Background

Access to healthcare is a fundamental human right that is often influenced by social norms and power structures. Implicit biases in society, healthcare, and education contribute to health inequalities. Incorporating equity and social justice into nursing and healthcare education, through norm-critical pedagogy can empower learners to address and promote social justice and health equity in patient care and community health.

Methods

The aim of the study was to describe characteristics and recurring elements of norm-critical literature in published research. This study followed Arksey and O’Malley’s scoping review framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews to report the findings. A search was conducted in across five scientific databases – CINAHL, APA PsycINFO, ERIC, Medline, and Web of Science – limiting results to English language articles. Two authors independently screened, extracted, and analysed the data, guided by selected key concepts based on the population, concept, and context framework. The included articles were condensed according to specific characteristics and analysed thematically.

Results

Sixteen articles were included in the review, and all published from 2017 onwards, primarily in nursing journals. Most of these articles employed qualitative methodologies. A thematic analysis generated three themes: ‘Redesigning education toward norm-critical pedagogy’, ‘Redefining one’s positionality as a teacher’, and ‘Transforming education for a norm-conscious sustainable healthcare future’.

Conclusions

This scoping review concludes that the characteristics of norm-critical literature, primarily centred on Western nursing education, has limited applicability in other healthcare educations. The literature describes key challenges in integrating norm-criticism into educational structures, often placing undue responsibility on individual teachers to adopt a norm-critical pedagogy. This review calls for further empirical research on norm-criticism to advance its use as a pedagogical model in nursing and healthcare education.

Background

Nursing education institutions have sought to incorporate health equity and social justice into curricula. However, nursing students report limited opportunities to engage with these perspectives during their studies. In a campus-based clinical learning environment, efforts have been made to support students in the advancement of health equity and social justice by integrating a norm-critical approach.

Aim

This study aimed to explore how nursing students made sense of norm-criticism in a campus-based clinical learning environment.DesignThe design of the study was qualitative, informed by narrative inquiry and a Goffmanian theoretical framework.

Setting

The study was carried out in a campus-based clinical learning environment for nursing education in a mid-sized university college.

Participants

The participants of the study consist of 14 undergraduate nursing students.MethodsThis study adopted a narrative methodology where the data was analyzed both structurally and thematically.

Results

This study demonstrates that students made sense of norm-criticism by framing it in three distinct phases. First, students encounter norm-criticism through norm-critical photographs, then they engage in critical reflection on norm-criticism, both in collaboration with peers and through personal reflection on their own positionality, and lastly, they find meaning in norm-criticism as a tool to change unequal nursing practices and provide person-centered nursing care.

Conclusion

This study highlights that, by mechanisms of impression management and reframing, nursing students regard and use norm-criticism as a reflective tool that empowers them to change healthcare structures and supports them in understanding how to provide person-centered care.

This discussion paper highlights the necessity of norm-critical and norm-creative approaches in nursing education to address healthcare inequalities. Traditional curricula have inadequately engaged with intersectional perspectives, marginalizing various social groups. By integrating norm-conscious pedagogy, nursing students can critically analyze power structures and develop inclusive healthcare solutions. The “Breaking Fences” project introduces innovative tools, such as the norm-lab+, to foster reflexivity and challenge discriminatory norms. Emphasizing social justice, sustainability and self-awareness, this approach equips future nurses to recognize and counter biases, ultimately promoting equitable healthcare practices. Implementing norm-conscious education is crucial for advancing inclusivity and social responsibility in nursing. 

Sjuksköterskans internationella etiska kod är tydlig: vård ska ges till dem som mest behöver den. Men om vi lär våra studenter att värna liv men förblir tysta när liv krossas i Gaza – vad är då vår sjuksköterskeetik värd? Det frågar sig fem sjuksköterskor som är lärare på sjuksköterskeutbildningen på Högskolan Väst i en debattartikel.

”Den svenska akademins tystnad om Gaza är inte neutral, utan ett ställningstagande.” Det skriver fem lärare, forskare och sjuksköterskor inom vårdutbildningar vid Högskolan Väst.

Background:

In nursing education, perspectives on social justice and health equity have increasingly been highlighted, mainly within the theoretical aspects of education. Various strategies have been used to integrate these concepts into practice-oriented learning activities. The strategy of norm-criticism aims to elevate the perspectives of equity and social justice in education. There is a need to integrate health equity into the practical aspects of education. This dissertation has thus explored a clinical learning environment (CBCLE) with norm-criticism and work-integrated learning (WIL) as parts of its educational structure.

Aims:

To explore the integration of and encounters with norm-criticism in a campus-based clinical learning environment for a work-integrated nursing education program.

Methods:

Study I was a scoping review of 16 peer-reviewed articles, with data that was thematically charted and analyzed to map out the existing research. Study II combined document analysis of 64 academic records with qualitative interviews of seven faculty members/stakeholders. This data was analyzed using reflexive thematic analysis. Study III involved participatory observation at a CBCLE, with field notes analyzed through reflexive thematic analysis. Study IV drew on narrative accounts from 14 undergraduate nursing students, which were analyzed through a narrative analysis and a theoretical analysis.

Results:

In Study I norm-critical research in nursing education was found to be predominantly qualitative and Western-oriented. Norm-criticism involved modifying curricula and learning environments to challenge norms and foster health equity. Teachers were encouraged to undergo a personal relearning process to teach more inclusively. In Study II the CBCLE was constructed to educate nursing students beyond the scope of traditional education and in partnership with societal elements. The WIL approach framed the incorporation of norm-criticism, allowing norm-criticism to be integrated and elevated to practical use. However, its inclusion caused institutional hesitation because of its political connotation. In Study III norm-critical dialogues were seldom initiated by the teachers, and only brief norm-critical moments were observed. Technical nursing skills were emphasized, which reinforced a theory-practice gap.

In Study IV students’ gradual engagement with norm-criticism evolved from confusion to meaning making, which called for deeper integration of norm-criticism. Through WIL, norm-criticism was operationalized, bridging theory and practice while shaping professional identity and critical consciousness.

Conclusion:

Norm-criticism at the CBCLE was interpreted across three layers. These included a structural pedagogical norm aligned with the WIL approach, a disruptive personal experience fostering reflection and professional formation, and a theoretical-practical tool to support health equity. These layers collectively redefined teaching and learning practices in nursing education, thus constituting a new normal for the field.

Bakgrund:

Inom sjuksköterskeutbildning har rättvis och jämlik hälsa fått allt större uppmärksamhet, främst inom utbildningarnas teoretiska delar. Olika lärstrategier har använts för att integrera dessa perspektiv i utbildningens praktiska delar. Genom en normkritisk strategi kan normer synliggöras och frågor om social rättvisa lyftas fram. Det finns ett behov att integrera rättvis och jämlik hälsa i sjuksköterskeutbildningars praktiska delar. Denna avhandling har utforskat en campusbaserad klinisk lärandemiljö (KLC) där normkritik och arbetsintegrerat lärande (AIL) utgör en del av den pedagogiska strukturen.

Syfte:

Att utforska möten med och integrering av normkritik i en campusbaserad klinisk lärandemiljö i ett arbetsintegrerat sjuksköterskeutbildningsprogram.

Metod:

Studie I granskade 16 peer-reviewade artiklar, där data tematiskt strukturerades och analyserades för att få en överblick över befintlig forskning. Studie II kombinerade dokumentanalys av 64 dokument med kvalitativa intervjuer med sju aktörer bestående av fakultetsmedarbetare och partners från civilsamhället. Data analyserades med reflexiv tematisk analys. Studie III utgjordes av deltagande observationer vid ett KLC, där fältanteckningar analyserades med reflexiv tematisk analys. Studie IV bestod av berättelser från 14 sjuksköterskestudenter på grundnivå, berättelserna tolkades med hjälp av narrativ analys samt genom ett teoretiskt raster.

Resultat:

I studie I framkom att normkritisk forskning inom sjuksköterskeutbildning främst är kvalitativ och västerländskt präglad. Normkritik medförde förändringar i läroplaner och lärandemiljöer för att kunna utmana normer och främja rättvis och jämlik hälsa. Lärare uppmuntrades att genomgå en personlig omlärningsprocess för att undervisa mer inkluderande. I studie II framkom att KLC konstruerades i samverkan med civilsamhället med målet att utbilda sjuksköterskestudenter på ett annat sätt än traditionell sjuksköterskeutbildning. AIL-ansatsen utgjorde en ram för att integrera och möjliggöra att normkritik kunde omsättas till praktisk tillämpning. Dock medförde implementeringen en institutionell tveksamhet till normkritiken på grund av dess politiska laddning. Studie III uppmärksammar att normkritiska dialoger sällan initierades av lärarna och endast korta normkritiska inslag i undervisningen observerades. Medicintekniska färdigheter i relation till omvårdnad betonades, vilket förstärkte klyftan mellan teori och praktik. I studie IV utvecklades studenternas gradvisa engagemang i normkritik från förvirring till meningsskapande, vilket tydliggjorde vikten av att införliva normkritik på en djupare nivå på KLC. Genom AIL kunde normkritik konkretiseras och förena teori och praktik samtidigt som kritisk medvetenhet och professionell identitet formades.

Slutsats:

Normkritik vid KLC representerade tre lager: en strukturell pedagogisk norm i linje med AIL-ansatsen, en utmanande personlig erfarenhet som främjade reflektion och professionell utveckling, samt ett teoretisk-praktiskt verktyg för att stödja rättvis och jämlik hälsa. Dessa nivåer omformade undervisningen och lärandet och utgjorde därmed det nya normala inom sjuksköterskeutbildningen.

Nursing education plays a pivotal role in shaping future nurse professionals who contribute to social justice and health equity. To achieve this goal, nursing teachers must employ effective learning strategies. One such strategy is norm-criticism, which promotes a critical reflection of the normative preconceptions that impact health equity. This study aimed to identify how nursing teachers approach norm-criticism during learning activities in a campus-based clinical learning environment with a norm-critical profile. Employing an ethnographic approach, we analyzed participant observational data using reflective thematic analysis. Our results revealed three overarching themes: “Teaching nursing disengaged from norm-criticism,” “Teaching norms and deflecting norm-criticism,” and “A hesitant norm-critical teaching.” This study concludes that the teachers did not have the tools or lacked knowledge in norm-critical teaching strategies, likely as consequence of inadequate faculty support and guidance. Ultimately, teachers should have access to norm-critical education and opportunities to learn how to carry out norm-critical teaching.

Nursing education is in the process of incorporating critical thinking, social justice, and health inequality perspectives into educational structures, aspiring to help nursing students develop into professional nurses prepared to provide equal care. Norm criticism is a pedagogical philosophy that promotes social justice. This qualitative case study aimed to gain an understanding of and elaborate on an educational development initiative in which norm criticism was incorporated into the composition of a new campus‐based clinical learning environment for nursing education. By analyzing documents and interviews with the help of reflexive thematic analysis three themes were generated: “Intention to educate beyondnursing education,” “Educating in alliance with society,” and “The educative ambiguity of the Clinical Learning Centre. ”The case study indicates that the incorporation of norm criticism into a campus‐based clinical learning environment may encourage nursing students to evolve social skills for nursing practice that support health equality within healthcare. By collaborating with society, nursing education can considerably improve its educational frameworks in alignment with societal demands. However, the inclusion of norm criticism in a setting such as a campus‐based clinical learning environment entails a clash with established institutionalized norms and being perceived as too proximate to politics.