Pearls encompass what educators can do to increase effectiveness with diverse students. Prized as gemstones and objects of beauty for centuries, pearls have become a metaphor for things that are rare, fine, admirable, and valuable. Like today’s nursing students and faculty, pearls come in all different shapes, sizes, colors, and grades. In both natural and cultured forms, pearls come from all over the world. Based on analysis of the perils and pitfalls of educating diverse nursing students, review of the literature, and personal academic and diversity experiences, the following “pearls of wisdom” are suggested as ways in which nursing education might be made more effective.
Development of Personal Cultural Competence Among Educators
Cultural competence is a process rather than an outcome for educators and students. Cultural competence changes in scope and depth over time based on individual and group experiences of cultural diversity, awareness or knowledge of ways in which groups and individuals are similar and distinct from one another, sensitivity or open attitudes toward self and others, and the acquisition and practice of skills. One size does not fit all, and the learning needs to be time-specific, place-specific, and lifelong. Nursing educators can role model for students through their own efforts to expand the scope and depth of cultural competence and demonstrate the ongoing quest for excellence that needs to be part of professional nursing practice. Five areas on which to focus personal cultural capacity building among faculty are:
- Know thyself.
- Think globally.
- Act locally.
- Find the keys.
- Listen and learn.
Know Thyself. The advice from Socrates to “know thyself” forms a foundation from which personal cultural capacity can grow. Educators need to examine their personal cultural histories and backgrounds as well as American “mainstream” cultural values; the cultures of their schools, colleges, and program; and the academic cultures of individual classrooms and clinical settings. An understanding of nursing’s professional culture including beliefs, values, and traditional approaches to the science and art of both nursing practice and nursing education is important.
Self-reflection regarding core beliefs, biases, and privilege opens the way to useful personal insights and better understanding of one’s personality, preferences, and patterns of behavior and thought. Specific strategies for better understanding oneself with regard to culture include seeking opportunities to engage with people from dissimilar backgrounds; extending travel, sabbatical, and international work experiences; taking additional coursework in cultural anthropology or transcultural nursing; and performing ongoing self-reflection.
Opportunities for joint faculty and student travel abroad can be one way to achieve cultural immersion experiences. For example, one of the authors (A.D.) offers a summer course entitled, “Health in a Developing Country: India.” During the course, both faculty and students provide 4 weeks of hands-on care in a variety of clinical sites in southern India as a culmination of the semester-long study of global health care issues. The opportunity to come face-to-face with patients, colleagues, and health systems that are different from those normally encountered by faculty and students can be a powerful way in which to know one’s own culture better.
Think Globally. Assessment is the first step in the nursing process and the next step toward understanding the commonalities and variations that occur within and between groups of students. What is the demographic profile of the students in each program and at each level? What groups are represented in terms of race, ethnicity, nationality, gender, sexual orientation, socioeconomic status, and age and generation?
Faculty do not need to know (nor is it possible to know) everything about every specific type of student, but basic assessment of what groups compose each student cohort allows for learning some of the things that can guide our thinking. For example, faculty at our large midwestern urban college of nursing need to know more about the cultural patterns of African Americans, whereas faculty at a college in the southwestern United States have more need to focus on the cultural traditions of Native American and Hispanic and Latino communities.
Geography, history, and immigration patterns, as well as age and gender distributions of nursing students and the communities they represent influence the particular patterns of enrollment and therefore the global knowledge that is needed by faculty to make nursing programs more culturally attuned to student needs. There are many sources of group profile information available ranging from various racial, ethnic, and national origin diversity guides in print and online, to The Chronicle of Higher Education ( http://www.chronicle.com), to Internet sources such as Beloit College’s Mindset List for each entering generation ( http://www.beloit.edu/mindset/).
In addition, the resources that are commonly available on our own college campuses should not be overlooked. Such resources might include offices dedicated to working specifically with international students, courses and tutoring programs designed to assist those learning English as a second language and those learning academic writing, and student assistance programs for those with learning difficulties and physical challenges. Many campuses have programs to encourage and facilitate travel abroad for both students and faculty. In nursing education, however, finding the time within our highly scheduled clinical curricula remains a creative challenge. Some programs have been moving toward combining the desire for more global connections with problem solving regarding limited clinical rotation space in traditional local health service settings. For example, students in a pediatric course might “front load” the didactic material in the first few weeks of the term and then travel to a clinic in Haiti or Mexico to complete an intensive 2 to 3 week period of clinical learning.
All information about group norms, preferences, and behaviors should be approached with a caveat emptor (buyer beware) attitude since the information provided varies in quality and accuracy depending on the source. Using several sources and triangulating the information obtained is always a stronger strategy than relying on a single source.
Act Locally. Because people are complex and dynamic participants in culture with a lot of variation both between groups and within groups, thinking globally about group differences is only a beginning. Knowing that a student, for example, is South Asian Indian and that South Asian Indian students may not ask questions in class does not allow prediction of whether a particular student will or will not ask questions in class. Patterns are global, but individual student behavior is local and may vary widely from group and generational patterns.
When teaching in a small seminar course, it is reasonable to expect that faculty will perform individual assessment of learning needs and preferred styles, and will work with students to ensure congruence between faculty and students is maximized. For those teaching in larger courses, individual assessment is more problematic and time consuming, but it can be performed. The best way to assess how students learn best is to ask them directly. This can be accomplished quite successfully by having students complete several “Getting to Know You” surveys in the first week of classes using an online survey option in available courseware. It also is useful to have students take one of the many free learning style inventories available online; such inventories yield a personalized assessment of the preferred way to process information (e.g., visual, auditory, kinesthetic). Providing an opportunity for students to discuss their personal styles and work together and with course faculty to explore ways to accommodate their learning needs could be an excellent adjunct to other active learning assignments.
One approach to the local educational patterns of diverse students is a four-step sequence of appreciating, accommodating, negotiating, and explicating. The first step after assessment of what students’ need and want is to simply appreciate the differences. Consider whether the observed values, beliefs, or behaviors need to be changed for some good reason, or whether they can be recognized, understood in context, and perhaps even provide learning opportunities for faculty and other students. One example of this type of appreciation is a nursing student who wears a traditional Muslim head covering (hijab) with her uniform. This usually does not require any intervention on the part of faculty.
The next step to consider is accommodation wherein the student need is addressed through modification of some type. For example, students with disabilities sometimes require special test-taking environments, and most schools have systems in place to accommodate such needs. Other students may need to have course assignment due dates adjusted around religious holidays or specific cultural events. At times, accommodation will not be sufficient to meet both the desires of the student and the needs of the curriculum. In such cases, the next step is negotiation.
Negotiation involves the search for mutually acceptable ways to meet course, curriculum, and professional objectives while being fair to all students and meeting diverse needs. Negotiation works particularly well with adult learners who are managing home, family, and employment activities with academic work. What arrangements can be mutually decided to meet scheduling conflicts? Do all assignments need to be completed in the same way at the same time, or is some personal latitude and choice possible? Allowing students to negotiate when assignments are due or when online examinations are to be taken is one way to address the unique needs of nontraditional students who must juggle a variety of student, worker, and family roles.
Explication comes into play when appreciation, accommodation, and negotiation are not possible. Some educational aspects can be conducted in only one way to meet certain standards. One prime example is the national certification examination for nurses: every RN takes the same test and the pass level is the same for everyone. Most American nursing education is conducted in English, so a fair amount of facility with the English language is required of all students. When there is no alternative, faculty need to at least acknowledge the difficulties students encounter and provide full explanations for why the activity must be done in only one particular way. Such explanations must be carefully thought out and clearly explained in course syllabi.
With some individual and group information in mind, coursework can be designed to take advantage of a variety of teaching and learning strategies so that the diversity of learning needs can be custom-fit to the diversity of teaching modalities. One such new modality involves having students engage in digital storytelling where they collect and interpret a variety of visual and auditory media available via the Internet to complete a narrative about themselves, their cultural heritage, or their cross-cultural experiences. More information on the uses of this new learning tool is available at the University of Houston College of Education Web site ( http://digitalstorytelling.coe.uh.edu/), as well as from other online sources (Educause Learning Initiative, 2007). This type of assignment has great potential for the type of in-depth self-reflection and comparative cultural analysis beneficial for students. The application of newer computer-assisted learning also may be appealing to the younger generations of students who are well-versed in technological techniques.
Find the Keys. Part of expanding faculty cultural capacity is defining the key concepts related to many of the perils and pitfalls identified for specific groups of nursing students. Educators need to understand constructs such as acculturation, marginalization, racism, sexism, homophobia, and ageism, both as they occur in American society and as they apply disproportionately to students of different backgrounds. Not only do we need to be able to teach about these complex constructs but we also need to appreciate the ways in which they influence the past and current experiences of our students. Frank discussion of experiences of both faculty members and students often is uncomfortable and open sharing is difficult. For example, an older Jewish clinical instructor on our faculty was hesitant to express her concerns about the practice skills of a young Muslim male student. Would the instructor be perceived as discriminating against the Arab student? Would there be a backlash from the student or from the program administration? To whom could the faculty member or the student turn for guidance and support? Providing individual mentoring, forums for the exploration of difficult interactions, and “safe spaces” within our organization are ways in which we can help each other and our students to understand such complex constructs.
The other types of keys that need to be found are key informants in our academic and service communities. Key informants are information-rich individuals within a particular cultural group who can help faculty find the right assessment questions to ask and identify alternative strategies that are responsive to specific student needs. Many such informants who could educate us from the emic or insider’s perspective are members of our own faculty or colleagues on our own campuses. Others are available just beyond our campus borders in the surrounding communities and in the clinical service organizations we use. Educators can role model open dialogue with diverse community members inside and outside of the classroom and can enlist those from the wider community to engage with students to share their expertise. Representatives of the many available nursing organizations also can be valuable key informants. For example, the National Black Nurses Association, National American Arab Nurses Association, National Association of Hispanic Nurses, Philippine Nurses Association of America, and Indian Nurses Association have all been useful in advising our faculty and students.
Listen and Learn. Increasing cultural diversity across many dimensions calls for nursing educators at all levels to shift from traditional pedagogy (how adults teach children) to andragogy (aimed at adult learners). Having learned about group patterns and assessed individual needs by asking good questions, we need to listen to what our students are saying. Thinking of creative and exciting ways to use a variety of presentations, discussions, and assignments to accommodate different learning styles can energize both faculty and students. Using a variety of assignments involving digital storytelling, personal journaling, and photo essays can move students beyond traditional reports about racial and ethnic groups to delve deeper into topics such as sexual orientation, homelessness, low health literacy, and rural-urban population concerns.
Recognizing the common adult learner need for immediate relevance suggests more hands-on, experiential, or immersive educational methods and adoption of problem-centered learning over test-centered or faculty-centered approaches. For example, in our senior community health nursing course, students are presented with a list of a dozen books that address the needs of various cultural groups using fiction and nonfiction narratives. The “Heart and Soul” assignment involves choosing a book and then discussing with classmates and presenting to the whole group the implications for nursing practice revealed in the reading. Books on the current list include The Spirit Catches You and You Fall Down (Fadiman, 1998), Nickel and Dimed (Ehrenreich, 2001), and The Glass Castle (Walls, 2005). The assignment has been well received by students and allows them to explore many sensitive affective issues in ways they have not previously considered.
All of these things take time within already overloaded teaching schedules and energy on the part of overworked faculty. No one approach will work for a diverse student body or with diverse faculty; however, the more options that are available, the higher the likelihood that students will find their education culturally congruent.