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Racism in nursing education:
a reflective journey
T
here is consistent evidence of the
need to improve the cultural com-
petence of nurses and address racism
in healthcare in the United King-
dom (UK) (Papadopoulos et al, 1995, 1998;
Gerrish et al, 1996). Racism is neglected in
nursing curricula despite the responsibility
of education providers to prepare culturally
competent practitioners (Narayanasamy and
White, 2005). This presupposes particular
curriculum content, but also demands that
lecturers have knowledge and skills which
facilitate culturally sensitive learning in the
classroom.
This article reports on a study of classroom
racism experienced by nursing students
and lecturers, and the ability of lecturers to
confront prejudice and deal with insensitivity
(Tilki et al, 2006). The impetus for the project
was intolerance and prejudice observed in
the classroom, concerns about its impact on
learning and the implications for clinical
global terrorism, endemic Islamophobia and
recent debates about multiculturalism all
impact on the relationship between nurses
and their patients. Literature suggests that if
nursing curricula are to prepare culturally
competent nurses they must encompass
cultural awareness, cultural sensitivity
(Burnard, 2005; Sargent et al, 2005) and
ensure anti-discriminatory/anti-racist
practice are addressed adequately (Nairn et
al, 2004; Cortis and Law, 2005).
The Race Relations Amendment Act (2000)
requires public authorities to tackle all forms
of racism. Yet racism within nursing curricula
and anti-racist education are largely neglected
in the preparation of nurses for practice (Cortis
and Law, 2005; Sargent et al, 2005). Foolchand
(2000) and Nairn et al (2004) argue that
explicit anti-racist measures are urgently
needed in nursing education. Narayanasamy
and White (2005) highlight the need for
professional development for nurse educators in
anti-racist and cultural competence education.
Since multiethnic cohorts are the norm in many
universities, the ‘whiteness’ of institutions must
be challenged (Husband, 2000; Purwar, 2001)
and Anglo/Eurocentric values embedded
in organizational cultures questioned (Allan
et al, 2004).
While there are many critics of the concept
of cultural competence (Culley, 2001;
Chenowethm et al, 2006), nursing literature
highlights a variety of strategies for preparing
culturally competent practitioners. Some argue
that the most effective way to equip nurses with
cultural knowledge, skills and competence is a
designated course or module (Lockhart and
Resick, 1997; Braithwaite et al, 2006). Others
suggest immersion or intensive experience
in another cultural setting (Wimpenny et
al, 2005). Sargent et al (2005) propose a
spiral curriculum, integrating transcultural
issues across programmes. Several models exist
to underpin and inform the development
of transcultural/cultural competence skills
(Papadopoulos et al, 1998; Narayanasamy,
2002). All these approaches have merits and
limitations but highlight the complexity of
transcultural education in pre-registration
Abstract
This article discusses the personal and professional journey of discovery
experienced by a nurse lecturer as a result of engagement in a project exploring
the impact of racism in the nursing classroom. The findings of the study
demonstrated the existence and complexity of racism, the impact of racism on
student learning, the limitations of lecturers in recognizing and addressing racism
and organizational factors which perpetuate institutional racism. The authors
describe the insight gained from the research process and how this has influenced
the practice of the first author and how reflection and mentorship by the second
author have challenged personal ethnocentricity, encouraged new ways of thinking,
enhanced confidence and encouraged experiential teaching strategies. The article
highlights the ways in which nurse lecturers might become culturally competent
and in particular addressing issues of racism in the classroom and enabling
learning which is applicable in practice.
Key words: Racism n Research n Reflective Practice n Education
Kathleen Markey is Senior Lecturer and Mary Tilki
is Principal Lecturer, School of Health and Social
Sciences, Middlesex University, Middlesex
Accepted for publication: January 2007
practice. The findings mirror other publications
(Sawley, 2001; Nairn et al, 2004; Cortis and
Law, 2005) but provide new insights into an
under-researched area.
This article discusses the personal,
professional journey of discovery experienced
by one nurse lecturer (KM), through her
engagement in research. The opportunity
to critically reflect with an experienced
transcultural researcher (MT), and deliberate
on and explore the findings, led to changes
in teaching, an enhanced knowledge and
confidence and a commitment to ongoing
development.
Literature review
Although cultural competence is a complex
and contested notion, it is widely regarded
as an essential attribute in nursing graduates
and is a core requisite for nurse education
(Canales and Bowers, 2001). Wimpenny et al
(2005) highlight that learning about culture
in the classroom is central to personal and
professional development, which is then
mirrored in clinical practice. However,
the development of culturally competent
practitioners continues to present a challenge
for nurse educators. Nursing does not occur
in a vacuum. Contemporary concerns about
Kathleen Markey, Mary Tilki
390
British Journal of Nursing, 2007, Vol 16, No 7
learning while Papadopoulos et al (1998)
and Burnard (2005) emphasize the critical
reflection needed to analyse personal and
professional ethnocentricity. Cortis and
Law (2005) highlight the lecturer as a role
model while Mezirow (1990) focuses on risk
taking and critical reflection as important
elements of transformative learning. Lecturers
need encouragement and guidance to adopt
culturally sensitive teaching strategies which
may be uncomfortable for them and resisted
by students.
A personal and professional
journey
At the start of this project, although not
complacent, I believed I had insight into
transcultural education issues and knew what
constituted racism. However, working with a
team reviewing literature, developing research
tools, collecting data, analysing findings and
writing a research report helped me realize
how superficial my insight was. Critically
reflecting on my own practice in the light of
literature and project findings has enhanced
my personal and professional development.
In particular, sharing misconceptions,
mistakes and anxieties during team meetings
provided a safe environment to discuss
understandings, feelings and perceptions.
The lead investigator stimulated reflexivity,
exploring feelings and perceptions of the
data, interpreting, questioning and justifying
interpretations and explanations during
analysis. I have tuned into internal processes
which are crucial elements of transformative
education, critically questioning my practice
and encouraging innovative and experiential
strategies when teaching. My reflections
are informed by Kolb’s framework (1984),
although the scope of the article does not
address this.
A painful enlightenment
Engaging in the project has been a positive
but painful enlightenment. The first
uncomfortable reality was the evidence
of racism between students from different
cultural backgrounds, by students against
lecturers and by lecturers against students.
The data have shown me that racism is a
complex and sensitive issue, manifested in
differing ways at individual and organizational
level. I now realize it is not confined to the
discriminatory attitudes or behaviours of
White people against Black people, but
includes Black against White as well as
discrimination between different cultural
groups who share the same skin colour:
and undergraduate nursing programmes. The
shifting, dynamic and contextual nature of
the term ‘culture’ makes it hard to define. The
term ‘cultural competence’ suggests that it is
a technical skill for which practitioners could
be trained and there is a danger that culture
could be explored in isolation and seen as
static (Chenowethm et al, 2006). There is a risk
of focusing on the culture of the client rather
than the dynamic created by the practitioner’s
culture (O’Hagan, 2001). However, these
problems are not insurmountable and the
success of any strategy relies on the abilities
of nurse lecturers to facilitate transcultural
learning (Braithwaite et al, 2006).
Duffy (2001) argues that current
transcultural learning and teaching strategies
do not meet learners’ needs because they fail
to move beyond differentiating the self from
the ‘other’, instead emphasizing the exotic
and generalizing cultural groups. Nurse
lecturers lack skills in teaching or developing
transcultural nursing and particularly in
addressing racism (Papadopoulos et al, 1995).
According to Culley (2001), legislation alone
cannot tackle institutional racism in nursing
because it fails to address underpinning
racist values and attitudes. Unless the ‘hearts
and minds’ dimension of anti-discriminatory
practice is acknowledged, compliance with
legislation is at best superficial. Because
racism is rarely intended, explicit or easily
discernable (Essed, 1991; Cortis and
Law, 2005), lecturers must understand its
complexity and the subtlety with which
it is expressed. Challenging and resolving
racism is difficult (Wieviorka, 1995) and
the psycho-emotional aspects are invariably
underestimated (Lowe, 2006). Fear, guilt and
uncertainty lead lecturers to avoid painful
or threatening issues, but because feelings
and misunderstandings are ignored, conflicts
remain unresolved, solutions are not found
and tensions escalate. Teaching and learning
strategies need to confront these issues
if lecturers are to handle sensitivities and
encourage different ways of thinking.
Although transformative educational
approaches are used in nursing education, the
wider cultural literature suggests their neglect
in relation to cultural competence. Reliance on
descriptive knowledge and didactic approaches
(Duffy, 2001), rather than experiential learning
(Razak, 1999) and eschewal of constructionist
and postmodern philosophies (Dogra, 2004),
fail to promote the critical awareness needed
for new ways of thinking (Mezirow and
associates, 2000). These authors emphasize
the ‘self ’ as a starting point for transformative
‘Just pick anyone who is in the
minority, because if you are in a
group where there is a lot of people
from one cultural background, then
they just gel together, then it will be
the ones who may be on their own
who are going to experience it.’
(Caribbean 1st year student)
I was not surprized that lecturers recounted
students’ disrespect for each other and lecturers
in the classroom, but before the project I had
not considered the potential racist undertones
of some actions:
‘Well, like tut-tutting and kissing
their teeth when somebody is
speaking. Laughing at someone’s
accent, only clapping when their
friends present or just generally
looking bored.’ (African lecturer
interviewee)
I was shocked by the subtle ways in which
racism was expressed and particularly by its
impact on students:
‘It makes me feel isolated … my
opinion isn’t valid, because I’m
Jamaican and maybe I’m not like
her.’ (Caribbean 3rd year student)
Although saddened, I could empathize with
lecturers who failed to challenge unacceptable
behaviour or offensive, discriminatory
attitudes:
‘A comment was made by a
[Black] student about homo-
sexuality. She said “in my culture
it’s forbidden, it’s disgusting, you
know. End of story”. The lecturer
said “OK, that’s your culture”. I’m
sure if I made that statement I
would have been challenged more.
I do think because she was Black
and because it was her culture
that she was allowed to say that.’
(English 3rd year student)
The students’ experiences made me
defensive, at times feeling the need to justify
colleagues’ behaviour. I could empathize
with the following lecturer, rationalizing
actions which might be perceived as racist by
students:
‘I could sometimes, without
realizing it, discriminate in some
way. For example, students who
repeatedly don’t do any work
British Journal of Nursing, 2007, Vol 16, No 7
391
EDUCATION AND DEVELOPMENT
or who are not interested. It has
nothing to do with their colour
of their skin or where they come
from, but sometimes you might
feel yourself very impatient and
just leave them out of the picture.’
(English lecturer interviewee)
However unintentional, thoughtlessness,
ignorance or tight timescales might have at
times desensitized me to learners’ needs:
‘I’m trying to express myself …
so you [lecturer] might give me
that look, “oh please hurry up”.
I’m thinking she is racist.’ (African
student FG2)
I was embarrassed by student accounts of
unfair treatment and angry with colleagues
whose insensitivity to overseas students was
particularly destructive:
‘She [White student] went on
Monday and was told [by the
lecturer] exactly what to do … so I
went and I explained myself and she
[White lecturer] said I can’t explain
anything, everything is in the book.’
(Caribbean 3rd year student)
‘She [lecturer] says if you keep
writing this English, this rubbish,
you won’t fi nish your nursing …
When you come out of the door
you see your tears on you.’ (African
student FG2)
The study especially highlighted the anxiety
experienced by students for whom English
was a second language and contributed to
perceptions of racism when lecturers were
insensitive or impatient:
‘… You know when I was trying to
say something, she [lecturer] was
doing this (rolls eyes up to heaven and
sighs heavily). So I think our lecturers
should be a bit more understanding.’
(African Student FG1)
The student narratives made me aware of
cultural behaviours and communication patterns
which I misunderstood and problematized:
‘Most of us Africans speak at the
top of our voices, we speak loudly.
Most White people talk quietly. So
if you are going to say “can you
soften your voice a bit?” That’s not
me. So, maybe if people can also
understand that.’ (African 2nd year
student)
I began to understand why students
preferred to stick with colleagues from their
own communities for group work. I had not
appreciated the extent to which students felt
displaced and alienated in unfamiliar and
hostile environments:
‘I want a sense of belonging, at
least she speaks my language, if I
go to Louise, maybe, my English
is not very good, and I will be
more comfortable with her. Maybe
beliefs, things like that so you are
comfortable, especially in this
foreign land.’ (African student FG2)
Equally I had not considered the extent
to which comfortable groupings were
exclusionary, potentially racist or isolationist:
‘I fi nd it very diffi cult and that
nearly put me off, because every
time I come to class, you sit with
groups, and you can’t join them.’
(African student FG2)
Like many colleagues, I was reluctant to
dictate working-groups and although I often
did this, I was anxious about being accused of
racism. I had not appreciated the benefits of
mixed cultural groupings in helping students
trust each other, challenge stereotypes and
develop transcultural understanding:
‘I’m sorry to say I was really scared
of Jamaicans when I fi rst came
to this country … Now I have
mixed with many of them and met
different Jamaicans. I know different
now.’
(African student FG1)
I now realize that despite resistance, students
enjoy mixed groups and are enriched by the
experience:
‘Socializing with different cultures
is the best part of group work.
I mix with a lot of people from
different cultures, and I fi nd this is
a very good experience because you
learn.’ (African 1st year student)
I admired and envied colleagues who felt
confident and comfortable to handle resistance or
challenge inappropriate classroom behaviour:
‘I’m always happy to challenge. I
try to probe and analyse.’ (English
lecturer interviewee)
‘... I’m very infl exible about issues
which relate to disrespect for other
people.’ (Asian lecturer interviewee)
The feelings articulated by the students have
left me with a greater awareness of classroom
dynamics and my role within them. Like many
colleagues, I rarely felt able to challenge. I
particularly lacked confidence differentiating
inappropriate behaviour from that which
might be racially motivated. Ironically, I was
reluctant to intervene for fear of accusations of
racism. This painful and awkward self-discovery
left me feeling exposed and vulnerable but
passionate to increase my knowledge, insight,
awareness and change my practice.
From reflection to application
The students’ perceptions and experiences of
racism have enabled me to recognize different
actions which may be racist or perceived as
such. My confidence in negotiating the grey
area between unacceptable and potentially racist
behaviour is increasing. I am getting better at
justifying judgements, identifying actions or
attitudes with possible racist undertones and
now explore these as learning opportunities.
I am fairly comfortable to admit what I
don’t know and accept that I don’t need to
know everything. Instead, I appreciate the
wealth of cultural knowledge among students
and am becoming more confident using
cultural/clinical scenarios which facilitate
sharing cultural information and experiences.
Student narratives have made me aware of the
differing expectations of students and lecturers.
Educational strategies facilitating participation,
challenging and critique are new to students
from countries where traditional, didactic and
passive approaches are the norm, so the value of
self-learning and learning from each other must
be emphasized. Although often unpopular and
resisted, I am increasingly encouraging students
to explore ethnocentric ideas and challenge
personal prejudices and assumptions.
Before this project, I believed that discussing
different cultures and especially non-UK cultures
was the starting point for cultural competence. I
now believe that transcultural skills development
begins with the ‘self ’, not the ‘other’, as this may
lead to stereotyping (Foolchand, 2000; Nairn et
al, 2004). Additionally, I recognize the importance
of exploring the heterogeneity of British and
White cultures to address ethnocentric or
stereotypical beliefs held by others. Discussions
with co-researchers and familiarity with the
Papadopoulos, Tilki and Taylor model (1998)
have helped me challenge my ethnocentrism
and feel comfortable encouraging the same
392
British Journal of Nursing, 2007, Vol 16, No 7
among students. I am acutely conscious that
not challenging unacceptable/racist behaviour
impacts negatively on learning. Mentorship
has allayed my fears of getting things wrong
and made me conscious of the greater dangers
of doing nothing. I have heard how
experienced colleagues address issues, especially
handling the uncertainty involved. I am
motivated to challenge, not just because of
the impact on learning but because of the
applicability of experiential classroom learning
to clinical practice.
I am inspired by Burnard (2005) and
Brathwaite et al (2006) to proactively mix
students from different cultures, providing
realistic, pragmatic opportunities for
experiential learning with focused tasks and
corporate goals. Razak’s (1999) work has
motivated me to persevere despite resistance
and I am increasingly confident mixing
groups to explore sensitive or taboo topics,
debate power issues, consider discrimination,
demythologize stereotypes and generally learn
through working together. These processes
are highly applicable to multi-disciplinary and
multi-ethnic teamwork in clinical settings.
There is an urgent need for greater
investment in helping overseas students to
adapt and become confident using their
English in a supportive environment. I am
keen to learn strategies to help students
develop their spoken English in a safe setting.
I would like to develop exercises which draw
on the experience of non-English speaking
students, relating these to communication
with patients whose English is limited.
I am conscious that the policies and practices
of the wider organization must change if
we are to address the needs of our multi-
ethnic students. I am acutely aware of the
psychological barriers at organizational level
to be overcome before this occurs (Lowe,
2006). I cannot make the necessary changes
alone, but in addition to adapting my teaching,
I can use my new knowledge to challenge
discriminatory systems and procedures.
Conclusion
The qualitative study underpinning this article
did not aim to generalize, but the literature
suggests that similar issues may occur in
other nursing departments. While this is the
account of one lecturer in one institution,
the findings are broadly consistent with
wider literature. Further research is needed to
explore the extent of the problem nationally,
especially identifying what knowledge and
skills lecturers need to be transculturally
competent. Lecturers clearly need to be
culturally aware, knowledgeable and sensitive.
They must use strategies that draw upon
the cultural knowledge and experience of
students, encourage dialogue, debate and
sharing ideas to break down barriers. They
must address, in particular, the nature, origins,
manifestations and impact of racism, and
manage that which occurs in the classroom,
especially the institutional type born out of
ignorance, thoughtlessness or ethnocentricity.
Although not the remit of this article, there
is clearly a need to investigate racism by and
against nursing students in clinical settings.
Continuing professional development
opportunities are needed to enable lecturers to
explore the issue of racism, addressing their
ethnocentricity as a precursor to handling issues
in the classroom. Mentorship or supervision
encourages lecturers to explore concerns around
insensitive or racist attitudes and behaviours and
handling uncomfortable classroom situations.
While greater attention is required for
curriculum issues, guidance is needed to prepare,
develop and refine teaching strategies and group
exercises which tease out cultural issues, explore
tensions and conflicts and manage these in the
classroom. Attention should focus on creating an
environment where critical reflection occurs,
blame is avoided, risk managed and new ideas
developed, tested and evaluated. The significance
of a credible, respected role model cannot be
overstated in modelling respect and self-critique,
questioning and challenging, deconstructing
myths and prejudices and reconstructing new
ways of thinking. These qualities, which can be
learned in the classroom, are highly transferable
to the clinical setting, just as my new found
knowledge and skills are applicable beyond the
classroom in the wider organization.
BJN
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EDUCATION AND DEVELOPMENT
KEY POINTS
I Racism is a complex and sensitive issue,
manifested in differing ways at individual
and organizational level.
n Racism is not always identified,
challenged or dealt with appropriately
because lecturers lack confidence.
n Reflecting on and challenging
ethnocentricity is the start of the lecturer’s
journey to culturally competent teaching.
n A supportive safe environment enables
lecturers to adopt anti-racist teaching
strategies.
n Mentorship/supervision can help lecturers
develop the transformative learning
approaches which are key to anti-racist
and cultural competence education.
British Journal of Nursing, 2007, Vol 16, No 7
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