False beliefs such as “blacks’ nerve endings are less sensitive than whites’,” and “blacks’ skin is thicker than whites’” have been shown to lead to undertreatment of black patients for pain.
Unfortunately, such bias persists. A 2015 study found that 50 percent of surveyed medical students and residents subscribe to these beliefs, among others.
Kristen Kirby, clinical associate professor of nursing at Purdue University, is working to combat biases in health care and improve the quality of treatment for minorities.
Kirby, a three-time Outstanding Teacher Award winner (2012, 2013, 2014) and winner of the Sigma Theta Tau Excellence in Education for the School of Nursing award (2017), is expected to earn her DNP from Rush University in August. She has dedicated her doctoral project to an overhaul of the School of Nursing’s diversity training in a 3-pillared approach: curricular assessment, faculty assessment and development, and student assessment and development.
Channeling privilege into necessary change
At the start, Kirby’s identity as a straight, white woman gave her pause.
“I felt like maybe I wasn’t the best person to handle that topic,” she says. “But on the other hand, I recognize that I do have more privilege than others, so maybe I can use that to advocate for those who are underrepresented or identify with a group that doesn’t have a lot of support.” Kirby adds that her concept of what diversity looks like has grown. “Diversity can include political differences, religious differences, socio-economic backgrounds and so on. It’s more than race.”
To combat the pervasive nature of bias, she set out to infuse the current curriculum in the School of Nursing with a more organized, systematic approach to diversity and inclusion education.
“What literature shows is that diversity training doesn’t work as well in an isolated class as when you infuse it throughout the entire curriculum,” Kirby says. “Not only does it say to the students that this is important in everything you do, but it shows the students themselves that we’re advocating for them and we’re advocating for their patients.”
Mary Ajuwon, a continuing lecturer at the School of Nursing, agrees. Ajuwon indicates how important Kirby’s project is, because change starts with nursing students — who may even find themselves disadvantaged by a lack of awareness and inclusion.
“This is a huge issue,” she says. “It’s huge and it’s not a maybe. It affects even international students and their performance; they might not understand what we’re doing in class.”
A progressively designed diversity curriculum, she says, is something needed at any level of education because it benefits people at all walks of life.
Janelle Smalls, a continuing lecturer who specializes in public health nursing, affirms Kirby’s assessment that in addition to racial disparities, one factor leading to poor patient health outcomes is a minimal exposure to LGBT populations. In fact, she’s made her own efforts to increase students’ awareness in her classroom.
She recently facilitated a class discussion based on literature reviews indicating that negative attitudes toward LGBT patients can be blamed, at least partly, on a lack of interaction with this population and limited LGBT-specific care covered in curriculum.
“I believe there are knowledge gaps in nursing as it relates to providing appropriate care to the vulnerable, the underserved, persons with various disabilities and LGBT populations,” she says.
A systematic, measurable approach
In the 2018 fall semester, Kirby established an intervention group in a senior-level course, NUR 41001, and added 20 hours of diversity and inclusion content.
The added content included a massive open online course (MOOC). The MOOC, which Dr. Charles Calahan, Assistant Director of Global Learning Development developed, allowed students to interact with people from all over the world. Additionally, students took the Harvard Implicit Bias tests and participated in Assessment Technology Institute (ATI) Civility Mentor Simulations and hours of experiential learning. Before the course, Kirby assessed the students in cultural competency to establish a baseline, and again at the end of the course to monitor their progress. More currently, the spring semester of NUR 41001 is serving as Kirby’s control group and she anticipates comparing the two groups in May.
On a bigger scale, Kirby is monitoring a cohort through diversity training from the very beginning of their BSN degrees all the way to graduation.
“To date, there’s no literature where something this comprehensive has been done,” she says. “Typically, it’s limited to a course, study abroad or a specific activity within a course.
Pam Karagory, interim head of the School of Nursing, and Kirby’s project facilitator, is enthusiastic about Kirby’s findings thus far.
“Kirby’s topic grabbed me, because it would have direct impact in the sustainability of our nursing curriculum,” she says. “Her preliminary data from the fall semester in the senior class was remarkable in terms of how much the students’ understanding of diversity and inclusion increased as a result of the curricular work that Kristen’s doing.”
Kirby is not yet ready to announce the results at this stage, but she is optimistic she is on the right track.
“I will say that the data is currently demonstrating that when students have intentional and standardized diversity and inclusion education, their individual and group assessment scores indicate a statistically significant increase,” she says.
Karagory and Kirby hope to develop a 1- to 2-credit hour course as a supplement to the expanded diversity content. The required course would include more experiential learning.
“My goal would be to have the students look at diversity from a very broad perspective,” she says. “I’d have students go spend time in the cultural centers on campus, and maybe work a semester in a cultural center. Or go work at the food pantry or homeless shelter. And I want them to look at how this affects their knowledge, attitudes and skills from a nursing perspective — nursing occurs everywhere.”
Kirby is thankful for an overwhelmingly positive response and participation in the project.
“I had all these faculty members saying, ‘I want to do that with you; can I be a part of the team?” Kirby says. “This has to be a faculty-led change, and I am fortunate to work alongside amazing, supportive and innovative colleagues who advocate for patients and students by preparing future nurses to provide safe, holistic, quality care. The results of this change will be ours, not mine.”