Diversity & Equality in Health and Care Open Access

Key words

nurse education, racism, transcultural nursing education

Introduction

The importance of transcultural nursing in affording sensitive, safe, quality care for all clients has been recognised since the seminal work of Leininger (1978) almost three decades ago. Throughout the 1990s different transcultural nursing models emerged mainly from the US (Giger and Davidhazar, 1990; Leininger, 1991,1995; Purnell and Paulanka, 1998; Campinha- Bacote, 1999) and Papadopoulos et al (1998) in the UK. Despite this expansive body of knowledge, there is still evidence that people from minority ethnic groups in Britain receive poor care (Culley, 2001; Holland and Hogg, 2001; Nairn et al, 2004; Narayanasamy and White, 2005). Nursing curricula prepare nursing students for clinical practice, and although good examples exist, transcultural nursing education is neglected, minimalist, tokenistic or happenstance (Gerrish et al, 1996; Gerrish and Papadopoulos, 1999; Narayanasamy and White, 2005).

In particular there is a neglect of racism in nursing curricula (Shaha, 1998; Sawley, 2000; Nairn et al, 2003; Cortis and Law 2005). Although the problem is not unique to healthcare education (Bhavnani et al, 2005), anti-racist strategies have been largely ignored in the education of nurses (Culley, 2001; Nairn et al, 2003) and caring professionals (O’Hagan, 2001). Racism is a sensitive issue which engenders anxiety, evokes blame and incurs feelings of anger or guilt among students and lecturers. It is not always intended, explicit, or discernible because it originates in socialised attitudes and behaviours enacted through systematic, familiar practices (Essed, 1991). For these reasons nursing lecturers are unskilled in addressing racism (Papadopoulos et al, 1995) or exploring conflicts, perceptions and experiences contributing to and reinforcing racial tensions (Shaha, 1998; Cortis and Law, 2005). Although the literature recognises the need to address racism (Alleyne et al, 1994; Papadopoulos et al, 1995), there is limited attention to how this might be achieved in nurse education (Foolchand, 2000; Nairn et al, 2004).

The article describes a study (Tilki et al, 2006) undertaken in a university preparing student nurses for clinical practice in diverse, multicultural and mostly deprived areas of London. It originated in the concerns of the researchers about racist attitudes and behaviours observed and reported by students and lecturers. The study is underpinned by the Papadopoulos, Tilki and Taylor (PTT) Cultural Competence Model (1998), the development of which originated in concerns about the adequacy of transcultural nursing models in the early 1990s.

The PTT model sought to address weaknesses in existing models and mirrored the critiques of Bruni (1988), Cortis (1993), Culley (1996), Lister (1999) and Price and Cortis (2000). Apart from concerns about the complexity of Leininger’s model and its transferability to a British context, the primary intention of the PTT model was to redress the neglect of socioeconomic factors, power relations and particularly structural racism. The focus of this model was not on providing cultural information but on promoting critical reflection, generating openness, and exploring and challenging personal and professional ethnocentricity. It aimed to shift the focus from the client’s culture to that of the practitioner, profession or organisation. Given the emphasis on skin colour in the UK, the PTT acknowledged that culture related to everybody, including the majority white population. Rather than viewing culture as a problem, the model emphasised richness and diversity, although acknowledging problems with unmet cultural need. It moved beyond static, deterministic characteristics to acknowledge the dynamic nature of culture and the shifting, contextual ways in which people adhere to it. Additionally it emphasised heterogeneity within any culture and similarities across cultures.

The authors propose that there are four stages in the development of cultural competence (see Figure 1) The first stage of the four-stage model is cultural awareness. This relates to personal cultural identity, values and beliefs and how these factors influence our perceptions and relationships with others. This was particularly relevant for the research because most racism in Britain today is unconscious and unintentional. The second stage, cultural knowledge, concerns socio-economic factors, power relationships and structural inequalities. It is particularly concerned with unconscious ethnocentric, stereotypical assumptions and organisational factors that discriminate against individuals or groups. The study sought to explore perceptions and experiences of discrimination especially those originating in ethnocentricity and stereotyping. Cultural sensitivity, stage three, relates to interpersonal relationships, trust, respect and appropriateness. It is concerned with behavioural norms and communication patterns which differ across cultures, potentially creating problems or misunderstanding. The research aimed to explore perceptions of trust, experiences of disrespect and behaviours prone to misinterpretation. The final stage, cultural competence, is a synthesis of earlier stages for assessment and diagnostic purposes and the delivery of culturally appropriate care. An important component of cultural competence is the ability to recognise and challenge racism, discrimination and oppressive practice. The research sought to explore students’ and teachers’ definitions of racism and the ability of teachers to recognise and address it (see Figure 1).

The study context

The Nursing and Midwifery Council (2004) sets explicit proficiency standards for culturally competent, anti-discriminatory practice in preregistration nursing education, while equality and diversity is a core dimension of all NHS jobs (Department of Health, 2004). The Race Relations (Amendment) Act (2000) places a legal duty on public authorities to promote equality. However, if lecturers fail to recognise or address discrimination, it is unlikely that statutory obligations will be met.

The study

Aim

The aim was to examine perceptions and experiences of classroom racism among students and lecturers and the ability of lecturers to address prejudice and racism.

Design

Qualitative methodology with an exploratory design aimed to elicit perceptions, meanings and experiences of racism from the perspective of students and lecturers (Denzin and Lincoln, 2003). Interpretive phenomenological analysis (IPA; Smith et al, 1999) provided a way of exploring meanings attributed by the participants to experiences and cognitions. It emphasises individual perceptions rather than objective accounts of events. IPA recognises that meaning is constructed in interaction between the participants’ accounts and the researcher’s interpretive framework, and is interpretive in that the researcher makes sense of the participants’ experiences. This therefore requires conscious awareness of the researcher’s conceptions, beliefs and experiences. It was anticipated that having researchers from different cultures would afford diverse interpretations and generate debate about the meanings attributed by participants to behaviours and attitudes.

Methods

Focus groups were a cost-effective data collection method which enabled differing perspectives to emerge, be explored and debated, elucidating the context or justification of different views and positions (Wilkinson, 1998). The focus group schedule was informed by the literature on racism and the researchers’ experiences of classroom tensions. The tool was flexible to facilitate probing of unanticipated issues emerging in focus groups. Interview schedules for students and lecturers were developed in the same manner but were shaped by issues emerging from the focus groups. The tools explored understanding of racism, perceptions/experiences of discrimination, skills and confidence of teachers in addressing cultural issues and managing associated tensions in the classroom.

Semi-structured interviews aimed to discuss issues, experiences and opinions that might have been uncomfortable in focus groups. Interviews allowed deeper exploration of issues arising in focus groups, especially the contradictions or tensions that emerged. Lecturer interviews afforded a safe forum for exploring perceptions of ability to challenge prejudice or handle racist incidents.

Sampling and recruitment

Purposive sampling was used to recruit first-, secondand third-year students from adult, child and mental health branches to the focus groups. Invitations to participate were posted on notice boards and the research was publicised by module leaders who encouraged students to participate in either the focus groups or the individual interviews. The intention was to interview students from cultures under-represented in the focus groups. Despite considerable publicity and personal contact only two students were interviewed.

All lecturers were invited by email to participate in the lecturer focus group. Four lecturers were purposively selected for their different ethnic backgrounds, branch expertise and lecturing experience. The intention was to explore differing attitudes or experiences relating to culture, age and nursing specialty.

Ethical considerations

Ethical approval was obtained from the university’s health ethics sub-committee. Consideration was given to protecting the confidentiality of participants and obtaining consent to collection, recording and subsequent use of data. Participants received written information about the project, and written consent was obtained. It was envisaged that participants might be reluctant to express true feelings or identify racist experiences, especially in focus groups. Ground rules were therefore agreed by each focus group and included listening, allowing others to speak without interruption, and not naming individuals or discussing issues outside the group. They also referred to being honest in a spirit of learning and sharing, while not regarding discussions to be personal or taking offence at a colleague’s contribution.

Data collection

Focus groups were facilitated by the research team between February and May 2005, while individual interviews took place between May and July 2005. Three focus groups were undertaken with students in their first, second and third year of training involving 10, 16 and 10 students, respectively (total 36). Student focus group participants were predominantly African, reflecting current recruitment patterns in the university.

One focus group involving 11 lecturers was conducted. The lecturers’ focus group included women and men of different cultures, expertise and experience

Interviews were undertaken with two students, a male and female, of English and European origin. Four lecturers were interviewed, two men and two women, from African, Asian, Caribbean and English backgrounds.

Focus groups and interviews were recorded with participants’ permission and transcribed verbatim.

Data analysis

Interpretive phenomenological analysis (Smith et al, 1999) informed by Bryman and Burgess (1994) and Miles and Huberman (1994) was undertaken. All members of the research team were involved in collecting data and, as normal with qualitative research, analysis began during the collection process. Team analysis was undertaken with meetings to discuss emerging data, clarify findings and promote interresearcher consistency. These meetings engendered considerable discussion, as researchers from different cultural background brought differing perspectives and understandings to the emerging data.

Focus group transcripts were read individually by all researchers, identifying key issues, concepts and themes in the data. Themes were coded and descriptions agreed to ensure consistency between analysts. Each researcher then worked with specific themes and a further team meeting examined overlaps, omissions and links.

Each researcher listened several times to recorded interviews of specific students or lecturers. They listened for recurring themes and similarities or contradictions between focus group and interview data, particularly noting new or unanticipated information. The team then discussed themes, similarities and contradictions across data sources, links between different categories and exploring causal relationships and explanations.

The trustworthiness of the data analysis process was enhanced by both researcher and method triangulation and comparisons with relevant research. Researcher triangulation was facilitated by team analysis and the cultural and professional diversity of members. Method triangulation compared focus group and interview data for consistency, while contradictions and inconsistencies were examined, debated and interpreted.

Reflexivity in the research process

The team consisted of two Irish, two Caribbean and two English lecturers, with varying research and teaching experience and cultural knowledge, which impacted at all stages of the research. These differing perspectives afforded a fertile ground for debate, especially when clarifying themes and justifying illustrative text during the analysis. All the team members were guilty of some behaviours that students perceived as racist, and defensively went to great lengths to question what was meant by racism. The perspective of the Caribbean researchers was particularly helpful. Because of past personal experiences they could empathise with students who believed they had experienced racism. Their understanding was particularly illuminating in exploring the distinction between unacceptable and racist behaviour and the tensions between African and Caribbean students. The Irish researchers repeatedly drew attention to the evidence that racism was not confined to black individuals. The English researchers reminded us of the heterogeneity of English and all cultural groups. The research process was painfully enlightening for all the researchers and a courageous reflective account of the journey for one researcher is available elsewhere (Markey and Tilki, 2007).

Findings and discussion

Four recurring themes emerged from the data with considerable consistency between students and lecturers and between focus groups and interviewees.

Understanding racism, predisposing factors and manifestation

When asked to define racism, the immediate response of lecturers and students was to explain it in relation to skin colour. Lecturers added spontaneously that racism was more complex than colour conceptualisations and, with prompting, students explained how their notions of racism had changed over time. For example:

‘Since I came into nursing, my opinion towards racism has completely changed, because I only thought it was between colours, but I’ve experienced it where the same colour people have got a big problem.’ (African student FG2)

Although examples of white/black racism were described, a recurrent theme in the focus groups and interviews was the tension between people from Africa and the Caribbean. To a lesser extent this was evident among students from different African countries, first- and second-generation Africans or people of mixed heritage. These tensions impacted on relationships, and conflicts were acted out in various ways in the classroom such as:

‘Tut-tutting and kissing their teeth when somebody is speaking. Laughing at someone’s accent ...’ (Asian lecturer interviewee)

However, while lecturers described such conflicts, not all considered underlying racial motivations because:

‘It can be difficult to decide whether it is racism or just poor interpersonal skills.’ (Caribbean lecturer interviewee)

Regardless of the subtlety of expression, students instinctively suspected racism and it made them feel marginalised. In their view:

‘It makes me feel isolated, because it feels like what I said was not valid ... that my opinion isn’t valid, just because I’m Jamaican ...’ (Caribbean student FG3)

It made students suspicious of unfamiliar people, even avoiding classes where they felt uncomfortable.

Racism and the lecturer

The data showed that lecturers could be racist, perceived as racist or be the victims of racism. Overt racism was rare, but black students cited a number of ways in which they were treated differently from their white colleagues. For example, a black student described how she and her white friend were treated when seeking help from a white lecturer. They were unable to see the lecturer together, so had separate appointments:

‘She [white student] went on Monday and was told exactly what to do. I thought, ‘‘I’ll go anyway and maybe I’ll understand even better’’. So I went and I explained myself. She said ‘‘everything is in the book. Just go and read your book and it will tell you exactly what I want’’. She told me off, don’t waste my time.’ (African student FG3)

A number of black students felt more comfortable and fairly treated by black lecturers. Some black students saw impatience, lack of attention or criticism from a white lecturer as racially motivated:

‘So maybe you [lecturer] are impatient or something and then we might interpret it maybe they don’t like me because of my colour ...’ (African student FG2)

Students repeatedly perceived the way some lecturers dealt with English as a second language as insensitive or discriminatory. It hindered learning and left them feeling isolated, devalued, demoralised and uncomfortable speaking or presenting in class. They questioned whether these lecturers were racist. For example:

‘It’s your language [English]. When you are speaking it you are comfortable. It’s my second language. I am thinking is she [lecturer] racist. When I was trying to say something, she was doing this [rolls eyes upwards, sighs heavily].’ (African student FG1)

There was no evidence that the small numbers of white students in the study felt unfairly treated by black lecturers. However, black lecturers recounted uncomfortable experiences and although not always certain whether student behaviours were racially motivated, they had a sense of being excluded. For example:

‘Five students sitting in the back row and they glared at me, but when an ethnic minority student asked a question they would snigger ... It could be that I’m confusing racist behaviour when it isn’t, but when I take into account their ethnic ... they, they, they ...OKthen, I will say it. They were white girls.’ (Caribbean lecturer LFG)

However, some black lecturers’ experiences of racism did not come from white students. According to one participant:

‘The English students usually treat me no differently. It is usually the black students.’ (African lecturer interviewee)

Two black lecturers described the way in which some black students identified with them, speaking to them in a shared language or having expectations that made them uncomfortable.While black students sometimes saw criticism by a white lecturer as racial discrimination, there was an additional dimension when a black lecturer was critical:

‘Some say it to you in a very cynical, roundabout way [pause]. He wants to be one of them [white] or he’s been here too long.’ (African lecturer interviewee)

The comfort zone

The term comfort zone relates to how students group themselves in the classroom when not specifically organised by lecturers. Although both black and white students liked to sit with friends for group work, itwas more important for black students because:

‘I want a sense of belonging, at least she speaks my language, if I go with Louise, maybe, my English is not very good ... I will be more comfortable with her. Maybe beliefs, things like that. Especially in this foreign land.’ (African student FG2)

However, the tendency to gather with friends or culturally similar people was potentially exclusionary and a problem for any student in a minority in the classroom:

‘I was the only white English person in the class and I was completely ignored when I first started.’ (English student FG2)

Experiences of racism led black students to mistrust white people and avoid situations that might evoke discriminatory behaviour. A black student described being treated less favourably than white colleagues and described how this engendered resentment:

' These [white] girls never did anything wrong to me, but because they are getting this privilege I start to resent them. It’s a foreign country to me and I feel so insecure. When that happens, it reminds me, that people still see me as a lesser being.’ (African student FG3)

Mixing with different cultures meant that students challenged the stereotypes they had when they started the programme. For example:

‘I worked with a Ugandan lady and she always fighting and putting people down. Because of that, I thought all Ugandans are like that. I know different now.’ (African student FG1)

Challenging racist or potentially racist behaviour

Although the data highlighted examples of good practice, several lecturers lacked confidence handling racial conflict in the classroom. The tension between fundamentalist religious beliefs and respect for difference was a recurring theme in the data. Some lecturers were reluctant to challenge traditional conservative attitudes and this impacted on their credibility with students. For example:

‘A comment was made by a [black] student about homosexuality. She said ‘‘in my culture, it’s forbidden, it’s disgusting’’. The lecturer said ‘‘OK, that’s your culture’’. I’m sure if I made that statement I would have been challenged. I do think because she was black and because it was her culture she was allowed to say that. It seemed to me that the lecturer was weak. I didn’t respect her really.’ (English student FG3)

Most inappropriate behaviour originated in ignorance or intolerance of difference. Reluctance to move out of the comfort zone may not necessarily have racist motives, but when lecturers insisted on mixed working groups it had a positive impact once initial resistance was overcome:

‘Socialising with different cultures is the best part of group work. I mix with a lot of people from different cultures, and I find there is a very good experience because you learn.’ (Caribbean student FG1)

The lecturer data demonstrated the need for guidance, support and mentorship. Many lecturers were experienced nurses and managers but lacked confidence in translating this into classroom practice. In their view:

‘There is too much emphasis on curriculum planning without looking at what goes on in the classroom. Too much of [a] void between what happens in the classroom and what is taught. There is a need for attention to methodology, how things are taught, classroom management.’ (English lecturer interviewee)

Discussion

The article describes the racism experienced by students and lecturers in one university nursing department, and although not aiming to generalise, it is possible that similar issues occur elsewhere. While ignorance and insensitivity might explain discrimination, individuals and organisations are no longer able to hide behind a veil of institutional racism. It is easy to focus on the responsibility of lecturers to address discrimination without considering the organisational and wider social factors involved. The data show that policies and practices designed for a predominantly British/Irish student body are no longer tenable given contemporary recruitment patterns. Since multi-ethnic student cohorts are the norm, there is a need to question the whiteness of the institution (Husband, 2000; Purwar, 2001) and the Anglocentric or Eurocentric norms and values embedded in organisational culture, practices and provision (Allan et al, 2004).

The Race Relations (Amendment) Act (2000) requires public authorities to address racism, but the Audit Commission (2004) highlights late, sporadic and superficial compliance with legislation. Barriers to progress include unexplored assumptions, institutional behaviours, resistance from staff and confusion about what should be achieved (Audit Commission, 2004), and this is evident in the findings. Husband (2000) suggests that inequality remains unchallenged because minority ethnic people are not seen as truly equal, and notions of tolerance presume they are in some way undesirable or undeserving. Culley (2001) argues that legislation alone fails to tackle values and racist attitudes which persist in hearts and minds. While the data find minimal evidence to support Husband’s and Culley’s contentions, their work highlights unconscious barriers militating against equality, and unless the hearts and minds dimension of antidiscriminatory practice is acknowledged adherence to legislation is likely to be superficial.

Lowe (2006) argues that the unconscious features of promoting equality are underappreciated and that anxiety, fear, guilt and uncertainty lead to avoidance and denial of work that is painful or threatening. This is borne out in the lecturer data. Gunaratnam and Lewis (2001) identify psychological processes which professionals engage in to deal with the emotional aspects of race issues. These authors draw upon Menzies-Lyth (1988) to demonstrate how tensions at individual level develop into social systems that protect against anxiety. The size of groups, the pace of work and limited resources were real issues for lecturers in this study, but it could be argued that they also protect individuals from insecurity, guilt or their own ethnocentricity.

While the data demonstrated significant problems at organisational level, individual lecturers must be responsible for their own practice. The findings highlight the need to appreciate the ethnohistories and culture of students. Lecturers must understand the culture shock experienced by overseas students and the impact of culture, gender and religion on perceptions and expectations. The findings echo those of Allan et al (2004), Alexis and Vydelingum (2004) and Winkelmann-Gleed ( 2005a, 2005b), highlighting the support needed if minority ethnic students are to function effectively and feel valued as individuals. A safe environment is crucial for students to be reflective, challenge ethnocentricity and explore emotive, sensitive issues. If, as the students suggest, lecturers do not appreciate diversity in communication styles, power and status, they misunderstand differences in participative learning, being critical and handling criticism (Burnard, 2005).

Cultural competence in nurse education relates not only to curriculum content but equally to pedagogical processes. The study highlights the complexity of racism and the difficulty for lecturers in detecting and addressing it because of uncertainty about whether behaviour is merely unacceptable or racially motivated. Resolving racist situations is therefore very difficult (Wieviorka 1995) and unless feelings and perceptions are explored, solutions are not found and conflicts escalate. Although transformative educational approaches are used in nursing,wider literature is critical of their neglect in relation to cultural issues. This reflects a focus on descriptive knowledge (Duffy, 2001), didacticism rather than experiential processes (Razak, 1999) and neglect of constructionist and postmodern educational philosophies (Dogra, 2004). These authors particularly emphasise the self as a starting point if transformative learning is to occur. However, the evidence suggests that lecturers feel ill-equipped to adopt techniques that enable students to explore unconscious ethnocentric ideas, and challenge personal prejudices and assumptions. Race-equality issues are painful and threatening, but fear of being perceived as racist can be as great a barrier for some lecturers.

Razak (1999) proposes coalitions in which groups of students collaborate to consider previously unexplored sensitive or taboo issues and this approach resonates with the findings relating to comfort zones. The data indicate tensions originating in colonialism and suggest that discrimination in society and Anglocentric organisations exacerbate suspicion and perceptions of racism. Lecturers did not generally understand the relationship between the comfort zones and wider alienation, or how attempts to find security perpetuate ignorance and prejudice. Organising coalitions could facilitate engagement, provide opportunities to debate power issues, explore discrimination, demythologise stereotypes and enable students to learn through working together. Proactively mixing students from different cultures, with focused tasks and corporate goals, can provide realistic, pragmatic opportunities for experiential learning.

Risk taking and critical reflection are important elements of transformative learning (Mezirow, 1990) which experienced lecturers in the study appeared comfortable with. Whether consciously or not, they acted as role models, encouraging self-awareness and self-critique. They were confident managing intolerance and prejudice, confronting and sensitively exploring cultural issues and using misunderstandings as learning opportunities.However, it is clear from the data that other lecturers need encouragement, support and guidance to adopt strategies which may be uncomfortable, challenging and resisted by students.

Study limitations

The scope of this study did not consider culture throughout the curriculum or the organisation. It could be argued that students or lecturers who had experienced racism were more attracted to participating in the project. Equally, it is possible that those who were most concerned with the prevention of racism or keen to learn how to manage it were more willing to participate. Funding, timing and human resources limited the number of semi-structured interviews undertaken and precluded a deeper exploration of issues, particularly about the impact of racism on student learning and how well or confidently lecturers dealt with conflict and tension. The tiny sample of two student interviews may reflect power relations and fears of retribution for speaking out, but in reality is probably related to interviews taking place during clinical placements. The study and this account have not done justice to the considerable good practice and commitment to equality found among lecturers and students.

Recommendations

Notwithstanding the limitations, the study has highlighted significant issues to be addressed and further researched. The findings raise awareness of how complex racism is, and illuminate inadvertent ways in which lecturers perpetrate or perpetuate it. The study elucidates the social, organisational, personal and professional factors which contribute to institutional racism, and the negative impact on the student experience.

There is no quick fix for tackling race-equality issues at individual or organisational level, as neither legislation nor didactic training handles the psychic dimension of racism. Racism operates at different levels of society and, being rooted in social and organisational contexts, needs to be engaged with, confronted and explored from differing perspectives. Ultimately the responsibility for the Race Relations (Amendment) Act lies with the institution, but the actual implementation relies upon the commitment and skill of individual lecturers.

However, the PPT model (Papadopoulos et al, 1998) is a user-friendly way to underpin the transcultural curriculum, is particularly geared towards transformative educational approaches, and thus offers a way forward. It is eminently suited to the development of cultural competence among lecturers, through continuing professional development, mentorship or supervision. The cultural awareness element explores personal identity, values and beliefs, examining the impact of ethnocentricity on relationships with clients and colleagues. It affords opportunities for lecturers to reflect and articulate the anxiety, fear or pain that inhibits their ability to address cultural issues, and propose ways to address this. Cultural knowledge requires lecturers to understand differing norms of communications, behaviour, customs and traditions, particularly learning from the students, and the heterogeneity within any group. Mentorship/supervision can support lecturers to admit their limitations and learn from students or more experienced colleagues. They can be supported in the use of real-life case studies or the development of appropriate cultural scenarios for teaching, learning and assessment purposes. Cultural sensitivity is about relationships in the classroom and requires that lecturers are sensitive to the alienation felt by students and the potential tensions existing between different groups. It relies on transformative strategies which require students and lecturers to transcend comfort zones, confront uncomfortable issues and negotiate acceptable solutions to problems. It is particularly suited to experiential techniques which explore sensitivities and confront conflict and manage it rather than avoid it. Lecturers must be supported to take risks, try out new ideas and acknowledge that some discomfort is unavoidable. Culturally competent lecturers are potential role models whose skills are transferable to the clinical setting. They are confident to admit that they don’t know, ask questions and have the courage to learn from others while using mistakes or misunderstandings as learning opportunities. Mentorship or individual/group supervision and a no-blame culture can empower lecturers to address sensitivities and challenge racism rather than avoid them for fear of getting it wrong.

Conclusion

For universities to work within race equality legislation and do justice to students and the patients they will ultimately nurse, attention must be paid to organisational factors and particularly racism within the wider transcultural curriculum. The nursing classroom is a microcosm of the clinical environment where people from diverse cultures bring different experiences, strengths and skills together to achieve collaborative goals. It is an ideal forum for learning about relationships with patients and clinical colleagues through the exploration, deconstruction and reconstruction of conscious and unconscious attitudes, beliefs and values. Not only is culturally competent teaching and learning transferable to clinical settings, it can be an empowering and satisfying experience for students and lecturers.

CONFLICTS OF INTERSET

None.

References

1. Allan H, Larsen J, Bryan K and Smith P (2004) The social reproduction of institutional racism: Internationally recruited nurses’ experiences of the British health services. Diversity in Health and Social Care 1:117–25.
2. Alexis O and Vydelingum V (2004) The lived experience of overseas black and minority ethnic nurses in the south of England. Diversity in Health and Social Care 1:13–20.
3. Alleyne J, Papadopoulos I and Tilki M (1994) Antiracism within transcultural nurse education. British Journal of Nursing 3:635–7.
4. Audit Commission (2004) The Journey to Race Equality: delivering improved services to local communities. London: Audit Commission.
5. Bhavnani R, Mirza H and Meetoo V (2005) Tackling the Roots of Racism: lessons for success. Bristol: Joseph Rowntree Foundation/The Policy Press. www.jrf.org.uk/ Knowledge/findings/socialpolicy/0535.asp (accessed 6 September 2007).
6. Bruni N (1988) A critical analysis of transcultural nursing theory. Australian Journal of Advanced Nursing 5:26–32.
7. Bryman A and Burgess R (1994) Analysing Qualitative Data. London: Routledge. Burnard P (2005) Issues in helping students from other cultures. Nurse Education Today 25:204–13.
8. Campinha-Bacote J (1999) A model and instrument for addressing cultural competence in health care. Journal of Nurse Education 38:203–7.
9. Cortis JD (1993) Transcultural nursing: appropriateness for Britain. Journal of Advances in Health and Nursing Care 12:67–77.
10. Cortis J and Law I (2005) Anti-racist innovation and nurse education. Nurse Education Today 25:176–80.
11. Culley L (1996)A critique of multiculturalism in health care: the challenge for nurse education. Journal of Advanced Nursing 23:564–70.
12. Culley L (2001) Equal opportunities policies and nursing employment in the British NHS. Journal of Advanced Nursing 33:130–7.
13. Denzin N and Lincoln Y (eds) (2003) Strategies of Qualitative Inquiry (2e). Thousand Oaks: Sage Publications.
14. Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process. London: Department of Health.
15. DograN(2004) Cultural competence or cultural sensibility? A comparison of two ideal type models to teach cultural diversity to medical students. International Journal of Medicine 5:223–31.
16. Duffy M (2001) A critique of cultural education in nursing. Journal of Advanced Nursing 36:487–95.
17. Essed P (1991) Understanding Everyday Racism: an interdisciplinary theory. London: Sage.
18. Foolchand MK (2000) The role of the department of health and other key institutions in the provision of equality. Nurse Education Today 20:443–8.
19. Gerrish K, Husband C and Mackenzie J (1996) Nursing for a Multi-ethnic Society. Buckingham: Open University Press.
20. Giger J and Davidhizar R (1991) Transcultural Nursing. St Louis: Mosby.
21. Gunaratnam Y and Lewis G (2001) Racialising emotional labour and emotionalising racialised labour: anger, fear and shame in social welfare. British Journal of Social Work Practice 15:131–48.
22. HollandKandHoggC(2001) Cultural Awareness in Nursing and Health Care: an introductory text. London: Arnold.
23. Husband C (2000) Recognising diversity and developing skills: the proper role of transcultural communication. European Journal of Social Work 3:225–34.
24. Leininger M (1978) Transcultural Nursing, Concepts, Theories and Practices. Columbus: Greyden Press.
25. LeiningerM(1995) Transcultural Nursing: concepts, theories, research and practices (2e). New York: McGraw-Hill.
26. Leininger M (ed.) (1991) Culture Care Diversity and Universality: a theory of nursing. National Nursing Press. Lister P (1991) A taxonomy for developing cultural competence. Nurse Education Today 19:313–18.
27. Lowe F(2006) Containing persecutory anxiety: child and adolescent mental health services and Black and minority ethnic communities. Journal of Social Work Practice 20:5–25.
28. Macpherson W (Chair) (1999) The Stephen Lawrence Inquiry. Report of an inquiry by Sir William Macpherson of Cluny. London: The Stationery Office.
29. MarkeyKandTilkiM(1997) Racism in nursing education: a reflective journey. British Journal of Nursing 16:390–3.
30. Menzies-Lyth I (1988) Containing Anxiety in Institutions: selected essays. Volume 1. London: Free Association Books.
31. Mezirow J (1990) Fostering Critical Reflection in Adulthood: a guide to transformative and emancipatory learning. San Francisco:
32. Jossey-Bass. MilesMandHuberman A (1994) Qualitative Data Analysis: an expanded sourcebook. Thousand Oaks: Sage.
33. Nairn S, Hardy C, Parumal L and Williams G (2004) Multicultural or anti racist teaching in nurse education: a critical appraisal. Nurse Education Today 24:188–96.
34. Narayanasmy A and White E (2005) A review of transcultural nursing. Nurse Education Today 25:102–11.
35. Nursing and Midwifery Council (2004) Standards of Proficiency for Pre-registration Nursing Education. Norwich: The Stationery Office.
36. O’Hagan K (2001) Cultural Competence in the Caring Professions. London: Jessica Kingsley Publishers. Papadopoulos I,
37. Alleyne J and Tilki M (1995) Teaching Transcultural Care: an investigation into the teaching methods suitable for transcultural education for nurses and midwives. London: Faculty of Health Studies, Middlesex University. 312
38. M Tilki, K Dye, K Markey et al Papadopoulos I,Tilki M and Taylor G (1998) Transcultural Care: issues for health professionals. Trowbridge: Quay Books.
39. Purnell L and Paulanka B (1998) Transcultural Health Care: a culturally competent approach. Philadelphia: FA Davis Company.
40. Price K and Cortis J (2000) The way forward for transcultural nursing. Nurse Education Today 20:233–43.
41. PurwarN(2001) The racialised somatic norm and the senior civil service. Sociology 35:651–70.
42. Race Relations (Amendment) Act (2000). London: The Stationery Office. Razak N (1999) Anti-discriminatory practice: pedagogical struggles and challenges. British Journal of Social Work 29:231–50.
43. Sawley L (2001) Perceptions of racism in the health service. Nursing Standard 15:333–5.
44. Shaha M (1998) Racism and its implications for ethical and moral reasoning in nursing practice: a tentative approach to a largely unexplored area. Nursing Ethics 5:138–46.
45. Smith J, Jarman M and Osborn M (1999) Doing interpretative phenomenological analysis. In: Murray M and Chamberlain K (eds) Qualitative Health Psychology: theories and methods. London: Sage.
46. Tilki M (1994) Learning from colleagues of different cultures. British Journal of Nursing 3:1118–24.
47. Tilki M, Dye K, MarkeyKet al (2006) Teaching Transcultural Care: racism in the nursing classroom. London: Middlesex University. www.mdx.ac.uk/www/rctsh/Racism_project. pdf (accessed 6 September 2007).
48. Wieviorka M (1995) The Arena of Racism. London: Sage. Wilkinson S (1998) Focus groups in health research: exploring the meanings of health and illness. Journal of Health Psychology 3:329–48.
49. Winkelmann-GleedA (2005a) Migrant nurses in the UK: facets of integration. Multicultural Nursing 1:26–30.
50. Winkelmann-Gleed A (2005b) Strangers in a British world: integration of international nurses. British Journal of Nursing 14:954–61.