National Review of Nursing Education
Multicultural Nursing Education
4. Nursing in multicultural context
4.1 History
The English ‘lady with the lamp’, Florence Nightingale , was perhaps the first transcultural nurse. Named for the Italian city in which she was born, Nightingale embodied an early principle of multiculturalism the need to understand the context as well as the patient. In 1854, England and France declared war on Russia. The soldiers were subjected to unsanitary, dismal conditions. While the French soldiers were under the care of trained nurses, the French Sisters of Charity, the English soldiers were neglected. The Secretary of War contacted Florence Nightingale and, on October 21, she took a group of nurses to Scutari in Turkey in order to work with Crimean war wounded. Nightingale nursing developed far from home and familiar cultural surrounds, in the context of caring for victims of war and displacement
The need to understand cultural context has arisen again and again in the course of nursing history. Nearly 150 years later, Dr. Esther Lucile Brown was a social anthropologist employed by the Russell Sage Foundation, and was selected by the National Nursing Council to implement a study of the practice of nursing. She organised conferences to discuss the societal needs for nurses . (Virtual nurse 2001).
The cultural context of nursing education is also apparent in the history of nursing in non-Western countries. Chan and Wong outline the history of nursing education in China and Hong Kong. The training of nurses in China, for example, preceded that of Hong Kong by more than half a century. In 1835, Dr Peter Parker, the first Protestant, medical Missionary to China, established the Canton dispensary. In 1884, Elizabeth McKechnie arrived in Shanghai from the USA and introduced the Nightingale system to China. The first school for Chinese nurses was established in Fuchou in 1888, by another American, Ella Johnson. In 1915, the Peking Union Medical College (PUMC) was set up and a decision was made to establish a nursing school at PUMC (Chan & Wong 1999).
The history of nursing highlights, too, examples of cultural methods. Mary Breckinridge, founder of The Frontier Nursing Service, employed ethnographic methodologies (participant observation, interviewing and fieldwork) towards construction of highly responsive health-service systems, developed under circumstances of duress, e.g. after World War I in pre-industrial Appalachia. In culturally representing the Appalachian, she drew upon first-hand field experience. Cross-cultural encounters of one kind or another supplied an infrastructure of meaning throughout her life. Breckinridge was perhaps the first nurse ethnographer.
Some attention has been paid to the historical context of nursing in Australia (Yuginovich 2000), but the links with the multicultural context have rarely been identified. (Hanna 1978). Nightingale’s system of nurse education was transported to Australia with Lucy Osborne who established the first School of Nursing at Sydney Hospital in 1868. Indeed, Nightingale herself vaguely alluded to cultural issues with Indigenous people in Australia in her writings. A fascinating account of these writings is provided by Judith Ann Barber (1999) at La Trobe University. Nightingale's evidence was derived largely from missionaries, especially Bishop Rudesindus Salvado of the Benedictine foundation of New Norcia in Western Australia. Barber reviews the attitudes to Australian Aborigines which emerge from Nightingale's and others’ writings and argues that their value to modern nursing is to stimulate a reappraisal of current attitudes to Aboriginal health (Barber 1999).
Australian standards of nursing education and licensure evolved during the nineteenth and twentieth centuries. Lynette Russell, Foundation Dean at the Faculty of Nursing at Sydney University, has collaborated in a comparative history of nursing education documenting this evolution: ‘The Nightingale model of nurse training was introduced into Australia in 1868 by Lucy Osborn, a Nightingale trainee, at what was then the Sydney infirmary. Initially, the Australian Trained Nurses Association controlled nurse training … During the 1920s and 1930s statutory authorities were introduced to control nurse training throughout Australia’. By 1984, the Federal government announced its support for the transfer of basic nurse education into the higher education sector and, in 1989, into the university sector (Lusk et al. 2001; Russell 1990).
In April 1998, the Royal College of Nursing Australia released a position statement on nursing practice in a culturally diverse Australian society. The College recommended that nursing schools and faculties encourage examination of undergraduate nursing curricula to ensure that the transcultural component is adequate to prepare students to provide culturally appropriate nursing practice; encourage research in cultural areas to inform and guide the preparation of students; and actively foster the growth of transcultural nursing as core knowledge for all undergraduate and postgraduate curricula.
In summary, cultural sensitivity and, one might say, passion, were embedded in nursing practice long before the birth of multicultural health as a discrete discipline. It is implicit if not always explicit. Nursing was always in the lead as a caring profession, sensitive to difference and diversity. Taken from the perspective of other health professions (such as medicine), nursing remains the leading profession in the response to diversity. The challenge for future nursing education is to systematically incorporate diversity principles without deconstructing them into academic pieces.
4.2 The New Agenda for a Multicultural Australia
On the eve of the new millennium, the Australian Government launched its New Agenda for Multicultural Australia (Commonwealth of Australia 1999).
Australia has built a social infrastructure of institutions, traditions and processes on a democratic foundation. Cultural diversity is one of the great social, cultural and economic resources. Australian unity in this diversity is based on such moral values as respect for difference, tolerance and a common commitment to freedom, and an overriding commitment to Australia's national interests. For multicultural Australia to continue to flourish for the good of all Australians, multicultural policies and programs should be built on the foundation of our democratic system, using the following principles:
Civic Duty, which obliges all Australians to support those basic structures and principles of Australian society which guarantee us our freedom and equality and enable diversity in our society to flourish;
Cultural Respect, which, subject to the law, gives all Australians the right to express their own culture and beliefs and obliges them to accept the right of others to do the same;
Social Equity, which entitles all Australians to equality of treatment and opportunity so that they are able to contribute to the social, political and economic life of Australia, free from discrimination, including on the grounds of race, culture, religion, language, location, gender or place of birth; and
Productive Diversity, which maximises for all Australians the significant cultural, social and economic dividends arising from the diversity of our population.
The New Agenda affirms that multiculturalism needs to be inclusive for all Australians, if it is to act as a unifying force for developing nationhood. This concept of multiculturalism includes Indigenous Australians as well as those of Anglo-Celtic origin, not just minority and ethnic groups. The refocused, inclusive policy of multiculturalism has clear implications for the education of health professionals in Australia. Both medical and nursing schools have begun the process of responding to this change in focus. For some, this had taken the form of curriculum content reappraisal; for others, it has led to curriculum transformation.
4.3 Chapter summary
The multicultural context of nursing education, although a recent concept in health, has roots in the history of nursing itself, It was the Nightingale model of nursing that was introduced into Australia in 1868, and despite many iterations of this model through the years, the recognition of our history brings circularity to the present discussion of culture in nursing education.
The new agenda for a multicultural Australia recognises culture as a unifying force for developing nationhood and highlights the social and economic benefits of cultural diversity. This sets the scene for the nurse of the future (as described in the New Zealand Strategic Review) as one who will understand and empathise with different value systems; will be flexible and adaptable in meeting the wider socio-economic realities confronting all peoples; will be more mobile in providing services and increasing access; and understands holistic views of health. Echoing Florence Nightingale’s pioneering work on the context and environment of patient care, the concept of multiculturalism is just starting to become embedded in nursing theory and education - not always as separately definable curriculum elements but as core principles for nursing practice. These core principles underpin all nursing practice and therefore all nursing education.
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