- Email: [email protected]
Nursing education: In pursuit of cosmopolitanism
Nurse Education Today 29 (2009) 566–569
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Nursing education: In pursuit of cosmopolitanism Odessa Petit dit Dariel * University of Nottingham, School of Nursing, Midwifery & Physiotherapy, Room B5, Queen’s Medical Centre, Nottingham NG7 2UH, UK
a r t i c l e
i n f o
Article history: Accepted 31 March 2009
Keywords: Cultural competence Nursing education Curricula Humanism
s u m m a r y Changing demographics, globalization, and an increasingly complex health care system demands progressive approaches to reaching our goals of competent transcultural care. Despite original contributions made by pioneers in cultural appreciation, nursing curricula are still falling short in addressing these issues in both education and practice. Many nurses enter their fields with little knowledge of the societal injustices and educational inequities that haunt the populations they care for. A cosmopolitan approach to nursing education is proposed to assist students in recognizing the complexity and uniqueness of individual experiences, rather than merely attempting to place them into categories based on gender, culture, race, or age. Being a global citizen and a cosmopolitan nurse requires participation in, and valuing of, the common good of society as a whole. Practicing the profession outside of comfort zones can lead to an appreciation for how all our choices are part of a complex global network. Nursing education should be responsible for developing in students the deepest knowledge base as well as the highest degree of critical independence. Cosmopolitan nurses could be the model for 21st century practitioners and future nurse leaders. Ó 2009 Elsevier Ltd. All rights reserved.
Cosmopolitanism The term ‘cosmopolitan’ can be defined in a number of ways. To some, the first things that come to mind are fashion models and misogynist advice on how to be a better woman (thanks to the once popular magazine by that name). The creators of that magazine most likely were focusing on the ‘sophisticated’ and ‘urbane’ definition of the term. For others, the word takes on a more cultured tone and can mean one who is well-travelled, who is free of national prejudices, or who simply has a good grasp of geography. A short review of history will discover the origins of the word dating back to the fourth century BC and coined by the Cynics as meaning, ‘citizen of the cosmos’ (Appiah, 2006, xiv). Despite its long and varied history, the term still evokes feelings of worldliness, coexistence and citizenship. Since it can be argued that education plays a significant part in shaping our attitudes and beliefs, it should be a goal of all institutions to prepare each generation with the ability to assume certain obligations and responsibilities (White, 2003). Cosmopolitanism and global citizenship should, therefore, be overarching themes at all levels of education. The concept of cosmopolitanism shares many of the same characteristics expected of nurses in today’s health care system. The first similarity is the need for a questioning mind in order to process and analyze the overwhelming amount of information nurses are faced with daily. An internal Socratic dialogue allows a nurse to
* Mobile: +44 07980 025941. E-mail address: [email protected]. 0260-6917/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2009.03.015
respond critically to each situation and make the most informed clinical judgments. Humanism and caring, as well as the need for intercultural appreciation and sensitivity, are also indispensable traits of all nurses to practice their profession, and are values shared with cosmopolitanism. Unfortunately, this sensitivity to diversity, worldliness, and freedom from prejudice so crucial to nurses tends to be the exception rather than the rule. Perhaps, a new approach to nursing education may assist us in reaching our goals of global citizens and cosmopolitan nurses. Diversity in nursing Traditionally, nursing education programs have been built on a framework that has focused on the white middle-class segment of our society and has concentrated on teaching students how to function effectively within that group (White, 2003). Educational institutions, in general, also tend to be based on this Eurocentric paradigm. This type of education reflects only part of the population and excludes intellectual thought, history, contributions and experiences from minority groups (Leonard, 2006). This can lead to cultural conflicts in the classroom when the instructional method and themes of the institution are inconsistent with that of the minority student (Leonard, 2006). By adopting such a curriculum, minority students may feel they are advocating and endorsing a dominant culture that ‘overrides, discounts, rejects, and violates the integrity of individuals or groups who do not model (these) characteristics’ (Puzan, 2003, p. 195). Although there have been efforts to confront racism and integrate diversity in most areas of
O. Petit dit Dariel / Nurse Education Today 29 (2009) 566–569
the social sciences, this has not been a primary focus in the nursing education literature (Puzan, 2003). There are, incidentally, a number of articles and reports that document high attrition rates of non-white students in schools of nursing in the US, which may be in large part due to a curriculum that does not reflect their own cultural perspectives (Leonard, 2006). Interestingly, a recent article based on research conducted in the UK found that nonwhite and foreign-born nursing students actually had higher rates of completion (Mulholland et al., 2008). The differences between the two countries in terms of nursing education and how each addresses diversity could yield some interesting and useful findings. In 2004, the US Department of Health and Human Services (HRSA, 2004) identified that the Registered Nurse Population consisted of 85% White/Caucasian; 4.2% were Black or African American; 3.1% were Asian, Native Hawaiian, or Other Pacific Islander; 1.7% were Hispanic or Latino; and 0.3% were American Indian or Alaska Native. In the UK, statistics from the Nursing and Midwifery Council statistics show that between the years 2000 and 2005, there were approximately 62,000 overseas nurses admitted to the register (Hunt, 2007). Yet despite this growing diversity within the nursing workforce there has been poor racial and cultural workforce diversity management in the UK health sector and incidents of discrimination and harassment (Hunt, 2007). The importance of the concept of cultural competence has been overlooked within EU health care systems and many migrant nurses from EU countries working in the United Kingdom indicate that they have experienced problems arising from a variety of issues related to cultural diversity (Cowan and Norman, 2006). Although both the US and European countries appear to have contrasting situations in regards to diversity within the nursing profession, both experience a similar problem which lies at the heart of this issue. The shortage of non-white faculty in nursing schools and in managerial positions in health care settings makes it difficult to tackle the relevant questions relating to this inequality or to engage in conversations that could confront the present situation in order for there to be effective change (Puzan, 2003). Without such diversity in faculty and management, there will be limited contributions in interpretations of reality and only influence from the dominant perspective in the development of knowledge in nursing. For the most part, research performed on cultural differences in nursing rarely focus on the issues relating to the unequal terrains of power in which their production of knowledge takes place, nor are there any studies aimed at resisting the disempowering message that they inevitable endorse (Puzan, 2003). It is still implied that any differences are considered deviations from ‘normative whiteness,’ regardless of what the census says about statistical minorities (Puzan, 2003, p. 197). Moya argues that to address this, faculty need to encourage continuing conversations with their students and find ways to ‘mobilize identities in the classroom’ (Moya, 2006, p. 104). This serves the dual purpose of empowering students as knowledge-producers capable of evaluating and transforming their society and contributing to the production of less biased accounts of events (Moya, 2006). The advent of e-learning and the newest form of interactive Web 2.0 applications has further put into question the classical perspectives of ‘expert’ knowledge and ‘truth,’ and has provided an opportunity for knowledge producers from all cultural backgrounds to unite and collaborate (Dede, 2008).
Why change now? According to the predictions of the United States Bureau of the Census, the dominant white population is expected to decrease from 69% to 49.6% by 2060 (Leonard, 2006, p. 87). Thus what used to be considered a ‘minority’ may no longer be so for long. In addi-
567
tion, the changing demographics will inevitably affect those seeking health care as well as those attending nursing schools. The Healthy People 2010 initiative (US Department of Health and Human Services, 2000), states that minority groups are presently over-represented in issues relating to health care problems; have a shorter life expectancy; and have higher mortality rates. As a member of a minority group, one is more likely to be victim of discrimination and experience barriers to health care (US Department of Health and Human Services, 2000). This could determine whether a person chooses to seek health care or follow a treatment plan (White, 2003). Therefore, cultural sensitivity is no longer an optional service but rather an obligation for all health care providers. It has been shown to facilitate the delivery of quality health care and increase positive patient outcomes (Killion, 2007). It is expected that in order to meet the needs of their patients, nurses must understand the concept of culture and have a working knowledge of differing perspectives. It may even be argued that ignoring a patient’s cultural beliefs is a breach of ethics because they play such a vital part in each person’s being. Beliefs are an integral part of a person’s self-identity and are the foundation of health care practices and behaviors (Leonard, 2006). These ways of knowing are manifestations and expressions of the diversity that we, as nurses, must respect. They are vital to the holistic and humanistic model we are expected to embrace, so addressing these cultural differences in nursing programs is critical. Unfortunately, despite the growing interest in alternative therapies, knowledge derived from indigenous peoples, folk psychology, and oral mythology are still considered unscientific (Puzan, 2003). Although cultural sensitivity is not a new concept in nursing, the manner in which educators approach the issue is in dire need of revision. As just mentioned, it is recognized that failing to respect a patient’s culture can negatively influence treatment adherence and overall health outcomes. In response to this, nursing education has focused on the use of a model created by Leininger, a pioneer nurse theorist on cultural diversity. Leininger classified various cultures into profiles from which nurses could draw in order to provide consistent and culturally sensitive care based on their cultural classifications (Leininger, 2002). Through various ethnographic studies, she has catalogued over one hundred cultures along with their associated attributes. The claim is that nurses having only little knowledge of a particular race or ethnicity can access this information about their culture, ways of life and customs, and consequently provide culturally appropriate care. Under this rubric of ‘culturally diverse nursing,’ students are instructed that health beliefs and self-care practices associated with certain minority groups need to be ‘identified and reconciled within the white, Eurocentric medical model’ (Puzan, 2003). Although useful when originally developed, these obsolete models of culture, rooted in traditional anthropology and oblivious to globalization, are no longer meeting the needs of 21st century nursing professionals, and only serve to reinforce the scientific hegemony that permeates both nursing education and practice (Puzan, 2003). Amartya Sen discusses the dangers inherent in such classifications when he states that ‘the conceptual weakness of the attempt to achieve a singular understanding of the people of the world through civilizational partitioning not only works against our shared humanity, but also undermines the diverse identities we all have which do not place us against each other along one uniquely rigid line of segregation’ (Sen, 2006, p. 46). Therefore, despite Leininger’s significant contributions to overall cultural appreciation in nursing education, nurses and other health care practitioners still display daily manifestations of white, cultural dominance such as a ‘routine invasion of privacy, disregard for personal and ethnic rituals, unquestioned deference towards medical and scientific procedures, and reliance on pharmacology, technology, and intrusive therapies’ (Puzan, 2003, p. 195). Also, it
568
O. Petit dit Dariel / Nurse Education Today 29 (2009) 566–569
is a consistent expectation that patients will conform to, and comply with, standardized plans of care that generally ignore not only racial differences, but gender and class as well. The progress that has been made in incorporating cultural content into nursing curricula still leaves a number of issues unaddressed. These include disagreement on what should be taught, lack of standards, limited and inconsistent formal evaluation of effectiveness, a decline of curricular specialty courses on culture, and inadequate faculty preparation (Lipson and Desanti, 2007).
Humanism in nursing education In addition to the changing demographics and the trend toward increased competence in transcultural care, the health care system is also changing. It has become obvious that the traditional models used in nursing education are not succeeding in developing the skills required of nurses to function in today’s complex health care environment. Critical thinking skills, clinical judgment, cultural sensitivity, autonomy, professionalism, technical competence, and ethics are only a few of the characteristics required of new nursing graduates, yet many nursing curricula fail to adequately address these. Hence there is an unquestionable need for change in the area of nursing education and a need for innovative solutions, a call made some time ago by the Nursing League for Nursing (NLN, 2004). I propose that nursing faculty adopt a cosmopolitan approach to education in order to address these issues and achieve the goal of providing humanistic nursing care (Patterson and Zderad, 1986). Without disregarding the effects of culture, it is proposed that humanistic nursing practice view patients ‘as a whole, a gestalt’ (Patterson and Zderad, 1986, p. 25). Nursing students should be guided to recognize the complexity and uniqueness of individuals’ experiences rather than attempting to place them into categories based on gender, culture, race, or age. Other approaches run the risk of encountering problems which lie in the limitations of mere recognition and accommodations of differences between cultures. It is impossible to objectively comprehend a culture different from our own because each person is bringing with them their own fixed ideas and their lived experiences to each encounter. No matter how many cultures we might claim to know or understand, we are still merely outsiders and observers as we ‘try to reconstruct those sets of rules for the patient’s practical conduct for everyday life’ (Kleiman et al., 2004, p. 251). Also, in assuming an understanding and familiarity with a patient’s culture and beliefs, we run the risk of hindering the nurse–patient relationship by ignoring the personal experiences and individual acculturation of that person and focusing entirely on the cultural category in which the patient has been placed (Kleiman et al., 2004). The humanistic model of nursing emphasizes the uniqueness of each individual and stresses the need to understand and respect the subjective meanings each patient assigns to any given situation, regardless of their ethnic characteristics. Barrett (2002, p. 96) similarly has argued that the frenzy in education and psychology to implement different methods of teaching or treatment based on culture ignores the ‘universality of our experiences’. The humanistic model promotes open and attentive attitudes towards patients and their health care needs, ‘free of supposition or judgments,’ on the premise that we are all unique human beings with our own subjective meanings (Kleiman et al., 2004, p. 251). In learning to apply a cosmopolitan and humanistic approach towards caring for patients, nursing students can then recognize the potentially negative aspects of culturally binding attributes and appreciate that although ethnicity and culture may provide some clues to how some individuals may react or respond, each patient is a unique human being. Nursing care must take into consid-
eration the subjective meaning each individual places in the health care situation regardless of their cultural affiliation. Nursing faculty play a key role in implementing the curricular changes required in this paradigm shift. It is up to them to build awareness and cultivate a respect for the uniqueness of each individual while appreciating the universality of humanity. By establishing respect and openness in classrooms and clinical settings, faculty lay a foundation toward favorable learning conditions. ‘The learning environment provides the meaningful context for addressing and redressing the ways bias occurs’ (Ginsberg, 2005, p. 224). This will not only create positive learning environments, but can also act as a model for nurse–patient interactions. It is not enough to include a couple of units on various cultural traditions, beliefs and practices in a program to satisfy the ‘cultural diversity’ requirement. Instead there must be a focus on how cultural exchanges actually shape people as human beings and how these humans then interact with one another. ‘Culture is not an isolated, mechanical aspect of life that can be used to explain phenomena in the classroom or that can be learned as a series of facts, physical elements or exotic characteristics’ (Ginsberg, 2005, p. 219). There must be a continuous conversation about the hearts and mind of diverse people in order to create transformational notions in our pluralistic democracy (Ginsberg, 2005).
Cosmopolitanism in nursing Many nurses enter their fields with little knowledge of the societal injustices and educational inequities which haunt many of those they care for. We are often socialized in ways that encourage us to harbor prejudices, stereotypes and misconceptions about groups which are different from ourselves (Vaughan, 2005). To counter this isolationism and to practice the art of humanistic, cosmopolitan nursing an immersion experience would be an excellent opportunity for nursing students to explore a world outside their own and to allow them to feel what it would be like to be a member of a minority group (Lipson and Desanti, 2007). Spending a few days a week throughout a semester in an environment unfamiliar to their own may provide some appreciation of the tensions associated with being a minority student in a school system, or a minority patient in a health care system. This type of activity might promote an embracement of diversity and encourage students to integrate intercultural perspectives and help them become critical consumers of culture. Critical thinking is not only an essential tool for nursing, it is also a life skill. Classrooms should be seen as a microcosm of a larger community with activities for students that provide opportunities to practice the implementation of these skills. Faculty, acting as facilitators, can share their own stories, experiences, and humanity while encouraging students to discuss, debate and disagree with the goal of mutual exchange and personal growth. Emphasizing diversity in classrooms allows opportunities for enhanced cultural sensitivity and enriching intellectual development. Technological tools, such as simulations and online discussion forums, should be taken advantage. There are now unprecedented opportunities to connect students from around the world through e-learning courses. One study, for example, utilized simulations to provide culturally diverse learning opportunities for both university-based and distance learning students. Through the culturally enhanced integrated simulations, students were given the opportunity to address clinical situations and the impact of culture in a relatively safe non-threatening environment where the impact of their biases could be explored (Rutledge et al., 2008). In conclusion, cosmopolitan nursing education can be seen as a systematic process of bringing together human diversity with the main objective of collaborating on knowledge production with
O. Petit dit Dariel / Nurse Education Today 29 (2009) 566–569
the commitment to the ethic of respect (Cornwell and Stoddard, 2006). This echoes the research which has been conducted through the Carnegie’s Preparation for the Professions Program (PPP). Nurse researchers involved in this study found that integrative teaching was the most effective method of instruction and included coaching, simulations, role modeling and articulating experiential learning (Hutchings and Huber, 2008). Being a global citizen and a cosmopolitan nurse, therefore, requires participation in, and valuing of, the common good of society as a whole. It means believing that all humans have the right to equal freedom and that one must be willing to actively support and protect this right (Cornwell and Stoddard, 2006). Present and future nurses would do well to experience practicing their profession outside of their comfort zones to better appreciate how the choices they make, the way they live, how they vote, and where they work and travel, are all part of a complex global network. While learning to think critically in the clinical setting, nurses must also appreciate the larger context of world events. By becoming active members in it we can avoid the tendency for political passivity. Since education is responsible for developing in students the deepest knowledge base as well as the highest degree of critical independence, cosmopolitan nurses could be the model for 21st century practitioners and future nurse leaders. References Appiah, K.A., 2006. Cosmopolitanism: Ethics in a World of Strangers, first ed. W.W. Norton and Company, New York. Barrett, D.E., 2002. Does culture matter? Society 40 (1), 92–99. Cornwell, G.H., Stoddard, E.W., 2006. Freedom, diversity, and global citizenship. Liberal Education 92 (2), 26–33. Cowan, D.T., Norman, I.N., 2006. Cultural competence in nursing: new meanings. Journal of Transcultural Nursing 17 (1), 82–88. Dede, C., 2008. A seismic shift in epistemology. Educause Review 43 (3), 80–81. Ginsberg, M.B., 2005. Cultural diversity, motivation, and differentiation. Theory into Practice 44 (3), 218–225. Health Resources and Services Administration (HRSA): US Department of Health and Human Services, 2004. The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses, US Government Printing
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Office, Washington, DC. Retrieved on 01.15.09 at. Hunt, B., 2007. Managing equality and cultural diversity in the health workforce. Journal of Clinical Nursing 16, 2252–2259. Hutchings, P., Huber, M.T., 2008. Placing theory in the scholarship of teaching and learning. Arts and Humanities in Higher Education 7 (3), 229–244. Killion, C.M., 2007. Patient-centered culturally sensitive health care: trend or major thrust in health care delivery? The Counseling Psychologist 35 (5), 726–734. Kleiman, S., Frederickson, K., Lundy, T., 2004. Using an eclectic model to educate students about cultural influences on the nurse–patient relationship. Nursing Education Perspectives 25 (5), 249–253. Leininger, M., 2002. Culture care theory: a major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing 13 (3), 189–192. Leonard, T., 2006. Exploring diversity in nursing education: research findings. Journal of Cultural Diversity 13 (2), 87–95. Lipson, J.G., Desanti, L.A., 2007. Current approaches to integrating elements of cultural competence in nursing education. Journal of Transcultural Nursing 18 (1), 10S–20S. Moya, P.M., 2006. What’s identity got to do with it? Mobilizing identities in the multicultural classroom. In: Alcoff, L., Hames-Garcia, M., Mohanty, S., Moya, P.M. (Eds.), Identity Politics Reconsidered, first ed. Palgrave, pp. 97– 117. Mulholland, J., Anionwu, E.N., Atkins, R., Tappern, M., Franks, P.J., 2008. Diversity, attrition and transition in nursing. Journal of Advanced Nursing 64 (1), 49–59. National League for Nursing, 2004. Position statement on innovation in nursing education: a call to reform. Nursing Education Perspectives 25 (1), 47–49. Patterson, J.G., Zderad, L.T., 1986. Humanistic Nursing, second ed. National League for Nursing, New York. Puzan, E., 2003. The unbearable whiteness of being (in nursing). Nursing Inquiry 10 (3), 193–200. Rutledge, C.M., Barham, P., Wiles, L., Benjamin, R.S., Eaton, P., Palmer, K., 2008. Integrative simulation: a novel approach to educating culturally competent nurses. Advances in Contemporary Transcultural Nursing (2nd ed.) 28 (1–2), 119–128. Contemporary Nurse Special Issue. Sen, A., 2006. Identity and Violence. The Illusion of Destiny, first ed. W.W. Norton and Company, New York. US Department of Health and Human Services, 2000. Healthy People 2010: Understanding and Improving Health, second ed. US Government Printing Office, Washington, DC. Retrieved on 01.15.09 at
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Nursing education: In pursuit of cosmopolitanism Odessa Petit dit Dariel * University of Nottingham, School of Nursing, Midwifery & Physiotherapy, Room B5, Queen’s Medical Centre, Nottingham NG7 2UH, UK
a r t i c l e
i n f o
Article history: Accepted 31 March 2009
Keywords: Cultural competence Nursing education Curricula Humanism
s u m m a r y Changing demographics, globalization, and an increasingly complex health care system demands progressive approaches to reaching our goals of competent transcultural care. Despite original contributions made by pioneers in cultural appreciation, nursing curricula are still falling short in addressing these issues in both education and practice. Many nurses enter their fields with little knowledge of the societal injustices and educational inequities that haunt the populations they care for. A cosmopolitan approach to nursing education is proposed to assist students in recognizing the complexity and uniqueness of individual experiences, rather than merely attempting to place them into categories based on gender, culture, race, or age. Being a global citizen and a cosmopolitan nurse requires participation in, and valuing of, the common good of society as a whole. Practicing the profession outside of comfort zones can lead to an appreciation for how all our choices are part of a complex global network. Nursing education should be responsible for developing in students the deepest knowledge base as well as the highest degree of critical independence. Cosmopolitan nurses could be the model for 21st century practitioners and future nurse leaders. Ó 2009 Elsevier Ltd. All rights reserved.
Cosmopolitanism The term ‘cosmopolitan’ can be defined in a number of ways. To some, the first things that come to mind are fashion models and misogynist advice on how to be a better woman (thanks to the once popular magazine by that name). The creators of that magazine most likely were focusing on the ‘sophisticated’ and ‘urbane’ definition of the term. For others, the word takes on a more cultured tone and can mean one who is well-travelled, who is free of national prejudices, or who simply has a good grasp of geography. A short review of history will discover the origins of the word dating back to the fourth century BC and coined by the Cynics as meaning, ‘citizen of the cosmos’ (Appiah, 2006, xiv). Despite its long and varied history, the term still evokes feelings of worldliness, coexistence and citizenship. Since it can be argued that education plays a significant part in shaping our attitudes and beliefs, it should be a goal of all institutions to prepare each generation with the ability to assume certain obligations and responsibilities (White, 2003). Cosmopolitanism and global citizenship should, therefore, be overarching themes at all levels of education. The concept of cosmopolitanism shares many of the same characteristics expected of nurses in today’s health care system. The first similarity is the need for a questioning mind in order to process and analyze the overwhelming amount of information nurses are faced with daily. An internal Socratic dialogue allows a nurse to
* Mobile: +44 07980 025941. E-mail address: [email protected]. 0260-6917/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2009.03.015
respond critically to each situation and make the most informed clinical judgments. Humanism and caring, as well as the need for intercultural appreciation and sensitivity, are also indispensable traits of all nurses to practice their profession, and are values shared with cosmopolitanism. Unfortunately, this sensitivity to diversity, worldliness, and freedom from prejudice so crucial to nurses tends to be the exception rather than the rule. Perhaps, a new approach to nursing education may assist us in reaching our goals of global citizens and cosmopolitan nurses. Diversity in nursing Traditionally, nursing education programs have been built on a framework that has focused on the white middle-class segment of our society and has concentrated on teaching students how to function effectively within that group (White, 2003). Educational institutions, in general, also tend to be based on this Eurocentric paradigm. This type of education reflects only part of the population and excludes intellectual thought, history, contributions and experiences from minority groups (Leonard, 2006). This can lead to cultural conflicts in the classroom when the instructional method and themes of the institution are inconsistent with that of the minority student (Leonard, 2006). By adopting such a curriculum, minority students may feel they are advocating and endorsing a dominant culture that ‘overrides, discounts, rejects, and violates the integrity of individuals or groups who do not model (these) characteristics’ (Puzan, 2003, p. 195). Although there have been efforts to confront racism and integrate diversity in most areas of
O. Petit dit Dariel / Nurse Education Today 29 (2009) 566–569
the social sciences, this has not been a primary focus in the nursing education literature (Puzan, 2003). There are, incidentally, a number of articles and reports that document high attrition rates of non-white students in schools of nursing in the US, which may be in large part due to a curriculum that does not reflect their own cultural perspectives (Leonard, 2006). Interestingly, a recent article based on research conducted in the UK found that nonwhite and foreign-born nursing students actually had higher rates of completion (Mulholland et al., 2008). The differences between the two countries in terms of nursing education and how each addresses diversity could yield some interesting and useful findings. In 2004, the US Department of Health and Human Services (HRSA, 2004) identified that the Registered Nurse Population consisted of 85% White/Caucasian; 4.2% were Black or African American; 3.1% were Asian, Native Hawaiian, or Other Pacific Islander; 1.7% were Hispanic or Latino; and 0.3% were American Indian or Alaska Native. In the UK, statistics from the Nursing and Midwifery Council statistics show that between the years 2000 and 2005, there were approximately 62,000 overseas nurses admitted to the register (Hunt, 2007). Yet despite this growing diversity within the nursing workforce there has been poor racial and cultural workforce diversity management in the UK health sector and incidents of discrimination and harassment (Hunt, 2007). The importance of the concept of cultural competence has been overlooked within EU health care systems and many migrant nurses from EU countries working in the United Kingdom indicate that they have experienced problems arising from a variety of issues related to cultural diversity (Cowan and Norman, 2006). Although both the US and European countries appear to have contrasting situations in regards to diversity within the nursing profession, both experience a similar problem which lies at the heart of this issue. The shortage of non-white faculty in nursing schools and in managerial positions in health care settings makes it difficult to tackle the relevant questions relating to this inequality or to engage in conversations that could confront the present situation in order for there to be effective change (Puzan, 2003). Without such diversity in faculty and management, there will be limited contributions in interpretations of reality and only influence from the dominant perspective in the development of knowledge in nursing. For the most part, research performed on cultural differences in nursing rarely focus on the issues relating to the unequal terrains of power in which their production of knowledge takes place, nor are there any studies aimed at resisting the disempowering message that they inevitable endorse (Puzan, 2003). It is still implied that any differences are considered deviations from ‘normative whiteness,’ regardless of what the census says about statistical minorities (Puzan, 2003, p. 197). Moya argues that to address this, faculty need to encourage continuing conversations with their students and find ways to ‘mobilize identities in the classroom’ (Moya, 2006, p. 104). This serves the dual purpose of empowering students as knowledge-producers capable of evaluating and transforming their society and contributing to the production of less biased accounts of events (Moya, 2006). The advent of e-learning and the newest form of interactive Web 2.0 applications has further put into question the classical perspectives of ‘expert’ knowledge and ‘truth,’ and has provided an opportunity for knowledge producers from all cultural backgrounds to unite and collaborate (Dede, 2008).
Why change now? According to the predictions of the United States Bureau of the Census, the dominant white population is expected to decrease from 69% to 49.6% by 2060 (Leonard, 2006, p. 87). Thus what used to be considered a ‘minority’ may no longer be so for long. In addi-
567
tion, the changing demographics will inevitably affect those seeking health care as well as those attending nursing schools. The Healthy People 2010 initiative (US Department of Health and Human Services, 2000), states that minority groups are presently over-represented in issues relating to health care problems; have a shorter life expectancy; and have higher mortality rates. As a member of a minority group, one is more likely to be victim of discrimination and experience barriers to health care (US Department of Health and Human Services, 2000). This could determine whether a person chooses to seek health care or follow a treatment plan (White, 2003). Therefore, cultural sensitivity is no longer an optional service but rather an obligation for all health care providers. It has been shown to facilitate the delivery of quality health care and increase positive patient outcomes (Killion, 2007). It is expected that in order to meet the needs of their patients, nurses must understand the concept of culture and have a working knowledge of differing perspectives. It may even be argued that ignoring a patient’s cultural beliefs is a breach of ethics because they play such a vital part in each person’s being. Beliefs are an integral part of a person’s self-identity and are the foundation of health care practices and behaviors (Leonard, 2006). These ways of knowing are manifestations and expressions of the diversity that we, as nurses, must respect. They are vital to the holistic and humanistic model we are expected to embrace, so addressing these cultural differences in nursing programs is critical. Unfortunately, despite the growing interest in alternative therapies, knowledge derived from indigenous peoples, folk psychology, and oral mythology are still considered unscientific (Puzan, 2003). Although cultural sensitivity is not a new concept in nursing, the manner in which educators approach the issue is in dire need of revision. As just mentioned, it is recognized that failing to respect a patient’s culture can negatively influence treatment adherence and overall health outcomes. In response to this, nursing education has focused on the use of a model created by Leininger, a pioneer nurse theorist on cultural diversity. Leininger classified various cultures into profiles from which nurses could draw in order to provide consistent and culturally sensitive care based on their cultural classifications (Leininger, 2002). Through various ethnographic studies, she has catalogued over one hundred cultures along with their associated attributes. The claim is that nurses having only little knowledge of a particular race or ethnicity can access this information about their culture, ways of life and customs, and consequently provide culturally appropriate care. Under this rubric of ‘culturally diverse nursing,’ students are instructed that health beliefs and self-care practices associated with certain minority groups need to be ‘identified and reconciled within the white, Eurocentric medical model’ (Puzan, 2003). Although useful when originally developed, these obsolete models of culture, rooted in traditional anthropology and oblivious to globalization, are no longer meeting the needs of 21st century nursing professionals, and only serve to reinforce the scientific hegemony that permeates both nursing education and practice (Puzan, 2003). Amartya Sen discusses the dangers inherent in such classifications when he states that ‘the conceptual weakness of the attempt to achieve a singular understanding of the people of the world through civilizational partitioning not only works against our shared humanity, but also undermines the diverse identities we all have which do not place us against each other along one uniquely rigid line of segregation’ (Sen, 2006, p. 46). Therefore, despite Leininger’s significant contributions to overall cultural appreciation in nursing education, nurses and other health care practitioners still display daily manifestations of white, cultural dominance such as a ‘routine invasion of privacy, disregard for personal and ethnic rituals, unquestioned deference towards medical and scientific procedures, and reliance on pharmacology, technology, and intrusive therapies’ (Puzan, 2003, p. 195). Also, it
568
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is a consistent expectation that patients will conform to, and comply with, standardized plans of care that generally ignore not only racial differences, but gender and class as well. The progress that has been made in incorporating cultural content into nursing curricula still leaves a number of issues unaddressed. These include disagreement on what should be taught, lack of standards, limited and inconsistent formal evaluation of effectiveness, a decline of curricular specialty courses on culture, and inadequate faculty preparation (Lipson and Desanti, 2007).
Humanism in nursing education In addition to the changing demographics and the trend toward increased competence in transcultural care, the health care system is also changing. It has become obvious that the traditional models used in nursing education are not succeeding in developing the skills required of nurses to function in today’s complex health care environment. Critical thinking skills, clinical judgment, cultural sensitivity, autonomy, professionalism, technical competence, and ethics are only a few of the characteristics required of new nursing graduates, yet many nursing curricula fail to adequately address these. Hence there is an unquestionable need for change in the area of nursing education and a need for innovative solutions, a call made some time ago by the Nursing League for Nursing (NLN, 2004). I propose that nursing faculty adopt a cosmopolitan approach to education in order to address these issues and achieve the goal of providing humanistic nursing care (Patterson and Zderad, 1986). Without disregarding the effects of culture, it is proposed that humanistic nursing practice view patients ‘as a whole, a gestalt’ (Patterson and Zderad, 1986, p. 25). Nursing students should be guided to recognize the complexity and uniqueness of individuals’ experiences rather than attempting to place them into categories based on gender, culture, race, or age. Other approaches run the risk of encountering problems which lie in the limitations of mere recognition and accommodations of differences between cultures. It is impossible to objectively comprehend a culture different from our own because each person is bringing with them their own fixed ideas and their lived experiences to each encounter. No matter how many cultures we might claim to know or understand, we are still merely outsiders and observers as we ‘try to reconstruct those sets of rules for the patient’s practical conduct for everyday life’ (Kleiman et al., 2004, p. 251). Also, in assuming an understanding and familiarity with a patient’s culture and beliefs, we run the risk of hindering the nurse–patient relationship by ignoring the personal experiences and individual acculturation of that person and focusing entirely on the cultural category in which the patient has been placed (Kleiman et al., 2004). The humanistic model of nursing emphasizes the uniqueness of each individual and stresses the need to understand and respect the subjective meanings each patient assigns to any given situation, regardless of their ethnic characteristics. Barrett (2002, p. 96) similarly has argued that the frenzy in education and psychology to implement different methods of teaching or treatment based on culture ignores the ‘universality of our experiences’. The humanistic model promotes open and attentive attitudes towards patients and their health care needs, ‘free of supposition or judgments,’ on the premise that we are all unique human beings with our own subjective meanings (Kleiman et al., 2004, p. 251). In learning to apply a cosmopolitan and humanistic approach towards caring for patients, nursing students can then recognize the potentially negative aspects of culturally binding attributes and appreciate that although ethnicity and culture may provide some clues to how some individuals may react or respond, each patient is a unique human being. Nursing care must take into consid-
eration the subjective meaning each individual places in the health care situation regardless of their cultural affiliation. Nursing faculty play a key role in implementing the curricular changes required in this paradigm shift. It is up to them to build awareness and cultivate a respect for the uniqueness of each individual while appreciating the universality of humanity. By establishing respect and openness in classrooms and clinical settings, faculty lay a foundation toward favorable learning conditions. ‘The learning environment provides the meaningful context for addressing and redressing the ways bias occurs’ (Ginsberg, 2005, p. 224). This will not only create positive learning environments, but can also act as a model for nurse–patient interactions. It is not enough to include a couple of units on various cultural traditions, beliefs and practices in a program to satisfy the ‘cultural diversity’ requirement. Instead there must be a focus on how cultural exchanges actually shape people as human beings and how these humans then interact with one another. ‘Culture is not an isolated, mechanical aspect of life that can be used to explain phenomena in the classroom or that can be learned as a series of facts, physical elements or exotic characteristics’ (Ginsberg, 2005, p. 219). There must be a continuous conversation about the hearts and mind of diverse people in order to create transformational notions in our pluralistic democracy (Ginsberg, 2005).
Cosmopolitanism in nursing Many nurses enter their fields with little knowledge of the societal injustices and educational inequities which haunt many of those they care for. We are often socialized in ways that encourage us to harbor prejudices, stereotypes and misconceptions about groups which are different from ourselves (Vaughan, 2005). To counter this isolationism and to practice the art of humanistic, cosmopolitan nursing an immersion experience would be an excellent opportunity for nursing students to explore a world outside their own and to allow them to feel what it would be like to be a member of a minority group (Lipson and Desanti, 2007). Spending a few days a week throughout a semester in an environment unfamiliar to their own may provide some appreciation of the tensions associated with being a minority student in a school system, or a minority patient in a health care system. This type of activity might promote an embracement of diversity and encourage students to integrate intercultural perspectives and help them become critical consumers of culture. Critical thinking is not only an essential tool for nursing, it is also a life skill. Classrooms should be seen as a microcosm of a larger community with activities for students that provide opportunities to practice the implementation of these skills. Faculty, acting as facilitators, can share their own stories, experiences, and humanity while encouraging students to discuss, debate and disagree with the goal of mutual exchange and personal growth. Emphasizing diversity in classrooms allows opportunities for enhanced cultural sensitivity and enriching intellectual development. Technological tools, such as simulations and online discussion forums, should be taken advantage. There are now unprecedented opportunities to connect students from around the world through e-learning courses. One study, for example, utilized simulations to provide culturally diverse learning opportunities for both university-based and distance learning students. Through the culturally enhanced integrated simulations, students were given the opportunity to address clinical situations and the impact of culture in a relatively safe non-threatening environment where the impact of their biases could be explored (Rutledge et al., 2008). In conclusion, cosmopolitan nursing education can be seen as a systematic process of bringing together human diversity with the main objective of collaborating on knowledge production with
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the commitment to the ethic of respect (Cornwell and Stoddard, 2006). This echoes the research which has been conducted through the Carnegie’s Preparation for the Professions Program (PPP). Nurse researchers involved in this study found that integrative teaching was the most effective method of instruction and included coaching, simulations, role modeling and articulating experiential learning (Hutchings and Huber, 2008). Being a global citizen and a cosmopolitan nurse, therefore, requires participation in, and valuing of, the common good of society as a whole. It means believing that all humans have the right to equal freedom and that one must be willing to actively support and protect this right (Cornwell and Stoddard, 2006). Present and future nurses would do well to experience practicing their profession outside of their comfort zones to better appreciate how the choices they make, the way they live, how they vote, and where they work and travel, are all part of a complex global network. While learning to think critically in the clinical setting, nurses must also appreciate the larger context of world events. By becoming active members in it we can avoid the tendency for political passivity. Since education is responsible for developing in students the deepest knowledge base as well as the highest degree of critical independence, cosmopolitan nurses could be the model for 21st century practitioners and future nurse leaders. References Appiah, K.A., 2006. Cosmopolitanism: Ethics in a World of Strangers, first ed. W.W. Norton and Company, New York. Barrett, D.E., 2002. Does culture matter? Society 40 (1), 92–99. Cornwell, G.H., Stoddard, E.W., 2006. Freedom, diversity, and global citizenship. Liberal Education 92 (2), 26–33. Cowan, D.T., Norman, I.N., 2006. Cultural competence in nursing: new meanings. Journal of Transcultural Nursing 17 (1), 82–88. Dede, C., 2008. A seismic shift in epistemology. Educause Review 43 (3), 80–81. Ginsberg, M.B., 2005. Cultural diversity, motivation, and differentiation. Theory into Practice 44 (3), 218–225. Health Resources and Services Administration (HRSA): US Department of Health and Human Services, 2004. The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses, US Government Printing
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