Nursing education in Bangladesh: analysis through an ethnonursing lens and critical social theory

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Bangladesh, like many other countries, is facing a nursing shortage. Overall, Bangladeshi nurses are inadequately trained, poorly paid, and disrespected as professionals. The Prime Minister of Bangladesh recognizes these challenges and has committed to upgrading nursing education. In 2009, she set a goal to revise the nursing education curriculum to International Council of Nurses standards, which in turn she hopes will enhance the social dignity of Bangladeshi nurses and the quality of care provided. In addition, the Bangladeshi Nurses Council acknowledges the need to educate nurses as critical thinkers. This context impacts how nursing education is offered. The purpose of this project is to holistically explore the social, historical, educational, and economical factors that influence nursing education in Bangladesh, with the goal of recommending teaching strategies that are culturally contextual and imbedded in the Caring Science Curriculum (Hills & Watson, 2011) for Canadian nursing volunteers teaching at International University of Business and Technology (IUBAT). I draw on my personal experience as volunteer nurse educator at IUBAT and the theoretical lens of Critical Social Theory to frame an analysis and an understanding of nursing education in Bangladeshi context. In addition, I employ Leininger’s theory of Culture Care Diversity and Universality and the Sunrise Enabler Model (Leininger, 1998; Leininger & McFarland, 2006) to develop pedagogical strategies for visiting Canadian Faculty. The goal of the project is to assist volunteer educators to deliver culturally contextual nursing education that aims to transform didactic education, presently utilized in Bangladeshi nursing education, to student-centered education embedded in critical thinking and the Caring Science Curriculum. Running head: TRANSCULTURAL NURSING EDUCATION 7 The ultimate goal of a professional nurse-scientist and humanist is to discover, know and creatively use culturally based care knowledge with its fullest meanings, expressions, symbols, and functions for healing, and to promote or maintain wellbeing (or health) with people of diverse cultures in the world (Leininger, 1991) Despite the significant progress in the last decade in both health and education, Bangladesh nurses are inadequately trained, poorly paid, and disrespected as professionals (Hadley et al., 2007a; Rahman & Hashem, 2000). In 2004, the International University of Business, Agriculture, and Technology (IUBAT) in Bangladesh, in collaboration with an advisory group operating through the Mid-Main Community Health Centre in Vancouver, Canada, created a four-year Bachelor of Science in Nursing (BSN) program. The program currently relies on foreign volunteer instructors to train both faculty and students because there is a lack of expertise in nursing education in Bangladesh. Unfortunately, based on anecdotal evidence with the BSN program at IUBAT, volunteers’ naiveté of cultural awareness and pedagogies create barriers in promoting nursing education. In this project, I employ Leininger’s (Leininger & McFarland, 2006) Theory of Culture Care Diversity and Universality along with The Sunrise Enabler model, in order to holistically explore the social, historical, educational, and economical factors that influence nursing education in Bangladesh. The ultimate goal is to use information from this project as a resource that will assist Canadian nursing volunteers teaching at IUBAT to tailor pedagogical material that is culturally contextual. An underlying assumption of this project is that if nursing volunteer instructors recognize students’ cultural references in all aspects of their teaching/learning interactions, then students will more likely be engaged as learners and critical thinkers. Background and Significance of the Project Nursing is often the backbone to providing quality health; unfortunately, nursing development in Bangladesh has been seriously hampered by social stigma. Religion plays a role; TRANSCULTURAL NURSING EDUCATION 8 there are significant numbers of Christian and Buddhist Bangladeshis, but the majority are Muslims (about 80%) and a sizeable minority (about 9%) Hindus (Rozario & Samuel, 2010). The nursing profession, as we know it in the Western world has not been acceptable as a profession to Muslim families. For example, traditional Islamic culture does not condone the physical contact between non-family females and males; therefore, it is mostly non-Muslims, males, widows, and unmarried women who apply for the nursing programs (Hadley et al., 2007). Nursing has often been perceived as “dirty work” that involves staying away from home at night and touching bodies of strangers; for female nurses, this has even led to an association between nursing and prostitution (Hadley et al., 2007). It is this very association that not only decreases the value of the “bride market,” a term used to convey the desirability of a woman for marriage, but also encourages nurses to distance themselves from direct patient care (Hadley et al, 2007). Because of the poor image of nursing in Bangladesh, Aminuzamman’s (2007) study revealed that 35% of the undergraduate students from various institutions would consider entering into the nursing profession, but only if they immigrated to North America or to Europe. None of the respondents would consider a nursing career in Bangladesh. The government of Bangladesh recognizes that in order to improve its citizens’ health, the poor image of nursing must change. Yet it has failed to make any significant financial commitment to nursing education. Bangladesh is facing a nursing crisis because nurses lack the necessary skills due to poor training and because the government does not fill the posts that are vacant (Ahmed, Hossain, Rajachowdhury, & Bhuiya, 2011; Berland, Richards, & Lund, 2010). By April 2011 the population of Bangladesh had reached over 162 million, and yet the nurse population is very low at 1 nurse per 2700 people and physicians comprise 1 per 3000 people (World Health Organization, 2011). Bangladesh is the only country that appears to have a higher physician TRANSCULTURAL NURSING EDUCATION 9 nurse ratio (Ahmed & Hossain, 2007; Ahmed, Hossain, Rajachowdhury, & Bhuiya, 2011). In addition to the social stigma described earlier, the low status of Bangladeshi nursing is related to the perception of nursing as an unskilled profession. The Prime Minister of Bangladesh in recognition of this has committed to upgrading the nursing education. In 2009, she promised to revise the nursing education curriculum to the International Council of Nurses (ICN) standards, which in turn she hopes will enhance the social dignity of Bangladeshi nurses and the quality of care provided. Besides social, economic, and cultural factors, a lack of local nursing education expertise may be contributing to the inferior quality of nursing and nursing education in Bangladesh. The Bangladesh’s nursing regulatory body, the Bangladesh Nursing Council (BNC) acknowledges that in order to meet the complex care needs of patients and communities, Bangladeshi nurses must be critical thinkers; but, many of the local nursing educators do not appear to have the necessary theoretical skills and knowledge or the required clinical skills to teach students effectively. Access to technology is limited for both faculty and the students, which in turn limits access to nursing resources; thus, maintaining and delivering education that is current and relevant is challenging. In addition, nursing resources are mostly available in English and this creates an additional barrier to education. Importantly, traditional Bangladeshi education is based on rote learning, and therefore, the instructors themselves may lack critical thinking and problem solving skills necessary in nursing. Consequently, IUBAT has been hosting five to seven volunteer nurses, from Canada, every semester, to teach the BSN curriculum at IUBAT. IUBAT is a nonprofit university founded by Dr. Alimulla Miyan in 1991 and is located in Uttara Model Town in the outskirts of the capital city of Dhaka. Approximately 6,000 students are registered in a variety of programs such as business, agriculture, engineering, computer sciences, hospitality management and nursing. Following consultation with the Ministry of TRANSCULTURAL NURSING EDUCATION 10 Education, the Bangladeshi Nursing Council (BNC), the Directorate of Nursing Services and other nursing bodies, the BSN program was initiated. During the 2012 annual IUBAT conference, Dr. Myian argued that if Bangaldeshi people’s health is to improve, nursing education must move away from traditional teacher-centered education to a student-centered curriculum. Due to a lack of local expertise in nursing education, in 2004, IUBAT invited the non-profit Mid-Main Community Health Centre located in Vancouver, Canada, to partner in delivering the BSN program, also referred to as the “Bangladeshi Project.” The objective of the Bangladeshi project is to educate Bangladeshi nurses to the level of international competency to enable them to teach nursing education (for example as a train-the trainer initiative). The faculty for the BSN program relies on Canadian volunteer nurses who teach the BSN program in English. Students progress through four years of three semesters each, with lectures, clinical labs, and clinical practice experience in hospitals and community agencies. Besides connecting Canadian nursing students and educators with their counterparts in Bangladesh, the volunteers have an opportunity to gain an in-depth understanding of global health issues, social and cultural determinants of health, as well as the problems of delivering culturally congruent nursing education (Berland, Richards, & Lund, 2010; Chavez, Bender, Hardie, & Gastaldo, 2010; Leininger, & McFarland, 2006). Volunteer Teaching at IUBAT Except for four local faculty members, the IUBAT nursing program is taug