Collegian
Volume 15, Issue 4 , Pages 143-149, October 2008

Beyond barriers:

The challenge of cultural diversity for nurse academics in the Australian context

  • Vicki Parker, RN, PhD

      Affiliations

    • Clinical Nurse Consultant Research and Practice Development, Hunter New England Area Health Service, School of Nursing and Midwifery, Faculty of Health, University of Newcastle, Locked bag 1, HRMC 2305, NSW, Australia
    • Corresponding Author InformationCorresponding author. Tel.: +61 2 49855925; fax: +61 2 49214972.
    • ,
  • Margaret McMillan, RN, PhD

      Affiliations

    • Faculty of Health, University of Newcastle, NSW, Australia
    • Tel.: +61 2 49216783.

Received 16 April 2007; accepted 23 July 2008.

Article Outline

Summary 

In spite of the increasing significance of cultural diversity for nursing, some Australian nurse teachers are not well prepared for the challenges they face, nor have nursing curricula been re-conceptualized to meet the changing needs of society and more specifically nursing students.

Although numerous teaching and learning programmes for inclusion of diversity are reported in the literature, both within Australia and overseas, there appears to be little commitment to the adoption of a more fundamental change in curricula and teaching and learning practices. In particular there appears to be little attention to how teachers negotiate meaningful social dynamics within multicultural learning contexts.

This article reports on the findings of a study carried out across two Schools of Nursing in Australia. The purpose of the study was to explore why schools have been reluctant to move to more culturally diverse models of teaching and learning. This paper reports on the findings of focus groups with teachers about their experiences of teaching in the context of cultural diversity.

Study findings explore teachers’ perceptions of cultural diversity and its impact on teaching and learning nursing. Teachers reported a range of tensions arising from lack of a shared philosophical view about curricula generally, lack of consideration of diversity as a significant issue for both teachers and students, limited perceptions of community as a key driver of curricula and a reluctance to address the difficult and contentious issues arising from diversity in the classroom.

Keywords: Cultural diversity, Curriculum, Teaching, Diversity, Difference

 

The later part of the twentieth century Australia has had the largest immigration program of any country in the world relative to existing population (Kalantzis, 2001). The number of Australians not born in the country is around 23% (Australian Bureau of Statistics, 2001). Add to this the recent trends in internationalization in both nursing education and nursing workforce and it becomes increasingly difficult to conceptualize curricula that prepare nurses and nurse educators for the complex dynamic work environment they will encounter. There is no doubt that nurses will be required to care for people from diverse backgrounds and that Australian nurse teachers will be required to teach groups of students from a range of different countries and cultures.

In 2004, there were 228,555 international students enrolled in Australian Universities, 24.2% of all students (Deumert et al., 2005). When students’ understandings and learning experiences are culturally different to those which guide teaching and learning processes and curriculum content they are at risk of being disadvantaged in their learning experiences. Teachers are also challenged by conflicts and tensions that result from divergent expectations and perspectives (Omeri, Malcolm, Ahern, & Wellington, 2003).

The study reported here utilised a critical ethnographic approach and was carried out across two schools of nursing in NSW, Australia (Parker, 2006). The study sought to understand the experiences of teachers and students who teach and learn nursing in the context of culturally diverse student populations. The purpose of the study was to engender critical debate about the implications of cultural diversity for students and teachers and to identify and explore possible tensions that operate to limit culturally diverse processes and outcomes in the context of learning nursing.

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Background to the study 

The Review of Nurse Education in Australia carried out in 2002 (DEST, 2002) identified a refocusing of curricula towards the cultivation of generic competencies associated with the provision of appropriate nursing care to people from diverse backgrounds. The literature is replete with studies that examine the development of cultural competence, cultural safety, transcultural nursing and transcultural experiences of health and illness (Leininger & McFarland, 2002; Omeri, 2003; Omeri et al., 2004, Omeri et al., 2006; Ramsden, 1990, Salimbene, 1999, Spence, 2001, Spence, 2003). In Australia, a number of universities have courses on Transcultural Nursing both at under-graduate and post-graduate levels and there is strong support for developing the role of Transcultural Nurse Practitioner (DEST, 2002; Omeri, 2003). Whilst these initiatives bring culture to the fore in nursing practice, little attention has been given to the educational processes that enable students to value, integrate and test multiple perspectives and cultural understandings in their learning of nursing. There is a dearth of research that examines pedagogical processes or relationships between nursing students and teachers in the context of diverse student populations. The capacity for individuals and organizations to engage with others in the teaching and learning process appears to be mainly determined by geographical or physical exposure to varying degrees or levels of diversity (DEST, 2002).

A 2003 systematic review conducted by Omeri et al. identified the need for further research relating to the experiences of nurse teachers in culturally and linguistically diverse situations. Their work found varying degrees of research in four key focus areas, namely, planning of education, delivery of education, student support and staff support and education. However, of the 34 studies reviewed only 7 included teachers as participants and only 4 involved only nursing students or teachers. Whilst there is increasing evidence of efforts to respond to all the four key areas, there is still an urgent need to better understand the challenges facing teachers and to support them in their teaching (Omeri et al., 2003).

Much attention, within the literature, has been given to the different communication norms of students from Asian backgrounds. Traditionally they have been the largest group of students studying in Australia (DEST, 2005). Differences between Asian and Western styles of communication arise from differing social and family relationships and associated values. Other important features of Asian communication that impact on learning and class dynamics include the notion of ‘face’, a reverence and respect for teachers, differing meanings of yes and no responses and quietness (Xu & Davidhizar, 2005). Although these differences are well acknowledged in the literature, there is very little attention given to how they impact on learning and teaching nursing. Further, generalisations about Asian students fail to recognise differences across and within students from Asian countries (Baumgart & Halse, 1999; Omeri et al., 2003).

Problems reported by international students include English as a Second Language (ESL), differing learning styles, differing expectations of teachers, financial difficulty, dealing with isolation, discrimination and other intercultural issues (Deumert et al., 2005, Moon, 2003; Parker, 2006; Parker & McMillan, 2007; Sanner, Wilson, & Samson, 2002).

Although conducted in only one Australian university, a study by Kumar (2005) highlights the ways in which international students are discursively represented. This study mapped the shift of government policy relating to international students from one driven primarily by aid, to emphasis on trade and internationalization. It also examined teaching, learning and welfare practices and concluded that international students are often subjected to practices that are exclusionary and inconsiderate of students histories and their aspirations (Parker & McMillan, 2007).

Also of concern to teachers is the low numbers of graduating indigenous students. The report entitled “gettin em and keepin em” (Commonwealth Department of Health & Ageing, 2002) highlighted the difficulties confronting indigenous students entering university in Australia, suggesting that for many attending university is a cross cultural experience where academic culture may be in conflict with indigenous culture. Although many universities have components of Aboriginal health included in the curriculum and processes in place to support Aboriginal students, recruitment and retention remains low. Reasons put forward for this are the relative lack of capital, lack of family support and encouragement, poor living conditions and marginalization and racism experienced by indigenous students and registered nurses (Goold, 2001; Goold & Usher, 2006).

In rejecting the qualifying nature of the adjective “multicultural”, Ellsworth (1999) offers the noun, multiculture as a means of re-conceptualizing and resituating education within multiple and heterogeneous notions of culture. Multiculture can be used to suggest that culture is always already multiple and in the process, always in the making (Ellsworth, 1999). In this sense, multiculture both characterises and constructs learning and learning communities. Similarly, Giroux (2001) challenges teachers to look for new ways to engage history by developing “…a critical watch over the relationship between historical events and the ways in which those events are produced and recalled through the narratives in which they unfold” (p. 60). Teachers need to ensure a fair, safe and meaningful experience for all students in culturally diverse learning contexts. Ovando and McLaren (2000, pp. xviii–xix) suggest four interactive dimensions which need to be considered: “the movement towards equity, curriculum reform, the process of becoming inter-culturally competent, and the commitment to combat prejudice and discrimination, especially racism”.

A number of factors have been identified as contributing to lack of focus on multiculture in the university classroom. Funding restrictions in Australian universities have led to increased teaching workloads for academics (Way, Thomson, & Treadgold, 2005), while difficulties associated with cross cultural communication (Xu & Davidhizar, 2005) and different thinking styles (Tiwari, Avery, & Lai, 2003) pose challenges in the classroom. There are difficulties of a personal and political nature that surface when addressing difference in a culturally diverse classroom (Richardson & Carryer, 2005) and there is also a reported lack of teaching expertise as well as support and education for teachers (Ciesielka, Conway, Schmacher, & Penrose, 2005; DEST, 2002, Omeri et al., 2003; Parker, 2006; Parker & McMillan, 2007; Richardson & Carryer, 2005).

The study reported here sought to understand and report the complexities and dilemmas faced by teachers of nursing in culturally diverse learning contexts. Critical ethnography was chosen for its focus on highlighting inequities and political tensions, and its intention to make topical the practices and views of people within social relations (Anderson, 1989, Carspecken, 1996).

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Research design and process 

The aims of the study were:

1.To examine factors which influence the incorporation of cultural diversity in nursing curricula.

2.To examine teaching and learning processes and their capacity to incorporate, and construct cultural difference and give voice to culturally different perspectives.

Approval for the study was given by the Research Ethics Committees of both Universities. The study involved two phases, Phase 1 employed focus groups and interviews with academics and document review. Phase 2, drawing on the experiences of students and teachers, employed class observation, interviews and focus groups and personal reflection on my role as a researcher and teacher. This article reports on the findings of Phase 1 only.

One regional and one metropolitan university were included in the study, each with multiple campuses and students from cultural and linguistically diverse (CALD) backgrounds. Initially, Heads of Schools of Nursing were notified by e-mail about the study. Information letters and expression of interest forms were then distributed to academics by e-mail. All prospective participants received an information letter by e-mail outlining the nature and purpose of the study. A contact number enabled them to obtain further detail of the study. Thirty people responded. With the exception of five people, all participants were born in Australia. A number had lived and worked overseas.

Five focus groups were carried out with nurse academics of varying experience and levels of seniority. Each focus group was conducted by the same researcher and ran for between one and a half and two hours. These sessions were attended by 27 academics, between three and seven per session. Most were nurses, however a small number of participants were either scientists or sociologists who teach into nursing programs. Participants were asked to consider a number of questions about factors that impact on the inclusion of cultural diversity in nursing curricula generally, and to reflect upon their own experiences of teaching students from diverse cultural backgrounds. Interviews were conducted with the three people who were unable to attend a focus group.

Analysis of transcripts began with initial coding of responses to questions. This was followed by comparison of responses across groups within universities and then across them, identifying common and key ideas, opinions and arguments. Preliminary associations and connections between the various themes and other meaning constructs were then tested, working back through the transcripts looking for strong examples, permutations and contradictions (Carspecken, 1996). This iterative process was continued until textual representation of the findings was fully integrated, representative of, and firmly grounded in the participants’ experiences (Lather, 1991).

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Study findings: exploring the tensions 

Teachers reported a range of tensions arising from lack of a shared philosophical view about curricula generally and a lack of consideration of diversity as a significant issue for both teachers and students. There was a limited perception of community as a key driver of curricula and reluctance to address the difficult and contentious issues arising from diversity in the classroom.

Absence of a shared philosophical view 

Participants, in the main, felt that the most fundamental factors impacting on what gets included in any curricula are the beliefs and values of those writing and enacting the curricula.

I think you demonstrate who you are and what you believe about education and about what you think is valuable in the content of your course and I think you find cultural diversity in the objectives but rarely translated into any other part. (FG 2)

We are what we value, we make happen what we value. (FG 2)

They felt that absence of a shared view about what nursing education should represent means decisions about what should be included are made in line with externally imposed policy and strategic direction rather than on the basis of a clearly articulated philosophical position. This lack of philosophical commitment results in over-representation of scientific and practical learning compared to more humanities-oriented learning. These academics agree that learning nursing requires both, however they differ as to where they believe the emphasis should lie. Tension exists between the need to prepare nurses for work and the need for a liberal arts education.

For many teachers, the concepts of culture and cultural diversity were nebulous and abstract. And yet one reported,

There is a lack of dialogue in regard to what constitutes cultural knowledge and if and how it should be incorporated, until this happens nothing will be achieved (FG1)

Because the major structural organizers for curricula have been physiological systems or medical diagnoses related to systems, culture could always be seen as belonging to those courses that operate outside the domain of nursing. Hence, academics say there is a lack of clarity about what the concept means and lack of accepted definitions of culture, cultural diversity and difference and no parameters for their inclusion or operationalization. As a consequence, difficulties arise in relation to scope, intended outcomes and assessment.

Community as the key driver 

Academics expressed the view that curricula are and should be strongly influenced by the needs of communities. Given that Schools of Nursing provide qualified health care workers, there can be no argument with this basic premise. What is problematic, however, is the way in which notions of community are conceptualized and how they advise curriculum development. Simplistically, curricula are seen as a reflection of the community they serve.

The more diverse the community from which the students and staff come then it is more likely that cultural diversity will automatically be incorporated because it is the ‘known world’. (FG3)

Communities, however, are inherently diverse and constantly changing, albeit some more than others. In planning courses in conjunction with our service partners, it may well be that their experience, and hence conception, of community will be contained within a fairly narrow geographic and socio-demographic space. Universities, on the other hand, are increasingly required to meet the needs of communities that are culturally disparate and geographically distanced, both within Australia and overseas.

Perceptions and assumptions about students 

How teachers perceive students’ attitudes to cultural diversity impacts on if and how they are likely to address difference in the classroom. Teachers describe students’ attitudes to difference as essentially negative. There is also a sense that students have a preference for certain forms of knowledge, such as disease processes over communication and decision making, and basic nursing skills over holistic care.

Some teachers suggested that there is little initiative or curiosity taken by some students in pursuing diverse explanations and experiences of health and illness because they do not see its relevance to their own practice of nursing. Students’ concerns are, seen to be, related primarily, to their future in the workforce and being able to perform nursing skills.

They do not see that they would be better nurses if they had a better understanding of cultural difference. Their focus is on skill development and procedures. (FG1)

There is also a view that there is a strong core of racism in Australian society, and hence some of that is represented in our student population. Along with this, there is concern that a lot of students come with values that are deeply entrenched which are not respecting of others. This is seen as a difficult thing to challenge because

adults have a lifetime of conditioning, it is difficult to change them (FG3).

Perceptions about teachers 

Teachers spoke about their School, or nurse academics in general, as possessing collective characteristics. For example, they said

we do not have the history of doing that here, and we haven’t decided what we mean by culture (FG3)

Another said

We do avoid things that are in any way controversial and we certainly do not address different cultures or different religious views in any depth at all…//…we do not accept the diversity within nursing (FG2)

There is a sense that much of what we do has become unconscious behaviour, and there is a lack of reflection on our teaching practices and ways of managing on a day-to-day basis. For some, there is also

loss of motivation from banging your head up against a brick wall (FG4)

when they have tried to make changes and confronted either active or passive resistance from management or colleagues.

There is also a perceived lack of diversity amongst nurse academics. As a group,

We do not reflect the diversity present in the student population. We tend to be like-minded, having similar histories and have been exposed to similar education that has inculcated certain views about nursing and nursing education (FG2).

Generally, these values are described as reflecting a white, middle class perspective of people who have in the main not lived and worked outside Australia, and who were trained as nurses in a highly medicalized hospital-based system. There was a general consensus that this limits our ability to deal with cultural diversity in the classroom.

I am not qualified to talk about cultural diversity (FG1).

I am very embedded in Australian culture (FG3).

Many teachers attributed lack of attention to diversity to their own and others’ lack of teaching expertise. However, there was much debate about whether experts are needed to teach in the context of cultural diversity or whether everyone should be able to. Several participants felt that for learning to be meaningful, it is up to individual course coordinators to see that cultural diversity is considered and individual teachers to see that links are made.

Difference as dangerous and difficult 

For most teachers in this study, cultural diversity is seen as dangerous territory. Talking about cultural difference with students could unleash the spectre of potential conflict. The teachers suggest that avoiding conflict typifies our behaviour as nurses, and is reflected in the culture of nurse academics. Nursing, as described by participants, is conservative and monocultural, but it is also seen as culturally diverse, with some specializations such as mental health having distinctively different cultures. There is also a perception that there are oppositional cultures such as those of university- trained and hospital-trained nurses. The hegemonic culture of health care, steeped in Western medical traditions and conservative health policy, is seen to subsume all other subcultures, which are expected to fit into the prevailing model. Nursing curriculum too is seen as a reflection of the dominant health care culture.

Participants commented,

…//…nurses themselves avoid controversy and conflict, and have a culture of doing as they are told (FG2).

Amongst participants there were a range of perceptions about, and reactions to teaching in the context of diversity.

People are uncomfortable. You have to be reasonably comfortable with yourself in your values and attitudes (FG2).

One of the fundamental tensions I find is that we are modelling one set of processes and espousing another, and the students are very aware of those inconsistencies (FG1).

Teachers perceive teaching about, and in the context of, diversity as difficult, dangerous and confronting. Those who do engage with students feel personally challenged by having their own value systems questioned, their often ‘taken for granted’ assumptions challenged and it is not always a comfortable place to be

You learn things about yourself that you didn’t really want to know and your students do the same by what you impart and role model (FG2).

It can get very heated and in fact what you are doing is reinforcing those stereotypes, I mean as soon as you challenge someone to question their stereotypes what you engender is a defensive response and that person closes their mind even more (FG1).

Teachers express difficulty in dealing with culturally bound-learning expectations and behaviours. Their difficulties lie in not understanding differences in learning styles, histories, preferences and practices, particularly for international students. There is also a lack of awareness and hence attention given to difference within the Australian student population. It is felt that often students from other countries have greater cultural capital than those who have grown up in Australia in areas of socio-economic disadvantage and who may be the first person in their family to pursue a university education. With both Schools of Nursing in the study having multiple campuses, it was felt that there were recognizable differences in student populations across campuses, and yet curricula were uniform for all.

Clearly, there are differences in how teachers perceive their role and the role of professional education generally. These perceptions are linked to understandings of adult learning that either include or negate the possibility of moral learning as integral to the learning of nursing. It is also evident that some teachers are more aware of, or at least interested in, their students’ identities and histories and hence more likely to encourage them to draw on their backgrounds in class discussion.

Many participants expressed the view that, as teachers, they are either not prepared to or do not believe it is appropriate to impose views and values on students. They are challenged by the personal difficulty and discomfort of dealing with classroom discussion about issues that they do not understand themselves. One relatively new teacher commented,

no-one talks about it, so you make assumptions that you are the only one who cannot cope FG2).

Because these academics, in the main, work in isolation, they feel unsupported and manage the best way they can, in many instances by ignoring the difficult issues. In the case of cultural diversity, they feel overwhelmed by the complexity and enormity of the issue:

Its just too big, difficulty arises in trying to get the mix right (FG4).

One teacher expressed a concern shared by many, saying,

Overcoming racism, but how? You have to be able to allow legitimate criticism, that is what universities are about, as well as fostering positive relationships. It has to come from a reasoned response rather than from a stereotypical response (FG3).

Academics see their work lives as characterized by struggle. They believe they are overworked, often unsupported and stifled in their efforts to achieve better outcomes for students. Cultural diversity is complex, intense, and not recognized. The skills needed to teach effectively in the context of and about diversity were described as,

subtle and needing to be seasoned, and yet we are expected to just do it (FG2).

Curriculum development as an essentially political process 

Participants view curricula are vehicles for expression of favour and support for particular ideas, organizations and factions. Hence, political correctness is perceived as a key determinant in making curriculum decisions. In attempting to meet the needs of various lobby groups, valuing and including some things may lead to a backlash from other groups. Walking the political tightrope means that academics are cautious when it comes to change, and yet they see the university's role in society as,

…//…pushing boundaries to the point where discussion can occur (FG 2).

Within a corporate environment, the need to meet the requirements of the highest bidder is a powerful influence. Many teachers feel powerless to influence decision-making and hence comply without question. There is a view, amongst teachers, that when curricula are written and reviewed there is a strong controlling agenda of what should be included and what should not. Controlling bodies with particular influence include registering bodies, the University and also Government in a much less direct way. However, there was also a strong view among some teachers that whilst the registering bodies clearly articulate a view about what must be included, inclusion is often reflected in the documentation only at a general level and not included in teaching and learning processes.

Allowing persuasion to occur then rests on a view of curricula as comprised essentially of content, whereby decisions can be made about what stays or goes in accordance with a list of areas of study suitable for inclusion. This is how academics have described it, a list of things to be ticked off, whereas, if curricula were conceived at more a conceptual level, then content would be seen as ‘instrument’ rather than ‘outcome’.

In a similar way, universities are seen to influence curriculum through policy, strategic direction statements and universal core skills, all of which make reference to cultural diversity and cultural inclusiveness. The university's place in the international market means that curricula need to be relevant to both local and international contexts. Academics expressed their discomfort related to internationalization. They feel unprepared to develop material that has cross-cultural application and are unsure about how to reconcile difficulties with language and learner expectations.

University policy is seen by some focus group members to reflect the rhetoric of democratic inclusion, where

It dictates what constitutes difference in our curricula, like EEO more so than the presence of international students. We meet our indigenous inclusion first, then gender balances, the disabled and then whatever comes next (FG4).

Imperatives to include cultural diversity in the absence of shared understandings, clear direction and agreed upon methods often leads to tokenistic inclusion of content. Where reference is made to such outcomes as equity and access, cultural sensitivity, cultural diversity and inclusiveness it is within statements on core skills and graduate attributes and broad statements of purpose. However there is often no translation into learning processes or assessment activities.

Implications of the study 

There is a need to further explore constructions of culture that impact and arise from contexts of learning and practice, and the historically situated everyday worlds of students and teachers. In order to understand and develop learning processes that value and incorporate difference, research must work from the premise that ‘Otherness’ is central to the learning of nursing.

The difficulty of dealing with incidences of classroom racism and other forms of discrimination needs to be acknowledged and explored to reduce the discomfort of both students and teachers. Education and support for teachers will help them to overcome fears about lack of structure and dealing with conflict and racism in class. Beginning teachers need to be supported to develop the skills to critically examine the ideological nature of teachers’ work and to be critically reflective in developing their own teaching practice. There needs to be research that examines the preparation of nurse teachers, particularly in relation to teaching students from diverse cultural backgrounds. Such research needs to include the development of models and processes that have the potential to undermine and replace the dominance of medical oriented, physiological systems based approaches. Such research needs to be well planned, programmed and adequately funded as a matter of urgency.

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Conclusion 

The pressing dilemma of cultural diversity is occurring at a time when teachers are being challenged to increase their productivity and the quality of their work, in a climate of increasing accountability and bureaucratization. Clearly, there is an obligation, both implied and explicit, for teachers to engage with cultural diversity at a socially responsible level as well as pedagogically. However, achievement of this goal is hampered by teachers being caught between the need to maintain the hegemonic ethnocentric position and structures they are used to, and in which they are imbedded, and the uncertainty of and lack of support for sustainable change. The historical unfolding of a dynamic cultural diversity poses new and often unanticipated challenges, pointing to the need for sustained focus and responsive strategies to support both students and teachers.

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PII: S1322-7696(08)00045-0

doi:10.1016/j.colegn.2008.07.001

Collegian
Volume 15, Issue 4 , Pages 143-149, October 2008

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