Addressing Positionality Within Case-Based Learning to Mitigate Systemic Racism in Health Care : Nurse Educator

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Addressing Positionality Within Case-Based Learning to Mitigate Systemic Racism in Health Care

Altman, Molly R. PhD, CNM, MPH; Kantrowitz-Gordon, Ira PhD, CNM; Moise, Elba BA, MPH; Malcolm, Katie PhD; Vidaković, Milan PhD; Barrington, Wendy PhD; O'Connor, M. Rebecca PhD, RN; de Castro, A. B. PhD, MSN/MPH, RN, FAAN

Author Information
doi: 10.1097/NNE.0000000000000937

Abstract

Case-based (or case study) learning is a teaching method traditionally used in nursing education that centers on predictable clinical patient scenarios with prompts for exploring history, physical examination components, diagnostic testing, differential diagnoses, and care planning.1 Case-based learning provides an opportunity for students to build clinical problem-solving and critical thinking skills before reaching bedside nursing-patient interactions. This teaching approach facilitates a level of preparation among nursing students to provide actual patient care while also preventing potential patient harm.2 Furthermore, it helps students develop critical thinking abilities and use evidence-based knowledge, diagnostic reasoning, and self-perception as a clinical provider, while providing exposure to common and uncommon clinical scenarios they may encounter in their clinical sites.3 Case studies do not often present right or wrong answers, but rather provide a valuable opportunity to address more or less appropriate, helpful, and inclusive strategies. They also call on students to share perspectives, incorporate theoretical understanding, and engage in reflective dialogue about clinical management and decision-making.4

Case-based learning has historically focused on the individual patient embedded in a given scenario, with emphasis on their medical, social, and family history. However, there is little consideration of how social determinants of health and structural impacts, particularly racism and its adverse health effects, bear upon patients' health status, access to and receiving quality health care services, and consequent patient outcomes. Such an approach adds to the complexity of designing and implementing case studies and necessarily broadens the learning objectives beyond traditional care competencies. Educators may also be reluctant to include the patient's race and ethnicity in case-based learning due to a concern about perpetuating stereotypes or misrepresenting race as a biological risk factor.5 If nurse educators and students are not prepared to acknowledge and identify how social determinants, such as racism, impact health as part of the overall patient assessment and care delivery, it becomes impossible to make the learning spaces—and, by extension, patient-care environments—equitable. Furthermore, students with marginalized identities can find their lived experiences minimized, and they may disengage from the learning experience. Inequity in the classroom is then extended into their clinical practice after graduation.

One way structural racism in health care manifests is by neglecting to incorporate or address positionality, defined as an understanding of one's own racial identities and their relationships to systems of power and oppression, into health care access and delivery or the training of health care professionals.6 Addressing positionality at the institutional, provider, and patient levels in case-based learning is one antiracist strategy to begin rectifying health disparities and moving health care toward equity. Most educators strive to maintain the façade of objective distance, projecting themselves as neutral (ie, without any specific backgrounds) and going out of their way to not divulge personal information or even begin to take it into account.7 The neglected part of educators in the educational context is their social identities and how they proactively and openly mobilize their identities for instruction and inclusivity. Whether case studies explicitly name social identities of patients (such as race, gender, age, social status, sexual orientation, etc), they run the risk of activating assumptions that equate social identities with fixed characteristics, behaviors, and ways of thinking that perpetuate stereotypes. For example, the assumption that Black patients are more pain-tolerant results in the well-documented undertreatment of Black patients' pain.8 Therefore, a new, more comprehensive approach to implementing case studies is necessary that takes into account the positionality, not only of patients but also of health care providers—and within the nursing education context, of students and educators—to counter the racial oppression and discrimination embedded in existing health care and educational systems.

This article was cocreated by a diverse team of nurse researchers, nurse educators, and educational developers, including educators who specialize in diversity, equity, and inclusion principles, at both the undergraduate and graduate levels. Our identities vary in racial background, gender, sexual orientation, and education (Supplemental Digital Content 1, https://links.lww.com/NE/A855, for author positionalities). Our collective knowledge consists of experiences of bias and discrimination across race, gender, sexual orientation, education, and nationality, all of which have influenced the perspectives shared within this article.

In this article, we describe a process for creating an inclusive, antiracist environment for case-based learning within nursing education. We outline steps for preparing students to more effectively examine case studies through social determinants of health framing and lens to mitigate harmful impacts from systemic racism and racial discrimination in clinical care. Components of this strategy include addressing the positionality of the learner and the educator, maintaining an inclusive environment during discussions, and case study implementation with a racial equity lens.

Nursing Education and Antiracism

The field of nursing has been challenged to address systemic racism and to integrate antiracism education in nurse education curriculum.9-11 Antiracism is an active approach toward disrupting and transforming practices and policies that support racism, discrimination, and inequity.12 However, most nursing curricula do not focus on antiracist approaches,13,14 but rather a cultural competence or transcultural model, which does not teach students to understand the systems of White privilege and systemic racism.15

In nursing, a cultural competence paradigm might focus on meaningful care for people from diverse cultural backgrounds rooted in their specific beliefs, attitudes, and practices.16 Yet this approach “allows nurses to depoliticize discussions of race and other social differences, largely ignoring the influence that systems of oppression, imperialism, and historical trauma have had on health in marginalized populations” [emphasis added].10(p255) For example, providing care to an immigrant merely based on an understanding of their culture of origin does not account for their past and present experiences of racial oppression as a marginalized individual in a system dominated by whiteness. Similarly, other nurse scholars and practitioners argue that transcultural approaches to nursing do not effectively address individual racial biases—the overt and covert forms of racial discrimination experienced by marginalized cultural groups—or systemic racism and its impact on inequitable health outcomes.17,18 Failing to recognize the diversity within each cultural group, the multiplicity of identities an individual holds, and how these identities relate to systems of power and oppression can perpetuate racial stereotypes and discrimination of the members of minoritized groups.

Antiracist education moves beyond a mere acknowledgment of different cultures by explicitly expanding the educational models and paradigms used to include the social, cultural, political, and institutional powers that influence how we are socialized to understand race, whiteness, and racial differences.15 It aims to educate learners by helping them identify and critically analyze racialized power relations, understand the social construction of race, and examine the interconnecting systems of oppression, such as racism, sexism, ableism, and classism, which promote and perpetuate the privilege of some at the expense of marginalizing and excluding others.19 Antiracist pedagogy centers the experiences of marginalized communities; acknowledges the interconnection of individual experience to larger systems of power, privilege, and oppression.; and aims to transform these systems. This understanding guides our work to ensure that marginalized communities and people receive equitable health care and are not taken advantage of, objectified, tokenized, or further marginalized by those with power.20-22

Approaches to nursing education that do not take into account the impact of systemic racism on social determinants of health and health outcomes can further contribute to the ongoing marginalization of nursing practitioners, patients, students, and faculty of color.23 For example, the sometimes insurmountable obstacles Black nurses face in receiving recognition and opportunities for professional advancement lead to attrition and invisibility as leaders.24 This also impacts other racially marginalized groups, including Native American, Latinx, and Asian American people.25 Yet these obstacles are not recognized by nurses in general who fail to see how health care professionals, and the larger health care institutions for which they work, perpetuate racism and discrimination and subsequently affect health disparities.24 Health sciences tend to approach and understand race from a biological rather than social perspective, which ignores that race is a social construct with no biological underpinnings, thus minimizing the sweeping effect racism has on both inequity and health.26,27 Antiracist pedagogy acknowledges these issues and frames race and racism as part of larger systemic and structural forces. Identifying the positionality and biases of faculty frames the conversation around systemic racism in a way that centers the relational nature of their identities to their actions, which can serve as a model for nursing students as they approach clinical care.

Positionality and Nursing Education

To address systemic racism and racial discrimination in nursing education, we propose that educators first consider and understand their positionality with regard to their role in the classroom and within case study implementation. Positionality is the culmination of how different aspects of our social identities (eg, race, gender, class) interact with others' social identities. The recognition of how they interact helps us understand our place within a complex network of societal structures and relationships.6 Understanding how one's social identities are linked to inequitable and unequal systems of power and privilege can help learners and educators situate themselves within those systems, understand systemic racism and how their actions contribute to it, account for the impact of racism and individual-level bias on patient-provider relationships, and resist implicit and explicit biases that perpetuate negative stereotypes.

Educators can most effectively help students understand and focus on positionality when they examine their own. In their framework for social justice education, Adams and Love28 suggest that educators interested in broadening equity reflect on what they bring to their classrooms, beginning with social identity awareness, understanding their own social identity, and how it impacts identities of students within the classroom. For example, an educator may identify as a second-generation Mexican-American, cisgender female, parent, and nurse. Their reflection continues with socialization awareness (how they came to know themselves with those identities and how socialization within societal structures impacted these identities) and social justice awareness (understanding of how societal structures impacted the life chances and opportunities of people with different identities including ideas of power and privilege within education and the classroom).28 The educator may reflect on their own experiences of oppression personally and culturally, how their students of differing identities may have experienced similar or different forms of oppression in their lives, and how the positionality of the educator and students informs interactions. The process of self-reflection, including reflection on these instances of awareness, provides educators with an opportunity to recognize how their positionality may impact their students within the classroom setting, given the inherent hierarchy between educator and student. Educators can engage in this self-reflection through journaling or structured workshops with colleagues;29,30 whichever approach they take requires commitment and recognition that the work is lifelong.

Recognizing positionality requires educators and students to examine how their social positions influence their beliefs, understanding, and behavior.31,32 It entails continuously reflecting on one's multiple social identities and their fluctuating intersections, how one's social identities are relationally shaped within hierarchies of power, and how they may influence one's biases and actions in relation to other people. Hierarchies of power might be nested in the educational context, with an inner hierarchy in the classroom between educator and students, and possibly among students, and an outer hierarchy in the broader society. Actively examining positionality can help us guide our actions and behaviors more critically so that we challenge oppressive and discriminatory effects of the systems of power that are in place.33 If educators do not understand positionality themselves and give students the opportunity to think through and act on their positionality, educators will continue to perpetuate existing systems of power (with all their oppressive and discriminatory effects) in the classroom as well as between student-nurses and their patients, negatively affecting the quality of care nurses provide.

We make a case for moving beyond understanding to including and mobilizing educators' positionality in the design and implementation of case studies for two reasons. The first is that case studies simulate the health care context that nursing students are preparing to work in. Case study context places a special responsibility on nurse educators to model the attitudes, approaches, and actions that students are expected to acquire and later apply in health care environments with patients. To make these interactions and relations effective, nurse educators should address the aspects that typically remain unspoken and unacknowledged, namely, the effects of oppression as a result of systemic racism that many nursing students and patients experience. When educators explicitly share their positionality and related experiences with systemic privilege and oppression to students, they model a process by which students can then be self-reflective and consider their positionality in their understanding of cases.

Secondly, awareness of educators' positionality mobilizes their capacity to create an inclusive learning environment. Conventional teaching practice is to normalize the identity of the educator (in nursing, typically White and female) in opposition to students, who are implicitly diverse and thus in need of special attention to comply with the norm that is the educator.34,35 Prior studies of educators with nonnormative identities (eg, queer person of color) show how their identities—spoken or, more often, unspoken—send messages to students about the expectations that all nonnormative identities and bodies should assimilate and conform to the norm.7 To model antiracist behaviors—the kinds of behaviors we want nursing students to emulate in their practice—the educator must actively engage themselves in acknowledging their own positionality, not only require it of the students.

Integrating Positionality Into Case-Based Learning

The work of integrating positionality into case-based learning should begin at the course design and development stage, in advance of actual instruction. Ideally, students will have had prior coursework on social determinants of health, systemic racism, implicit bias, and intersectionality prior to engaging in this type of activity. This is an important first opportunity to engage in discussions and activities on power and oppression.

The first step for the educator is to make sure that they understand their own racial identity and its relationship to the systems of power and oppression that perpetuate health inequities. Prior to the class, educators should take time to reflect on their own identities and positionality as it relates to the planned class time (Table 1). This reflection, particularly for those new to antiracism, is often most useful when the educator is engaged with others also seeking to expand knowledge and understanding.

Table 1 - Reflective Writing Activity for the Nurse Educator
How do you racially identify? How have others identified you in terms of race?
How is your racial identity situated in terms of power and privilege in the context of the United States?
Growing up, how did you identify and navigate your racial identity?
How has your racial identity impacted your lived experiences and interactions with others as a nurse educator? As a student? As a nurse? As a patient?
What lessons have you learned about your racial identity and the racial identity of others based on interacting with others with different identities?
How often do you talk about race or racism in different contexts? Why or why not?

To model a reflection on positionality for students, educators can consider sharing pieces of their racial identity reflection from Table 1 in class. Because whiteness is often ignored or wrongly assumed to be a “neutral” identity, it is especially important for White educators to explicitly acknowledge their racial identities and their privilege of or proximity to whiteness. It is also important for educators of color to feel empowered to acknowledge their racial identities and other salient identities to challenge the dominant teaching pedagogies that are often considered race-neutral.

After the educator has modeled an exploration of positionality for students, students can then reflect on their own identity and positionality. In regard to identity, we recommend students be given an opportunity to reflect on the same or similar questions asked of the educator (Table 2). Positionality can then be explored without a need to know about the specific cases to be discussed in class. For example, in preparation for a class on preterm labor and birth, the student can reflect on how their positionality influences their understanding of the topic, as well as thinking about how one's positionality impacts their ability to consider alternate ways of thinking or acting (Supplemental Digital Content 2, https://links.lww.com/NE/A856, Exemplar). Reflection on one's positionality can be incorporated into the didactic preparation for the class using a single question prompt for a brief reflective paragraph that is turned in the day before class meets and receives full credit if done sincerely (Table 2). Educators can review responses to better understand the positionalities of the students and sensitively use that information to facilitate the case discussion. In assessing their own positionality, educators should answer the same questions as the students to accomplish the same necessary reflection in preparation for the case. The educator's response can be modeled in class to begin a discussion of positionality related to the class session's topic and cases.

Table 2 - Student Reflective Writing Activity to Do Before Engaging in Case Study Assignment
In preparation for next week's case study topic, consider your racial identity and lived experiences using the prompts from .
Think about your different identities (race, ethnicity, gender, sexual orientation, parenting status, immigration status, ability, education level, etc) and how they may affect patient interactions in the context of (insert clinical focus [eg, preterm labor and birth]). How does your identity help shape your understanding of the dynamics in the case study topic and allow for alternative ways of knowing? Summarize your thoughts in a single paragraph.

During case study implementation, the educator should plan time to explore the power dynamics present in the case. This process can occur prior to starting case exploration as a way to set the stage for the case, or as a follow-up in the form of a debrief after the case study has been reviewed. Prompts that could facilitate this conversation include “What identities in the case were named? What identities are assumed or implied?” “How does the nurse's role (and related power) influence interactions with patients?” and “How could the nurse's identity or positionality in relation to the patient influence care decisions or management?”

At the end of class, students can complete a short reflective writing assignment in which they consider how positionality affected their understanding of and engagement with the case (Table 3). Expectations for this assignment include the ability for students to not only recognize how their positionality played a role in their understanding (eg, “my social class may have prohibited me from understanding the impacts of job instability on accessing care”) but also how that knowledge then changed how they interacted with the case (eg, “I sought to learn more from the patient about how job insecurity was impacting them and their perceptions of health care access”).

Table 3 - Student Reflective Writing Assignment After Class
Look back at the reflection you completed before class:
How did your positionality affect your understanding of the case and the patient?
Were there aspects of the case or the patient experience that you recognized being impacted by your positionality? Please describe.
How did it influence how you chose to interact with the patient in the learning activity?
Were there aspects that you wish you considered that you may not have during the activity?
How did my interaction align with or perpetuate systemic racism?

Student responses can be collected anonymously at the end of class and contribute to the educator's reflection, which includes an examination of how the cased-based learning incorporated the positionality of the educator, patients, and students and achieved learning objectives (Table 4). Writing in response to these questions supports the educator's reflective work and facilitates a formative and summative evaluation process for course improvement and evaluation. The reflections from students can provide valuable feedback that can be addressed in the next class meeting.

Table 4 - Reflective Writing After Class for the Nurse Educator
How were the learning goals of the case achieved?
How did the case discussion include an analysis of positionality?
How did the case-based learning activity allow for the examination of clinical issues using a racial equity lens?
How might your positionality (ie, your racial/ethnic identity and/or other social identities) have impacted student engagement with the case discussion?
(Examples: stereotypes, exclusion vs inclusion, silencing, uncomfortable dynamics)

We recognize that the work of reflecting upon positionality can be challenging for educators and students. It may be necessary to allow students to keep these reflections to themselves or submit them anonymously to provide psychological safety for students. Additionally, there should be mechanisms for addressing hurtful or insensitive remarks and facilitating difficult discussions in the classroom, such as the HEALS (Halt, Engage, Allow, Listen, Synthesize) model developed by the University of California San Francisco School of Nursing,36 or other mechanisms that pause conversation and allow for reflection and mitigation of harm to marginalized students. The educator needs to proceed cautiously so as not to put marginalized students at further disadvantage or fear when they are asked to center their social identities in writing, in-class discussions, or in small groups.

Conclusion

Approaches that explicitly aim to address racial biases typically focus on students' identities, experiences, and backgrounds but do not include the educators' and often miss out on critical opportunities to recognize the interplay between respective positionalities. To learn effectively, students need to establish a reciprocal relationship with their educator in terms of their identities, experiences, and backgrounds, and to do that, educators need to actively engage their positionality. By centering positionality of marginalized students and their voices, we intend to create an inclusive, antiracist classroom—one that uses case-based learning to address systemic oppression in the classroom and patient scenarios and, conversely, models in the classroom the kind of interaction that students can apply in their future work with patients and other health care providers.

References

1. Popil I. Promotion of critical thinking by using case studies as teaching method. Nurse Educ Today. 2011;31(2):204–207. doi:10.1016/j.nedt.2010.06.002.
2. McLean SF. Case-based learning and its application in medical and health-care fields: a review of worldwide literature. J Med Educ Curric Dev. 2016;3:39–49. doi:10.4137/JMECD.S20377.
3. Kantar LD, Massouh A. Case-based learning: what traditional curricula fail to teach. Nurse Educ Today. 2015;35(8):e8–e14. doi:10.1016/j.nedt.2015.03.010.
4. Forsgren S, Christensen T, Hedemalm A. Evaluation of the case method in nursing education. Nurse Educ Pract. 2014;14(2):164–169. doi:10.1016/j.nepr.2013.08.003.
5. Keeton VF. What's race got to do with it? A close look at the misuse of race in case-based nursing education. Nurse Educ. 2020;45(3):122–124. doi:10.1097/NNE.0000000000000707.
6. Maher FA, Tetreault MKT. The Feminist Classroom: Dynamics of Gender, Race, and Privilege. Rowman & Littlefield Publishers; 2001.
7. Garland-Thomson R, Grumet MR. The Teacher's Body: Embodiment, Authority, and Identity in the Academy. SUNY Press; 2012.
8. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and Whites. Proc Natl Acad Sci U S A. 2016;113(16):4296–4301. doi:10.1073/pnas.1516047113.
9. Puzan E. The unbearable whiteness of being (in nursing). Nurs Inq. 2003;10(3):193–200.
10. Hassouneh D. Anti-racist pedagogy: challenges faced by faculty of color in predominantly White schools of nursing. J Nurs Educ. 2006;45(7):255–262. doi:10.3928/01484834-20060701-04.
11. Blanchet Garneau A, Browne AJ, Varcoe C. Drawing on antiracist approaches toward a critical antidiscriminatory pedagogy for nursing. Nurs Inq. 2018;25(1). doi:10.1111/nin.12211.
12. Kendi IX. How to Be an Antiracist. One World/Ballantine; 2019.
13. Cortis J, Law IG. Anti-racist innovation and nurse education. Nurse Educ Today. 2005;25(3):204–213. doi:10.1016/j.nedt.2005.01.008.
14. Nairn S, Hardy C, Parumal L, Williams GA. Multicultural or anti-racist teaching in nurse education: a critical appraisal. Nurse Educ Today. 2004;24(3):188–195. doi:10.1016/j.nedt.2003.11.007.
15. Schroeder C, Diangelo R. Addressing whiteness in nursing education: the sociopolitical climate project at the University of Washington School of nursing. ANS Adv Nurs Sci. 2010;33(3):244–255. doi:10.1097/ANS.0b013e3181eb41cf.
16. Allen J. Improving cross-cultural care and antiracism in nursing education: a literature review. Nurse Educ Today. 2010;30(4):314–320. doi:10.1016/j.nedt.2009.08.007.
17. Campesino M. Beyond transculturalism: critiques of cultural education in nursing. J Nurs Educ. 2008;47(7):298–304. doi:10.3928/01484834-20080701-02.
18. Sagar PL, Sagar DY. Current state of transcultural nursing theories, models, and approaches. Annu Rev Nurs Res. 2018;37(1):25–41. doi:10.1891/0739-6686.37.1.25.
19. Carr PR, Klassen TR. The role of racial minority teachers in anti-racist education. Can Ethn Stud. 1996;28:126–138.
20. Hooks B. Yearning: Race, Gender, and Cultural Politics. Routledge; 2015.
21. Hooks B. Teaching Community: A Pedagogy of Hope. Routledge; 2003.
22. West C. Black culture and postmodernism. In: Remaking History. Vol. 4. Bay Press; 1989:87–96.
23. Wren Serbin J, Donnelly E. The impact of racism and midwifery's lack of racial diversity: a literature review. J Midwifery Womens Health. 2016;61(6):694–706. doi:10.1111/jmwh.12572.
24. Bennett C, Hamilton EK, Rochani H. Exploring race in nursing: teaching nursing students about racial inequality using the historical lens. Online J Issues Nurs. 2019;24(2). doi:10.3912/OJIN.Vol24No02PPT20.
25. Ezenwa MO. Hope for healing in the face of embittered race relations in the United States: one nurse's perspective. In: Minority Nurse. Springer Publishing Company; 2015.
26. Bridges KM, Keel T, Obasogie OK. Introduction: critical race theory and the health sciences. Am J Law Med. 2017;43(2–3):179–182. doi:10.1177/0098858817723657.
27. Jensen C. The social construction of race, inequality, and the invisible role of the state. In: State Crimes Against Democracy. Springer; 2013:135–155.
28. Adams M, Love BJ. A social justice education faculty development framework for a post-Grutter era. In: Social Justice Education: Inviting Faculty to Transform Their Institutions. Stylus Publishing; 2009:3–25.
29. O'Connor MR, Barrington WE, Buchanan DT, et al. Short-term outcomes of a diversity, equity, and inclusion institute for nursing faculty. J Nurs Educ. 2019;58(11):633–640. doi:10.3928/01484834-20191021-04.
30. Schuessler JB, Wilder B, Byrd LW. Reflective journaling and development of cultural humility in students. Nurs Educ Perspect. 2012;33(2):96–99. doi:10.5480/1536-5026-33.2.96.
31. DiAngelo R. Teacher preparation pedagogy, critical reflection and. In: Banks JA, ed. Encyclopedia of Diversity in Education. Vol. 1.  SAGE Publications, Inc.; 2012:2137–2138.
32. Holm AL, Rowe Gorosh M, Brady M, White-Perkins D. Recognizing privilege and bias: an interactive exercise to expand health care providers' personal awareness. Acad Med. 2017;92(3):360–364. doi:10.1097/ACM.0000000000001290.
33. White AA 3rd, Logghe HJ, Goodenough DA, et al. Self-awareness and cultural identity as an effort to reduce bias in medicine. J Racial Ethn Health Disparities. 2018;5(1):34–49. doi:10.1007/s40615-017-0340-6.
34. Tengelin E, Dahlborg-Lyckhage E. Discourses with potential to disrupt traditional nursing education: nursing teachers' talk about norm-critical competence. Nurs Inq. 2017;24(1). doi:10.1111/nin.12166.
35. Holland AE. The lived experience of teaching about race in cultural nursing education. J Transcult Nurs. 2015;26(1):92–100. doi:10.1177/1043659614523995.
36. University of California San Francisco School of Nursing. The HEALS Model. University of California San Francisco; 2017.
Keywords:

case-based learning; nursing education methods; positionality; problem-based learning; race relations; systemic racism

Supplemental Digital Content

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