The purpose of this study was to explore associate degree nurse (ADN) educators' perceptions of using best teaching practices to provide culturally sensitive and inclusive nursing education (CSINE). CSINE can facilitate engaging and preparing culturally diverse nursing students for the nursing workforce. Nurses are crucial to the delivery of essential health services to meet the complex health care needs of culturally diverse patients (World Health Organization, 2016). Around the globe, communities have become more culturally diverse, and a diverse workforce is necessary to improve patient health and reduce health disparities (Glazer et al., 2016; Institute of Medicine, 2010). Excellence in nursing education is required to prepare a strong and diverse nursing workforce to meet complex health care needs. Both the American Association of Colleges of Nursing (2017) and the National League for Nursing (2016) have made recommendations regarding the need for a more diverse nursing workforce and for nurse educators to provide CSINE.
To meet the needs of diverse students, nurse educators should be equipped to teach in multicultural settings (Billings, 2015a, 2015b; Dewald, 2012). One of the competencies identified for certified nurse educators is to facilitate learner development and socialization, including knowing how to meet the unique learning needs of culturally diverse students (National League for Nursing, 2018a). However, many nurse educators, especially in the clinical learning environment, have not had any formal education on providing CSINE (Jeffreys, 2015). Nurse educators have reported challenges in relating to culturally diverse students and meeting their varied academic and holistic needs (Abu-Arab & Parry, 2015; Marzilli & Mastel-Smith, 2017; Newton, Pront, & Giles, 2016; Oikarainen et al., 2017). These challenges include differences in expectations among and between students and nurse educators (Clarke, 2010; Melby, Dodgson, & Tarrant, 2008).
Students from different cultural backgrounds learn and process information differently (Henze & Zhu, 2012). Cultural norms and ways of learning will influence students' learning expectations and approaches to learning (Brown, Ward-Panckhurst, & Cooper, 2013) and their response to learning activities (Wlodkowski & Ginsberg, 2017). Nurse educators need to be willing to adapt and develop teaching strategies that promotes the success of culturally diverse nursing students (Sommers, 2018).
To address these challenges, nurse educators can provide CSINE that is “characterized by openness to diversity, with mutual respect and trust for others” (Dewald, 2012, p. 410). Culturally responsive teaching is appropriate for all disciplines and cultures to engage students while respecting students' cultural integrity, developing relationships, and supporting learning that deepens their knowledge and enthusiasm for learning (Wlodkowski & Ginsberg, 2017). Billings (2008) described inclusive teaching as being responsive to diversity within a class; assisting students to focus on their own culture, attitudes, and beliefs; and learning to communicate and collaborate with other students, nurse educators, and patients. An inclusive environment in nursing education will require intentionally embracing differences and not merely tolerating them (American Association of Colleges of Nursing, 2017).
Dewald (2012) conducted a Delphi study to describe teaching practices in nursing that are culturally responsive. Her results were grouped into 13 categories: modeling, respect, communication, caring, clinical, self-reflection, empowerment, personalization, recruitment, support, resources, faculty, and classroom. She concluded further research was needed in describing and using these teaching strategies to improve learning outcomes, increase recruitment, and improve retention for culturally diverse nursing students.
Although some strategies and teaching practices that promote CSINE have been identified in the literature, faculty awareness of these practices, as well as the challenges in using them, are unclear. The purpose of this study was to explore ADN educators' perceptions of using best teaching practices for providing CSINE. Areas that were examined include ADN educators' perceptions of:
- Implementation of best teaching strategies and practices for use with culturally diverse nursing students.
- Challenges of implementing best teaching strategies and practices in the classroom and clinical learning environment.
- Benefits of implementing best teaching strategies and practices in the classroom and clinical learning environment.
- Education received and education desired on the provision of culturally sensitive and inclusive nursing education.
A descriptive qualitative approach with open-ended broad survey questions and interviews was used. Before the study began, human subject approval was obtained from the University of Kansas institutional review board. Informed consent was obtained from all participants.
Setting and Sample
ADN educators in Kansas who attended the annual meeting of the Kansas Council of Associate Degree Nurse Educators in October 2018 were invited to participate in this study. Participants completed a survey regarding their perceptions and use of best teaching strategies and practices for providing CSINE. Participants also were asked to complete a follow-up interview.
ADN educators were chosen for the study sample because nurse educators play a key role in preparing culturally sensitive and diverse students (National League for Nursing, 2016). ADN programs have a lower first-time pass rate on the National Licensure Examination for Registered Nurses® and a higher rate of student attrition compared with baccalaureate nursing programs (Kansas State Board of Nursing, 2016). Community colleges are the largest gateway for nontraditional students and enroll a high proportion of low-income and minority students (The Century Foundation, 2013; Wlodkowski & Ginsberg, 2017). These nurse educators were deemed appropriate for exploring this phenomenon of educating culturally diverse nursing students.
The survey consisted of 9 demographic items and 30 survey questions. The survey was developed using the 13 categories from Dewald's (2012) study. The 13 categories were organized into four sets of teaching strategies and practices. Based on the literature review, further descriptors were added to enhance clarity:
- Set 1: Modeling, Respecting, Communicating, and Caring. This set encompassed creating an environment for mutual connection and respect, as well as incorporating students' values and perspectives.
- Set 2: Supporting, Personalizing, and Empowering. This set encompassed helping students develop a positive attitude for learning.
- Set 3: Recruiting, Supporting Faculty Expectations, and Providing Resources. This set encompassed promoting and valuing cultural diversity.
- Set 4: Self-Reflecting, Engaging Clinical Teaching Methods, and Engaging Classroom Teaching Methods. This set encompassed enhancing meaning in learning activities, as well as establishing an engaging and challenging learning environment.
The survey was peer reviewed by two nationally recognized faculty, including experts in nursing education and measurement. The survey items of the four sets were reviewed by two nationally recognized content experts in CSINE. The final survey was pilot tested by three faculty prior to the study to assure clarity.
To assist in reflecting on the use of the strategies in their own teaching, participants were asked to agree or disagree to the statement, “I use these strategies on a regular basis as I plan, teach, and interact with students.” They also were asked to provide an example of how they had used one of the strategies in their teaching, challenges encountered in implementing the strategies, and any benefits or outcomes derived from implementing the strategies.
Participants also were asked to describe what education they had received on using the teaching strategies, their educational preparation for providing CSINE, and what additional education they would like about teaching culturally diverse nursing students. Two final questions allowed participants to share their final thoughts and best tips about teaching culturally diverse nursing students and promoting CSINE. Follow-up interviews were completed using semistructured interview prompts. These prompts were finalized following data collection and survey analysis, adding depth and detail to the survey findings.
Data Collection and Management
Surveys were distributed during the association meeting, and an online version of the survey also was made available using Research Electronic Data Capture (REDCap™) tools hosted at the University of Kansas Medical Center (Harris et al., 2009). All of the participants chose to complete the paper version of the survey. The written responses were entered into REDCap for data management, and the responses to the open-ended questions were exported to a spreadsheet file for analysis.
Descriptive and Qualitative Analysis. The agree/disagree statements were analyzed and displayed with frequency distributions and percentages. Data immersion occurred by reading and rereading the open-ended responses. Simple content analysis started with a deductive approach to analyze responses to the open-ended questions and to review the data to discern patterns and categories as guided by Waltz, Strickland, and Lenz (2010). Several iterations occurred before grouping similar codes to establish the final categories that emerged from the data as directed by Bradshaw, Atkinson, and Doody (2017).
The purpose of the interviews was to confirm findings and add depth and detail to the survey findings; simple content analysis was used to analyze the responses. The results of the interviews were reviewed with a team member to confirm support for the findings and determine whether any new information emerged.
Rigor and Trustworthiness. Credibility was maintained by (a) ongoing reflection and scrutiny of the researcher by a team member to acknowledge and discuss any potential bias, (b) member checking throughout the interviews, and (c) triangulation of data with alternative data sources to determine support of the survey findings (Marshall & Rossman, 2016). To promote transferability and dependability, a logbook was maintained to document the process and decisions of the study and to provide a detailed audit trail. Confirmability was maintained by deriving the findings from the data and seeking alternate categories and explanations as final categories were developed (Patton, 2015).
Results and Discussion
Of the 130 ADN educators who received surveys, 101 returned a completed survey for 77.7% response rate. Almost all of the participants were white females (96%); one participant was Black/African American, one was Native American, one was Asian, and one was other. Average age of the participants was 49.8 years, and average teaching experience was 8.6 years (Table 1). Participants reported approximately 20% of the students they taught were considered diverse. Of the 105 counties in Kansas, participants lived in 43 counties, with most participants living in rural or densely settled rural counties in central Kansas. Most of the participants taught in both classroom and clinical practice environments, and many also taught in laboratory and simulation learning environments. Half of the participants (56%) described their educational preparation for teaching culturally diverse students as being moderate.
Participant Demographics (N = 101)
As the purpose of the dichotomous questions was intended to help participants self-reflect prior to answering the open-ended questions, it was not surprising to find a high percentage of agreement for the CSINE statements (Table 2). For two categories, respecting and caring, 100% of the participants agreed that they used those strategies on a regular basis. Most of the other statements ranged in agreement from 94.4% to 98.9%, with one exception. In the category of recruiting, only 67.9% of participants agreed. One participant who disagreed commented, “Our faculty are not involved in recruiting students or faculty.”
Survey Reflective Statements (N = 101)
Four categories emerged from the narrative data (open-ended questions) to describe the nurse educators' perceptions of strategies and challenges to implement CSINE. These categories included personalize approaches and support individual nursing students, consider resources (use those available and advocate for those needed), promote cultural diversity broadly, and use active teaching methods and strategies with students.
Personalize Approaches and Support Individual Nursing Students. Participants described the importance of a personalized approach with comments such as “get to know your students on an individual level, there are many differences in a cultural group” and “I work one on one with students to help them understand materials.” Teaching strategies included reviewing exams individually with students, working with students to identify specific learning barriers and styles, helping students set goals, encouraging the development of self-confidence, and being available to students. One participant commented about “empowering students to learn that they are powerful and can own their learning.” Another participant noted that “not everyone learns the same way. . . it is important to find what works for them!”
Participants identified challenges to implementing a personal approach, such as students might not want extra help, might not be motivated, or might not be willing to share their problems. Another challenge that participants encountered was “learning what barriers each individual student has.” Approaches to meeting these challenges were to recognize all students, not just culturally diverse students, have strengths and weaknesses, and to use a variety of teaching-learning activities (Jeffreys, 2014).
Use Available Resources and Advocate for Those Needed. Numerous comments described using available resources and advocating for those needed. Participants' strategies that related to resources included “textbooks and resources have great ideas to incorporate learning activities in classroom” and obtaining textbooks in the language of the students. Participants noted a variety of resources were needed, including encouraging students to use campus resources and tutoring provided by the nursing department.
Participants described challenges, with lack of time mentioned repeatedly. Other challenges included the lack of available resources, students' underutilization of the available resources, and not enough tutors (nursing specific) or clinical faculty. A lack of access to technology and the Internet for some students was also a challenge.
Related to these challenges, nurse educators can advocate for the availability of support centers for all areas of language (speaking, writing, listening, and reading), study skills workshops, computer labs, and tutoring. Research supports the use of small study groups and literacy support workshops as having an impact on student success (Ooms, Fergy, Marks-Maran, Burke, & Sheehy, 2013). Faculty education in this area is indicated.
Promote Cultural Diversity Broadly. Participants described promoting cultural diversity broadly. One participant commented, “I am a ‘diverse educator,’ I welcome the opportunity and challenges involved in teaching a culturally diverse classroom.” Another participant noted that since a majority of those attending the conference were white, “looking forward to more diversity” in educators was a future goal. Teaching strategies included being involved with recruitment of culturally diverse faculty and students to reflect the “same diversity as the community we serve.” Other strategies included achieving “cultural diversity throughout the curriculum,” seeking “clinical RNs who are from various cultures” to work with students, and not avoiding “patients in clinical setting based on need of a translator.”
The participants described challenges in promoting cultural diversity broadly. One of the challenges identified was bias; one participant noted having “experienced expressions of racial bias and prejudice” from others. Some participants noted that they need to remove their “own bias/slang when teaching” and that some students “struggle to admit potential bias they may have.” Another challenge was that a variety of backgrounds may result in difficulty in coming together in some situations. A lack of staff diversity for clinical placement also was another challenge identified.
Related to these findings, nurse educators need to challenge unintentional and intentional bias in themselves and help students to do the same (National League for Nursing, 2016, 2018b). This includes not only seeking self-awareness, but also reviewing text and images on websites, as well as syllabi and evaluation materials for evidence of bias (Billings, 2008). Addressing the need for unity when multiple backgrounds are present requires a commitment to develop safe, civil, and collegial learning environments (National League for Nursing, 2018c). A beginning approach to the lack of diversity in the clinical placement setting may be addressed by having students research and give presentations about other cultures.
Use Active Teaching Methods and Strategies With Students. Participants described various active teaching strategies relevant to CSINE in the classroom, laboratory/simulation, and clinical learning environments. One participant noted that while teaching, it was important to “show cultural interactions through meetings with students and patients.” Sample implementation strategies included allowing students to talk about their culture in class and having a diversity day with students being divided into groups and working throughout the semester on their assigned cultural group. Other strategies were to use assignments that included cultural perspectives, such as case studies, simulations, and readings.
Participants identified challenges to implementing these strategies. Several participants commented on challenges in the online environment and noted that “not all students enjoy or are successful with online presentations.” Other challenges were “rude, disrespectful patients [toward culturally diverse nursing students]” and the difference of “how these [strategies] are shown/modeled in classroom versus clinical practice.” Literature indicates that nurses regularly experience incivility from patients and families that may result in stress and that managers should help nurses anticipate and cope with such incivility (Campana & Hammoud, 2015). Nurse educators also can help students anticipate and cope with incivility in the clinical setting and use discrepancies between classroom and clinical practice as teaching opportunities.
Additional Survey Questions on CSINE
The survey included additional questions that asked participants about anticipated outcomes of CSINE and their own educational needs regarding CSINE. Categories identified included benefits and outcomes, further education needs, and follow-up interview findings.
Benefits and Outcomes. Select benefits and outcomes of implementing CSINE were described with comments such as “better relationships and support with the students,” “it helps me learn as well,” and “improves critical thinking.” Participants described that both faculty and students benefited and that it “makes teaching and learning easier.” Many of the benefits identified were specific to students' improved knowledge, behaviors and skills, and attitudes. Participants hoped implementation of CSINE would result in increased enrollment of culturally diverse students and improved retention of nursing students throughout the program, resulting in “more culturally competent students and future nurses.” The adoption of holistic admission processes may help increase the diversity of students accepted into a nursing program (Glazer et al., 2016).
Further Educational Needs. Participants described a need for gaining additional education regarding CSINE. They indicated that online continuing education, webinars, and workshops would be helpful formats to receive such education. Participants noted it is the responsibility of nurse educators to promote cultural awareness; educators need to know that it is an “ongoing learning process,” and as one participant noted, “Don't be afraid. Just do it!” Topics identified for additional education included: specific cultures, including those in the community; population health; promotion of cultural sensitivity; how to include CSINE throughout the curriculum; use of relevant nursing theories; and how to help students understand the importance of cultural sensitivity. Continuing education methods have been effective in improving educators' awareness of the diverse academic needs of diverse students (Beard, 2016).
Follow-Up Interview Findings. Three survey participants who concurred with the findings from the survey data were interviewed. One participant agreed that “these findings concur with what we are seeing in Kansas.” When discussing the topics suggested for gaining needed education about CSINE, another participant noted that the topics listed “pretty much hits it.” Another participant had received education about cultural diversity but noted that “it wasn't specific for teaching” diverse students.
Participants provided additional insights regarding the four categories that emerged from the data:
- Use personalized approaches: “You have to keep encouraging them and building them up so they know they have the confidence that they can do this [nursing school],” and “It is super important to know what to do to encourage the student.”
- Consider resources: “Helpful that textbook highlights specific cultural considerations,” and “Nursing is…a specialty; unless you are a nurse, it is difficult to tutor in those topics.”
- Promote cultural diversity broadly: “As an educator…it is our job to enable or promote cultural diversity,” and “Some of the older generation made it quite clear they didn't care for them [darker skinned students]…. It was difficult…kind of eye opening.”
- Use active teaching strategies: Participants described a cultural diversity day, which is a “health care research presentation on a particular day”; “The need for modeling professional behavior was stressed, even when students demonstrated incivility toward others”; and “As students' stress level goes up, they tend to turn on each other…. It can certainly affect the staff…. We need to make sure that we are still modeling professional behavior.”
This study explored ADN educators' perceptions on providing CSINE and provides a picture of what it is like to teach culturally diverse nursing students in the midwestern United States. This study highlighted some of the challenges nurse educators face, especially in rural communities. It is important to recognize that students learn in different ways and that a variety of learning strategies should be used to personalize the teaching-learning relationship. While nurse educators need to be aware of available resources, it is important to recognize that resources may not always be easily available. Further education is indicated to help educators be aware of needed resources and know how to access these in their academic and extended communities.
When promoting cultural diversity broadly, being aware of bias present in one's self, other educators, students, and the curriculum is vital. A challenge described broadly by the participants was the incivility of patients in the clinical learning environment. Experiences with patients being rude and uncivil, especially toward culturally diverse nursing students, were described. Although previous nursing literature has discussed the issue of incivility among faculty, students, and health care staff and the effect on patient outcomes (Kerber, Woith, Jenkins, & Schafer Astroth, 2015; National League for Nursing, 2018b), the issue of the effect of uncivil patients on students needs to be addressed further. Additional work also is indicated to bridge CSINE from the classroom to the clinical learning environment.
This study reinforces the importance of using active learning strategies in a variety of learning environments. For example, in a meta-analysis of 225 studies, Freeman et al. (2014) found that student performance on exams increased with active learning strategies versus traditional lecturing and that the increase in scores was reflected across all class sizes. The participants in this study used many different active learning strategies and described select benefits they had experienced using those strategies.
Implications for Education and Practice Environments
Although participant responses indicated high percentages of using CSINE practices, ongoing concerns and challenges related to CSINE still exist. The results from this study could be used to offer guidance to nurse educators in both academic and practice environments about implementing CSINE. Examples include:
- Personalize approaches: knowing the students individually, helping the students identify their own learning issues, and giving time line feedback.
- Consider resources: using a variety of textbook and technology resources, using tutoring, knowing what resources are available, and advocating for additional student resources.
- Promote cultural diversity broadly: having culturally diverse students and faculty, integrating cultural competence throughout the curriculum, setting the expectations for mutual respect in all interactions, recognizing potential bias, and preparing students for potential incivility.
- Use active teaching methods and strategies: using a variety of active strategies in a variety of learning environments and recognizing some students may be unfamiliar with active strategies.
As CSINE is implemented in both the academic and practice environments, nurse educators need to remember it is their responsibility to promote cultural awareness and implement CSINE. Some of the general benefits that participants identified in this study will be observed in the academic environment, whereas other benefits may not be observed until after students graduate and enter the practice environment. Ongoing education on CSINE practices is indicated for all.
Implications for Research
More work is needed on how best to empower faculty to use CSINE strategies. Further research is needed on (a) determining the most effective way for nurse educators in academic and practice institutions to learn about CSINE, (b) exploring specific outcomes of CSINE, including possible relationships to the implementation of active teaching strategies, and (c) developing teaching tools to assist with implementation of CSINE. In addition, further research is indicated to explore the challenges of incivility from patients to students, particularly diverse students.
The participants for this study were all ADN educators from community colleges in one state, which may limit the general-izability of the study findings. The ADN educators who chose not to participate may be different from those who chose to participate, which may contribute to sample bias. Replicating this study in other locations and with faculty teaching in baccalaureate and advanced degree programs would provide additional information.
The findings of this study assist in better understanding nurse educators' perspectives on implementing CSINE with diverse nursing students. The findings, while supporting Dewald's work (2012), extend her descriptors and provide four categories of information for faculty to consider. Results also provide information for further naming outcomes of CSINE and emphasize educators' needs for further education. The findings indicate many nurse educators are implementing CSINE, yet challenges remain. Based on the findings, guidance can be provided to nurse educators in both the academic and practice setting on how to best implement CSINE and consider approaches to overcome challenges. The ultimate care goal is for diverse students being recruited, retained, and prepared to provide safe and effective patient care. Guiding and supporting nurse educators in implementing CSINE can support this goal.
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Participant Demographics (N = 101)
| Mean (SD)||49.8 (11.8)|
| Median (range)||51 (24 to 71)|
|Length of time teachinga (y)|
| Mean (SD)||8.6 (8.7)|
| Median (range)||7 (0 to 36)|
|Percentage of students diverseb|
| Mean (SD)||20.6 (20.9)|
| Median (range)||10 (0 to 80)|
|Gender, n (%)|
| Male||5 (5)|
| Female||96 (95)|
|County of residence by population density,an (%)|
| Frontier (< 6 people per square mile)||8 (8)|
| Rural (6 to 19.9 people per square mile)||20 (20)|
| Densely-settled rural (20 to 39.9 people per square mile)||33 (33)|
| Semi-urban (40 to 149.9 people per square mile)||21 (21)|
| Urban (≥150 people per square mile)||18 (18)|
Survey Reflective Statements (N = 101)
|Variable||Agree, n (%)||Disagree, n (%)|
|Set 1: Modeling, Respecting, Communicating, and Caringa|
| Modeling||96 (97)||3 (3)|
| Respecting||100 (100)||0 (0)|
| Communicating||97 (97)||3 (3)|
| Caring||99 (100)||0 (0)|
|Set 2: Supporting, Personalizing, and Empoweringb|
| Personalizing||92 (96.8)||3 (3.2)|
| Supporting||92 (97.9)||2 (2.1)|
| Empowering||93 (98.9)||1 (1.1)|
|Set 3: Recruiting, Supporting Faculty Expectations, and Providing Resourcesc|
| Recruiting||57 (67.9)||27 (32.1)|
| Supporting Faculty Expectations||84 (95.5)||4 (4.5)|
| Using Resources||85 (95.5)||4 (4.5)|
|Set 4: Self-Reflecting, Engaging Clinical Teaching Methods, and|
|Engaging Classroom Teaching Methodsc|
| Self-Reflecting||86 (95.6)||4 (4.4)|
| Engaging Clinical Teaching Methods||85 (94.4)||5 (5.6)|
| Engaging Classroom Teaching Methods||86 (96.6)||3 (3.4)|