Decolonization in health professions education: reflections on teaching through a transgressive pedagogy.

BACKGROUND
Canadian health educators travel to the global south to provide expertise in health education. Considering the history of relations between the north and south, educators and healthcare providers from Canada should critically examine their practices and consider non-colonizing ways to relate to their Southern colleagues.


METHODS
Using her experience as a teacher with the Toronto Addis Ababa Academic Collaboration in Nursing, the author explored issues of identity and representation as a registered nurse and PhD candidate teaching in Ethiopia. Transgressive pedagogy was used to question how her personal, professional, and institutional identities impacted her role as a teacher.


RESULTS
Thinking and acting transgressively can decrease colonizing relations by acknowledging boundaries and limitations within present ideas of teaching and global health work and help moving beyond them. The act of being transgressive begins with a deeper understanding and consciousness of who we are as people and as educators.


CONCLUSION
Working responsibly in the global south means being critical about historical relations and transparent about one's own history and desires for teaching abroad.


Introduction
As a registered nurse who has travelled globally on voluntary medical trips and now as a doctoral candidate in the roles of teacher and researcher, I am regularly questioning what it means to live and teach in non-colonizing ways. I have realized this is not an easy feat for several reasons. However, it is necessary as I work with and in a healthcare system that historically has contributed to western colonization. This very system continues to perpetuate an unequal power dynamic between the global north and south in teaching and health professions education.
As Sefa Dei stated, "Colonial refers not simply to north/south, but also to the way in which knowledge can be imposed on others through imperial relations. It is also a discursive approach to interrogate why, within communities, some knowledge is validated or privileged as opposed to other forms of knowledge." 1p.70 In this paper, I explore ways of breaking free from the colonial relations that are present in health professions education, learned through my dual experiences of being a PhD candidate and a teacher with the Toronto Addis Ababa Academic Collaboration -Nursing (TAAAC-Nursing).
I make no qualms in clearly articulating that I situate myself as a teacher and researcher within and through critical theories. This is a conscious decision. To think through a critical theoretical lens means that I do not accept society as is, but rather, I question how and why society is the way it is, how I am positioned in society, how I see myself, and also what needs to change in order to eliminate inequities for marginalized populations. [2][3][4] In the following pages, I will begin with questioning my own positionality as a starting point and key element of engaging with decolonizing thought. I am not separate or distinct from the very systems that I critique. Thus, challenging my own history is important to continuously uproot dominant ideologies of normalcy that are based on "…highly unequal societies in which economic inequity, racism, and class discrimination are empirical realities." 5p there was a whiteness that represented what it meant to be Canadian and my blackness was the "other" to that definition. Being reflexive, I realize I also "othered" others, often asking where they were from if they were racialized. This is problematic in two ways: first, I reproduced the same racism I experienced, and secondly, I made an assumption that white skin represented a collective identity. 8,9 As a nurse, I have worked globally in clinical roles over the past 12 years enhancing my practice through experiential learning. 10 Kolb's theory suggests that experiences can be used to transform how learners think about various healthcare practices or health issues through different learning styles. 10 One of the most influential trips that challenged me to re-think how I conceptualized public health, healthcare, and my role took Considering Kolb's learning cycle (Figure 1), I have transitioned through each stage. 10 Now, as a doctoral candidate and new teacher, I am once again using active experience to engage critically and learn through my experiences.

Experience of a Canadian nurse teaching in Ethiopia
TAAAC-Nursing is a part of the Toronto Addis Ababa Academic Collaboration (TAAAC), a university wide partnership between University of Toronto (U of T) and Addis Ababa University (AAU). 12,13 The specific collaboration between U of T's Bloomberg Faculty of Nursing and AAU's Department of Nursing has been focused on the development of Ethiopian academic nursing leadership through the Masters of Nursing program at AAU. 12 With the recognition of unequal power dynamics that often impact working relationships between north-south partnerships, the priorities of TAAAC-Nursing activities are always directed by the Ethiopian partners who determine what is needed from their Canadian colleagues. 12 I initially learned about TAAAC-Nursing in 2013 and my first step was a conversation with Dr. Amy  negatively impact the social determinants of health. Together we recognized that I would be a good fit for the program and the program was a good fit for me.
Prior to travelling I had mixed emotions of excitement and confusion. I was excited to be able to have the opportunity to once again set foot on a continent that holds the mystery of my ancestry -an ancestry that in many ways has always remained unknown to me. As Sefa Dei has indicated, "it is generally accepted that the influence of globalization is far-reaching. Scripting human lives, bodies, and communities, globalization has found its way in every facet of the African existence -social, material, physical, spiritual, cultural, political, economic, and psychological." 14p.68 Therefore, Ethiopia has inevitably been influenced by globalization.
Italy's attempts to colonize Ethiopia have created debates on whether the country was colonized in the same way as other African nations during the same time period. 15 Notably, the treaty of Wichale in the nineteenth century created a contentious relationship with each country claiming power and authority for their country's foreign relations. 15 Italy's eventual acknowledgement of Ethiopia as an independent state, through the treaty of Addis Ababa and the defeat of Italy's army by Ethiopia, was viewed as a victory in resisting colonization by Ethiopia and other African nations. 15  Additionally, as a racialized Canadian, who has often been positioned in the margins of society, it was uncomfortable to realize that I am respected as an expert, simply by virtue of where I live and the historical relations between the north and south. I wrestled with how my teaching, and even the program as a whole, could perpetuate the decentering of Africa and African ways of knowing in relation to the global north. To continuously "checkin" with myself to ensure I was always aware of the unavoidable power dynamics between the Ethiopian colleagues and myself, I chose to approach and reflect on my teaching through a transgressive pedagogy.

Transgressive pedagogy
Hooks (sic), a feminist theorist, activist, writer, cultural critic, and professor, defines a transgressive pedagogy as one that expands beyond societal and institutional boundaries by engaging directly with questions of bias that perpetuate systems of domination, and also finds new ways to teach diverse groups of students. 16 To me, being transgressive is not simply a role you put on when you step into a classroom as a teacher or when you enter institutions or settings that represent unequal power dynamics. 16 To believe that you only focus on being transgressive when standing in the front of a classroom means that a movement against and beyond the defined boundaries of teaching is not particularly conceivable because you have already been limited by the definitions of that role. To be e14 transgressive is to think and live transgressively every day.

Personal transgressive-ness
In their discussion on aboriginal research methodology, Absolon and Willet highlight the importance of the researcher's positionality to Indigenous methodologies. 17 They indicate that "neutrality or objectivity do not exist in research, since all research is conducted and observed through human epistemological lenses." 17p.97 Therefore, it is necessary for researchers who will contribute to new knowledge to explicitly locate themselves for transparency and self-accountability. 17 Although Absolon and Willet are addressing researchers, these principles can be applied to teaching. 17 It is not possible to teach from a place of neutrality or objectivity. These past four years have been a process of decolonization because I released many opinions that I held as an ultimate truth and have continuously re-visited who I am, who and what I represent from the past, present, and for the future.
Drinking the water at the stream that day was a symbolic step towards dismantling all that has been taught to me and "giving myself permission" to create my own knowledge, re-learn more about my own history, and recognize that knowledge and ways of knowing come from many different places and in diverse forms. "Seeking our truth in our location aids us in recovering ourselves and our strengths, and in uncovering historical oppressions. Our perceptions of who we are and how we locate ourselves are a e15 result of our own personal and political consciousness. Nonetheless, recovering truth inherently implies taking off the blinders to become conscious." 17p.119 Centering myself throughout these four years and unlearning much of what I had been taught has provided me with a deeper understanding of the impact that education and teaching has on people in their personal and professional roles. However, I must also recognize that having allocated time to simply think and develop my thoughts, together with opportunities to converse with different thinkers would not have been accessible had I not been in this program, which is a privileged position.

Professional transgressions
Like myself, I am sure that many other nurses have been asked why they did not become a doctor or been told that to improve as a nurse means to become a physician. These comments reflect a longstanding history of a professional hierarchy within the healthcare system, where nurses have been steadfast in challenging limited perceptions of a nurse's role and redefining the spaces that we can occupy. 18 Essentially, the profession of nursing has frequently operated at the periphery of power and prestige in healthcare systems. Even though I would argue that nurses are the backbone of this system, our skills are not always valued. 18 When I thought about working in Ethiopia, I was focused primarily on the individual interactions between my fellow travel teacher, the Ethiopian nurses, and myself. However, I did not consider the surrounding space or the dynamics between physicians and nurses that could impact our teaching environment. On this trip, the pursuit of greater knowledge proved to be a reminder of the realities our profession faces when attempting to expand the role of nurses.
During my visit, the Ethiopian nurses were told they could not practice clinical skills within the intensive care unit unless it was performing traditional nursing tasks such as bathing patients. They were also told that the education of medical students took precedence over their need to learn and therefore, they could not be in the intensive care unit at all. The complexities of the situation were made even more evident as staff nurses understood the unfairness of the situation but did not feel they were in a position of power to challenge it.
While we were requesting students not to engage those physicians who were perturbed by the presence of our group, these students stood strong in their desire to learn. Rectifying this situation did not happen without help from the organizers of TAAAC and TAAAC-Nursing, as the tension was most likely caused by our approach as foreign teachers who did not know how to effectively prevent or address conflict in working relationships within this local context.
Initially, I thought about this situation in relation to my role as an emergency room nurse where the working relationships between most physicians and nurses are quite good. Through this perspective, it would be easy to see this as a situation that occurs in healthcare systems "over there," where the nursing profession is at a different place in their professional spectrum. However, through a critical perspective, I acknowledge that the department I currently work in also faces similar challenges with the sharing of learning opportunities for resident doctors and nursing students.
As I reflect back on that situation, I recognize a missed opportunity to engage in further conversations with Ethiopian nurses about how they navigate tensions such as the ones experienced in the ICU. Being in the country for less than one month when this situation occurred, I was not quick to challenge or move beyond established boundaries because I did not have a complete understanding of the dynamics within the local healthcare system. In this situation, I chose to remain in the traditional role of a teacher and let the program coordinator, Vanessa Wright, address the situation by engaging in conversations with departmental heads and the organizers of both TAAAC and TAAAC-Nursing. These conversations were necessary to understand and learn how our Ethiopian physician colleagues interpreted our presence and approach as disrespectful.
However, thinking through the entire teaching experience I believe that to contribute to Ethiopia's nursing profession, in the manner that TAAAC-Nursing has developed, is a form of resistance. The difference in this program is that Canadian nurses contributed to providing expertise for nurses to e16 operate in leadership positions as educators. This in itself is transgressive because as Ethiopian nurses gain more expertise and different skill sets, they can possibly provide opportunities for other Ethiopian nurses to branch out into different settings. So, teaching was about technical knowledge, but also ways of collaborating, valuing difference, and creating strategies for survival.
Negotiating the possibility of transgressiveness also meant recognizing the potential of colonizing practices, as this experience has shown. To deal with this reality, I was aware of my actions and more importantly, I paid keen attention to how the Ethiopian colleagues responded to my actions. For me, the best indicators that I was transgressive came from my careful observation and the communication with some nurses once this trip was finished.

Institutional transgressions
"It [Academia] is that contradictory place where knowledge is colonized but also contested -a place that engenders student mobilizations and progressive movements of various kinds. It is one of the few remaining spaces in a rapidly privatized world that offers some semblance of a public arena for dialogue, engagement, and visioning of democracy and justice. Although these spaces are shrinking rapidly, dialogue, disagreement, and controversy are still possible and sanctioned in the academy". 3p.170 I have chosen to consider the university as an institution for transgressiveness for several reasons. First, it is a space that I have occupied for the past four years as a student. As hooks stated, I have felt both the pressures to conform to a particular way of speaking and writing, yet also challenged in many ways to question my own thinking.
2 Secondly, it is through this space that I had the opportunity to teach nurses in Ethiopia. Lastly, the discussion on transgressive pedagogy in teaching would not be complete without considering the space in which one needs to be and chooses to be transgressive. This discussion on institutional transgressions is by no means exhaustive, as I believe that there are complexities in how transgressive spaces are occupied and accessed within large institutions on different levels. For example, I am focusing on understanding spaces where the Faculty of Nursing provides opportunities to move beyond and against boundaries; however, the Faculty of Nursing must also be considered within a larger university community that has its own hierarchies of academic knowledge, power dynamics, and financial e17 obligations. This I also consider with respect to our Ethiopian partners and wonder how similar their need is to be transgressive within their own environment.

Conclusion
Globalization has provided opportunities for us as Canadian educators to teach and learn abroad, but we must be aware of the implications of north-south partnerships and of education being used to colonize our colleagues in the global south. It is inevitable that we will continue to travel, work, and teach globally but this must be done in a responsible way with an acknowledgement of who we are, the privileges we are afforded, and what our perspectives are of who we interact with when we teach. To be aware means to acknowledge that we are constantly a work in progress and that every day provides new opportunities to be reflective and critical in how we operate in this world especially as educators. This process is not easy, and we will face struggles and uneasiness in acknowledging our own shortcomings. However, this is a necessary process in the pursuit of social justice. Applying a transgressive pedagogy to my teaching experience provided an opportunity for me to think more critically about the spaces I occupy in my teaching and how I can continue to move against and beyond set boundaries. I believe that this process begins with a better understanding of self, which is the basis from which professional and institutional identities are built.