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Major Article

Queering the Classroom: Teaching Nurses Against Oppression

    Journal of Nursing Education, 2023;62(4):193–198
    Published Online:https://doi.org/10.3928/01484834-20230208-02Cited by:1

    Abstract

    Background:

    Teaching about oppression risks replicating harm and reproducing othering. This occurs despite nurse educators' best intentions, with implications for both learners and recipients of nursing care. Teaching against oppression attends to the interlocking matrices of domination that construct otherness and propagate harm.

    Method:

    This article presents a norm-critical approach to education that interrogates the power and praxes that structure nursing education through a queer theoretical lens. First, terms, such as norm-criticism, norms, power, othering, and queerness, are defined. Next, the stakes of norm-critical, queer perspectives in nursing education praxis are discussed. Finally, these concepts are applied to brief case scenarios.

    Results:

    A queered perspective reveals the co-construction of norms, power, and othering in familiar nursing education praxis scenarios.

    Conclusion:

    This article serves as a call to action for nursing educators, inviting them into critical reflexivity by offering a queered lens through which to dismantle oppression within the practice and praxis of nursing education. [J Nurs Educ. 2023;62(4):193–198.]

    Introduction

    Teaching about oppression reinforces othering and normativity, despite good intentions and well-meaning efforts. Teaching against oppression, however, is the intervention needed to dismantle injustice and construct more just, equitable possibilities for nursing education. Teaching against oppression requires a commitment to disrupting the structures that maintain privilege associated with dominant and normative identities (Kumashiro, 2002). This distinction is subtle but important and maps on to the shift away from cultural competency toward cultural humility, safety, and responsiveness in nursing education praxis. Yet, even nurse educators who wish to enact an inclusive model of education can find themselves on the shoals of othering, reinforcing structures of power and inequity in their education praxis, a reminder that effect must always be prioritized over intent alone. The key word here is structures: nursing faculty and nursing learners' function within interlocking systems of oppression that perpetuate harm and deficit models of difference (Hill Collins, 2009). Nurse educators often lack the tools to critically interrogate and transform their praxis, in part because education itself often lacks the tools to critically interrogate and transform praxis. This points to the reality that no one person alone can dismantle structural inequity. However, nurse educators as a collective can queer our perspective and reimagine nursing education from a norm-critical standpoint (Ahmed, 2006; Tengelin, 2019).

    This article introduces “norm-criticism” as a way to critique, dismantle, and rebuild nursing education. Norm-criticism is a pedagogical framework with roots in queer studies; thus, to enact norm-critical education praxis is to embody queerness. We use queerness to mean a lens that affords a view of assumptions and norms from a different angle or as Ahmed (2006) writes, “To make things queer is certainly to disturb the order of things” (p. 565). The roots of this article lie in one of the author's (C.M.N.) dissertation research, which was adapted for a collaborative virtual poster presented at a national nursing education conference. A forthcoming companion article will detail the features of the conference poster itself. In the current article, we will lay the foundation and describe our emerging pedagogical framework. In this discussion, we attempt to model queer norm-criticism and lay the theoretical foundations for transformation of nursing education praxis. First, we define key terms, including norm-criticism, norms, power, othering, and queerness. Next, we discuss what is at stake in failing to embrace norm-critical, queer perspectives on nursing education praxis and provide three case scenarios that apply these principles. Finally, we conclude with a call to action for nursing educators. A note on the word “we”—when we use the word “we,” we are referring to ourselves as authors; when we mean nurse educators more broadly, we will specify that and use collective pronouns (“ours”) because we (the authors) are nurse educators as well.

    Theorizing Queer Norm-Criticism

    What follows is an outline of a pedagogical framework for nursing education. This framework is built on the notion of queerness as praxis. To animate this framework, we unpack several key concepts that are salient to the work of norm-criticism and its queer lens. These concepts include norms, power, othering, norm-criticism, and queerness. To teach against oppression, it is first necessary to consider our politics and positionality.

    Politics and Positionality

    One critical dimension of our theoretical work is attending to the power dynamics that shape nursing, education, and health care as political endeavors. We embrace radical feminist literary critic Kate Millett's (2016) definition of politics—politics are simply power-structured relationships. In describing a process of applying norm-criticism to nursing education, it is important to explicitly address our positionality as nursing educators and scholars. As Harden (1996) wrote nearly 30 years ago, “We must accept that teaching is a political activity and be aware that everything we teach is value-laden and that neutrality is a myth” (p. 35). We approach the project of teaching nursing, whether with student learners or faculty peers, as an explicitly political activity, and our praxis is deeply indebted to the pedagogy of the oppressed (Freire, 1970), the theory of emancipatory nursing praxis (Walter, 2017), and abolitionist activists within and beyond nursing education (bell hooks, 1994; Cite Black Women Collective, 2017; Combahee River Collective, 1978; Kaba, 2021; Love, n.d.; Stommel, 2018; Walker, 2021). This is particularly important for nursing and nursing education, which all too often has embraced a stance of apoliticism. We find this to be both disingenuous and a disservice to the discipline as well as those we teach and accompany in care.

    Furthermore, as the 20th century radical feminist slogan says, “the personal is political” (Hanish, 2006). To this end, to enact our queer feminist praxes, we explicitly acknowledge that we are two queer, White nurse educators whose teaching praxis necessarily includes a continuous process of self-reflexivity. Johansson and Theodorsson (2013) correctly observed, “The norm-critical gaze of the educator has to be directed towards oneself; one's own actions, values, norms, relations and identities” (p. 120). We readily acknowledge that our viewpoints are afforded a certain degree of privilege within our discipline of nursing education because of our own proximity to dominant, normative identities, including unearned white and class privilege as well as access to education. Even as we describe our norm-critical framework and teaching, we work to keep ourselves and each other accountable, inhabiting that “norm-critical gaze.”

    Norm-Criticism

    Norm-criticism has its origins in Swedish pedagogical theory. Norm-criticism only recently has begun to be explored within nursing education and is primarily concerned with interrogating and deconstructing powerful norms that contribute to inequity and oppression (Johansson & Theodorsson, 2013, Tengelin, 2019). Often, in addressing gaps in nursing education concerning diversity, unconscious bias, cultural humility, or most of all cultural competency, the solution is more—more emphasis on the importance of preparing students to care for a more diverse patient population, more exposure to different cultural practices, concerns about adding more material to curricula that are already jam-packed, and sometimes more data about health disparities and implicit bias (Davis & O'Brien, 2020; McNiel & Elertson, 2018). Yet the framework of norm-criticism and its aim to disrupt harmful norms suggests that “changing oppression requires disruptive knowledge, not simply more knowledge” (Kumashiro, 2002, p. 34). Therefore, rather than considering a deconstruction and disruption of oppressive structures and systems to be additive, more—more material, more courses, and more learning outcomes to measure—norm-criticism allows us instead to question and disrupt established norms and practices with the aim of creating a truly antioppressive teaching praxis.

    Norms, Power, and Othering

    The concepts at the core of the theory of norm-criticism are norms, power, and othering. Within this theory, norms, power, and othering function together like the interlocking, dynamic, and inexorable movement of gears within a clock—and similarly hidden from view. Norm-criticism seeks to disrupt “interlocking systems” of oppression from within their internal workings (Hill Collins, 2009). To disrupt norms, power, and othering, these concepts need to be understood within the nursing education context.

    Norms. The concept of norms is rooted in the word “normal,” which is a “social and contested construct” (Kumashiro, 2002, p. 45). The function of norms is to divide and subjugate nondominant groups to the will and desires of dominant groups (bell hooks, 1994). Tengelin and Dahlborg-Lyckhage (2017) define norms as “cultural forces that regulate and control human notions, identity and behavior” (p. 2). Nursing education is full of norms that are situated within socially constructed contexts, reinforce the supremacy of dominant groups, and regulate and control student and faculty behavior. These include normative whiteness, compulsory heterosexuality, and white bourgeois femininity. Enforcing a particular hegemony, or dominant set of ideas, means that these norms structure both what is normed and what is Othered (Jacob et al., 2021; Krabbe, 2021). One particularly pernicious snarl for thinking about norms and how power operates is that, particularly for those who occupy dominant groups, these norms appear natural, invisible, and simply the order of things. Norm-criticism demands that we interrogate both norms and the power and knowledge that produces them.

    The normative whiteness that structures nursing, and subsequently nursing education, is rooted in the white supremacy that pervades American culture more broadly (Bell, 2021; Bonini & Matias, 2021). Following legal scholar Frances Lee Ansley (1989), when we invoke the term “white supremacy,” we do not intend to conjure images of white men in white pointed hats. Rather, we use Ansley's definition of white supremacy as a set of conditions in which “whites overwhelmingly control power and material resources, conscious and unconscious ideas of white superiority and entitlement are widespread, and relations of white dominance and non-white subordination are daily re-enacted across a broad array of institutions and social settings” (Ansley, 1989, p. 1024. In other words, white supremacy is an arrangement of power and knowledge that enforces whiteness as default, normal, and baked in (Reddy, 1998). Compulsory heterosexuality and white femininity are enforced as a function of white cisheteropatriarchy, where power differentials demand conformity with gender, sexuality, and racial norms. This is as true in nursing and nursing education as it is in any other institution embedded in the white hegemony of the United States.

    We need look no further than the legacy of Florence Nightingale and its role in nursing education to see these norms on display (Smith, 2020). The name Florence Nightingale evokes the image of the “lady with the lamp” in both the nursing and popular imagination, a vision of white Victorian femininity. Nightingale's key interventions in nursing were organizational: Nightingale sanitized the discipline for the daughters of respectable white families while exporting a training model around the world to shape nurses to her specifications (Waite & Nardi, 2019). This meant supplanting those nurses who might be understood as “lowly servants—untrained, drunk, and slovenly” (Enloe, 2021, para. 24) who had previously nursed in hospital settings. Among those denied entry by Nightingale herself was Mother Mary Seacole (2019, p. 79), who perceived her exclusion to be a function of her “duskier skin.” These interventions constructed a discipline in which whiteness, femininity, and compulsory heterosexuality were—and remain—normative.

    These norms operate in synchrony, reinforcing one another and shoring up hegemony while holding the other at arm's length. The operation of these norms fades to invisibility to those who occupy dominant space: those who are white, who are cisgender, who are heterosexual, and who embody white femininity. At the same time, these normative expectations are, following women's studies scholar Maureen Reddy (1998) and nurse anthropologist Evelyn Barbee (1993), abundantly clear to those who do not inhabit them.

    Power. The poststructuralist view is useful in understanding how power contributes to the dynamics of center and margin in the mechanisms described by the theory of norm-criticism. In this view, power is neither fixed nor top-down (Foucault, 1980). Rather, power exists in a “capillary form,” permeating and circulating through all interactions. In this construction, all parties are simultaneously subject and object of power, an ongoing negotiation of agency rather than an authoritarian diktat (Bradbury-Jones et al.; 2008; Kuokkanen & Leino-Kilpi, 2000). Innumerable points of confrontation irreducibly link power and knowledge, where what is known and knowable is a function of power, and power is reciprocally reinforced by that which is known and knowable (Foucault, 1980). Power and knowledge fused can exist in both causative and mutually reinforcing relationships (Bradbury-Jones et al., 2008). The critical take-away is that power inflects relationships and interactions at every interface, irrespective of intent or desire.

    Othering. Othering is a dynamic process involving labeling based on perceived differences from hegemonic norms, essentialism, and structural forces (Canales, 2000; Jacob et al., 2021; Jauregui et al., 2020; Krabbe, 2021;). Tengelin (2019) noted, “There is no quintessential ‘Other.’ Hierarchies are quite contextual and can shift from time and place” (p. 22). The contextuality of Other points to the dynamism of othering as a process rather than a fixed set of hierarchical facts. This is congruent with sociologist Patricia Hill Collins' (2009) matrix of domination, which points to the interlocking, irreducible, and processual nature of oppression that is not stable but is instead always enacted.

    However, othering's function within nursing education praxis, like that of power and norms, is pernicious and difficult to uproot, including among nursing educators. A study of nursing educators' reflections on their experiences in a “norm-aware caring” training reflects the difficulty of resisting othering processes (Tengelin & Dahlborg-Lyckhage, 2017). The authors demonstrate that the educators who had experienced this training, which was meant to shift their thinking about norms and othering within their teaching practices, still situated themselves as normative within their teaching contexts, while othering students (or possibly, colleagues) who may be different from the assumed, contextualized norm. The persistence of this binary, normative/non-normative framing among nurse educators is exemplified by one participant's statement, “In this class of 20, or a hundred, there might be…someone homosexual, some transsexual [sic] person, and so on. I think that's a good tip, a good thought to keep in one's mind” (Tengelin & Dahlborg-Lyckhage, 2017, p. 3). The researchers noted the educators in their study consistently identified that changing their way of thinking might be good for those students who were “Other,” a well-intended sentiment that fundamentally does not change the process of othering (Tengelin & Dahlborg-Lyckhage, 2017).

    Queerness as Praxis

    If norms, power, and othering operate in synchronized, interlocking, and inexorable concert behind the scenes in nursing education, the physics of their inevitability and invisibility is the inertia that shapes the order of things, the way things are. To disrupt that inertia requires a queer perspective, one that sees things at a slant and “disturb[s] the order of things” (Ahmed, 2006, p. 565). Norm-criticism indeed aims to disturb the order of things. Attending the interlocking and mutually reinforcing operations of norms, power, and othering in nursing education necessarily means disturbing—and possibly deconstructing and entirely rebuilding—the order of things.

    Using Norm-Criticism to Queer the Classroom: Application

    To disrupt the interlocking and dynamic forces of norms, power, and othering within nursing education, we must strive to apply a consistent, equal and opposite force of critical reflexivity. We need to critically examine our teaching for opportunities to question normative positions, upend power imbalances, and disrupt and redirect language, practices, and expectations that reify othering. This kind of persistence in the commitment to queering our nursing teaching practice is both demanding and essential. Browne and Reimer-Kirkham (2014) warn against “equity fatigue,” citing “a sense of negativity, critique without end, guilt about unequal relations of power, or hopelessness about the scope of social and health inequities” (p. 31). This equity fatigue can lead to a dialectical resistance among nursing educators who may both understand their responsibility to challenge the status quo but make a choice—out of fatigue, hopelessness, or some other force—to maintain it (McEldowney, 2003). Norm-criticism gives us the tools to see both equity fatigue and dialectical resistance as functions of the interlocking gears—norms, power, and othering—and use reflexivity as a form of resistance.

    Kumashiro (2002) described a structural approach to teaching against and dismantling oppression within education praxis by giving a concrete example of problematizing a norm with the use of critical reflexivity: “[U]nderstanding the oppression of queer students goes beyond an emphasis on homophobia and individual fear to consider heterosexism (“heteronormativity”) and how the social demands of being ‘normal’ are what help to promote queer-based oppression” (p. 45). In other words, individual actors, both queer and non-queer, operate within a structure of heteronormativity regardless of individual beliefs or efforts at inclusion, and this is the level at which antioppression education and praxis need to operate. Imagine how the educator quoted by Tengelin and Dahlborg-Lyckhage (2017) might have experienced the “norm-aware caring” training differently if the educator had been able to queer his or her understanding of the oppression of queer and transgender students. This example sets the stage for us to explore a few case studies for opportunities to apply a norm-critical queer lens to nursing education praxis. These case examples are not intended to represent a finite or definitive checklist for applying norm-critical thinking to nursing education. There are many other types of scenarios in which norms, power, and othering appear in ways that reinforce inequity and harm. These are meant as an invitation to readers to conduct their own analysis of their teaching practice, materials, and environment.

    Cultural Competency Versus Cultural Safety

    • “Patients from eastern cultures may prefer hot things to cold things when they are ill with a fever.”

    • “Jewish patients are more likely to complain of pain.”

    • “Patients from diverse cultures may have unique needs in health care settings.”

    In the 20 years since Campinha-Bacote's (2002) transcultural model of “cultural competency” was first introduced into nursing education praxis, phrases such as the ones listed have made their essentializing and white-centering appearance in nursing education materials across curricula. A norm-critical assessment of this still commonly used model for teaching nursing care across differences reveals the deep assumptions of the whiteness and cultural dominance of the intended audience. Ingram (2012) offers an example of its application to practice by stating “[A]ll healthcare professionals [must] be prepared to care for ethnic minorities” (p. 696)—a statement that entirely ignores the fact that many health care professionals themselves are part of racialized, minoritized groups. Although this model gives a brief nod to “self-awareness,” its primary features remain colonization and conquest of fixed knowledge about “different” cultures, rendering it unsuitable for a norm-critical approach to nursing education.

    More recently, the construct of cultural humility has gained traction in nursing education as an alternative framework for transcultural nursing (Hughes et al., 2020). This model moves away from the idea that cultural knowledge can be “mastered” with a competency-based model and emphasizes empathy, respect, and self-reflection (Hughes et al., 2020). However, cultural humility still centers interpersonal and intrapersonal interactions and intersections between nurses and patients (or faculty and students) in a way that gives only surface consideration to the systemic power dynamics that create a supportive or threatening health care environment (Foronda et al., 2016). We posit that the model of cultural safety, which requires interrogation of the environment of care—and, for that matter, of learning—provides a more comprehensive frame for addressing teaching, learning, and nursing across difference and power (Curtis et al., 2019). Cultural safety “foregrounds power differentials within society, the requirement for health professionals to reflect on interpersonal power differences (their own and that of the patient), and how the transfer of power within multiple contexts can facilitate appropriate care” (Curtis et al., 2019, p. 12). This key difference between cultural safety and the competency and humility models makes it best suited for a norm-critical pedagogical approach.

    Pronouns [Not] Required

    The topic of pronouns recently came up in one of our workshops on providing culturally safe nursing care to transgender and gender-diverse people. We invited participants to share their strategies on fostering inclusive environments. One nursing faculty member suggested that requiring students to share their pronouns could be a remedy for making both clinical practice and classroom praxis more inclusive. However, mandating that people share their pronouns can create an alienating environment for some individuals, despite the practice being intended to foster cultural safety. Many individuals may freely share pronouns or other markers of non-normative, minoritized identity; for other individuals, mandating this kind of reporting forces a choice they may not be prepared to make—either outing themselves when they are not ready to disclose or choosing to label themselves with pronouns congruent with hegemonic expressions that fit uncomfortably. Our discussion concluded with the suggestion that faculty consider sharing their own pronouns, leaving it open to care-receivers or learners what, if any, information about their identities they share in the clinical or learning space.

    As we intimated above, we often approach care and teaching with good intentions that result in harmful effects; “pronouns required” could be an example of this. Requiring pronouns creates a new norm, which can be quite potent. However, the burden here is disproportionate and reinforces compulsory cisnormativity by continuing to center expectations around both cisgender identity and expectations around disclosure. The process of “coming out” has been embraced in many ways as a liberatory and celebratory act for those whose lives and experiences exist outside the gender binary and heterosexuality. Yet this process of disclosure is tied to a culture of cisheteronormativity or the idea that everyone is cisgender or straight until proven otherwise. Therefore, if we consider “coming out” in light of othering, mandated disclosure of gender identity through compulsory pronoun declaration becomes fraught. We also must attend to the power differential inherent in education settings between educators and learners—what may be intended as inviting may be received as coercive or overwhelming. For faculty, disclosing pronouns and inviting learners to share as they desire holds space for transgender and gender-diverse students without demanding conformity to a new norm that is also steeped in cisheteronormativity, albeit from a different place.

    Queering the Poster

    Traditional conference posters position authors as authorities, experts on their research, intervention, and findings, while positioning other conference participants as learners. This two-dimensional, unidirectional model of information sharing, although familiar, is both limited and limiting in the opportunities it gives participants at a traditional professional conference to engage in co-creation of knowledge and sharing of ideas. Not all abstracts are accepted; there are good logistical reasons why this may be the case, but it also raises the question of which kinds of knowledge sharing and “content delivery” are included, and which kinds are excluded. Interrogating this structure is part of norm-criticism and of queering the conference poster.

    At the 2021 American Association of Colleges of Nursing Diversity Symposium, we presented our poster titled, Queer the Classroom: Disrupt White Cisheteronormativity, which was created to be an immersive learning and teaching experience for creators and participants, one that facilitated multidirectional information and experience sharing. This poster and its presentation were prepared as an open conversation, the goal of which is to question and deconstruct power dynamics as they exist in educational spaces even among each other as educators, queering our pedagogical expectations, desires, and practices. Participation in the poster session—from internet-platform based questions and idea sharing to additions to the musical playlist associated with the poster—continued well beyond the end of the symposium.

    A Call to Question

    We call this a “call to question” rather than “a call to action” because the interrogation, queering, and deconstructing that comes from questioning norms, power, and othering within nursing education will lead the way to action—and this action cannot be driven by any one individual or any one group. If the goal is to end oppressive practices in nursing education, nurse educators must confront our gatekeeping tendencies, cleave our grasp on power, and embrace multiplicity. To this end, we offer a list of questions that is decidedly nonexhaustive: In nursing texts, standards, competencies, classrooms, whose voices, experiences, and images are centered? Whose are marginalized, omitted, or silenced? Whose expertise on a given subject or experience “counts”? Who is “us” and who is “them” or “not us” in classrooms, clinical learning spaces, and simulation laboratories? How do we, as educators, model a norm-critical approach to nursing? We can lead the way when we demonstrably reflect on and note our power and positionality, display genuine attentiveness to cultural humility and safety (Curtis et al., 2019), and offer sincere apologies when we make mistakes that harm others (Whitney et al., 2020). What other questions can nurse educators ask to free ourselves and our students from the “hidden curriculum” (Kelly, 2020)? This is a starting place, a jumping-off point, rather than a definitive how-to or the singular text for transforming nursing education praxis.

    Conclusion

    Education can be, as bell hooks (1994) taught us, as we see others enacting, as we strive to do, a practice of freedom. To realize that potential, nursing educators have work to do. To teach against oppression, nurse educators must continually interrogate their praxis to “learn to constantly ask, ‘What are hidden ways that my practices reinforce oppression?’” (Kumashiro, 2015, p. 13). Without this initial, intentional, and iterative intervention, teaching will always revert to enforcing hegemonic norms. Learning to recognize the interlocking “gears” of norms, power, and othering in our teaching practices, materials, structures, and systems is the necessary starting place. The metaphor of the clock and gears shows us that without persistent attention and disruption, the gears will continue to turn. Reflection is a necessary starting place for antioppressive and queer teaching praxis, but it is not sufficient for transformation.

    Teaching against oppression and embracing queerness as praxis requires doing. Taking the insights gained from reflecting on praxis, teachers must then move to change the way they do things, bringing their colleagues and students along. Untangling the snarl of norms, power, and othering in the ideas and materials we inherit can allow us to envision a more just and more equitable present and future for nursing education and thus the discipline of nursing. However, this is a perpetual motion machine and one that requires us to stay engaged with thinking about the biases and limitations that consciously and unconsciously form the basis for our teaching praxes. We can choose to do things differently, again and again, to create the world our students and the communities we accompany in care need and deserve.

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