A call for norm-consciousness as points of departure in nursing education

Abstract

This discussion paper highlights the necessity of norm-critical and norm-creative approaches in nursing education to address healthcare inequalities. Traditional curricula have inadequately engaged with intersectional perspectives, marginalizing various social groups. By integrating norm-conscious pedagogy, nursing students can critically analyze power structures and develop inclusive healthcare solutions. The “Breaking Fences” project introduces innovative tools, such as the norm-lab+, to foster reflexivity and challenge discriminatory norms. Emphasizing social justice, sustainability and self-awareness, this approach equips future nurses to recognize and counter biases, ultimately promoting equitable healthcare practices. Implementing norm-conscious education is crucial for advancing inclusivity and social responsibility in nursing.

The need for norm-critical thinking in nursing education

There is a notable lack of teaching of norm-critical thinking and theory in the nursing field. ¹ This critique stems from the observation that nursing students have historically been deprived of exposure to intersectional perspectives, which are essential for deconstructing and understanding the increasingly intricate system of power structures that influence healthcare. However, there has been a discernible shift toward greater interest in these perspectives, even in nursing literature, as global challenges and the rise of authoritarian ideologies have become increasingly pressing.^2,3 The newly awakened interest in elaborating on the deconstructing of power structures in nursing literature is crucial, especially since the clinical approach that has dominated nursing education, over several decades and around the world, has not adequately addressed questions concerning health inequality and unequal care. ⁴

Intersectional marginalization in healthcare

Women and minorities have long experienced structures of marginalization, specifically in relation to sexual identity, race and ethnicity, disability, and socioeconomic status, both within society and within the healthcare system. Early feminist critics have highlighted that this marginalization is deeply intertwined with the notion that knowledge is constructed within a system founded on dichotomies such as man versus woman, rationality versus compassion, private versus public, logic versus madness and heterosexuality versus homosexuality. ⁵ This system has been termed “disembodied Western rationality,” and is more commonly referred to by these critics as “objectivity”.

In addition to addressing norms related to gender and minority statuses, particularly concerning sexual identity, race and ethnicity, it is imperative to explore and challenge other biases that are less discussed but equally impactful in healthcare. This includes, but is not limited to, biases against certain age groups, people with non-standard body weights, visible body conditions and less visible mental health issues. They can be addressed by means such as utilizing Crip theory, which Karlsson and Rydström ⁶ described as a diverse assembly of critical perspectives on dis/ability, and outlines how it can be used to analyze social relations and intersectionality in contemporary societies. These critical perspectives can significantly complicate access to and provision of care for nursing students not only in terms of understanding societal stigma, but also in the way healthcare professionals, who have access to this sensitive information, might consciously or unconsciously act upon these biases. For example, individuals with visible health issues or non-standard body weight may face discrimination or bias that impacts the quality and type of care they receive.

Whether addressing the patient, the healthcare team or the nurse as an individual member of that team, the process of learning how to engage in professional criticism plays a significant role in nursing education. This practice encourages nursing students to enhance their self-concept and self-realization. As Castillo et al. ⁷ suggested, the practice also fosters the development of social skills that are essential for responsible nursing practice and the promotion of health equity. This view is supported by Abu et al., ⁸ who emphasized the need for the incorporation of social justice issues into nursing education, which can empower nurses to take action to reduce health inequalities.

Addressing prejudices is crucial to ensure that healthcare education and practice move towards a more inclusive, equitable and holistic approach to patient care. By broadening the scope of norm-critical and norm-creative pedagogy to encompass these areas, nursing education can equip future healthcare professionals with the tools they need to recognize and counteract inequality in all its forms, helping them work towards social inclusion and sustainability in their professional conduct.

The role of norm-critical and norm-creative pedagogy

Aiming for norm-consciousness as a learning outcome typically involves two areas of approaches and learning activities for the students: norm-criticism and norm- creativity. ⁹ The norm-creative approach entails initially being norm-critical, challenging social norms that contribute to inequalities and social exclusion. It then involves being norm-creative, developing solutions that counteract limiting norms by envisioning alternatives. Norm-criticism entails using educational methods to elucidate, describe and scrutinize how various norms create power imbalances in social settings and their repercussions for individuals, groups and society at large. Norm-criticism is a pedagogical framework that has its roots in queer studies: “to en­act norm-critical education is to embody queerness; thus, making things queer is to disturb the order of things”. ¹⁰ The norm-creative approach builds on this foundation by envisioning and developing alternatives to limiting norms. Through this dual approach, students are not only able to critique societal norms, but also are equipped to imagine and implement solutions that promote greater inclusion and equity. When norm-criticism and norm-creativity are implemented effectively in nursing education, they can challenge and reshape the framework within which healthcare professionals operate, enabling them to address the multifaceted nature of health inequality in a more holistic and inclusive manner.

Norm-creative pedagogy involves methods that, in an exploratory manner, provide additional perspectives to challenge and expand existing viewpoints. Valderama-Wallace et al. (2020) aligned with Tengelin et al. ¹¹ in asserting that nursing education would benefit from norm-critical perspectives, which encourage students to critically examine their own positions relative to norms, power and privilege. These contemporary ideas further support Blanchet Garneau's (2018) proposal for a critical anti-discriminatory pedagogy (CADP), which offers a more direct and substantiated approach to fostering self-reflexive development. Consequently, a commitment to norm-conscious education promotes social sustainability by inspiring students to develop innovative healthcare strategies that ensure equitable access for all individuals, regardless of sexual identity, race, ethnicity, socioeconomic status or cultural background. Whether addressing the patient, the healthcare team, or the nurse as an individual member of that team, the process of learning how to engage in professional criticism plays a significant role in nursing education. This practice encourages nursing students to enhance their self-concept and self-realization. As Castillo et al. ⁷ suggested, it also fosters the development of social skills that are essential for responsible nursing practice and the promotion of health equity. This view is supported by Abu et al., ⁸ who emphasized the need to incorporate social justice issues into nursing education, which can empower nurses to take action toward reducing health inequalities.

The educational challenge: Teaching equality, social justice and sustainability

Addressing social justice, equity and sustainability in nursing education demands more than just presenting objective facts and clinical skills. It requires the fostering of a deep understanding of how privileges related to health are distributed and how these privileges often remain imperceptible to those who hold them. ¹²

The educational challenge for nursing faculties lies in providing students with experiences that facilitate addressing these issues and understanding their own position within these structures of power. This demands an unwavering focus on norm-consciousness, which, through a nuanced, reflexive lens, examines the distribution of privileges related to health in a manner that enables students to recognize signs of inequality in complex situations and empowers them to work towards social inclusion.^11,13 Therefore, it is important to stress that an increased emphasis on norm consciousness serves as a highly resource-efficient approach to advancing equity in healthcare and social sustainability in society.

To paraphrase Margaret Newman, ¹⁴ norm-consciousness can be viewed as a process of health in becoming more of oneself and attaining new dimensions of belonging with others – an expanding consciousness. Learning to become more of oneself aligns with the fundamental objectives of nursing philosophy and practice: enhancing social inclusion, fostering active citizenship and promoting personal development. ¹⁵

Challenges and opportunities for nursing educators

Despite the importance of norm-consciousness in nursing education, faculty members often face resistance to addressing social norms in their teaching. Many educators remain reluctant to tackle sensitive topics related to social norms and health disparities, and there is a lack of non-judgmental, inclusive teaching tools available for these discussions. ¹¹ To overcome this challenge, it is necessary to change this approach and help nursing and social work faculties include these topics in their teaching, to make new forms of teaching and learning tools available, and, above all, to provide opportunities for self-reflection on norm-consciousness issues by teachers themselves so that they can guide and educate students in this norm-critical direction. Castillo et al. ⁷ presented contributions to the reflection and understanding of how the contexts of nursing education are fundamental in the rationale and praxis of experiencing learning, focused outward, in tune and empathy with social communities, always changing, with their new criteria and ways of seeing the social being. It would be in this engaging interaction that the student would emerge as a being with skills, in a binomial training-nursing versus the holistic citizen, as a social being.

The “Breaking Fences” project

“Breaking Fences” is a joint EU-STARS project initiated by researchers from Sweden, Czech Republic and Portugal. In the project, we have undertaken the initiative to implement a range of new educational tools targeting social norms and health equality utilizing the norm-lab as the focal point as an educational activity for nursing students as well as for teachers and trainers in health education. The norm-lab is a defined analog/digital visible surface of reflexivity where we as faculty work together with students on themes regarding social norms and health that offers participants the chance to reflect and contribute to the norm-lab with their own expressions. The physically defined space of the norm-lab creates a focal point for educational sharpness concerning social norms that, over time, also serves as an evolving ongoing exhibition offering additional perspectives to existing views. The tools of how to set up and educate in a norm-lab, as well as the results of norm-lab education we conducted, are available on the project's website (https://www.breakingfences.se).

Our project seeks to establish a focal point for educational rigor regarding questions about social norms and health by utilizing norm-critical and norm-creative approaches that can compensate for the historical neglect of these questions in nursing education. By offering this set of educational tools through the norm-lab as a central hub, we will enable students to acquire relevant innovative skills, ensuring that those who are in need are not overlooked when help is available to them.

The tools and approaches that the Breaking Fences project offer will hopefully be one of several ways in which nursing students can be imbued with the norm-consciousness they need to promote social inclusion and sustainability in their professional lives, as well as to become more of themselves in the same process.

Conclusions

Incorporating both norm-criticism and norm-creativity into nursing education is vital for educating norm consciousness healthcare professionals who can critically assess and actively challenge the social norms that contribute to health inequalities. Norm-criticism helps students deconstruct harmful power structures, while norm-creativity encourages them to innovate and promote inclusive, sustainable solutions. Projects such as Breaking Fences offer essential tools to nurture norm-consciousness, empowering students to recognize and address the diverse dimensions of inequity. By integrating these pedagogical approaches, nursing education can drive a shift towards a more equitable and socially responsible healthcare system.