Traditionally, nursing and other professional groups drew from the predominantly white majority high school graduate. With American society becoming more racially diverse, nursing and other disciplines have experienced increases in minority enrollments. Andrews reports that, according to the U.S. Census Bureau, by the year 2000, minorities will constitute nearly one fourth of the total population, and more than half (51.1%) by 2080 (Andrews, 1990, 1992). From a nursing perspective, the increasing minority population requires the preparation of minority nurses to assist in articulating and understanding the culture, health care needs, and care of minority clients.
However, nursing education (academia) has not always recognized that the Euro-American (Anglo) culture-based curriculum often creates a greater demand for personal and academic growth of minority students than for the majority middle-class student (Bruyère, 1991; National League for Nursing [NLN], 1991). Sensitivity and support will be needed to recruit and retain multicultural groups in the nursing profession, because ". . . only 1/2 of minority students in higher education successfully complete the first two years of college." (Hornett, 1989, p. 13). Therefore, greater understanding of the culture and world view of nursing education/academia and the diverse people groups entering nursing is needed.
Unfortunately, awareness of one's culture and world view often does not occur at a cognitive level. It is not unusual when teaching courses in transcultural nursing for students from the Anglo culture to state they do not have a culture. This lack of self-knowledge about one's own culture and that of others creates stress and conflict. Students' and faculty's expectations are not being met and neither understands why; in other words, cross-cultural conflict occurs. Therefore, this article discusses nursing education's culture and world view, juxtaposing it with the traditional Native American's culture and world view and how it affects learning and performance within the context of nursing education.
Because all cultures could not be discussed, the American Indian (Native American) was chosen. According to the 1990 Nursing Datasource Research Report, Native Americans are the least represented of all minority groups - including men - in nursing education programs. First-year college enrollments and nursing school admission in 1989 indicated that Native American enrollments were 0.5% (490) and 1989 Native American graduations from all basic nursing programs (RN) were 0.5% (317) (NLN, 1991, pp. 15, 30). Moreover, Native Americans have consistently been identified as the most underrepresented of all minority groups in American colleges and universities. Approximately 27% of Native Americans (Wauters, Bruce, Black, & Hocker, 1989, p. 53), 39.9% Hispanics, and 45% Blacks (U.S. Bureau of the Census, 1992, p. 163) enroll in college following high school compared with almost 50% Anglo students (Wauters et al.). Even though there has been an increase in high school graduation rates among Native Americans, enrollment in colleges has declined since the early 1970s (Prieto, 1989, p. 388).
For the purposes of this article, definitions of the major concepts will be provided. Culture is defined as a set of customs, beliefs, traditions, and values that provide the patterns for human definition of life situations. Succinctly, culture is a way of life, interrelated in its various facets, not inherited but learned, that shares and defines the boundaries of different groups (Boyle & Andrews, 1989; Giger & Davidhizar, 1991).
Often, world view is used in the terms of ideology or religion but in this context refers to the central assumptions, concepts, and premises that are assumed true and have neither been questioned, reasoned, nor necessarily proved, and that permeate every aspect of life. It "... is the basic assumption about the nature of reality" (Galanti, 1991, p. 5). Because world view permeates every aspect of life,
. . . members of a culture share a world view without necessarily recognizing it. Thinking itself is patterned on the world view, because the culture imparts a particular eet of symbols to be used in thinking. Because these symbols are taken for granted, people do not normally question the cultural bias of their very thoughts (Boyle St Andrews, 1989, p. 21.).
Nursing as a culture transmits its survival through nursing education/academia. The world view is based on the Anglo middle class culture (Figure 1). The educational focus is linear, sequential, time-oriented, individualistic, competitive, dualistic, and with a domination of nature. This is manifested through the educational framework by teaching fragmented and separate parts of the content or isolated skills with narrowly defined objectives. Testing of the content is typically done with multiple-choice exams containing only one right answer.
Juxtaposed to this culture is the incoming Native American student whose culture traditionally transmitted its survival through legends, stories, and role-modeling. The world view and learning is perceived through a circular or spiral thought process or patterning, which is holistic, pluralistic, and framed in an event orientation that emphasizes cooperating groups that are considered one with or part of each other and nature/environment. This is manifested in the educational framework by presenting more than one right answer as well as pragmatic applications to presented information with the facts being interpreted and related through personal experiences. The written essay with an integrated skills exam provides the best opportunity for such students to display their knowledge.
To further understand the concepts used in Figure 1, each grouping will be discussed with examples.
Holistic, the entire picture or the depth and breadth of a particular subject, is perceived without breaking it down into parts. The entire landscape is viewed. This links with the spiral and circular thought processes that move from concept to concept without being linear or sequential. Information and conclusions are not placed within a stepwise methodology. Instead, the individual provides conclusions that do not have the expected supports from the academic perspective, leaps of faith, or assumptions, even though the conclusions are obvious to the person presenting the information.
Native and Anglo/Nursing Education: World View and Perception Differences
The holistic thinker who has not acculturated to the academic setting will often write long, run-on sentences that appear to contain more than one concept in each paragraph. The run-on sentences could be broken into several sentences and probably placed in separate paragraphs, but the holistic thinker considers these sentences to contain only one concept or thought. Moreover, the similar information could be placed in one paragraph; but, to the holistic thinker, it appears that the major concept and its linkages with the other concepts is being left out of the reasoning process. Yet, to the nurse educator, the paper appears scattered and disorganized. The student's matrices are so wide and the concepts so broad, often, the faculty has difficulty knowing where the student is coming from, much less where the paper is headed. As Mehan (1981) states:
To be successful in [the] classroom . . . students must not only know the content of academic subjects, they must know the appropriate form in which to cast their academic knowledge. Although it is incumbent upon students to display what they know during lessons, they must also know how to display it (p. 5).
Unfortunately, the inability to write and speak in an acceptable academic manner often has been equated with lack of intelligence rather than the lack of learned skills; the student has been dismissed or failed without having been provided the necessary supports for learning academic skills.
In the linear, sequential thought process of academe, a spoken or written presentation is expected to have three components: the introduction, which states what is going to be said; the body, which does what was stated; and the conclusion/summary, which restates what one has said. This would not be the process in an individual less acculturated to the academic setting as described above. Acculturation is when individuals adapt and learn a culture other than their original culture.
Receptivity to Information
In nursing education it would not be unusual for skills and information to be presented in a fragmented, compartmentalized, linear, and sequential manner. For example, an individual may be given a skills lab to learn certain basic nursing skills without the complete information as to its importance. An example of fragmented or compartmentalized learning is learning to take blood pressure. The skill may be learned well but the "why* may not be known until the lecture is given. To a holistic person this would present difficulty because the depth and breadth of the reasoning for taking a blood pressure would be missing.
Dualism means there are only two ways to approach subject matter and answer questions - it is right or it is wrong, while pluralism allows for more than one process or several correct answers. For example, the multiple-choice test provides for only one correct answer and provides only fragmented information from which to make the choice.
Event orientation means that events schedule one's life and the retelling of situations or need is related within the frame of an event or events. These individuals/groups do not watch a clock or schedule themselves according to clock time. The wedding or the party or the meeting does not begin until everyone arrives nor does someone leave to go to another event until that event is completed. From a time-oriented individual's or group's perspective, these behaviors are perceived as lateness, and have been interpreted as unreliability and untrustworthiness. This is not the case if an individual is taking care of someone or a stressful situation has occurred. These persons will stay until the issue or crisis is resolved. They are both dependable and trustworthy.
If the group or individual is ruled by clock time, the opposite might be perceived. The person leaving a situation or an event prior to closure based on a clock-time schedule could be perceived as unavailable and undependable because he or she does not always come when an event begins nor remain until it has ended. In a class setting or clinical setting, the student may be late according to clock time but often will stay when everyone is ready to leave because complete learning has not been experienced.
In time orientation, events and schedules are ruled by clock time. The academic setting has clinical and lectures scheduled according to clock time. Therefore, teaching and learning are clock-time prescribed.
Group emphasis is considered more appropriate than individual achievement. Wilma Mankiller (1991), principal chief of the Cherokee Nation, expressed it this way:
In many Native communities, there is a much greater emphasis on the collective achievements of the family or the community than on those of the individual. Native people who have achieved great personal success, though respected, are not held in the same esteem as those who have achieved great success in helping others. The latter are held in the highest esteem.
In the classroom the student often will not bring attention to self by answering or asking questions even when they know the appropriate responses.
Cooperative effort is expected from individuals within the group. Each individual brings the rest of the group with them; they are interdependent not only with each other but with their surroundings. Interdependence could be expressed as oneness with or part of nature as well as with others. Therefore, behavior that isolates or draws attention to an individual or requires them to be extremely verbal in the classroom often will be met with noncompliance or silence. Not only does group emphasis impact classroom behavior, test-taking responses are affected as well. Should a multiple-choice question have a keyed response that states individual and a distracter that states family, the distracter will be chosen rather than the keyed response because, from a group orientation, the individual is incorporated into the family.
In the academic setting, individual behavior is the norm. Frequently, instructors will single out excellence in students or will call on individual students to respond. Each person is to show that they are individually competent and often a competitive spirit is shown. Autocratic and authoritarian styles, which dominate the educational setting, could be considered to dominate nature. While nursing education emphasizes consideration of client and family wishes in planning health care, often there has been reluctance to incorporate this participatory model; frequently, the plan of care is imposed upon the client (domination).
In Figure 1, the terms are the extremes of a continuum. To determine groups or individuals as always one or the other is to label and stereotype. Depending on the group's or individuara exposure to different ways of perceiving and thinking, there will be diversity of attitudes and behaviors. Caution must be exercised to prevent stereotyping. Another paramount concern is that this discussion of world views should never be used for "nefarious comparison or the devaluing of persons" (Fowler, 1987, p. 80). Properly used, this discussion can provide significant help in guiding students and planning nursing educational programs and approaches.
Response to New Information
World view impacts receptivity to information as well as the response behaviors (Figure 2). The academically acculturated student has been taught to receive information from a skeptical, analytical, and objective perspective (the scientific process/nursing process). Knowledge is not accepted until judgment is rendered.
Within the Native American framework, knowledge is accepted, tried out in a subjective manner, and pragmatically, eclectically evaluated. Because there is the potential for knowledge and insight to come from anywhere, it is recognized that all must be respected (oneness with others/nature) (Figure 2).
When information is received, a response is expected (Figure 3). Initially, the Native American may do nothing observable. Silence toward the information does not mean a "yes* or "no" response; it means that the information will be taken, considered, and placed within a holistic framework. As information is considered, it is integrated with previous learning and tied to practical knowledge already acquired (spiral and circular thought processes). Different aspects of the information will be considered and even tried in private before positive or negative public action/ demonstration occurs. The process is as important as the outcome; therefore, action will not be forthcoming unless it has been mastered in private. The student will observe the instructor until the material is learned. In other words, competence precedes performance. This can only be accomplished through cooperation with individuals of an established group.
In the classroom, the teacher would not be interrupted nor would argumentation and discussion occur initially. The individual presenting the information receives respectful behavior, empathie listening, and no interruptions. Within a group-led context, discussion and ideas would be presented but not in an individualistic manner; participative responses are expected (pluralism and group cooperation).
Reflectivity and placing information within a holistic perspective requires time. Therefore, to place the learning and practice within a time framework often creates difficulty for Native American students. For example, time limits apply to papers for course work or performing a skill. Unfortunately, if Native American students do not feel that the breadth and depth of the skill or the material in the paper has been mastered, they will not submit the paper or perform the required skill. To them, it is better not to do it at all if it cannot be done well. For example, one student who had the highest grade in a nursing class refused to take the final exam because she felt she had not mastered the course work. Another student became very upset and angry about the time deadline for a written assignment. When the instructor inquired into the matter, it was learned the student was gathering more than the required information and was not comfortable until the depth and breadth of the information had been acquired.
In contrast, it is not unusual for the Anglo student to provide the "bare bones" requested and to ask "What do I need to know for the exam?" The depth and breadth can be gathered at a later date, if it is felt it would be useful; otherwise, it is considered time wasted. The Anglo student often responds to the information presented before thinking it through completely; it would not be unusual to interrupt the speaker to clarify a point or to argue rather than hearing the person out. This behavior appears impulsive and disrespectful to the Native American student. From the Anglo world view in the classroom, it is considered creditable for at least trying; in fact, if you don't try, you have failed. The attempt is often considered as important as the actual activity. It is through actions or attempts, observations of the results, thinking about the results, and clarifying that understanding and competency occur.
Awareness of nursing's educational culture and world view will provide the nurse educator with a means for becoming a culture broker or interpreter for Native American students and other culturally diverse students. When one is not aware of his or her own culture, one is ignorant of the issues that confront students. Reality and understanding are perceived differently. Even though the same language is spoken and possibly defined in the same terms, the response to the information or process will be different. For example, both the Anglo and the Native American student may have the same type of difficulty in their course work. The Anglo student will seek out faculty and request assistance; the Native American student will not. Faculty will need to take the initiative. If faculty are not aware of these cultural considerations, the student will not receive the necessary assistance and the instructor will be perplexed as to why that student did not request help.
In working as culture broker/interpreter with students, affirming the student's culture is necessary; otherwise, students may feel or perceive that the educational setting requires them to change culturally to succeed, Students need to be encouraged to share from their perspective in order for faculty and students to come to common understanding. As noted earlier, some individuals are not aware of their own cultures. They may have difficulty articulating their world view and culture and its impact on their learning behaviors.
As dialogue continues, students can be reassured that they apparently learn very well since they were able to progress to this stage in their nursing education. How they learn, assimilate, and act on information are skills they have learned well. They are just as capable of learning other skills that will allow them to succeed in their nursing education. From a pragmatic perspective, by knowing more than one way of perceiving, learning, and responding to information, students automatically have more options from which to choose. This allows them to choose to respond to situations based on which skills will be more efficacious rather than reacting reflexively or from a "knee-jerk" position. In objectifying the learning process and required skills, the students are not threatened that they are being changed or asked to deny their culture. When faculty and student choose to work together, they both change, growing and expanding their horizons in positive and affirming ways.
Adaptation Strategies in a Nursing Education Setting
In viewing the exchange with students as an arena for change and growth, the context becomes question-oriented rather than problem-oriented. A problem orientation often results in students and their abilities being perceived as problems, as when speaking, performance or lack of performance, and writing are not academically acceptable. Rather than acknowledging that the inability to perform in an academically sound manner is due to a lack of learned behaviors, this inability becomes attributed to a lack of intelligence or an inability to learn. Therefore, from a problem orientation, the choice would be toward resolution that includes only one action-oriented, objectified answer. In other words, if students cannot perform the required academic skills, they are automatically eliminated. For instance, Graduate Record Exam (GRE) scores must be 1000 or above to be considered for graduate study with no other criteria considered.
In choosing to become questi on -oriented, faculty are choosing to be open and involved as persons - responding to questions with their being rather than with actionoriented behaviors, and comprehensive within the context of the question - what is the a priori question? What are the meanings and definitions, as there is no one definition or one correct answer? As in the example of graduate admissions, undergraduate GPA, grades from nonmatriculated graduate courses, and teacher recommendation, along with GRE scores will be considered.
Frequently, it has been stated that standards have been lowered to allow such individuals into course work. This is not the case: students may not graduate or pass courses below standard. They are being given opportunities to learn the required skills. Lowered standards occur if students are allowed to graduate below standard. If support systems and bridge courses are not in place, then refusal of admission is necessary because the student is being set up to fail and victim blaming occurs; "they could not do the work."
In being open to expanding horizons and interpreting nursing educational culture to Native American students. faculty can develop new educational methodologies, which could change faculty attitudes and classroom activities and encourage students to develop attitudes and activities that would promote educational success. Figure 4 outlines the following suggestions for working within a multicultural context where world views and thinking are diverse (Anglo and Native American).
Suggestions/Strategies for Teaching Native American Students
Once faculty are aware of their own world view and leadership skills and are able to identify their students' world views and traditional leadership skills, differences can be discussed openly (Figure 4). As interpreter of the nursing educational world view, faculty will need to be honest and realistic as to the required expectations for nursing courses. In providing these expectations, faculty are to be actively demanding in a warm and supportive manner rather than from a detached stance. Precisely guided assignments within a specific structure will promote focused learning for those who are more holistic. For example, in teaching how to write a paper in the correct form, the educator must approach the student and request frequent teacher-scheduled interactions in which to provide positive supervision. Another way to teach is to role-model writing a paper or to encourage the student to have an outsider read the paper for suggestions.
Within the curriculum, modules should provide a whole picture or a complete concept (holistic) using imagery, analogies, and a multi-level approach with minimal time limits on assignments. Minimal time limits on assignments allow students to reflectively evaluate and integrate learning with previous personal experience and knowledge. Conceptual modular developmental teaching could be used when teaching nursing care standards and peer review, both of which contain many elements such as group dynamics, quality assurance programs, change theory, and research. Each of these elements would be taught separately and would stand alone. Yet, as one element is learned, it also would be used to build new and additional knowledge. An assignment for this module may include a paper where segments would be due at the end of each element taught. Thus, a multifaceted paper would be produced with diminished tension because parts would have been completed throughout the module.
Classroom activities could include areas for imitation and observation, such as live interviews, videos, computerassisted instruction (CAI), and collaborative learning (Figure 4).
Provide time for practice before performance. Refrain from singling out a student in the classroom setting unless previous arrangements have been made and agreed upon. When students are performing, communicate that it is okay to make mistakes in the practice setting because this is a safe place to practice and learn. Also, provide mechanisms for students to "save face," to allow maintenance and promotion of a positive self-image.
Students are to be encouraged to focus on the positives of developing skills that promote functioning in multiple cultures - being self-reliant, continuing to be generous by sharing with each other the areas that they have mastered, and maintaining their respect for wisdom.
Faculty should be aware of both the culture and world view of nursing's Anglo culture-based curriculum. For faculty and students to come to common ground and understanding in the areas of education, health care needs, and culturally appropriate nursing care, students need to share their respective world views.
Nursing's survival is transmitted through the academic arena; the Native American's survival was traditionally transmitted through legends, stories, and role modeling. If faculty and students become culture brokers/interpreters between the world views of nursing and the Native American, student success is enhanced. In reviewing the continuum of these world views, it is imperative that caution must be exercised to prevent generalizations, stereotyping, nefarious comparison, or the devaluing of persons. Properly used, this knowledge can provide significant help for faculty in guiding students and in planning nursing educational approaches and programs.
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Native and Anglo/Nursing Education: World View and Perception Differences
Receptivity to Information
Response to New Information
Suggestions/Strategies for Teaching Native American Students