Cultural Diversity In Nursing Education summarize in 750 to 800-word Cultural Diversity in Nursing Education: Perils, Pitfalls, and Pearls Hedi Bednarz, M

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summarize in 750 to 800-word

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

Hedi Bednarz, MSN, ACNS-BC, CNE, Stephanie Schim, PhD, RN, PHCNS-BC, and Ardith
Doorenbos, PhD, RN
Ms. Bednarz is Clinical Instructor and Dr. Schim is Associate Professor, Wayne State University,
Detroit, Michigan; and Dr. Doorenbos is Assistant Professor, University of Washington, Seattle,
Washington

Abstract
Increasing diversity in the classroom challenges nursing educators to identify issues that
complicate teaching (perils), analyze barriers for themselves and their students (pitfalls), and select
new strategies for working with nontraditional students (pearls). This article identifies concerns
arising from attitudes and values within nursing and common approaches to diversity education,
and then discusses key issues in nursing education that relate to human nature, culture, faculty
workload, and student demographics. Finally, some strategies are proposed for increasing the
effectiveness of professional preparation with diverse students through a focus on culturally
congruent education and development of faculty cultural competence.

With expanding immigration, increasing globalization, and minority population growth,
there is a need to enrich the diversity within the nursing profession to better meet the needs
of our changing society (Barbee & Gibson, 2001). Universities, colleges, and nursing
programs specifically are beginning to focus on increasing diversity as they seek to
effectively prepare nursing students to serve diverse clients and communities. Currently,
nontraditional students are replacing traditional students in many nursing programs
nationwide (Jeffreys, 2004). The American Association of Colleges of Nursing (AACN)
estimates approximately 73% of undergraduate nursing students are now considered
nontraditional (2005). According to Jeffreys (2004), the term nontraditional refers to any
student who meets one or more of the following criteria: aged 25 or older, commutes to
school, enrolled part time, is male, is a member of an ethnic or racial minority group, speaks
English as a second or additional language, has dependent children, and holds a general
equivalency diploma (GED) or has required remedial classes. The terms nontraditional or
diverse are considered interchangeable for the purpose of describing students who differ
from the long-established patterns for traditional undergraduate nursing students. Traditional
students generally have been young unmarried women entering nursing programs as first-
time students soon after completion of their secondary education (AACN, 2005).

Expansion of diversity within the nursing student body and thereby in the nursing profession
is acknowledged as a desirable goal that promises to benefit both the practice discipline and
the people nurses serve. In recent years, there have been several efforts to support gr within
nursing educationowth in diversity. In 2002, Johnson and Johnson launched a Campaign for
Nursing’s Future (Buerhaus, Donelan, Norman, & Dittus, 2005). The campaign was

Copyright © SLACK Incorporated
Address correspondence to Hedi Bednarz, MSN, ACNS-BC, CNE, Clinical Instructor, Wayne State University, College of Nursing,
5557 Cass Avenue, Room 237, Detroit, MI 48202; ah4969@wayne.edu..

NIH Public Access
Author Manuscript
J Nurs Educ. Author manuscript; available in PMC 2010 August 13.

Published in final edited form as:
J Nurs Educ. 2010 May ; 49(5): 253–260. doi:10.3928/01484834-20100115-02.

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designed to raise public awareness of nursing as a career and to attract more individuals into
the nursing profession. Much of the emphasis of this widespread media campaign was on the
recruitment of men and underrepresented minorities. In the policy arena, the American
Nurses Association set a goal to achieve a diverse workforce and the National League for
Nursing listed changing demographics and increasing diversity as top trends to monitor
(Gooden, Porter, Gonzalez, & Mims, 2001; Heller, Oros, & Durney-Crowley, 2000).

As early as 1998, the Pew Health Professions Commission recommended “that the health
profession workforce reflects the diversity of the nation’s population” (Heller et al., 2000, p.
4). Recent government reports have highlighted the need to expand health care workforce
diversity and increase provider cultural competence to address persistent health disparities
(Fortier & Bishop, 2004; Smedley, Stith, & Nelson, 2003). The message has been embraced,
and nursing classrooms are filled with students of all ages, from every corner of the globe,
and from every walk of life.

However, achievement of the diversity goals in nursing education is not without difficulties.
As Williams and Calvillo (2002) have suggested, diversity challenges educators who are
trying to maximize learning and student success. This article identifies issues (perils),
analyzes barriers (pitfalls), and discusses strategies (pearls) that nurse educators can use to
improve the effectiveness of teaching with diverse students.

PERILS
Perils encompass issues that make teaching a diverse student body difficult. Many issues
make it difficult for nursing educators to work effectively with cohorts of diverse students.
Some of the issues derive from strong common attitudes and values that are observed within
the culture of nursing and the subculture of nursing education. One such attitude is that to
avoid unwanted discrimination, everyone should be treated the same, regardless of race,
ethnicity, country of origin, gender, age, socioeconomic status, or any other characteristic.
Another closely held value is the Golden Rule to “do unto others as you would have them do
unto you.” This value suggests students should be treated as we would want to be treated (or
as we were treated during our initial nurses’ training).

Regardless of the personal background of the nursing faculty, there are some who contend
that what Campinha-Bacote (1999) terms unconscious incompetence with regard to diversity
issues is the norm. Faculty members are generally well-intentioned people (mostly women)
who aim to be nice to everyone and who do not perceive personal problems with racism,
sexism, homophobia, or any other of the toxic “isms” that prevail in American society. The
“isms” exist, of course, but “not in me personally” or “among my colleagues” (hooks, 2003).
All of these perils, which are rooted in long-held values and traditions, create significant
obstacles to recognizing the realities among today’s nursing students and put up barriers to
student success.

Sometimes, the perils of educating a diverse student body lie in the common approaches that
have been suggested for diversity training. One such approach is the search for correct
answers to what “those people” need and want. “Those people” might be foreign-born, older
or younger, male, or part-time students, or represent any other nontraditional group in the
nursing program. Books and articles are sought to explain what “they” want and how faculty
should treat “people like them.” If the designated diversity committee is meeting, there are
ethnic potluck lunches where faculty and students can sample the deliciously strange foods
of other cultures and see people wearing traditional outfits. This often is followed by a panel
discussion about what various groups need and want. There is nothing wrong with any of
these approaches except they often fall short of generating the level of interest or insight

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necessary to identify the pitfalls that affect nontraditional students nor do they suggest any
appropriate actions to make nursing education excellent for all types of students.

PITFALLS
Pitfalls encompass the issues for diversity in nursing education.

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

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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.

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Some of the most frequently cited pitfalls and greatest frustrations for students and
faculty relate to language and communication.

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
caregivers 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

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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).

PEARLS
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.

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.

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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

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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 …

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