Creative Education
2013. Vol.4, No.4, 283-286
Published Online April 2013 in SciRes ( DOI:10.4236/ce.2013.44042
Dialogic Learning in the Training of Nurses
Maria Dolores Bardallo1, José Luis Medina2, Adelaida Zabalegui3
1Department of Nursing, International University of Catalunya, Barcelona, Spain
2Department of Education, Barcelona University, Barcelona, Spain
3Hospital Clinic of Barcelona, Barcelona, Spain
Received May 24th, 2012; revised June 26th, 2012; accepted July 12th, 2012
Copyright © 2013 Maria Dolores Bardallo et al. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
This document, of a theoretical nature, presents a reflection on dialogic rationality in nursing instruction,
based on the principles that define this postmodern approach to education. The principles governing the
development of dialogic pedagogy fall within the very epistemology of care, defining the explicit and im-
plicit relationships that exist between knowledge and the practice of care. The objective of the document
is: To share a reflection on the rationality that permeates education in nursing and to present a theoretical
framework for transforming and emancipating teaching practice in nursing. The conclusions of the docu-
ment are: 1) The dialogic orientation of nursing instruction provides a view of the reality of care that is
consistent with the meaning of nursing practice; 2) It favors the creation of intersubjectivities between
teacher and student that generate development and personal and professional growth that transcend the
educational act to embed themselves in care practice itself and the relationship with the person being
cared for; and 3) It represents a framework for transforming care practice and the power relationships es-
tablished through the legitimized discourses.
Keywords: Dialogic Learning; Nursing
About Dialogic Learning
Based on the constructivist approach of Vygotsky (1979), on
social (Beck, 1998; Giddens, 1994; Habermas, 2003) and edu-
cational (Freire, 1997) theories, the concept of dialogic learning
in Spain was formulated by Flecha (2003) after several years of
research in the field of adult learning. Along the same trans-
formative lines, authors such as Scribner (1988) and Brunner
(1988) have demonstrated how people resolve conflict situa-
tions or confront new learning through dialogue. People interact
and help each other by sharing their knowledge or by confront-
ing new challenges.
Societies are becoming increasingly dialogic (Flecha, Gómez,
Puigvert, and Beck, 2001) due to the fact that dialogue is in-
creasingly present as a form of relationship and exchange in all
environments, both public and private, at a political and social
level. Sociological analyses show the increased prominence of
dialogue in relation to industrial society.
Under the new social model, the principles of traditional
modernity are being radicalized to open up new forms of coex-
istence that are more egalitarian and inclusive; these new forms
permit dialogue and joint reflection with other cultures, with
people who have different life options, where gender and age
cease to be perceived as a burden to become attributes of diver-
sity and socio-cultural richness.
Not only are dialogic realities expanding, but also dialogic
purposes. In the field of health, as in education, the increased
participation of the main actors is a fact, as is the resolution of
conflicts through dialogue and mediation, demonstrating that it
is possible to attain equality in difference, an equality of rights
that includes respect for diversity (Aubert, Duque, Fisas, and
Valls, 2004).
The transition from the industrial society to the knowledge
society has been accompanied by a radical crisis in the sub-
ject-object division of traditional modernity. Modernity is a
philosophical and sociological concept, which can be defined as
the proposal of imposing the reason as transcendental rule to
the society. In this way, ideal of progress and critical thinking
are constructed in the light of reason that provides absolute
truths. The breakdown of this division has given rise to oppos-
ing paths: one, the dissolution of the subject and, therefore, the
renunciation of any transformative orientation; the other, inter-
subjectivity (defined as the creation of shared spaces for learn-
ing and social interaction in which meanings are created and
agreed by a human group) through which transformation is
undertaken jointly with the persons involved, through dialogue
and discussion.
Throughout history, authors have offered numerous propos-
als on the subject of social change based on education. Among
others, there are Rousseau, who placed the pupil at the center of
the process, or Dewey, with his democratic pedagogy, Freire
and liberation pedagogy, etc. All of these take on increasing
importance in the dialogic area, in which a change in the
teacher-student relationship is emphasized. Freire expanded this
dialogue to the entire educational community by considering
that learning is influenced by the environment in which the
student lives and not only by the teacher-student relationship.
The development of the social sciences has proved Freire
right. Habermas places dialogue at the center of his sociological
thesis. Giddens clarifies transformations driven by social
Copyright © 2013 SciRe s . 283
movements. Beck talks about reflexive modernization. Dia-
logue, reflexivity and transformation, the three pillars that sup-
port dialogic learning. In the field of nursing, dialogue with
other disciplines and with persons receiving nursing care is a
challenge and a growing necessity for democratizing care and
incorporating its protagonists’ presence and voices. Care, from
the standpoint of the inclusion of culturally created health prac-
tices, implies recognizing the knowledge and the meanings that
people construct intersubjectively to make sense of their health
and disease experiences. Care, understood from this dialogic
perspective, opens the door to the transformation of profes-
sional practice and disciplinary development under conditions
of equality with disciplines that even today situate their dis-
course in spaces of power legitimiz ed by control and exclusion
by virtue of the knowledge deposited in them.
From the perspective of dialogic action, protagonism in care
or in education is not exercised by the dominant elites, or by
doctors, nurses, or teachers, or even by the proclaimed majority.
It is found in intersubjectivity. Emphasizing intersubjectivity as
the center of creation and decision-making means overcoming
objectivist ideas.
The approach to the reality of care or to the educational real-
ity must be done critically in order to transform it and transform
ourselves. To do this, cooperation is achieved through dialogue
and communication, thus avoiding falling into power relation-
ships and the conquest of spaces that do not correspond to one,
relationships that are always associated with some form of vio-
lence (Aubert et al., 2004). This involves the horizontalization,
making egalitarian, of the acts of caring/being cared for and
teaching/learning, preventing the hierarchical distribution of
roles among those who provide care or teach (superiors), and
those who are cared for or taught (inferiors).
This characteristic is fundamental if we want a society with
critical-thinking persons who are responsible for their own
health and committed to the health of the community, who are
capable of assuming empowerment. Autonomous individuals,
people who are collaborative, responsible and committed to
their own development and lifelong learning, have all skills that
are central to the construction of a knowledge society.
Five Principles for Transforming Care
Practice and Nursing Education
Egalitarian Dialogue
A dialogue is egalitarian when the value of the different con-
tributions is attributed to the arguments that sustain them,
without being measured by the positions of power held by those
who submit them (Flecha, 2003: p. 14).
The supposition that knowledge is mediated by power rela-
tionships is particularly significant in the field of nursing. Per-
haps the most significant contribution of this socio-critical the-
ory has been the recognition of the influence that social institu-
tions and the socio-cultural context exerts on how healthcare
practice and the teaching of nursing professionals is understood,
from which the manner of taking decisions about transmitting
knowledge and relating to students is derived.
When a nursing instructor imposes his or her truth on a stu-
dent under the coercion, explicit or implicit, of the power to
give the student a failing grade, does not give any alternative to
the student abusing of the established wisdom of authority. This
reveals knowledge to be an instrument of power rather than a
potential of service enabled by the possession of knowledge.
The instructor is not only teaching a nursing procedure, he or
she is also modeling the use of knowledge. The instructor is
revealing a model of a relationship with the “Other”, whether
this is the student or a person being cared for, based on what the
“Other” possesses instead of what the “Other” is. In most cases
this is unconscious.
Egalitarian dialogue also has a mutual advantage: the teacher
and student learn and grow together because both reconstruct
their interpretations of reality based on the arguments presented
(Adorno & Popper, 1973).
In the theory of Habermas (2003) on Communication Action,
he has pointed out the need of dialog and consensus in order to
promote human relations. Besides, Beck and Giddens (1994) had
identified transformational perspective that includes the reflexive
process in human relations. Moreover, Freire (1997) had included
the egalitarian dialogue in cases of extreme inequality.
Through education based on egalitarian dialogue, acquiring
the skills required to survive in the knowledge society is easier
and more profound than with traditional teaching methods. The
culture of egalitarian dialogue brings us closer to responsible
social participation, to active citizenship. It is a commitment to
sustained transformation and the search for new ways to a more
participatory democracy.
In the field of nursing, the culture of dialogue is represented
by the humanist theory of Paterson and Zderad (2007), who,
influenced by the thinking of Hüsserl, Dewey, Buber and Mar-
cel, conceptualize care as an experience of encounter between
the nurse and the patient. In this encounter the participants con-
struct their own meaning of being and becoming through inter-
subjective dialogue. In this intersubjectivity, the nurse and the
patient share their knowledge, their experiences and their way
of being and existing in the world. Each of them contributes an
experience that will facilitate a dialogue through which both
will learn and initiate a process of personal growth. Therefore,
the nurse-patient relationship is an integral part of care and
plays a role in it through an intersubjective transaction, one of
human dialogue about a shared situation in which both are pre-
sent (Meleis, 1997).
In our opinion, education as a form of care participates in the
philosophy expressed by Paterson and Zderad for the purely
healthcare environment. As a result, we considered it appropri-
ate to assimilate the nurse-patient relationship into that posed in
a teacher-student relationship. Both situations pursue the objec-
tive, at the very least, of the development and growth of the
person being cared for/educated. Both are human actions of a
moral nature in which an intersubjectivity is created that gives
meaning to the encounter.
The dialogue between teacher and student is built on every-
day experiences in the practice of care, progressively incorpo-
rating (although not in all cases) elements of their own experi-
ences that connect with the teaching-learning experience in
which both are immersed. Educational interaction based on
communicative action promotes self-esteem in the participants
and generates knowledge through dialogue-based discussion in
which the incursions of one or the other are not categorized as
better or worse, but are appreciated as different on the horizon-
tal plane of the relationship.
Cultural Intelligence
With their interpretive categories, privileged groups deter-
mine the social valuation of their forms of communication as
Copyright © 2013 SciRe s .
intelligent and those of less privileged sectors as deficient
(Flecha, 2003: p. 20).
The most notable contributions to overcome this approach
come from research that initially differentiates between fluid
intelligence and crystallized intelligence and, later, between
academic intelligence and practical intelligence, with the latter
emphasizing the tacit knowledge that we acquire through action
and daily experience (Stenberg & Wagner, 1986; Scribner,
1988). Thus, it can be demonstrated that persons categorized as
slow in academic environments maybe very effective in work
environments or daily life.
Cultural intelligence incorporates academic and practical in-
telligence and the other human abilities of language and action
that make it possible to reach agreement in different social en-
vironments. However, in contrast to each of these, cultural in-
telligence presupposes interaction, interaction based on com-
munity action, using verbal and non-verbal means, through
which agreements are reached in cognitive, ethical, aesthetic,
and affective environments (Flecha, 2003).
Cultural intelligence exists in all persons. It is a universal
capacity because all persons have the innate ability to commu-
nicate through language. Some develop it through academic
and theoretical training, others through more practice-based
training and still others through the school of life. But all of
them can transfer these skills from one environment to another
if the conditio n s are right.
The hierarchical division of knowledge into theoretical
knowledge and practical knowledge, and the greater value of
truth placed on the former, produces a negative effect of dis-
trust in the abilities of people who possess practical knowledge
obtained in social and work environments, far removed from
academia. Historically, consideration of nursing as an applied
science has made it dependent on more academically qualified
types of learning which have hindered its insertion in the cur-
rent of legitimized knowledge of the scientific community.
However, the inclusionary category of cultural intelligence
proposed by the dialogic approach is closer to the epistemology
of care and to educational practice, a category from which
analysis and comprehension can be oriented towards active
participation of people in their health or teaching-learning
processes. It allows for a commitment to horizontal relation-
ships based on the abilities of the main actors, as opposed to
their deficits. It advocates recognition of the cultural practices
of people and the complementarity contributed by experts.
Educational interaction based on dialogue makes mutual
recognition and interactive self-confidence one of its funda-
mental pillars. This environment of trust-based encounters fa-
vors cultural transference by placing value on the contribution
of each protagonist in the relationship. It is a tool for dialogic
creativity or knowledge generation based on active listening
and participation. It is an opportunity that should be taken into
account in teacher-student interaction and fostered by health
and education organizations.
The idea of transformation is at the heart of any educational
process. On this subject, Paulo Freire (1997) stated that we are
not beings of adaptation but rather of transformation. This fact,
so evident in education, can be analyzed from very different
perspectives. From that of traditional modernity, transformation
occurs because someone is considered a subject and the trans-
formative role is attributed to other people, based on instru-
mental rationality in which a subject acts upon an object to
transform it. This is the rationality currently operating in the
practice of care and education, in spite of the fact that trans-
forming initiatives are taking place in both environments. The
postmodern perspective denies the possibility and benefit of
transformation (Giroux & Flecha, 1992). The reproduction model
(Althusser, 1992), which maintained that education reproduced
social inequalities and denied the possibility of overcoming
these, has been widely superseded by the transformative theses
of Habermas (2003) or Giddens (1994). If society and educa-
tion are merely a consequence of structures, the question we
could ask ourselves is where do people fit in, what role does the
movement of social groups play or how is new knowledge cre-
ated. The dual character of action has been demonstrated with
theories such as those of Habermas (system and lifeworld) and
Giddens with his structure and human agency. Therefore if, in
addition to structures, the intersubjective relationship of people
(lifeworld—human agency) creates society and education, po-
litical and pedagogic actions must consider what orientation
they want to give to the transformations they inevitably produce
(Flecha, 2003).
The dialogic perspective supports the possibility and the ad-
vantage of transformations, provided they are produced within
a framework of equality and participation, dialogue and inclu-
sive consensus. The product of intersubjectivity represents the
differences, recognized and unified through the consensus of
the people who participate. Moving from positions of invisibil-
ity to positions of shared knowledge creation substantially
changes the situation of the people involved in an educational
interaction. It is this dialogic, communicative, creation that
transforms structures and people that makes social, occupa-
tional and intellectual emancipation possible. Thanks to the
transformation processes occurring in health and educational
institutions based on dialogic action, a centrifugal dynamic is
being produced that extends, more or less explicitly, to the en-
tire community. Research-action groups, both in health and in
education, are an example of this.
Instrumental Dimension
From the most traditional analytical perspectives on educa-
tional analysis, there is a tendency to juxtapose, to enforce a
dichotomy between, the alternatives of instrumental learning
versus dialogic learning. The most conservative positions tend
to condemn the dialogic alternative, as they consider that de-
mocratizing teaching is synonymous with a loss of quality of
technical and scientific learning. On the other hand, other in-
novative alternatives in pedagogic renewal propose training that
is more humanistic than technical. Other positions, in a reduc-
tionist interpretation of Habermas’s theory, contrast the ideas of
communicative learning and instrumental learning (Flecha,
The traditional nursing curriculum is based, mainly and as
corresponds to rationality, on instrumental learning, despite the
vehement incorporation of the holistic vision of the person into
nursing language. This could give the impression that profes-
sional competence would be unattainable if not for the instru-
mental orientation of learning. However, the very epistemology
of care practice clashes with this initial impression.
From its holistic and inclusive vision, dialogic learning pro-
motes the acquisition of instrumental abilities in those areas
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Copyright © 2013 SciRe s .
where this type of knowledge is pertinent, without abandoning
its practical-dialogic rationality. It does not try to avoid instru-
mental learning. It rejects the instrumentalization of the learn-
ing process, through which objectives and procedures are con-
structed outside of people, alienating them by putting forth
arguments of a technical nature that serve minority and exclu-
sionary interests. To build care or educational interaction from
dialogic rationality means a commitment to doing this with
people and for people, around whom the professional practices
revolve. Dialogic interaction places us in the position of think-
ing about what other people say, about what we say and how
we argue this. When dialogue is truly equal, it promotes intense
reflection because there is a need to understand the arguments
of others and to create arguments of one's own (Giddens, 1994).
Creation of Meaning
Humanity is heading for the challenge of recreating the
meaning of its existence, lost in the tangled web of the indus-
trial and technological revolution. The principal point of refer-
ence lies within the each person. Human being has to recreate
the meaning of his existence that has been lost with the indus-
trial revolution and technology. It is common to hear people
talk about the loss of values. We could instead assert that values
are changing, that they are being recreated in a society that is
open to many possibilities thanks to education and access to
information sources. It is true that we cannot resort to tradition
to find meaning in our lives, but this doesn’t mean that there are
no values; there are other values that arise from the uncertainty
generated by a society in which options are ever broader and
more diverse. This means that the person has increasing control
over his or her own life and must define a life project. Through
dialogue and shared reflection, people find the support neces-
sary to define their life project in a much more informed way.
Dialogic learning breaks with social determinism; it equips
the mind appropriately so that people can take informed deci-
sions from the multiple options offered to them (Aubert et al.,
2004). Nursing practice today is directed at persons with a
greater knowledge of their environment, with greater possibili-
ties of accessing knowledge and with diverse positions with
regard to their health and quality of life. Intercultural coexis-
tence is generating new values and diverse practices in individ-
ual and collective healthcare. In this multicultural context,
nursing practice finds its meaning in the empowerment of the
persons being cared for, in participation to transform health
services and in the transmission of these values to future pro-
fessionals. Education understood from the dialogic perspective
fosters the empowerment of students by considering them as
capable subjects within the learning process, at the same time
as it favors the teacher’s dialogic practice, both in the educa-
tional environment and in the care environment.
The social changes we are witnessing favor dialogue and
consensus to break down previously insurmountable barriers.
Symmetric dialogue facilitates the acquisition and development
of skills that companies today consider necessary for obtaining
a job. In this dialogue, people are learning to communicate, to
find ways of understanding and to overcome difficulties.
The dialogic orientation of nursing instruction provides a
view of the reality of care that is consistent with the meaning of
nursing practice and favors the creation of intersubjectivities
between the teacher and student, generating development and
personal and professional growth; these are intersubjectivities
that transcend the educational act to become embedded in the
practice of care itself and in the relationship with the person
being cared for.
It represents a framework for transforming care practice and
the power relationships established through the legitimized
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