Cultural Diversity in Nursing Education: Perils, Pitfalls, and Pearls

Education, Human Nature, and Culture

Although there are myriad unrecognized concerns with regard to educating the new cohorts of nontraditional nursing students, three areas of particular concern add layers of complexity to the effective education of future nursing professionals. These areas are:

• Nature of nurses’ training and education.
• Human nature.
• Nature of culture itself.

The term education refers to a process by which some known information and skills are effectively transmitted to learners who need to get the information and who will turn that new knowledge into actions or behaviors. Since the late 1940s, nursing has been making a transition from the early apprenticeship training programs toward collegiate education. The term training refers to a relatively stable knowledge base that can be taught by specific processes and rules.

Education presumes the need to engage in problem solving and critical thinking to synthesize more complex and changing knowledge into appropriate courses of action. Nursing has a long and rich history of being a uniform discipline both in terms of attire and in the nature of our education and practice (Schim, 1997). Nursing has, of course, made great strides toward scholarship and advancing education to produce professional practitioners who are able to deal with the nuances and complexities of modern health care. However, the value of uniformity remains as an important subtext within the discipline, and it is therefore often difficult to see the changes that a more diverse student body demands. It is also difficult for many to envision new ways of tailoring nursing education to accommodate different student needs, and it may be equally difficult for some to even recognize the need to make such changes.

Another area that greatly affects the education of diverse students is the very nature of culture and cultural differences. Culture, according to classic anthropologist Tylor (1871), is that “complex whole which includes knowledge, belief, art, law, morals, custom, and any other capabilities and habits acquired by man as a member of society” (as cited in Erickson & Murphy, 2001, p. 26). Culture is acquired, dynamic, and largely unconscious. Culture is ubiquitous and often unexamined. Culture changes both through conscious effort, education, and experience, and by unplanned happenstance and history. Current American culture is concerned with the issue of political correctness, and the consequences for making an error in speech or action can be dramatic. Academic culture includes a raging debate about public and private speech, and many faculty members fear being labeled as insensitive or ignorant. It is much easier for individuals to teach what they were taught in the ways that they know than to venture out into the unfamiliar.

Cross-Cultural Communication

Some of the most frequently cited pitfalls and greatest frustrations for students and faculty relate to language and communication. McKeachie and Svinicki eloquently stated that the “bread and butter of teaching is the act of communication” (2005, p. 152). Language is the main mode of communication between nursing instructor and student; however, whether it is the spoken word or written work, language often can become a major stumbling block. Language issues become even more complex when faculty members and students have different backgrounds and speak different languages or dialects. Language also can be a major issue for local students from different communities, educational systems, and social strata. In addition, because nursing and medicine have their own unique cultures, professional languages, and jargon, cross-cultural communication among faculty, students, and other members of the health care team can become even more difficult.

An example of some communication issues based on language and cultural differences was observed recently during a clinical rotation on a busy medical-surgical unit in a large hospital in the midwestern United States. The clinical group comprised students from a college of nursing who were finishing their second medical-surgical adult health course. Students in the group came from Nigeria, Cameroon, Iran, the Philippines, India, and Albania; two of the students were local. The students were reading charts of their assigned patients for the day and besides the challenges of deciphering the handwriting, they were also trying to comprehend the abbreviations in the general medical notes. The student from Iran asked the student from Nigeria what the abbreviation “DIB” in the chart meant. The Nigerian student answered that it meant difficulty in breathing or the same thing as “SOB” (shortness of breath). The Iranian student, a little exasperated, said, “Well, they should use SOB because I know what that means.” One of the local students explained to the others that the abbreviation SOB should not be used in charting because in American slang English, the abbreviation also means “son of a bitch,” which is considered an insult. The Nigerian student and her Iranian classmate looked at one another and commiserated about their difficulties with medical language, nursing language, and the American language (T. Clayton, personnel communication, November 11, 2006).

Another undergraduate student, a physician trained in China who was attending nursing school, provided an example of cultural communication difficulties that go beyond language proficiency. After several weeks of in-class theory and practice about communicating with patients, the student began a clinical rotation on a medical unit. He was observed on several occasions to pick up a patient’s medications, shove the cup under the patient’s nose, and command, “Take!” That patients might be politely asked to take their medications or be allowed to ask questions or refuse care was completely out of this student’s realm of experience or imagination. In this case, the student’s proficiency with English was adequate, but his cultural background as a man and physician in China created significant barriers.

Cultural variations in approaches to academic work have been widely reported. Whereas the American higher education system places high value on independent thought and solo performance, students from many other cultures are taught to value work sharing and helping the whole group to achieve. This fundamental difference can have major ramifications for assignments and examinations in nursing education.

In addition, even the basics of classroom etiquette are culturally variable. An experience teaching in southern India demonstrated some of the dramatic differences that students and faculty may encounter. In the U.S. classroom, students usually begin to pack up their books and notes approximately 5 minutes before the end of a session, and there is a stampede to the exit as soon as the hour strikes. In the Indian classroom, when the lecture ended, the teacher asked for questions (there were none as public questioning may be seen as an inappropriate challenge to authority) and none of the students moved. After a short period of silence, students rose and filed out in an orderly fashion. A few students who wanted more information approached the teacher after the session rather than be seen as impolite in front of the group.

Gender Challenges

The enrollment of more men in nursing programs is having a significant impact on educational challenges. As demonstrated in work by Tannen (2001), men and women tend to have significantly different communication styles. Nursing, as a largely female-dominated practice discipline, has developed an emphasis on building and maintaining interpersonal relationships. Men entering the field often come with a more task-oriented instrumental approach to the work. Men and women from differing cultural, ethnic, and religious traditions also come to the business of caring with distinct role expectations and gender norms. In addition, diverse patients, families, and communities have specific gender expectations with regard to caregivers. For example, in some cultures, men prefer male care-givers whereas women prefer female caregivers. There is tremendous within-group variation, however, and even in the mainstream American culture, men and women may have strong preferences about the gender of their nurses. The fact that more than 91% of nursing faculty members are women (U.S. Bureau of Labor Statistics, 2008) creates additional challenges with the expanding group of male nursing students.

Age and Additional Responsibilities

Whereas the traditional nursing student was most likely an unmarried young woman, today’s nontraditional student is likely to be older and have more family and work responsibilities outside the classroom (AACN, 2005; Bond et al., 2008; Seldomridge & DiBartolo, 2007; Wong, Seago, Keane, & Grumback, 2008). The challenges of family commitments among second-degree accelerated nursing students have received some attention (Weitzel & McCahon, 2008; Wong et al., 2008). Family obligations such as direct care for dependent children and aging parents, maintenance of a spousal relationship, attendance at family gatherings and children’s school events, and daily operational needs of a home often leave little time for study. Such competing demands on student time and attention become even more acute when students are the primary financial supporter, single parent, or both.

Although entering students may be cautioned about trying to work full time while navigating a rigorous nursing curriculum, most find that even with financial aid, they must maintain paid employment to keep up with basic family, home, transportation, and tuition costs. In one recent study, being male, having dependent children, and being a member of an ethnic minority were associated with increased difficulty in affording college education (Wong et al., 2008). The fact that most American family health insurance comes from employer-paid plans creates an additional reason for nontraditional students to keep working while pursuing their nursing education.

Another pitfall for nursing education frequently observed is the confounding of student and faculty age with generational differences. Generational differences are attributed to the patterns that are created because individuals share a “peer personality” rooted in their particular age location in history (Strauss & Howe, 1991). Each generation has its own set of values, ideas, ethics, and culture that influences for many how they interact with faculty representing a previous generation (or two). With labels such as Millennials, Generation X, Baby Boomers, and Silent Generation, each cohort displays characteristics that may seem unfamiliar and sometimes unacceptable to older faculty. For example, Millennial students who are currently in college classrooms have grown up with computers and the Internet. They are used to having immediate feedback and information availability 24/7 using the Internet and their laptops. Silent Generation and Baby Boomer faculty often are challenged to keep up with the technology explosion and may be grieving the fact that students do not visit the campus library any more. As the diversity of ages included in curriculum cohorts expands, the challenge to faculty to understand the learning needs of multiple generations becomes even greater.

Preparation for Advanced Academic Work

Confounding racial, ethnic, language, gender, age, and other aspects of cultural diversity among nursing students is the observed shift in preparation for rigorous academic work. The usual complaint whenever educators gather is that today’s students are not prepared for the “three Rs” of nursing education: reading, (w)riting, and research. The National League for Nursing (2008) estimated one of every three qualified applications was rejected due to lack of program capacity. Although this might indicate that only the top two thirds of candidates are granted admission and that enrolling students should be among the most academically prepared, the data suggest many students struggle with the high demands of nursing education. Although students in accelerated second-degree programs have demonstrated prior ability to complete academic work, many have been out of school for significant periods of time before making the difficult transition from the prior academic discipline to nursing. Students in first-time nursing programs may have achieved excellent grades in their secondary educations, but they often are observed to lack basic reading, study, and academic writing skills.

Unfortunately, the burden of less-than-adequate academic preparation for nursing study has fallen disproportionately on students from urban and traditionally underrepresented minority groups and is reflected in the higher attrition rates among such students. Educationally disadvantaged students are those who may be the first in their families to seek postsecondary education, who were educationally disrupted due to frequent moves during elementary and secondary school years, who attended low-achieving schools, who use English as a nonprimary language, or who may have myriad other barriers to preparation (Gilchrist & Rector, 2007).

Culturally Congruent Nursing Education

Culturally congruent care is defined as behaviors or decisions that are designed to fit with cultural values to provide meaningful, beneficial, and satisfying health care. This definition recently has been adopted, along with elements of several other established cultural competence models, into a multidimensional midrange theory of culturally congruent care (Schim, Doorenbos, Benkert, & Miller, 2007). Considering the perils and pitfalls of nursing education, a better “fit” between the provider-educator variables and the client-student variables is needed to provide and support meaningful, beneficial, and satisfying nursing education and professional practice.

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.