Nurse Education Today 34 (2014) 890–893
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Cultivating social justice learning & leadership skills: A timely endeavor for undergraduate student nurses Roberta Waite a,⁎, Stephanie Brooks b,1 a b
Drexel University, College of Nursing and Health Professions, 1505 Race Street, Bellet Bldg, 527, MS 1030, Philadelphia, PA 19102, United States Drexel University, Couple and Family Therapy Department, 1505 Race Street MS 905, Philadelphia, PA 19102, United States
a r t i c l e
i n f o
Article history: Accepted 20 February 2014 Keywords: Undergraduate nursing education Leadership Social justice
© 2014 Elsevier Ltd. All rights reserved.
Introduction Global citizenship is an integral component of nursing student education; all nurses, regardless of where they practice, will care for patients who have origins in other parts of the world (Mill et al., 2010). While the American Association of Colleges of Nursing has identified the relevance of social justice and the International Council of Nurses has denoted the significance of social responsibility in the nursing profession, demonstration of social justice within undergraduate nursing education is scarce (Tyler-Viola et al., 2009). In North America specifically, the challenge is to understand how social justice is operationalized into practice starting early in students' academic experiences. For example, the American Nurses Association (2001, 2004, & 2008) has established several pivotal documents that guide nursing practice and standards of care. It is important to note that these documents place great emphasis on the direct care of the individual with much less emphasis on the broader issues of social justice and health system reform. The message delivered via these documents supports a nurse's duty to the patient which is indicated to be his/her primary commitment (Bekemeier and Butterfield, 2005). Reimer-Kirkham and Browne (2006) stated that professional nurse's broad scope of influence is critical to addressing the sustained collective systemic injustices such as
⁎ Corresponding author. Tel.: +1 215 762 4975. E-mail addresses: [email protected] (R. Waite), [email protected] (S. Brooks). 1 Tel.: +1 215 762 6781.
http://dx.doi.org/10.1016/j.nedt.2014.02.009 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
poverty, homelessness, stigma, and racialization in order to promote effective change (Mill et al., 2010). It is unfortunate that the practice of social justice theory has been neglected in nursing education and the nursing profession (Ellis, 2013). The ever changing demographics in our society calls for increased nursing skills; therefore, students in undergraduate programs need to learn to work effectively with diverse populations and to provide professional leadership. While nurse educators have endeavored to develop students' awareness, knowledge, and sensitivity towards multiculturalism, we have yet to be effective; this represents a major challenge for addressing the needs of culturally diverse societies. Anderson et al. (2009) stated that “it is our lack of concern about the social disadvantages of ‘others’ at local, national, and global levels that leads to serious health disparities” (p.283). Beyond structural barriers that focus on providing access to healthcare (e.g., health insurance), our challenge is to ensure equitable health outcomes nationally and globally. This requires looking beyond the healthcare industry to wider societal concerns that deepen the perpetuation of inequality in health. When developing foundational understanding about the nursing profession, we must implore our nursing students to act on social change. They must understand that it is their responsibility to be knowledgeable about population health issues and social factors (e.g., world hunger, environmental pollution, lack of access to health care, violation of human rights and inequitable distribution of nursing and health care resources) that contribute disproportionately to disease and disability among populations (Bekemeier and Butterfield, 2005). These authors also reported that nurse educators cannot afford to educate nursing students using a “think small” position by focusing principally on care to individual patients with its goal to improve health only through
R. Waite, S. Brooks / Nurse Education Today 34 (2014) 890–893
incremental change. Essentially nursing educators must appeal to students to exercise leadership to improve and repair broken systems that promote injustices of health disparities and impede steps to positive health outcomes. In addition to educating undergraduate nursing students, leaders in education and the health professions must recognize that integration of social justice principles is an essential component of changing healthcare delivery systems. The determinants of population health (e.g., social, environmental, economic, political, cultural) must be addressed through advocacy, education and training, policy, and practice (Garner et al., 2009). Mill et al. (2010) stated that disparities in healthcare within and across nations demand that nursing students: (1) understand the interconnectedness between local and global health challenges, and (2) contribute to the creation and implementation of solutions to these challenges. Furthermore, there is a dearth of knowledge linking social justice and leadership models and, in particular, leadership approaches in the nursing profession. This brief innovative thought piece: (1) reflects on the interrelationship between multiculturalism, cultural competence, and social justice; (2) advances an argument for understanding the relationship between social justice and student learning; and (3) examines the need to revise nursing education, particularly the ethical mandate and professional responsibility to introduce social justice in prelicensure or preregistration nurse leadership education. This approach, cultivating social justice and leadership skills, is requisite learning for nursing students providing them with the capacity for critical thinking and advocacy skills needed for social action related to their chosen profession.
Interrelationship of Multiculturalism and Cultural Competence Promoting understanding about multiculturalism, a concept used to reflect the diversity of American culture, with its focus on attitudinal, behavioral, and cultural traits is widely accepted as a catalyst for some improvements in health disparities and health care delivery and practices (Hester, 2012). Many healthcare professions require curricula that address cultural diversity, which typically involves imparting knowledge, developing skills, and changing attitudes to support the cultural competence of practitioners. Diversity encapsulates differences among people (e.g., ability, age, ethnicity, gender identity, race, sexual orientation, social class, religion, and geographic origin). Culture becomes another layer within each diverse group, thereby requiring practitioners' commitment to a lifelong learning process. Cultural competence, “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in crosscultural situations,” is a controversial concept as it insinuates that there is an end point (Hester, 2012, p.281). Culture however is not static, simplistic, or ahistorical (Hester, 2012). In addition, health care practitioners are not experts on culture, therefore learning expands and is enriched with each encounter. Nurses are on the frontlines of many healthcare initiatives globally, resulting in opportunities for necessary critical reflection for increased self-awareness and recognition of ethnocentric views. Cultural bridging, a more contemporary concept found in the literature, speaks to increased mutuality in encounters instead of falling into stereotypical notions of other in cross-cultural exchange (Leefers and Mitchell, 2010). Therefore, individuals learn to understand concepts and values as reflected in the customary expressions of a designated culture and to demonstrate respect and include perspectives of these different stakeholders. If language and cultural support are needed, these services would be provided to enable individuals to have access to health and health promoting services and information. A cultural bridge is therefore provided for individuals and their families to obtain services; in addition, this interchange develops the individual's skills
891
(e.g., student nurse) in the services setting to support people in a culturally sensitive way. To affect substantive change, educational content promoting cultural awareness and sensitivity needs to stem from a pedagogical perspective using an action-oriented approach or social justice framework to prepare healthcare professionals (i.e., student nurses) to become change agents. Since cultural diversity is a conduit for implementing social justice, both are conceptually linked to each other; yet they have separate narratives and outcomes. A social justice doctrine provides a larger system perspective and includes ways that power and privilege contextualize and make meaning of cultural differences within dominant and local communities. Understanding the Relationship of Social Justice and Student Learning Paulo Freire (1986), a Brazilian educator and influential leader of social justice education, posits that individuals committed to social action must develop “conscientization” or critical consciousness. Critical consciousness is a “reflective wakefulness” of how power, privilege, and inequities are entrenched in our social reality, and in turn, it permeates all relationships (Freire, 1986). At the most evolved level of commitment, implementation of social justice seeks to eliminate structural inequities in society by diluting power and privilege, while promoting fairness for marginalized and underserved people. Hegtvedt (2007) stated that all individuals are treated with dignity and respect through macro- and micro-change in three areas: action (distributive justice), attitude (procedural justice), and process (interactional justice). Distributive justice reflects how equitably goods are distributed in our society (e.g., insurance for healthcare coverage), while procedural justice refers to the fairness of those mechanisms for receiving such goods (access to and value of services). Interactional justice highlights how others treat individuals during interpersonal exchanges. Social justice may appear to be a simple concept to implement; however, it is rife with complexities and paradox. Social justice stimulates culturally competent nurses to act as agents of change for the advancement of human dignity and equity. What is fair and just to some becomes controversial to others, sometimes disempowering and paralyzing communities and larger systems (e.g., government, healthcare, education). For example, access to healthcare may require institutions to develop policies, procedures, and programs with differential payment systems that would require consumers with wealth or the institution to absorb cost of services for uninsured or underinsured consumers. Conversely, best practices would require spending more time giving informed consent to patients and their families which could in turn interfere with maintaining well-timed schedules for medical staff and other patients. Given the role that nurses play within the context of community, healthcare leadership skills, competencies, and behaviors need to be developed early in their career (Garner et al., 2009). As such, nursing education programs can be an integral part of moving upstream by addressing how factors such as neighborhood conditions, working conditions, education, income and wealth, stress, and race and racism affect communities' health and health outcomes. While foundational guidelines (e.g., the American Nurses Association, 2001) require that student nurses become more conscious of the broader social causes of health issues, student nurses must first learn to view these issues with a social justice perspective and then take action to address these issues. The practice of social justice theory in nursing extends beyond its ethical tradition since nursing holds a unique place in health care and society as witnesses of both injustice and suffering — suffering that they can speak about with direct knowledge and their opportunity to motivate those suffering to take action for social justice (Ellis, 2013). Taken together, social justice can (1) serve to enlighten nurses about systematic barriers, power structures, and social determinants of health that influence the health status of their patients and (2) cultivate a
892
R. Waite, S. Brooks / Nurse Education Today 34 (2014) 890–893
political competence that can initiate political/policy action for change that can benefit patients as well as the collective other (Ellis, 2013). Social justice is an integral component of leadership development during the student's learning process which can create the potential for a strong impact on health equity. With increased emphasis on student learning and the development of a social justice perspective in nursing, the profession can be more proactive in thinking about and addressing poor health conditions in a different way. That is, educators must move student learning and the predominate way of thinking in nursing beyond the individual client to the collective society, as well as shift from tertiary (reactionary) care to primary (preventative) care (Ellis, 2013). Expanding Leadership Curricula in Nursing Education Focused programs on leadership development are sparse in undergraduate nursing education curricula (Garner et al., 2009; Hendricks et al., 2010). Yet, leadership skills are requisite for nurses at every level including those just entering the profession. Thus, preparation of prelicensure nurses must extend beyond the lens of a medical model which is task-oriented towards valuing equally the self-development of “soft skills” — skills that embrace the principles of: 1) promoting emotional intelligence; 2) recognizing leaders who can be individuals holding formal and informal positions; 3) appreciating that each student can learn to be an effective leader; 4) understanding that leaders effect growth and change while working for the common good; 5) honoring the fact that leaders require intercultural competence; 6) respecting that individuals' knowledge, skills, abilities, and ethical values guide how they lead others; 7) considering that leaders foster interprofessional learning; and 8) advocating that leaders must promote self-knowledge, equity, personal empowerment, collaboration, social responsibility, service, and social justice. For nurses, leadership for social justice is critical for conducting an examination of and putting forth solutions to concerns that have created and reproduced societal inequities that have adversely affected the health of those who receive nursing care. The competing demands in healthcare institutions (e.g., cost containment, inadequate resources, and over extended personnel) culminate and create ineffective healthcare delivery systems which in effect lead to structural inaction. This requires nurses to cultivate leadership skills in order to effectively engage in system interventions. Becoming healthcare change agents requires nurses to be nimble, self-aware, and ready to assess organizational impasses that impede quality of care and improved health outcomes. We, therefore, strongly believe that the ability to provide leadership is a fundamental nursing competency for all nurses and in particular for nurses who provide care to marginalized and underserved populations. Currently, most leadership skills are targeted to students at the graduate level and nurses seeking executive positions. Contemporary expectations of nurses (e.g., interprofessional collaboration, team leadership, and effective care for increasingly diverse patients) require development of leadership skills that can no longer be reserved for a select few. It is no longer an exclusive prerogative of the upper echelon of administrators or more senior nurses; rather, it is a quality that is now expected of nurses at every level of the profession (Hendricks et al., 2010). Educational programs must therefore re-examine their approaches to student nurse preparation implementing curricular and experiential learning to heighten and make bold steps to broaden students' learning (Garner et al., 2009). These students will be joining ranks with the largest segment of professionals in healthcare. Furthermore, they will be at the forefront of healthcare delivery with a pivotal focus on improving the health of all individuals, families, and communities. The inclusion of social justice leadership approaches in undergraduate education has the potential to impact a variety of nursing
issues positively at a global level that are interconnected to patient outcomes. This includes factors such as the level of culture specific patient care knowledge and style of leadership that is transformational at a substantive level that can effectively address threats to quality patient care among a multinational workforce (Oulton, 2006; Suliman, 2009). Promoting Social Justice in Nursing Education Social justice education, educating for a non-oppressive society, is critical to the nursing profession, nationally and internationally. Groh et al. (2011) reported that “The centrality of leadership and the promotion of social justice in the nursing profession are particularly relevant at this time (p.401).” Both of these concepts are identified as essentials of baccalaureate education for professional nursing practice (American Association of Colleges of Nursing, 2008). Integrating social justice principles into leadership models is critical to implementation. Traditional leadership models have focused on individualistic goal attainment and contractual relationships, and they lack focus on contextual variables. Cultural encounters can be a useful learning tool for cultivating nurse leadership roles (Hester, 2012). Moreover, employing a social justice leadership approach rests on the health care practitioner's ability to identify personal and professional values that both define and inform decision making, leadership styles, and strategies (Bradley et al., 2012). Providing education that develops nurse leaders with social justice competence requires at a minimum linking self-awareness, cultural diversity, contextual issues, and familiarity with systemic inequalities. A healthcare-leadership genogram is a tool that can enhance nursing students' self-awareness by exploring the intersections between their family of origin history, professional values, and experiences with conflict, power, privilege, and leadership styles (Blum, 2008; McGoldrick et al., 2008). Specifically, many couple and family therapy programs use the Cultural Genogram (Hardy and Laszloffy, 1995) and the Person of the Therapist Training model (Aponte et al., 2009) as learning tools to promote both cultural and personal self-awareness, which in turn fosters professional development. Both paradigms have components introduced in didactic courses and subsequently offer the clinical supervisor a template to help students' transfer this awareness to culturally informed clinical practice. Similarly, couple and family therapy and psychology educational programs committed to social justice offer exemplars that can be easily adapted in nursing curriculum (Ariel et al., 2010; Toporek and Vaughn, 2010). While contemporary theories and models of leadership intentionally have “contextual factors [that] set the boundaries within which leaders and followers interact and determine the constraints and demands that are placed on leaders; …leadership is embedded in context and is socially constructed” (Smith, 2009, p.43). Smith (2009) acknowledged that the current societal status quo of social benefits, such as education and health care, is shaped by an inequitable distribution of and access to power and resources within which we are undoubtedly located. Students and professional nurses are not only within this system, the system is within us; thus, it is the medium in which current professional nursing was conceived and from which our practices have evolved. Given this dynamic, we surely participate in it, “even if unintentionally—except when we take purposive action to the contrary” (Smith, 2009, p.85). Thus, not taking action is not a neutral position. When we elect to leave oppression unacknowledged, we implicitly promote inequity by aiding to obscure its reality (Smith, 2009). Toporek and Vaughn (2010) noted that no social justice training can be “learned top-down but within a shared power paradigm” between faculty and student (p.181). Faculty are not center stage; classes become less instructive and more experiential. Pedagogical approaches expand to include consciousness (e.g., sociocultural) raising linking student's personal experiences and social issues; participatory learning is increased; self-reflection is routine practice; and projects that promote students' activism and citizenship are key. While students are engaged in these challenging processes (e.g., reflection and sociocultural
R. Waite, S. Brooks / Nurse Education Today 34 (2014) 890–893
consciousness) faculty are as well. Service learning is also important where students are collaboratively with marginalized communities. A continuous process of scaffolding student experiences while concomitantly challenging them helps with student development. Creativity and purposeful change are needed to promote authentic selfawareness among students and faculty alike, as beliefs mediate knowledge, expectations, and actions. While awareness of and openness to issues of cultural sensitivity and diversity are essential qualifications for development of students' leadership capacity and efficacy, we must move towards social action. Educational leadership programs for nursing students should aim to develop (1) transformational thinkers who are both active and reflective practitioners and (2) scholars who are also directly engaged in initiatives that are emancipatory in nature. Involving nursing students in collaborative problem solving initiatives with community-based groups teaches them to find their voice and necessary skills to promote change. Partnerships with heroic community leaders provide opportunities to gain practical knowledge about activism, fairness, and justice within complex systems. This is a global crisis that requires nurse educators to re-examine the foundations of undergraduate nursing curricula and take courageous steps needed to make every nurse a courageous leader. We need to meet the needs of our 21st century leaders who are striving to be professional nurses and provide the paradigm that will generate the critical skills they will need to take on leadership challenges of the future — skills that encompass social action and social change for improved and just healthcare. References American Association of Colleges of Nursing, 2008. The essentials of Baccalaureate Education for Professional Nursing Practice. Essential IV. Retrieved from www.aacn.nche. edu/Education/pdf/BaccEssentials08.pdf. American Nurses Association, 2001. Code of Ethics for Nurses with Interpretive Statements. American Nurses Association, Washington, DC. American Nurses Association, 2004. Nursing: Scope and Standards of Practice. American Nurses Publishing, Washington, DC. Anderson, J., Rodney, P., Reimer-Kirkham, S., Browne, A., Khan, K., Lynam, J., 2009. Inequities in health and healthcare viewed through the ethical lens of critical social justice contextual knowledge for the global priorities ahead. Adv. Nurs. Sci. 32 (4), 282–294. Aponte, H.J., Powell, F.D., Brooks, S., Watson, M.F., Litzke, C., Lawless, J., Johnson, E., 2009. Training the person of the therapist in an academic setting. J. Marital. Fam. Ther. 35, 381–394. Ariel, J., Hernández-Wolfe, P., Stearns, S., 2010. Expanding Our Social Justice Practices: Advances in Theory and Training. AFTA Monograph Series, American Family Therapy Academy, Washington, DC (Winter).
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Bekemeier, B., Butterfield, P., 2005. Unreconciled inconsistencies: a critical review of the concept of social justice in 3 national nursing documents. Adv. Nurs. Sci. 28 (2), 152–162. Blum, M.E., 2008. Self-defined leadership: exploring family history to enhance future leadership. In: Harvey, M., Barbour, J. (Eds.), Building Leadership Bridges, Global Leadership: Portrait of the Past Vision for the Future. International Leadership Association, The James Mac Gregor Burns Academy of Leadership, College Park, MD. Bradley, J.M., Werth, J.L., Hastings, S.L., Pierce, T.W., 2012. A qualitative study of rural mental health practitioners regarding the potential professional consequences of social justice advocacy. Prof. Psychol. Res. Pract. 43 (4), 356–363. Ellis, S., 2013. The Existing Intersection of Social Justice and Nursing. (Bachelor's Thesis) Retrieved from http://publications.theseus.fi/bitstream/handle/10024/55352/ schuyler_ellis_thesis_final.pdf?sequence=1. Freire, P., 1986. Pedagogy of the Oppressed. Continuum, New York, NY. Garner, B.L., Metcalfe, S.E., Hallyburton, A., 2009. International collaboration: a concept model to engage nursing leaders and promote global nursing education partnerships. Nurse Educ. Pract. 9 (2), 102–108. Groh, C.J., Stallwood, L.G., Daniels, J.J., 2011. Service-learning in nursing education: its impact on leadership and social justice. Nurs. Educ. Perspect. 32 (6), 400–405. Hardy, K.V., Laszloffy, T.A., 1995. The cultural genogram: key to training culturally competent family therapists. J. Marital. Fam. Ther. 21 (3), 227–237. Hegtvedt, K.A., 2007. Theories of social justice. In: Ritzer, G. (Ed.), Blackwell Encyclopedia of Sociology. Blackwell Publishing, Malvern, MA, pp. 4432–4436. Hendricks, V., Cope, V., Harris, M., 2010. A leadership program in an undergraduate nursing course in Western Australia: building leaders in our midst. Nurse Educ. Today 30 (3), 252–257. Hester, R.J., 2012. The promise and paradox of cultural competence. HEC Forum 24 (4), 279–291. Leefers, J., Mitchell, E., 2010. Conceptual model for partnership and sustainability in global health. Public Health Nurs. 28 (1), 91–102. McGoldrick, M., Gerson, R., Petry, S., 2008. Genograms: Assessment and Intervention, Third ed. Norton, New York, NY. Mill, J., Astle, B., Ogilvie, L., Gastaldo, D., 2010. Linking global citizenship, undergraduate nursing education, and professional nursing: curricular innovation in the 21st century. Adv. Nurs. Sci. 33 (3), E1–E11. Oulton, J.A., 2006. The global nursing shortage: an overview of issues and actions. Policy Polit. Nurs. Pract. 7 (3), 345–398. Reimer-Kirkham, S., Browne, A.J., 2006. Toward a critical theoretical interpretation of social justice discourses in nursing. Adv. Nurs. Sci. 29 (4), 324–339. Smith, L., 2009. Enhancing training and practice in the context of poverty. Train. Educ. Prof. Psychol. 3 (2), 84–93. Suliman, W.A., 2009. Leadership styles a nurse managers in a multinational environment. Nurs. Adm. Q. 33 (4), 301–309. Toporek, R.L., Vaughn, S.R., 2010. Social justice in the training of professional psychologists: moving forward. Train. Educ. Prof. Psychol. 4 (3), 177–182. Tyler-Viola, L., Nicholas, P., Corless, I., Barry, D., Hoyt, P., Fitzpatrick, J., Davis, S., 2009. Social responsibility of nursing: a global perspective. Policy Polit. Nurs. Pract. 10 (2), 110–118.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Cultivating social justice learning & leadership skills: A timely endeavor for undergraduate student nurses Roberta Waite a,⁎, Stephanie Brooks b,1 a b
Drexel University, College of Nursing and Health Professions, 1505 Race Street, Bellet Bldg, 527, MS 1030, Philadelphia, PA 19102, United States Drexel University, Couple and Family Therapy Department, 1505 Race Street MS 905, Philadelphia, PA 19102, United States
a r t i c l e
i n f o
Article history: Accepted 20 February 2014 Keywords: Undergraduate nursing education Leadership Social justice
© 2014 Elsevier Ltd. All rights reserved.
Introduction Global citizenship is an integral component of nursing student education; all nurses, regardless of where they practice, will care for patients who have origins in other parts of the world (Mill et al., 2010). While the American Association of Colleges of Nursing has identified the relevance of social justice and the International Council of Nurses has denoted the significance of social responsibility in the nursing profession, demonstration of social justice within undergraduate nursing education is scarce (Tyler-Viola et al., 2009). In North America specifically, the challenge is to understand how social justice is operationalized into practice starting early in students' academic experiences. For example, the American Nurses Association (2001, 2004, & 2008) has established several pivotal documents that guide nursing practice and standards of care. It is important to note that these documents place great emphasis on the direct care of the individual with much less emphasis on the broader issues of social justice and health system reform. The message delivered via these documents supports a nurse's duty to the patient which is indicated to be his/her primary commitment (Bekemeier and Butterfield, 2005). Reimer-Kirkham and Browne (2006) stated that professional nurse's broad scope of influence is critical to addressing the sustained collective systemic injustices such as
⁎ Corresponding author. Tel.: +1 215 762 4975. E-mail addresses: [email protected] (R. Waite), [email protected] (S. Brooks). 1 Tel.: +1 215 762 6781.
http://dx.doi.org/10.1016/j.nedt.2014.02.009 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
poverty, homelessness, stigma, and racialization in order to promote effective change (Mill et al., 2010). It is unfortunate that the practice of social justice theory has been neglected in nursing education and the nursing profession (Ellis, 2013). The ever changing demographics in our society calls for increased nursing skills; therefore, students in undergraduate programs need to learn to work effectively with diverse populations and to provide professional leadership. While nurse educators have endeavored to develop students' awareness, knowledge, and sensitivity towards multiculturalism, we have yet to be effective; this represents a major challenge for addressing the needs of culturally diverse societies. Anderson et al. (2009) stated that “it is our lack of concern about the social disadvantages of ‘others’ at local, national, and global levels that leads to serious health disparities” (p.283). Beyond structural barriers that focus on providing access to healthcare (e.g., health insurance), our challenge is to ensure equitable health outcomes nationally and globally. This requires looking beyond the healthcare industry to wider societal concerns that deepen the perpetuation of inequality in health. When developing foundational understanding about the nursing profession, we must implore our nursing students to act on social change. They must understand that it is their responsibility to be knowledgeable about population health issues and social factors (e.g., world hunger, environmental pollution, lack of access to health care, violation of human rights and inequitable distribution of nursing and health care resources) that contribute disproportionately to disease and disability among populations (Bekemeier and Butterfield, 2005). These authors also reported that nurse educators cannot afford to educate nursing students using a “think small” position by focusing principally on care to individual patients with its goal to improve health only through
R. Waite, S. Brooks / Nurse Education Today 34 (2014) 890–893
incremental change. Essentially nursing educators must appeal to students to exercise leadership to improve and repair broken systems that promote injustices of health disparities and impede steps to positive health outcomes. In addition to educating undergraduate nursing students, leaders in education and the health professions must recognize that integration of social justice principles is an essential component of changing healthcare delivery systems. The determinants of population health (e.g., social, environmental, economic, political, cultural) must be addressed through advocacy, education and training, policy, and practice (Garner et al., 2009). Mill et al. (2010) stated that disparities in healthcare within and across nations demand that nursing students: (1) understand the interconnectedness between local and global health challenges, and (2) contribute to the creation and implementation of solutions to these challenges. Furthermore, there is a dearth of knowledge linking social justice and leadership models and, in particular, leadership approaches in the nursing profession. This brief innovative thought piece: (1) reflects on the interrelationship between multiculturalism, cultural competence, and social justice; (2) advances an argument for understanding the relationship between social justice and student learning; and (3) examines the need to revise nursing education, particularly the ethical mandate and professional responsibility to introduce social justice in prelicensure or preregistration nurse leadership education. This approach, cultivating social justice and leadership skills, is requisite learning for nursing students providing them with the capacity for critical thinking and advocacy skills needed for social action related to their chosen profession.
Interrelationship of Multiculturalism and Cultural Competence Promoting understanding about multiculturalism, a concept used to reflect the diversity of American culture, with its focus on attitudinal, behavioral, and cultural traits is widely accepted as a catalyst for some improvements in health disparities and health care delivery and practices (Hester, 2012). Many healthcare professions require curricula that address cultural diversity, which typically involves imparting knowledge, developing skills, and changing attitudes to support the cultural competence of practitioners. Diversity encapsulates differences among people (e.g., ability, age, ethnicity, gender identity, race, sexual orientation, social class, religion, and geographic origin). Culture becomes another layer within each diverse group, thereby requiring practitioners' commitment to a lifelong learning process. Cultural competence, “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in crosscultural situations,” is a controversial concept as it insinuates that there is an end point (Hester, 2012, p.281). Culture however is not static, simplistic, or ahistorical (Hester, 2012). In addition, health care practitioners are not experts on culture, therefore learning expands and is enriched with each encounter. Nurses are on the frontlines of many healthcare initiatives globally, resulting in opportunities for necessary critical reflection for increased self-awareness and recognition of ethnocentric views. Cultural bridging, a more contemporary concept found in the literature, speaks to increased mutuality in encounters instead of falling into stereotypical notions of other in cross-cultural exchange (Leefers and Mitchell, 2010). Therefore, individuals learn to understand concepts and values as reflected in the customary expressions of a designated culture and to demonstrate respect and include perspectives of these different stakeholders. If language and cultural support are needed, these services would be provided to enable individuals to have access to health and health promoting services and information. A cultural bridge is therefore provided for individuals and their families to obtain services; in addition, this interchange develops the individual's skills
891
(e.g., student nurse) in the services setting to support people in a culturally sensitive way. To affect substantive change, educational content promoting cultural awareness and sensitivity needs to stem from a pedagogical perspective using an action-oriented approach or social justice framework to prepare healthcare professionals (i.e., student nurses) to become change agents. Since cultural diversity is a conduit for implementing social justice, both are conceptually linked to each other; yet they have separate narratives and outcomes. A social justice doctrine provides a larger system perspective and includes ways that power and privilege contextualize and make meaning of cultural differences within dominant and local communities. Understanding the Relationship of Social Justice and Student Learning Paulo Freire (1986), a Brazilian educator and influential leader of social justice education, posits that individuals committed to social action must develop “conscientization” or critical consciousness. Critical consciousness is a “reflective wakefulness” of how power, privilege, and inequities are entrenched in our social reality, and in turn, it permeates all relationships (Freire, 1986). At the most evolved level of commitment, implementation of social justice seeks to eliminate structural inequities in society by diluting power and privilege, while promoting fairness for marginalized and underserved people. Hegtvedt (2007) stated that all individuals are treated with dignity and respect through macro- and micro-change in three areas: action (distributive justice), attitude (procedural justice), and process (interactional justice). Distributive justice reflects how equitably goods are distributed in our society (e.g., insurance for healthcare coverage), while procedural justice refers to the fairness of those mechanisms for receiving such goods (access to and value of services). Interactional justice highlights how others treat individuals during interpersonal exchanges. Social justice may appear to be a simple concept to implement; however, it is rife with complexities and paradox. Social justice stimulates culturally competent nurses to act as agents of change for the advancement of human dignity and equity. What is fair and just to some becomes controversial to others, sometimes disempowering and paralyzing communities and larger systems (e.g., government, healthcare, education). For example, access to healthcare may require institutions to develop policies, procedures, and programs with differential payment systems that would require consumers with wealth or the institution to absorb cost of services for uninsured or underinsured consumers. Conversely, best practices would require spending more time giving informed consent to patients and their families which could in turn interfere with maintaining well-timed schedules for medical staff and other patients. Given the role that nurses play within the context of community, healthcare leadership skills, competencies, and behaviors need to be developed early in their career (Garner et al., 2009). As such, nursing education programs can be an integral part of moving upstream by addressing how factors such as neighborhood conditions, working conditions, education, income and wealth, stress, and race and racism affect communities' health and health outcomes. While foundational guidelines (e.g., the American Nurses Association, 2001) require that student nurses become more conscious of the broader social causes of health issues, student nurses must first learn to view these issues with a social justice perspective and then take action to address these issues. The practice of social justice theory in nursing extends beyond its ethical tradition since nursing holds a unique place in health care and society as witnesses of both injustice and suffering — suffering that they can speak about with direct knowledge and their opportunity to motivate those suffering to take action for social justice (Ellis, 2013). Taken together, social justice can (1) serve to enlighten nurses about systematic barriers, power structures, and social determinants of health that influence the health status of their patients and (2) cultivate a
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political competence that can initiate political/policy action for change that can benefit patients as well as the collective other (Ellis, 2013). Social justice is an integral component of leadership development during the student's learning process which can create the potential for a strong impact on health equity. With increased emphasis on student learning and the development of a social justice perspective in nursing, the profession can be more proactive in thinking about and addressing poor health conditions in a different way. That is, educators must move student learning and the predominate way of thinking in nursing beyond the individual client to the collective society, as well as shift from tertiary (reactionary) care to primary (preventative) care (Ellis, 2013). Expanding Leadership Curricula in Nursing Education Focused programs on leadership development are sparse in undergraduate nursing education curricula (Garner et al., 2009; Hendricks et al., 2010). Yet, leadership skills are requisite for nurses at every level including those just entering the profession. Thus, preparation of prelicensure nurses must extend beyond the lens of a medical model which is task-oriented towards valuing equally the self-development of “soft skills” — skills that embrace the principles of: 1) promoting emotional intelligence; 2) recognizing leaders who can be individuals holding formal and informal positions; 3) appreciating that each student can learn to be an effective leader; 4) understanding that leaders effect growth and change while working for the common good; 5) honoring the fact that leaders require intercultural competence; 6) respecting that individuals' knowledge, skills, abilities, and ethical values guide how they lead others; 7) considering that leaders foster interprofessional learning; and 8) advocating that leaders must promote self-knowledge, equity, personal empowerment, collaboration, social responsibility, service, and social justice. For nurses, leadership for social justice is critical for conducting an examination of and putting forth solutions to concerns that have created and reproduced societal inequities that have adversely affected the health of those who receive nursing care. The competing demands in healthcare institutions (e.g., cost containment, inadequate resources, and over extended personnel) culminate and create ineffective healthcare delivery systems which in effect lead to structural inaction. This requires nurses to cultivate leadership skills in order to effectively engage in system interventions. Becoming healthcare change agents requires nurses to be nimble, self-aware, and ready to assess organizational impasses that impede quality of care and improved health outcomes. We, therefore, strongly believe that the ability to provide leadership is a fundamental nursing competency for all nurses and in particular for nurses who provide care to marginalized and underserved populations. Currently, most leadership skills are targeted to students at the graduate level and nurses seeking executive positions. Contemporary expectations of nurses (e.g., interprofessional collaboration, team leadership, and effective care for increasingly diverse patients) require development of leadership skills that can no longer be reserved for a select few. It is no longer an exclusive prerogative of the upper echelon of administrators or more senior nurses; rather, it is a quality that is now expected of nurses at every level of the profession (Hendricks et al., 2010). Educational programs must therefore re-examine their approaches to student nurse preparation implementing curricular and experiential learning to heighten and make bold steps to broaden students' learning (Garner et al., 2009). These students will be joining ranks with the largest segment of professionals in healthcare. Furthermore, they will be at the forefront of healthcare delivery with a pivotal focus on improving the health of all individuals, families, and communities. The inclusion of social justice leadership approaches in undergraduate education has the potential to impact a variety of nursing
issues positively at a global level that are interconnected to patient outcomes. This includes factors such as the level of culture specific patient care knowledge and style of leadership that is transformational at a substantive level that can effectively address threats to quality patient care among a multinational workforce (Oulton, 2006; Suliman, 2009). Promoting Social Justice in Nursing Education Social justice education, educating for a non-oppressive society, is critical to the nursing profession, nationally and internationally. Groh et al. (2011) reported that “The centrality of leadership and the promotion of social justice in the nursing profession are particularly relevant at this time (p.401).” Both of these concepts are identified as essentials of baccalaureate education for professional nursing practice (American Association of Colleges of Nursing, 2008). Integrating social justice principles into leadership models is critical to implementation. Traditional leadership models have focused on individualistic goal attainment and contractual relationships, and they lack focus on contextual variables. Cultural encounters can be a useful learning tool for cultivating nurse leadership roles (Hester, 2012). Moreover, employing a social justice leadership approach rests on the health care practitioner's ability to identify personal and professional values that both define and inform decision making, leadership styles, and strategies (Bradley et al., 2012). Providing education that develops nurse leaders with social justice competence requires at a minimum linking self-awareness, cultural diversity, contextual issues, and familiarity with systemic inequalities. A healthcare-leadership genogram is a tool that can enhance nursing students' self-awareness by exploring the intersections between their family of origin history, professional values, and experiences with conflict, power, privilege, and leadership styles (Blum, 2008; McGoldrick et al., 2008). Specifically, many couple and family therapy programs use the Cultural Genogram (Hardy and Laszloffy, 1995) and the Person of the Therapist Training model (Aponte et al., 2009) as learning tools to promote both cultural and personal self-awareness, which in turn fosters professional development. Both paradigms have components introduced in didactic courses and subsequently offer the clinical supervisor a template to help students' transfer this awareness to culturally informed clinical practice. Similarly, couple and family therapy and psychology educational programs committed to social justice offer exemplars that can be easily adapted in nursing curriculum (Ariel et al., 2010; Toporek and Vaughn, 2010). While contemporary theories and models of leadership intentionally have “contextual factors [that] set the boundaries within which leaders and followers interact and determine the constraints and demands that are placed on leaders; …leadership is embedded in context and is socially constructed” (Smith, 2009, p.43). Smith (2009) acknowledged that the current societal status quo of social benefits, such as education and health care, is shaped by an inequitable distribution of and access to power and resources within which we are undoubtedly located. Students and professional nurses are not only within this system, the system is within us; thus, it is the medium in which current professional nursing was conceived and from which our practices have evolved. Given this dynamic, we surely participate in it, “even if unintentionally—except when we take purposive action to the contrary” (Smith, 2009, p.85). Thus, not taking action is not a neutral position. When we elect to leave oppression unacknowledged, we implicitly promote inequity by aiding to obscure its reality (Smith, 2009). Toporek and Vaughn (2010) noted that no social justice training can be “learned top-down but within a shared power paradigm” between faculty and student (p.181). Faculty are not center stage; classes become less instructive and more experiential. Pedagogical approaches expand to include consciousness (e.g., sociocultural) raising linking student's personal experiences and social issues; participatory learning is increased; self-reflection is routine practice; and projects that promote students' activism and citizenship are key. While students are engaged in these challenging processes (e.g., reflection and sociocultural
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consciousness) faculty are as well. Service learning is also important where students are collaboratively with marginalized communities. A continuous process of scaffolding student experiences while concomitantly challenging them helps with student development. Creativity and purposeful change are needed to promote authentic selfawareness among students and faculty alike, as beliefs mediate knowledge, expectations, and actions. While awareness of and openness to issues of cultural sensitivity and diversity are essential qualifications for development of students' leadership capacity and efficacy, we must move towards social action. Educational leadership programs for nursing students should aim to develop (1) transformational thinkers who are both active and reflective practitioners and (2) scholars who are also directly engaged in initiatives that are emancipatory in nature. Involving nursing students in collaborative problem solving initiatives with community-based groups teaches them to find their voice and necessary skills to promote change. Partnerships with heroic community leaders provide opportunities to gain practical knowledge about activism, fairness, and justice within complex systems. This is a global crisis that requires nurse educators to re-examine the foundations of undergraduate nursing curricula and take courageous steps needed to make every nurse a courageous leader. We need to meet the needs of our 21st century leaders who are striving to be professional nurses and provide the paradigm that will generate the critical skills they will need to take on leadership challenges of the future — skills that encompass social action and social change for improved and just healthcare. References American Association of Colleges of Nursing, 2008. The essentials of Baccalaureate Education for Professional Nursing Practice. Essential IV. Retrieved from www.aacn.nche. edu/Education/pdf/BaccEssentials08.pdf. American Nurses Association, 2001. Code of Ethics for Nurses with Interpretive Statements. American Nurses Association, Washington, DC. American Nurses Association, 2004. Nursing: Scope and Standards of Practice. American Nurses Publishing, Washington, DC. Anderson, J., Rodney, P., Reimer-Kirkham, S., Browne, A., Khan, K., Lynam, J., 2009. Inequities in health and healthcare viewed through the ethical lens of critical social justice contextual knowledge for the global priorities ahead. Adv. Nurs. Sci. 32 (4), 282–294. Aponte, H.J., Powell, F.D., Brooks, S., Watson, M.F., Litzke, C., Lawless, J., Johnson, E., 2009. Training the person of the therapist in an academic setting. J. Marital. Fam. Ther. 35, 381–394. Ariel, J., Hernández-Wolfe, P., Stearns, S., 2010. Expanding Our Social Justice Practices: Advances in Theory and Training. AFTA Monograph Series, American Family Therapy Academy, Washington, DC (Winter).
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