Nursing education, in preparing students to give culturally sensitive client care, must examine values, beliefs, and lifestyles as well as myths, stereotypes, and stigmata regarding many group and personal characteristics. Educators can help students move through this process beyond the childhood egocentric world view that most people are "just like me" where "like me" is a positive and "unlike me" is a negative. A goal of nursing education is to assist students to move beyond their own ethnocentric world views.
To this end, the Decker School of Nursing at the State University of New York (SUNY) at Binghamton was awarded a curriculum development grant to investigate multicultural concepts in the nursing curriculum. A faculty committee with expertise in multiculturalism, curriculum design, and program evaluation was formed to accomplish this work. The university's mission statement and school of nursing's philosophy (SUNY at Binghamton, 1990) were reviewed. The American Nurses Association (ANA) concept model (1986), which focuses on the integration of multicultural concepts throughout the curriculum, was selected to guide curricular analysis of courses in the upper-division major in nursing.
A broad operational definition of multiculturalism was chosen because it was recognized that oppression affects all people whenever they feel disenfranchised by a monocultural perspective (Equity Institute, 1989). The following variables of ethnicity, race, gender, sexual orientation, spirituality/religion, family style/makeup, ability, age, region of origin, language, physical appearance, and socioeconomic status were selected from a variety of concepts. Impediments to appropriate inclusion of diverse cultural content were identified as stereotyping, bias, insensitivity, phobia, omission, and inappropriate commission. A model was developed as an organizing framework for analyzing the curriculum by examining each concept in the operational definition against the impediments listed (Figure).
Each of 14 required and 10 elective undergraduate nursing courses were studied. The model guided the committee in interviewing faculty and reviewing course syllabi and materials, textbooks, instructional videos, and clinical experiences. Areas of inclusion or omission in the curriculum were noted.
Content areas in which faculty felt a lack of knowledge were also identified. Students representing diversity in relation to gender, race, ethnicity, language, and prior educational experiences provided information regarding their perceptions of the integration of multiculturalism in the curriculum. They also shared feelings and anecdotes describing clinical incidents of felt prejudice and insensitivity.
Final steps in the curricular analysis included giving feedback to course coordinators and faculty regarding the committee's findings on multicultural course content and experiences. Specific recommendations were shared with the undergraduate curriculum committee, administration, and the faculty development committee. A six-month postevaluation survey was later administered to assess the degree of implementation of recommendations.
Figure. Organizing framework for curricular analysis of cultural diversity.
Results of curricular analysis indicated that faculty' valued individuality and were reluctant to make generalizations regarding populations for fear that this would lead to additional stereotyping. Faculty became aware that individuals have their own monocultural perspectives that need expansion to function in a pluralistic society. The challenge of teaching about similarities within cultural groups while emphasizing the uniqueness of individuals became apparent.
Varying degrees of discomfort in presenting certain content such as nonheterosexual sexuality, obesity, and nonclinical aspects of sexuality in general were expressed. Faculty experienced anxiety in relation to the amount of time necessary to become more informed regarding culturespecific content. For example, the challenge of truly mastering knowledge related to the many variations among Asian cultures would require extensive preparation and research. In addition, once new content was selected, it needed to be integrated into lecture notes, hand-outs, and test items. Often faculty felt the urgency to give higher priority to staying current with technology and treatment knowledge rather than cultural views and lifestyle practices. The need for faculty development was expressed regarding an update on transcultural nursing, sessions on strategies to address student-faculty discrimination issues, and an opportunity to become familiar with diversity-oriented audiovisual materials.
Curricular analysis indicated that some multicultural content was well addressed (e.g., Native American, Moslem, stigma of unpopular diseases) while other areas were not (e.g., nonheterosexual orientation, specific information about cultures unfamiliar to faculty). Analysis of multimedia resources and textbooks was very revealing. For example, most videotapes showed slim, Euro-American, female nurses in their 30s portrayed in middle- to upper-class socioeconomic settings. Many current nursing texts tended to cluster diversity content in one chapter with the major focus on culture and race. Such issues as gender, spirituality, regionalism, ageism, or sexual orientation were not commonly addressed.
Information shared by students was particularly insightful. Students perceived various faculty members to be either open or closed to discussions of sensitive multicultural issues. These perceptions were based on demonstrated willingness of faculty members to entertain discussions and share viewpoints that differed from their own.
The four students who volunteered to work with the committee verbalized their own and others' experiences of bias that occurred during hospital and community clinical laboratories. For example, one male student was teased about the aroma of his after-shave lotion. Another reported that agency staff cited the student's skin color as the cause of a client's noncompliance. A male student was told his female client could not void because as a male, he "made the patient feel uncomfortable." At one agency, males were informed that they could not leave their coats in the all-female locker room but no alternate arrangements were made. A female Latino student felt that all Latino students were labeled "Hispanic" rather than being recognized as coming from many cultures and countries. These problems seem related, in part, to the limited degree of cultural diversity in the local community. This was in contrast to the university nursing student population, which included greater diversity in terms of people of color and those not born in the United States. Students expressed hesitancy in verbalizing incidents of felt prejudice for fear that this would be reflected in negative clinical evaluations. Consequently, most of the above incidents were not communicated to faculty until well after the courses were completed.
Nursing students with English as a second language (ESL) felt that they had unique educational needs in early semesters in the nursing program, such as additional time for testing and the use of a translation dictionary. Forming multicultural peer relationships in college and caring for clients of cultural diversity were highly valued by students as a means of becoming sensitized to multicultural perspectives.
It can be noted that this curricular analysis was limited by traits of the committee members. The faculty component of the committee consisted of third-generation EuroAmerican, nonobese, heterosexual females in their 40s. Students were all under 25 years of age. Neither faculty nor student members were disabled.
Faculty received feedback about their courses in terms of identified multicultural content that might be added. The critiques of videos and textbooks were also shared, together with suggestions for changes in course syllabi and materials to reflect an increased multicultural perspective. General findings and significant anonymous anecdotes were presented at meetings of the full faculty to sharpen consciousness of diversity issues.
Faculty development seminars were held on specific topics that faculty had identified as problematic, such as homophobia and cultural differences in communication styles. A video produced on the SUNY at Binghamton campus dealing with prejudices against women and racial minorities was viewed and discussed. This video was added to the requirements for first-semester junior nursing students. Faculty attended brief, conveniently scheduled seminars dealing with transcultural aspects of pain and teaching ESL students. These were led by experts from other divisions on campus at no fee.
The faculty's informal summative evaluations of seminars were positive. Attendance averages of 85% to 90% supported the faculty's perceived valuing of the seminars. Faculty stated that seminars helped to broaden their multicultural perspectives and decrease their monocultural views. Comments reflected appreciation for initiating dialogue on sensitive issues, increasing culture-specific knowledge bases, and heightening awareness by simple exposure to diverse cultural views.
Curricular resources were augmented as a result of the curricular analysis process. Asian and African infant mannequins of both sexes were purchased for the student learning laboratory. A subscription to the Journal of Transcultural Nursing and additional library books relating to multicultural issues were purchased. Videos suggested for purchase were previewed to assess for increased sensitivity to the value of diversity and avoidance of stereotyping of actors and actresses by race, sex, physical appearance, and role. It was noted that discrimination by omission was far more common than by commission. For example, a number of videos on psychosocial aspects of death and dying featured only middle- to upper-class Euro- Americans.
Proposals for additional resources included (1) a Multicultural Resource Center in the Decker School of Nursing learning laboratory, (2) a resource list of university and community multicultural experts, and (3) nursing liaisons to campus-diversity-oriented groups (e.g., Lesbian, Gay, and Bisexual Students Union; Office of Students with Disabilities; Black Students Union; International Students Association). These proposals are being phased in over time as budget and faculty resources permit.
The nursing assessment tool used by students to collect data for nursing histories on clients and families was revised to reflect sensitivity to many of the multicultural concepts and diverse family structures identified in this analysis. This revision is of ongoing and permanent significance because it is in print and widely used by all undergraduate students and faculty in several required nursing practice courses during both junior and senior years.
Recommendations for faculty included networking to share valuable resources when these were discovered. Continuation of faculty development seminars was urged to increase culture-specific knowledge and multicultural awareness and sensitivity. Faculty and students were encouraged to value and share their own cultural diversity. Frequent articulation of the very existence of diversity in academia was recommended.
Appropriate committees and administrative personnel were asked to address concerns identified by students. These included socialization of males into the nursing profession, special learning needs of ESL students, and appreciation for unique learning styles. Positive reinforcement of individuals, encouragement of support groups, and heightened sensitivity of all nursing students, faculty, and clinical agency staff to the feelings of victims of prejudice were recognized as important. Faculty and administration were urged to be sensitive to diversity in future selections of textbooks, audiovisual materials, and purchases of human models for clinical skills practice. Members of the committee have unofficially, but with clear legitimation from administration, acted as diversity "watch dogs" in all areas of committee work and problem-solving, often interjecting verbal reminders to consider the \ implications of multiculturalism in a variety of arenas.
Recommendations to Decker School of Nursing administrators included (1) prioritizing financial support for faculty to gain specific knowledge in cultural diversity, (2) developing approaches to address existing prejudice and cultural insensitivity that may surface from time to time in the local health care delivery systems, and (3) aggressively seeking faculty appointments representative of diversity in its broadest sense.
It was evident throughout the project process that the current body of knowledge regarding diversity lacks concreteness and boundaries. This makes curricular analysis for multicultural content even more essential in nursing to assure that students are optimally educated with exposure to culturally sensitive information and experiences that will promote a desire for lifelong learning in this area. Use of the model presented in this article facilitates a comprehensive analysis of a broad array of concepts for the education of professional nurses. Other concepts perhaps could and should be selected by other nursing programs. Faculty development is crucial to meet the diversity awareness challenge. With open and honest dialogue in a supportive atmosphere, nursing faculty can create curricula to prepare nurses for a pluralistic society.
- American Nurses Association. (1986). Cultural diversity in the nursing curriculum: A guide for implementation. Kansas City, MO: Author.
- Equity Institute, Inc. (1989). Introductory multicultural organizational development program. Amherst, MA: Author.
- State University of New York at Binghamton. (1990). Self-study 1990 (SUNY-B) (Draft prepared for the University Community on November 13, 1990). Binghamton, NY: Author.