Clinical exchange: one model to achieve culturally sensitive care

© 2000 Blackwell Science Ltd

Nursing Inquiry

2000;

7

: 61–71

F e a t u r e

Blackwell Science, Ltd

Clinical exchange: one modelto achieve culturally sensitive care

Julie

Scholes

a

and Diana

Moore

b

a

Centre for Nursing and Midwifery Research, and

b

University of Brighton, Brighton, England, UK

Accepted for publication 5 October 1999

SCHOLES J and MOORE D.

Nursing Inquiry

2000;

7

: 61–71

Clinical exchange: one model to achieve culturally sensitive care

This paper reports on a clinical exchange programme that formed part of a pre-registration European nursing degree run bythree collaborating institutions in England, Holland and Spain. The course included: common and shared learning includ-ing two summer schools; and the development of a second language before the students went on a three-month clinicalplacement in one of the other base institutions’ clinical environments. The aim of the course was to enable students tobecome culturally sensitive carers. This was achieved by developing a programme based on transcultural nursing principlesin theory and practice. Data were gathered by interview, focus groups, and questionnaires from 79 exchange students, foster-ing the strategies of illuminative evaluation. The paper examines: how the aims of the course were met; the factors thatinhibited the attainment of certain goals; and how the acquisition of a second language influenced the students’ learningabout nursing. A model is presented to illustrate the process of transformative learning from the exchange experience.

Key words:

clinical exchange, culturally sensitive care, curriculum innovation, preregistration European nursing degree,transcultural nursing.

This paper will report on the international elements of apre-registration European nursing degree. The programmeis based in three institutions: the University of Brighton,UK; the Hogeschool Utrecht, the Netherlands and theEscuela Universitaria de Enfermeria, Vitoria in the Basqueregion of Spain. The aim of the course was to developnurses with culturally sensitive caring skills fit to practisein another country for which they had linguisticcompetence.

This paper is based on a longitudinal evaluation of theprogramme fostering strategies of illuminative evaluation(Parlett and Hamilton 1972). Data were gathered by inter-views, questionnaires and documentary analysis. Data wereanalysed using the constant comparative method (Glaserand Strauss 1967). The aim of the evaluation was to iden-tify both the process and outcome of this course on theteachers and students involved in the initiative at the threebase institutions. This paper focuses upon the Dutch

and Spanish students’ UK experiences and the Englishstudents’ experiences in the Netherlands and Spain.

First, the key issues raised in the literature whichdirectly influenced the development and aims of theprogramme are addressed. The paper then reports on thestudents’ experience of summer school and exchangeand proceeds to analyse how this effected the acquisitionof culturally sensitive caring skills. The paper concludeswith an exploration of some of the key implications forcurriculum design with European partners.

TRANSCULTURAL NURSING

As our world conflates through the use of technologyand travel, we can no longer maintain a single culturalperspective (Leininger 1994; Meleis 1996). Societies areincreasingly becoming more diverse and this requireshealth care and nursing to take account of differing needs.Transcultural nursing is:

focused on comparative care, values, beliefs and practicesof individuals or groups of similar or different cultures withthe goal of providing culture specific and universal care

Correspondence: Dr Julie Scholes, Centre for Nursing & Midwifery Research, Uni-versity of Brighton, Westlain House, Village Way, Falmes, Brighton, BN1 9PH, UK.. E-mail: <[email protected]>

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practices in promoting health or well-being or to helppeople to face unfavourable human conditions, illness, ordeath in culturally meaningful ways. (Leininger 1995, 58)

These perspectives need to be integrated into basic nursetraining programmes and nurtured in graduates who pre-pare for specialist roles (DeSantis 1994).

To achieve competence in transcultural care thereneeds to be: recognition of one’s own values; opennessto cultural differences; possession of a person-orientatedlearning style; and use of the cultural resources available(DeSantis 1991). To achieve such outcomes, the curric-ulum should address course content in themes which lendthemselves to transcultural issues (Papadopoulos et al. 1994).Thus the entire curriculum is involved and so too are allthe teaching staff (McGee 1994).

Achieving culturally sensitive care is a process ratherthan an end product (Camphina-Boyte 1994) and requiresboth emotional and cognitive preparation (Spitzer et al.1996). False awareness of stereotypes needs to be resolvedbefore knowledge and skills can be effectively learned(Pederson 1988). To do this requires a supportive environ-ment in which both students and teachers can franklydiscuss the issues (McGee 1992) and explore ethnocentricways of knowing about science and nursing (Abdullah1995). Although classroom discussion of the issues is import-ant to prime the student, it needs to be consolidatedthrough experiential learning (DeSantis 1991; Abdullah1995; Meleis 1996).

EXCHANGE AS A PARTICULAR MODEL TO DEVELOP CULTURALLY SENSITIVE CARE

Some argue that learning about other cultures can beachieved by exposure to ethnic groups within our own soci-ety (Tilki et al. 1994; Gerrish et al. 1996). Others suggestthat this can most effectively be achieved by travellingabroad and immersion into another culture for no lessthan 3 months (Garvey 1997). Total immersion in the cul-ture allows the individual time to come to terms with thatculture (Williamson 1994) and gives students the oppor-tunity to work with staff as well as clients from alternativecultural backgrounds. Most importantly, this triggers twoimportant connections: the first being that the nursesshare a common profession; the second, that the studentsthrust into an alternative culture, experience minority statusand thus disadvantage (struggling with a second languageand working in an environment which is relatively strange).Through this experience they make connections withindividuals which transcend stereotypical clustering, i.e.,at the point of gender, power, and sexuality (Abu Laghod

1991; Hart 1998). In the context of working as a nursingstudent, concepts such as hope, suffering, knowing thepatient as person and healing transcend any single culturalorientation and enable the nurse to make connectionswith patients through the act of caring (Leininger 1991).Making connections with people opens the possibility tolearn, to empower, to listen, to value, which then opensup new forms of understanding (Rosaldo 1989). Thus theymake connections with the situation of patients whichfundamentally influences their construct of the nurse–patient relationship. Comparison and critical reflectionare seen as key ingredients to achieve these outcomes(DeSantis 1991; Abdullah 1995; Meleis 1996).

To become culturally sensitive students need to tem-porarily suspend their own cultural traditions in order toperceive the situation of others (DeSantis 1994). To do thisnurses have to be conscious of their own values and beliefsso they can explicitly compare those with the views of thepatient (DeSantis 1994; Tripp-Reimer et al. 1984). This isa complex process as both are operating under personalcultural rules and expectations, some of which may beshared and others not (Tripp-Reimer et al. 1984). For thenurse this is made up of three elements: the nurse’s per-sonal beliefs and values; the nurse’s professional beliefsand values; and the context in which the interaction takesplace (the institution, the politics of the organisation andhealth care system). Sometimes these values are so closethey do not lend themselves to critical scrutiny. Clinicalexchange exposes the student to an alternative culture andlanguage. Such an experience creates dysjuncture for thestudent who has to reconsider what has been taken forgranted in their own system, alongside analysis of the sys-tem that is novel. Therefore, not only do the studentsbecome sensitive to the perspective of others, but theyalso become increasingly self-aware of the multiple factorsinfluencing their everyday interaction with the patient.This is important in that the nurse can take account ofsuffering that may stem from cultural distress, and therebyrelieve cultural pain (Leininger 1995).

So, if exchange is considered to be such a powerfulexperience to enable culturally sensitive care, why is thisnot more common within UK nursing curriculum? First,the UKCC has only recognised student experiences abroadas clinically recordable hours towards registration since 1995(UKCC 1995). Second, funding has been a particularproblem.

In 1987 the European Community Action Scheme for theMobility of University Students (ERASMUS) was launchedby the Council of the European Communities. By providingfinancial assistance they hoped to encourage student


Culturally sensitive care


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mobility, and create opportunities for exchange. The ultimateaim was to foster the breakdown of cultural and linguisticbarriers and increase the opportunity for the cross fertilisa-tion of ideas between the universities from developed andless developed states in Europe (Williamson 1994). How-ever, accessing this financial support is time-consumingand complex. Funds awarded to institutions fall shortof the actual sum required. So, despite the possibility ofthese monies being made available, they have not enablednursing student exchange on any large scale (LeonardoSeminar 1998). A UK survey (ENB 1996) identified that 36institutions across England (

n

= 78) had a strategic plan forinternational links. A total of 58% of these links were withcountries within the European Union and 45% of thesecourses enabled students to participate in care. Although anincreasing number of courses make provision for exchange,only 3% stated they had any provision to support exchangewithin their contracts. Therefore, exchange remains pro-hibitive to the majority of student nurses for three mainreasons: time, finances and language proficiency.

The paper now turns to explore the way in which onepreregistration nursing degree programme, which includesinternational exchange, tackled these issues analysing thefactors that have influenced the evolution of the pro-gramme and the impact of international exchange on thestudents learning about nursing. First, the way data werecollected is outlined.

METHODOLOGY

Illuminative evaluation is one of a genre of education evalu-ations within the naturalistic evaluation tradition (Scriven1991). This process places great emphasis upon the pro-cess of learning as well as the outcomes which are influ-enced by the context, or learning milieu (Parlett andHamilton 1972). The approach draws upon multiple per-spectives and uses multi methods to gather data. Equalvalue is accorded to idiosyncratic as well as commonthemes emergent through the data. Data collection and

analysis run concurrently, with emergent themes drivingthe focus of subsequent enquiry. Data are analysed by theconstant comparative method (Glaser and Strauss 1967).Participants are involved in the verification and validationof emergent themes. Great emphasis is placed upon redu-cing the power relations that exist between the researcherand researched and encouraging open dialogue and debate(MacDonald and Walker 1977). For a detailed account ofthe approach please see

Beyond the numbers game

(Hamiltonet al. 1977).

This paper is based upon a component of the overallevaluation which is being conducted in all three base insti-tutions. All the elements of the course are influential in thedevelopment of the students, however, this paper focusesupon the process of learning triggered by the three-monthclinical exchange in the third year of the course. Specificelements of the course that directly affected this experi-ence are outlined. These data were gathered in England,in English, from Dutch and Spanish students on exchange(

n

= 48) and from the Brighton-based students on theirreturn from exchange in Spain and Holland (

n

= 31). Afew Spanish students with weaker English expressed reluc-tance at having to complete the questionnaires in Englishbut were encouraged to do so by their peers. It was notedthat the Dutch students wrote about their experiences inmore formal and restrained tones than when they talkedabout them at interview. Both Dutch and Spanish studentsconsulted one another over the translation of certain terms(notably about their feelings). These discussions took placein their first language and with the help of translation dic-tionaries were recorded in English. All the quotes includedin this paper have come from the questionnaires com-pleted by the students at the end of the allocation. Thefirst cohorts of students received a draft of the ‘case’,written in English, for verification. However, feedback froma significant sample of the Dutch and Spanish studentsproved to be disappointing. Subsequent groups gave feed-back in response to a presentation delivered at the annualENI conference. This approach ensured a greater number

Table 1 The participant sample by cohort

Dutch (DStd) Spanish(SStd) UK/NL Std UK/Spain Std Total

1996 9 0 8 0 171997 9 7 6 3 251998 3 7 5 1 161999 6 7 3 5 21

27 21 22 9 79



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of students were engaged in the process and it also offeredstudents the opportunity to contradict analytical errors andput forward alternative views. Table 1 lists the participantsample by cohort.

THE EUROPEAN NURSING INITIATIVE (ENI)

The aim of the initiative was to:• create a deeper and enriched vision of nursing based

upon the understanding of colleagues in three Europeancountries;

• generate a common core curriculum which had mutualrecognition of awards and course credits;

• create the possibility to cross fertilise the better aspects ofpractice from one setting to another.

Curriculum development began in 1990. The teamwere made up of lecturers of nursing, although some ofthe Dutch participants were not nurses, e.g., theologians,psychologists, educationalists. The Dutch–English coursestarted in 1993, and the Spanish programme started in1994 due to a change in Spanish partner institution.

The curriculum was founded on transcultural prin-ciples in theory and practice. The programme has fourkey features: common learning across strands of the cur-riculum; shared learning with other international ENIstudents; common assessments (language, comparative studyand dissertation); two summer schools; the development(or enhancement) of a second language; and a three-month clinical exchange programme so students have theopportunity to practice abroad and live the transculturalexperience.

Validation issues

The Dutch have an established framework for graduateentry to the profession, although the majority still registeras diplomats (Jansen 1997). Their programmes lead to ageneric nursing qualification.

Strategically, the initiative offered Spanish nursingstudents an undergraduate programme, taught in theEscuela de Enfermeria, Vitoria but validated by the Universityof Brighton. This was seen as a way of supporting under-graduate nursing preparation until Spain developed its ownnursing degree programmes. Spanish nurses were able totake degrees in other subject areas, but the profession wasstill in dialogue with the authorities over the benefits ofa degree in nursing as a point of entry to the profession.This meant that the Spanish students had to completetheir diploma training to ensure local recognition of theirprofessional qualification.

In the UK the four-year course leads to an honoursdegree in European nursing, a certificate in languages forprofessional purposes and registration with the UnitedKingdom Central Council (UKCC).

A pragmatic decision was taken early in the developmentof the course that the Dutch ENI programme would bevalidated by the Hogeschool, but the University of Brightonand English National Board would validate the dedicatedENI content in the Spanish and English-based courses.

The risks of the innovation

This was the first course of its kind in Europe and thecurriculum designers sought to be as innovative as pos-sible, but recognised they were taking certain risks. Theyincluded:• developing a programme that relied upon student and

teacher mobility and the development of linguistic skillsin a second language without a guarantee of financialassistance from ERASMUS funds;

• introducing graduate nursing to Spain; raising issuesabout supervision and support for the undergraduatestudent both in the school and the practice environ-ment; and issues of employability on graduation;

• achieving linguistic competence for the clinical exchangeplacement without compromising the learning aboutnursing;

• finding sufficient amounts of translated literature toenable teaching which was based upon research fromother European countries;

• recruiting a sufficient number of potential studentswho had linguistic competence and wanted a career innursing and had combined languages and science sub-jects to fulfil the entry criteria;

• sustaining the vision and ongoing developments acrossthe three countries to ensure parity.

The impact of modularisation and semesterisation

Maintaining commonality across the courses was furtherchallenged when each country, at different times, startedto modularise and then semesterise their programmes.Initial curriculum development had taken place with allthree countries represented. Modularisation and semester-isation had to be done at each base. Retaining theuniqueness of the internationally agreed elements of theprogramme during modularisation was a continuing strugglefor the three course leaders. First, none of the course leadersat this stage had been involved in the initial curriculum




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design. Second, it was problematic to disentangle specificelements from the whole without creating fragmentationand losing the transcultural essence of the course. Andfinally, it became increasingly difficult to co-ordinate sharedlearning among students within the base institution andorganise chunks of time for shared learning or exchangewith the international students.

Therefore, the original ambition to create a pro-gramme that was common to all three countries was notrealised because country-specific frameworks for bothcourses and requirements for registration were too diverse.As the course has evolved, teachers are decreasingly con-cerned about creating a common course run in threedifferent institutions. Instead the course is now onewhich has shared and common elements, in which thestudents come together and through which they canexchange ideas. What unifies the programme is thecommon conceptual framework elicited from initial valuesclarification by the original curriculum developers, whichis revisited at each international meeting and in the annualconference.

The common learning component

The programme specifically incorporated research andtheory about nursing and European healthcare systems,notably, English, Spanish and Dutch. This content was toenable students to gain comparative insight into macrocontextual and sociopolitical factors influencing healthcare provision. Originally, transcultural comparisons wereto inform all elements of the course, but this was affectedby modularisation. As a result, these elements of the coursebecame ‘cluster modules’, specific to students on the ENIpathway. For the English students, this included a 300-hourlanguage programme delivered by the language depart-ment at Brighton University over the first 3 years of theprogramme. The Spanish students had to fund their ownlanguage course and complete this in their own time. TheDutch formally learn English in school and could attendan informal language programme in their own time if theyfelt it was necessary. All students had to demonstrate suffi-cient linguistic competence to communicate effectively inthe practice setting before they went on the exchange.When they arrived at their exchange university, they had abrief intensive language programme which addressed localand professional terminology.

The purpose of the language course was to enablestudents to live and work in the host country so they couldlearn about nursing. It was considered that the learningthat occurred in another culture when one was competent

in that country’s language would be significantly greaterthan learning without linguistic competence (Williamson1994). It was considered unethical from all perspectivesfor a nurse to be in the practice setting whilst unable tocommunicate with the patients and other members of thehealth care team. This meant recruiting students who wereprepared to learn either English, Dutch or Spanish as asecond language. Although problematic in England torecruit to the Dutch strand, in Spain this proved to beimpossible. For the Dutch, fewer students enlisted for theSpanish strand than the English. Therefore, the hope thatan equal number of students would sit in each cohort wasnot realised. This meant that the relative cost per studentfor the course increased significantly, especially for lan-guage preparation. It also created an imbalance in thenumber of students from each country base at summerschool and the absence of Spanish students on the Nether-lands exchange. This demonstrates a key problem forEuropean exchange programmes that include linguisticcompetence, because of the wide range of languages anddialects across mainland Europe.

Summer schools

A two-week summer school was run at the end of thefirst and second year. They were conducted in the hostcountry’s language. This was the first opportunity for thestudents to have shared learning with their internationalpeers. The cohort was divided into two, so that half stayedbehind to host, whilst their colleagues travelled to theirlink country. This process was reversed in the secondsummer school.

The aim of the summer schools was to enable studentsto share their similarities whilst valuing and respectingtheir differences. Preparation of material for summer schoolstook considerable international effort and thought. Thestudents studied core units of learning which included:‘views’ of nursing; professional judgement; healthcaresystems; codes of conduct; and practice. Visits to clinicalsettings stimulated a great deal of debate as nursing andthe architectural space of health care facilities were com-pared. Students were exposed to alternative views whichmade them start to challenge their own values and beliefs.This, for some, was quite an uncomfortable experience,although they valued the opportunity to build relation-ships with their international peers, share ideas, and feel apart of the ‘ENI community’.

The programme of the summer school demanded agreat deal of the teachers and students. The teachersfound they had to adapt the pace of learning to fit the



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needs of the Dutch, Spanish and English students (eachgroup with differing expectations about didactic and dia-lectic teaching methods). When facilitating the group, theteachers were sometimes surprised by the student responseor lack of one. Many of the students could understandwhat was said to them, but didn’t expect, or lacked suf-ficient confidence, to speak in front of the group. Thissignificantly affected the amount of dialogue betweenthe students, who had to be encouraged to break intodiscussion in their first language, and then report backthe outcome of their debates (but this experience stimu-lated intensive self-directed study in preparation for theexchange). The teachers had to reflexively manage thesesituations, and students had to learn to be patient as thissignificantly slowed the pace of the sessions. In addition,host language speakers, teachers and students, needed tolower their language speeds at all times and use idiomswith care. However, evaluative feedback from the studentshas helped to make the programme responsive to thestudents’ needs, pace the content more appropriately,and ensure increasing parity of input across the threeinstitutions.

Preparation for exchange

At Brighton theoretical input, 10 weeks prior to theexchange, was largely framed to prepare the students forthe placement. This included a liberal arts and culturalprogramme enhancing their understanding and use of atranscultural framework of nursing. But the studentsneeded time to consider the implications of the exchangeand verbalise their concerns. Key issues for them duringthis time were how going abroad for 3 months wouldimpact upon personal relationships and their finances.They were also extremely anxious about their clinical andlinguistic competence to practise safely during the alloca-tion, albeit under supervision. The teachers found thatthey had to handle this worry work before they could movethe students to consider other theoretical elements of thecourse.

The Dutch and Spanish students had end-of-yearexams immediately prior to the exchange. This meantthat dedicated time for them to consider the implicationsof the exchange were conflated into a much shorter timeframe. Without sufficient time to prepare for exchange,the students arrived in this country and encountered anumber of difficulties when they first started the alloca-tion (not least of which was an unexpected degree ofculture shock). Although traumatic at the time, the valu-able learning that took place from this experience has

enabled all concerned to help frame realistic expectationsfor the students who travel abroad. Using past exchangestudents to help the students going on exchange to con-sider the emotional impact of the experience has proved tobe invaluable.

THE EXCHANGE

The aim of the exchange was to enable students to live theexperience of transcultural nursing and to capture alter-native approaches to enrich their own practice. It was hopedthis experience would enable the students to become morecritical, tolerate ambiguity, foster a sensitivity to the influ-ence of culture within health care and relate to patientswith a greater depth of empathy and understanding.

Although the students were nomadic, being allocatedto different clinical environments throughout their train-ing, this was the first time they had lived and workedabroad for 3 months. They experienced social dislocation,which was profound and confusing.

[In Spain] I understand all the things, you’ve got control,but here especially in the beginning it doesn’t happen.Things you do automatically, without thinking, you seehere doing in a different way. It makes you think about it.It makes you humble. (S.Std. [1] 16.6.1999)

Most importantly, the impact of social dislocation enabledthem to empathically connect with a patient’s experienceof hospitalisation:

Now I know what the patients feel when they are in ahospital out of their homes without their relatives in acompletely new environment. Now I see the importanceto be

near

the patient and talk to them. (S.Std [4] 18.6.1997)

‘Letting go’

The students found it difficult to make sense of theirinitial experience, and drew the conclusion that this wasbecause they were thinking and expecting situations to beas they were at home. To cope with this, the students foundthey had to let go of their Dutch, Spanish or English think-ing and consider things in the way of their hosts. The pro-cess of ‘letting go’ of all their cultural assumptions andassuming those of the host environment was very stressfulbut had a potent impact upon learning. For some, thisexperience was too daunting. Ironically, the very factorsthat were intended to open debate and comparison,caused the less mature students to become defensiveand dwell upon their ethnocentric values. This was moreproblematic with the first cohort, but enabled all concerned




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to reconsider the emotional and cognitive preparationrequired to enable transformative learning from theexchange. However, many of those students and sub-sequent cohorts felt that confronting the intensity andchallenge of the experience enabled them to mature andgain personal insight.

Triggers for critical reflection and transformative learning

The students were surprised by their limitations in compre-hending the language, but more importantly,

understand-ing

their colleagues and patients. Accent, affect, andculture meant that although words were recognised, their

meaning

remained unclear. This caused the student to stopand consider the meaning of every communication, whichin turn caused them to reflect upon everything and everyaction

—

nothing

could be taken for granted and everythingneeded to be verified. Previous strategies for coping withsuch novelty, acquired from training to this point, wererendered redundant by an inability to find the language toconvey meaning and make sense of the encounter.

It was frustrating at times. A simple sentence took minutesto formulate and 10 to explain! …. It is difficult to describehow stupid, inferior and incompetent I felt … But the senseof achievement when something went well and the depthof analysis that was necessary to go through it and dealwith the hard stuff made it really rich. (B.Std. [8] 4.8.1997)

The use of a second language had an unexpected impacton the students’ learning about nursing, because every-thing had to be carefully considered, each point had to bestructured and presented with a logic that could enhance acommon understanding. This process of itself caused thestudents to carefully consider what was happening aroundthem, ask questions and seek clarification. Nothing couldbe assumed or taken for granted, but under the guise of‘foreign student’ they were able to ask naive questions, taketime to consider and compare, and be analytical. Theexchange students were continually forced into a situationof making sense of complex and simple situations whichmay have been taken for granted in their own nursing cul-ture, using their first language. So the exchange caused thestudents to start to challenge some of the fundamentals oftheir practice and their value system of nursing.

I have learned not to judge too soon. New things aren’tnecessarily worse or better given time you see that it alldepends on the situation you’re in. I think I’ve got abroader view of nursing now. (D.Std [5] 16.6.1999)

In terms of communicating with patients, the studentslearnt how to convey meaning beyond the spoken word;

how to make connections with patients as people andexpress empathy and care:

Sometimes I could not understand the patients…. Icould see in their faces they needed help and the onlything I could do was hold their hand. But now I know thatsometimes you don’t need to do anything and it is betterto be near to the patient without saying anything. I don’tthink I would have learned this in my own countrybecause … there wouldn’t have been the silence. (S.Std[3] 18.6.1997)

Drawing upon their experience of feeling isolated andmarginal, the students could identify the ways in whichthey were enabled to integrate and use these strategieswith a patient/client. This enabled the student to makeconnections with people, in a way that may seem like com-mon sense, but is perhaps uncommonly common sense(Macleod 1994). The experience acted as a powerfulreflective tool which helped the students to make sense oftheir personal theory of nursing.

Living in the UK you learn customs and cultural factorsthat have influence on people. This has helped me to real-ise that people are different according to the environ-ment where they are living, so we have to see the personin a different way. That is the holism in nursing. (S.Std.[5] 17.6.1998)


Crucial to the outcomes was setting realistic expectations;an optimistic outlook and a determination to see thepotential for learning out of any situation. They becamemore aware of their limitations but used this to considerhow this might affect future interactions with patients.

I have learnt more about the things I don’t know aboutculture and people and therefore the room that needs tobe left for the translation of terms, and feelings. I willnever forget the fear that I experienced and … I willalways try to remember the feelings and attempt to empa-thise with people who are [adapting] to change … or dis-ability. (B.Std [15] 4.8.97)

The lived experience of transcultural nursing had aprofound and influential impact on the students. It ignitedtheir enthusiasm, enabled them to gain insights into theirpractice beyond that of an allocation in their own culture.A summary of all the students’ accounts of the learningthat had taken place as a result of the exchange are listedin Table 2. The way they felt this would influence theirpractice back in their home base is listed in Table 3.

These self-reported outcomes demonstrate that thestudents believed they had personally and professionallymatured as a result of the exchange. The transitional pro-cess that effected this type of learning is modelled in



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Table 2 Summary of student’s accounts of the learning that had taken place from exchange (n = 79)

Students’ accounts

ProfessionalChanging their view of how they wish to nurse and be as a nurseGreater insight into their own value system of nursing, which enhanced the value they placed in the nursing professionGreater understanding about multidisciplinary team work and factors influencing power relationships within the teamGreater confidence to use research and rational to support actionsReflective insight into the way they could relate to patients and colleaguesEnhanced understanding about non-verbal communication and the meaning ascribed to the spoken word

Learning about learningIncreased open-mindedness, flexibilityIncreased self-reliance and confidence to self-direct learningMore analytical of things that happen in practice and prepared to consider how environmental factors influence eventsAnalytical of simple and complex situations, the importance of objective, reflective and sensitive analysisQuestion familiar as well as ‘strange’ experiencesEstablishing realistic expectations and learning objectives

PersonalIncreased linguistic competenceEnhanced recognition of their own limitations and strengthsPersonal insight into their capacity to cope with difficult and sometimes stressful situations which brought about increased

confidence and self-reliance

Table 3 Summary of students’ accounts of the influence of cultural exchange on future practice (n = 79)

Students’ accounts

Working with patientsIncreased empathy with the vulnerability of patientsIncreased pool of knowledge and skillsRecognition, acknowledgement and valuing of differencesEnhanced ability to find the right questions to ascertain the patient’s perspectiveDrive to help patients achieve what they want from the healthcare systemMore confident to involve relatives in the care of patientsWill not assume understanding, always verifies that mutual understanding has been achieved

Working with colleaguesIncreased confidence to challenge and explore the meaning behind practiceRecognition that there is no one right or wrong way of doing things, only suitable responses to the situationPerseverance — more self-assured and increased personal confidence to examine issues with colleaguesMore accepting of constructive criticismEnhanced skills to consider ways in which they can facilitate reflection in other students and colleaguesGreater insight into the real meaning behind actions and words

Working in the healthcare systemSeeing the positive and not just the negative from situationsBeing more alert to subtle and small differences that influence practiceFeeling they can cope with more demands in their base country, having managed the clinical exchange

Working in the professionBeing more reflexive and reflective about practiceSeeing a future for themselves as a nursePride in their chosen professionUse research more to influence clinical decisions and actions




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Figure 1. Central to this process was the familiar beingrendered strange by a new culture and communicating ina new language which created dysjuncture and triggeredtransformative learning. But in what way did this experi-ence enable the students to be more culturally sensitivecarers? The most important aspect was their insight intomaking connections with individuals and using themselves ina therapeutic way to demonstrate emotional presence, genuineconcern and empathy. In this way they could make connec-tions with patients from any subcultural context, be thatrelated to ethnicity, sexuality, disease, disability or addiction.

A recent follow-up phone interview with two cohorts ofUK graduates (

n

= 18) has shown that these skills haveserved the alumnae well in their early career. The graduates(

n

= 11) self-reported that their work colleagues had com-mented on their ability to handle ‘difficult patients’; relateto people with stigmatising problems and communicatewith patients whose first language was not English and notnecessarily Spanish or Dutch. Although the sample size issmall and these data only come from UK-based students,this is an encouraging indication of positive long-term out-comes as a result of the exchange. It also illuminates howthis learning promotes culturally sensitive care in the broadestsense of the term ‘culture’. These outcomes will be monitoredover the next 10 years to identify the impact of the pro-gramme on the nurses’ career pathways and destinations.

Learning from comparison

The comparisons the students made between the twosystems were tempered with caution, as they realised thelimitations of the experience which could not be consideredgeneralisable. Certain factors were identified as person-dependent, e.g. the quality and level of supervision whilst

in clinical practice, although preceptorship was a newphenomenon to the Spanish students whose previousexperience was supervision by the ward sister or tutor. TheDutch students felt that their weekly supervisory sessions inUtrecht were more confrontational, emotional, longer anddeeper than any facilitated reflection they experienced onexchange. This view was confirmed by the English studentswho found the forthrightness and depth of explorationfrom their Dutch colleagues initially shocking but alsorefreshing and valuable.

The Spanish students had less of a pool of ‘homegrown’ nursing research to influence their practice thaneither the Dutch or English students. The Dutch studentsnoted that their English preceptors drew upon research toreinforce their rationale, whilst their Dutch preceptorsgave a rationale but would not necessarily quote a specificpiece of evidence to support their actions. This caused allthe students to debate and value the strength that camefrom practice grounded in research evidence and a will toapply this more effectively to their future practice.

Visiting students observed the number of English nurseswho were studying for a higher academic qualification andconsidered this to be proportionally greater than at home.Other aspects of difference were: the Dutch studentscautiously noted that the wards seemed to be less tidy thanwards they had encountered in their local hospitals, andthe Spanish students felt that the wards were more chaoticthan they were used to. They also noted that ward staffspent more time talking to the patients and they hoped tobe able to apply this to their practice on return to Vitoria.

Managing the students’ re-entry to their own culture

Experience of running four cohorts of student exchangehas illuminated the need to pay more attention to theissues of preparing the students for re-entry of their ownculture. This needed to occur at the end of the allocation,as well as facilitation by teachers once the studentsreturned to their own institution. Students found theirexperiences on exchange so diverse and powerful that theSpanish and Dutch contingents hardly recognised oneanother on return. Furthermore, they found that theywanted to relay their experiences in their second lan-guage, some aspects of which defied translation backinto their first language. The insights from their clinicalexperience were exaggerated and culturally dramatic. Thisneeded to be harnessed and translated back into meaning-ful learning for future nursing practice. This took time andcareful facilitation by the teaching staff, who found this

Figure 1 The process of developing cultural sensitivity from exchange



70


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particularly challenging as many did not have experienceof nursing abroad. However, this situation thrust the teachersinto the reality of being taught by the students.

The course is a source of great pride for the institu-tions involved. It is the first of its kind in Europe. It seeks topromote a ‘European dimension’ of nursing through thecommon and shared learning components. The notion ofwhat constitutes the ‘European’ element, rather than com-parison of three countries’ ways of working that happen tobe based in Europe, is an area which is frequently con-tested and debated among the teaching staff. Such debatescan potentially divert the attention away from develop-ments which can enhance the positive learning achievedfrom sharing among international students and from clin-ical exchange.

IMPLICATIONS FOR CURRICULUM DESIGN WITH EUROPEAN PARTNERS

Running a programme across the continent of Europe ismade problematic because of the diverse mix of countries,languages and dialects. Each country has its own frame-works for registration and education provision. Althoughthe European Communities Council has attempted toidentify common theoretical outcomes to ensure greaterparity of initial preparation, and thereby increase qualifiednurse mobility, the country-specific interpretation of theserules still leaves greater differences than commonality. Thishas significant implications for curriculum developersattempting to design pre-registration international courses,particularly those aspiring to introduce nursing degrees tocountries where this is not a traditional level of entry to theprofession.

The diverse mix of cultures, languages and views ofnursing that is evident within the continent of Europe,means that an ambition to generate a universally acceptableconceptual nursing framework is a chimera. Therefore, itis probably more important to acknowledge difference andtap that comparison to inform learning that enables cultur-ally sensitive care, to draw upon the better aspects of prac-tice from different countries and use that as a basis forpractice development (Lynam 1992). However, extremecaution needs to be exercised to ensure that dominantcultural orientations or notions of science do not suppresslocally effective ways of nursing that would ultimately resultin culturally incompetent caring. The authors conclude thata way to ensure this does not happen is through learningwhich makes connections with individuals in a manner thatacknowledges and celebrates cultural difference, but findsa mutually acceptable way of working. The transformative

learning experience that the students encountered whilston exchange is one model to achieve this outcome.

ACKNOWLEDGEMENTS

The authors thank all the students who took part in thisstudy.

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Documents

Clinical exchange: one model to achieve culturally sensitive care