National Review of Nursing Education
Multicultural Nursing Education
Executive Summary
The project Nursing Education in Multicultural Context aimed to explore assumptions and concepts about multicultural health within the context of Australian nursing education. It also aimed to map the ways in which current nursing education addresses multicultural health, with a view to recommending strategies for enhancing cultural competence in nursing.
A systematic, qualitative approach was used to explore the meanings and implications of culture and diversity among key stakeholders in Australian nursing education. Thirty-four universities and Colleges offering undergraduate and postgraduate nursing education were surveyed to determine the breadth of approaches to the multicultural context of nursing education. Twenty-seven responses were received to the survey (79 per cent response rate) and in-depth interviews were conducted with spokespersons from seven universities in five states across Australia. Focus groups were held with recent graduates of nursing programs in New South Wales to determine a perspective on the translation of multicultural nursing education into the practice setting.
Themes arising from the responses were considered within the current policy frameworks of State and Territory Nurses Registration Boards, the Australian Nursing Council and the professional nursing Colleges. Current educational approaches offered to undergraduate and postgraduate nursing students are discussed within the framework of international literature.
The spectrum of responses ranged from a uni-dimensional view with emphasis on language and ethnicity to one that attempted to interweave culture and diversity into all units of study, including practicum. Cultivation of generic competencies associated with care and support of people from diverse backgrounds is evident in nursing curricula. Curriculum content with regard to both Indigenous health and the health needs of other culturally and linguistically diverse groups remains narrowly focussed in addressing the wider issues of public and primary health care. In a practical sense, the capacity of individuals or organisations to engage with others (community, other disciplines, consumers) in the conception or teaching of culture appears to be determined mainly by geographical or physical exposure to local levels of diversity. There is willingness among many Australian nursing schools to regard diversity as a positive and productive opportunity, and now there is a need for leadership to provide the national agenda for a culturally competent nursing education.
The peak professional nursing organisations provide some guidance, but there is no link with the registering bodies In addition, the requirements for cultural competency in nursing and interpretation are left largely to the discretion of the academic body or institution. There is some investment in recruiting or retaining the overseas-born or overseas-qualified nurses to Australian nursing. However, recruitment efforts largely target those nurses who have been educated in a Western system and who are recruited for their capacity to fit rapidly into the Anglo-Celtic nursing workforce, rather than for their diversity as a dividend to enrich the system.
The issues that emerge from these responses by the schools of nursing are:
- Agreement among stakeholders (including academic staff, clinical workforce, and peak professional organizations) regarding the need for a framework for nursing education that builds upon foundations of multiculturalism and diversity
- The impact of education and curriculum on the personal and professional construction of nursing practice in a diverse nation
- The role of reflection and life-long learning in increasing awareness of the social, political and economic contexts of culture and health, and developing culturally competent care
- Ensuring that the representation of culture at the curriculum and practice level is appropriate to the community
- The need for partnership between nursing academics, educators and colleagues in the workplace
- Systematic investigation into the cultural needs of students, staff, patients or clients
- Investment in the recruitment and retention of both Indigenous nurses and nurses from other cultures
- Attention to arrangements for overseas-qualified nurses seeking work in Australia
- Continuing efforts to engage with other disciplines or communities (including medicine, public health, allied health) in multicultural research and practice
These issues are too important to be left to chance. There are unanswered questions about the fundamentals of culturally competent nursing education in Australia. While there are specific examples of innovation and leadership in particular settings, more needs to be done to evaluate the impact of education on cultural competence, and to ensure that nurse education mirrors the diversity of the Australian population and nursing workforce. Communities were not consulted, and we did not check how communities are involved in nursing school development. There is a need for consultation with communities in the future development of this agenda
It is possible to identify three main streams under which further investigation could enhance cultural competence in nursing:
- Attracting more students and staff from culturally diverse backgrounds;
- Developing a learning framework that teaches skills in self-awareness, questioning and a commitment to lifelong learning;
- Provide a clear and consistent identification of what is required of nurses in terms of cultural competence or safety from governing bodies, faculties, workplaces, other disciplines and clients/patients.
The diverse approaches to culture within nurse education (as witnessed by the scope of this investigation) can meet the changing needs and demands of the nursing labour force, when a fundamental level of understanding or agreement on what is required of nurses in the cultural context has been reached. In addition, indicators of the future delivery of healthcare show that more of nursing work is likely to occur outside the acute hospital setting, yet much of nursing education remains directed towards this somewhat narrow focus. A commitment to further investigation and research aimed at broadening both the content and context of culture is necessary at all levels of nursing education.
Apart from generic capabilities which should underpin all health care workers, specific capabilities are needed by specialists, for example, in aged care nursing, mental health nursing, and those engaged in midwifery. Such issues have not been considered in any detail in this report.
The findings bear comparison with the international standards documented in the literature review. In some ways, what is happening in Australia reflects thinking in nursing education worldwide, but there are particular cultural and contextual issues facing nursing education in Australia.
Acknowledgements
Rosemary Snodgrass and Donna Waters carried out technical and background research work, and assisted in writing, in particular, the findings of the survey. Their substantial contribution is gratefully acknowledged.
Reta Creegan acted as Chair of the Reference Group, and brought considerable authority to the task. All the members of the Reference Group contributed their expertise as researchers and educators in nursing and in other fields.
We thank the Deans of Nursing and their staff who willingly responded with information about the cultural context of nursing education at their institutions, and those who participated in focus group discussions.
Reference Group
Professor Lydia Bennett, Director, Urban Health Nursing Research Unit, Sydney Hospital and Sydney Eye Hospital (South Eastern Sydney Area Health Service), and Department of Family and Community Nursing, The University of Sydney
Associate Professor Diane Brown, Acting Dean, Faculty of Nursing, Midwifery and Health, Associate Dean, Teaching and Learning, University of Technology, Sydney
Professor Lynn Chenoweth, Director, Health & Ageing Research Unit, South Eastern Sydney Area Health Service, Professor, Aged & Extended Care Nursing, University of Technology, Sydney
Ms Reta Creegan, Visiting Professor, Centre of Health Services Management, University of Technology, Sydney
Professor Jackie Crisp, Professor of Child and Adolescent Nursing, Sydney Children's Hospital, South East Health and the Faculty of Nursing, Midwifery and Health at the University of Technology Sydney, Conjoint Professor, Faculty of Medicine, University of New South Wales
Professor Doug Elliott, Professor of Nursing (Critical Care), Prince of Wales Hospital and Department of Clinical Nursing, The University of Sydney
Ms Sue Hanson, Director, Nursing Education & Research, South Eastern Sydney Area Health Service, University of Technology, Sydney
Professor Arie Rotem, Director, Centre for International and Multicultural Health, University of New South Wales
Dr Anna Whelan, Senior Lecturer/MHA Academic Co-ordinator, Graduate Management Program Faculty of Medicine, University of New South Wales, Sydney
Professor Edward White, Area Professorial Mental Health Nursing Unit, South East Sydney Area Health Service, St George Hospital, Kogarah, New South Wales and University of Technology, Sydney.
Definitions/Glossary:
Cultural competence
A dynamic process of framing assumptions, knowledge and meanings from a culture other than one’s own .
Care that is sensitive to issues related to culture, race and gender and sexual orientation … It is also care that is provided within the cultural context of the client (American Academy of Nursing (AAN) Expert Panel Report, 1992, p.278).
Cultural safety (kawa whakaruruhua)
The effective nursing of a person/family from another culture by a nurse who has undertaken a process of reflection on his/her own cultural identity and recognises the impact of the nurse’s culture on his/her own nursing practice (Nursing Council of New Zealand 1996 in Spence D, Journal of Transcultural Nursing 2001;12(2):100-106).
Multiculturalism and diversity
The term multiculturalism summarises the way we address the challenges and opportunities of our cultural diversity. It is a term which recognises and celebrates Australia’s cultural diversity. It accepts and respects the right of all Australians to express and share their individual cultural heritage within an overriding commitment to Australia and the basic structures and values of Australian democracy. It also refers specifically to the strategies, policies and programs that are designed to (a) make our administrative, social and economic structure more responsive… (b) promote social harmony among the different groups in our society; and (c) optimise the benefits of our cultural diversity for all Australians .(Commonwealth of Australia 1999).
Transcultural Nursing
An area of nursing which focuses upon the comparative study and analysis of different cultures and sub-cultures with respect to nursing and health-illness practices, beliefs and values, with the goal of generating scientific and humanistic knowledge and of using this knowledge to provide culture specific and culture universal nursing care practices .(Leininger 1998).
Preamble
1.1 National Review of Nursing Education
The National Review of Nursing Education conducted by the Department of Education, Training and Youth Affairs (DETYA) aims to determine how the education currently offered to nurses through universities and Technical and Further Education Institutions is meeting the needs of a changing labour market. The review is timely, occurring against a background of nursing shortages and widespread dissatisfaction with pay and conditions and a recognition of the highly complex set of factors affecting recruitment and retention within the nursing profession.
The terms of reference for the review outline a strategy for examining a broad range of issues from the perspective of both the health industry and education sectors. The framework seeks to make recommendations on these issues with reference to the effectiveness of current arrangements for the education and training of nurses, factors within the labour market that affect the employment of nurses, the choice of nursing as an occupation and the key factors governing supply and demand for nursing education .(Department of Education Training and Youth Affairs 2001).
The National Review has commissioned research papers and literature reviews on several specific issues including enrolled nurses; job turnover and growth in nursing occupations; knowledge and skills required by rural nurses to meet the challenges of the changing workforce in the 21st century; mental health nursing; models of nursing education and training; multicultural nursing education; nursing career pathway; nursing skills and knowledge requirements in the new millennium; recruitment, retention, education, knowledge and training of nurses with an aged care focus; review of Australian midwifery education; review of nurse regulations, standards for nursing care and the relationship between skill mix and patient outcomes; scoping nurse education and practice; student expectations of nursing education and; the scope of nursing in Australia: a snapshot of the challenges and skills needed. This report outlines findings from the multicultural nursing education project.
1.2 Context of the consultation
Nursing Education in Multicultural Context is the only commissioned project addressing the social and cultural context of nursing education. The Multicultural Health Program (MHP), Centre for International and Multicultural Health, at the University of New South Wales was commissioned to undertake the project.
The MHP is positioned amongst a cluster of innovations in the Faculty aiming to lead a systemic change in the quality of health care. The MHP is located within the School of Public Health and Community Medicine, and the Centre for International and Multicultural Health of the Faculty of Medicine. The head of the MHP is Maurice Eisenbruch, Professor of Multicultural Health.
The charter of the MHP includes championing a community based multidisciplinary research agenda in multicultural and diversity health across the spectrum of health professions, in urban and rural areas of New South Wales. The MHP develops postgraduate courses in multicultural health and cultural diversity in the context of population and public health, and offers professional training and continuing education. The interdisciplinary interests of the MHP embrace medicine, psychiatry, psychology, public health, nursing, anthropology, and sociology. The MHP is therefore in a unique position to conduct this review of Nursing Education in Multicultural Context.
The project has progressed with specific representation and specialist advice from a reference group convened for the project and representing the interests of various areas of nursing, management and education.
1.3 Scope of the project
The scope of the project was to determine assumptions and concepts about nursing education within the context of multicultural health and the ways in which nursing education addresses (or fails to address) multicultural health. While focusing on the ethnic and linguistic diversity of Australian society, it is recognised that the context of multicultural health includes many other dimensions of diversity. Aboriginality was not included in the brief, but is clearly of such importance that it has been included as far as possible. Community perceptions are also clearly of great importance. These were not documented in the project due to the amount of time required to carry out effective community consultation. The lack of this information is recognised as a deficiency of the present report.
Even though every effort was made to engage every appropriate group in the nursing educational sector, there are limitations to be noted in terms of representation. Within the short time frame, some institutions did not respond. There was a variability in the depth and breadth of responses. The respondents (from Deans to lecturers) varied in the extent to which they were able to provide a detailed account of the incorporation of multicultural education in represented their institutions.
The reference group was chosen as uniquely positioned a mixture of clinical and academic members of the nursing profession. Members were drawn from three NSW metropolitan universities. The group helped to position the research across generic diversity dimension, and nursing other health disciplines including medicine and public health. The reference group provided a sounding board to ensure the appropriate nursing perspective, providing a useful complement to the multicultural focus of the investigator. The group helped to position the research against more generic interests in diversity and nursing and in relation to the interests of other health disciplines including medicine and public health.
This study has demonstrated a widespread commitment and acknowledgement of the need for nursing to be culturally competent. What also has to be acknowledged from the analysis of the data generated by this study is the great diversity between nursing faculties in thinking about this the framework used by the respondents is nursing, not diversity and multiculturalism.
The diversity issues facing nursing in Australia are similar to those faced by medicine, public health and allied health professions. The Multicultural Health Program at University of New South Wales is developing benchmarks for cultural competence in selection, learning activity designs, and assessment of undergraduate medical students, and it is hoped that parallel efforts in nursing can be of mutual benefit. Broad capabilities in cultural competence can then be interpreted as competency statements for each professional group within health, medical, nursing and allied health.
This study highlights the need for collaborative work with other academics in multicultural health to establish core cultural competencies in nursing practice. These cultural competencies can then inform the development of educational principles and practices, curriculum, recruitment policy and practices, staff development, and every other aspect of nursing education and clinical nursing practice. Despite the gains in defining cultural competencies internationally, there is at this stage no clearly articulated set of competencies addressing cultural aspects of nursing practice in the Australian context. Further work will be needed. A proposed agenda is to establish a core set of capabilities that will secure cultural safety within Australian health care services.
There are some notable limitations of the present report. The project method was specifically developed to provide a snapshot of the multicultural context of Australian nursing education within a three-month timeframe. Initially, this was through a survey to the Deans of Nursing Faculties and Heads of Colleges offering undergraduate and postgraduate nursing education. The survey required a reply within two weeks of receipt and in some instances, was referred to other members of faculty to complete. The project team is therefore not able to comment upon whether the actual survey respondents were the most appropriate to answer questions on the multicultural aspects of nursing education within their Faculty or College.
It is also to be noted that this report focuses on Registered Nurses, and that Enrolled Nurse education is not considered. The Enrolled Nurse program has traditionally been a stepping stone into the BN programs. This may have implications for the consideration of alternative pathways in nurse education. At this point in Australian nursing, this is a stepping stone for a range of culturally and linguistically diverse backgrounds including people and for Indigenous peoples. The curriculum content and education practices of these courses were not examined in this study.
Identification of the gaps, inconsistencies or problems by those within the higher education sector and those representing other peak professional nursing groups will provide a means of proposing recommendations upon which to base strategies for enhancing cultural competence in nursing.
Any comments or queries should be sent to: highered@dest.gov.au
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