Introducing human rights and health into a nursing curriculum

Curationis 30(4): 53-60 Aim The introduction o f a module in Health and Human Rights into a Postgraduate di­ ploma curriculum for registered nurses is described. Background An important component of nursing programmes in South Africa has been teaching of the principles of ethical practice and relevant ethical codes. A number of factors have contributed to the need to include human rights as an integral component of nursing curricula in South Africa. These include the Bill o f Rights in the Constitution of South Africa and the implications thereof for health care delivery, the primary health care approach in the delivery o f health care in South Africa, the development and accept­ ance o f Patients’ Rights Charters, and the recognition of the role that health profes­ sionals played whether through lack of knowledge and awareness or direct involve­ ment in the human rights violations in the health sector exposed during the hearings o f the Truth and Reconciliation Commission. Module description An outline of themes covered in the course content is described, together with exam­ ples of learning activities and teaching materials. Reflections of the course convenor and students are used to highlight the importance o f inclusion of health and human rights as foundational to ethical nursing practice, regardless o f the health care setting.


Introduction and background
"Nursing shares with other health p ro fessio n a ls a com m itm ent to the well-being o f the patient and to a professional practice based on codes o f ethics" (A m nesty International, 1997: 1).
Historically, nurses have played an im portant role in health care provision and in upholding humane values in the care o f their patients.An important com po nent o f nursing program m e curricula in South A frica has been teaching o f the principles o f ethical practice and the rel evant ethical codes.
H um an rights, which include the right to health and access to health care and re fer to essential social determ inants of health and well-being of people, overlap w ith th e p rin c ip le s an d n o rm s o f bioethics (Marks, 2003: 1).Wildschut, in a paper presented to the International Council o f Nurses Ethics Conference in 2001, stated: "Awareness o f human rights is crucial fo r nurses, as they are often at the fo re fro n t o f critical decisions and procedures and are able to see the im m ediate effects on pa tien ts an d their relatives o f hum an rights violations " (2001: 1).From the recom m endations m ade by the Truth and Reconciliation Com m ission (TRC) it is clear that health professionals have an ethical obligation to place the well-being o f their patients at the fo refro n t o f th eir professional

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c o m m itm e n ts (T h e T ru th and Reconciliation Comm ission, 2002: v. 5, 33440).
A num ber o f factors contributed to the need to include hum an rights as an inte gral com ponent o f nursing curricula in South Africa.These included the Bill of Rights in the C onstitution o f South A f rica Act No. 108 o f 1996 (South Africa (Republic), 1996) and the implications thereof for health care delivery; the pri mary health care approach in the deliv ery of health care in South Africa as stipu lated in the National Health Act No. 61 of 2003 (South A frica (Republic)), the de velopm ent and acceptance o f the Pa tients ' Rights Charter (National D epart ment of Health South Africa, 2002), and the recognition o f the role that health professionals played -through lack of knowledge and awareness or direct in volvement and complicity -in the human rights violations in the health sector ex posed during the hearings o f the TRC (B a ld w in -R a g a v e n , L o n d o n and de G ruchy, 2000: 2 3 0 -3 2 ; L ondon and Baldwin-Ragaven, 2006:20).
During the apartheid years there were many incidents in which health profes sionals were com plicit in the violation of the hum an rights o f persons in their care.M edical doctors in particular played a controversial role in the detention and torture o f political activists (Baldwin-Ragaven, de Gruchy and London, 1999: 91-118).Baldwin-Ragaven etal. ( 1999:91) make a distinction betw een active par ticipation in the torture and abuse o f pris oners and detainees and collusion (ei ther active or passive) resulting in the violation o f human rights.Although the role o f other health professionals in hu man rights violations in South Africa was not as fully docum ented, the TRC found that "the health sector, through apathy, acceptance o f the status quo and acts o f omission, allowed the creation o f an en v ir o n m e n t in w h ic h th e h e a lth o f millions o f South Africans was neglected, even a t times actively compromised, and in which violation o f ethical codes o f p ra c tic e w ere fr e q u e n t, fa c ilita tin g violations o f hum an rights" (The Truth and Reconciliation Commission, 2002 v. 5:250).
As frontline health care providers dur ing the years o f the apartheid regime in South Africa, nurses not only had to deal with consequences o f the violation o f the human rights o f their patients, but were seldom able to challenge the State about these abuses.Ethical codes regulate professional con duct and provide a standard by which the behaviour o f health professionals can be evaluated in their role of protect ing the public from harm.However, these codes do not adequately assist the health professional in dealing with abuses such as those which occurred under the apart heid regime (Steere and Dowdall, 1990: 14).Violation o f the rights of patients in cluded reporting injured persons to the se c u rity fo rc e s, p e rm ittin g secu rity forces to compromise the care of patients, failing to accurately record a patient's condition, breaking confidentiality and failing to act as the patient's advocate.Both the South African Nursing Council (1997: 3-5) and the Democratic Nurses Organisation o f South Africa (DENOSA) (1997: 3-4) (which replaced the South A frican N ursing A ssociation), in their subm issions to the TRC accepted re sp o n sib ility fo r the p a rt th at nurses played in violating the rights o f patients under apartheid.These bodies com m it ted th em selv es to p rom oting hum an rights in nursing curricula and prom ot ing awareness am ong nurse educators.In its final report the TRC (2002 v. 5:334-40) made fifty-six recom m endations in order to prevent hum an rights abuses within the health sector, and emphasised the im portance o f inclusion o f human rights education for health profession als.
The linkages betw een health and human rig h ts are in ex tricab le and com plex.M a n n , G o s tin , G ru s k in , B re n n a n , Lazzarini and Fineberg (1999:11-17) offer a three-part fram ew ork for considering these, and argue that: (i) health policies and program m es may have beneficial or adverse impacts on hum an rights, par ticularly in public health; (ii) health care practices and health care research may inadvertently violate hum an rights; and (iii) violations o f hum an rights may have adverse health effects on individuals and groups.
Health professionals are challenged by dual loyalty conflicts which may violate p atien ts' rights (Steere and D ow dall, 1990: 12, 14;Rubenstein, 2003: 270).Nurses and m idw ives not only face in creasingly com plex ethical decisions in the workplace, but deal daily with human rights issues.They are also increasingly at risk o f violence in their work environ ments, and it is therefore crucial that they have access to hum an rights education in order to prom ote a hum an rights ethos in the workplace and to protect their own rights (International Council o f Nurses, 2001:1;Amnesty International, 2005:650).Amnesty International calls for a stronger hum an rights role for nurses and m id wives, which in turn would "strengthen nurses' capacity to protect the rights and interests of patients and contribute to a more just society" (2005:649).
Vulnerability and the impact o f ill-health can be m inim ised by taking appropriate steps to respect, protect and fulfil hu man rights (World H ealth Organization, 2001:7).The prom otion o f human rights is therefore an essential part o f efforts to p ro m o te an d p ro te c t p u b lic h e a lth (H annibal and L aw rence, 1999: 412; M annei al., 1999:14; 16).Health profes sionals should learn about hum an rights in order to protect rights through identi fying, docum enting and testifying about rights violations (Austin, 2001:192-3).

Rights
The main features o f hum an rights have been identified as follow s (International Federation o f Red Cross and Red Cres ce n t S o c ie tie s and F ra n g o is-X a v ie r Bagnoud Center for H ealth and Human Rights, 1999:21-2; Giuskin andTarantola, 2002:313): • people have rights sim ply be cause they are human; • these rights cannot be earned, nor lost for bad behaviour; • they encom pass the fundam en tal principles of humanity; • they are universal -with no ac count o f race, gender or colour; • they treat all people as equal -  R agaven (2006: 21-22) identify these rights as: "the right to receive health care services; rights related to the un derlying conditions fo r health, which through their fulfilm ent, enhance health; r ig h ts f o r v u ln e r a b le g r o u p s a n d fo u n d a tio n a l rights that acknow ledge our com m on hum anity and principles o f e q u ity ".

Health and Human Rights
H ealth as a hum an right has its roots in the public health m ovem ent o f the 19th century (Mann, 1999: 439-41;Hassim, Hey wood & Berger, 2007:7).The right to health was first formally recognised in 1946 when the Constitution o f the World Health Organization was adopted, which states: "The enjoym ent and exercise o f all hum an rights affects the health o f in d ivid u a ls.This is esp ecia lly evid en t when considering the modern definition o f health 'as a state o f complete physi cal, m en ta l or so cia l w ell-being, not merely the absence o f disease or infir mity ' " (World Health Organization, 1986 [online]).Chapm an (1994: 7) defines the right to health care as "a right to a basic and adequate standard o f health care consistent with societal resources" .This right is inclusive of freedom s such as the right to be free from discrim ination and involuntary m edical treatment, includes entitlem ents such as the right to essen tial prim ary health care, and extends to the underlying determ inants o f health such as access to safe water and adequate nutrition (W orld H ealth Organization, 2001: 11;Hunt, 2002: 8)."The right re quires an effective, inclusive health sys tem o f good quality" (Hunt, 2006: 604).
The rights to health and health care are evident in a num ber of key international instrum ents on hum an rights, and are also enshrined in numerous national con stitutions (Hunt, 2006: 603)

Human Rights
Health professionals constitute an essen tial elem ent to ensuring fulfilm ent of the right to health (World Health Organiza

Knowledge:
• U nderstand the conceptual fram ew ork for hum an rights, including definitions o f hum an rights (in general and as they relate to health), the basic rights o f the individual, fam ily and community, and the inter-relationships betw een health and hum an rights.

•
Identify how human rights are im pacted by the health sector and how human rights violations im pact on health and the roles and attitudes o f health professionals.
• Identify the various Codes o f Conduct for health professionals (specifically nurses and m idwives) within the interna tional and South African context.
• Acquire greater insight into the issues o f human rights in health and health care.
• Acquire knowledge o f the relevant conventions, constitutional issues/bodies, and resources available, e.g.materials, organisations, documents, legal procedures, etc.
• Engage with patients' rights and the role o f the nurse in advocacy on behalf o f vulnerable individuals and groups within his/her care.

Attitudes:
• Build awareness o f and respect for individual, group and cultural differences (including race, gender, sexual orienta tion, religion, etc.).
• Prom ote the com mitment o f each student (health professional) to respect the rights o f all clients and patients and to sensitive, equitable and appropriate care and treatm ent o f all with whom he/she com es into contact.

Skills:
• Be able prom ote the adoption o f a hum an rights culture w ithin the workplace.
• Be able to identify a hum an rights issue impacting on health within the workplace.
• U tilise the resources, knowledge and skills to facilitate changes in practice.1), content and learning activities.
In a country in w hich the hum an rights o f the majority o f the population have long been denied or violated, it was rec ognised that the introduction o f such a m odule was bound to raise sensitive is sues for the convenors as well as the stu dents.

Module: Aim and learning outcomes
The module focuses on the relationship betw een health and hum an rights and attempts to address the following ques tions: • H ow does one define and under stand hum an rights?
• W hat is the basis for hum an rights concerns among health professionals?
• H ow can health professionals improve individual and commu nity health by protecting and prom oting hum an rights?(Amnesty International, 1997: first screen) The field o f hum an rights literature is vast, and the task o f distilling this to iden tify the ap propriate content fo r p o st graduate nursing students proved chal lenging.The module deals with sensitive issues and planning therefore had to take into account tim e for "debriefing " and closure o f the topic for the day.

Module description and outline
The m odule is divided into sessions of 2-3 hours.E ach deals w ith a theme or sub-theme.The themes included in the m odule attem pt to provide the stu dent with an overview o f the issues while rem aining practical through the use of case studies and practical assignments.
In an introductory session the student is introduced to the core principles of hu m an rights and given a brief background to the developm ent o f hum an rights in South Africa.The m ajor codes and docu m entation relating to hum an rights are exam ined -including the Universal D ec laration o f Human Rights, the South A f rican Constitution and Bill of Rights, the African Charter on Human and People's R ights and other international codes re lating to health and hum an rights.
A second them e on H ealth and Human R ights in South A frica challenges stu dents to confront the past human rights violations and the im pact o f these on health, and in particular the role o f the health sector under the apartheid regime.
Transcripts from the Health Sector hear ings o f the TRC are exam ined to under stand the depth and breadth o f the hu m an rights violations that occurred.Is sues such as institutionalised violence, racism and inequity in the health care system are discussed.Students are en couraged to reflect on and bring to this session exam ples from their own experi ence, both personally and professionally as appropriate, o f issues and practices that could be considered an abuse o f hum an rights.
A them e o f discrim ination in health care and the im pact thereof on the health of individuals, fam ilies, com m unities and vulnerable groups deals with many o f the challenges facing health care workers.
This them e addresses language rights, forcible treatment, HIV/AIDS, confiden tiality, sexuality and disability and the rights to inform ation as a m echanism to the realisation o f rights (London, 2007: 14).Issues such as unrecognised eco nom ic and social rights and the health consequences o f underdevelopm ent are examined.W omen's and children's rights as a special category are highlighted, with p articu lar referen ce to South A frica, where the problems o f domestic violence, rape, child abuse and prostitution are part o f the daily experiences o f m any women and children.
T h e h e a lth c o n se q u e n c e s o f sex u al abuse, dom estic violence, lack of access to sexual and reproductive rights are dealt with by nurses and midwives at all levels o f care.The conventions relating to the rights o f the child, and elim ination of discrim ination and o f violence against wom en are examined.
A nother them e deals with the health im pacts o f violence in a num ber o f forms, including societal violence, institution alised violence (political systems, pris ons), arm ed conflict, torture, and the health status o f refugees and displaced persons.The pivotal role o f health pro fessionals in docum enting and respond ing to violations and in prevention ef forts is highlighted.
A m odule such as this is designed not m erely as a historical and current over view o f the topic, but should also facili tate the understanding o f current prac tices and the im portance o f incorporat ing hum an rights into nursing practice.Therefore, the module concludes by iden tifying situations in which nurses may be vulnerable to hum an rights abuse or to com m itting acts which could be con sidered a hum an rights violation (e.g. in forensic settings), in order to enable stu dents to develop standards for practice within the workplace (Hannibal et al., 1999: 411-3).The importance o f docu m enting hum an rights violations and the role o f the state institutions supporting c o n stitu tio n al dem ocracy and hum an rights is highlighted.The role of nurses' organisations in transformation, address ing hum an rights issues and lobbying for change is emphasised.

Learning activities and assessment
An ongoing requirem ent throughout the m odule is that students scan the media for evidence o f human rights violations which have a direct or indirect impact on health, as well as for stories o f human rights 'successes'.Students collect arti cles from newspapers and journals and critically observe the visual media.Their reflections are recorded in a personal jour nal, in which they are encouraged to link what they read and observe with the rel evant hum an rights documents.This ex ercise raises awareness o f events, poli cies and actions that directly and indi rectly impact on health and human rights.
Further learning activities include analy sis o f case studies and use o f audiovisual clips from the media.Persons with par ticular backgrounds such as disability and children's rights are invited to share their experiences with the students.A s signments which have to be completed by students in this module include re flective journals in which students are encouraged to think and write about their own experiences and to reflect on the practices in their w orkplaces.A ssess ments are formative and summative.The form ative assignm ent is an essay on a hum an rights and health topic which is followed by a summative assignment of a more practical nature in which the stu dent is required to identify a workplace practice w hich is in conflict with human rights principles /codes and to devise a practical plan to change the practice.

Can such a module help to change practice?
C hanging practice is difficult; yet, if Mann etal.'s (1999:8-11) proposition that the prom otion and protection o f human rights and the prom otion and protection of health are fundamentally linked is taken seriously, then health care workers have to begin to m ake a difference to the health o f the individuals and com m uni ties that they serve by changing prac tices w hich violate human rights.

Reflections of lecturer and students
As with m any new courses, the enthusi asm o f the teacher often m eans that the first offering is pressured and overloaded.

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Such was the case in the presentation of the first module in H ealth and Human Rights.A num ber o f pioneers in the hu man rights field contributed to the m od ule, and although students engaged with the issues under discussion, insufficient time was given for them to process the feelings that were generated by the is sues.Student tensions w ere evident in relation to personal experiences -those who had not suffered the indignities of the previous oppressive regim e felt that the past was overemphasised, while there were those who felt that their pain was being recognised for the first time.This tension reflects the anxieties which are part o f the transition and transform ation of South Africa, and required sensitive handling.In the offering of the m odule the form at was changed to a less pressured content using a case study approach; this has been more accessible and acceptable to the students.
W  Curricula which include hum an rights as part of the course content should ensure that the learning context is taken into consideration, and that learners' personal backgrounds and experiences are re spected.Learners enter such a course with a wealth o f personal understanding and experience, and the nurse educator should be skilled in order to assist the students to engage w ith their ow n expe riences as they engage with the new con tent.It is im portant that the nurse educa tor is also willing to engage with proc esses that form the context o f his/her own understanding o f hum an rights.
There are enorm ous challenges facing nursing education in South A frica at this time, as well as facing the health sector in general.Health and hum an rights are inextricably linked (Mann etal., 1999:18), and exploration o f this link m ay help to revitalise the health field as w ell as con tributing to broadening hum an rights thinking and practice.As a society we are judged by our actions tow ards the m ost vulnerable, and the health profes sional is at the forefront o f this task.
"N urse educators should ensure that nursing curricula at the undergraduate, graduate and continuing education lev els are regularly updated to m eet the needs o f the changing healthcare envi ronm ent" (Maze, 2005:547).Nurse edu cators have to m eet the challenge o f pre paring nurses and m idwives who are not only accountable and com petent in ethi cal decision-m aking, but also com m itted to the prom otion o f hum an rights and the facilitation o f a hum an rights culture within the health sector and broader com munity.

2000.
U The adoption by the United Nations Gen eral Assem bly o f the U niversal D eclara tion o f Human Rights in 1948 provided a fundam ental reference point and laid the cornerstone o f the m odem hum an rights m ovem ent.T he standards set by the D eclaration were not considered legally b in d in g , but rath er as goals tow ards w hich nations th at su b scribed to the D eclaration could strive.There are nu m erous codes and declarations w hich have emanated from this initial movement w hich are now regarded as fundamental to the m anner in w hich hum an beings should be treated.T hese treaties and codes have im plications for nurses and m idwives, and include the: International Covenant on Civil and Political Rights a n d I n te rn a tio n a l C o v e n a n t on Econom ic, Social and Cultural Rights (United Nations, 1966); Convention on the Rights o f the Child (U nited Nations General Assembly, 1989); Convention on th e E lim in a tio n o f a ll F o rm s o f D is c rim in a tio n a g a in s t W om en (C ED A W ) (U n ited N a tio n s G eneral Assembly, 1979) and D eclaration on the R ig h ts o f D isab le d P erso n s (U nited Nations General Assembly, 1975).
N ITED NATIONS 1966: International Covenant on Econom ic, Social and Cul tural Rights.New York: U nited Nations.UNITED NATIONS GENERAL ASSEM BLY 1975: D eclaration on the Rights o f D isa b le d P e rso n s.R e s o lu tio n 3447 (XXX).New York: United Nations.UNITED NATIONS GENERAL ASSEM BLY 1979: The Convention on the Elimi nation o f all Form s o f D iscrim ination against W omen [CEDAW].New York: United Nations.UNITED NATIONS GENERAL ASSEM BLY 1989: Convention on the Rights o f the Child.Resolution 44/25 o f 20 Novem ber 1989.http://www.ohchr.org/english/law/pdf/crc.pdf.A ccessed 7 M ay 2006.W IL D S C H U T , G 2001: H um an Rights N ursing.Paper presented at: ICN Ethics Conference, 2001; Copenhagen.W O R L D H EA LTH O R G A N IZA TIO N 1978: Declaration o f Alma-Ata.Geneva: WHO.W O R L D H EA LTH O R G A N IZA TIO N 1986: T he C onstitution o f the W orld Health Organisation 1946.(In W HO, ed 1986: Basic Documents.36th ed.Geneva: WHO.W O R L D H EA LTH O R G A N IZA TIO N 2001: 25 q u e stio n s and a n sw ers on health and hum an rights.Geneva: WHO.W O R L D H EA LTH O R G A N IZA TIO N 2002: Advancing the Dialogue on Health & Human Rights.Paper presented at: H um an R ights Day C om m em oration, 2002; Geneva.

Table 1 . Learning objectives for Health and Human Rights module.
A m ong the reco m m en d atio n s o f the South African TRC(2002 v.5: 335)was that o f training o f health professionals: "Training in human rights should be a fundam ental and integral aspect o f all curricula fo r health professionals.This training should address facto rs affect ing h um an rig h ts p ra c tic e , such as