Contemporary Nurse, 2017
Vol. 53, No. 3, 348–354, https://doi.org/10.1080/10376178.2017.1353397
A discussion of nursing students’ experiences of culture shock during an
international clinical placement and the clinical facilitators’ role
Cathy Maginnisa* and Judith Andersonb
a
School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Dubbo Campus, Locked
Bag 49, Dubbo, NSW 2830, Australia; bSchool of Nursing, Midwifery and Indigenous Health, Charles Sturt
University, Bathurst Campus, Panorama Ave, Bathurst, NSW 2795, Australia
(Received 22 November 2016; accepted 19 June 2017)
Aim: This paper examines the meaning and experience of culture shock for nursing students
undertaking an international clinical placement (ICP) and the role of the clinical facilitator.
Results: Oberg’s four stages of adapting to culture shock were aligned to anecdotal
conversations with nursing students on an ICP. All four stages were identified in anecdotal
conversations with the students. Support by the accompanying clinical facilitator is pivotalin
overcoming culture shock and maximising the learning experience.
Conclusion: It is essential that students are prepared for the change in cultural norms and are
supported by the academic staff to work through the processes required to adapt to culture
shock. Planning and preparation prior to departure is essential to assist with managing
culture shock with an emphasis on the inclusion of cultural norms and beliefs. The role of
the facilitator is crucial to guide and support the students through the culture shock process.
Keywords: culture shock; international; clinical placement; facilitators; nursing; nursing
students; educators; University
Introduction
International clinical placements (ICP) provide opportunities to engage nursing students in cultural awareness and increase their responsiveness through cultural immersion. ICP do not
occur without challenges and one challenge many students experience when undertaking an
ICP is that of culture shock. The purpose of this article is to discuss culture shock experienced
by nursing students undertaking an ICP and the role of the clinical facilitator. Cultural competence
is taught to students throughout the Bachelor of Nursing course. Students are provided with an
overview of the international experience related to the country of origin population and the
major cultural and lifestyle differences. Articles are provided for students to read related to cultural shock and international placements. Online meetings are provided with the university and
briefings with the partnering organisation. Student expectations and their roles are discussed in
these meetings and at the destination. Support by the accompanying nursing academic staff (facilitator) is essential to support students to adjust and adapt to culture shock and to maximise their
learning opportunities. There is a dearth of literature regarding ICP and culture shock in nursing
students or the role of the facilitator in this process. The role of the facilitator is integral in assisting students to overcome culture shock, to embrace the differences and enable an effective
*Corresponding author. Email: cmaginnis@csu.edu.au
© 2017 Informa UK Limited, trading as Taylor & Francis Group
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learning experience. This paper includes anecdotal conversations and observations from nursing
students on ICP and has been aligned to Oberg’s (1960) stages of culture shock adaptation.
International clinical placement (ICP)
ICPs add value to pre-registration nursing curricula, providing insights into international health
concerns and experience of culturally competent care (Egenes, 2012; Jenkins, Balneaves, &
Lust, 2011; Maginnis, Anderson, Brown, & Stanley, 2015). Agreements with partnering organisations are entered into based on availability and applicability to specific subjects in the curriculum
that is then approved by the governing authority. Students are immersed in a new culture and practice nursing care whilst engaging in a transcultural exchange which facilitates appreciation and
consideration for another culture and health care system (Browne, Wall, & Jordan, 2015;
Tuckett & Crompton, 2013). Some degree of culture shock is seen as inevitable as a result of
the loss of familiar cues of social interaction (Oberg, 1960).
An expected outcome of ICP is that students demonstrate increased cultural awareness and
employ the skills they have learnt (Norton & Marks-Maran, 2014; Tuckett & Crompton,
2013). Research has identified a greater cognitive growth in participants undertaking ICP and
easier transition from student nurse to registered nurse (Jenkins et al., 2011). A cultural awareness,
responsiveness and sensitivity develops that can be applied to other situations and enhance their
nursing career (Charles et al., 2014; Jenkins et al., 2011; Oberg, 1960).
Clinical facilitator
The term clinical facilitator is used here to refer to a registered nurse employed by a University for
the duration of the clinical placement to supervise the nursing student (Sanderson & Lea, 2012,
p. 334). For the ICP the facilitator is a member of the academic staff already working as a permanent staff member who is a registered nurse. The clinical facilitator provides supervision,
support and assesses students during their clinical placement (Andrews & Ford, 2013). Facilitators are also required to liaise with health care staff at the destination to ensure students receive
opportunities to meet their learning objectives. The facilitator role is complex, especially on an
ICP where interpreters are required to converse with the local health staff and villagers,
making it a very challenging role.
Egenes (2012) suggests that the role of the faculty member from the student’s country of
origin is crucial in the alleviation of culture shock. This person should provide support, serve
as a filter to sort the student’s experiences and provide insight into the new culture. This is
done by being a sounding board through continuous dialogue with the students, helping
them to process new knowledge and insights, validating feelings and encouraging the appropriate
expression of those feelings. This article describes the experiences of two facilitators who
supervised two groups of students, totalling 21, in two different countries undertaking a two
week ICP.
Culture shock
The term culture shock was first used by Oberg (1960) to describe the feelings experienced by
people immersed in an unfamiliar culture where individuals were removed from the everyday
cues they relied upon to engage in daily life. Harvey & Park (2012, p. 355) describe it in a
more negative manner as a “disorder that occurs in response to the transition from one cultural
setting to another” due to the loss of accustomed behavioural patterns and cues. It occurs when
an individual moves geographically, such as for an ICP. Kokko (2011, p. 679) explained
culture shock as an “encounter with difference that caused confusion among the exchange
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nursing students because they had to face their own prejudices, stereotypes and systems of
values”. This, reinforces the importance of understanding the different culture and the necessity
in preparing students for ICP.
Culture shock can inhibit the students’ ability to learn and participate as the stress of a new
culture can be overwhelming (Foronda & Belknap, 2012; Kokko, 2011). Culture shock has no
defined time limits with some studies finding it resolved quickly or was experienced for a
longer time period; there is no defined time line for each phase of the process of adjusting to
culture shock (Foronda & Belknap, 2012; Jenkins et al., 2011; Kokko, 2011). Initial confusion
and frustration develops into cultural awareness that can be viewed as a precondition of the learning process (Kokko, 2011). Support has been identified by Charles et al. (2014) as playing a major
part in overcoming the culture shock experienced by students.
Indications of culture shock include confusion, anxiety, silence, immobility, agitation and
anger as well as feelings of grief, separation anxiety and an inability to face differences related
to culture (Foronda & Belknap, 2012; Harvey & Park, 2012; Oberg, 1960). Oberg (1960) identified four stages of this process: (1). Euphoria at the beginning of the experience, (2). Discontent
and irritability, (3). Progress in adjustment and (4). Adaptation. Not all people experience each
stage in this process.
Euphoria at the beginning of the experience
Euphoria is related to an initial honeymoon phase of excitement and wonder at the new experience, a fascination with the new, where the person feels important and special due to their difference in appearance, language, customs and culture (Oberg, 1960). This is a time of anticipation
and excitement accompanied by a degree of anxiety (Egenes, 2012; Oberg, 1960). Students
described this excitement and apprehension in relation to how the villagers would react to
them teaching them how to wash their hands and clean their teeth. The unknown factors
created anxiety where the unknown encompassed age, language barriers, cultural naivety, availability of water and facilities to demonstrate and deliver health education and health care. This
apprehension was balanced by a sense of excitement and privilege experienced by students.
A sense of excitement and apprehension was very evident in the early stages of the ICP. All
students were observed by the facilitators to go through this phase during the ICP. Students indicated that they were keen to learn and benefit from the experience. This was a very positive phase
and required little intervention from the facilitators bar daily debriefing and encouraging reflection
at the end of each day or after a specific experience.
Discontent and irritability
As described by Oberg (1960) this second phase is characterised by frustration and even aggression towards the unfamiliar and challenging conditions experienced, due to differing cultural
practices and health care system. This is all part of the process of adjustment and the irritability
and discontent is often aimed at the host country and is characterised by a need to band together
and vocalise the discontent with the differences, rather than embracing them (Egenes, 2012;
Oberg, 1960). The students on these ICPs, vocalised discontent and irritability at their inability
to make change when encountering situations, they felt required improvement such as teaching
hand hygiene when the villagers had no running water nor soap. They also questioned the effectiveness of teaching one lesson without follow up and this was exacerbated by frustration with
language barriers. Often the villagers spoke different dialects of the language and this could
result in lengthy interpretation sessions to elicit a minimal response. Students discussed feeling
overwhelmed by the complexities of the situation that the local villagers faced with lifestyle
restrictions such as access to nutritional food. The students voiced an overwhelming need to
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contribute and assist and were thwarted by the limited time frame of the ICP and the different
models of health care, provision of care and other cultural aspects that impinged on the health
care of these villagers. Another concern was how outsiders were perceived and whether they
were perceived as another pretentious westerner or being paternalistic in their interactions.
The role of the facilitator in this stage was debriefing and reiterating the concept of primary
health care and that educating the villagers empowers change (Bender & Walker, 2013). This
often involved debriefing during the remote clinics on a one on one basis as well as in a group
debriefing at the end of the day.
Progress in adjustment
Oberg (1960) describe a progress in adjustment which occurs as irritability decreases and the individual becomes less critical and begins to open themselves to the new experience. There is a
resulting increase in confidence in the ability to communicate, interact and contribute. As the
voicing of concerns and frustration decreases there is an emerging appreciation of the new
culture and experiences (Egenes, 2012; Oberg, 1960). The students on these ICP indicated a
respect and acknowledgement of the services in the local area and working together with the
local health care staff engendered a sense of working as a team.
Students developed respect for the local community members and acknowledged the services
provided in the remote areas by the health care staff, whilst also developing a greater understanding and respect for each other. Working together in unfamiliar surroundings gave them an opportunity to progress in their understanding of team work, taking on leadership roles and
demonstrated a progress in the student’s adjustment to their environment. This adjustment
focussed on respect. Respect for the health care organisations which were working in challenging
circumstances and respect for each other and the support they were providing to each other. The
facilitator’s role was integral in supporting and encouraging students to work as a team.
Adaptation
Adaptation occurs when the individual accepts and embraces the differences (Oberg, 1960). It is
recognition that they are a visitor and that understanding the cultural differences and immersing
themselves in a different culture does not mean giving up their own. Students compared and contrasted the health care systems and identified advantages and disadvantages (Egenes, 2012;
Oberg, 1960). Different approaches, work for different countries and people and the students’
gradual realisation and acceptance that difference did not equate to being wrong was evidence
of acceptance in keeping with Oberg’s (1960) stages. Students commented on their expectations
for the trip and that having material objects did not equate to a happy life. All spoke of the people
highlighting their generosity and happiness with so little. The facilitators’ role was to guide reflection and debriefing individually and as a group.
Discussion
Student preconceptions and a lack of understanding of the cultural differences often emerged as
key factors associated with culture shock. These factors included simple cultural differences such
as food, weather, travel and language. Students were often able to identify similarities and differences between the new cultures and health care systems in comparison with those in the students’
country of origin (Charles et al., 2014; Egenes, 2012; Oberg, 1960). Cultural awareness and cultural sensitivity was usually evident by the completion of the ICP and developed as part of the
culture shock adaptation. Students developed an awareness of the new culture and a basic
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understanding of the differences (Browne, Fetherston, & Medigovich, 2015; Norton & MarksMaran, 2014, p. 41). Students were encouraged to reflect on strategies they could employ in
the future based on these experiences. From general conversations and the facilitators observations, it was surmised that not all students experienced each stage of the model identified by
Oberg (1960) but each experienced one or more of the stages and all stages with their accompanying emotions were observed during the various ICPs. Preparation and prior knowledge about
culture shock emerged as important aspects in preparing students for an ICP. This requirement to
prepare students for the experience is supported by other authors (Gower, Duggan, Dantas, &
Boldy, 2016).
Language is a limitation to cultural immersion and resultant cultural awareness, without communication there is a sense of isolation and difference, rather than immersion and acceptance.
Language is essential for communication and this can be difficult with the need to utilise
interpreters (Browne, Fetherston, et al., 2015; Oberg, 1960; Tuckett & Crompton, 2013). Many
villagers spoke in different dialects which then had to be translated to the general language
and then to English, causing a lack of detail and a long delay in receiving a response which
caused frustration This challenge was highlighted by Tuckett and Crompton (2013) and
Hovland and Johannessen (2015) where not being able to speak directly to the patients was an
impediment and this was observed where the indigenous peoples spoke different dialects from
the mainstream language. This becomes a part of the culture shock as students struggle with
the lengthy conversations to obtain a one word or short answer and the need to repeat the
process several times to gain more information to ascertain the presenting problem. However,
this is also a useful learning experience for students who upon their return to their country of
origin may work with Indigenous, migrant or refugee populations.
Adequate preparation is key to overcoming culture shock focussing on an understanding of
the respective country’s health care system, cultural traditions with clear expectations of the students’ role and scope of practice whilst on an ICP (Jenkins et al., 2011; Norton & Marks-Maran,
2014). Egenes (2012) identifies a common theme in the conceptualisation of culture shock as
being the relationship between a lack of knowledge about the host culture and the presentation
of features which are consistent with culture shock, recommending education about the culture
prior to and during the experience. Planning and preparation should include information about
the location, appropriate behaviour such as wearing of appropriate clothing to show respect, overview of the health care system and the main cultural beliefs and differences. Preparation requires
an acknowledgement and identification of one’s own values, beliefs and cultural practices and
reflection on how these may be challenged in another culture and without the comfort of the
normal cues associated with everyday life to provide culturally responsive care (Harvey &
Park, 2012). Foronda and Belknap (2012) identify student preparation for any ICP as ideally
beginning six months prior to departure and many other universities which send students
abroad adopt this process in the country of origin.
Where to from here
The more frequent the interactions with the host people and culture, the less symptoms of culture
shock are evidenced (Egenes, 2012; Foronda & Belknap, 2012). A lack of knowledge about the
new culture and cultural norms exacerbates culture shock and the resultant symptoms attributed to
culture shock. Education on culture shock is one suggestion to assist students to identify and
manage culture shock (Egenes, 2012). This does not take initiative away from the student
finding further information. The preparation package must include information on the nursing
practice they will engage in, remembering that flexibility is essential as the practice setting and
clients are unknown (Norton & Marks-Maran, 2014). Facilitating education sessions pertinent to
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the differences in nursing practice are another strategy facilitators can introduce to alleviate culture
shock and assist with critical thinking and reflection as part of the debriefing process (Jenkins et al.,
2011). The ability to reflect and debrief is a strategy that is widely accepted as an appropriate method
to address culture shock. Bender and Walker (2013) discuss the need to debrief and view it as an
obligation of facilitators, especially with ICP. Thus, the role of the facilitator is crucial not only
to ensure clinical requirements are met but to provide a supportive framework and to facilitate
the link between theory and clinical environments (Browne, Wall, et al., 2015). Further research
is required on ICP and culture shock and the role of the facilitator in this process.
Conclusion
The opportunity to undertake an ICP increases cultural awareness, sensitivity, competence and
respect for another culture. Culture shock is an aspect of ICP that requires planning, preparation
and support to ensure students assimilate into the new culture and maximise the learning experience. Preparation prior to departure is essential focussing on the difference in culture, health care
system, expectations of nursing students and their role. Support from the facilitators is essential
and they must be fully briefed on the destination, their role and responsibility. Development of
cultural competence is an outcome of any ICP and the process to gain an awareness of this
concept ultimately includes a degree of culture shock experienced by all participants, the aim
for facilitators is to minimise the amount and support students through this process to maximise
their learning experience.
Impact statement paragraph
Culture shock is an aspect of international clinical placements. It requires planning, preparation
and support from clinical facilitators to ensure students assimilate into the new culture and to
maximise their learning experience. This paper highlights the value of Oberg’s stages of
culture shock to assist in the preparation of students and to support them whilst they are completing their international clinical placements.
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