Diversity & Equality in Health and Care Open Access

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- (2010) Volume 7, Issue 4

Critical practice in health and social care: understanding and developing learning and teaching opportunities in diverse learning environments

Mary Pat Sullivan PhD1*, Subhash Pokhrel PhD2, Kee Hean Lim MSc3

Lecturer in Social Work, School of Health Sciences and Social Care

Lecturer in Public Health and Health Economics, Graduate School

Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Brunel University, Uxbridge, UK=

*Corresponding Author:
Mary Pat Sullivan
Lecturer in Social Work, School of Health Sciences and Social Care Brunel University
Uxbridge UB8 3PH, UK.
Tel: +44 (0)1895 268846
email: mary.sullivan@brunel.ac.uk

Received: 13 April 2010 Accepted: 9 September 2010

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The health and social care work environment is being increasingly challenged to implement a range of strategic initiatives to respond to needs in diverse communities. Thus diverse communities of learning in higher education may represent an opportunity to educate students so that they can engage in critical and culturally competent practice in health and social care. This paper presents findings from a study that explored pedagogical approaches to diversity as forming an integral part of professional training for students in health and social care programmes.More specifically, the aim of the study was to develop an understanding of ‘interactional diversity’ and its potential impact on developing critical action and cultural competence among future practitioners. Data were collected using a cross-sectional survey and in-depth interviews with a sample of students and academic staff in programmes that educate future health and social care practitioners. The key findings suggest that both academic staff and students demonstrated some readiness for opportunities to engage more fully with the diverse learning communities in health and social care. Broadly speaking, staff and students in health programmes were less likely to recognise the value of interactional diversity, and this was reflected in the curriculum. Social work students, closely followed by students in physiotherapy, indicated high levels of confidence about future practice with diverse groups. However, the need for proactive strategies to develop interactional diversity, a curriculum that reflects diversity, learning environments that facilitate growth from conflict, and linkages between classroom and practice learning also emerged as relevant to reinforcing positive learning climates on the university campus. Interactional diversity as a learning and teaching tool has important implications for the development of health and social care practitioners who are able to respond to diverse groups of service users, and who also contribute to the development of socially cohesive communities

What is known on this subject

• There is a pressing need for cultural competence training in health and social care.

• ‘Interactional diversity’ has a positive impact on academic skill development and student learning outcomes.

• There are important challenges to implementing teaching strategies to address diversity and cultural competence.

What this paper adds

• It explains how ‘interactional diversity’ may contribute to learning and teaching in health and social care programmes that are preparing students for culturally competent and critical practice.

• It considers possible barriers to maximising learning and teaching in diverse learning environments.

• It discusses strategies in higher education to maximise the benefits of ‘interactional diversity.’

Key words

complex social interaction, critical practice, cultural competence, interactional diversity, learning and teaching


In the UK, public-sector services in increasingly diverse communities are developing and implementing service frameworks that embrace an equality, human rights and social cohesion agenda for action. Health and social care is a good example of where the workforce is being challenged to become more strategic and innovative to ensure that service users do not experience discrimination and disadvantage. The recently published guide, A Dialogue of Equals (Department of Health, 2008, p. iii), which addresses community engagement with marginalised groups to reduce health inequalities, uses the phrase ‘Look beneath the surface, change the way we think’ to challenge healthcare professionals to initiate meaningful dialogue with their ‘partners’ in service development. The personalisation agenda in social care also emphasises individuals having control over the services that they need and how these are delivered, and aims to ensure freedom from discrimination or harassment (Department of Health, 2005). Thus critical practice in health and social care embodies the notion of action aimed at social progress, namely the establishment of social structures that permit opportunity, justice and equality for all citizens (Adams et al, 2002).

A similar picture exists within the higher education environment. In response to the Government’s initiative on widening participation, universities throughout the UK have made a commitment to attract and meet the learning needs of a diverse student population (National Committee of Inquiry into Higher Education, 1997; Powney, 2002; Jones, 2006). Similarly, the university classroom in the UK has also changed as a result of immigration patterns and the large number of international students who are attracted to a range of educational opportunities here. As such, pedagogical approaches to dealing with diversity form an integral part of the student’s education.

For health and social care educators several important challenges emerge. Among these is the thoughtful consideration of how to effectively utilise a range of learning and teaching tools that are responsive to the diverse student population, and what methods are best implemented to prepare students for practice, given the current environment. Moreover, there is the question of whether student diversity in the university presents a seemingly overlooked opportunity to prepare future health and social care practitioners for culturally competent and critical practice.

This paper reports on a study that explored teaching and learning experiences which promote ‘interactional diversity’ or proactive learning strategies and tools that increase opportunities for interaction among diverse groups of students (Marin, 2000). The specific research questions included the following:

• What are the students’ perspectives regarding their experienceswithin a diverse learning environment?

• How does student diversity contribute to learning and prepare students for future clinical practice with a diverse client/patient population?

• Howare teaching staff responding to student diversity in the classroom? In the practice learning setting?

• What factors assist and/or challenge academic staff in their response to diversity?

The study’s theoretical underpinnings lay in critical pedagogy, given its commitment to critical dialogue and critique, creating opportunities for intellectual engagement that is characterised by active learning and the development of multiple perspectives about the social world around us (Giroux, 1997). Underlying the critical approach in its pursuit of social justice is an attempt to raise critical consciousness by analysing dominant discourses with regard to power, discrimination, inequity, and identities of race, gender, class, sexual orientation, religion, age and ability (Wong, 2004). Thus the ‘pedagogical project’ creates a communicative space in which to share multiple subjectivities, link personal and social issues, and develop students for active citizenship (Giroux, 1997; Nagda et al, 1999; Wong, 2004).

Following a brief review of the literature, findings from a cross-sectional student survey and in-depth interviews with faculty and students are presented. The paper concludes with recommendations for developing interactional diversity in higher education for students in health and social care as a foundation for cultural competence and critical practice.

Interactional diversity

Unlike cultural competence, which focuses on skill development in relation to knowledge, values and ideas that underpin professional practice with diverse service users (Walker, 2005), interactional diversity focuses on the perceived benefits of formal and informal interaction. Its appeal is its potential to attend to a range of diverse societal groups regardless of teaching content, and its emphasis on interaction rather than didactic instruction (Gurin et al, 2002). It also has the potential to equip students to critically engage with teaching that directly focuses on cultural competence (Papadopoulos et al, 2004; Browne and Varcoe, 2006; Colvin-Burque et al, 2007) and critical practice.

Until more recently, arguments about the benefits of diversity in higher education have lacked both empirical evidence and a theoretical rationale to support the link between diversity and educational outcomes (Gurin et al, 2002). In North America, a vast body of research evidence has emerged which argues that a wide variety of individual, institutional and societal benefits are related to diversity experiences.

Within a critical paradigm, Nagda et al (2004) and others have argued that the classroom is an in-vivo learning situation for multicultural democracy, that is, it prepares students to reconstruct a society that serves the interests of all groups. Using student survey data, Laird (2005),Nagda et al (2004),Asada et al (2003), Gurin et al (2002) and Marin (2000) have identified positive learning outcomes for undergraduate students who were enrolled in diversity-related modules. After controlling for background characteristics, those students who were exposed to a range of diversity experiences within these modules rated themselves higher than non-participating students in the areas of academic self-confidence (e.g. academic ability), development of self (e.g. critical thinking) and social agency (e.g. commitment to community service). Gurin et al (2002, 2004), using large-scale studies of more than 10 000 students, have continued to demonstrate positive learning outcomes, including the development of a range of academic skills and characteristics associated with citizenship, such as perspective taking, mutuality and reciprocity, acceptance of conflict, capacity to perceive difference, and interest in the wider social world.

Studies in the USA by Mayhew et al (2005), Gurin et al (2002) and Hurtado et al (2002) have outlined a number of organisational dimensions that have an impact on the development of a positive climate for diversity. The more positive the climate, the more comfortable the students, and the more effective the learning environment for the development of active citizenship. The key dimensions identified as creating a positive climate include the following:

• the institution’s legacy of inclusion or exclusion

• structural diversity or the representation of diverse groups on campus

• a psychological climate characterised by the perceptions, attitudes and beliefs about diversity and inclusion

• a behavioural climate characterised by how diverse groups interactwith one another in and outside the classroom.

Studies examining the learning outcomes as a result of informal social interaction among diverse groups of friends have also indicated positive student development in areas of awareness and leadership skills (Marin, 2000; Antonio, 2001).

A smaller body of research has explored knowledge, beliefs and attitudes regarding diversity among teaching staff. Although the education literature suggests that faculty generally embrace and value a diverse learning environment, there is some evidence that implementing teaching strategies that are responsive to diversity in the classroom continues to be a challenge (Hall et al, 1998; Maruyama and Moreno, 2000; Marcy, 2004; Garcia et al, 2005; Mayhew et al, 2005). Similarly, it appears that academic staff have responded to the challenge of educating a diverse student population by adapting curriculum and teaching methods, and in some cases by developing modules and/or workshops specific to diversity and cultural competence. However, this is primarily a US perspective, where multiculturalism is historically inherent to the origins of the country itself. Studies exploring student perceptions of learning alongside a diverse group of peers demonstrate positive learning outcomes (Rozas, 2007), as well as a variety of less enthusiastic experiences based on a host of factors such as general environment or instructor characteristics (Holley and Steiner, 2005; Lawless et al, 2005).

Although in the UK there has been some work to describe planning in higher education as a result of widening participation (e.g. Powney, 2002; Lawless et al, 2005), less is understood about what has supported or what has challenged the changes. Moreover, very little has been documented in terms of how diversity is integrated into educational programmes designed to promote cultural competence, and the outcomes of these efforts (Papadopoulos et al, 2004; Dogra, 2005).

To summarise, the research suggests that interactional diversity across a range of academic programmes has a positive impact on enhancing educational outcomes. Specifically, the evidence confirms interactional diversity, particularly structural, classroom and informal diversity, as contributing to student development in relation to their membership of a pluralistic democratic society. However, the research is largely located in America. How these potential benefits are being realised elsewhere, and with students who are preparing for cultural competence in the fields of health and social care, is less well understood.



The study was conducted in one School at a large university in southern England. The School provides research-led teaching for approximately 2000 fulltime and part-time undergraduate and postgraduate students.


The sample was drawn from students and academic staff in undergraduate and postgraduate social work, occupational therapy, physiotherapy and health studies. Based on the student census, the survey was administered during a 3-week period in the winter term of study for students registered (full- or part-time) in their final year of undergraduate or postgraduate study (n = 420). During this same period all members of teaching staff received an electronic message describing the purpose of the research and expectations for volunteer participation in an in-depth interview.

A total of 304 students responded to the survey, giving a very high response rate of 72%. In total, 37.5% of the students were studying occupational therapy, 25% social work, 24% physiotherapy and 13.5% health studies. Recalling that a positive climate for diversity includes the extent to which diverse groups are represented on campus (Gurin et al, 2002; Hurtado et al, 2002; Mayhew et al, 2005), the students who completed the survey represented a very diverse group, as indicated in Figure 1.

Further analysis demonstrated that representation from diverse groups varied among programmes, with both the undergraduate and postgraduate social work programme being the most diverse in terms of race, religion, age, learning difficulties and sexual orientation. Students in the undergraduate physiotherapy programme were the least diverse with regard to these same characteristics.

In total, 32 returned surveys indicated agreement to participate in a 1-hour semi-structured interview. Of those, 10 students were randomly selected to explore their learning and teaching experiences in greater depth. Semi-structured interviews were also conducted with a volunteer sample of academic staff (n = 10). Five of the student interviews were conducted in social work and five in the health-related programmes. Seven of the students were female, nine were heterosexual, and the students were from a variety of ethno-racial and religious backgrounds. Academic interviews were conducted with six lecturers and four senior lecturers with duration of teaching experience ranging from 4 to 20 or more years. Three staff members were male. Two interviews were conducted in social work, and the remainder in health programmes. Seven staff members classified themselves as white.

Data collection

The study utilised a mixed methods approach to permit an in-depth description and understanding of different aspects of interactional diversity in the School, and conditions that either encouraged or hindered its impact on professional training. Consistent with much of the research in this area, the study utilised a crosssectional survey, and in-depth interviews with academic staff and students. Ethical approval was received from the university ethics committee.

The survey instrument that was used in this study was designed by the researchers to address the first two research questions. The survey questions were divided into four sections to elicit a description of student diversity in the School, and an understanding of the experiences of learning in a diverse classroom. Section 1 asked questions designed to elicit information about demographic characteristics. Sections 2 and 3 focused on student perceptions of diversity in the School and diversity as a learning tool. The final section explored academic self-confidence, critical thinking and social agency based on the work of Laird (2005). It was piloted using a sample of postgraduate first-year students followed by a review and revision by the researchers.


Figure 1: Survey sample description (n = 304)

At the end of a regularly scheduled lecture for each programme and programme level, one researcher attended the class to explain the purpose of the research and voluntary participation, and to provide the survey for distribution and completion. Arrangements were made for completed surveys to be deposited at a central collection point.

Interviews were then conducted with a sample of students and academic staff. Unlike the survey, this approach permitted a more in-depth exploration of interaction, critical engagement and dialogue in the learning settings. Informed consent was obtained from 10 student volunteers, and the interviews were used to clarify understanding of some of the responses that emerged from the survey results. Similarly, interviews were conducted with 10 volunteers from the teaching staff. These questions, which had been piloted 12 months earlier, focused on the last two research questions to obtain in-depth descriptions of how staff were responding to a diverse student population. All of the interviews were digitally recorded and transcribed verbatim.

Data analysis

The survey data analysis was largely descriptive, to illustrate the underlying patterns in the data.The analysis was performed using SPSS. First, group means and percentages were calculated in order to describe the variation in the sample. Then wherever appropriate, non-parametric or parametric tests were performed to establish the statistical significance of the differences in responses between the groups.

The interview data were coded and analysed in accordance with thematic content analysis (Miles and Huberman, 1994), with the aid of NVivo software. A list of descriptive codes was established, informed by the research questions and conceptual underpinnings, and was revised as necessary during the early coding stage. This was followed by patterned coding to examine overarching meaning units and variations in the data, including memoing, until descriptive conclusions could be established. The descriptive conclusionswere interpreted from the key concepts in the above-mentioned literature.



The student body was representative of a diverse learning environment. More importantly, a significant majority of the students strongly agreed or agreed that the university and their programme of study supported diverse groups. There was little variation between programmes. Furthering the examination of a positive climate for diversity (Mayhew et al, 2005), the majority of the students indicated that they had neither experienced nor witnessed discrimination in the classroom or on campus. However, a significant minority stated that they had experienced (17%) or witnessed (26%) discrimination. Further analysis indicated that these students, by comparison with their peers, perceived the university or programme support for diversity less positively.

A positive behavioural climate for diversity considers the extent to which diverse groups interact with one another (Hurtado et al, 2002; Mayhew et al, 2005). The students were asked to rate their desire to interact with diverse groups of students, an area that is not identified in the existing research literature. For 10 different types of diversity, students were asked to rate their desire to interact on a five-point Likert scale (where – 2 = very weak, – 1 = weak, 0 = neutral, + 1 = strong and + 2 = very strong). Figure 2 shows the percentage level of desire to interact for each type of diversity across all students.

Most of the students did not simply go through the list and tick a strong or weak desire for all groups, but rather they gave different ratings of desire according to each group. And registration in social work, for example, did not guarantee a stronger desire to interact across difference than registration in a health programme. Although desire was strong for all types of diversity, students rated the strongest desire to interact with different racial/ethnic groups or age groups.Aweak desire or lack of desire was most frequently reported for individuals belonging to different religious groups, or for individuals with a different sexual orientation. Thus a weak desire or a very weak desire may support the argument of Marin (2000) that interaction among diverse groups needs to be activated. Furthermore, Nagda et al (2004) and Asada et al (2003) have argued that increasing opportunities for interaction is associated with improved motivation to interact across difference. Desire as a percentage of the maximumattainable score for each diversity group was also established, and a paired student’s t-test was performed to test for differences between scores for social work and all health programmes combined. No statistically significant difference was found.


Figure 2:Desire to interact with diverse groups (n = 304)

Students in social work (60.5%) or occupational therapy (56.7%) were more likely to indicate a need for increased formal opportunities for interaction across different groups than students in physiotherapy (45.1%) or the other health programmes (41.5%). Students fromnon-white backgrounds tended to express a need for more interaction opportunities than white students. With regard to informal interaction, 60% of all students suggested that there should be an increased number of opportunities for interaction outside the classroom.

Approximately 80% of all students expressed the view that a diverse learning environment had made a positive contribution to their development. However, the level of perceived agreement with curriculum outcomes varied significantly across the programme of study (P < 0.05). Generally speaking, social work students reported being more confident than students in the other disciplines. However, confidence among physiotherapy students did not lag far behind. Physiotherapy students were the most confident in their ability to communicate across difference, but were the least confident with regard to development of their critical thinking skills. This high level of confidence among physiotherapy students was also noted by Hean et al (2006). Overall, occupational therapy students were the least confident. The results are shown in Table 1.


Five interrelated themes related to the psychological and behavioural climate of the classroom emerged from the interviews with students and academic members of staff, and aid further understanding of some of the findings of the survey.

Student readiness

Although the students had been asked to rate their desire to interact with diverse groups, the findings of the interviews more appropriately captured desire as a degree of readiness. Students’ degree of readiness most often related to their socialisation prior to embarking on their studies. These social experiences were described as positive (thus encouraging readiness), negative (reinforcing an attraction to similarity) or simply few in number (which meant that they expressed openness to learning in the university environment). For example, a physiotherapy student commented on her background, which had a negative effect on her desire to interact:

Sexual orientation, I think that’s part of my ignorance. I don’t see how ... I think I’ve probably got an ignorant view of sexuality in terms of kind of openly gay people, openly gay men and openly gay women. But you know, it’s not one of my desires to want to interact with that ... because of kind of like my family background and their beliefs. If I did kind of have an openly gay friend, they’d never be able to interact socially with my family ... you kind of stick to what’s comfortable for you.

(Physiotherapy student)

Pre-university experience has been highlighted in the literature as being an important consideration in the endorsement of interactional diversity either to confront negative social stereotypes among the student population or to facilitate the promotion of a positive climate for diversity (Hall et al, 1998; Hurtado et al, 2002; Asada et al, 2003; Umbach and Milem, 2004; Mayhew et al, 2005).

For six students, however, their desire to interact with difference appeared to be more closely aligned to their desire for personal and professional growth. Specifically, university represented a time of transition in their lives as they prepared for anticipated social interaction in their professional careers. For these students, opportunities for interactional diversity in the classroom and on campus needed to be increased.


Table 1 :Percentage of perceived agreement with curriculum outcomes by programme of study (n=304)

However, student readiness for interactional diversity was mediated by a number of university experiences, which appeared to either eradicate a positive desire or allay a negative one. These university experiences, as described by the students and academic staff, come to light in the following sections.

Academic readiness

There was fairly consistent recognition that cultural competence was important for all of the students in these programmes. Yet widening participation had had a varied impact on different programmes, and pressure in all programmes to ensure that teaching focused on core skills development meant that there was also variation in how and to what extent instruction focused on cultural awareness through to cultural competence or critical cultural competence. For example, occupational therapy was admitting more students from diverse backgrounds and had some instruction on practice with culturally diverse groups. Physiotherapy studentswere predominantly white and English, and practice with diverse groups was viewed only as a future priority. The social work programme had a long history of attracting students fromvarious backgrounds, yet cultural competence did not appear as an educational outcome, although critical practice did. None of the programmes delivered a specific module on working with diversity. Interestingly, there was a tendency among all those interviewed to view diversity in the classroom as a sensitive political issue rather than a potential in-vivo learning situation:

But pressure from university is to graduate students. It’s about money and not about quality teaching. I don’t talk about diversity. Being [ethnic background] has only been a problem for me. It’s better not to talk about it and be English. Diversity just gets in the way. Being different is not good in this country.


Whether this staff member really supported these views or not, teaching efforts were primarily focused on awareness raising through didactic instruction as opposed to purposeful opportunities for structured interaction. Exceptions were noted among the three lecturers who were members of an ethnic-minority group. Here the issues for student learning appeared to be well understood, but even these were criticised as ‘not necessarily good enough’:

It should be the responsibility of every one teacher to say, how can I engage? ... It’s a society that we’re dealing with, you know, they’re there and you say client A is, isn’t just client A, he’s either black, a woman, disabled, you know, has a whole identity there you have to engage with. That’s what it comes down to in the end. Here’s the client identity, here’s your identity, some of it will be similar, some of it will be different. What are you going to take into account when actually thinking about how you deal with this client, how you form a relationship with that client, how you offer services for that client ... there isn’t a universal client that is, you know, raceless, genderless, you know, disability-less ... students should be asking these questions ... let’s just talk about our difference and see what that means in terms of thinking about this client, that’s the sort of thing that we should be doing all the time.


It was equally noteworthy that eight members of staff stated that they did not know how to use diversity in the classroom as a learning tool. It was commonly assumed that ‘awareness’ was sufficient for ‘effective working’, or that diverse groups of students simply learn from one another ‘naturally.’ This was in contrast to another academic’s observation that students appeared to form distinct friendship groups, typically racial ones, from the outset of their studies.

A final issue for staff was their discomfort with conflict in the classroom, and their management of the interactive process among students. For example, they were not confident that they could foster genuine dialogue when potentially oppressive ideas were being expressed by students. Although it was recognised by some that cultivating an environment which challenges the predominant discourse and encourages students to think ‘outside the box’ is an academic responsibility (Wong, 2004), ‘it’s difficult to hold on to with all the stresses we have on the job.’ These findings are consistent with those of Garcia et al (2005), Maruyama and Moreno (2000) and Hall et al (1998), and appear to reinforce the idea that changes in teaching and learning practices may only be achieved through significant institutional leadership.

Unsafe classroom

Both students and academic staff viewed the classroom as an unsafe environment in which to engage in a range of diversity experiences. From the student perspective, there was recognition that although the classroom should be ‘the right time and place’ and an environment in which individuals ‘should be able to fall down and get back up again’, risk taking was not viewed positively. Students were simply afraid of being judged by their peers and by those who would evaluate their work. Similar views have been expressed by Holley and Steiner (2005) and Papadopoulos et al (2004) when exploring models for teaching cultural competence. Social work students were more vocal than those in the other disciplines, probably as a result of a professional emphasis on being agents of change, and anti-oppressive models of practice. For example, one social work student was surprised to hear a stereotypical comment about homosexuality in the classroom, and remarked on the behaviour of both the lecturer and the students:

Often I think the lecturer sometimes has been just taken aback and just kind of changed the subject and they’d move on, but with the other students you’d see a lot of head shakes and a lot of frowns. But there doesn’t seem to be much input, people are shaking their heads and complaining and rolling their eyes but they don’t actually ... and I myself as well, I’ve been given this [opportunity] but don’t actually input or challenge these oppressive views or, you know, promote certain differences.

(Social work student)

Examples of academic staff appearing to circumvent potential areas of conflict and students simply remaining quiet were not uncommon. Staff appeared to have little confidence in managing potential conflict, and as one experienced academic stated, ‘learning to agree is simple; learning to disagree is a very different matter.’ The effective management of this type of conflict has been highlighted by Wong (2004), Garcia et al (2005) and others.

Diversity as a learning and teaching tool

Academic staff were generally unaware of how to use diversity in the classroom as a learning and teaching tool for developing cultural competence and critical practice. For example, lecturers tended to use small group exercises, but these were not planned to promote interactional diversity. Furthermore, staff acknowledged that case studies and reading lists, for example, did not necessarily always reflect the diversity of the population. A review of the academic curriculum confirmed that attention to culturally competent or critical professional practice was inconsistent. Although more infused within the curriculumof social work and occupational therapy, approaches to learning and teaching appeared to remain within the domain of individual lecturers.

Surprisingly, the student surveys indicated high levels of confidence about future practice with diverse groups. In fact, the confidence levels of physiotherapy students were as high as or higher than those of students on other programmes, despite the fact that they had the least amount of input and interaction with regard to practice with diverse groups. A few important findings emerged which demonstrated that skill development was not well understood by the students. First, students most readily accredited their skill development to practice learning or current employment. A part-time nursing student explained her experience and emphasised social interaction as she concluded that:

My current workplace has definitely made me think more about what ... how I say and how things are perceived and I guess how English my thoughts are ... so definitely my workplace ... I don’t think within an educational institution I’ve questioned it so much ... because I guess, you know, in the workplace you have to work with others.

(Nursing student)

Students in health programmes seemed to understand that skill development equated to knowing the organisational policies on discrimination and equal opportunities. One of these students specifically mentioned that working with difference involved using her ‘common sense’, which was interesting as it seemed to capture how students framed the absence of attention to diversity both in the classroom and in practice learning. In other words, so long as they knew the organisational rules, common sense would guide practice.

Social work students tended to agree that they were confident about ‘talking the talk’, but less confident about ‘walking the walk.’ In other words, they were skilled at using anti-oppressive language and articulating theoretical arguments, but they were less certain what this meant for daily practice, even after completing several placements.

Diversity in the practice learning environment

It is worth making one final point about practice learning (or current work experience in the case of part-time students), as it emerged in all of the interviews as an important feature for development with regard to working with difference. The students consistently reported that concerted attention to culturally competent practice was not commonplace. Rather, working with a client from a different background happened by chance, and any deep learning was more or less the responsibility of the student. The number of such chances was typically high, but the nature of learning was left unexplored. Academic staff reported that links between classroom learning and learning in practice were either weak or non-existent. Thus the potential bridging between the two environments with regard to learning about diversity, culturally competent practice and critical action was not well understood.


The principal aim of this study was to explore interactional diversity as a potential learning and teaching tool in health and social care programmes. Consistent with a critical pedagogical lens, interactional diversity is concernedwith constructive learning strategies that promote student interaction across different groups to facilitate critical engagement and dialogue, mutuality, and social agency. It becomes particularly relevant given the more acute concern about increasing diversity in many societies, the challenges of contemporary practice in health and social care, and the imperative for critical practice and cultural competence in the caring professions. Although the findings of the study suggest that interactional diversity was less well developed and less well understood than in the USA, for example, they nevertheless provide some key messages for critical approaches to educating future health and social care practitioners in the UK and elsewhere.

The findings of both the survey and the interviews supported the contention of Marin (2000) that the promotion of structural diversity in and of itself was not sufficient to create effective learning environments, and that the potential outcomes of diversity in the classroom needed to be activated. Thus the institution’s psychological and behavioural climate, which plays a key role with regard to learning out comes for practice with diverse service user groups, required strategic attention by teaching staff.

In addition, it became very apparent that a student’s desire to interact in the first place was a complex area. The desire was often rooted in previous positive and negative experiences, and was not necessarily static. In the absence of desire, both critical pedagogy and research evidence would suggest that it is incumbent on the institution or programme to create opportunities to foster it (Giroux, 1997; Marin, 2000; Asada et al, 2003). As those students who were interviewed indicated, group formation occurred naturally at the start of their programme, and remained fairly closed and constant unless there were activities that encouraged reformation of groups.

Does diversity in the classroom continue to present an overlooked opportunity to educate students for culturally competent and critical practice? Formal classroom interactional diversity appeared to be less well developed and understood, and thus affected the behavioural and psychological climate (Gurin et al, 2002; Hurtado et al, 2002; Mayhew et al, 2005). The findings from students appeared to indicate that purposive interactional diversity was limited across programmes of study, that curricula continued to be structured according to dominant ideology, that opportunities to explore dominant values, attitudes and beliefs were limited, and that activities to bridge practice learning with classroomlearning were almost non-existent. From the academics’ perspective, work pressures and lack of knowledge appeared to overshadow recognition of the likely learning opportunities. Importantly, however, features of critical pedagogy were more apparent in social work and occupational therapy than in physiotherapy and health studies. These findings are more consistent with those of Hall et al (1998) and Marcy (2004), who comment on the need for more institutional commitment to diversity and transformed educational practices, than with those of Maruyama and Moreno (2000), who found academic staff well prepared to teach in diverse classrooms. However, further research is needed, particularly in view of the anticipated substantial shifts in higher education due to budget restrictions.

Despite the limited opportunities for interaction in the classroom, students perceived increased confidence levels in the development of aspects of self (Marin, 2000; Gurin et al, 2002; Asada et al, 2003; Nagda et al, 2004; Laird, 2005). According to the interviewed students, this area of development seemed to be more related to practice learning than to classroom learning, and related to positive experiences of diversity in earlier life. Mayhew et al (2005) and Hurtado et al (2002) have also documented the important influence of pre-university experience. For some, the awareness of discrimination policies equated to confidence in managing conflict or engaging in social action without recognition of the complexity of the area itself, which might indeed contribute to a decreased level of confidence.

In terms of those programmes that instruct students with regard to cultural competence and critical practice, these findings also emphasise the importance of academic practices that facilitate social interaction to raise awareness, facilitate knowledge development and promote sensitivity to ‘the other.’ However, one must recognise the limitations of stopping here. In and of itself, awareness raising does not equate to practitioner skill for culturally competent practice or guide the practitioner to critically consider the underlying systemic structures that lead to the marginalisation of certain groups (Papadopoulos et al, 2004; Browne and Varcoe, 2006). Thus interactional diversity seems to provide a solid foundation from which to facilitate the building of skills for critical and cultural competent practice. This issue was particularly relevant with regard to practice learning where interactional diversity took place.

In the light of the study demonstrating the structural diversity within this School, consideration of the classroom as an in-vivo environment to develop a psychological and behavioural climate for diversity was highly relevant. The findings suggest that there was sufficient readiness (positive or negative) among both students and academic staff to maximise a variety of learning opportunities. The matter then becomes one of strategically building on interactional diversity to achieve its full benefits. The implications for academic practice include:

• using interaction to develop essential understanding of similar and different identities among students

• creating learning environments that permit dominant discourses to be challenged, and that facilitate growth opportunities from conflict or reactions to the unfamiliar (Wong, 2004; Comerford, 2005; Garcia et al, 2005)

• developing curricula that reflect health and social care in a diverse society (e.g. cultural competence)

• formally bridging classroom and practice learning to ensure continued growth and development. This latter point is highly significant given that the research literature has not adequately addressed professional programmes to explore learning in a combination of environments.

The next step is the development of research to systematically evaluate learning outcomes based on interactional diversity, in order to more fully understand howto develop critical and culturally competent practitioners in health and social care. This becomes even more relevant as the delivery of education continues to be transformed due to, for example, various technological developments, distance learning, reduced budgets, increasing class sizes, role changes for academic staff, and so on.

Briefly, the limitations of this study should be acknowledged. Students may have been inclined to provide what they perceived to be desirable responses to the self-completed questionnaire. In addition, the researchers recognise that there is often a difference between stated and actual behaviour. Most importantly, the findings must be considered within the context in which the study took place, and generalising the results to another School or university may be inappropriate.


Even in the broadest sense, the role of higher education in the promotion of citizenship and social cohesion has not diminished. For educators preparing future practitioners in health and social care for critical and culturally competent practice, the current context demands that everyone is not only skilled at working with a range of service users, but also capable of contributing to workplace environments that cultivate acceptance, equality and social progress.


This researchwas funded by the university’s Academic Practice Development Unit. The views and opinions expressed are solely those of the researchers.