Nursing curricula must reflect cultural knowledge of ethnic groups because nurses work with diverse patients. It has been recommended that nursing faculty identify and reduce Eurocentric bias in nursing curricula (Byrne, 2001; Campinha-Bacote, 1998; Lenburg et al., 1995; Tanner, 1996). In general, bias may be identified by determining whose interest is portrayed and whose is excluded (Sadker & Sadker, 1982, 1994a). Eurocentric bias, or Eurocentrism, was defined by the Council on Interracial Books for Children (1980) as, "the consideration of events and people exclusively from the perspective of whites [sic] who came to the United States from Europe" (p. 5). Additional forms of bias are ageism, sexism, and racism. According to hooks (1995) and West (1993), all knowledge and perspectives have embedded bias. However, total exclusion of ethnic groups promotes further marginalization and invisibility, exacerbating tensions related to difference. Group exclusion is one type of instructional bias that contributes to limiting, slanting, or in some way controlling information presented to students or learners (Council on Interracial Books for Children, 1980).
The purpose of this article is to describe the background for development of The Byrne Guide for lnclusionary Cultural Content. This Guide is intended to help nurse educators identify and reduce bias in their instructional material. In addition, this Guide may be used to evaluate existing materials or create new materials, such as textbooks, syllabi, computer software, audiovisual materials, manuscripts, or examinations.
Nursing scholars have advocated for cultural competence (Baldwin, 1999; Campinha-Bacote 1998, 1999; Lenburg et al., 1995; Tanner, 1996). CampinhaBacote's (1999) model of cultural competence includes personal awareness, knowledge, skill, encounters, and desire. Cultural awareness is defined as:
the deliberate, cognitive process in which health care providers become appreciative and sensitive to the values, beliefs, lifeways, practices and problem-solving strategies of clients' cultures (CampinhaBacote, 1999, p. 204).
Specifically, individuals must examine their own prejudices and biases. This awareness may be difficult because individuals tend to be blind to their biases or ethnocentric in their perspectives. Therefore, explicit examples of bias and assumptions may help educators and nurses be less ethnocentric in their practice (Mclntosh, 1T88). Understanding and using the Byrne Guide for lnclusionary Cultural Content is one step in an ongoing process of becoming culturally competent.
Exclusionary knowledge claims in curricula have been captured in a model of "four errors basic to dominant tradition" by Minnich (1990). The first error, faulty generalization, occurs when one specific group is represented, but the content is generalized to all people. The second error, circular reasoning, occurs when a norm or ideal is based on an exclusive category, usually defined by a dominant, White male perspective. This type of norm or ideal can negate the experiences of people outside the category on which it was based. The third error, mystified concepts, results from the first two errors and occurs when ideas, notions, and categories are so embedded in cultural norms that they are rarely questioned. For example, Minnich (1990) described how individualism is valued and revered in American culture. However, the aspects of individualism that remain silent are how individualism undermines community and the interdependence of women and other cultural groups. The fourth error, partial knowledge, results from the first three errors. Partial knowledge supports only a part of a group of people, without representing or including the whole group. The historical notion of Columbus discovering America is an example of partial knowledge because it excludes "natives" of this country and explorers from other continents. Partial knowledge contributes to "exclusionary" knowledge claims, rather than a curricular goal of inclusionary knowledge.
Gender Inclusion Models
Previous theoretical works in sociology and women's studies identified curricular models that examined gender inclusion in curricula (Andersen, 1988; Mclntosh, 1988; Rosser, 1989; Tetreault, 1985, 1987). Tetreault (1985, 1987) outlined a feminist phase theory, an experientially derived model that identifies five curricular phases to reach a gender-inclusive curriculum. Phase one reflects an exclusive presentation of Eurocentric, male-defined knowledge, absent of women. Phase two involves a contribution curriculum in which women become an addition to the curriculum. Phase three reflects a bifocal curriculum that occurs when women's experiences are contrasted to men's. However, this comparison of men and women supports dichotomization and dualism. Phase four represents a womencentered curriculum in which women are studied and understood on their own terms (e.g., a course on the history of women authors). Phase five, or the ideal curriculum, is a gender-balanced curriculum that is pluralistic and multifocal. This perspective shifts knowledge from being male defined to an inclusive curriculum for all men and women. These five phases provide a framework for researching and communicating gender inclusion in curricula (Twombly, 1993). The authors did not find any research that used Tetrault's model (1985, 1987) to analyze nursing curricula.
Ethnicity and Multicultural Inclusion Modela
A similar type of model identified four levels of inclusionary content for ethnicity (Banks, 1994; Banks & Banks, 1993). The terms inclusionary curriculum and multicultural curriculum have been used interchangeably to reflect inclusion of ethnic and gender content. The first level for multicultural curricular reform is a contribution approach, which focuses on heroes and holidays (e.g., celebrating or acknowledging African Americans only on Martin Luther King Day). The second level is an additive approach, which occurs when content is added to the curriculum without changing the inherent structure or perspective of a course. The third level is a transformation approach in which the structure of the curriculum is changed to enable students to view concepts, issues, events, and themes from the perspectives of diverse ethnic and cultural groups. The fourth level is the social action approach, which:
extends the transformative curriculum by enabling students to pursue projects and activities that allow them to take personal, social, and civic actions related to the concepts, problems, and issues they have studied (Banks, 1994, p. 27).
Tetrault's (1985, 1987) feminist phase model and Banks's (1994) multicultural model strive for inclusionary content in curricula to ensure social action and justice. Minnich (1990) and Frankenberg (1993) suggested that curricula should be the focus for change. Minnich (1990) stated:
[A]s long as we do not engage in critique and correction of the curriculum, the framework of meaning behind particular questions of what to teach to whom will continue to prove inhospitable to all those who have been excluded from knowledge and knowledge-making, and so also from effective participation in understanding and exercising power on a basic cultural level, (p. 11-12)
Most of the theoretical work on inclusionary content in curricula has been in the disciplines of sociology and education. In addition, the background surrounding this scholarship occurred during the 1970s and early 1980s. The Sex Discrimination Act was passed in 1975 and led to many studies exposing gender inequity in instructional materials, language, and social opportunities. As gender bias was exposed, so was racial or ethnic bias Sadker & Sadker, 1980). Therefore, many textbook evaluations and scholarship addressing multicultural inclusion were published more than 10 to 20 years ago (Andersen, 1988, Banks, 1994; Banks & Banks, 1993; Council on Interracial Books for Children, 1977, 1980; Tetreault, 1985). However, this scholarship currently is applicable as educators and nurses search for strategies to become culturally competent in their teaching and nursing practices. Instructional biases may include gender, racial, religious, or ethnic exclusion of content- The next section of this article defines Sadker and Sadker's (1982, 1994a) six categories of bias found in instructional materials.
Categories of Bias in Instructional Materials
Sadker and Sadker (1982) identified that language reflects the bias of society. In an early study, Sadker and Sadker J (1980) used content analysis to research male and female gender inclusion. Their sample included 24 of the most widely used teacher education textbooks. Sadker and Sadker (1994b) continued their research on gender bias using classroom " observation, and the title of their book, Failing at Fairness: How America's Scft.oois Cheat Girls, captures their findings. Although Sadker and Sadker's (1980, 1982, 1994b) scholarship has focused on gender bias, they have reported finding racial and ethnic bias. In a summary of their work, Sadker and Sadker (1982, 1994a) identified six categories of bias found in instructional materials:
* Invisibility or omission.
* Imbalance and selectivity.
* Fragmentation and isolation.
* Linguistic bias.
Invisibility or Omission
Invisibility, the first category of bias, occurs when particular groups are omitted or not represented in text and/or illustrations. In fundamental nursing textbooks, * Byroe (2000) found omissions of African American leaders, African American history, and topics relevant to African American people, such as Mongolian spots, keloids, assessment techniques, and norms for darkly pigmented people. It has ^ been suggested that African American people are invisible within the nursing culture because of the small number of African American RNs and the absence of documentation of African American nurses' contributions in nursing textbooks (Barbee, 1993; Byrae, 2000). When invisibility occurs in textbooks, or experientially, it teaches people from nondominant cultures that they are less important and less significant in society than people from dominant cultures.
Another common instructional bias is stereotyping. This occurs when there is an untruth or oversimplification about the traits and behaviors common to an entire group of people (Council on Interracial Books for Children, 1977, 1980; hooks, 1995; Pieterse, 1992; Reid, 1994; TrippReimer & Fox, 1990). Stereotypes can refer to a number of variables, such as physical appearance, intellectual attributes, personality characteristics, career roles, domestic roles, social placement, gender, and ethnicity. Byrne (2000) noted the stereotypes of matriarchy and magico-religious health practices in the portrayal of African American people. Stereotyping denies the reality of individual differences and inhibits people's understanding of diversity and complexity (Sadker & Sadker, 1982).
Imbalance and Selectivity
The third category of instructional bias is imbalance and selectivity. Insight into this perspective results from examining whose "truth" is being reported. An exclusive and culturally privileged perspective of an issue leads to an unbalanced account of a situation and limits students' knowledge of situations (Council on Interracial Books for Children, 1977, 1980; Sadker & Sadker, 1982, 1994a; White, 1990). According to Byrne (2000), an example of imbalance and selectivity is fundamental nursing textbooks' common labeling of skin color as pink and hair as silky and resilient.
An example of imbalance in health care is generalizing research findings for White middle-class men to all people, regardless of their race, class, or gender. Specifically, health care professionals have been taught that crushing chest pain is indicative of a myocardial infarction, although this norm only applies to White men. The signs and symptoms of a myocardial infarction in women and African American men are different (Lee, 1997). However, this knowledge has yet to replace the assumption about crushing chest pain, which ignores the actual experiences of many patients. An unbalanced and selective view perpetuates partial knowledge of an issue by negating the complexity of a phenomenon from a variety of perspectives.
Another category of instructional bias, unreality, occurs when instructional materials ignore unpleasant or negative facts (McCarthy, 1990; Sadker & Sadker, 1982, 1994a). When controversial topics are presented unrealisticaliy, students lack the information to recognize, understand, or change circumstances that plague society. A frequent example of this bias is how racism or oppression is rarely addressed or even mentioned in textbooks (Byrne, 2000; Feagin & Vera, 1995; Tullman, 1992).
Fragmentation and Isolation
Fragmentation occurs when nondominant groups are presented physically or visually separate from "mainstream" content (Sadker & Sadker, 1982, 1994a). This bias is present when information about nondominant groups is located in boxes at the side of the page (e.g. , African American nurse leaders) or in separate chapters or sections (e.g., culture and nursing) (Byrne, 2000). When Eurocentrism is dominant, other cultural groups are kept on the fringes of the page (Reid, 1994).
Examples of fragmentation and isolation imply that the history, experiences, and contributions of many cultural and ethnic groups may be "within the margins" of nursing knowledge. Therefore, when educators add material about a variety of cultural groups, it is important to not fragment that content in a separate page, table, or addendum. This formatting inadvertently designates the content as less important than the information that historically has been the mainstream perspective.
The final category of instructional bias is linguistic bias. Language and metaphors often depict cultural bias (Council on Interracial Books for Children, 1980; Sadker & Sadker, 1982). Examples of gender-laden terms indicative of linguistic bias include stewardess, chairman, or workmen. These terms have been replaced by flight attendant, chairperson, or worker. A linguistic bias found in health-related textbooks is the use of feminine pronouns for nurses and male pronouns for doctors.
An example of cultural or ethnic linguistic bias is presenting groups as "primitive" or "exotic," which results in dehumanizing and defining people only as they relate to a dominant group (Three Rivers, 1991). Another example of linguistic bias is how words containing "black" frequently have negative connotations, such as blacklisted, blackballed, black mark, blackmail, black market, and black sheep (Reid, 1994). Linguistic bias also occurs when professionals working in a field dominated by White people refer to people of other cultures or races by labeling them, such as a "Black" nurse or a "Latino" administrator. Describing individuals' race or ethnicity may label them as different or outside traditional professional norms.
Previous researchers (Byrne, 2000; Huffman, 1996, 1998; Sadker & Sadker, 1982) have used the six categories of bias in instructional materials to document textbook examples of bias. Language is an important construct of race, class, and gender (Desiinone, 1993). Learning materials are created and communicated via language, which plays an important role in establishing boundaries and categories to understand differences. The Byrne Guide for Inclusionary Cultural Content may help educators identify and reduce instructional bias.
Background on the Byrne Guide for Inclusionary Cultural Content
In a previous study, a guide was constructed to collect and analyze data related to the portrayal of African American people in fundamental nursing textbooks (Byrne, 2000). Three best-selling fundamental textbooks were selected as a data source because they were used early in and throughout a nursing program representing nursing knowledge. The Byrne Guide for Inclusionary Cultural Content was derived from a synthesis of many guides for children's story books, basal readers, literature anthologies, dictionaries, biographies, math textbooks, career education textbooks, and U.S. history textbooks (Table) (Banks, 1994; Council on Interracial Books for Children, 1980; Sadker & Sadker, 1982). For the initial study, each section of the Byrne Guide for lnclusionary Cultural Content incorporated one or more of Sadker and Sadker's (1982) categories of bias and contained content-specific questions addressing history, cultural authenticity, or physical assessment parameters. It also was used to collect data related to four types of textbook content (i.e., textual language, illustrations, linguistics or word usage, and references).
Excerpts from the Byrne Guide for Inclusionary Cultural Content*
The initial Guide was revised many times, incorporating the critique and suggestions provided by an expert in gender bias, Dr. David Sadker (personal communication, June 16, 1997, January 10, 1999), a dissertation committee, and three nurse educators knowledgeable in multicultural education. These people provided feedback related to clarity and simplicity of use of the guide.
The initial format of the Guide helped the author and the three educators identify racial bias. However, it was extremely lengthy, redundant, and cumbersome to use. Therefore, the author and the three educators collaborated again to simplify the Guide and expand it to include various types of instructional bias. The Guide was created within an interpretive, hermeneutic methodological paradigm. The assumptions supporting this are that there can be no psychometric testing or measurement of the concept of bias because it is dynamic and socially and culturally embedded. Bias must be interpreted and continually challenged as it evolves with cultural changes.
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Excerpts from the Byrne Guide for Inclusionary Cultural Content*