This article discusses the use of Stone Soup, a metaphor used with undergraduate nursing students to create an inclusive learning environment focused on culturally responsive nursing care. The American Association of Colleges of Nursing (AACN, 2017a) and the National League for Nursing (2016) endorse the provision of culturally sensitive and inclusive nursing education. According to Smith (2017), inclusive learning environments start with respecting, appreciating, and embracing diverse points of view during class discussions and recognizing that students want to find meaning in what they learn within their own cultural framework. Sommers and Bonnel (2020) concurred, advocating for the use of personalized teaching approaches where faculty get to know students individually and invite multiple perspectives. Other examples of inclusive teaching strategies include ensuring that reading assignments, case studies, classroom content, and simulations represent diverse populations and health concerns; these strategies foster a sense of belonging for minority nursing students (Smith, 2017; Woodley & Lewallen, 2019; Woodley & Lewallen, 2020).
When inclusive teaching strategies are not used, underrepresented minority nursing students report feeling as though Caucasian is the default and that they are invisible; in turn, these students become less apt to participate in class discussions and more likely to self-isolate (Debrew et al., 2014; Woodley & Lewallen, 2020). Underrepresented minority nursing students already have higher attrition rates from prelicensure programs than the majority group (AACN, 2017b). The nursing profession cannot afford to lose more of the students who add diversity to the profession and enhance nursing's ability to provide culturally sensitive care to increasingly diverse patient populations.
Nurse educators need to develop a multitude of inclusive teaching strategies that can be created, tested, and evaluated. In this project, a metaphor of Stone Soup helped to establish and maintain a dynamic classroom environment where reciprocal accountability of faculty and students was emphasized and where multiple perspectives were regularly sought out over the teaching semester. Metaphors have been successfully used to help students to remember and retain content (Chan & Nyback, 2015; Purnell et al., 2013). Because metaphors may be potentially misunderstood by students who are nonnative English speakers (Weitzel & Davidson-Shivers, 2004), careful attention was given to the selection of a metaphor that is simple, relatable for students, and not culturally specific.
Stone Soup is a centuries-old folk tale told in different iterations across many cultures around the globe. Its message is simple but powerful. A stranger comes to a village with only a large cooking pot. He approaches the villagers to see if they might cocreate a meal, but they refuse and shut their doors. The stranger then fills the pot with water from a local stream, and places it on a roaring fire. He places several stones at the bottom of the pot and begins to boil the water. As he tends to the pot, curious villagers approach. The stranger tastes the “soup,” announcing that although it is very good, its flavor would be enhanced by the addition of other ingredients. One villager brings spices to add to the soup. Another offers vegetables. One by one, the villagers contribute unique ingredients, and before long, the soup has turned into a rich and hearty meal that feeds the entire village. As they partake in the meal, the villagers marvel at the depth and richness of the dish that they cocreated, all from the meager beginnings of stone soup. In turn, their relationships with other community members become more personalized and meaningful, and overall community engagement and productivity is enhanced.
This project was not intended to be a formal study, but rather an evaluation of an educational innovation that took place over 2 academic years (four semesters) within the classroom of an undergraduate pediatric nursing course. The course was taught in the senior year of a baccalaureate nursing program at a large public urban university in the Southeastern United States. The goals of the teaching innovation were to (a) enhance student participation and a sense of belonging for all students in the course, including underrepresented minority nursing students; (b) establish the culture of the classroom learning environment as one of inclusivity and reciprocal accountability among faculty and students; and (c) promote group learning of culturally responsive nursing care through students and faculty sharing personal and professional experiences to enhance group learning.
For this project, a three-pronged teaching strategy was implemented, with each prong starting in week one of the course. First, an animated short story of Stone Soup was presented to students using a public YouTube video. Following the video, faculty facilitated a detailed classroom discussion of how the story of Stone Soup related to student engagement and learning within the class. Emphasis was placed on the value of many students sharing collective experiences to enrich everyone's learning and that doing so would provide a platform upon which discussions of culturally responsive nursing care could be based. A comparison was made of faculty-based lectures being like single-ingredient soups, compared to the rich depth of flavors that would arise when students and faculty from a variety of backgrounds shared personal and professional experiences. Next, using the Poll Everywhere online platform, faculty and students anonymously indicated their families' country of origin on a global map. This exercise provided an immediate visual cue about the collective geographical diversity in the classroom. Finally, the course faculty member announced that she would learn each student's name in the class, analogous to learning the names of individual ingredients in a soup. This was achieved by students initially repeating their names early in the semester and encouraging students to introduce themselves in class breaks. The faculty member also studied individual student photos and used online pronunciation guides along with student feedback to learn correct pronunciation of names. Classes sizes for this project ranged from 65 to 102 students, and the faculty member learned student names by week 5 of the 14-week course, with occasional reminders from students needed.
References to the metaphor of Stone Soup were made in subsequent classes, providing an opportunity where students could volunteer their own family's experiences, health beliefs, and practices related to classroom content, or share their own professional experiences from the clinical setting. In some classes, students participated within small groups to discuss how their own personal and family experiences might compare with a patient's experience or family expectations from a different culture. In other classes, large group discussions took place, where students from a wide variety of backgrounds volunteered insights and lived experiences to inform how nurses could provide culturally responsive care in similar patient and family situations. Professional experiences from the clinical setting shared by faculty and students included honest and poignant stories of when culturally responsive nursing care was provided and how the patients and families responded positively, as well as when attempts fell short, prompting future reflection and discussion. Students were consistently thanked by faculty for their unique contributions to classroom discussions. As the semesters went on, students also modeled this behavior by thanking each other for contributing. No incentives were provided for class participation, other than the knowledge that by sharing their unique experiences, individuals were actively contributing to the collective learning of the group.
Student feedback was solicited during week 12 of the 15-week course using a brief, anonymous, optional online survey. Week 12 was chosen so that students could comment on their experiences in the class over the semester, but not have the survey compete with online end-of-semester course evaluations and final examinations. Questions posed to students were:
- Did the story of Stone Soup woven throughout this class help you feel that your own input into class discussion was valuable?
- Did contributions made by your classmates enhance your understanding of culturally responsive nursing care?
- Do you believe that class discussions were richer because of the tone set by Stone Soup and the global map exercise?
- Did course faculty learning and calling you by name enhance your sense of belonging in the class?
- On a scale of 1 (extremely uncomfortable) to 100 (extremely comfortable), rate your comfort level for participating in this class.
Students were also invited to include narrative comments in a free text box of the survey if they wished.
A total of 258 students responded to the survey, representing an overall response rate of 78.7%. Results were positive. Most students (85.6%) indicated that hearing, discussing, and revisiting the story of Stone Soup throughout semester made them feel that their input into class discussion was valuable. Most students (93%) reported that they learned more about providing culturally responsive care because of their classmates' contributions to group discussions. Almost all (98.3%) perceived that class discussions were richer because of the classroom tone set by the Stone Soup metaphor and global map activity of the first class. Almost every student (97%) also reported that faculty knowing and calling them by name enhanced their sense of belonging in the class. The mean comfort level for participating in the class was 88 on a scale of 1 to 100, with a range of 72 to 100. Narrative comments were overall extremely positive; no negative comments were received. Remarks included, “my classmates' stories really opened up my eyes about why patients and families might react in a certain way,” “I never realized how important culturally responsive care was before this class,” and “Our class became exceptionally aware of cultural variations… that was amazing. I had never had a professor ask for input from personal experiences some of us may have had.”
From a faculty perspective, this teaching strategy greatly enhanced overall classroom participation. Not only did confident and talkative members of the class participate regularly and often, but so did students who stated that they had been quiet in previous classroom environments. Class participation among underrepresented minority nursing students was especially notable compared to previous iterations of the course. It was common for students to begin their insights with phrases such as “In my hometown...,” or “Where I grew up….” By using the teaching strategies described in this article, course faculty noted an increased depth, breadth, and consistency of student engagement and participation across the majority of class members—so much so that it was challenging at times to end the class because students wanted to keep discussions flowing. Course faculty also noted that contributions from students in the class reflected many aspects of diversity and culture, such as how growing up in urban versus rural settings, holding certain religious beliefs, or immigrating to the United States from a different country shaped their families' health beliefs and practices, as well as their own. In addition, discussions reflective of intersectionality took place over the semester, such as how we each belong to more than one culture at the same time, and how these layers of culture influence our health beliefs, values, behaviors, and interactions with others.
The collective energy, enthusiasm, and depth of discussion around culturally responsive nursing care was particularly palpable during specific classes. These classes included pediatric pain assessment and expressions of pain, family-centered care of the dying child, caring for pediatric patients with intellectual and developmental disabilities, and patients born with a visible physical defect such as cleft lip and palate, gastroschisis, and meningomyelocele. For example, a classroom discussion of family-centered care—an important concept in pediatric nursing—reflected many types of families with whom students would be working, such as those with varying sexual identity and expression, single parent families, families living in poverty, and those with and without health care insurance. In another class, students shared how a child with an intellectual and developmental disability might be viewed by members of their own communities, and how cultural and religious beliefs and values would potentially affect the family's experience. In a third example, students shared how a newborn with a cleft lip and palate might be viewed in their own culture, provided context for family and community reactions, and discussed how social media expectations might influence parental responses. Often, these same students who offered personal insights also offered specific suggestions for their colleagues to increase sensitivity into the importance of holistic, family-centered care.
The combination of strategies described in this educational innovation shows promise as an effective way to promote an inclusive and student-centered learning environment. These strategies yielded high classroom participation, a sense of belonging across diverse groups of students, rich classroom discussions, and heightened student awareness and understanding of culturally responsive nursing care. Research is needed to test whether the combination of strategies is more effective than one or more of the strategies alone. In addition, more formal research should examine differences in student engagement as a result of these teaching and learning strategies compared with baseline data. Because this was an evaluation of an educational innovation and not a formal research study, student feedback was elicited using only a simple survey. In addition, demographic data of student respondents to the online questionnaire were not gathered. Therefore, it is unknown whether the teaching strategies described here were more effective for some groups of students than others. More formal studies comparing student responses and outcomes by race, ethnicity, gender, or other parameters would be helpful in making these determinations.
Today's learning environments in nursing must be intentionally designed to be student centered and rich with intellectual engagement and meaningful collaboration among students and faculty. It is critical that nurse educators use inclusive teaching strategies which foster the engagement of all students in the class. The educational innovation described in this article shows promise as an example of a student-centered and inclusive teaching strategy. This may inspire future generations of nurses who are empowered to competently and confidently provide culturally responsive care to meet the complex needs of an increasingly diverse patient population.
- American Association of Colleges of Nursing. (2017a). AACN position statement: Diversity, inclusion, and equity in academic nursing. http://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Diversity
- American Association of Colleges of Nursing. (2017b). Research and Data Center: Latest data on race and ethnicity. http://www.aacnnursing.org/News-Information/Research-Data
- Chan, E. A. & Nyback, M. H. (2015). A virtual caravan—A metaphor for home-internationalization through social media: A qualitative content analysis. Nurse Education Today, 35, 828–832 doi:10.1016/j.nedt.2015.01.024 [CrossRef] PMID:25717018
- Debrew, J. K., Lewallen, L. P. & Chun, E. (2014). Outsiders in nursing education: Cultural sensitivity in clinical education. Journal of Professional Nursing, 30(2), 149–154 doi:10.1016/j.profnurs.2013.08.005 [CrossRef] PMID:24720943
- National League for Nursing. (2016). Achieving diversity and meaningful inclusion in nursing education: A living document from the National League for Nursing. NLN Vision Series. http://www.nln.org/docs/default-source/about/vision-statement-achieving-diversity.pdf
- Purnell, M. J., Lange, B., Bailey, C., Drozdowicz, A., Eckes, S., Kinchen, E. & Smith-Atkinson, N. (2013). The covered wagon journey: Student chronicles in advanced holistic nursing. Creative Nursing, 19(1), 16–20 doi:10.1891/1078-45184.108.40.206 [CrossRef] PMID:23600022
- Smith, L. (2017). Cultural competence: A nurse educator's guide. Nursing2017, 47(9), 18–21 doi:10.1097/01.NURSE.0000522019.07806.83 [CrossRef]
- Sommers, C. L. & Bonnel, W. B. (2020). Nurse educator's perspectives on implementing culturally sensitive and inclusive nursing education. Journal of Nursing Education, 59(3), 126–132 doi:10.3928/01484834-20200220-02 [CrossRef] PMID:32130413
- Weitzel, M. & Davidson-Shivers, G. (2004). Effects of metaphors for Asian and majority-culture students. Home Health Care Management & Practice, 17(1), 14–21 doi:10.1177/1084822304268155 [CrossRef]
- Woodley, L. K. & Lewallen, L. P. (2019). Acculturation into nursing for Hispanic/Latino prelicensure nursing students and new graduates: Integrative review of literature. Nurse Educator, 44(5), 255–260 doi:10.1097/NNE.0000000000000610 [CrossRef] PMID:30735148
- Woodley, L. K. & Lewallen, L. P. (2020). Acculturating into nursing for Hispanic/Latinx baccalaureate nursing students: A secondary data analysis. Nursing Education Perspectives, 41(4), 235–240 doi:10.1097/01.NEP.0000000000000627 [CrossRef] PMID:32168091