Exploring the experiences of DEI among Swedish undergraduate nursing students: A qualitative study

Abstract

Diversity, equity and inclusion (DEI) are recognised as essential components of nursing education and clinical practice. The DEI framework aims to broaden knowledge and reduce health disparities. However, the ways in which DEI is applied may vary across national and educational settings due to its context-sensitive nature. The present study aimed to explore how Swedish undergraduate nursing students in their final semester described the phenomenon of DEI within the context of their education. Data were collected through sentence-completion involving 43 participants. The completed sentences were analysed using content analysis, and the study is reported in accordance with COREQ (i.e. Consolidated Criteria for Reporting Qualitative Research) guidelines. Three main categories emerged: 1) Recognising diversity as a foundation of nursing education and practice; 2) Advancing equity in nursing education and person-centred systems of care; and 3) Promoting inclusive practices in nursing education and healthcare delivery. The participating students viewed DEI as interconnected and multifaceted concepts, demonstrating reflective awareness and an ethically grounded understanding of DEI principles as integral to nursing education and practice. The findings highlight the importance of context-sensitive approaches to integrating DEI into nursing education and clinical practice.

Introduction

Diversity, equity and inclusion (DEI), also referred to as equity, diversity and inclusion (EDI), are recognised as essential components of both nursing education and clinical practice. DEI encompasses multiple dimensions important to nursing such as racial and social injustice, ¹ creating a safe and inclusive learning environment for students, ² and diversifying the nursing workforce. ³ These are key aspects that nursing education programmes must address to prepare students and registered nurses (RN) to meet the healthcare needs of increasingly diverse societies, and help to narrow existing gaps in health care through education, policy development and research. ⁴

Leininger's Culture Care Diversity and Universality Theory ⁵ shaped awareness within the nursing context of how factors such as language and culture influence care and it is regarded as a globally applicable theory. According to the American Association of Colleges of Nursing, ⁶ DEI components are frequently addressed in nursing education ⁷ as follows:

Diversity: “A broad range of individual, population, and social characteristics, including but not limited to age; sex; race; ethnicity; sexual orientation; gender identity; family structures; geographic locations; national origin; immigrants and refugees; language; physical, functional, and learning abilities; religious beliefs; and socioeconomic status”.

Equity: “The ability to recognize the differences in the resources or knowledge needed to allow individuals to fully participate in society, including access to higher education, with the goal of overcoming obstacles to ensure fairness”.

Inclusion: “Environmental and organizational cultures in which faculty, students, staff, and administrators with diverse characteristics thrive”.

As a framework, DEI aims to expand knowledge and create pathways to reduce health disparities stemming from factors such as access to care, prejudice, bias and discrimination. ⁸ Theories related to DEI are numerous and extend beyond the nursing context, yet they remain essential for the delivery of patient-centred and culturally sensitive care. ⁹ Historically, nursing theories and conceptual models have primarily been rooted in Anglo-Saxon thought, which may influence how DEI strategies are implemented in educational and clinical contexts across different countries. ¹⁰

The origins of DEI differ across countries. In the USA, DEI initiatives are deeply rooted in the civil rights movement, particularly following the Civil Rights Act of 1964, ¹¹ which laid the foundation for affirmative action policies. Systemic racism and limited awareness of unconscious bias and attitudes are increasingly recognised as public health concerns. ¹² The Tri-Council for Nursing, ¹³ which includes the American Association of Colleges of Nursing, emphasises the need to support DEI across nursing education, clinical practice and the wider healthcare system. Many nursing schools and academic institutions have developed formal strategic plans to advance DEI. A survey conducted in the United States by Dowling et al., ⁴ examining DEI and the impact of social determinants of health (SDOH) on health outcomes, found that nursing students perceived curricula incorporating DEI and SDOH as promoting self-reflection, critical evaluation of healthcare systems and enhanced competence in DEI-SDOH areas. Similarly, Victor et al. ¹⁴ reported that nursing students engaged in self-reflection on DEI-related topics, suggesting that curricula addressing DEI concepts increase students’ awareness, sensitivity, knowledge, competence and capacity for holistic care. However, contemporary challenges, shaped by ongoing policy debates and legal actions aimed at limiting race-conscious initiatives, have led some nursing schools to discontinue their DEI strategic plans. In the UK, as in other countries with a colonial past, the historical impact of colonialism on healthcare^15–16 has been essential to recognise in developing DEI strategies. The Equality Act 2010 ¹⁷ consolidated previous anti-discrimination legislations into a single framework, providing legal protection against discrimination in the workplace and wider society. The Act underpins many institutional DEI strategies. The Royal College of Nursing has introduced an EDI strategy aimed at moving from a non-discriminatory, non-racist stance towards an explicitly anti-racist and anti-discriminatory culture. ¹⁸ Another influential body, the Council of Deans of Health Group, ¹⁹ encourages higher education institutions to strengthen their EDI agendas and adopt more equitable practices. A study on race equality within UK nursing programmes underscored the importance of prioritising DEI initiatives to foster a more inclusive, equitable and supportive educational environment. ²⁰ Building on this, Playfair et al. ²¹ emphasised that meaningful and sustained institutional support is essential for tranforming the culture of racism within nursing education.

The Nordic countries share a strong emphasis on gender equality and anti-discrimination measures, primarily linked to the labor market. In Finland, these principles are enshrined in the Non-Discrimination Act, ²² while, in Norway, they are upheld through the Equality and Anti-Discrimination Act. ²³ Denmark lacks a single comprehensive act but has several laws, including the Danish Act on Equal Treatment. ²⁴ Gender inequality and its implications in the Nordic healthcare sector are also highlighted in a Nordregio report. ²⁵

In Sweden, the Discrimination Act ²⁶ covers multiple areas, including gender, transgender identity or expression, ethnicity, religion or other belief, disability, sexual orientation and age. The Act also explicitly prohibits discrimination in health and medical care and other medical services. These legal frameworks are reflected in national documents such as the Swedish Society of Nursing's Strategy for Equity in Care and Health, ²⁷ which emphasises promoting the health of refugees and asylum seekers.

A thematic evaluation of nursing education within the Swedish higher education system, ²⁸ highlighted that nursing programmes must respond to the growing and increasingly complex needs of the healthcare sector. The Swedish nursing curriculum explicitly emphasises equality, particularly ensuring that women and men have equal opportunities and conditions to shape both society and their own lives. A high-quality learning environment is defined as one that is stimulating, respectful and inclusive, where all forms of harassment, discrimination or offensive behaviour are unequivocally rejected (Extract from a Swedish Nursing Curriculum, 2019).

A scoping review ²⁹ on equity, diversity and inclusion in nursing educational institutions found that most studies originated from the USA and Canada, with only two studies originated from the Nordic countries. These focused on gender-related issues, such as gender equality in higher education ³⁰ and new theoretical tools for researching educational gender segregation. ³¹ These findings imply different approaches and departures around the globe where for example the USA and the UK have a deeply rooted tradition of developing DEI strategies, whereas the Nordic countries have a strong emphasis on gender equality. The need for DEI strategies in nursing education and clinical practice is evident; hence, the ways in which DEI is operationalised across national and educational nursing settings remain highly relevant, as context-sensitivity may shape nursing students’ understanding and interpretation of DEI.

Consequently, acknowledging the importance of context in nursing education and in the implementation of DEI-related strategies, the present study aimed to explore how Swedish undergraduate nursing students in their final (sixth) semester described the phenomenon of DEI within the context of their education.

Methods

This study employed a sentence-completion technique, a qualitative research method in which participants are presented with a set of incomplete sentences and asked to complete them in any way they choose.^32–33 The method was selected to capture the diverse ways in which individuals describe and understand the constituent parts of DEI: diversity, equity and inclusion. The Consolidated Criteria for Reporting Qualitative Research (COREQ) were used to enhance the transparency and quality of this study. The completed sentences were analysed using qualitative content analysis, as described by Graneheim & Lundman. ³⁴

Setting

The undergraduate nursing programme is a 3-year, full-time course of study (180 ECTS credits) focused primarily on caring and nursing science. It leads to a bachelor's degree in nursing and qualification as an RN. Participants in this study were nursing students enrolled in their sixth and final semester.

Recruitment and sample

All students enrolled in the sixth semester were invited to participate in the study. Participants were those present in the classroom on the day of data collection (n = 73). The researchers (female and male) who had no prior relationship with the students, informed them both orally and in writing about the aim of the study, that participation was voluntary and that they could withdraw at any time without consequences for their grades. Confidentiality was assured.

Data collection

Data were collected at the university during a scheduled lecture for sixth semester nursing students. A lecturer from the nursing programme was present to answer any procedural questions. The students received a sheet of paper containing demographic questions on gender and age range, followed by three open-ended prompts formulated as incomplete sentences:

‘I describe diversity as …..’, ‘I describe equity as …’ and ‘I describe inclusion as …’. Students were instructed to complete each sentence with whatever came to mind upon reading it. They spent approximately 20 min completing the task. In total, 43 nursing students participated in the study; 34 women (80%), 8 men (18%) and 1 (2%) “not identified gender”.

Data analysis

The analysis process followed the qualitative content analysis described by Graneheim and Lundman. ³⁴

The analysis process consisted of six stages. In stage one, all completed sentences were transcribed and translated into English, and organised into three separated documents, one for each concept (diversity, equity and inclusion). All of the investigators read the material to gain an overall understanding. The completed sentences from the nursing students revealed a range of descriptions for each concept. Thereafter, in stage two, meaning units within the descriptions of each concept were identified. This was done by indicating and segmenting the transcript according to units. Next in stage three, these meaning units of each concept were condensed, shortened while still preserving the core meaning. In stage four the condensed meaning units were labelled with codes capturing the essence of the content. In the following stage five, codes were grouped into subcategories based on similarities and differences representing the manifest content. All of the investigators reviewed the codes and subcategories to ensure they represented and agreed with the nursing students’ written complete sentences. In the final and sixth stage, main categories were developed based on the identified subcategories for each concept.

Quotations from participants was presented using “P” to denote participant. Gender or age span was not included because no differences were noted in these variables.

Ethical considerations

Permission to conduct the study was obtained from the head of department. The study was conducted in 2024 within an undergraduate nursing education context at a Swedish university. In accordance with the Swedish Ethical Review Act, ³⁵ the study did not require formal ethical approval. However, the research was conducted in accordance with the ethical guidelines outlined in the Declaration of Helsinki. ³⁶

Results

The nursing students’ descriptions of DEI revealed the interrelated nature of its constituent parts, as well as the challenges associated with their implementation. The main categories and subcategories are presented below (Table 1).

Table 1.

Main categories and subcategories.

Recognising diversity as a foundation of nursing education and practice

Navigating individual needs and collective perspectives

Approaches to learning in a multicultural context

Addressing patient needs and variability in nursing practice

Advancing equity in nursing education and person-centred systems of care

Balancing equal treatment and fairness in society

Preparing for fair care and providing support when needed

Ensuring quality, person-centred care, and equity among staff

Promoting inclusive practices in nursing education and healthcare delivery

Belonging and adapting to individual needs

Implementation challenges

Engaging patients and fostering workplace collaboration

Recognising diversity as a foundation of nursing education and practice

In this main category diversity was described in a broad sense, encompassing not only culture, ethnicity and religion but also gender, age, personality, sexual orientation and individual life experiences. This multidimensional perspective informed the students’ descriptions of how nursing education and clinical practice should adapt to address both individual and collective needs. Their descriptions illustrated an understanding of diversity that extended beyond cultural or ethnic dimensions, reflecting a holistic and ethically grounded view of nursing care.

In the subcategory, “Navigating individual needs and collective perspectives”, the students expressed a general understanding of diversity as a broad concept encompassing ethnicity, gender, age, religion, sexual orientation and personality traits. One student described this perspective as:

A variation of ethnicity, personality, gender, age, religion, faith and thoughts. (P38)

Diversity was also described as a fundamental component of a functioning, modern society, particularly in shared contexts where individuals from diverse backgrounds engage in common activities. As one student noted:

A prerequisite for a functioning and modern society. (P11)

The students’ descriptions revealed their awareness of the need to balance collective cohesion with personalised attention. Diversity was described not only in terms of cultural or ethnic differences but also as encompassing variations in education, life experiences and personal characteristics.

When many different people find themselves in the same situation and in the same place with the same task. (P14)

They highlighted the ethical responsibility of both educational and professional institutions to address and support individual needs, emphasising the importance of fostering an inclusive environment grounded in respect and equity.

In the subcategory, “Approaches to learning in a multicultural context”, the nursing students described the curriculum as a vehicle for promoting awareness of diversity, particularly through the presence of multicultural perspectives that reflect a pluralistic society. However, while some acknowledged the presence of such content in the education, others noted such content as superficial – one student's description:

But no deeper explanation and overview was included. (P1)

The nursing students described the diversity within their own group – differences in nationality, religion, age and gender – as an asset that enriched the learning environment. As one student expressed:

We are also of different ages and of different genders. It is very enriching and gives more angles of approach throughout life. (P12)

Such peer diversity was described as contributing to broader perspectives and enhanced empathy during professional development.

The subcategory, “Addressing patient needs and variability in nursing practice”, was described as closely linked to clinical practice. The nursing students emphasised the necessity of a holistic approach to patient care, recognising each patient's unique cultural, religious, and personal values. One student described it as:

Great variation in care in terms of culture, religion and other personal values. (P31)

The students’ descriptions also acknowledged challenges that may arise when cultural values or beliefs conflict with standard procedures.

Sometimes cultures can “clash” with each other. However, it must not affect work or care (P19)

Additionally, diversity among nursing staff was also viewed as an asset, with students pointing to the value of interdisciplinary collaboration and knowledge-sharing in the delivery of comprehensive patient care.

Advancing equity in nursing education and person-centred systems of care

This main category described how nursing students understood equity as a balance between equal treatment and contextual fairness. Despite some conceptual overlap, students described an emerging awareness that fairness is context-dependent and that achieving equity may require adapting care to individual needs. They expressed commitment to both universal rights and individualised care, recognising that fairness may sometimes necessitate differential treatment to achieve equitable outcomes. Students also expressed that a truly equitable society – and healthcare system – must address both structural equality and equity grounded in personal need. In the subcategory, “Balancing equal treatment and fairness in society”, most nursing students equated equity with equal treatment, emphasising uniform rights and opportunities regardless of gender, ethnicity, sexual orientation, disability, political views or nationality. One student described this view:

That everyone goes under e.g., the same law, rules, norms, and standards regardless of background and have the same rights. (P30)

The students emphasised that no individual should be favored over another, highlighting their descriptions of the importance of impartiality in public institutions and systems. However, they also demonstrated a more nuanced understanding of the concept. While recognising that providing the same conditions to all may appear just, they acknowledged that it does not always result in fairness. One student noted that everyone may be granted the same opportunity, but it is ultimately the individual's responsibility to make use of it. As one student described it:

It may be about treating people equally, but it may not be fair. (P25)

Additionally, age was identified as a factor influencing equity, particularly in professional environments where older individuals may be perceived differently. One student described it as:

Justice for me is equal conditions both in education and in terms of wages in the labor market. (P12)

In the subcategory, “Preparing for fair care and providing support when needed”, the nursing students described their education as instrumental in fostering an understanding of equitable care delivery. One student's description:

In the education, we have been taught that care must be fair. (P1)

Students emphasised the importance of fairness within the learning environment, including equal participation and impartial treatment by educators, essential for preparing future nurses to uphold these same values in clinical practice:

That all people are treated equally and receive the same conditions in education. (P27)

The students highlighted that equality in education must include equity – recognising and responding to diverse needs in the educational context. They stressed that all students, regardless of background, should have access to appropriate resources and support mechanisms. Those with special needs must be granted the tools necessary for their development and academic success. One student described this view:

Everyone has the same rights and justice means, for example, that support is prioritised according to needs. (P8)

Furthermore, the importance of non-discrimination based on sexuality, gender, or ethnicity emerged as a recurring theme in the students’ descriptions, reflecting the student's belief that equitable education requires proactive measures to ensure inclusivity.

In the subcategory, “Ensuring quality, person-centered care, and equity among staff”, the nursing students described how equity should be operationalised in clinical settings. They emphasised that all individuals, regardless of gender, age, religion, sexual orientation or background, are entitled to the same standard of care. This view was described as:

Everyone should get the same treatment or that we should all have the same obligations. That everyone gets equal care. (P22)

The right to equitable treatment was described as fundamental, with one student stating:

Equity means equal benefits are given. The right care for everyone. (P28)

The students described that care should be tailored to individual patient needs. While the students affirmed the importance of equal access to care, they also recognised that achieving true equity may require individualised approaches. One student expressed it as:

All patients deserve the right care, but it is important to think about their needs. (P3)

Another student described it as:

Equity can be different and mean different things, but in my opinion, it means that everyone should have the same opportunities and rights in all contexts, at the same time as individual person-centred care which is individualised. (P26)

The students expressed clear views regarding intra-professional equity. They described a collaborative and respectful work environment as essential for achieving high-quality care. They emphasised equal rights among all staff members to express opinions and contribute to patient care decisions, regardless of their position within the organisational order. As one student described it:

That everyone has the right to express their opinions and that there will be no hierarchy among the healthcare staff as everyone still works towards the same goal, which is the best possible care for the patient. (P7)

Promoting inclusive practices in nursing education and healthcare delivery

This main category highlighted the importance of recognising individual differences, ensuring equitable participation in educational and clinical settings and fostering inclusive collaboration in patient care and professional environments. It underscored the need for both structural and interpersonal approaches to inclusion, aiming to cultivate healthcare cultures where diversity is valued and all individuals – students, patients, families and staff – feel seen, heard and meaningfully included. In the subcategory, “Belonging and adapting to individual needs”, the nursing students described inclusion as ensuring everyone is involved regardless of differences such as religion, sexual orientation, gender, age, or socio-economic background. Common descriptions included:

No one should feel left out. (P18)

Students emphasised that inclusion involves being part of a group or society, regardless of stereotypes or other distinctions. A sense of belonging and feeling included within a community were considered key elements.

They described that each situation is unique and should be adapted to meet individual needs. The students also highlighted the importance of having opportunities to express opinions and have a voice, which they regarded as central to inclusion. A recurring description was:

Everyone has the right to be accepted by the society to which they belong. (P20)

In the subcategory, “Implementation challenges”, the students described experiences from both classroom and clinical settings, emphasising that everyone should have the opportunity to participate and be acknowledged. They stressed that all individuals’ thoughts should be considered and valued. Fairness and equal participation were regarded as essential, regardless of background or identity. Clinical training was described as a context where students’ self-esteem could be positively influenced, depending on supervisors’ attitudes and their willingness to involve students in clinical tasks which was described as crucial for inclusion. One student described it:

As a student, to be included in tasks during your VFU (clinical training) – that the supervisors dare to let the students in – is important for self-esteem and feeling included” (P7)

They also emphasised the need for greater diversity among both educators and students as a means of fostering inclusion. One student described this as:

To include all types of people – not just a specific type – in nursing education. (P28)

Students also expressed concerns about the lack of practical tools for implementing inclusion. As one student stated:

This is something I feel we haven't really covered. We’ve talked about everyone's right to care, but how to actually achieve inclusion has not been addressed. (P1)

In the subcategory, “Engaging patients and fostering workplace collaboration”, the students described inclusion within the context of care and their future professional roles, emphasising that both patients and their families should be involved in care discussions and decisions. The descriptions highlighted the importance of recognising underrepresented or marginalised patient groups. One student described it:

Even if a group is underrepresented, it's important for us as nurses to learn relevant information about all patients. (P2)

The importance of creating an inclusive work environment where all team members are involved and no one is excluded was emphasised:

Everyone at work should feel included, regardless of background or culture. (P19)

Inclusion was consistently described as ensuring that all individuals feel informed, heard and valued, regardless of cultural or personal background.

Discussion

Our findings highlighted the contextual influence – or lack thereof – of DEI in Swedish nursing education. While formal strategies are not yet established, aspects of DEI are visible within the curriculum. Although DEI strategies are more prevalent in the USA and the UK, there remains a lack of consensus within the nursing academic community regarding a clear definition of DEI. ²⁹ Is it possible to have an overall standardised definition? The concept of “local histories, global designs”, acknowledges that, while social realities differ, similar power dynamics persist, highlighting the tension between dominant global structures and local knowledge systems that resist and challenge them. ³⁷ The present study underscored the need not only to clarify the constituent parts of DEI, but also to recognise the importance of context-sensitive approaches that reflect local conditions in nursing education and clinical practice. Lessons can be drawn from international examples, but without shared historical, legal and policy frameworks, DEI strategies must not only be interpreted, but also developed with careful consideration of the specific local-global context.

Despite the absence of formal DEI strategies, the findings indicated that certain areas are emphasised within Swedish nursing education, such as gender equality, non-discrimination, support for students with special needs, fair and person-centred care, and inclusive work environments. These priorities reflect strong legislative foundations, such as one of the cornerstones for Swedish healthcare, the Health and Medical Services Act, ³⁸ interpreted as equal care being provided to need and not based on factors such as income, age, gender, nationality or ethnicity. The core competencies of nursing education, including person-centred care ³⁹ and the emphasis on equitable and respectful work environments, are also linked to strong labour legislation reflected in the Discrimination Act. ²⁶

Our findings can be interpreted as showing that nursing students described the different aspects of DEI separately, with diversity understood as a broad, multifaceted and essential element in both education and clinical care, influencing their ethical outlook. The students consistently recognised the value of diversity for enhancing understanding, enriching learning and improving the quality of patient care. One central aspect highlighted in this study was the importance of diversity within the classroom, specifically the benefits of diverse representation among educators and students. Okenwa-Emegwa & Eriksson ⁴⁰ found that diversity-rich classrooms and interactive learning tools, such as role-play, positively influence nursing students’ understanding of equality, equity and human rights. Their findings underscore the importance of learning environments that reflect societal diversity – among both faculty and students. Similarly, Cubelo ⁴¹ recommends implementing unbiased recruitment practices in higher education institutions to increase faculty diversity, while Heaslip et al. ⁴² emphasise widening participation in nursing education in order to prepare a workforce capable of meeting the needs of increasingly diverse patient populations. In contrast, professional nursing organisations in the USA have a long tradition of explicitly addressing racism and practices to ensure diversity in the nursing workforce. ⁴³

Furthermore, the findings revealed a multilayered understanding of equity, characterised by a balance between equal treatment and equity, suggesting that equitable treatment may require differentiated approaches based on individual needs and societal structure. The findings showed the participants’ awareness of gender as a factor in equal treatment, in line with the Nordic emphasis on gender equality.^22–25 Although some theoretical confusion between the concepts of equality and equity was evident, the findings suggested that students possessed practical, experienced-based knowledge of these ideas. Across educational and clinical contexts, inclusion was conceived as both a moral obligation and a practical necessity. Students expressed a clear understanding of the values underpinning inclusion, while also acknowledging challenges related to implementation. Inclusion, as depicted in their descriptions, is not merely an ideal, but a dynamic, participatory process requiring sustained commitment from individuals, institutions and systems. Students’ descriptions on belonging, acceptance and inclusion demonstrated a developing professional commitment to social justice and inclusive practice within nursing. This highlights the importance of providing sustainable skills, knowledge and tools to support inclusive care. ⁴⁴

A notable strength of the study findings was that students actively linked DEI principles to core nursing values such as respect, person-centredness and fairness, demonstrating ethical engagement and professional awareness despite limited formal DEI training. Although the nursing education exposed students to aspects of DEI with the intent of raising awareness, the findings indicated a lack of structured opportunities and institutional strategies to foster deeper knowledge and practical competence. This fragmented understanding may have implications for both nursing education and clinical practice. ²⁹

In contrast to the USA and the UK,^13,18 Swedish nursing educational institutions have no long-standing tradition of explicit DEI strategies, which may influence students’ depth of knowledge in this area as highlighted in the present study. Several scholars advocate for the integration of DEI-related content through curriculum development, dedicated courses on cultural competence, and ongoing institutional training supported by institutional strategies.^45–47 However, studies explicitly focusing on the DEI concept within European nursing education remain scarce, and publications addressing DEI strategies in nursing educational institutions have only begun to gain prominence in the 2020s. ²⁹ A scoping review by Wolbring & Nguyen ⁴⁸ revealed significant gaps in the academic discourse on DEI, highlighting the need for further research and clearer implementation strategies.

Although there is a widespread discussion about the importance of integrating DEI into nursing education, such integration remains a long-term process that requires persistence. ⁴⁹ According to Cary et al. ⁵⁰ continuing institutional effort is essential to strengthen diversity and inclusion in nursing education. The Code of Ethics for Nurses ⁵¹ stresses that nursing is founded on valuing and respecting human life and rights, regardless of nationality, language, religion, race, age, political view or social status. Nevertheless, several studies highlight the presence of a hidden curriculum that shapes nursing education by influencing values and structural awareness.^52–53 To increase awareness of this hidden curriculum, targeted educational initiatives could serve as an effective tool. ⁵⁴

The findings also indicated the need for more in-depth pedagogical engagement and the use of practical tools to enhance the integration of DEI principles. Monforto et al. ⁵⁵ emphasise the crucial role of nurse educators in prioritising DEI through intentional learning activities, which are vital for reducing health disparities, promoting health equity and improving outcomes across diverse populations. Stewart ⁵⁶ similarly argues that nurse educators should foster learning spaces that promote critical consciousness and structural competence. Innovative teaching methods such as scenario-based learning and simulation have been suggested to enhance DEI awareness among students, educators and clinical staff. Holz & May ⁵⁷ highlight the value of simulation-based education for raising DEI awareness; however, for such methods to be effective, educators must feel adequately prepared and institutionally supported. ⁵⁸

Golding & Fencl ⁵⁹ further argue that self-awareness of personal biases among educators and clinical staff is a necessary starting point for improving care for diverse patient populations. Although participants in the present study acknowledged the central role of DEI in person-centred and high-quality care, they also identified challenges related to insufficient educational preparation and rigid workplace structures. Successful implementation of DEI requires more than individual awareness or competence; it depends on organisational commitment and strategic collaboration across both academic and clinical settings. Education plays a pivotal role in this transformation by instilling the value of diversity from the outset of professional training.^60–61 As Morrison et al. ⁶² argue, long-term cultural change within healthcare organisations demands strategic leadership and the development of inclusive organisational cultures.

Methodological considerations

In line with qualitative research traditions, trustworthiness^63–64 was addressed through the criteria of transferability, confirmability, credibility and dependability. The study had limitations because it included only a single group of undergraduate nursing students within a specific educational and cultural context, which may affect transferability. Recruitment was limited to those present on the day of data collection, which may have influenced those who agreed to participate. The sentence-completion technique may also have constrained the confirmation of participants’ responses because no follow-up interviews were conducted to clarify their written descriptions, potentially affecting confirmability.

Despite these limitations, credibility was enhanced through continuous discussions and reflective dialogues among researchers during data analysis, as well as through adherence to the COREQ guidelines. Finally, dependability was supported by a clear description of the analytical steps and the inclusion of illustrative quotations to ensure transparency.

Conclusions

The findings of the present study highlight the critical importance of strengthening the integration of DEI principles in both nursing education and clinical practice. Although students value multicultural and diverse learning environments, as well as person-centered care, they often lack the tools, frameworks and guidance required to apply DEI principles effectively in clinical settings. To implement DEI successfully within nursing educational and clinical practice environments, nursing students must be supported through robust education in person-centred care.

While formal DEI strategies are not yet embedded within Swedish nursing education, students nevertheless demonstrate strong ethical awareness and a clear willingness to advocate for patient inclusion and equitable healthcare. Nursing curricula should therefore incorporate more practical training in cultural competence, equitable care delivery and inclusive teamwork. Importantly, DEI strategies cannot simply be transferred from one context to another; rather, they must be carefully conceptualised and implemented within healthcare organisations, with careful attention to specific contextual and structural dynamics.

Fostering cultural sensitivity, person-centred care and inclusive learning environments is essential for preparing students to deliver care in increasingly diverse healthcare contexts. Registered nurses, in their roles as clinical supervisors and educators, should receive targeted training to cultivate inclusive educational environments in which all students – regardless of background – feel supported and well prepared to provide equitable, person-centred care. Healthcare organisations also share responsibility for promoting DEI principles within both the workforce and patient care interactions. Strengthening DEI integration across educational and clinical domains will better equip nursing students to meet the needs of diverse patient populations, collaborate effectively in interdisciplinary teams, and advocate for more inclusive and equitable healthcare organisations.