Enriching the Cognitive Apprenticeship in Nursing Curricula: Combatting Racism and Improving Inter-Professional Communication and Teamwork

November 8, 2021 Patricia Benner, R.N., Ph.D. FAAN

We continue to focus on enriching and integrating the three high-end apprenticeships:

1) The Cognitive Apprenticeship dealing with the science, technologies, humanities required for knowledgeable, safe nursing practice;

2) The Practice Apprenticeship focuses on skilled know-how,  the productive higher-order thinking in action required for safe and effective practice;

3) Ethical Comportment and Formation refers to enacting skills, character, and knowledge to provide excellent nursing care in actual, practice situations. Ethical Comportment and Formation, the Third Apprenticeship is the most integrative of the three high-end apprenticeships because without enacting notions of good internal to the practice of nursing, one cannot effectively use situated judgment about which course of action is most prudent and in the best interests of the patient.

All three apprenticeships are highly inter-related and must be considered as a “whole cloth” in the thinking of educators, students, and practicing nurses.

All health care workers have a moral mandate to end the racism that daily takes a large toll on all diverse populations, and this requires enriching curriculum to address healthcare inequities caused by systemic, implicit bias, and all forms of preferential treatment based upon race or any form of diversity in the population. Racism has been declared a public health crisis, and nurse educators, nursing students, and practicing nurses have a long tradition of championing social justice as a means to improving the health of the population (Fowler, M., 2016). As Kenya Beard notes in this month’s video presentation, when health care professionals engage in racism, “People die.” As noted in a primer on Anti-Racism (Jackson, O’Brien & Fields, 2020):

Racism affects one’s lived experience in ways that have tangible consequences. Stereotyping, bias, lack of representation, and racism perpetuate false beliefs, lead to misdiagnosis, dangerously narrow clinical decision making, and perpetuate implicit bias, all of which lead to real health disparities. These forces also affect the integrity and safety of the learning climate and thus may impact the success of our learners. Therefore, as educators and clinicians, for our students and our patients, we have a moral imperative to confront and dismantle racism (Jackson, O’Brien & Fields 2020, P. 1)

Dr. Kenya Beard offers the following guidelines for “Facilitating Race-Related Discourse:

Recognize:  Respond to race-related bias.

Restate:  Seek clarification as to what was said.

Remove:  Redirect stigmatized information away from the individual.

Reflect:  Potential biases erroneously influence thoughts.

Recover Illuminate and Recover:  Illuminate and discuss deeper perspectives.

Rebuild: Delegitimize Stereotypes and reaffirm professional values.

An educational climate that is silent on the public health crisis of systemic, and implicit unacknowledged racism is complicit with racism and the current health care crisis created by racism in our society (click here).

Paul, Knight, Campbell, and Aronson note:

Over the past decade, this legitimization of public health challenges in White communities and the diminishment of analogous public health challenges in Black communities has played out prominently in medicine’s responses to police violence and gun violence. In 2013, young Black Americans formed Black Lives Matter, a national movement against anti-Black racism and the unjust killing of  Black people by police. Police violence is one of the leading causes of death among young Black American men: the lifetime risk of death at the hands of police for Black men is estimated to be 1 in 1000 (Edwards, Lee, Esposito, 2019). Police violence against unarmed Black Americans has been shown to cause serious psychological suffering among Black Americans generally, (Bor, et.al., 2018) and racism-related stress adversely affects Black Americans’ health regardless of their socio-economic circumstances or geographic location. Yet with rare exceptions, including the American Public Health Association and the medical student-led White Coats for Black Lives organization, medical societies, and public health organizations have until recently remained silent on the issue of protecting Black lives from police violence (Paul, Knight, Campbell & Aronson, 2020).

Informed Awareness: Raising Consciousness on the Public Health Care Crisis of Systemic Racism and Implicit Racism Biases

Nursing curricula must thoroughly inform the student of the current public health crisis of the poorer health care outcomes for patients of color. The first obligation to address the high impact of systemic racism and implicit bias on clinical diagnosis and treatment is to inform students about this real and extensive public health care crisis. Without awareness of the extent of the problem, students will not practice, nor engage in policy activism to radically reform our health care institutions to make them more equitable for all races. To that end, we offer a list of references and resources at the end of this article.

Designing Front-Line Practice Interventions for Implicit and Systemic Racism

Every student nurse can be coached to intervene in system biases in each of their patient care assignments. Students can be taught to discover and directly intervene in implicit and systemic racism such as the following evidence-based racial disparities: 1) less than adequate and equitable pain management for people of color; 2) diminished sharing of Information and patient education for people of color; 3) less thorough work-up and diagnostic accuracy and follow-up for people of color; 4) lack of aggressive diagnostic testing, treatment, and follow-up in emergency room visits for people of color compared to white persons (Institute of Medicine, 2003).

Nursing students can be coached on how to directly run interference and correct oversights in the quality of health care to patients of color. This kind of consistent front-line nursing intervention has the potential of mitigating some of the inequitable health care delivered in our current health care system. While intervening in sub-standard care caused by racism may seem beyond the scope and the imagination of nursing students, in fact, it is in line with the student nurse’s/nurse educator’s partnered legal and professional responsibility to ensure that best evidence-based medicine and nursing is practiced, correcting for sub-standard practice where it occurs. This mandate to ensure the highest standards of practice by student nurses can be made into a formal compact between nursing and health care administrators and the School of Nursing in order to support the nursing student’s lower-power position as a student practicing professional nursing.

Teaching Students to Identify and Change Racist Health Care Practices

Equally important is to teach students to address policies, and practices that cause a lack of equity in access and treatment of patients of color. Addressing racist health care policies and practices needs to be integrated throughout the curriculum, and not just in a single topic in a single course. Giving the gravity of inequities in health care availability and quality for people of color, concerted and systematic approaches in the day to day health care delivered to individual patients and families, and the policies and practices that contribute to inequities in health care for people of color must be a top priority in all educational settings, as well in all sectors of health care.

Improving Interdisciplinary Communication and Teamwork

Dr. Meg Zamorodi brings home the connections between the need to eliminate systemic racism and the role of effective interprofessional communication to assist in that goal. Teamwork and collaborative practice with a shared vision for eliminating health care inequities and social injustice due to racism are essential to dismantle racism in all health care settings. Dr. Zamorodi, a doctorally prepared nurse, is Assistant Provost for Interdisciplinary Education at the University of North Carolina. She offers a vision for interprofessional education throughout the curriculum as a strategy for improving the quality of care and decreasing health care errors.

Health care errors are the third leading cause of death in the United States. She notes that 70% of health care errors involve a breakdown in communication among the health care team. These communication errors can be reduced if the health care team members improve their communication strategies and their understanding of one another’s practice. She encourages nurse educators to coach their students to ‘stay in the room’ when doctors enter, to increase communication and clarity about shared health care goals and collaborative patient care. She and her colleagues at the University of North Carolina have worked out many teaching-learning activities threaded through all health care professions’ courses, including active projects to improve health care in specific health care delivery sites, such as rural health care centers. Their interdisciplinary curriculum encourages that students from different health care disciplines learn from and about each other throughout their curricula.

Conclusion

These are but two urgent, high-priority examples of curricular areas that need to be re-examined in the Cognitive Apprenticeship. We also have an urgent need to streamline and simplify our curriculum offerings based upon the most frequently encountered patient care needs in today’s health care systems and in caring for our aging population. Many schools are expanding their community and ambulatory care in their cognitive apprenticeship in response to the shift in the majority of health care being delivered outside of hospitals and health care centers. From the Carnegie Study (Benner, Sutphen, Leonard-Kahn & Day, 2009), we know that we need to upgrade the level of pathophysiology and pharmacology taught in nursing schools, especially for students returning to schools of nursing to obtain their baccalaureate degree, and beyond. Most nursing curricula do not assess students’ gaps in knowledge that have occurred since the nurse was last engaged in nursing education. The Cognitive Apprenticeship has to be constantly renewed, updated, and adjusted for cognitive overload. Courses need to focus on content that is most relevant in today’s health care system.

References:

Andrea Jackson, MD, MAS, Meghan O’Brien MD, MBE, and Rachel Fields, MS, (2020) Anti-Racism and Race Literacy: A Primer and Toolkit for Medical Educators. Updated June 26, 2020. The University of California, School of Medicine.

Benner, P., Sutphen, M., Leonard-Kahn, V., Day, L. (2010) Educating Nurses: A Call for Radical Transformation. Jossey-Bass & Carnegie Foundation for Advancement of Teaching.

Bor J, Venkataramani AS, Williams DR, Tsai AC. (2018) “Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study.” Lancet 2018;392:302-310.

Edwards F, Lee H, Esposito M. (2019) “Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex.” Proc Natl Acad Sci U S A 2019;116:16793-16798.

Fowler, Marsha D.M. (2016) “Heritage ethics: Toward a thicker account of nursing ethics.” Nursing Ethics 23 (1): 7–21.

https://nexusipe.org/informing/about-national-center/news/ipe-guidance A Resource for Developing Interprofessional Education. Guidance on Developing Quality Interprofessional Education for the Health Professions

Institute of Medicine; (2002) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care…Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors Washington (DC): National Academies Press (US); 2002

IPE Simulation – Interprofessional Competencies. https://www.simulationiq.com/software/ipe-training

Notable Anti-Racism Curriculum Resources

Disparities. June 2017. Available: https://www.irp.wisc.edu/resource/mortgage-markets-and-the-roots-ofracial-health-disparities/

https://implicit.harvard.edu/implicit/aboutus.html Project Implicit is a 501(c)(3) non-profit organization and international collaboration of researchers who are interested in implicit social cognition. Project Implicit was founded in 1998 by three scientists – Dr. Tony Greenwald (University of Washington), Dr. Mahzarin Banaji (Harvard University), and Dr. Brian Nosek (University of Virginia). Project Implicit Health (formerly Project Implicit Mental Health) was launched in 2011 and is led by Dr. Bethany Teachman (University of Virginia) and Dr. Matt Nock (Harvard University).

The mission of Project Implicit is to educate the public about bias and to provide a “virtual laboratory” for collecting data on the internet. Project Implicit scientists produce high-impact research that forms the basis of our scientific knowledge about bias and disparities.

Please visit https://www.projectimplicit.net to learn more about our team and the programs and services that we offer.

Recommended Books

Listed in Andrea Jackson, MD, MAS, Meghan O’Brien MD, MBE, and Rachel Fields, MS, (2020) Anti-Racism and Race Literacy: A Primer and Toolkit for Medical Educators. Updated June 26, 2020. The University of California, School of Medicine

Coates, Ta-Nehisi. We Were Eight Years in Power: An American Tragedy. New York: One World.2017.

Davis, Angela Y. 1944-, and Frank Barat. Freedom Is a Constant Struggle: Ferguson, Palestine, and the Foundations of a Movement. Chicago, Illinois: Haymarket Books, 2016.

Green, Laurie B., Mckiernan-González, John, & Summers, Martin, eds. Precarious Prescriptions: Contested Histories of Race and Health in North America. University of Minnesota Press, 2014.

Irvin Painter, Nell. The History of White People. W. W. Norton & Company, 2010.

Kendi, Ibrham. Stamped from the Beginning: The definitive history of racist ideas in America. Random House; 2017.

Khan-Cullors, Patrisse. When They Call You a Terrorist: A Black Lives Matter Memoir. First edition. New York: St Martin’s Press, 2018.

Roberts, Dorothy. (2011). Fatal Invention: How science, politics, and big business re-create race in the twenty-first century. New York, NY: The New Press.

Stanfield, John. Rethinking Race and Ethnicity in Research Methods. New York, Routledge, 2011. Thandeka. Learning to be White: Money, Race, and God in America. Continuum, 1999.

Zuberi, Tukufu. Bonilla-Silva Eduardo. White Logic, White Methods: Racism and Methodology. Lanham, Rowman & Littlefield Publishers, Inc., 2008.

Noteworthy Syllabus on Anti-Racism from UCSF:Noteworthy Syllabus on Anti-Racism from UCSF

Antoine S. Johnson, Elise A. Mitchell, Ayah Niriddin, (August 12, 2020) Syllabus: A History of Anti-Black Racism in Medicine  Department of Human and Social Sciences, UCSF. Humsci@ucsf.edu By Antoine S. Johnson, Elise A. Mitchell, Ayah Nuriddin August 12, 2020

Week 1. Medical and Scientific Theories of Racial Difference

Week 2. The African Diasporic Roots of Western Medicine and Science

Week 3. Medicine, Health and the Slave Trade(s)

Week 4. Slavery Era Medical Practitioners and Practices

Week 5. Disability in Slavery and Freedom

Week 6. Medicine, Reproduction, and Childhood in the Era of Slavery

Week 7. Medicine and Health in Post-Emancipation Era Societies

Week 8. Medicine, Public Health and Racial Uplift

Week 9. Eugenics and Progressive Era Racial Science

Week 10. Black People as Experimental Subjects

Week 11. 20th Century Race and Mental Health

Week 12. Race and Medicine from Civil Rights to Black Power

Week 13. 20th and 21st Century Social and Environmental Effects of Racism

Week 14. HIV/AIDS in Black America and its Legacy

Week 15. Genetics & the Re-biologization of Race

Week 16. Anti-Black Racism & COVID-19

Recommended Textbooks and Edited Volumes

*We are incredibly grateful to Dr. Ezelle Sanford III and Dr. Nic John Ramos for their input, support, and perspectives.

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