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the attempt to change a stereotype (Wood, 2003).
Students achieve understanding of cul- tural diversity by engaging in processes to promote their cultural awareness. The teach- ing strategies used most often to move stu- dents toward cultural competence include virtual patient encounters where students can apply cultural skills and knowledge to diverse patient populations in a safe manner (Rutledge et al., 2008); diversity experiences among students and faculty outside of the classroom that might involve a guest speaker (Ranzijn, McConnochie, Nolan, & Wharton, 2007); or more formal cultural diversity events aimed at examining diversity issues to increase cultural awareness (Sanner, Baldwin, Cannella, Charles, & Parker, 2010).
Studying abroad and immersion experiences also promote cultural awareness and sensi- tivity, and decrease stereotyping (Ruddock &
Turner, 2007).
SYNOPSIS
There are three key points in understand- ing cultural diversity. First, professional nursing organizations value cultural diver- sity. For example, the American Association of Colleges of Nursing (AACN, 2014) sup- ports more faculty and student diversity in nursing programs: “racial and ethnic diversity of health professions faculty and students helps to ensure that all students will develop the cultural competencies necessary for caring for patients in an increasingly diverse nation.” The National League for Nursing (NLN, 2014) supports the creation of “a culture of diversity”
within nursing programs that “embraces acceptance, respect and inclusivity that is about understanding ourselves and each other and moving beyond simple tolerance to embracing and celebrating the richness of each individual. While diversity can be about individual differences, it also encom- passes institutional and system-wide behavior.” Finally, the National Advisory for Nursing Education and Practice stresses the need for increased numbers of minority w w w. n l n . o r g /f a c u l t y p r o g r a m s/
Diversity_Toolkit/diversity_toolkit.pdf United States Census Bureau. (2010). Overview
of race and Hispanic origin. Retrieved from http://www.census.gov/prod/cen2010/
briefs/c2010br-02.pdf
Susan Peck Tipperman
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ULTURALD
IVERSITYDEFINITION
Definitions of cultural diversity vary and may include differences in race, age, eth- nicity, religion, and gender within a situ- ation, group, or institution (Wood, 2003).
It may also be the coexistence of different ethnic, gender, racial, and socioeconomic groups within one social unit (Wood, 2003) or the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteris- tics of a population of people (Purnell &
Paulanka, 2003, p. 3).
APPLICATION
Cultural diversity is a complex, multifac- eted concept that is essential to the educa- tion of nurses. Its complexity is inherent in the multiple ways in which it can be viewed. For example, in the context of representation, the term is used to depict images of particular social groups, which tend to be defined by race, gender, age, or socioeconomic status. When used in the context of ideology, the term does not refer to real people, but rather to a set of beliefs for the purpose of changing people’s atti- tudes. When an event happens and people’s thoughts need to be changed, diversity training or sensitivity training can be used to affirm a different set of beliefs or justify
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American Association of Colleges of Nursing (AACN). (2014). Diversity and equality of opportunity. Retrieved from http://www .aacn.nche.edu/publications/position/
diversity-equality
Bednarz, H., Schim, S., & Doorenbos, A.
(2010). Cultural diversity in nursing edu- cation: Perils, pitfalls and pearls. Journal of Nursing Education, 49(5), 253–260.
National League for Nursing (NLN). (2014).
Global/diversity initiatives. Retrieved from http://www.nln.org/aboutnln/globaldi- versity/index.htm
Purnell, L., & Paulanka, B. (2003). Transcultural health care: A culturally competent approach (2nd ed.). Philadelphia, PA: F. A. Davis.
Ranzijn, R., McConnochie, K., Nolan, A., &
Wharton, M. (2007). Towards cultural competence: Australian indigenous content in undergraduate psychology.
Australian Psychologist, 43(2), 132–139.
Ruddock, H., & Turner, D. (2007). Developing cultural sensitivity: Nursing students’
experience of a study abroad programme.
Journal of Advanced Nursing, 59(4), 361–369.
Rutledge, C., Barham, P., Wiles, L., Richardean, B., Eaton, S., & Palmer, K. (2008). Integrative simulation: A novel approach to educating culturally competent nurses. Contemporary Nurse: A Journal for the Australian Nursing Profession, 28(1/2), 119.
Sanner, S., Baldwin, D., Cannella, K., Charles, J., & Parker, L. (2010). The impact of cul- tural diversity forum on students’ open- ness to diversity. Journal of Cultural Diversity, 17(2), 56–61.
The Sullivan Commission. (2007). Missing persons: Minorities in the health profes- sions, a report of the Sullivan Commission on diversity in the health care workforce.
Retrieved from www.sullivancommission .org
U.S. Census Bureau. (2007). Population.
Retrieved from http://www.census.gov/
prod/www/abs/popula.html
Villarruel, A., Bigelow, A., & Alvarez, C.
(2014). Integrating the 3Ds: A nursing per- spective. Public Health Reports, 129(Suppl.
2), 37–44.
nurses in education and leadership roles to develop models of care that meet the health care needs of minority populations. The second key point is that despite the nursing profession’s valuing of diversity and put- ting forth strategies to increase the nursing workforce diversity, there has only been a small increase in the numbers of minor- ity nurses while the majority of the nurs- ing workforce remains White (The Sullivan Commission, 2007). Villarruel, Bigelow, and Alvarez (2014) purport that a disconnect exists between what the nursing profession says about the value of diversity and what it has been able to actually accomplish in increasing the nursing workforce diversity.
This disconnect is of great concern because U.S. minorities will be the majority by 2042, increasing from 34% in 2008 to 54% in 2042 (U.S. Census Bureau, 2007). Furthermore, the continued increase in immigration and minority populations in the United States indicates that more nontraditional rather than traditional students are seeking nurs- ing degrees, making the need to integrate diversity within nursing programs and the nursing profession a priority (Bednarz, Schim, & Doorenbos, 2010). A third key point is that nurse educators must shoul- der the responsibility of moving students toward cultural competence and increas- ing cultural sensitivity so that they are qualifi ed to provide culturally appropriate patient care.
RECOMMENDATIONS
Preparation of graduates to care for patients in culturally appropriate ways can be achieved by integrating cultural diversity into clinical and capstone experiences. Nurse educators must also be skilled at facilitat- ing students through the steps of becoming culturally competent. There is a need for future research to focus on evaluating the effectiveness of learning activities aimed at promoting students’ cultural awareness and competence and linking them to student learning outcomes.
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historical and sociopolitical contexts in terms of what these contexts mean in work- ing relationships where there is a difference (Richardson & Carryer, 2005). Other sugges- tions include focusing on the ways in which power is embedded in nursing practice and is inherent in the relations between nurses and patients (Jeffs, 2001).
Cultural safety education might be experienced as unsafe by both students and teachers, from both majority and minor- ity groups, because it involves dealing with power relations and tensions, which are often threatening and raise powerful emo- tions of blame and guilt (Arieli, Friedman, &
Hirschfeld, 2012). In order to teach cultural safety, educators have the responsibility to construct a learning environment where all students feel safe to refl ect on and give expression to their cultural identities (Jeffs, 2001). Engaging in refl exivity, both as teach- ers and as learners, is key to cultural safety education.
SYNOPSIS
The concept of cultural safety was intro- duced by Ramsden, a Mauri nurse from New Zealand, in the late 1980s (Papps &
Ramsden, 1996; Ramsden, 2002). In 1991, the New Zealand Nursing Council ruled that the state examination would include 20%
on cultural safety. The concept of cultural safety was further developed by Ramsden and other scholars who suggested a broader meaning where culture referred not only to ethnic differences but also to differences such as gender, age group, sexual prefer- ence, religion, profession, and disability (Ramsden, 2002). Cultural safety is a key competency for professional responsibil- ity. It includes demonstrating professional, legal, ethical, and cultural safety. These categories are examined through the appli- cation of physiological and psychosocial knowledge, as well as communication and clinical skills (Nursing Council of New Zealand, 2002/2012).
Cultural safety in nursing education is focused on educating students to be Wood, P. (2003). Diversity. The invention of
a concept. San Francisco, CA: Encounter Books.
Susan Sanner
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ULTURALS
AFETYDEFINITION
Cultural safety refers to awareness and action aimed at ensuring patients from dif- ferent backgrounds feel safe in their clinical encounters. It is a conscious provision of care that takes into account how power relations infl uence health care. This conscious provi- sion of care aims to protect the identities of patients, particularly those from minorities and disempowered groups.
APPLICATION
Cultural safety is a key component in edu- cating nurses to deliver humane and effec- tive care. In order to provide culturally safe care, nurses and other caregivers need to understand the ways in which power struc- tures infl uence health, and to refl ect on how personal and professional power positions infl uence their encounters with patients (Ramsden, 2002). Cultural safety education is particularly important in diverse societies with histories or present situations of colo- nialism, racism, discrimination, and confl ict (Arieli, Mashiach-Eizenberg, Friedman, &
Hirschfeld, 2012).
Translating the concept of cultural safety into nursing education practice is complex and challenging. The major goals for educators and students include identi- fying conscious and subconscious percep- tions of others and acknowledging how these perceptions infl uence the provision of care. Education focuses on transforming negative perceptions and attitudes toward others (Ramsden, 2002). Educational strat- egies include providing knowledge on
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safety in nursing education. International Nursing Review, 59(2), 187–193.
Arieli, D., Mashiach-Eizenberg, M., Friedman, V., & Hirschfeld, M. (2012). Cultural safety and nursing education in divided societ- ies. Nursing Education Perspectives, 33(6), 364–368.
Cash, P. A., Moffi tt, P., Fraser, J., Grewall, S., Holmes, V., Mahara, S., . . . Nagel, D.
(2013). Writing refl exivity to illuminate the meanings in cultural safety. Refl ective Practice, 14(6), 825–839.
Doutrich, D., Arcus, K., Dekker, L., Spuck, J.,
& Pollock-Robinson, C. (2012). Cultural safety in New Zealand and the United States: Looking at a way forward together.
Journal of Transcultural Nursing, 23(2), 143–150.
Jeffs, L. 2001. Teaching cultural safety the culturally safe way. Nursing Praxis in New Zealand, 17(3), 41–50.
McEldowney, R., & Connor, M. J. (2011).
Cultural safety as an ethic of care: A prax- iological process. Journal of Transcultural Nursing, 22(4), 342–349.
Nursing Council of New Zealand.
(2002/2012). Handbook for nursing depart- ments offering programs leading to registra- tion as an enrolled nurse or registered nurse.
Wellington: Author.
Papps, E., & Ramsden, I. (1996). Cultural safety in nursing: The New Zealand expe- rience. International Journal for Quality in Health Care, 8(5), 491–497.
Phiri, J., Dietsch, E., & Bonner, A. (2010).
Cultural safety and its importance for Australian midwifery practice. Collegian, 173, 105–111.
Ramsden, I. M. (2002). Cultural safety and nurs- ing education in Aotearoa and Waipounamu.
A thesis submitted to the Victoria University of Wellington for the fulfi ll- ment of the requirements for the degree of Doctor of Philosophy in Nursing.
Richardson, F. (2010). Cultural safety in nurs- ing education and practice in Aoterearoa New Zealand. A thesis submitted to Massey University in partial fulfi llment of the requirements for the degree of doctor of philosophy.
reflective of their own attitudes toward patients and their power relations with patients, rather than on their cultural cus- toms and perspectives. While the goal of cultural competence education is to educate a professional nurse who treats patients in a culturally appropriate way (Wells & Black, 2000), the educational aim of cultural safety is a nurse who inves- tigates the strategies, which can illumi- nate the factors that threaten the patients’
sense of safety (Ramsden, 2002). There have been some attempts to combine the two concepts—cultural safety and cul- tural competence—and develop a model for an ethic of care based on both concepts (McEldowney & Connor, 2011). Cultural safety education is also an institutional responsibility, because structural condi- tions enable provision and/or teaching of culturally safe care (Richardson, 2010).
Cultural safety became a key concept in nursing education in the 21st century.
The meanings of the concept and its appli- cation have been explored by scholars in New Zealand and Australia (Phiri, Dietsch,
& Bonner 2010); Canada (Cash et al., 2013);
the United States (Doutrich, Arcus, Dekker, Spuck, & Pollock-Robinson, 2012); and Israel (Arieli et al., 2012).
RECOMMENDATIONS
Integrating cultural safety in nursing educa- tion necessitates educating nursing students to perceive themselves as active social agents who endeavor to promote social justice.
Nursing educators should be responsible for designing adequate cultural safety educa- tion programs that will take into consider- ation the specifi c power relation structures of each society, as well as the backgrounds of students and teachers. Because the idea of cultural safety may encounter resistance, there is a need for institutional, national, and international support for this educational perspective
Arieli, D., Friedman, V., & Hirschfeld, M.
(2012). Challenges on the path to cultural
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At the institutional level, curriculum development requires support of both the faculty and administration (Ruchala, 2011).
Faculty engagement in the process includes utilization of knowledge, skills, and exper- tise; serving on curriculum committees;
updating courses with current information each time the course is taught; as well as mentoring faculty who have less experience in the curriculum design process. Support from administration includes assurance of needed resources; physical, secretarial, and workload support; external consultants; and assurance that the work invested in the cur- riculum is valued and needed by the institu- tion (Ruchala, 2011).
The NLN and the American Association of Colleges of Nursing (AACN) provide guidelines and competencies related to cur- riculum development and accreditation.
NLN have been developed as suggestions for faculty as they strive to achieve a level of outstanding performance or service, relevant to all types of programs and institutions.
Indicators of the curriculum as a Hallmark of Excellence in Nursing Education include an evidence-based curriculum that is fl exible and refl ective of current societal and health care trends. Additional indicators include research and innovation, local and global perspective, cultural learning, student val- ues development and socialization, prepara- tion for the roles that are essential to quality nursing practice, learning that supports evi- dence-based practice, and multidisciplinary approaches to care and clinical competence (NLN, 2004).
AACN curriculum standards provide a framework for positioning baccalaureate and graduate-degree nursing programs to meet the health care challenges of a new century. The AACN guidelines have been implemented in a curriculum design to produce suffi cient numbers of nurses for a health system in continual change. The AACN Essentials series outlines the nec- essary curriculum content and expected competencies of graduates from baccalaure- ate, master’s, and doctor of nursing practice programs, as well as the clinical support Richardson, F., & Carryer, J. (2005). Teaching
cultural safety in a New Zealand nurs- ing education program. Journal of Nursing Education, 44(5), 201–208.
Wells, S., & Black, R. (2000). Cultural compe- tence for health professionals. Bethesda, MD:
AOTA.
Daniella Arieli
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URRICULUMD
EVELOPMENTDEFINITION
Curriculum development is the process of designing a formal plan of study that pro- vides the philosophical underpinnings, goals, and guidelines for the delivery of a specifi c educational program (Keating, 2011).
Curriculum development refers to design- ing new programs and evaluating/revising existing programs (Kim, 2012).
APPLICATION
Nursing curriculum development, ongoing evaluation, and redesign of curriculum are the responsibility of the faculty (Ruchala, 2011). Nurse educators are responsible for formulating program outcomes and design- ing curricula that refl ect contemporary health care trends and prepare graduates to function effectively in the health care environment (National League for Nursing [NLN], 2005). To this end, nurse educators have the multiple responsibilities of ensur- ing that the curriculum refl ects institu- tional and departmental mission, vision, philosophy, and internal processes, as well as the standards of individual State Boards of Nursing and national accrediting agen- cies. Integration of these standards into the curriculum helps administrators and faculty to prepare for program approval or review and accreditation by ensuring that the program meets essential quality stan- dards (Keating, 2011).
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based education) has come to be associated with competency-based education. The key principle in this approach is the develop- ment of educational programs and applica- tion of learning processes, beginning with identifying outcomes expected as a result of an educational process. Competency-based education advocates for a time-independent approach. Curricular contents and learning processes are driven by outcomes/compe- tencies specifi ed for educational programs.
In professional education, this means iden- tifi cation of competencies needed by gradu- ates to meet the needs of specifi c professional roles determined by professions and social needs (Kim, 2012).
RECOMMENDATIONS
Integrated and comprehensive curricu- lum development takes into consideration appraisal of feedback from graduates and current learners, expectations of consumers of health care, recent developments in regu- lations and standards, and changes in higher education and health care. Nursing curricu- lum needs to achieve a balance between the body of nursing knowledge; skills such as communication, teamwork, and leadership:
and analytical and critical thinking (Waters et al., 2012). Ensuring continuous quality in nursing education with the goal of producing graduates who show evidence of competen- cies in the beginning registered nurse and advanced practice roles requires ongoing dialogue on reforming the process of cur- riculum development and considering new models of nursing education in the context of accreditation.
American Association of Colleges of Nursing (AACN). (2014). Education resources.
Retrieved from http://www.aacn.nche .edu/education-resources
Keating, S. (2011). Introduction to the history of curriculum development and curricu- lum approval process. In S. Keating (Ed.), Curriculum development and evaluation in nursing (2nd ed., pp. 1–4). New York, NY:
Springer.
needed for the full spectrum of academic nursing (AACN, 2014).
SYNOPSIS
Dynamic changes in health care, health care workforce education, and the call to better prepare students for the registered nurse and advanced practice role have generated dialogue regarding continuous curricu- lum review to prevent curriculum drift and ensure quality (van de Mortel & Bird, 2010) as well as curriculum development process reform and consideration of new models (Kim, 2012; Waters, Rochester, & McMillan, 2012). Signifi cant changes occur in the dis- cipline, context of employment, higher edu- cation, and health care sector in between accreditation cycles (Waters et al., 2012).
Challenges for faculty in schools of nursing include keeping curricula relevant and cur- rent, responsive to innovations in practice and teaching and learning (Waters et al., 2012) as years pass in between accreditation and formal reaccreditation cycles (van de Mortel & Bird, 2010).
Curriculum drift, a widening gap between the accredited curriculum and the taught curriculum, occurs when changes to a course occur and the changes are not mon- itored. Possible reasons for this include the close protective association of the curriculum and academic freedom, faculty autonomy in development and delivery of their courses, and faculty teaching their courses in isolation (van de Mortel & Bird, 2010). Van de Mortel and Bird (2010) propose a continuous curric- ulum review that provides a data-informed process that addresses quality improvement of the curriculum; ensures that issues with delivery affecting the student experience are identifi ed and addressed; contains cur- riculum drift while encouraging positive change; and provides opportunity for team building, development of leadership skills, holistic perspective of the curriculum, and faculty development in the form of sharing wisdom.
Outcomes-based education (also referred to in the literature as abilities-