatments, or ideological tensions such as between the public health and medical models (Duffy, 1995, Radcliffe, 2000). Ill equipped graduates may feel powerless to make a positive influence and subsequently experience self-doubt, tentativeness, or emotional distress (Cohen & Erickson, 2006). This is when critical thinking, cultural awareness and issue-based problem solving are so important. The aim is to achieve transformative learning, that is when individuals realise how and why assumptions have constrained the way they understand the world, and so begin to consciously use other strategies to rethink issues and define their worlds differently (Giroux, 2000).

Topics for transformative learning can be any aspects of a culture, which have become naturalised, overlooked and taken-for-granted, and about which learners may lack strategies or have become resigned or disillusioned (McAllister, 2005). Transformative learning aims to stimulate fundamental shifts in students’ personal and professional values so that they are sensitised to issues of social injustice, power imbalance and inequities, and then equipped to make social change. In relation to nursing, transformative learning can show nursing students ways to be more open to and sensitive about difference, and the need to be participatory with clients and respectful in teams (McAllister et al., 2006).

Second-order history learning involves this critical thinking, preparing students to make informed decisions, understand differing perspectives, identify and make sense of competing accounts and make judgments about the significance of issues/events (Levesque, 2005). In this way of learning, students and teachers are more collaborative, co-constructing new ideas and solutions to problems. Students develop a sense of perspective and connectedness with the past, humility and a deeper understanding of professionalism and critical thinking which underpins better clinical judgment and reasoning (Sokol, 2008).

Transformative learning experiences entail applied humanism, where the use of liberal educational strategies such as narrative, poetry, metaphors, film and literature can evoke imagination, empathy and care—all key skills for the contemporary health professional (O'Sullivan & Morrell, 2002) and operate as useful adjuncts to the more traditional focus on scientific and technical learning in nursing.

Identifying topics and creating learning material 

History learning offers an opportunity to develop nursing students to be critical and constructive thinkers, and have a positive professional identity. Knowing why we teach history and identifying learning outcomes will help teachers to make good decisions about what to include in a history of nursing course as well as how to engage students so that they find it interesting, relevant and challenging.

Nursing in general and nursing in Australia, have such rich and complex histories and so much of it is relevant to understanding nursing cultural practices today, hence it is difficult to choose topics, especially when the dedicated time available may be as minimal as 12h. However, Phillips (2002) produced a framework that is helpful in determining the historical significance of an issue and thus in choosing key topics. It may be useful to consult this framework when making the decision to include or exclude a certain topic for the Australian context (Table 1).

Table 1. Adaptation of Phillips’ framework to determine historical significance.

	Concept	Rationale and questions to consider in selecting relevant topics and source material
	1. Importance	What was considered of primary influence or concern to those who lived the event, whether or not their judgements about its importance of the event was subsequently shown to be justified.
		Key questions include: Who were/have been affected by the event? Why was it important to them?
	2. Profundity	How deeply people were/have been affected by the event.
		Key questions include: Was the event superficial or deeply affecting? How were people's lives affected?
	3. Quantity	The number of people affected by the event.
		Key question includes: Did the event affect many, everyone, just a few?
	4. Durability	The length of time people were/are affected by the event.
		Key questions include: How durable was the event in time? Was the event lasting or only ephemeral?
	5. Relevance	The extent to which the event has contributed to historical understanding or meaning-making supported by evidence.
		Key questions include: Is the event relevant to our understanding of the past and/or present? Does the event have a sense or significance to us?

It may also be helpful in guiding the development of student activities that prompt their active involvement and analysis of the issue. An important qualification to make is that these decisions need to be re-visited every five or ten years, because the concept of historical relevance is of course temporal and contestable.

It is also important to acknowledge that history learning is a specialised skill and there is, as Wiggins (1989, p. 44) warned, “A futility of trying to teach everything of importance”. Nonetheless, students who are more aware of their past may be more likely to develop insight and foresight and thus be more prepared, critical and constructive thinkers.

Using these concepts and principles, what follows are examples that demonstrate the use of the transformative learning approach, showing how it offers potential to inspire students of nursing so that they appreciate history's relevance for contemporary living and lifelong learning.

Historical developments that shape nursing 

In nursing and health's evolution there have been many events and movements that have been formative in shaping and developing nursing's collective identity and influence within Australian society (see Table 4). After briefly introducing these developments perhaps on a timeline or by generating discussion following the viewing of a video clip (such as the Apple Mac Ad, Think Different) that foregrounds the notion of thinkers who contributed to world paradigm shifts by thinking differently, students could then choose one of the topics presented in Table 4, to independently or collaboratively research and then report back on how a historical event shaped nursing in Australia. By engaging students in a task early on in the learning, teachers are modelling a transformative, rather than a transmission learning style.

Table 4. Developments that shaped nursing.

	•Wars (Boer, WWI, WWII, Vietnam): raised public profile for nurses, impetus for expanded roles and new treatments
	•Colonial Australia: challenges of creating systems to reach diverse groups
	•Union Movement: e.g. the Eureka stockade and the radicalisation of workers to join together to assert their rights and needs
	•Industrialisation: rise of hierarchy, large hospitals and health technology
	•Hygiene movement: influence on all levels of work within healthcare (architecture, kitchens and food, laundry, nursing work, sterilisation, hand washing)
	•Civil rights and Peace: consumer involvement in healthcare, need for culturally safe care
	•Women's movement: equal rights, equal pay for nurses in the workforce
	•Community healthcare movement: deinstitutionalisation, role change
	•Transfer of nursing education from hospitals to higher education

The following strategy has been used effectively by one author of this paper (4) to help students who have little understanding of the past. Students were asked to construct their own nursing history timelines, and then collectively agree on a common timeline, having argued why particular events should be included. This helps students to understand the selectivity associated with history understanding.

Embedded cultural practices in nursing 

Opportunities to discuss the emergence of values in nursing are important both to transformative learning and to historical inquiry. The following strategy helps students to appreciate the value of making ordinary the extraordinary. It also helps to meet the objective of developing evaluation skills.

Historical personalities 

In the Australian survey (Madsen et al., 2009), the most commonly mentioned historical nursing personality utilised within history learning in Australia was Florence Nightingale. She was of course hugely important for nursing's history (as well as for public health) but many students know little about her. Further, Nightingale was not the only important nurse in our history. Dorothy Dix, Mother Theresa, Mary Seacole and Edith Cavell were other internationally known nurses. There are also Australian icons worthy of study. Australian nursing figures that could feature in biographical studies are contained in Table 5.

Table 5. Sample indication of nurses who are the subject of biographies.

	Name	Description	Biography
	Lucy Osburn	Founder of Florence Nightingale's system of nursing in Australia	Judith Godden, Lucy Osburn, a lady displaced. Florence Nightingale's envoy to Australia, Sydney: Sydney University Press, 2006.
	Muriel Knox Doherty	Nurse educator, administrator, author and humanitarian	Doherty, Muriel Knox, Off the Record—the life and times of Muriel Knox Doherty 1896–1988, ed by R. Lynette Russell, Sydney: NSW College of Nursing, 1996.
	Elizabeth Kenny	Queensland nurse who developed a controversial treatment for polio	Wade Alexander, Sister Elizabeth Kenny Maverick heroine of the polio treatment controversy, Central Queensland Press, 2003.
	Agnes Hodgson	Australian Nurse in the Australian Nurse in the Spanish Civil War (1936–1939)	Keene, Judith The Last Mile to Huesca. An Australian Nurse in the Spanish Civil War, Sydney: University of New South Wales Press, 1988.
	Rhoda Roberts	Indigenous nurse, arts presenter and actor,	Roberta Sykes, Murawina. Australian Women of High Achievement, Sydney: Doubleday, 1993.
	Jean Headberry	Nurse educator	Wilkinson, Joan, “You would not be suitable as a nurse, dear”, Jean Evelyn Headberry, FNM 1911–1993, Melbourne: Melbourne School of Nursing Past Trainees Association, 1999.
	Narrelle Hobbes	Australian nurse in World War I	Melanie Oppenheimer, Oceans of love: Narrelle—an Australian nurse in World War I, Sydney, N.S.W.: ABC Books for the Australian Broadcasting Corporation, 2006.

History of people can be brought to life through biographical accounts. These can be used to inspire the learner to reflect on their own aspirations and activate them to become change agents, to cope with challenges and to be resilient, confident and reflective practitioners. Larger than life characters tend to overlook the reality that achievements and struggles did not occur in isolation and more common and no less noteworthy were the more ordinary lives of nurses and patients. Context examination, rather than just iconography is important. Borsay (2008) argues that overlooking ordinary lives can prevent a more comprehensive analysis of the economic, social, political and cultural environments in which people lived. Examining the context allows students to appreciate that choices were made under particular circumstances, that few choices are made without serious constraints on decision-making, and that past choices need to be reviewed as circumstances change (Theakston, 1997). This can be done evocatively using primary sources such as oral histories, many of which are available in national libraries.

In order to ignite students’ imagination, as well as teach critical thinking skills important to historians and clinicians, the following activity that utilises biographical learning was developed by Author 4. The task requires a tutorial presentation and a written report. The following detail is provided: Many universities have buildings named after famous people. You read in your newspaper an announcement that your university has decided to name one of its building after an important figure in nursing history. The University stresses that it is not succumbing to the ‘great man’ theory of history but wishes to honour a nurse and her or his achievements. All hell breaks loose after this announcement with people demanding that the building be named after their particular nominated nurse.

The University's student organisation is undecided and so commissions you to make a case about who you think the building should be named after. They ask you for an oral and written report, stressing that they do not want a mere description of the person and cause. They want a clear, reasoned argument why they should have the building named after a particular person. The student organisation emphasises in their brief to you that they are not nursing historians, so they need you to provide relevant background material to the life and times of the nurse you suggest. They stress too that, for legal reasons, the person you write about should be dead. You are also expected to provide an honest assessment of the limitations of your case (in terms of available evidence) and recommendations for any further research. Note that you can also present a case against naming the building after any one nurse.

An adaptation of this activity is recommended for international students: The nursing school at your home (overseas) University has decided to name their buildings after famous nurses from a selected number of countries. Australia is one of those countries and you have been asked to nominate an Australian nurse. The expectations of your University are the same as outlined above, except they also ask you to indicate how the nurse you nominate reflects the values of nursing in your home country today.

This assessable activity on its own may take up much of a student's learning and is not something that can be done as a single tutorial activity if students are going to understand the context sufficiently to be able to discern the above. Nonetheless, it provides an interesting option for learning over a term.

Hard messages nurses need to hear 

Nelson and Gordon (2006) insightfully argue that nursing history is heavily dominated by the idea of the good nurse, and this has grown to mythic proportions, such that when nursing history is discussed it is usually biased towards the achievements and good things, rather than the bad. Yet, students can learn from both. Indeed the bad stories are arguably more newsworthy and captivating. Davies (2007) says that in choosing history topics, one needs to answer questions such as: What are the hard messages nurses need to hear?

This resonates with Nelson and Gordon's argument and if the myth of the good nurse is the only story that students hear, then they will not be learning the truth of such events as nurses involvement in eugenic-inspired mass murder during Nazi Germany (Benedict & Kuhla, 1999), in supporting unethical studies (Wade, 1993), in their involvement in abuse of vulnerable people such as those who are elderly, disabled or have psychiatric problems (Lachs & Pillemer, 2004), in their involvement in murder or mercy killings (Linedecker and Burt, 1990, Ramsland, 2007).

Discussion of the particular, through case study analysis, could lead to discussion about whether it is possible to make generalisations about nursing. If so, what are these universal truths? If not, then why do stereotypes flourish, and how can they be refuted? This discussion provides an important opportunity to explore what may have made the “bad” nurse—particularly in the context of nurses taught to be totally obedient and that in the past “ethics” was taught mostly as appropriate etiquette around senior members of staff and doctors.

This could then open the way for examination of other hard messages, not about the bad nurse, but about nursing having to make difficult ethical decisions. Nurses who are whistleblowers (see Firtko & Jackson, 2005), conscientious objectors (Birch, 1998), activists and politicians (see the ICN network at http://www.icn.ch/npnnet.htm), providing international aid and working in the military (Fry, Harvey, Hurley, & Foley, 2002).

Nurses’ and Australian nurses’ contributions to the world 

Davies (2007) also challenges us to ask: Who is this history for? If for new nurses, then they need more than an understanding of the past—they need to consider international perspectives, nursing's contributions to healthcare and nursing's relationship with health policy and the state. She argues there is a need to focus less on the process of nursing becoming a profession and more on how professional identity develops, and to focus more on nursing practice, nursing knowledge and the issue of caring within practice; and the lives of ordinary nurses. Perhaps students could be challenged to produce their own WebQuest exploring and detailing the diverse contributions nurses have made to the world over time. Table 6 provides trigger material to prompt such an investigation.

Table 6. Triggers to prompt student-led productions on contributions from nurses.

	•Renowned nursing theorists: e.g. Peplau, Parse, Watson, Leinenger, Roper
	•Emerging nursing theories: e.g. comfort (Kolcaba), recovery (Barker), chronic sorrow (Eakes, Burke and Hainsworth), peaceful end of life (Ruland and Moore)
	•Inventions: e.g. The crash cart invented by Anita Dorr; The Royal Flying Doctor Medical Chest (1942)
	•The bilby pouch (portable humidicrib)
	•A nurse's chatelaine (today's joey)
	•Websites such as
	οhttp://www.adb.online.anu.edu.au/biogs/A080137b.htm
	οhttp://www2.hud.ac.uk/hhs/acn/wyhon/international_history.php
	οhttp://www.florence-nightingale.co.uk/cms/
	οBrightSparcs at www.asap.unimelb.edu.au/bsparcs