Nursing Inquiry. 2020;00:e12366. wileyonlinelibrary.com/journal/nin | 1 of 10 https://doi.org/10.1111/nin.12366
1 | INTRODUCTION
In this study, we explored child health care (CHC) nurses’ ped-agogical knowledge when they support parents through par-ent education (PE) groups. We did this by investigating how the nurses applied the knowledge using various teaching practices to provide learning environments appropriate for use in PE groups. New parents often feel that the transition to parenthood is highly
stressful and many parents ask for support in their parenting (Asenhed, Kilstam, Alehagen, & Baggens, 2014; Barimani, Vikström, Rosander, Forslund Frykedal, & Berlin, 2017; Kralik, Visentin, & van Loon, 2006; Taylor & Johnson, 2013). In Sweden, new parents are offered tax-funded PE groups after childbirth in CHC services as a way to support them; leaders of these groups are primarily CHC nurses. A number of studies have highlighted the opportunities for PE groups to give strength to parents in their parenting (Ahldén, Received: 3 February 2020
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Revised: 14 May 2020|
Accepted: 16 May 2020DOI: 10.1111/nin.12366 F E A T U R E
Child health care nurses’ use of teaching practices and forms
of knowledge episteme, techne and phronesis when leading
parent education groups
Karin Forslund Frykedal
1,2| Michael Rosander
1| Mia Barimani
3,4| Anita Berlin
4 1Department of Behavioural Sciences andLearning, Linköping University, Linköping, Sweden
2Department of Social and Behavioural Studies, University West, Trollhättan, Sweden
3Stockholm County Council, Academic Primary Care Centre, Stockholm, Sweden 4Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
Correspondence
Karin Forslund Frykedal, Division of Education, Teaching and Learning, Department of Behavioural Sciences and Learning, Linköping University, Linköping SE-581 83, Sweden.
Division of Educational Science and Languages, Department of Social and Behavioural Studies, University West, Trollhättan SE-461 32, Sweden. Emails: karin.forslund.frykedal@liu.se; karin.forslund-frykedal@hv.se Funding information
This work was supported by the Swedish Research Council (grant # 2016-03550).
Abstract
This study explores child health care nurses’ pedagogical knowledge when support-ing parents in their parenthood ussupport-ing various teachsupport-ing practices, that is how to or-ganise and process the content during parent education groups in primary health care. The aim is to identify teaching practices used by child health care nurses and to analyse such practices with regard to Aristotle's three forms of knowledge to com-prehensively examine child health care nurses’ use of knowledge in practice. A quali-tative methodological design alongside the analysis of video-recordings was used. The results showed that child health care nurses used four teaching practices: lectur-ing, demonstration, conversation and supervision. Their use of episteme was promi-nent, but they also seemed to master techne in combination with episteme during the first three teaching practices. During the conversation teaching practice, the child health nurses rarely succeeded. Consequently, they missed opportunities to identify mothers’ expressed concerns and to act in the best interests of both the mothers and their infants by the use of phronesis. In health care, however, theoretical episteme is superordinate to productive knowledge or phronesis, which also became evident in this study. Nevertheless, more interactive pedagogical practices are needed if more use of phronesis is to become a reality in parent education groups.
K E Y W O R D S
child health care nurses, episteme, forms of knowledge, parent education groups, phronesis, teaching practices, techne
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
Göransson, Josefsson, & Alehagen, 2012; Asenhed et al., 2014; Barimani et al., 2017; Berlin, Törnqvist, & Barimani, 2016; Schrader McMillan, Barlow, & Redshaw, 2009; Svensson, Barclay, & Cooke, 2009). However, group leaders express feelings that they do not have enough pedagogical knowledge to lead PE groups (Barlow, Redshaw, & Underdown, 2009; Berlin, Rosander, Forslund Frykedal, & Barimani, 2018; Forslund Frykedal, Barimani, Rosander, & Berlin, 2019; Forslund Frykedal, Rosander, Berlin, & Barimani, 2016; Lefèvre, Lundqvist, Drevenhorn, & Hallström, 2015, 2016). The leaders act as experts and lecturers, and not as moderators to facilitate discussion and interaction between the parents (Berlin et al., 2018; Berlin et al., 2016; Forslund Frykedal & Rosander, 2015; Hoddinott, Allan, Avenell, & Britten, 2010; Lefèvre, Lundqvist, Drevenhorn, & Hallström, 2014), which is what many parents want (Berlin et al., 2018, Berlin, Rosander, Forslund Frykedal & Barimani, in review; Forslund Frykedal, Rosander, Barimani, & Berlin, 2019; Forslund Frykedal & Rosander, 2015; Ho & Holroyd, 2002). The goals for the PE groups are to support parents in the transition to parenthood, increase knowledge about child development and co-parenting relationships and help parents to develop social networks (National Handbook of Child Health Services, 2019; SOU, 2008). No formal education in group leader-ship is available in Sweden for CHC nurses (Department of Health & Social Affairs, 2018; SOU, 2008), but the nurses are instead offered tutorial materials, PE group manuals, and occasionally, they partic-ipate in short training sessions (National Handbook of Child Health Services, 2019). Thus, if the nurses do not have enough pedagogical knowledge to lead the groups and no formal education is offered, important questions are raised: how do they support parents to strengthen them in their parenting skills in the PE group setting? What pedagogical practices and forms of knowledge do they use?
1.1 | Theoretical framework
To understand the group leaders’ use of knowledge when leading PE groups, Aristotle's knowledge hierarchy can be applied, including the epistemological concepts: episteme, techne and phronesis. Knowledge is, according to Aristotle (Aristotle & Ross, 2000), ‘a state of capac-ity to demonstrate’ (p. 93). Svensson (1992) gave a more extended meaning of the definition: ‘Knowledge usually means something that can be given the form: “I know…” which can either be demonstrated in practical action, or with a verbal formulation’ (p. 42). Episteme re-fers to the logic behind an action and relates to reflective and in-vestigative scientific context-independent knowledge. A CHC nurse who recommends breastfeeding applies episteme based on general/ scientific knowledge about the benefits of a baby receiving breast milk. Techne refers to a technology adapted for a particular task, which relates to knowing how to perform a task and is characterised by a combination of action and reflection (Gustavsson, 2002). It is both context-dependent and independent knowledge. For example, knowledge about how to apply and carry out interactive learning by a leader to parents and in parent-to-parent interactions and commu-nication can be referred to as techne. The third form of knowledge
termed phronesis implies judgement-based, context-dependent and action-oriented knowledge tied to ethics, practical activities and practical wisdom, which develops from experience and includes more emotional aspects of knowledge creation (Gustavsson, 2000). Phronesis is productive knowledge that a CHC nurse requires to make the right decisions and to handle ethical dilemmas in such a way that would be good for the parents and their infants, particularly regarding having a clear idea of what would help parents to flourish. Aristotle's definition of phronesis is ‘a true and reasoned state of capacity to act with regard to the things that are good for humans’ (Aristotle & Ross, 2000, p. 95).
According to Marlow et al. (2015), the three forms of knowledge are constructed in praxis and used simultaneously when carrying out activities. A number of contemporary scholars have broadened Aristotle's view of phronesis (e.g. Jenkins, Kinsella, & DeLuca, 2018) to include: embodiment as an embodied experience of knowing the right action to take in a situation, open-mindedness as a capacity to be curi-ous and open to recognising a situation in different ways,
perceptive-ness as an ability to perceive sensory impressions that show ‘aesthetic
understanding’ and reflexivity as a capacity to interrogate and question one's own assumptions and prior understanding. Jenkins et al. (2018) stated that these perspectives ‘may be fruitful for re-imagining phro-nesis for the discipline of nursing in contemporary times’ (p. 4).
Allmark (2017) advocated that Aristotle's system with differ-ent forms of knowledge can have practical implications for nursing practice. In Aristotle's knowledge hierarchy, theoretical science,
episteme, is superior to practical science, techne, and productive
science, phronesis. Despite this, Aristotle claimed that neither the practical science nor the productive science can exist without epis-teme (Allmark, 2017). Kinsella and Pitman (2012) acknowledged that episteme, techne and phronesis are all required for nurses’ practice. The challenge, according to Kinsella and Pitman, is that episteme and techne are privileged within CHC nurses’ practice. By eliminat-ing phronesis, the nurses’ ethical, moral approach, which would be beneficial for parents, would be incomplete.
To investigate how CHC nurses apply their knowledge in PE groups, we studied different teaching practices (Brophy & Goods, 1986); that is, observable actions the nurses were engaged in to support parents in PE groups. The basic dimensions of teaching practices are (a) clarity of presentation and structure in the instruction; (b) level of support-ive climate in the group, including individual orientation; and (c) the assignment and how motivating it is for the group (Klieme, Pauli, & Reusser, 2009). According to Klieme et al. (2009), these dimensions are related to different teaching practices. For example, structure-ori-ented teaching can relate to more leader-centred actions, while sup-portive-oriented teaching can relate to more parent-centred actions, which in turn may be linked to positive social relations.
To summarise, research indicates that CHC nurses express hav-ing insufficient pedagogical knowledge to lead PE groups. At the same time, research into parents’ perspectives indicates that many parents want discussion and interaction in the PE groups. In this study, we explored CHC nurses’ pedagogical knowledge and how they used this to support parents in their parenthood through vari-ous teaching practices during the PE groups. The aim was twofold:
(a) to identify the teaching practices used by CHC nurses and (b) to analyse the practices with regard to Aristotle's three forms of knowl-edge in order to examine CHC nurses’ use of knowlknowl-edge in practice.
2 | METHODS
2.1 | Design
This study had a qualitative design. Data were gathered using video-recordings and analysed using two content analysis approaches (Hsieh & Shannon, 2005).
2.2 | Participants and selection
The study focused on PE groups after childbirth led by CHC nurses. Participants were recruited through the administrative office of one Swedish county council by means of oral and written communication regarding the study. The health care developer, in turn, forwarded in-formation to all those responsible for CHC in the region. A total of eight female nurses (35 to 65 years) volunteered to participate in the study. Four PE group sessions were observed. Two nurses were present at each meeting. A total of six mothers participated in the PE groups: four were primiparas and two had other children. We did not ask for the mothers’ exact age, but an estimate is that all six were in their thirties.
2.3 | Ethical considerations
The four ethical principles of the British Psychological Society (2014), based on respect, competence, responsibility and integrity, were prac-tised throughout the study. We sought and received oral and written informed consent from all participants, both health professionals and parents. Crucially, we were mindful that the participants experienced their participation as voluntary and that they could withdraw their participation at any time. If one participant said no, we would not ob-serve the group. The study was approved by the regional Research and Ethics Committee at Linköping University, Sweden (# 2013/401–31).
2.4 | Data collection
The method for data collection was video observation. Observational methods in qualitative research are considered to give a detailed de-scription of the participants and their activities. Furthermore, video observations allow repeated viewing of the natural settings in the PE groups (Knoblauch, Tuma, & Schnettler, 2013). Four PE group ses-sions were video-recorded. Two cameras were used to record the sessions, one focusing on the leaders and one focusing on the moth-ers and their infants. The video-recorded material was collected from September to December 2014. The recorded material varied in length (50–88 min/session) and spanned a total of 4 hr and 16 min.
2.5 | Data analysis
Two qualitative content analysis approaches were applied (Hsieh & Shannon, 2005) to interpret the video data: conventional (induc-tive category development) and direc(induc-tive (deduc(induc-tive category de-velopment). The analysis was conducted over four steps and began by viewing the video-recorded PE group sessions several times to generate an overview and understanding of the collected data. The analysis was guided by the two aims of the study.
In step two, a conventional content analysis (Hsieh & Shannon, 2005) was utilised to examine ways that nurses arranged, or-ganised and processed the content during the PE groups, that is to ex-amine the different teaching practices they used. This was performed by observing the nurses’ actions concerning how they (a) structured their instructions, (b) interacted and communicated with the mothers and (c) how the assignment given seemed to motivate and activate the mothers. During this step, an analysis of the transcription of relevant video sequences concerning the different teaching practices was ini-tiated and also continued in steps three and four. Furthermore, differ-ent teaching practices were examined and similarities and differences in the forms of knowledge used were compared. Similar descriptions were grouped together in six preliminary teaching practices: lecturing, demonstration, conversation with response pattern or silence after the leader's question, conversation with leader's added information, conversation with reciprocal interaction and supervision.
The third step was to review the six teaching practices by analys-ing the videos again, with the aim of identifyanalys-ing the core aspects and dimensions in each practice. This resulted in a reduction from six to four teaching practices: lecturing, demonstration, conversation and supervision. The conversation teaching practice includes all three aforementioned aspects of conversation.
The fourth and final step involved a directed content analysis with guidance using theoretical definitions of the three forms of knowledge: episteme, techne and phronesis. Video sequences were selected, in which leaders used the different forms of knowledge in connection with the different teaching practices. In this step, quotes were also categorised into different forms of knowledge.
3 | RESULTS
The presentation of the results starts with a short description of the four PE group meetings, followed by a description of the different teaching practices. Finally, we present the forms of knowledge the leaders used in their teaching practices.
3.1 | The four PE group meetings
There were four PE group meetings. In the first and fourth meetings, six mothers and their infants participated; a big brother to one of the infants also participated. At the second and third meetings, five mothers and their infants participated; two leaders were present in
each meeting. However, since the leaders only participated on one occasion the mothers and their infants met a total of eight leaders during the four PE groups. Additionally, the meetings covered differ-ent topics. The four PE groups are summarised in Table 1.
3.2 | Leaders’ use of knowledge in the
teaching practices
The different teaching practices often had no clear boundaries. The nurses performed four different teaching practices during the meet-ings: (a) lecturing; (b) demonstrating the selected issue; (c) convers-ing with, response pattern or silence after the nurses’ questions, nurses’ added information, reciprocal interaction between nurses and mothers; and (d) supervision. The four teaching practices and how the three forms of knowledge, episteme, techne and phronesis, were expressed in each practice are summarised in Table 2.
3.3 | Lecturing
The teaching practice—lecture—concerns the leaders’ presentations on selected subjects, such as food for babies, allergies, sleep, child-hood illnesses and diseases, child safety and CPR to provide knowl-edge. Artefacts, especially films and dolls, were used as illustrations, and brochures or notes were used as supports to help mothers re-member what they had learned. The leaders tried to motivate the mothers to do what they thought would be good for them and their infants. During the lectures, the leaders also asked questions di-rected to the whole group, for example: ‘Is there anything you won-der about?’ or ‘Have you had experiences of this?’. The questions were often followed by silence in the group. Thus, during the lec-tures the mothers were mostly quiet.
3.3.1 | Forms of knowledge
The leaders presented the different subjects using a credible and factual approach. They primarily used theoretical knowledge, which represented the nurses’ knowledge of their profession. Moreover,
they occasionally drew support from the brochures or the notes by taking a look at them before they continued to speak. The form of knowledge which is most relevant in this teaching practice is
episteme.
The leaders used the knowledge form of techne during the lec-tures when they were presenting, arguing, motivating and asking questions concerning the selected topics. In this context, techne and episteme were integrated with each other as the leaders’ ex-pert knowledge in the selected topics has to be processed through techne. The leaders’ intention with their questions was to give moth-ers the opportunity to find answmoth-ers to their queries and to start a conversation in the group. During the lectures, the leaders showed an openness to the mothers’ concerns and experiences, and they possessed the professional epistemic knowledge needed to respond appropriately. However, they did not succeed very often with start-ing a conversation as their use of techne in these situations was insufficient.
The knowledge form phronesis was used by the leaders in situa-tions in which the leaders seemed to perceive that to do good for the mothers and their infants some form of action was required of them in the situation. However, during the lecturing there were few situ-ations when the leaders’ actions could be interpreted as a direct use of phronesis as the mothers were mostly quiet and questions from them were quite unusual. One example of a situation where phrone-sis was used was when one of the leaders asked if the mothers had seen each other outside of the PE groups; the mothers answered ‘no’. Then, the leader explained the importance of mothers being in a social context and socialising with other parents and said: ‘Now you have an excellent opportunity to take each other's mobile numbers. I know PE groups who have held together for a long time and they get so much out of it’.
3.4 | Demonstration
The teaching practice—demonstrating—is about the leaders’ display and presentation of selected issues connected to infants’ well-be-ing, to help mothers to prevent accidents and to rescue the infant in the event of an accident by demonstrating this knowledge to the mothers. During the four PE groups, the leaders demonstrated baby
PE group No. of CHC nurses No. of Mothers No. of Children Topics
1 2 6 7 Introductions and baby
massage
2 2 5 5 Sleep and childhood
diseases/illness
3 2 5 5 Making and tasting own
baby food
4 2 6 7 Child safety and
cardiopulmonary resuscitation
TA B L E 1 CHC nurses, mothers,
children and topics in the four PE group meetings
massage, child safety equipment, how to handle blockages in the upper airways and CPR. All three events started with a film. After each film, the leaders followed up in different ways:
During the baby massage video, one leader showed the massage movements on a doll while she provided verbal instructions, explana-tions about the movements and theoretical explanaexplana-tions: ‘The first lit-tle movement is called milking, much like milking a cow. Start from the hip fairly firmly and pull down. […] Then ‘hug’ around the leg with your hands from above the hip and all the way down. What you simply do is stretch the baby's muscles and get started with the blood circulation’. During the demonstration of child safety equipment, one of the lead-ers asked a question that started convlead-ersations in the group and the leaders seized the opportunity to display the baby safety equipment one at a time. While performing the demonstrations, the leader also showed the mothers how to use the equipment. During these periods,
the mothers had questions which led to conversations between lead-ers and mothlead-ers. When demonstrating blockages in the upper airways and CPR, one leader showed the different steps and how to perform them on a doll. On several occasions, the leader asked the mothers: ‘Do you have any thoughts about performing these steps?’. Unlike the demonstration of child safety equipment, not all demonstrations in-cluded conversation, rather conversations were exceptions although the leaders tried to initiate them by asking questions.
3.4.1 | Forms of knowledge
The subject areas which the leaders demonstrated have different pur-poses: the massage was for the baby's well-being; child safety was to prevent accidents, and CPR was for rescuing the infant in the event
TA B L E 2 Teaching practices and forms of knowledge expressed in PE groups
Teaching practices
Forms of knowledge
Episteme Techne Phronesis
Lecturing—presentations on selected subjects to provide knowledge
Use expert knowledge representing the nurses’ knowledge of their trade Brochures, notes and films as
support
Teach, ask questions, argue, persuade and motivate around issues concerning the infants’ care
On rare occasions openness to the mothers’ concerns and experiences
Demonstration—display and presentation of selected issues connected to the infant's well-being, preventing accidents and rescuing in the event of an accident to provide knowledge
Use theoretical knowledge about baby massage, blockage of upper airway, CPR and child safety Brochures and films as
support
Demonstrating massage movements with a doll, CPR movements and how to handle blockage of upper airway Demonstrating child safety equipment
while instructing how to use the equipment
Pay attention to the mothers’ and infants’ situations in the PE group and respond to their needs
Conversation—nurses and mothers talk with each other to construct knowledge collaboratively
Conversation in which parents contributing with just one turn-taking or remaining silent after the leader's question
Use pictures to display different situations in connection to infant care, couple relationships, co-parenting
Use personal experience
Ask questions and compare Show openness to the mothers’ situations
Conversation where the leader regularly adds information
Use professional and personal experiences Use expert knowledge
representing the nurses’ knowledge of their trade
Nurses’ skills of their trade Reflections on what is good for the mothers and their infants to be able to do the best for them
Conversation with reciprocal interaction between leaders and mothers
Use theoretical knowledge based on personal and professional experiences
Peer-talk and answer questions Leaders acts as ‘babysitter’ Answer mothers’ questions
Listening to receive information from the mothers
Openness about concerns from the mothers which the leaders respond to with their expert skills
Supervision—guide the mothers when performing baby massage on their infants to make certain that they learn to do it correctly
Use brochure and professional knowledge when answering the mothers’ questions
Illustrate with a doll the massage movements while instructing how to do the movements
Attentions on mothers’ massage movements to secure the infants’ well-being
of an accident. All three demonstrations started with a film, although the films gave different impressions, which likely influenced the subse-quent activities. The film about baby massage showed massage move-ments and gave the leader a starting point for her demonstration. The film about child safety equipment led to a question that gave inspiration for a lively and instructive conversation in which the leader could inte-grate her demonstration. Finally, the film about blockages in the upper airways and CPR failed to help the leader start a conversation which she seemed to want. It is likely that these distinct differences in subject areas influenced the leaders’ performance and use of knowledge forms.
Throughout the baby massage, the leader simultaneously demon-strated the massage movements, gave verbal instructions about the movements, explained the advantage of massage and what is happening in the child's body. The leaders’ use of the techne and episteme knowl-edge forms was integrated. By using a brochure, the leader gained theo-retical knowledge, episteme, which she used during the demonstrations. The film together with questions from the leaders during the safety demonstration started conversations. The film as an artefact supported the leaders’ use of episteme. Likewise, as in the demonstration of baby massage, the leaders’ use of the techne and episteme knowledge forms was integrated. Furthermore, the leaders’ use of phronesis was obvious in some situations during the child safety demonstrations.
3.5 | Conversation
The teaching practice—conversation—is about leaders’ and mothers’ talking with each other to construct knowledge jointly. Three dif-ferent forms of conversations occurred regularly in varying lengths during all four PE group sessions. The conversations were mostly short, and it was mainly the leaders who spoke but occasionally the conversations involved several mothers and continued for a longer period. In the following sections, examples of the three main forms of conversations are described.
3.5.1 | Conversations with response patterns or
silence after leaders’ questions
During the first PE group session, the leaders started by showing pictures, followed by one or more questions. These conversations foremost had a response pattern; that is, the leader asked a ques-tion, which a mother answered, followed by the leader's evaluation or commentary. The leader occasionally responded with her own experiences, and when it became quiet in the group, she sometimes commented on her own question. In the following section, the leader showed a picture of a father who changed a diaper on the child, and the mother monitored so that everything was done correctly. One of the leaders said:
Leader: Sometimes you can feel this way! Is it some-thing you recognise?
There is a light laughter from some mothers followed by silence
Leader: You are very worried about this little baby… you want it to be so good for the child… you want to be an excellent mum…
A long silence
Leader: What do you experience as most comforting? The quote above is an example of the leader's comments about her own question and the long silence, which prompts the leader to ask another question.
3.5.2 | Conversation with information
The leader sat on the floor and acted as a ‘babysitter’ in the con-versation, involving the leader and the mothers. The conversation often follows a certain form, which starts with the leader asking a question before the mothers start talking to each other and with the leader. After a few comments, the topic of the conversa-tion was ended by the leader, who added more informaconversa-tion/facts around the topic that had been discussed, as here in a conversa-tion about teeth:
Leader: We talked about teeth… who was it whose child has started teething?
Mother 1: I think my child's teething is in progress! Leader: Yes […] When the baby starts to get its teeth varies
[…]
Mother 2: But what is the most common age they start getting teeth?
Leader: Between 6 and 7 months is usually the most common. Mother 2: but they can get…
Leader: Yes, they can get [the first teeth] earlier. And just that con-nection between loose stools and teeth…now they get teeth at the same time that they have loose stools. It is not an ac-tual connection but when the body has an infection, cold or loose stools the immune system is active against that and the immune system around the gums decreases. Then the teeth can come out easier because they are underneath it [the gums]. You can see the bumps for months before the teeth break out. It has a connection, but you must not attribute the fever and stomach to the teeth.
In this conversation, the leader started by picking a topic the group talked about and questioned it, which started a conversation that ended with the leader's information about teething.
3.5.3 | Conversations with interaction
During the second PE meeting, one of the infants screamed with hunger. It took a while before the mother prepared the supplement so the boy screamed for quite a while before getting food. The fol-lowing conversation then occurred.
Leader: You don't miss a baby who is hungry, it sounds very clear. Have you come to know the difference in the screams of your baby?
Mother 1: Yes
Leader: If it is normal or if it is something else, have you come to that?
Mother 2: Yes, it is difficult, but I’m beginning to hear the difference… Leader: Yes, and the child can't either at the beginning, they also
have to learn, but that is very clear.
Mother 3: Yes, there is a difference in his screams now.
Mother 4: The scream comes almost immediately, there is no warn-ing. It is screaming directly.
Mother 5: Yes, but it is so funny, it goes so fast, she hardly can wake up, sometimes she screams with her eyes closed that she is hungry. So [I think] 'you may well wake up and look at me', but no she just screams.
In this quote, all mothers and the leader were participating in the conversation. The stimuli that started the conversations were the ba-by's scream, and the leader took the opportunity to ask a question that engaged the mothers to share their experiences.
3.5.4 | Forms of knowledge
It is evident that on a number of occasions the leaders tried to start conversations in the PE group. Sometimes the leaders were successful but mostly the conversations were not long. It seems like some aspects, situations or artefacts could be triggers to starting conversations that involved the mothers. Well-formulated questions, subjects that the mothers had ex-perience of or were of interest to them, and some of the films and situations which the leader gave attention to were exam-ples that helped the leaders to carry out interesting and instruc-tive conversations. During the conversations, the leaders used subjects from their expert knowledge of their profession and also knowledge from their personal experiences. Just as in the earlier teaching practices, techne and episteme are integrated when the leaders use the ‘Conversations in the group’ teaching practice. Additionally, the leaders paid attention to situations in which they took some form of action or communicated verbally. It was likely easier to do so when the mothers were more ac-tive compared to the other two teaching practices during which the mothers were rather silent and passive. Consequently, there were more examples of the leaders’ use of phronesis during the conversations.
3.6 | Supervision
The teaching practice—supervise—is about guiding and supporting the mothers when they are performing baby massage on their in-fants to ensure they do it correctly. The leaders provided both visual and verbal instructions about the different massage movements and gave advice to the mothers about appropriate occasions of when to do the massage, such as ‘Start the massage when the child is alert and wants to be involved!’. The leader also gave advice around the benefits of fathers’ participation: ‘It's great because dad can do the baby massage too’. Furthermore, they recommended that the moth-ers use the brochure: ‘In this brochure, you have the movements outlined. It is quite easy, but it can be good to have it in the beginning if you do not remember the moves’. Observation of the mothers by monitoring them and giving them support when someone needed it or asked for advice was another thing the leaders did. As mentioned previously, a mother attended with both her newborn child and her 2-year-old son. When a movie about baby massage was shown, the mother needed to change the nappy of the big brother and was not able to watch the film. When the mother came back, the film was over and the other mothers had started massaging their children. One of the leaders then sat next to the mother and child and in-structed her on the massage movements. When that was done, the leader started playing with the big brother, which gave the mother the opportunity to massage her infant son.
3.6.1 | Forms of knowledge
In supervising practice, the mothers were active either through tak-ing physical action or verbal communication. The supervision makes it easier for the leaders to pay attention to the mothers’ situations, queries or problems. To be able to use phronesis requires the leader to perceive the mothers’ needs in a situation, make a judgement on how they must act in relation to that and then carry out the action. A clear example of the leaders’ use of phronesis was in the situation when the leader supervised the mother giving baby massage and then played with the big brother to make it possible for the mother to massage her baby without interruptions from the big brother. In these situations, the leader also had to use episteme to know what to do and techne to know how to do it.
4 | DISCUSSION
With reference to the theoretical framework of Aristotle and con-temporary scholars that have broadened particularly the view of phronesis, the aim of the study was to identify the teaching prac-tices used by the CHC nurses. Furthermore, the aim has also been to analyse the practices with regard to Aristotle's three forms of knowledge to examine possible learning approaches that the lead-ers apply when working with the parents. It is reasonable to assume, like Forslund Frykedal et al. (2016), that the leaders use different
forms of knowledge based on their formal education, together with their experiences and emotions when they create the learning envi-ronment for parents by using different teaching practices in the PE groups.
Four teaching practices were examined in the study. The leaders used all three forms of knowledge—episteme, techne and phronesis—during the practices but to varying degrees (see Table 2). During the lectures in the PE groups, the leaders con-veyed information they had planned to deliver mostly by using episteme and techne. There were very few situations where nesis was used by the leaders during the lectures. The use of phro-nesis may depend on the level of difficulty for leaders to sense the mothers’ attitudes, opinions, emotions and actions (Allmark, 2017; Gustavsson, 2000; Jenkins et al., 2018). It may also depend on the difficulty of judging the situation, which would help guide moral actions. The difficulties for the leaders in this study were appar-ent as the mothers were mostly quiet and did not express their thoughts and feelings. During the practices, the leaders’ demon-stration and supervision seem to fulfil their intention with the PE groups by delivering the content they had planned, but by using all three knowledge forms more equally, although episteme and techne were used the most. The conversations were often rather short and it was mostly the leaders who spoke, except for the con-versations with reciprocal interaction; this did not give many op-portunities for interplay between either the mothers or between leaders and mothers. However, the fact that there were new lead-ers for each PE group may have influenced the relationship devel-opment (se also Klieme et al., 2009), and it may have been easier for the leaders to use phronesis if they had had the possibility to get to know the mothers more deeply (Allmark, 2017; Jenkins et al., 2018).
Both conversation and supervision teaching practices were ar-ranged so that the mothers could process the content in a more active way, either through actions or verbally, compared to lec-turing and demonstration. These two former practices were or-ganised with an active communicating leader and with mothers as listeners. In the conversation and supervision practices, it was easier for the leaders to pay attention to the mothers’ sit-uations. In that way, these two teaching practices were more mother- and baby-centred compared to the other two, lecturing and demonstrating. Lecturing and demonstrating were more er-centred and when applied it was more difficult for the lead-ers to perceive the mothlead-ers’ experiences. This was easier during the other two teaching practices (conversation and supervision) where the mothers better expressed their thoughts and feelings in their actions and conversations. Aristotle claimed that there is a knowledge hierarchy, where theoretical knowledge episteme is superior to practical knowledge techne and productive knowledge
phronesis (Allmark, 2017). We may assume that this also applies to
health care and medical practices. Thus, an interpretation is that the leaders’ use of episteme is superordinate in the knowledge hi-erarchy of their professional practices, and also in their teaching practices. This may explain why the leaders seem to master the
teaching practices of lecturing and demonstration in which they could use their theoretical expertise representing their profes-sional knowledge. Furthermore, this may explain why the leaders were not as successful in carrying out well-functioning conversa-tions. Mothers could have had better opportunities to learn more interactively if the leaders had had the ability to use the teaching practices better. Notably, there were no sharp boundaries be-tween the teaching practices and the forms of knowledge, as they were all intertwined, and some were also integrated with each other in the practices.
The goals for the PE groups are to support parents in their transition to parenthood, increasing knowledge about child de-velopment and co-parenting relationships, and developing social networks (Gagnon & Sandall, 2007; National Handbook of Child Health Services, 2019; SOU, 2008). The content in the teaching practices was mainly based on facts linked to the infant, such as sleep, the infant's well-being, breastfeeding, food, illness and safety, but not so much on aspects such as parenting or couple relationships. This resulted in good attention paid to the goal of PE groups to improve parents’ knowledge about child development. The social network goal was mentioned but was not supported by the leaders. According to the goal about co-parenting and cou-ple relationships, in the first meeting the leaders tried to start a conversation about this topic by using pictures. However, they were not particularly successful. The co-parenting subject was raised ad hoc a few more times but without a subsequent deeper conversation.
The study led to new questions, and there is a need to gather more knowledge about leaders’ use of knowledge, skills and sensibilities when leading the PE groups. This is crucial because several studies have indicated that leaders express a feeling of not having enough pedagogical knowledge to lead PE groups (Barlow et al., 2009; Berlin et al., 2018; Forslund Frykedal, Barimani, et al., 2019; Forslund Frykedal et al., 2016; Lefèvre, Lundqvist, Drevenhorn, & Hallström, 2015, 2016). Additionally, many new parents feel the transition to parenthood is highly stressful and ask for support in their parenting (Asenhed et al., 2014; Barimani et al., 2017; Kralik et al., 2006; Taylor & Johnson, 2013). Consequently, PE groups that can support parents in their parenthood are important (Department of Health & Social Affairs, 2018; Lefèvre, Lundqvist, Drevenhorn, & Hallström, 2016).
Teaching is vastly complex and difficult and requires a combi-nation of subject matter knowledge and pedagogical knowledge (Shulman, 1986, 1987), and not least significant training in educa-tional practice. The leaders in this study have subject matter knowl-edge but would benefit from more pedagogical knowlknowl-edge to be able to create more parent-centred teaching (Klieme et al., 2009) and use phronesis more frequently in the PE groups.
4.1 | Methodological considerations
To be able to address the study aims, the use of video-recordings was critical. However, video-recording mothers, their infants and
CHC nurses during PE groups are not unproblematic in relation to methodological, but also ethical issues. The video-recording most likely influenced both mothers and nurses, particularly at the begin-ning of the groups and possibly less so as the sessions continued. This may have inhibited the nurses’ interaction and communication with the mothers, which in turn may have influenced the study re-sults (Blikstad-Balas, 2016). However, with time the video-recorder most probably became more accepted in the PE groups and thereby may have had less influence on the participants (Granström, 2004). Video-recording was the only data collection method used in the study, which limited the sampled data to observations of activities and communication in the groups.
5 | CONCLUSIONS
The leaders seemed to most effectively master the lecturing teach-ing practice, and they also appeared to master demonstration and supervision relatively successfully. In all three practices, the use of episteme is most prominent. The leaders also seemed to master
techne in combination with episteme during these three teaching
practices. However, during the conversation practice the leaders rarely succeeded in initiating and supporting deeper conversations. Thereby, they missed opportunities to address mothers’ expressed concerns and to act in the best interests of the mothers and their infants by the use of phronesis.
The study has revealed that interaction and communication be-tween leaders and parents are important prerequisites for leaders’ use of phronesis. As a result, conversation and supervision are the two most appropriate pedagogical practices for the use of phrone-sis. However, in health care, as in other medical practices, theoreti-cal knowledge, episteme, is superordinate to productive knowledge,
phronesis, which also became evident in this study. Nevertheless,
more interactive pedagogical practices are needed if more use of phronesis is to become reality in PE groups.
ORCID
Karin Forslund Frykedal https://orcid.
org/0000-0003-1391-3346
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How to cite this article: Forslund Frykedal K, Rosander M,
Barimani M, Berlin A. Child health care nurses’ use of teaching practices and forms of knowledge episteme, techne and phronesis when leading parent education groups. Nurs
