Implementing the multicultural education perspective into the nursing education curriculum.

Nurse educators are faced with the challenge of implementing educational programs that value the diversity of students and that positively portray this diversity at the same time meeting the overall goals of the institutions. The literature has shown that with the implementation of this concept, the curriculum and instruction will be changed to produce an awareness, acceptance, and affirmation of cultural diversity. This article was written to provide nurse educators with strategies for implementing the multicultural concept into their nursing programs. An outline of essential knowledge, a guideline for critiquing a nursing education program, theory, justification for the approach will be presented.

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Educational institutions play a major role in shaping the attitudes and beliefs of the youth in the nation. The overall goal of these institutions is to prepare each generation to assume the obligations and responsibilities of a productive citizen. Today's school population represents a multicultural group. These people come from different ethnic backgrounds, classes, religions, and native languages. Educators are, therefore, faced with the challenge of implementing educational programs that values this diversity and that positively portray that diversity at the same time meeting the overall goals of their institutions.

Probably the most significant change in higher education during the past several decades has been the dramatic change in the composition of college students (Levine & Cureton, 1998). A recent survey by the U.S. Department of Education (1996) indicated that fewer than 16% of undergraduates conform to the conventional image of a full time student, 19 to 22 years old, and living on campus. In addition, these significant changes in student demographics have been mirrored by changes that are occurring in the broader culture. For example, W. C. Sue and D. Sue (1999) reported that more than one third of the current American populations consist of ethnic minorities, and projections indicate that the United States will have a majority minority culture sometime between 2003 and 2005.

The dramatic changes in the composition of college students should dictate a significant change in how universities/colleges and schools &nursing approach higher education. Traditionally, education programs have been guided by the principles of middle-class white segment of our society and have been aimed at helping prospective students to function effectively within that group. These institutions must be willing to explore and to implement the multicultural education perspective into their programs. Santrock (2001) defines the multicultural education as "education that values diversity and includes the perspectives of a variety of cultural groups on a regular basis" (p. 171). However, institutions have been reluctant in implementing this approach to education. Wuest (1992) identified two major explanations for this reluctancy to move more aggressively in implementing the multicultural approach to nursing education from the literature. She deduced the following reasons: (1) nurse educators often lack the preparation and knowledge base required to include theory and experience in this field, and (2) the school's location has an influence on the opportunity to practice transcultural nursing and to see it in operation by experience nurses.

In facilitating the progress of society from one of cultural singularism to one of cultural pluralism, administrators and faculty must provide leadership of individuals commitment to a social system where individual worth and dignity are fundamental tenants; thus, requiring nursing school administrators to design their total educational process and educational content to reflect a commitment to cultural pluralism. The task of achieving this goal is difficult, but not impossible. The challenge lies in the attitudes of" the people toward the value of culturally diverse society. As a result, cultural differences will be treated as differences rather than deficiencies.

Purpose

In general, the need for our educational system to adopt the multicultural approach is not a new concept. It refers to the actualization of cultural pluralism in the schools (Heward & Orlansky, 1992). With the implementation of the multicultural concept, the curriculum and instruction are changed to produce an awareness, acceptance, and affirmation of cultural diversity (Grant & Sleeter, 1989). Additional benefits of the multicultural education approach were identified by Banks (1989), a leading developer and advocate of the multicultural education program. Banks presented the following major goals of the approach:

1. To increase the academic achievement of all students.

2. To help all students develop more positive attitudes toward different cultural, racial, ethnic, and religious groups.

3. To help students from victimized groups develop confidence in their ability to succeed academically and to influence societal institutions.

4. To help all students learn to consider the perspectives of other groups. (pp. 2-6)

Justification

Excluding the descendents of the native-born American Indians, Eskimos, and Hawaiians, every American is a descendent of immigrants. Obviously, it would be a misconception to hypothesize that all Americans are molded to the same pattern. The American population represents a wide range of ethnic and racial groups, backgrounds, experiences, customs, and ideologies. It would seem obvious that faculty can no longer teach all students in the classroom as if they have the same needs, values and aspirations. Students have different needs and skills that must be recognized in developing educational and health care programs. These programs must reflect their differences in physical and mental abilities, age, sex, socioeconomic status, religion, language, beliefs, and ethnicity or national origins.

Also, with the advancement in transportation technology, distances between far points in the world seem closer. Vastly different cultural groups are no longer separated by oceans or mountains. As a result, there are large numbers of visitors from other countries using our country's various public and private facilities. As the nurse works in the main areas of health care, the nurse can expect to have clients from many cultures. Therefore, the nurses must become actively involved in bridging cultural gaps and increasing understanding among human beings (Hammer & Joseph, 19861).

Why Should Nurses Be Concerned About Diversity Within Their Client Population

As a member of a minority group, one is a victim to barriers of acceptance, to outright discrimination, to identification by stereotyping, and to being the victim of scapegoating (Garrison, Kingston, & Bernard, 1967). All of these factors are reflected in the person's concept of self. Consequently, the person who grows up under such conditions may be unalterably marked by such traits as lack of self-confidence, a lack of emotional security, and distrustfulness (Garrison, Kingston, & Bernard, 1967). Also, low self-esteem is indicated by conviction of inferiority, fear of social encounters, self-consciousness, sensitivity to criticism, lack of confidence, remaining in the shadows, and listening, not participating; whereas, high esteem is indicated by academic and social success, confidence and optimism. These attitudes will determine whether a group will seek health care and follow health care treatment plans. Nurses must understand how their behaviors and attitudes can affect their clients.

Researchers have found that bias possessed by teachers and children of middle and higher classes and the middle-class oriented curriculum offerings contribute to the maladjustment of children who come to school with a language, experiences, and backgrounds, that are not represented in the school's orientation of educational (Garrison et al, 1967). Consequently, these children do not find school relevant, do no like the school environment and the learning experience and eventually become dropouts. Those students who do not drop out of middle school and high school eventually come to college. They bring some of these maladjustments to the college setting.

Approximately, seventeen percent of basic baccalaureate students identify themselves as African-American, Hispanic, Asian-American, or American Indian (American Association of Colleges of Nursing [AACN], 1996). Attrition rates for minority students in nursing are between 15% and 85% and are related to academic difficulties in the classroom and insufficient numbers of faculty committed to helping students succeed (O'Neil, 1992). These students can face a number of barriers that affect their ability to be successful in college. According to Campbell and Davis (1996), the nature of these barriers may be personal, academic, or institutional. These barriers include lack of identification with the campus, low faculty commitment to student success, financial problems, and personal factors. College is for most students the last change to succeed. College faculty can play and important role in reversing this problem and facilitate the success of minority students.

First of all, the curriculum must be directed toward the personal development of the students and toward nursing students in providing them with an education that will enable them to work with clients from different backgrounds and economic status. This approach would empower the nursing students with a better attitude about themselves and others. It will also help them to have a better attitude about heir abilities to succeed in nursing and in society. Additionally, nursing students will have the knowledge and skills to help empower their clients in developing a better attitude about their own worth and potentials for happiness, peace, and health.

Next, university administrators and faculty must be willing to examine the role of faculty in promoting the success of students. Effective teachers have the greatest impact on students' success. Good (cited in Paccione, 2000, p. 980) concluded, "... some of the strongest messages teachers communicate to students are expressed through classroom behavior ... Teachers may have the best intentions in the world, but if they behave inequitably, real damage occurs" (p. 632). Hence, teachers who are able to build rapport with students have the opportunity to make a significant difference (Paccione, 2000). Paccione (2000) further stated that the one way that teachers are able to establish this rapport and make a connection with students from different races and cultures is by becoming cultural competent. To become competent one must become a cultural broker (Gay cited in Paccione, 2000).

   A cultural broker is one who thoroughly
   understands different cultural systems,
   is able to interpret cultural symbols from
   one frame of reference to another can
   mediate cultural incompatibilities, and
   knows how to build bridges or establish
   linkages across cultures that facilitate
   the instructional process. (p. 287 cited
   in Paccione, 2000, p. 980).

It takes a skillful and committed teacher to become a cultural broker for the growing population of students from different races and cultures (Paccione, 2000). This will entail the faculty being able to talk with students about their feelings and experiences as they progress through the program. Research has shown that frequency and quality of student non-classroom discussions with faculty are significantly and positively correlated with academic achievement (Cohorn & Giulliano; Pascarella; Terenzini & Pascarella cited in Boulter, 20021)) and informal student-faculty contact was associated with persistence in college (Pascarella cited in Boulter, 2002).

All faculty members regardless of cultural background can serve as a role model. Faculty can demonstrate behaviors that are consistent in illustrating cultural sensitivity to the diversity of the students in their classroom and on their campus. They guide students in thinking critically about cultural and ethnic issues, and they forestall or reduce bias, cultivate acceptance, and serve as a cultural mediators (J. A. Banks & C. A. Banks cited in Santrock, 2001). Also, faculty needs to serve as the middle person between the culture of the school and the culture of certain students, especially those who are unsuccessful academically (Diaz cited in Santrock, 2001).

Leininger has written extensively concerning why nurses should take a multicultural perspective to their education and practice. She has identified problems nurses encountered in their practice when they do not recognize cultures in working with clients. For example, Leininger (1978a) found that health professional who have little knowledge about differences in cultural values, beliefs, and practices of people have had very little impact in transcultural work. They have become frustrated and disappointed and tend to settle back to what they were accustomed to doing with their white middle-class clients and their families. Also, they experience cultural shock which Leininger (1978a) defined as "feelings of helplessness and discomfort and a state of disorientation experienced by an outsider attempting to comprehend or effectively adapt to a different cultural group because of differences in cultural beliefs" (p. 57). Additionally, she found that the closer the new roles of health providers fit the culture, the less confused and angry the people will be about a change in health practices (Leininger, 1978a).

Finally, Leininger (1978b) wrote that the undemanding of the cultural specific verbal and nonverbal forms of communication is extremely important. She observed that:

1. Local language use brings the nurse closer to the cultural groups and helps the nurse to understand both the subtle and major ideas being expressed.

2. By understanding the language expressions, the cultural secrets, taboos and general facts become known to the nurse.

3. It also helps the nurse to know specific aspects of the culture's life ways, their processes of caring, and the rationale for their care and cure activities.

The increasing diversity of the American population is requiring nurses to have a vast knowledge of the influence of culture on health. They need to read about different cultures, study ethnic art, music, movies, plays, and creative writings, attend ethnic communities and different churches, and work and interact with people from other cultural backgrounds. It is through such long-term cultural experiences and commitment that educators, students, and nurses can most effectively overcome fear and misconceptions about a particular cultural group.

What Knowledge Should Nurses Have?

To practice nursing from a multicultural perspective, nurses should have specific knowledge about the specific needs, characteristics and differences in ideas, values, customs, and experiences of people from various racial and ethnic groups. A suggested outline of the essential knowledge includes but not limited to:

1. Knowledge about biocultural variations when assessing and planning care of clients from various ethnic and racial backgrounds.

2. Knowledge of cultural views on pregnancy, childbirth, and child rearing.

3. Knowledge of cultural variations in growth and development.

4. Knowledge of culturally relevant background information related to specific diseases, such as, hypertension, diabetes, heart disease or other long-term health problems that require changes in patterns of living.

5. Knowledge of the influences of one's culture and world view on emotions and mental health.

6. Knowledge of key aspects of transcultural pain management.

7. Knowledge of cultural variation in diet.

8. Knowledge of religious variations in relationship to dying, death, bereavement, organ transplants, euthanasia, and other ethnical and moral issues.

9. Knowledge of social systems for at least the following people:

a. African-Americans

b. Hispanic-Americans

c. Asian-Americans

d. Native Americans

Guidelines for Critiquing the Nursing Education Program

Nursing education faculty and administrators should assess their existing programs for elements of the multicultural educational perspective. This assessment should begin with the mission statement. The mission statement of the university and the school of nursing need to be examined to determine whether they explicitly mention the importance of supporting cultural diversity (Agosto, 2001). For example, Agosto recommended that such a statement would be: "To challenge students to acquire knowledge and skills which will enable them to function responsibly in a diverse society" (p. 38). Once the mission statement is evaluated and worded to reflect the importance of supporting cultural diversity in education, the next steps involve planning and implementing the key elements of the multicultural educational perspective. The planning and implementation phases of the program should focus on those elements that were not identified in the assessment phase. The following suggested guideline is a modification of the work presented by White and Smith (1980) and is recommended to guide your thinking and critiquing of your program. Nursing faculty and administration should determine whether their nursing education program meets the following key elements:

1. Create an atmosphere reflecting an acceptance of and a respect for racial differences.

2. Utilize multiethnic materials to teach fundamental health care skills.

3. Focus on the similarities and differences among ethnic groups.

4. Help client to better understand themselves in light of their heritages.

5. Include a study of societal problems, racial group member experiences, such as racism, prejudice, discrimination, and exploration.

6. Include both positive and negative aspects of ethnic group's experiences.

7.Examine the diversity within each ethnic group's experience.

8. Help students develop sound knowledge, concepts, and generalizations concerning people of different heritages.

9.Utilize instructional materials, which address racism, sexism, ageism, and handicapism honestly and realistically.

10. Avoid instructional and guidance practices based on stereotyped and ethnocentric perceptions.

11. Operate a library and resource center that utilize a variety of materials on the histories, experiences, and culture of many different groups.

Since nurses will see clients when they are at their most vulnerable point, these clients do not deserve to be insulted or mistreated or inadequately cared for due to differences in background or due to the lack of knowledge the nurse has about the client's cultural practices. Hence, it is important that nurse educators cannot ignore transcultural nursing. The nurse educator and the nursing student must learn to be sensitive of cultural specific psychosocial and biological needs of clients. The multicultural education perspective will provide the knowledge and skills nurses need to make an impact in transcultural nursing care.

References

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American Association of Colleges Nursing. (1996). Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: Author.

Banks, J. A. (1989). Multicultural education: Characteristics and goals. In J. A. Banks & C. A. Banks (Eds.). Multicultural education: Issues and perspectives. Boston: Allyn & Bacon.

Boulter, L. T. (2002). Self-concept as a predictor of college freshman academic adjustment. College Student Journal, 36, 234-246. Retrieved from the Education Full Text database.

Burgess, W., & Ragland, E. C. (1983). Community health nursing: Philosophy, process, practices. Norwalk, CT: Appleton-Century-Crafts.

Campbell, A., & Davis, S. (1996). Faculty commitment: Retaining minority nursing students in majority institutions. Journal of Nursing Education, 35, 298-303.

Garrison, K. C., Kingston, A. J., & Bernard, H. W. (19673. The psychology of childhood: A survey of development and socialization. New York: Charles Scribner's Sons.

Grant, C. A., & Sleeter, C. E. (1989). Race, class, sender, exceptionality, and educational reform. In J. A. Banks & C. A. Banks. (eds.). Multicultural education: Issues and perspective. Boston: Allyn & Bacon.

Hamer, C. C., & Joseph, D. H. (1986). Basic concepts of helping: A holistic approach. Norwalk, CT: Appleton-Century-Crafts.

Heward, W. L., & Orlansky, M.D. (1992). Exceptional children: A n introductory survey of special education (4fll ed.). New York: Merrill.

Leininger, M. (1978a). Towards conceptualization of transcultural health care systems: Concepts and a model. In M. Leininger. (ed.). Transcultural nursing: Concepts, theories, and practices. New York: John Wiley & Sons.

Leininger, M. (1978b). Ethnoscience: A promising research approach to improve nursing practice. In M. Leininger. (ed.). Transcultural nursing: Concepts, theories, and practice. New York: John Wiley & Sons.

Levine, A., & Cureton, J. S. (1998). When hope and fear collide: A portrait of today's college student. San Francisco: Jossey-Bass.

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Paccione, A. V. (2000). Developing a commitment to multicultural education. Teachers College Record, 102, 980-1005. Retrieved from the Education Full Text database.

Santrock, J. W. (20013. Educational psychology. Boston: McGraw-Hill.

Sue, W. S., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd ed.). New York: John Wiley.

White, H. L., & Smith, E. (1980, February). Strategies for teaching reading with a multicultural perspective. Paper presented at the meeting of the Mississippi Reading Association, Biloxi, MS.

U.S. Department of Education. (1996). National Center for Education Statistics, Digest of education, 96-133. Washington, DC: Government Printing Office.

Wuest. J. (1992). Joining together: Students and faculty learn about transcultural nursing Journal of Nursing Education, 31, 90-92.

Hazel L. White, Associate Professor/Family Nurse Practitioner, Graduate Nursing Programs and Nurse Managed Family Health Care Center, Southern University and A. & M. College Baton Rouge.

Correspondence concerning this article should be addressed to Dr. Hazel L. White, Associate Professor, P.O. Box 11794, Southern University and A&M College, Baton Rouge, LA 70813; Email: [e-mail].