Nursing practice is guided by nursing ethics, which influences educator practice. Nursing ethical principles align with critical and open pedagogy. Critical pedagogy with its social justice (SJ) lens can address sociocultural barriers (SCBs) by revealing structures and practices that disadvantage students.1 Open pedagogy increases educational accessibility through student-centered and power-balanced practices. Critical and open pedagogy removes SCBs in higher education (HE).2,3 This literature review aligns and connects the Canada and US nursing codes of ethics with critical and open pedagogy in nursing education.
Increased access to nursing education is urgently needed to mitigate the nursing shortage4 and to facilitate responsive professional development to prepare nurses to respond to societal health care needs.5 Nursing education has met access challenges with various strategies including moving to distance education. Distance education reduces barriers such as geographical divides and facilitates the balance of personal and professional commitments6; however, SCBs continue to disadvantage some students.7
SCBs in HE consist of relational power dynamics and inequitable practices7 that unduly affect diverse students.8,9 As a result, the Canadian and US nursing workforce is disproportionately heteronormative white able-bodied women.10–13 This is problematic not only from an SJ perspective but also from a health perspective, as workforce diversification results in professionals who are positioned to decrease health inequities within diverse populations.14,15
Critical and Open Pedagogy
Critical pedagogy supports equitable practices in education by moving from a passive model to one of engaged and critical practices whereby educators and students collaborate to expose oppressive structures and practices.1 Open pedagogy, which originated in distance education, empowers students through critical, student-centered practices and prioritizes relationships between students, between educators, and between students and educators.16,17 Finally, open pedagogy removes barriers to knowledge development and distribution with the open educational resource (OER) movement.17
Nursing Ethical Frameworks
Experienced nurses often become nurse educators because they are knowledgeable and skilled practitioners.18 Nursing ethics underlay educator practice. The ethical principles of dignity, patient autonomy, patient-centered approach, health promotion, accountability, competence, SJ, equity, and safety are found in both the Canadian and US RN codes of ethics.19,20 These principles align with many characteristics found in critical and open pedagogy (see Supplemental Digital Content, Figure 1, available at: https://links.lww.com/NE/B150).
A narrative thematic synthesis review of Canadian and US nursing education literature focusing on critical and open pedagogy characteristics was conducted. Examples of critical and open pedagogy were analyzed using a nursing ethical framework.
Both nursing-specific and interdisciplinary databases including Proquest Nursing & Allied Health Source, Science Direct, CINAHL Plus with Full-text, [email protected] Full-text, and ABI/Inform Complete databases were searched. Terms were set to match specific database synonyms. Sources were not limited to primary research as several conceptual articles and literature reviews provided rich conceptual discussions.
Inclusion and Exclusion Criteria
Inclusion criteria were English translation; published from January 1, 2015, to August 1, 2021 (to address current literature); and focused on Canada or US RN education, nursing values or ethics, and characteristics of critical and open pedagogy.
Literature screening included 3 phases: title, abstract, and full-text of the article. First, all titles were reviewed by the first author and rejections were confirmed with an abstract review. The second phase included independent abstract review by 2 authors. Any questionable abstracts were moved forward. Third, all full-text screens were completed by the first author, with a second author screen if questionable. This process resulted in 29 full-text sources for thematic analysis. Supplemental Digital Content, Figure 2 (available at: https://links.lww.com/NE/B151) details the literature screening process.
The first author reviewed all full-text articles line by line, and every fifth article was independently coded by the second or third author for agreement, congruency, and as bias control. There were 19 US sources, 9 Canadian sources, and 1 source had both US and Canadian perspectives. There were 12 qualitative, 2 mixed-methods, 1 literature review, and 14 conceptual articles.
NVivo 12 (QSR International, Burlington, Massachusetts) software was used to code the literature review following a similar narrative thematic synthesis literature review process by other authors.21 Initially, general themes were developed inductively and then reviewed and revised to establish the contemporary state of the literature. The themes were then reflected upon to see how they translated to the ethical principle's framework. Thus, theme development moved from descriptive to analytical whereby “the reviewers ‘go beyond’ the primary studies and generate new interpretive constructs, explanations or hypotheses”22(p1) (see Supplemental Digital Content, Table, available at: https://links.lww.com/NE/B152, for source characteristics).
The discussion is framed by critical and open pedagogy analytical themes identified within the common nursing ethical principles of both codes (see Supplemental Digital Content, Figure 1, available at: https://links.lww.com/NE/B150). Using ethics that are foundational to principles of practice allows nurse educators to consider pedagogical practices from a place of knowing. Discussion is ordered in how each principle flowed from one to the next; order is not based on frequency of codes assigned.
Ethics and Educator Practice
In accordance with inclusion criteria, all sources connected ethical principles to critical and open pedagogical strategies. Strategies were exemplified through program ideals, curricular choices, and educator classroom practice.8,10,16,23–29 Sixteen sources explicitly referenced connecting nursing education pedagogical strategies and nursing ethical principles. Furthermore, sources revealed that as RNs move to the role of educator, they can model foundational nursing ethics for students through their teaching practice.8,23,25,30,31
Principle of Dignity
Dignity is recognizing individual worth19 and is central to the principle of relational practice found in critical and open pedagogy. Examples of relational practice integration included peer-to-peer collaborative practices15,23,30,32 such as through service-learning opportunities involving partnering of nursing students from host and visiting countries,32 formal peer editing,23 resource sharing among classmates,15,23 and informal networking of students using social platforms.15 These opportunities emphasized equality of voices and the importance of individual contributions to achieving team goals.23,30,32
The student-educator relationship was also explored, with a noted shift from teacher-centric to student-centered pedagogy.29,30 Student-centered pedagogy includes partnerships where the teacher becomes a facilitator or mentor and the student moves from knowledge consumer33 to knowledge coproducer.29,30,34–36 This was exemplified through strategies such as open research initiatives with undergraduate students29 or OER textbook development with student partners.36 Moving to a more collaborative and less hierarchical relationship results in power redistribution between educators and students.8,23,29,30,36
Principle of Patient Autonomy/Student Autonomy
Collaborative student-educator relationships result in increased student voice and choice regarding assessment practices, expectations, learning outcomes, and learning resources.23,29,30,36,37 These collaborations also remove traditional gatekeeping practices in HE8,29,31 such as the need for a high grade point average to qualify for undergraduate research opportunities giving all interested students a chance to be researchers.29 Such initiatives enable students to embrace their role as knowledge producers. Student-educator collaborations provide educators with transformative learning as they reflect on their critical pedagogy practices and about how students perceive the knowledge production process.23,29,30,36 Student autonomy happens through a student-centered approach in critical and open pedagogy.
Principle of Patient-Centered Approach/Student-Centered Approach
Centering the student in educational experiences was prevalent in discussions of critical and open pedagogy.10,23,29,36,38 Student-centeredness was described as the educator focusing attention on seeing what is best in students and then working with students to develop paths for success.23,29 Student-centered educators use relational practice to facilitate deep and meaningful learning where students feel safe to scaffold nursing knowledge onto their ways of knowing,10,29,30 empowering them to celebrate their uniquity.30 Students may also experience increased socialization to the profession when in collaborative relationships with educators,15,36,39 increased confidence acquired through classroom interactions, and the enhanced likelihood of becoming advocates in their professional roles.23,34
Principle of Health Promotion/Education Promotion
Promotion focuses on facilitating and advocating for optimal levels of education. Nurse educators optimize learning through transformative teaching and learning strategies categorized as critical inquiry activities such as thinking about nursing at a system rather than at a surface level, focusing on topics such as health determinants, challenging dominant narratives, and thinking about nursing from culturally relevant framing.10,15,23,28,30,35,40,41 Reflective practice was recommended to develop a deeper connection between nursing practice and personal and professional assumptions and biases, resulting in change and growth at an attitudinal level.*
Principles of Accountability and Competence
Educators are accountable for developing competence in the Scholarship of Teaching and Learning (SoTL).42 Educators require pedagogical professional development specific to equity-oriented approaches such as universal design principles to increase inclusive and meaningful student experiences.23,43,44 Challenges remain despite the call for increased valuing and practicing of transformative pedagogy. There was a noted continued lack of theoretical application of critical and open pedagogy in nursing education, despite recognition that these are successful evidence-informed pedagogies.23,29,43,45 Limited application of critical and open pedagogy by educators is related to limited pedagogical knowledge, lack of time to apply the pedagogy, and absence of supportive institutional policies.13,43,45
Principles of SJ, Equity, and Safety
The ethical principles of SJ, equity, and safety closely align with critical and open pedagogy whereby nurse educators “uphold principles of justice by safeguarding human rights, equity and fairness and by promoting the public good.”19(p4) Authors called for nursing education to overcome racism and exclusionary practices to promote SJ.† A predominantly heteronormative white able-bodied female representation in nursing and nursing education can create an unsafe learning context and working environment for diverse students.8,10,11,13,27,31,45 Racism is exhibited in many ways including educators perpetuation and reliance on westernized colonial frames of reference10,45 and implicitly and explicitly enacting westernized superiority values.13,26,32 The challenges of understanding and addressing racism and exclusionary practices result in nurse educators being uncomfortable with race-related discourse.8,10,27,30,31,47
Nursing educators need to practice with an SJ lens13,23,24,26,27,38 through the integration of principles of equity, diversity, and inclusion (EDI).14,15,27,32,39,41,45,47 EDI strategies include the use of holistic admission processes10,14,15 and recruitment and retainment of minority students facilitated by intentional opportunity for interaction with diverse faculty and students.13,31,39,45 Additional strategies include social, financial, and academic programs to support students who may face challenges with academic writing (particularly if English is not a first language), science, and mathematics.10,15,45
Advocacy is commonly aligned with the profession of nursing and facilitated by SJ practices.13,23,28,47 However, although the nursing profession readily ascribes to advocacy practices, tension exists regarding what types of activism are appropriate for nurses.27,28 Nurses need to move beyond advocacy to activism. For students to gain advocacy and activism skills, these must be in the curriculum.28,29,31,47 Learning activities that teach about the role of advocacy and activism include critical discourse on current events, writing letters to the local newspaper editors about issues, and attendance at political rallies.28
When nurse educators model SJ practices, students learn to use their voices as advocates and activists.23,28–30 After graduation, students become RNs who critically examine power in interprofessional relationships (such as between differently credentialed nurses) to improve relational practices, ultimately benefiting the health system.48 In summary, educators listening to the voices of nursing students through safe, inclusive, and SJ practices can potentially increase workforce diversity and improved health outcomes.14,15,30,34,39,45,47
Discussion of Practice Implications
Characteristics of critical and open pedagogy align with nursing ethics and are described in nurse educator practices. Moving to intentional and consistent integration of these pedagogies could facilitate the continued evolution of nursing education. Through critical and open pedagogy, nurse educators and students can highlight, dismantle, and change HE to remove SCBs and create learning environments that motivate graduates to carry forward ethical principles to their practice. The following are suggestions for nurse educators that have emerged from the literature.
Commit to the SoTL
Enacting critical and open pedagogy starts with recognizing that educators can be more effective if they develop their SoTL. Educator practice is a unique science and art that needs more attention across HE, and this starts with institutional recognition of the value of the SoTL.42 Most nursing undergraduate and graduate programs require that applicants for faculty positions have a graduate degree qualification (doctoral degree preferred). To facilitate enough qualified nurse educators, more graduate programs are needed to prepare candidates for these roles. Ongoing professional development focused on the SoTL should be required.16
Understand Assumptions and Practices
Canada and the US have a concerning colonial past resulting in continued injustices perpetuated by class, race, gender, and religious bias that permeate all systems, including nursing education.10,13,27,31,41 To begin, nurse educators need to reflect deeply on their participation in practices and systems that perpetuate SCBs. It is imperative to understand how inherent privilege underlies traditional beliefs and assumptions about society, the nursing profession, and HE. This reflection also includes accepting the discomfort that comes with acknowledging racism and exclusion in nursing education.8,10 Neither health care nor HE can fix what is broken if it is not acknowledged to be broken.
Commit to Critical and Open Pedagogical Teaching and Learning
Critical and open pedagogy helps educators to pursue a more equitable society, profession, and HE experience. To achieve pedagogy that is critical and open, educators need to continually reflect on how to pursue awareness, understanding, and action in HE. Educators need to consider which approaches facilitate equitable and student-centered practices that are open and share power, knowledge, and resources. Many of the critical and open practices from the Findings section can be enacted to potentially decrease SCBs and facilitate the evolution of nursing education.
Gaps in the Research
Further research is needed to understand the connection between ethical practices that link the RN practice role to the RN educator role. The focus on critical pedagogy in nursing education is growing, but more research is needed. Open pedagogy stemming from distance education shows promise in HE, but more research is needed specifically in distance nursing education. Although evidence of critical and open pedagogical practices was found, explicit integration of critical and open pedagogy in nursing education is underexplored.
There is a need for research into critical and open pedagogy in nursing education. When integrated, critical and open pedagogy has the potential to improve the HE experience from classroom to institutional level while shaping nursing into a more SJ profession.
1. Fovet F. Educational Recovery for PK-12 Education During and After a Pandemic. IGI Global; 2021.
2. Baran E, AlZoubi D. Affordances, challenges, and impact of open pedagogy: examining students' voices. Distance Educ. 2020;41(2):230–244. doi:10.1080/01587919.2020.1757409
3. Tietjen P, Asino TI. What is open pedagogy? Identifying commonalities. IRRODL. 2021;22(2):185–204. doi:10.19173/irrodl.v22i2.5161
4. International Council of Nurses (ICN). International Council of Nurses Policy Brief. The Global Nursing Shortage and Nurse Retention. ICN; 2020.
5. Canadian Nurses Association. Framework for the Practice of Registered Nurses in Canada. 2nd ed. Canadian Nurses Association; 2015. Accessed March 15, 2021. www.cna-aiic.ca/∼/media/cna/page-content/pdf-en/framework-for-the-pracice-of-registered-nurses-in-canada.pdf?la=en
6. Carter L, Beattie B, Caswell W, et al. An examination of interprofessional team functioning in a BScN blended learning program: implications for accessible distance-based nursing education programs. Can J Univ Contin Educ. 2016;41(1). doi:10.21225/D5QW3Q
7. Bali M, Cronin C, Jhangiani R. Framing open educational practices from a social justice perspective. J Interactive Media Educ. 2020(1):10. doi:10.5334/jime.565
8. Davis JN, Sullivan K, Guzman A. Catalyst for growth: the implications of co-curricular experiences for nursing education. J Nursing Educ. 2018;57(2):110–114. doi:10.3928/01484834-20180123-09
9. Valderama-Wallace CP. Critical discourse analysis of social justice in nursing's foundational documents. Public Health Nurs. 2017;34(4):363–369. doi:10.1111/phn.12327
10. Bonini SM, Matias CE. The impact of whiteness on the education of nurses. J Prof Nurs. 2021;37(3):620–625. doi:10.1016/j.profnurs.2021.02.009
11. Epstein I, Stephens L, Severino SM, et al. “Ask me what I need”: a call for shifting responsibility upwards and creating inclusive learning environments in clinical placement. Nurse Educ Today. 2020;92:104505. doi:10.1016/j.nedt.2020.104505
12. Jefferies K, Tamlyn D, Aston M, et al. Promoting visible minority diversity in Canadian nursing. Can J Nurs Res. 2019;51(1):3–5. doi:10.1177_0844562118795812
13. Waite R, Nardi D. Nursing colonialism in America: implications for nursing leadership. J Prof Nurs. 2019;35(1):18–25. doi:10.1016/j.profnurs.2017.12.013
14. Jung I, Lee J. A cross-cultural approach to the adoption of open educational resources in higher education. Br J Educ Technol. 2020;51(1):263–280. doi:10.1111/bjet.12820
15. Noone J, Najjar R, Quintana AD, et al. Nursing workforce diversity: promising educational practices. J Prof Nurs. 2020;36(5):386–394. doi:10.1016/j.profnurs.2020.02.011
16. Carey T, Davis A, Ferreras S, et al. Using open educational practices to support institutional strategic excellence in teaching, learning & scholarship. Open Praxis. 2015;7(2):161–171.
17. Conole G, Brown M. Reflecting on the impact of the open education movement. J Learn Dev. 2018;5(3):187–203.
18. Brown TH. Exploring new learning paradigms a reflection on Barber, Donnelly, and Rizvi (2013): “An avalanche is coming: higher education and the revolution ahead.” IRRODL. 2015;16(4):227–234.
19. Canadian Nurses Association. Code of Ethics for Registered Nurses. Canadian Nurses Association; 2017. Accessed February 25, 2022. https://www.cna-aiic.ca/-/media/cna/page-content/pdf-en/code-of-ethics-2017-edition-secure-interactive.pdf
21. Romanello R, Chiarvesio M. Early internationalizing firms: 2004-2018. J Int Entrepreneurship. 2019;17(2):172–219. doi:10.1007/s10843-018-02418
22. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:1–10. doi:10.1186/1471-2288-8-45
23. Chinn PL, Falk-Rafael A. Embracing the focus of the discipline of nursing: critical caring pedagogy. J Nurs Scholarsh. 2018;50(6):687–694. doi:10.1111/jnu.12426
24. Gardenier D, Gibson-Young LM, Patrick R. Should nursing programs at schools that prohibit same-sex marriage be accredited? J Nurse Pract. 2019;15(4):272–273. doi:10.1016/j.nurpra.2019.01.003
25. Grace P. Enhancing nurse moral agency: the leadership promise of doctor of nursing practice preparation. Online J Issues Nurs. 2018;23(1):1–11. doi:10.3912/OJIN.Vol23No01Man04
26. McDermott-Levy R, Leffers J, Mayaka J. Ethical principles and guidelines of global health nursing practice. Nurs Outlook. 2018;66(5):473–481. doi:10.1016/j.outlook.2018.06.013
27. Valderama-Wallace C, Apesoa-Varano E. “Social justice is a dream”: tensions and contradictions in nursing education. Public Health Nurs. 2019;36(5):735–743. doi:10.1111/phn.12630
28. Buck-McFadyen E, MacDonnell J. Contested practice: political activism in nursing and implications for nursing education. Int J Nurs Educ Scholarsh. 2017(1). doi:10.1515/ijnes-2016-0026
29. Zanchetta MS, Bailey A, Kolisnyk O, et al. Mentors' and mentees' intellectual-partnership through the lens of the transformative learning theory. Nurse Educ Pract. 2017;25:111–120. doi:10.1016/j.nepr.2017.05.009
30. Day L, Beard KV. Meaningful inclusion of diverse voices: the case for culturally responsive teaching in nursing education. J Prof Nurs. 2019;35(4):277–281. doi:10.1016/j.profnurs.2019.01.002
31. Zanchetta MS, Cognet M, Rahman R, et al. Blindness, deafness, silence and invisibility that shields racism in nursing education-practice in multicultural hubs of immigration. J Prof Nurs. 2020;37(2):467–476. doi:10.1016/j.profnurs.2020.06.012
32. Healey-Walsh J, Stuart-Shor E, Muchira J. Through the lens of postcolonial theory: establishing global north-south partnerships. Nurs Educ Perspect. 2019;40(5):270–277. doi:10.1097/01.NEP.0000000000000556
33. Amgott N. Critical literacy in #DigitalActivism: collaborative choice and action. Int J Inf Learn Technol. 2018;35(5):329–341. doi:10.1108/IJILT-05-2018-0060
34. Sumo JN, Staffileno BA, Warner K, et al. The development of an online diversity and inclusion community: promoting a culture of inclusion within a college of nursing. J Prof Nurs. 2021;37(1):18–23. doi:10.1016/j.profnurs.2020.10.002
35. Van Bewer V, Woodgate R, Martin D, et al. Exploring theatre of the oppressed and forum theatre as pedagogies in nursing education. Nurse Educ Today. 2021;103:104940. doi:10.1016/j.profnurs.2020.11.002
36. Verkuyl M, Lapum J, St-Amant O, et al. Engaging nursing students in the production of open educational resources. Nurse Educ Today. 2018;71:75. doi:10.1016/j.nedt.2018.09.012
37. Gazarian P, Cronin J, Jahng I, et al. Use of course-specific open educational resources in a graduate nursing course. J Nursing Educ. 2020;59(10):577–580.
38. Bova C, Perry D, Kane A, et al. Expanding horizons: Lonergan's philosophy as a guide to PhD program pedagogy. Nurs Outlook. 2018;66(1):77–83. doi:10.1016/j.outlook.2017.07.003
39. Woods-Giscombe C, Johnson Rowsey P, Kneipp S, et al. Student perspectives on recruiting underrepresented ethnic minority students to nursing: enhancing outreach, engaging family, and correcting misconceptions. J Prof Nurs. 2020;36(2):43–49. doi: 10.1016/j.profnurs.2019.08.006
40. LeBlanc R. Digital story telling in social justice nursing education. Public Health Nurs. 2017;34(4):395–400. doi:10.1111/phn.12337
41. Van Bewer V, Woodgate R, Martin D, et al. An indigenous and arts-influenced framework for anti-racist practice in nursing education. J Prof Nurs. 2021;37(1):65–72. doi:10.1016/j.profnurs.2020.11.002
42. Bates T. Teaching in a Digital Age. CC: Contact North/Contact Nord; 2016.
43. Levey J. Universal design for instruction in nursing education: an integrative review. Nurs Educ Perspect. 2018;39(3):156–161. doi:10.1097/01.NEP.0000000000000249
44. Bassendowski S. #Blimage. Can J Nurs Inform. 2019;14(1/2). Accessed September 26, 2020. https://cjni.net/journal/?p=5968
45. Starkey T. The critical factors that influence faculty attitudes and perceptions of teaching English as second language nursing students: a grounded theory research study. Nurse Educ Today. 2015;35(5):718–725. doi:10.1016/j.nedt.2015.01.017
46. Drevdahl D. Impersonating culture: the effects of using simulated experiences to teach cultural competence. J Prof Nurs. 2018;34(3):195–204. doi:10.1016/j.profnurs.2017.10.006
47. Darcy-Mahoney A, Carter B, Green K, et al. Looking backwards to move forward: using a social mission lens in nursing education. J Prof Nurs. 2020;36(5):412–416. doi:10.1016/j.profnurs.2020
48. Limoges J, Jagos K. The influences of nursing education on the socialization and professional working relationships of Canadian practical and degree nursing students: a critical analysis. Nurse Educ Today. 2015;35(10):1023–1027. doi:10.1016/j.nedt.2015.07.018