Integrating social justice in health care curriculum: Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing Blanchet Garneau, A., Browne, A.J., Varcoe, C. Suggested citation: Blanchet Garneau, A., Browne, A.J., Varcoe, C. (2016). Integrating social justice in health care curriculum: Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing. 2nd International Critical Perspectives in Nursing and Healthcare, Sydney, Australia. Abstract Nursing as a discipline has a unique contribution to advancing the social justice agenda in healthcare practices and education. However, even if social justice is claimed to be a core value of the profession, researchers, practicing nurses, educators, and students are continually challenged to understand how social justice could be enacted in caring practices. In this paper, we discuss the place and relevance of a critical antidiscriminatory pedagogy for nursing (CADP). We argue that, because discrimination is inherent to the production and maintenance of inequities and injustices, adopting a CADP offers opportunities for nurses and future nurses to develop their capacity to counteract racism and other forms of individual and systemic discrimination in health care. Grounded in critical theories and pedagogies, this approach involves an explicit examination of structural conditions and power dynamics, and a praxis informed by critical consciousness that can positively impact caring practices and change conditions of social injustice. A CADP challenges the liberal individualist paradigm, as well as culturalist and racializing processes prevalent in nursing education and situates nursing practice as responsive to health inequities. Thus, a CADP is a promising way to translate social justice into nursing education through transformative learning. 1 Background A growing body of research continues to demonstrate the profound effects of health and social inequities on peoples’ health, access to care and overall well-being. Knowing that race and racism are key determinants of health inequities (Krieger, 2014; Solar & Irwin, 2010), racializing and discriminatory processes are primary targets for social justice interventions. However, racial discrimination rarely operates in isolation from other social dynamics. For example, experiences of discrimination have been shown to be amplified by issues of poverty, substance use, or stigmatizing chronic conditions such as HIV or mental health issues (Varcoe, Browne, & Ponic, 2013). Varcoe et al. (2013) argue that while the impacts of discrimination may be interpersonal and obvious, they are more likely to be systematic, built into the structures of society, and often invisible. Discrimination then refers to “all means of expressing and institutionalizing social relationships of dominance and oppression” (Krieger, 2014, p. 250). In this paper, we focus attention on the value-added of focusing on multiple, intersecting forms of discrimination, including for example, the stigma of poverty, the impact of racialization, ageism, and gendered inequities, among others, and how these are often co-constituted determinants of health and well-being for individuals, communities, and populations. We pay particular attention to systemic discrimination as inherent to the production and maintenance of health and social inequities and injustices (Krieger, 2014; Marmot, Friel, Bell, Houweling, & Taylor, 2008), and the potential of a critical antidiscriminatory pedagogy (CADP) to enhance the capacity for nursing to address key social justice issues. We argue that integrating CADP in nursing education holds promise for moving social justice as a professional value into transformative learning and action. Approaches to Addressing Social Justice and Heath Inequities in Nursing To address health and healthcare inequities, scholars and nursing educators have advocated for curricular changes based on the principles of social justice (Chinn, 2014; Hardy, 2011). As Thorne (2014) argues, even if some scholars have operated from a stance of liberal individualism, social justice “has been a dominant normative position for nursing for as long as we have been 2 professionalized” (p.79). However, Canales and Drevdahl (2014) argue that even if social justice is at the core of the nursing discipline, it is generally absent or may operate as mere rhetoric in the nursing curriculum. Culturally congruent care and multicultural approaches Because inequities and injustices are hypervisible for racialized groups, the translation of social justice in nursing practice and education has been dominated by attention to cultural sensitivity, drawing on a plethora of theories and models orienting nursing practice and education towards culturally congruent care (Andrews & Boyle, 2002; Campinha-Bacote, 1998; Leininger, 1991; Papadopoulos, Tilki, & Taylor, 1998; Purnell & Paulanka, 2008). These theories and models have been developed from a cultural diversity and multiculturalist perspective, often founded in culturalist ideology, which is prominent in nursing and promoted by a majority of schools, universities, and other public institutions (Vandenberg & Kalischuk, 2014). In such approaches, health behaviors, for example, are seen as primarily determined by an individual's presumed ethnocultural, and often racialized identity. As a consequence, and in concert with the long recognized dominance of liberal individualism in nursing (Browne, 2001), racialism and culturalism are frequently used to explain behaviors and health issues (Browne & Reimer- Kirkham, 2014; Varcoe et al., 2013). This can lead to practices that separate culture from its social, economic and political context and reinforce racializing and intersecting culturalist processes (Blanchet Garneau, 2016; Downing & Kowal, 2011). Recent empirical studies have highlighted that educational approaches focusing on culture alone are not sufficient to address discrimination and racism issues in healthcare (Allen, Brown, Duff, Nesbitt, & Hepner, 2013; Hardy, 2011). Thus, even with the best intention of providing culturally congruent care, multicultural approaches have failed to challenge racism and discrimination at the level of clinical practice, as well as at the organizational and systemic levels. Racial discrimination and anti-racist approaches In concert with the critiques of individualistic and multicultural approaches in nursing education, some authors have argued for a critical turn cultural competence and toward the inclusion of concepts related to racism and other individual and systemic forms of discrimination in its conceptualization and in health professionals’ education (Almutairi & Rodney, 2013; Blanchet 3 Garneau & Pepin, 2015; Herring, Spangaro, Lauw, & McNamara, 2013; Sakamoto, 2007). For example, strategies involving critical reflection (Blanchet Garneau, 2016) and reflexive antiracism training (Franklin, Paradies, & Kowal, 2014) have been presented as promising alternative to multiculturalist education. These strategies include reflection upon the sources and impacts of discrimination and racism in society while avoiding essentialist perspectives on culture. Antiracist pedagogy is theoretically grounded in the critical pedagogy and orients students through an analysis of systems of oppression and domination to « explain and counteract the persistence and impact of racism using praxis as its focus to promote social justice for the creation of a democratic society in every respect » (Blakeney, 2005, p. 119). However, as much as anti-racist pedagogy has to offer to nursing education in terms of promoting reflection and action on the structural causes of racism, it is imperative that nursing education prepares nurses not only to address racism as a basic social process with harmful impacts but racism as it intersects with multiple social locations, such as gender and class. If social justice is a goal of nursing, an approach is required that takes into account multiple intersecting forms of structural and interpersonal discrimination, with an emphasis on racism. The CADP we discuss in this paper builds on ideas related to anti-racist approaches, but it extends beyond its singular dimension to an intersectional perspective. CADP also pushes beyond culturally sensitive, tolerant, and respectful attitudes promoted by multiculturalist approaches. Expanding Beyond Anti-racist and Multiculturalist Perspectives A CADP both acknowledges and challenges the long tradition of liberal individualism in healthcare, as well as culturalist and racializing processes prevalent in nursing. In this approach, education based on developing humanistic care that is sensitive and respectful, without addressing structural conditions related to health and healthcare is insufficient (Dovidio, 2015). Building on antiracist pedagogy and developed from a critical perspective, the CADP we discuss in this paper extends beyond an individualistic and essentialist perspective of discrimination. Indeed, it is grounded in an intersectional perspective, which investigates “the interaction of numerous characteristics of vulnerable populations, not only at the individual level but also at 4 structural levels so as to capture the multiple contexts that shape individual lives and health statuses” (Dhamoon & Hankivsky, 2011, p. 16). Intersectional perspectives are useful in drawing attention to complex dynamics of racism, gendered inequities, economic disparities, and other social processes, and how they interact and are often co-constituted to influence health and well- being. Thus we focus on racial discrimination, keeping in mind these complex dynamics, and drawing on intersectional theory to illuminate them. A CADP offers a framework for health care professionals to analyze power relations at multiple levels and in multiple intertwined contexts to look at and disrupt structural dynamics producing and reproducing systemic discrimination. It gives them the opportunity to develop strategies to change conditions of social injustices. The Aims and Features of a CADP A CADP is closely linked to its critical theoretical roots as it aims to foster transformative learning oriented toward action to counteract the effects of discrimination both at individual and systemic levels in healthcare. To achieve this transformative learning, two processes are central to a CADP: an explicit examination of structural conditions and power dynamics and a praxis informed by critical consciousness. An explicit examination of structural conditions and power dynamics A CADP brings a contextualized perspective on culture and health, which helps to understand the power relations and dynamics of oppression in health care and to act upon structural inequities such as discrimination and structural racism. Doane and Varcoe (2015) argue that health professionals need to simultaneously intervene to address structural conditions at the contextual level. Hence, nurses ought to develop skills to infuse their caring practices with a contextualized view to counteract racism and discrimination in healthcare and address health inequities (Thompson, 2014). A CADP shifts the mere act of discrimination between two persons to an analysis of structural processes by looking at power relations at play in discriminatory processes. A CADP is then explicitly concerned with power relations, knowing that power operates at all levels and not just in a hierarchical, top-down manner. 5 Critical thinking is essential to analyze of structural conditions and power dynamics involved in the interlocking systems of oppression embedded in society and affecting health and healthcare. Developing critical thinking among students and nurses is central to a CADP. However, critical thinking as part of a CADP departs from an analytic philosophy perspective, which frames how critical thinking is currently conceived and taught in nursing. Following this perspective, thinking critically focuses on cognitive processes, such as recognizing false inferences and logical fallacies, and being able to distinguish opinion from evidence (Brookfield, 2007). Although these are essential intellectual functions for nursing practice, this focus on cognitive processes tends to neglect social and political critique (Kincheloe, 2000). From a critical theoretical perspective, educators acknowledge the multiple methods of producing knowledge and challenge bipolar and true-or-false epistemologies in the service of challenging normative ideas and approaches, and to shifting the status quo. They advocate for diverse perspectives on similar events and the importance of contextuality. Critical pedagogy leads students and nurse to engage in a reflexive dialogue to analyze ways power operates and its effects on social structures. The legitimacy of power structures is then challenged and leads students and nurses to be able to challenge the status quo. A praxis informed by critical consciousness Praxis is the dialectical relation between theory and practice, where reflection facilitates “a dialogue between theory and practice to develop a new understanding of the world of practice, and a new ability to change practice” (Nairn, Chambers, Thompson, McGarry, & Chambers, 2012, p. 190). In critical pedagogy, Freire (1970) conceptualizes praxis as simultaneous reflection and action to transform the world. The processes of reflection and action both interact to develop critical consciousness among students and give them the power to act and resolve or change situations (Freire, 1970). The development of critical consciousness is inherent to a CADP because it involves new forms of understanding that connect one more directly to acting to counteract discrimination. A CADP considers that structural and interpersonal discrimination are inseparable and positions the individual within the larger forces at play in discriminatory processes. It supports students and 6 nurses in developing a new understanding of their social location and focusing their attention on their responsibility for action – even if they perceive themselves as separate from or not implicated in the conditions that give rise to discrimination. They are invited to critically think about their social location and uncover structural and systemic taken-for-granted assumptions that shape their practice. The exploration of personal experience as structurally produced is then always linked to a contextualized perspective of the world and with knowledge of how one can counteract the effects of discrimination in healthcare. Critical consciousness is then different from consciousness raising. Being aware of racism and discrimination in not enough, and a CADP helps students to articulate this critical consciousness with action. If only consciousness is raised without articulating it with action, there is a risk that this awareness causes feelings of helplessness and powerlessness among students, and paralyze their action (Mooney & Nolan, 2006). In line with a critical theoretical stance, one alternative is to reorient reflection toward social, political, economic, cultural contexts within which a person live and reflect on how this context is shaping his or her everyday life and actions. Examining the self from a critical perspective thus tend to avoid feelings of guilt and shame regarding privileged social locations and orient students towards responsibility for action grounded in contextualized knowledge. For example, from a CADP perspective, Euro-Canadian middle-class students are not viewed as being responsible for what they might construct as their White privilege but are encouraged to take responsibility for their action or inaction about intersecting forms of discrimination in health care. Being aware without invoking guilt or attributing responsibility for this context is one way to foster agency instead of blaming one for his or her social position (Young, 2011). “We must lift as we climb”: Educating to uncover, challenge and disrupt discriminatory processes Teaching from a critical antidiscriminatory perspective implies to teach with a specific social and political intent, a transformative impetus, which is to act upon individual and systemic discrimination. “Lift as we climb” was the motto of the National Association of Colored Women’s Clubs founded in 1896. The idea behind this phrase is that transformative processes are collective and people need each other to make significant changes in the world. Transformative processes require a social movement across lines of race, gender, and class, and at multiple levels 7 of organization of the society in which we live. The implementation of a CADP at the curriculum level will then involve changes in institutional policies and procedures, and in teaching approaches (Rowan et al., 2013; Thackrah & Thompson, 2013). Critically conscious educators for collective and safe learning We suggest that collective learning might be well suited to develop critical consciousness and foster transformative learning among students and nurses. However, group learning also brings challenges related to power dynamics amongst team members. Authors such as Ellsworth (1989), Gore (1992), and Lather (1992) have highlighted the uncovered division in critical pedagogy between the « critically aware teachers » and the « ideologically duped students » (Brookfield, 2007, p. 327). Gore (1992) and Lather (1992) have both argued that when the focus is only on developing critical consciousness of the learners, educators tend to assume the correctness of their ideological reading of the world. Ellsworth (1989) raised that educators ought to take into account their own positionalities and learned racism, classism, or sexism. The adoption of an intersectionality lens in a CADP allows considering the positionality of the educators and their self-criticality as equally important as those of the learners. Thus, educators, as well as learners, can learn from becoming critically conscious. Educators must engage in self-criticism about the ideologies that underlie teaching methods because teaching can also lend itself to the reproduction of social inequities. Educators must, therefore, avoid indoctrinating students but stimulate them to examine the way power and knowledge work together and reinforce one another. Following the same logic, we must not assume that classrooms are safe heavens. As Brookfield (2007, p. 359) states, "Neither learners nor teachers leave their racial, class, or gender identities at the classroom door, nor do they forget their previous participation in discussions with all the humiliations and manipulations these often entailed." There are many times in a group where expressing one's voice may not feel safe. Educators can most certainly suggest ways to foster a safe learning environment, but we cannot assume that they have the power to create spaces that are free of prejudice. In addition, silence should not be automatically associated to voicelessness but could also be considered a deliberate political choice (Ellsworth, 1989). We believe that creating a safe environment to question what is taken for granted and to imagine ways to do and 8 think things differently is a collective responsibility that is shared by educators and learners. Conclusion The nursing discipline has a unique contribution to advancing social justice in healthcare practices and education. Considering the multidimensionality and the various interpretation of social justice, we do not presume that a CADP is the one and only way to translate social justice in nursing education. As classrooms and workplaces are subject to infinite possibilities and combinations of learning preferences and intersecting social positions, a variety of approaches and methodologies will be necessary to develop the field of CADP. Efforts to integrate social justice into nursing education from multiple perspectives are encouraged in this direction. Suggested discussion points: - Does CADP offer anything new to our understanding of what is needed to affect transformative shifts in nursing education? - How is support for CADP possible among professoriates that are not familiar with these critical theoretical underpinnings? - We state in the paper that "educators must engage in self-criticism" and "educators must, therefore, avoid indoctrinating students but stimulate them to examine the way power and knowledge work together and reinforce one another," how can these « musts » be achieved? 9 References Allen, J., Brown, L., Duff, C., Nesbitt, P., & Hepner, A. (2013). Development and evaluation of a teaching and learning approach in cross-cultural care and antidiscrimination in university nursing students. Nurse Education Today, 33(12), 1592-1598. doi:10.1016/j.nedt.2012.12.006 Almutairi, A. F., & Rodney, P. (2013). Critical Cultural Competence for Culturally Diverse Workforces: Toward Equitable and Peaceful Health Care. 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