Cultural Humility: Reflective Essay

96 Nursing Education Perspectives

Reflective Journaling and Development of C U LT U R A L H U M I L I T Y I N S T U D E N T S

JENNY B. SCHUESSLER, BARBARA WILDER, AND LINDA W. BYRD

ABSTRACT Cultural humility requires self-evaluation and the awareness that one’s own culture is not the only or best one. Teaching health

care providers to become culturally humble includes the development of critical thinking skills and the ability to reflect on practice. Journaling as

a teaching strategy helps students develop these skills. This article describes the use of reflective journaling as students progressed through four

semesters of a community clinical experience. This qualitative, descriptive study was based on the principles of naturalistic inquiry with person-

centered written reflections. Two hundred journal entries from 50 students were reviewed, and 11 themes were identified. Cultural humility can-

not be learned merely in the classroom with traditional teaching methods. Reflection on experiences over time leads to the development of cul-

tural humility.

ULTURAL HUMILITY, AND THE COMMITMENT TO ADDRESS

POWER IMBALANCES IN THE PATIENT-CLINICIAN

DYNAMIC, REQUIRES LIFELONG DEDICATION TO SELF-EVALUATION

AND CRITIQUE (Tervalon & Murray-Garcia, 1998). For faculty, the

challenge involves more than teaching concepts and their applica-

tion in the performance of clinical skills. It expands to include the

development of critical thinking skills, self-understanding, and the

ability to reflect on one’s own practice. Essentially, cultural humil-

ity requires embracing the belief that one’s own culture is not the

only or best culture.

For more than a decade, the Auburn University School of Nursing

(SON) in Auburn, Alabama, has been in partnership with the local

housing authority (AHA), a low-income public housing provider. This

partnership, described elsewhere (Hamner, Wilder, & Byrd, 2007),

includes a nursing care clinic staffed three days per week by the nurs-

ing outreach instructor and Auburn students. The SON has a commu-

nity-based curriculum, founded on the belief that nursing is not

bound by the four walls of a hospital and that nursing care is a uni-

versal need. Part of bringing this belief to life is the requirement that

students participate in the partnership as part of their clinical experi-

ences as they matriculate through the curriculum.

When this clinical experience was first introduced, students

perceived it as different and somewhat stressful. These students,

the vast majority of whom were young, upper-middle-class white

women, had little experience with people different from them-

selves. It also became apparent that learning took place affectively

and cognitively in ways that could not be assessed by traditional

clinical evaluation tools and formal evaluation of teaching presen-

tations. Faculty determined that reflective writing, a useful mecha-

nism for understanding and internalizing experiences, would be

helpful to students participating in these clinical experiences

(Craft, 2005). This article reports on a study based, in part, on the

principles of naturalistic inquiry (Erlandson, Harris, Skipper, &

Allen, 1993). The primary question was, “What does reflective

journaling reveal about the experience of cultural humility in nurs-

ing students participating in the community partnership clinical?”

Why Reflective Journaling Journaling helps students

develop critical thinking, self-understanding, and reflection

(Billings, 2006; Craft, 2005; Daroszewski, Kinser, & Lloyd, 2004;

King & LaRocco, 2006). Pedro (2006) stated that writing is a good

tool for learning reflection that helps students solve problems and

learn about what they do. Journaling involves writing to learn, and

the journal becomes a permanent record of thoughts. When a

learner writes down a thought, the thought takes shape and form.

Journaling helps students engage in introspection and analyze sit-

uations critically. It should not be too structured, because students’

thoughts and reflections can become be constricted (Craft).

The practice of reflection, making meaning out of life experi-

ences, is inherent in journaling (Kerka, 2002). Diekelmann (2003)

described how reflection ultimately fosters thinking in action and

encourages students to have a critical eye and promote a safe envi-

ronment. Reflection fosters thinking that changes practice, and is

not merely a rote or routine expeience. When reflective thinking is

paired with journaling as a learning activity, students develop self-

analysis and an increased awareness of their environment.

Method The Internal Review Board for the Protection of Human

Subjects of Auburn University approved this study. For each of the

four semesters students had community partnership clinical expe-

C

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M a r c h / A p r i l Vol.33 No.2 97

riences at the AHA, semi-structured interview questions were

assigned. For the first semester experience, students were asked to

reflect on their expectations of what the clinical experience would

be like before they went and what the reality of the experience was.

For the second and third semesters, students were asked to

describe and reflect on their clinical time at the AHA. For the

fourth and final semester, students were asked to reflect on their

thoughts about the entire experience and its impact on their profes-

sional development.

All students having experiences at the AHA participated in

reflective journaling as they progressed through the curriculum.

Course faculty who were not involved in reviewing the journals

documented participation. To promote reflection on personal expe-

riences, a major purpose of journaling (Daroszewski et al., 2004),

grades were not assigned and names were removed from the jour-

nals before the faculty began their review.

Three faculty reviewed the journal entries of 50 students over a

period of two years as they progressed through the curriculum. A

total of 200 journal entrees were reviewed. Eleven themes emerged

in response to the questions asked in the four clinical courses:

three from the first semester, four from the second and third semes-

ters, and four from the final semester.

Findings REFLECTIONS FROM THE FIRST SEMESTER

Students began to see the importance of nursing in the commu-

nity, but were more interested in practicing psychomotor skills,

such as injections typically performed in traditional hospital

settings. However, even in this first clinical experience, stu-

dents were beginning to develop cultural humility.

Analysis of journal entries revealed three broad themes as

students reflected on their expectations prior to the clinical at

the AHA and described the reality as it was experienced. Even

though their instructions for journaling did not mention the

practice of psychomotor skills, students often wrote of having

the chance to practice these skills; for example, “I learned how

to take a manual blood pressure” and “I got to do finger sticks”

were mentioned repeatedly.

The second broad theme that emerged was a beginning under-

standing of the importance of culture in the lives of clients.

“The open discussion regarding cultural differences helped a

lot. We, as nursing students, must be constantly aware that our

personal culture is not the only one. We must provide culturally

competent care not only to individuals of racial or ethnic minor-

ity groups, but also to individuals belonging to groups held

together by factors such as sexual orientation, socioe-conomic

status, and religion.”

“I noticed that the clinical was also a social gathering for

clients. A lot of them sat around talking to each other after

getting their assessments. Being there seemed to lift a lot of

their spirits and all asked when the next time the clinic

would be held.”

Finally, it was clear that this first semester experience taught

students to begin to understand and value community nursing. One

student put it clearly:

“When offering health care in this setting, big impacts can be

made. The client is more likely to participate in primary prevention

if they are close to the location of health care. The nurse in the

community cannot only do screenings and prevention, she can also

teach the clients about healthy lifestyle choices. The nurse sees the

environment the clients are living in and is able to adjust interven-

tions to the unique aspects of the clients’ lives. The community

nurse also understands and grasps a better picture of the commu-

nity as a whole unit and how to fix the health problem on a larger

scale.”

REFLECTIONS FROM THE SECOND AND THIRD SEMESTERS

As students progressed through the curriculum, their journals

revealed a maturity and self-understanding not seen in earlier writ-

ings. The majority of students at the SON come from socioeco-

nomic backgrounds where experience with lack of health insur-

ance or the inability to afford medicine and basic health care is

unlikely. Although students are exposed in class to the fact that

some people must literally choose between medicine and food, this

notion became a reality in the clinical experience and helped stu-

dents see the impact of health care disparities. Students showed

creativity in meeting the needs of the population they were teach-

ing. Clearly, students learned by doing that teaching benefits when

the culture of the audience is considered.

With the simple instruction to reflect on what they learned dur-

ing the clinical, students were free to express what they were think-

ing and feeling. Four themes became apparent. First, students

expressed an awareness of health disparities for those experiencing

poverty and a concern about the health care delivery system in the

United States. They frequently made comments such as these:

“I became more conscientious of the great need for accessible health

care for the elderly and poor. Two main factors which I found to inter-

fere with optimal health care for clients were the lack of transportation

to seek health care, and the inability to afford medications as needed.”

“It was upsetting to me that some of the residents’ blood pressure was

so high. When I asked if they were taking their blood pressure medicine,

they replied they were not because they couldn’t afford it. That was the

only part of the day that I did not like. It seems so unfair and cruel not

to provide adequate health care and medications at a reasonable price.”

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98 Nursing Education Perspectives

A major assignment at the clinics was designing and imple-

menting health promotion teaching projects. Students described

how they critically examined their teaching and learning to tailor

their teaching to the audience. Comments included:

“These clients could not afford a gym membership and many did

not have transportation to it. We taught them how easy it is to apply

exercise techniques in their lives, you don’t have to go to a gym to do

it. We gave examples of easy ways to get your heart rate up such as

walking, playing with grandchildren, or doing housework. We also

gave the example of lifting a can of beans or bags of flour if they

wanted to work their arm muscles.”

“Our group went to Wal-Mart and picked out some items that

would make a nutritious, low calorie, but extremely inexpensive

meal. This was to demonstrate that if you plan ahead, you can eat

a good meal for very little money.”

Another theme that emerged revolved around identifying trust

as an important component of community health nursing.

“As a nurse, you have to be able to form a trusting relationship

with clients. This is not done through taking vital signs and doing

procedures. This is done through talking and listening to the con-

cerns of our patients. There will be many times in our career that we

won’t be able to physically do something for our patients to make

them better, but I can always give of my heart, time, and knowledge

and understanding to help someone, whether it is at the bedside of a

hospital unit or in the community. This is what the clinics…have

helped me learn to do.”

Students reflected on the importance of encouragement, support,

and being nonjudgmental when working with clients. They wrote:

“One client is currently trying to lose weight and is also attend-

ing classes at the community college. She confided that several of her

friends and family have been telling her that she is too old and too

heavy to do these things. I talked to her about dealing with discour-

agement and then tried to encourage her by helping her to focusing

on how far she had come from where she started.”

“One way we could improve our presentation would be to go back

and take out the negative connotations. For instance, one of the

things we said was that tobacco users can be stinky. We should have

said something like, some people believe that tobacco product users

tend to carry the smoky smell with them even if they are not actively

using at that point. Next time, when we are presenting as a group,

we must remain as nonjudgmental as possible.”

Reflections from the Fourth Semester At this time in

their education, students’ writings suggested an ability to reflect on

their own practice. They now understood that nursing was not just

about doing something to the patient, such as taking a blood pres-

sure, but nursing is about interacting with patients in the way that

meets the patient’s needs. As part of this final experience, senior

students mentored juniors. By doing this, they were able to see how

far they had progressed. Students not only began to reflect on how

people are alike, but also on how differences in culture are inter-

esting and special.

Three themes emerged. First, it was obvious students gained con-

fidence in themselves as they matriculated through the curriculum.

“Out of all of my clinic experiences, this one was the most reward-

ing. During my first year, I was eager to talk to residents, but I was

scared at the same time. I did not have the same comfort level ask-

ing them about their health as I do now. I felt as though I was fol-

lowing a list of criteria that I had to meet. Now, it was just part of

our conversation. I was just being the nurse.”

“One of the junior students was satisfied when she asked a patient

what day it was and he replied, ‘It’s Wednesday.’ She had charted

that he was oriented to time, but I was able to show her that just

because he knew what day it was, didn’t mean that he was oriented

to time at all. Upon further assessment, we found that he didn’t know

the season, the month, the year, or even who was the current presi-

dent (interestingly enough, he said Coolidge). Through more thor-

ough assessment, I was able to show the junior nursing students how

important it is to ask several questions and not just settle with the

first answer that they get from patients.”

Another theme expressed in the fourth semester writings was an

understanding of the importance of health promotion and disease

prevention.

“I have learned a lot about the importance of early intervention.

I have seen with my own two eyes how patients have benefited from

heath promotion.”

“Many of the residents that came into the clinic expressed lifestyle

changes that they are currently involved in such as exercising more

and making better food choices. By making these choices, positive

results are bound to happen.”

The fourth-semester journal entries reflected how students had

changed their thinking and feelings about people from a different

culture. Students wrote:

“When I first started going to the housing authority, I had nega-

tive thoughts about violence and so on as being a part of living there.

When I started interacting with clients I was able to see how alike we

all are. I think about how they feel when they are judged by people

every day just like I used to do. This experience has taught me to be

more accepting of people and cultures different than mine.”

“In thinking back to my times at the clinic, I remember one very

interesting client who believed in some kind of metaphysical reli-

gion and did some sort of prayer meditation with arm motions

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before I pricked his finger. At the time it freaked me out, but now I

am able to understand and accept a client’s culture that is differ-

ent from mine.”

“I couldn’t believe what I put in my first journal entry. I was so

judgmental. I talked about people wearing old clothes that needed to

retire and said their appearance looked a little diminished compared

to persons of a higher socioeconomic status. After working there all

this time, I now know that some of the best people I will ever meet live

at the housing authority. You surely can’t judge a book by its cover.”

Discussion What reflective journaling reveals about the

experience of cultural humility in nursing students participat-

ing in the community partnership clinical was the broad ques-

tion guiding this study. Cultural humility development begins

in the first semester as students practice thinking and self-

reflection in their journals and begin to recognize the impor-

tance of culture. These students are new to interaction with

clients, and interaction with clients of a different culture has

a tremendous impact on them. For the first time, they have

conversations with people different from themselves about the

meaning and experience of being from a certain culture.

Beginning to understand that their culture it not the only one

is an eye-opening experience.

Enhancement of cultural humility continued in the second

and third semesters. Students were no longer novices to nursing

and the environment of the nursing care clinics. Two concepts

grasped by students promoted cultural humility. First, students

saw firsthand that poverty creates health care disparities. They

left these clinical experiences fully aware of the imbalance in

power in the patient-health care provider relationship brought

about by lack of resources. Second, the health promotion teach-

ing projects they undertook drove home the fact that culture

must be considered when teaching clients.

Although the development of cultural humility is a lifelong

process, cultural humility appeared well developed in students

during the fourth semester. Students saw the beauty of differ-

ences as well as how all human beings are alike. They began to

understand that health care is best delivered through a respect-

ful partnership with the patient. Students realized that judg-

mental attitudes, based on stereotypes, are faced almost daily

by housing authority residents. They were determined to fight

judgmental thinking and behavior in themselves.

In summary, reflective journaling helps students progressively

develop their critical thinking, self-reflection skills, and cultural

humility. Cultural humility cannot be learned solely in the class-

room with traditional teaching methods. Rather, it requires reflec-

tion on experiences over time. Attentiveness to cultural issues and

applying self-awareness and reflection in the care of patients helps

students understand and address health care disparities.

About the Author The authors are faculty at Auburn University

School of Nursing, Auburn, Alabama. Jenny B. Schuessler, DNS,

RN, is associate dean and professor. Barbara Wilder, DNS, CRNP, is

coordinator of the nurse practitioner program and professor. Lynda

W. Byrd, PhD, CRNP, is a clinical assistant professor. For more

information, contact Dr. Schuessler at [email protected].

Key Words Cultural Humility – Reflective Journaling – Cultural

Competence – Diversity – Clinical Nursing Education

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