My name is Jessica Biles and I am a white woman with links to many wonderful cultures inclusive of Catalan, Scottish, Irish and Australia. I am married to academic Brett, a Murrawarri man and we have two children Stella and Audrey. I have held an academic position within the School of Nursing, Midwifery and Indigenous Health at Charles Sturt University since 2008. After being involved in the teaching of subjects focused on Indigenous Australian health care, I noticed that often the pedagogical focus of teaching and learning was geared towards the deficit model. To me, this didn’t align with my personal or professional values and lived experiences. This model isn’t sustainable or successful (Sherwood, 2013). Instead the onus of responsibility should not be on the patient but instead geared towards the clinician. How can the clinician adapt to suit the needs of the client/community rather than how can the client adapt to suit the needs of the health professional? Coupled with my personal experiences raising two girls it was clear that we need to learn from history, consult, collaborate, respect and reorientate our focus to a strengths-based approach. This has stimulated my interested in effective teaching strategies in cultural competence and more broadly cultural competence development in health care.

Knowledge and Scholarship Isn Indigenous Australian Competence Cultural and Nursing

Importantly, to consider nursing curriculum experiences focus needs to be firstly positioned on Indigenous Australian health. Health outcomes for Indigenous Australian people are consistently and significantly worse than for non-Indigenous Australian people (Australian Institute of Health and Welfare, 2016). In 2008 and subsequent years, the Australian government recognised the importance of the change required to reduce health disparities by aligning strategic funding to the Close the Gap campaign. Despite initiatives health outcomes remain disparate. Coronary heart disease, diabetes mellitus and respiratory disease are reported as the highest causes of deaths within Indigenous Australian communities (Australian Bureau of Statistics, 2015) raising concern about ongoing inequality in health care within Australia. This highlights the need to provide equality in health care for Indigenous Australian people. Registered nurses comprise at least 57% of the healthcare workforce (Australian Institute of Health and Welfare, 2016). Any change made by nursing practise can evoke lasting change and positive outcomes for the clients of nurses and midwives.

As preparation for practise-ready graduates, cultural competency is increasingly being embraced within undergraduate nursing education (ANMAC, 2016). While nursing standards are responsive to regulating practise and health curriculum frameworks support design, our understanding on how students best learn about Indigenous Australian cultural competence in nursing is still evolving (Biles & Biles, 2019).

Methods of Unearthing the Voice of Bachelor of Nursing Learners in Indigenous Australian Cultural Competence

As a way of unearthing student voices in a Bachelor of Nursing programme, my doctoral study aimed to explore the learning experiences of undergraduate nursing students studying Indigenous Australian cultural competence. The participants of the study were fifteen undergraduate students enrolled in an Indigenous Australian cultural competency subject within the Bachelor of Nursing Course. The study followed the subsequent journey of students through their first and final year of university. At the time of this research, the curriculum that students were studying hosted a standalone first-year subject focused on Indigenous Australian history, culture and health. The subject was a theoretical opportunity to study history, health and culture. It was offered online only and did not involve any form of experiential experience. Discrete learning objectives focused on discipline-specific knowledge around Indigenous Australian health were scattered through other nursing subjects in the first and final year of study.

Hermeneutic phenomenology was used to explore students’ experiences, perceptions and learning about cultural competency to address the following research questions (Biles, 2017):

  • What are the lived experiences and perceptions of student nurses studying a subject designed to address Indigenous Australian cultural competence?

  • What are the lived experiences of the journey of Indigenous Australian cultural competence for nursing students across the duration of their course?

  • What influences the lived experiences of Indigenous Australian cultural competence for nursing students? (Biles, 2017; Biles, Coyle, Bernoth, Hill, 2016).

Hermeneutic phenomenology aligns within a constructivist framework and lends itself to the ontological stance of multiple realities (Denzin & Lincoln, 2001). In this research the phenomena of Indigenous Australian cultural competence in nursing was interpreted and reconstructed to show or reveal multiple realities. The research approach creates a process of interpretation by the researcher (Guba & Lincoln, 1985) and the participant. Homogenous purposive sampling was used and focused towards undergraduate nursing students in their first and final years within an undergraduate nursing degree. Data collection involved a single in-depth semi-structured interview with each participant at the end of their first and final years of study.

Data analysis involved four distinct phases resulting in the development of four constructs, using a process that is detailed. These phases were not linear and occurred concurrently and importantly were facilitated by hermeneutic circle strategies. Each phase incorporated the movement through the hermeneutic circle, viewing data as whole and part in both year levels of data (Finlay, 2011; vanManen, 1997) consistent with hermeneutic research. This process occurred in all facets of both first year and final year data and when data was combined to make one whole.

Findings that Informed Curriculum Design and Modification

Findings revealed the importance of four major themes to undergraduate nursing students: Moving to a Different World Viewpoint, Making Connections, Seeking the Truth, and The Core of Truth Seeking. Participants in both first year and third year shared their perspectives in relation to their knowledge and development in Indigenous Australian health and understanding of cultural competence. The findings revealed an interrelationship between all major themes. Interestingly, the first-year findings showed a period of rapid growth and transformation (reported elsewhere) (Biles et al., 2016).

The model in Fig. 12.1 represents participants’ perspectives and is categorised into three overarching themes: Influences of the curriculum on student learning, Influences of student experiences and The Unique Personal Journey. The following section will interpret experience into ways that students learnt Indigenous Australian cultural competence.

Fig. 12.1
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Student experiences in learning Indigenous Australian cultural competence (From Biles, 2017, p. 259.)

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Influences of the Curriculum on Student Learning

Participants reported that the curriculum was an influence to their learning experiences in the area of Indigenous Australian cultural competence. What was different in this research, compared to other models of learning in Indigenous Australian cultural competence was that participants evidenced learning as not being linear, moving beyond the classroom (and curriculum) and deeply personal to participants. This new knowledge suggests that the curriculum to be responsive to a range of ways that learners could connect in a personal and deep way. To participants the curriculum had the potential to influence the ability of the learner to connect with the learning experience. The curriculum was central to participants experiences. It played an important role in determining whether a participant had the opportunity to make a connection and search for their truth, and created a shift in their viewpoint.

Participants suggested that the content within a curriculum was not enough to facilitate their journey. Enacting the curriculum needs authenticity and integrity in its delivery. That is, learning needs to be meaningful and real to learners. Participants in this research were confused by a single subject approach. They were confused by how it aligned with their study (Biles et al., 2016). In addition, they questioned staff members’ journey in Indigenous Australian cultural competence. This research revealed that it is important that teaching staff within a school engage with the philosophical stance of the curriculum to ensure that it is enacted. Not doing so does impact the experience and learning of undergraduate nursing students.

Enabling Learning in the Area of Indigenous Australian Cultural Competence

Participants explained that the curriculum enabled the opportunity to connect. This connection stimulated a transformative experience which has been described as the experience of a moment in time when we have a new emotional response to a situation (Mezirow, 1997). It can be thought of as the light bulb moment (as experienced by 1st year participants) or having an emotive response in experiential learning (revealed by the connections described by all participants) and linked to a way of thinking critically (Mezirow, 1997). Participants wanted to connect to people, to experiences, to each other. This occurred through books, experiences online postings and relationships, to name just a few strategies. The classroom in this curriculum moved beyond traditional settings and involved online spaces, clinical placement and the personal learning that took place outside of the formal education setting.

Learning wasn’t necessarily noted in the discrete subject but constructed through the participants’ real life experiences. Life experiences were very important and were brought to light through the participants seeking a connection beyond the context of the curriculum when opportunities were not presented within it and also when they chose to compare their previous truth.

Mindfulness of the Hidden Curriculum

What was interesting in this research was the reliance of participants on the hidden curriculum. This is the learning that occurs beyond the university subject, such as learning from attending a movie, reading a book or through a conversation. It is usually deeply personal to the learner (Biles, 2017). Scholars in the educational space agree that learning outside of the classroom and curriculum is beneficial in both testing metacognitive applications and overall personal development (Bentley, 2012).

This research has highlighted that it is important for curricula to provide opportunities for this to occur in the area of Indigenous Australian cultural competence. This style of learning takes courage from both educator and learner as we cannot anticipate all of the opportunities that arise challenging the application in an accredited course. However, this should not deter educators from embarking on ways to reach higher levels of metacognition enabling the journey of Indigenous Australian cultural competence.

Influences of Student Experiences

A number of factors influence the overall experience of participants. These are important to consider when considering curriculum development in Indigenous Australian cultural competence in nursing. This section will explore a number of influences that impacted students’ growth, learning and development in Indigenous Australian cultural competence.

Online Safety is Important to Student Experiences in Indigenous Australian Cultural Competence

Learning experiences within the course impacted the participants’ learning in Indigenous Australian cultural competence. The impact that a discrete online subject can have on a curriculum was raised as questionable by participants. They expressed concern about the safety in an online environment. Online learning experiences are becoming increasingly popular in the Australian tertiary sector with around 81% of learners working remotely off campus in the online space in 2010 (Australian Bureau of Statistics, 2015). The impact this has on learning development in the area of Indigenous Australian cultural competence is not known.

Safety in the online space, particularly during the first year, was a concern for some participants in this research and aligns with our understanding of online learning student challenges (Clark, Ahten, & Werth, 2012). Safety concerns for participants involved the posting of their thoughts using an online platform. Would they be judged? Did they have the skills to articulate their thoughts through text? Would they offend? Would there be trolls?

As we move to a world where online learning is regularly preferred by both educational institutions and learners the need to consider safety when exploring Indigenous Australian cultural competence is increasingly important. In current Indigenous Australian cultural competence education, it is vital that participants feel safe in their discussion, leading to the desire to create meaningful and safe clinical interactions that encourage connections (Durey, 2010).

Making Connections Embodies the Experiences in Indigenous Australian Cultural Competence

In nursing educational research, it has been widely accepted that nurses need to embody the experience of becoming a nurse (Benner, Stephen, Leonard, & Day, 2010). In psychology literature, this involves theories such as the Social Identity Theory (Tajfel & Turner, 1979). This theory explains how we see ourselves in the world. Through the lens of the Social Identity Theory it is suggested we link ourselves with like-minded people, cultural groups, and belief systems and divide our world into how we align ourselves in comparison to others (Trepte, 2006).

In contrast the Social Division Theory, highlights differences, divides and create social rules that groups of people follow (Payne & Payne, 2004). Generally, division is accepted by the majority (dominant) group of people and social inequalities soon follow. This theory resonates with the experience of undergraduate nursing students while attending clinical placement. It was evidenced that students largely chose not to speak up when incidents occurred on clinical placement, such as an instance of racial bias (Biles, 2017). What was clear was that the experience generated learning. Students felt that they needed to follow the dominant group, did not “call out racisms” and this was cited mainly due to the power imbalance between student and professional. However, the experience was valuable to their learning and was translated as an example of “how not to be” when a qualified professional. These incidents indicate that cultural support is paramount to students attending clinical placement. While the learning was deeply powerful where participants had a clear view of the type of practitioner they aspired to be they also are culturally unsafe. Incidents of racial bias are the “ugly” truth of mainstream health services. They shouldn’t be hidden from students view as they generate important experiential learning that has the ability to transform worldviews. However, it is imperative that students have appropriate support during experiences that facilitates cultural support.

Critical Thinking in Indigenous Australian Cultural Competence

Critical thinking was facilitated by specific attributes that assisted participants’ ability to connect, search and critically think. This supports the concept that the absence of critical thinking would lead to a stagnant model of Indigenous Australian cultural competence where progress and change are not evident.

Research in critical thinking suggests our understanding has evolved. Early perspectives of critical thinking saw the skill as a philosophical perspective, today scholars in education view critical thinking as a process (Facione, 1990) that require attributes. This implies that the teaching and the application of critical thinking needs to be a multidimensional process with regard to complex situations. In this research, ways for learners to critically reflect were reliant on the connections that they made and connections were dependent on curriculum opportunities, personal learning and the attributes used by each participant. The attributes, such as openness, empathy and respect facilitated connection which was essential in their learning in Indigenous Australian cultural competence.

Learning Was Uncomfortable

Participants expressed that learning during their journey of Indigenous Australian cultural competence was uncomfortable. They were challenged by the very notion of how the learning about Indigenous Australian peoples aligned with the broader Bachelor of Nursing curriculum, challenged by racist clinical experiences, emotions that arose during learning experiences, their previous knowledge and the inner reflections that were stimulated by the journey of Indigenous Australian cultural competence. However, it was within this discomfort that world views were challenged and movement occurred. Making a space to maintain discomfort in nursing curriculum has not been well explored.

Boler (2011) discusses the notion that there needs to be space in curriculum where learners have the opportunity to both feel and reconsider world views. Boler believes that it is the space in which we become uncomfortable that drives us to the exploration of our inner values and requires us to be reflective thinkers and this aligns with research findings in my study.

Participants in the study openly disclosed their discomfort in clinical situations, within the online learning spaces, and as they had new experiences that challenged their world views.

Like Boler, Durey (2010) recognises the need for nurses studying Indigenous Australian health to be able to reflect on their own beliefs and culture and when doing this they need to be challenged openly about their cultural prejudices and misconceptions regardless of how uncomfortable it may be. Hall and Fields (2012) have furthered this discussion by acknowledging that the nursing profession is historically built on Western, white structures therefore influencing practise (Yoon, Hacker, Hewitt, Abrams, & Cleary, 2012). Personal experiences are therefore paramount in the exploration of Indigenous Australian cultural competence in ensuring social connections in clinical relationships (Yoon et al., 2012) as disclosed by participants’ in my study. The importance of being open to discomfort is an important finding in this study and should be taken into account by curriculum designers.

The Paradox of Experiences Did not Inhibit the Journey

Participants revealed that they were apt to finding themselves in a situation, mainly clinical situations, where learning in Indigenous Australian cultural competence was challenging and uncomfortable. Aligning with both Kolb (1984) and Mezirow (1997), it is generally accepted that experiences, both negative and/or positive, are important if the learner is able to reflect and make sense of the situation. Boler (2011) advocates that experiences in the area of cultural situations can be uncomfortable but remain useful. The challenge for participants was the negative practice experiences (discovered within clinical placement situations) that participants reflected on and how these experiences aligned with their current worldviews (Biles, 2017).

In this research participants indicated that clinical placement was important. They actively sought opportunities to engage meaningfully. Exploration of support provided to nursing students attending an Indigenous Australian health placement has not been well researched. However, we can conclude that mentoring and supportive clinical environments would increase the sense of belonging for learners in their ability to connect, thus providing support in experiences they deem negative, which may lead to greater opportunities for learning in the area of Indigenous Australian cultural competence.

The Unique Personal Journey

The Personal Learning

Personal learning moved beyond the curriculum and beyond the profession, and influenced the participants and their worldviews. All participants openly discussed feelings, emotions and situations that influenced their learning journey in Indigenous Australian cultural competence: clinical placement, books, conversations and personal relationships all had an impact. Although little has been written about the influence of personal learning in the area of Indigenous Australian cultural competence we have seen the influence of personal self- reflection and its contribution to professional identity as a nurse. Interestingly, my research revealed that personal learning can stimulate development in Indigenous Australian cultural competence (Biles, 2017).

The curriculum moved beyond the university learning and teaching and became reliant on the personal journey. Many have theorised that professional identity encompasses but is not limited to reflective practice, professional reasoning, critical thinking, values and the recognition of the hidden curriculum (Peel, 2005). Interestingly, theories that support professional identity transformation have been linked to Kolb and Mezirow (Trede, Macklin, & Bridges, 2012) and deemed as required authentic and meaningful learning experiences that shift between personal and professional learning opportunities inclusive of situations that may provoke discomfort (Trede, et al., 2012). Learning for participants occurred, was self-driven (relying on personal attributes) and continued for participants in their attempts to become a nurse with skills, behaviours and attitudes in the area of Indigenous Australian cultural competence.

Participants embraced the personal learning and cited a change to their worldviews.

Personal Attributes Are Central to the Journey of Indigenous Australian Cultural Competence

Participants cited a number of attributes that helped their learning journey. Little is known about how to support attribute development in undergraduate programmes in the area of Indigenous Australian cultural competence learning. Previous studies on personal attributes in the wider context of nursing within Australia found insignificant relationships between personal attributes at the foundational years of a course in comparison to the point of graduation (Pitt, Powis, Levett-Jones, & Hunter, 2014). Learning in the area of attribute development in Indigenous Australian cultural competence is said to require constant reflection on self and exploration of personal biases, attributes and behaviours that can exclude minority groups from care (Ranzijn, McConnochie, Day, & Nolan, 2006). In the wider space of cultural competence attribute development it has been flagged that teaching staff are key in ensuring that positive learning spaces within both classroom and curricula are made available. This raises the importance of staff exhibiting attributes in Indigenous Australian cultural competence (Goerke & Kickett, 2013). Participants in this research felt disconnected when this was not evident. Participants cited that teaching staff did not facilitate their journey, and thus generated a greater sense of personal responsibility for each learner (Biles, 2017).

Language as the Marker that the Journey Was Incomplete

The participants in this study expressed concern about having the appropriate language skills. They openly expressed worry about the language they used, knowing how to articulate concepts such as race and culture, and how to best phrase their thoughts in the online space. Participants sometimes rationalised their reluctance to engage online as due to their inability to rectify language errors, based on their questions about the safety of the online space. This highlights the interrelationship that student learning has with the unique and personal journey of individuals. Language was deeply personal and related to the social connections the participants had in their world.

Relevance of the Research

Participants’ experiences when synthesised with educational literature have generated a model of learning Indigenous Australian cultural competence in nursing. Figure 12.2 displays how the model of experiences aligns with a model of learning and will be useful for educators, curriculum designers or learners on a journey of Indigenous Australian cultural competence. This model of learning is different from other models and relies on the ability of the learner to experience connection, truth seeking and a change in worldview (Biles, 2017). The model if non-linear, relies on connection, seeking the truth through the use of attributes and provokes a change in the participant’s worldviews. This model is the first model that reveals how nursing students learning Indigenous Australian cultural competence. Contextual ways to enable learning have been revealed within the discussion of this chapter. Importantly, this research is bound by the context and requires further analysis in its transferability.

Fig. 12.2
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Learning Indigenous Australian cultural competence in nursing (From Biles, 2017, p. 261.)

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Conversations and Building Relationships

While this research was underway, preliminary analysis was informing a curriculum redesign within a Bachelor of Nursing program. Historically Indigenous Australian content within this undergraduate programme experienced high attrition and poor student experience evaluations with students citing the disconnection between Indigenous Australian content and general nursing subjects in a Bachelor of Nursing programme. Learning objectives were splattered in the first and final year of study with a heavy reliance on the discrete subject. Generally, students were unable to draw links on the content and see its applicability to nursing practise (Biles & Anderson, 2018). The piecemeal approach to delivery, relying on a stand-alone single subject in the Bachelor of Nursing programme, added to the complexity of experience for learners and required a new way of embedding Indigenous Australian cultural competence content. In 2014, during a curriculum review period, a review team, after considering students’ experiences, decided to take a different approach and embed Indigenous Australian cultural competence across the three years of the programme.

This approach relied on a wider team of academics with skills and expertise in teaching Indigenous Australian knowledge and history. Conversations on content were carefully crafted with the curriculum review team, the wider learning and teaching support staff and importantly a number of community members. Congruent with literature in this space, conversation and community consultation was considered key to embedding Indigenous Australian content in a curriculum (Sherwood & Russell-Mundine, 2017). The team shared papers, experiences and participated in conversations both with each other and with community working parties. It was considered important that local communities were consulted in the design phase so that their rich feedback could inform the teaching and learning of nurses. These experiences shaped the way content was embedded in the curriculum and where it was placed.

Indigenous Australian cultural competence was embedded across all three years of the Bachelor of Nursing programme through the method of constructive alignments. Embracing the university’s Indigenous Education Strategy and the National Best Practice Framework for Indigenous Cultural Competency in Australian Universities (2011) enabled content and skills to be evidenced in all three years of the programme. It was thought that this would enable students to have the best opportunity to acquire the skills necessary for the journey of Indigenous Australian cultural competence. For example, critical thinking was considered important in the journey of Indigenous Australian cultural competence, so was clearly embedded in first-year nursing subjects as a learning objective.

Development involved consultation with a number of key stakeholders, internal university approval/endorsement through the Indigenous Board of Studies and a formal accreditation process and approval through the Australian Nursing and Midwifery Accreditation Council. The course was successfully accredited in 2015. Evaluation of the effectiveness of this approach is yet to be determined.

Conclusion

The journey of Indigenous Australian cultural competence in nursing is imperative. The research provides much needed insight into students learning Indigenous Australian cultural competence. We now have foundational knowledge that nurses require a connection, need to actively seek their truth and have the opportunity to change their worldview. Staff need to be on this journey and therefore universities need to facilitate ongoing scaffold professional development for staff involved in curriculum design. Students are aware when staff are not authentic and this impacts their learning. Importantly, we now know that the journey for nurses is not linear, it is ongoing even during clinical placements not associated with the Indigenous Australian subjects. Therefore, we have a responsibility to elicit cultural mentorship and support for learners across a curriculum.

As nurses, we have the capacity to consider others and provide options for care. It is important that we consider and modify (where appropriate) our thoughts, behaviours, beliefs and attitudes to accommodate the client. This research and subsequent journey of curriculum design is not to be viewed as a recipe. Rather it is one way to consider how to provide learning opportunities for students studying a Bachelor of Nursing programme. Importantly, learning is optimal if staff and students alike are on a journey of Indigenous Australian cultural competence.