Microsoft Word - Copy Edit Costa.docx IHTP, 2(2), 217-222, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 IHTP 217 Are nurses being heard? The power of Freirean dialogue to transform the nursing profession Idevania G. Costa1 1School of Nursing and Faculty of Health Science, Lakehead University, Thunder Bay, ON, Canada Corresponding author: I. G. Costa (igcosta@lakeheadu.ca) ABSTRACT Nurses need to acquire knowledge about interactive communication, apply critical thinking in prevention and management of illness, and act as patient advocates especially among marginalized and vulnerable populations. This three-pronged approach usually begin during their student years and should include a dialogue framework for use during nursing encounters with patients, family members, and other healthcare providers and for improving the safety and effectiveness of patient care. Therefore, the nursing curriculum should not only include topics related to illness prevention and management, but also prepare nurses to identify and advocate for social justice and health equality by creating a lively and interactive learning environment to allow nurses to build their self-confidence to act and become change agents. Certainly, the COVID-19 pandemic, which exacerbated a nursing shortage and led to limited access to services and poor quality of care for all, underscores the urgency of the Freirean dialogic approach of action-reflection-action. Using this approach, all stakeholders collaborate, discuss, and implement solutions, grow together, and become change agents toward improving nursing care for all. KEYWORDS Action-Oriented; Freirean Dialogic Approach; Nursing Practice; Patient Advocates; Reflection BACKGROUND As a clinical nurse for over twenty-five years, I have witnessed the power of dialogue to transform day to day practice and build strong team collaboration. As a nursing professor for over two decades, I attest that dialogue is at the heart of the teaching and learning process as Freire described in the 1970s. I argue that when nursing professors and students engage in mutual dialogue during learning activities a real interaction and class engagement takes place. As students become protagonists of their learning, professors become facilitators and thereby hold open space for further dialogue, interaction, and reflection. Professors and students share experiences as they learn from each other and grow together as human beings to advocate for social justice and health equality for all. Through the nursing profession they become empowered change agents. This paper aims to present an overview of Paulo Freire’s theory of dialogue and “problem-posing education” as well as their application to nursing profession and highlight some potential benefits and contributions to clinical practice and education. I also argue that interacting and sharing constitutes the foundation of the learning process in which professors and students make learning meaningful to both and beneficial to societal improvement; and that dialogue is the vehicle through which such improvement takes place. Furthermore, dialogue at the heart of the learning process may help nurses to be open to ideas and different point of views to understand the struggles IHTP, 2(2), 217-222, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 IHTP 218 that vulnerable populations face when navigating their social lives and health care systems. FREIRE’S METHODOLOGY OF EDUCATION Paulo Freire (1921–1997) was a Brazilian educator, well known for his emancipatory method of humanizing education for adults. He advocated liberating education and creative learning rather than imposing ready-made knowledge. In his work Freire emphasized the process of learning as a social and political activity (Okigbo, 1996). Nurses interacting with patients, families, and institutions in social and political settings must commit to a process of learning to listen that encourages and implements critical reflection. Such reflection can result in recognizing forms of oppression and social injustice and opens minds to understand the struggles of others’ life journeys (Giroux, 1995). Scholars from different disciplines agree that Freire was one of the most influential educational theorists of the twentieth century (Durakoglu, 2013; Freire & Vittoria, 2007; Roberts, 1998; Smith, 2002), as well an advocate of addressing the many ways oppression takes place in our society and affects vulnerable populations. Freire’s ideology for adult education transcends the narrow, mechanical strategy of rote learning: read, recite, write, repeat. In that strategy, objectifying the student also objectifies the teacher (or professor) and the subject becomes an afterthought. The reality that the professor imparts is motionless, lifeless, static, and predictable (Freire, 2002). In this methodology, words lose their power and meaning, transforming teaching into a mechanical act for the delivery of information direct to the brain of students. Freire labels this phenomenon as the “banking of education” in which professors deposit knowledge and the students receive, memorize, and repeat. This kind of education diminishes students’ creativity, self-confidence, and empowerment to become change agents in society. It is not the situation that oppresses them, but rather it is the banking of education model identified and described by Freire that makes the oppressed consciousness passive subjects, and thus speechless and incapable of transforming society. Freire proposes an alternative method he named “problem-posing education.” In this model, guided mutual dialogue creates and sustains a lively and interactive learning environment that allows student growth. For Freire, dialogue is an encounter between people to transform the reality of where they live, work, study, or interact — and by extension their own society. Freire’s critical pedagogy/education focuses entirely on the liberation of the individual from oppressive forces of society by addressing questions such as what, where, and why we read, write, and speak the way we do. It means not just to teach for the sake of teaching but to use reading, writing, and speaking to continuously increase our understanding of the world around us (Okigbo, 1996) and transform it as a better place for all. For Freire, what takes place in the banking model is not education, but domestication guided by oppression (Freire, 2002). Applying Freire’s methodology to the nursing profession Dialogue is not a debate but a conversation that encourages nurses to come together to reflect on their reality and discuss actions toward issues with which they do not conform. Freire calls this “conversation praxis”, which means reflection- action-reflection toward changing a perceived reality (Freire, 1970). When nurses come together in a dialogical encounter, they bring different perspectives and viewpoints about a situation, an encounter that encourages them to uncover different issues in the nursing profession and act. There are many reasons why reflection-action- reflection driven by dialogue is applicable to the nursing profession: 1) dialogue is the foundation of human interaction and essential in the process of nursing communication; 2) dialogue helps nurses to come together and use their advocacy skills to improve healthcare and quality of life for those with the greatest need; and 3) dialogue empowers nurses to act toward transforming their practice and society. The following sections demonstrate how the Freirean approach applies to nursing practice and education. DIALOGUE AS A FOUNDATION OF HUMAN INTERACTION IHTP, 2(2), 217-222, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 IHTP 219 Interacting and sharing constitute the core of the learning experience for both professors and students; and dialogue is the vehicle through which this takes place. Dialogue is an essential part of the process of communication and helps to build a good and respectful relationship among individuals who live in a world with wide social diversity. For Freire, dialogue is a human phenomenon anchored in the essence of the word. Therefore, it is important to find the words to guide the dialogue and make it happen as a constitutive element compounded basically by the action-reflection- action occasioned by the words or themes used during the dialogue (Freire, 1970). It is only by interaction and reflection that human beings can take control of their situation, and create, with some guidance and encouragement, ways to implement actions to transform their reality; through this process they become change agents. In addition, the purpose of dialogue is to critically investigate a specific object, situation, problem, or theme with a view to explain, clarify and understand the object and “naming the world” (Freire, 1970). Freire defines “naming the world” as a process in which dialogue, between human beings, creates a shared sense of what the world and place they are immerse in is (Tufte & Mefalopulos, 2009). This process of learning and discovering helps people to find a sense of hope and dignity, which leads to the conclusion that what is unnamed is invisible. Freire also asserts that every human being in the world, whether perceived as ignorant or submerged in the “culture of silence,” can look critically at the world in a dialogical encounter with others. Dialogue leads to human interaction in which participants wake up to themselves and one another to reflect and act in a movement of transformation. Freire’s approach can be used in the nursing curriculum to prepare nurses to appreciate what they already know and take control of their own body of knowledge to create changes and transform the reality they are not conformed with. As I have reflected on Freire’s writing and engage my critical thinking and nursing experience, I have become fascinated about the power of dialogue. I perceive it as a vehicle to sustain the critical thinking of nurses in their role as communicators and advocates for social justice and health equality. This thinking does not separate itself from action in which reality is a process of becoming rather than a predetermined state of being. Critical thinking requires a rigorous analysis of existing and oppressive reality and how it may be transformed to a better one. Nurses should be prepared to practice dialogue to demonstrate critical thinking and reasoning during their interaction with all stakeholders with the purpose of uncovering, addressing, and advocating for a better workplace and quality of care and life for those who need it the most. In exploring Freire, Roberts (1998) asserts that dialogue provides educators and coordinators a means to enter the learners’ world as well as to allow learners to enter the educators’ and coordinators’ world. Finally, Freire wants us to be aware of the importance of dialogue to human interaction and society and its importance for naming the world. In Vittoria’s 2007 interview with Paulo Freire’s wife, Ana Maria Araujo Freire, Freire’s spouse explained that as an educator with a wide vision of the world, Freire sincerely believed that people need to communicate and interact with others with respect and openness to diversity, cultural sensitivity, and a culture of humility. The power of dialogue is again highlighted to help people to come together to address oppression in different communities. Dialogue as a tool for nurse empowerment The dialogic practice of reflection-action- reflection helps nurses to learn from, interact with, and collaborate with each other; thereby become change agents and more finely attuned social beings. Freire (1970) states that without an openness to others’ ideas and points of view and an attitude of humility, faith, and hope in the words we communicate, dialogue can neither exist nor help people to grow together. To illustrate the importance of humility in a dialogical way and use it to change the mindset toward social justice, Freire invites each of us individually to reflect on some questions: How can I advocate for social justice and use a powerful dialogue if I am conformed to prevailing social reality and position myself as a privileged member IHTP, 2(2), 217-222, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 IHTP 220 of it? In other words, if I cannot recognize others’ struggles to access services and resources and their reality of oppression? How can I dialogue and advocate for transformation if I do not recognize the need for changes in society or workplaces? How can I engage in dialogue to transform society if I am closed to — and even offended by — the opinion and points of view of others? How can I dialogue if I am afraid of the possibility of showing my opinion for social justice and challenge the status quo of oppression? For Freire, self- sufficiency or a mindset of complacent satisfaction is incompatible with dialogue (Freire, 1970) and would prevent changes and human growth toward a better society. As a nursing communicator and advocate for social justice and health equality, I agree that faith and hope are also important components of dialogue. The reason for that is because they work as a motivation or fuel that moves us in the direction of our beliefs, empowering us to “speak up” and act towards changing the reality around us. In fact, Freire perceived that the faith allows men and women to believe in their power to change and transform the world, which can also be applied to nursing practice to encourage nurses to believe in their power as change agents in the workplace and society. By coming together nurses can create and re-create a new reality where patients, families, and healthcare providers interact with each other not as static subjects but with dynamism guided by action-reflection-action and critical thinking. Freire emphasized the need to maintain our hope as an essential component to move us to pursue and advocate for a new future reality. Yet, he stressed that it can be carried out only in interaction with others in society (Freire, 1970). In summary, when nurses come together and engage in reflection about a reality that needs to be changed, they become empowered to transform their practice and society. How dialogue empowers nurses to transform their practice and society According to Freire (1970), while dialogue can empower and lead to transformation, hopelessness perpetuates the culture of silence that makes human beings cross their arms and wait for the world to transform by itself. Freire’s question: How can the world be transformed without the efforts of the dialoguers? I have added two more questions: How can I change the world if I do not want to leave my comfort zone? How can I leave my comfort zone if I do not believe in my power to transform the world? Faith leads to motivation and motivation leads to actions and transformation. If nurses want to be heard, they must use their knowledge and the power of dialogue to interact effectively and conscientiously with society and the world. Powerful dialogue becomes a means to transform the world and the reality inside it (Freire, 1970). In my own experience, I have witnessed the benefit of the power of dialogue used as a fuel to transform nursing practice and implement desired changes in the nursing profession. Historically, nurses have been immersed in the culture of silence and afraid of using their vast knowledge and the power of dialogue to clearly state their own needs as professionals and advocates. Nurses must speak up about their needs as professionals for better working conditions and respect for their years of education as well as their comprehensive and expanding knowledge. There is an urgent need for preparing nurses to engage in political roles and use their body of knowledge and power of dialogue to advocate for improvements in workplace, salary, and the number of nurses to provide quality patient care. Nursing bodies and associations must come together and use the power of dialogue to advocate for policies that prevent nursing burnout due to staff shortages that damage their mental health, afflictions that have been widely witnessed during the COVID-19 pandemic (Arnetz et al, 2020; Galanis, et al., 2021). Freire implies that human beings were born not to be silent, or prevented from using their knowledge, critical thinking, and self-reflecting on their own struggles and those of others. When words are used just to communicate a message without allowing those receiving the message to reflect on them and express their point of view, human beings become passive subjects in society and find themselves incapable of transforming their reality. Because it is important to connect and share ideas and to consider the experience and knowledge of others sharing the same space, “dialogue is an existential necessity” (Freire, 1970, p. 88). IHTP, 2(2), 217-222, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 IHTP 221 Nurses have always been recognized as important professionals among the healthcare team; and during COVID-19, nurses were deemed essential workers across the globe. However, a shortage of nurses before the current pandemic was intensified even more during COVID-19’s outbreaks and quarantine (International Council of Nurses, 2021a, 2021b). Nurses have a history of working during crises and of overcoming barriers. However, nurses’ concerns and signs of stress and burnout are not always taken into consideration (Galanis, et al., 2021). It is time to break the silence and advocate for changes in the workplace. Conforming to what we receive: an extensive scope of practice, fewer hours of rest, and low salaries incompatible with extensive years of education and experience do not speak to the recognition we have received as “heroes” and essential workers during the pandemic. We deserve more and should continue advocating for more! It is time for nurses to speak up and be heard! IMPLICATIONS While some readers may view the application of Freire’s methodology and his dialogic approach as idealistic, others may view it as ambitious and impractical. Still others may view it as lacking a research foundation. The foundation of dialogue is reason, respect, and the exchange of ideas and reflections that will lead to action — not domination, control, or competition (Levin, Meyer & Ellis, 2007). A dialogue among nurses who come together to advocate for addressing nursing shortages and improving the safety and effectiveness of patient care “is no more reasonable than Florence Nightingale sharing her observations with British surgeons that wounds were not causing death, but lack of food, hygiene, and warmth” (Levin, Meyer & Ellis, 2007, p. 81). Freire’s methodology of dialogue can be used as an action-oriented framework that builds upon different viewpoints and perspectives and encourages true collaboration among change agents on the healthcare team. For example, Lavin and colleagues proposed some assumptions that seem to be well aligned to Freire’s methodology and applicable to the nursing profession: 1) even some opposing views contribute depth to dialogue; 2) dialogue will open nurses’ minds and encourage understanding of different perspectives; 3) dialogue is not a rigid process but rather fluent and dynamic; 4) dialogue leads to action; and 5) preconceptions or injudicious judgment affects the insights attained by an open mind and undermines the outcomes of dialogue. Freirean dialogue should be integrated into the nursing profession for many reasons. At the heart of nursing education, dialogue helps nurses to learn and reflect on the many reasons why people with less status feel hopeless and powerless to change their reality, and instead conform to it rather than protest to improve the health care system to provide better access for all individuals in society. After travelling to multiple countries and understanding different realities, Freire concluded, “There is a third world in the first world and there is a first world in the third world” (Freire & Vittoria, 2007, p. 100). As an advocacy tool, dialogue helps nurses in their many spheres of work to break up the silence that perpetuates social injustice and conformity with ineffective healthcare models. In health education dialogue is a crucial tool that helps to create and re-create a new social reality where people stuck on lower rungs of society can have their voices heard and needs addressed. Nurses across the globe must use dialogue as an instrument to uncover the impact of the nursing shortage on the delivery of quality of care. Ultimately, dialogue is a powerful tool that should be used to highlight social and cultural diversity, needs and concerns, social injustice, and health inequality across countries, regardless of nurses and patients being considered part of the first world or the third world! CONCLUSION In conclusion, Freirean dialogue can be used in the nursing profession to interact, discuss, relate, advocate, and take action to advance nursing education and practice. Guided by love, hope, faith, and humility to address each other’s ideas and beliefs of reality, nurses can respectfully consider each point of view, knowledge, and experience to transform their profession and society. IHTP, 2(2), 217-222, 2022 CC BY-NC-ND 4.0 ISSN 2563-9269 IHTP 222 Nurses must use the power of dialogue to speak up to improve the safety and effectiveness of patient care across jurisdictions. They must believe in their power as health educators, researchers, and advocates to change the future of healthcare and speak up for a healthcare model that places patients as an active agent in society. Nurses are required to continue working to the best of their capability while protecting their own physical and mental health and the health of the public. Instead of conforming to the current reality, nurses must use the power of dialogue to continue advocating for better salaries and workplace conditions that if not addressed can greatly diminish the nursing profession and nursing care. Nurses around the world are stronger together and essential together, and by coming together and using the power of dialogue they can transform the reality that perpetuate injustice and neglect toward the nursing profession and those it purports to care for. REFERENCES Arnetz J.E., Goetz C.M., Arnetz B.B., Arble E. (2020). Nurse Reports of stressful situations during the covid-19 pandemic: Qualitative analysis of survey responses. International Journal of Environmental Research and Public Health, 3;17(21):8126. doi: 10.3390/ijerph17218126. PMID: 33153198; PMCID: PMC7663126. Durakoglu, A. (2013). Paulo Freire’s perception of dialogue-based education. International Journal on New Trends in Education and Their Implications, 4(3), 102–107. Freire, A.M.A., & Vittoria, P. (2007). Dialogue on Paulo Freire. Interamerican Journal of Education for Democracy,1(1),97–117. Freire, P. (1970). Pedagogy of the oppressed. Seabury Press. Galanis P., Varka I., Fragkou D., et al. (2021). 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