Student nurses’ experiences of living and studying in a different
culture to their own and the development of cultural sensitivity
By
Heidi Ruddock Christensen
Submitted in partial fulfilment of the requirements for the degree of
Master of Health Science (Nursing)
Faculty of Health and Behavioural Sciences
School of Nursing
Deakin University
January 2005
Table of Contents
Abstract
………………………………………………………………………………
Acknowledgements
………………………………………………………………….
03
04
Chapter 1: Overview of the thesis
Introduction
………………………………………………………………………….
Background to the proposed research
Aim
1
3
7
Rational and importance of the study
Research approach and limitation of the study
7
7
Chapter 2: Literature Review
Introduction
Historical perspective of culture in nursing
International experience. Definition and history
International Education
Studies in International Education
Definition of culture
9
10
14
16
18
20
Cultural sensitivity
Cultural sensitivity and nursing
Conclusion
25
28
32
Chapter 3 Methodology
Introduction
The methodological approach to the study
Phenomenology: Edmund Husserl
Hermeneutics
Heideggerian phenomenology
34
34
36
37
37
Gadamerian phenomenology
Conclusion
39
44
Chapter 4: Method
Introduction
Study participants
Data collection
Ethical considerations
46
46
50
52
01
Data Analysis
Trustworthiness
Conclusion
53
57
59
Chapter 5: Findings
Pre-understanding
Foreprojections or early understandings
Lone
Lena
Bent
61
64
64
69
73
Signe
Inge
Jette
Susanne
76
80
84
87
90
92
93
96
99
Fusion of Horizon:
Experiencing transition from one culture to another
Adjusting to cultural differences
Developing cultural sensitivity and growing personally
Conclusion
Chapter 6: Discussion
Introduction
Journey towards expanded understanding
The process of developing cultural sensitivity from an international exchange
Conclusion
100
101
103
112
Chapter 7: Conclusion
Introduction
Recommendation for further study
113
115
References
116
Appendix A
Appendix B
Appendix C
Appendix D
Glossary of Terms
Plain Language Statement - Head of School
Plain Language Statement - Student
Sample Questions
124
125
126
127
02
Abstract
With the increase of culturally diverse people residing in Denmark, it has become
imperative to provide student nurses with knowledge and skills that will enable them to
become culturally sensitive in order interact effectively with clients from culturally
diverse backgrounds. The aim of this study was to explore whether student nurses
develop cultural sensitivity as a consequence of living and studying in a culture that is
different from their own. Seven Danish student nurses who had participated in student
exchanges in Jamaica, Australia, Malta and Greenland took part in this study. A
qualitative research methodology based on Gadamer’s hermeneutic philosophy was
utilized. Open dialogical in depth interviews were used to collect data. Three horizons
emerged from the data analysis. These were experiencing transition from one culture to
another, adjusting to cultural differences and developing cultural sensitivity and
growing personally.
The international learning experiences as a context for developing cultural sensitivity
was characterized by periods of psychological stress in the beginning of the exchange,
involvement with the people in the host culture, direct patient contact, personal
characteristics of openness and flexibility and support networks facilitated the students
transition and adjustment to the host culture. Reflection on their experiences with
students from a similar background to themselves and clinical mentors from the host
culture assisted the students in their understanding of cultural diversity.
03
Acknowledgements
I would like to acknowledge the following people for their support.
 Dr de Sales Turner, my supervisor in Australia for her consistent encouragement,
wisdom and advice, which have been invaluable throughout this study.
 Dr. Margarethe Lorensen, my supervisor in Norway for support, understanding
and reasoned judgement throughout this study.
 To the participants of this study, who openly and enthusiastically shared their stories.
Thank you so much for the part you played in bringing this work into being.
04
Introduction:
Nursing in Denmark today is becoming a multicultural experience and since the 1960’s
Denmark has become a multicultural, pluralistic society. The population of 5.3 million
people is becoming culturally and ethnically diverse. In 1991, 4.4 % of the population
were immigrants, and in 2001 this figure was 7.2 %. It is projected that 9.5 % of the
total population will be immigrants in 2020 (Årbog, 2001) Reasons for the increasing
culturally and ethnically diverse population are work, immigration and refugee status
(Jensen, 1998).
In spite of the population becoming more culturally diverse the health care system and
nursing education has remained mono-cultural, focusing on the norms and needs of the
majority culture. According to Zarreparvar (2000) the health care professionals in the
Danish health care system consider the “New Danes “ or ethnic minority as a problem
and source of irritation (p.228). For example, the health care system and its health
professionals expect the user of the health care system to speak the Danish language and
have knowledge of their rights and responsibilities, as well as be an active participant in
their treatment. Zarrehparvar’s claims that lack of fulfilment of these expectations leads
to inadequate service, discrimination and inadequate care and treatment for ethnic
minorities.
Zarrehparvar’s claims are supported by a study conducted by an anthropologist in an
obstetric ward in a general hospital in Copenhagen. Jahn (2001) found ethnic minorities
were often classified as “problematic patients” (p.80). Staff claimed these patients did
not know the rules and brought other traditions and ways of thinking into the very
1
regulated work of the hospital. For these reasons, ethnic minorities were often left
alone, did not receive the same care or treatment, nor the same information or time as
the Danish patients. Reasons offered for this were language difficulties and the nurses
lacked knowledge of the ethnic patients’ culture. Based on the findings from Jahn’s
study, Roland (2002) suggested that the health care system has also failed the registered
nurses, as they are inadequately prepared educationally to meet the needs of the clients
from diverse cultural backgrounds and often feel at a loss when providing care, leading
to irritation and anger within themselves. Roland has recommended that undergraduate
nursing programs prepare student nurses to become culturally sensitive, in order to meet
the needs of the clients with a different cultural background.
Zarrehparvar (2000) has defined cultural sensitivity as an awareness of oneself and
one’s own culture. She goes on to say this awareness is essential to being open and
respectful to cultural differences. Lynam (1992); Ramsden (1999); and Mitchelson and
Latham (2000) have supported this definition, by claiming that exploring and
confirming one’s own cultural values and prejudices are essential to increasing
awareness and cultural sensitivity to people from diverse cultural backgrounds. Locke
(1992) has claimed that to help in relationships with the culturally diverse, it is
necessary to know one’s own biases, values and interests, as well as one’s own culture,
in order to enhance one’s sensitivity to another culture. He goes on to say that the first
step to understanding others is having awareness of the self. McMurray (2003) is in
agreement that cultural sensitivity requires openness and respect for cultural differences.
However, she has claimed that cultural sensitivity includes more than being open and
respectful to cultural differences. It also requires understanding the dynamics of
another culture, enabling the nurse to assess the elements within the behaviour patterns
2
of social roles that makes them special and conducive to health. Bennett (1986) is in
agreement with McMurray and has defined cultural sensitivity as awareness of the
importance of cultural differences and to the points of view of people from other
cultures. It is therefore relevant to explore how student nurses develop cultural
sensitivity, given the changing demographics of the Danish population.
Studies on the effects of international education report that transition and adaptation to
another culture is an effective way for students to develop an understanding of oneself,
one’s culture, and to develop cultural sensitivity ( Kaufmann, 1992; Bennett,1986;
Martin, 1989; Zorn, 1996). Thus, this study explores whether being involved in an
international learning experience promotes cultural sensitivity in student nurses.
Background:
The art of meeting people from other cultures consists of the ability to move into the
other’s world without loosing oneself and at the same time being open and embracing
the differences in a multicultural society (Hansen, 2001). Styles (1993) referred to the
21st century as the International Century. Since the end of WW2, the Cold War, and the
fall of the Berlin Wall, as well as the advent of rapidly advancing technology,
cyberspace, complex bureaucracies and increasing ethnic diversities, we have moved
from a world in which society, commerce and education have been defined within the
boundary of nation states, to one in which they are perceived as part of a global
community (Toffler, 1980; Hansen, 2001). Globalisation with its changing demographic
trends and reasons for cultural diversities compels us to evaluate how we promote
cultural sensitivity in nursing education and practice. This is essential to understand the
multifaceted and co-dependent collection of cultural, political, economic and
3
representational beliefs that inform different populations’ views about health, illness,
birth and death.
Denmark is becoming a multicultural society as demonstrated by the following
demographic trends. During the period from 1991 to 2001 there was an increase in
immigrants from 140,369 to 308,674 people, with 11.2 % of these migrants coming
from other Scandinavian countries; 16.4 % from European Union (EU) countries; 2.3 %
from North America; and 70.1% from third world countries. The projected figure for the
migrant population is 504,400 in 2020 (Årbog, 2001). In comparison with multicultural
societies such as the United States of America these figures are small. In 1998 70% of
the population in the United States of America (U.S.A) was of White European descent.
However, by the year 2020 it is estimated that only 53% will be of white European
descent (U.S, Census, 1998). In spite of the fact that the Danish figures are small in
comparison with the United States, the figures represent a shift from a mono-cultural
society to a need for an increased understanding of other cultures and the importance of
acknowledging the meaning of culture in health care. These figures indicate that
Denmark has become a destination for immigrants and refugees seeking a change in
lifestyles and opportunities. Whether this change is voluntarily or is due to a traumatic
displacement after war, famine, religion and political persecution, these people leave
their homeland to settle in Denmark, which they perceive as offering relative safety,
freedom and opportunities for personal success (Jensen, 1999).
As Denmark is becoming more diverse, there is an increasing need for nurse educators
and student nurses to develop an understanding of culture, its relationship to illness and
health and the context in which culturally sensitive care is delivered. It is therefore
4
important that student nurses develop an understanding of the influences of culture on
health, awareness of the impact of one’s own cultural background on interaction with
others and sensitivity towards the diverse cultural groups as part of their curriculum.
Amendments made to Danish Nurses Education Act in 2002 recognized the principles
set out by the World Health Organization (WHO) in that people have a right and duty to
participate individually and collectively in the planning and implementation of their
health care. Implicit in this principle is an imperative to acknowledge cultural
differences in health perspectives, social organizations and management styles. Another
principle for the global objectives is found in the Jakarta Declaration and requires
investment in health care to meet the needs of certain groups such as women, children,
older people, indigenous, poor and marginalized populations (Jakarta Declaration,
World Health Organization, 2002).
Based on the global objectives to meet the health needs of people from diverse cultural
backgrounds, the Danish Nurses Education Act requires that undergraduate nursing
education must prepare student nurses to be able to work in partnership with patients,
relatives, colleagues and other disciplines regardless of their ethnicity, culture, religion
and language (Bekendtgørelse, 2001). The challenge for nurses are that people should
be nursed with regard for all that makes them unique, rather than regardless of ethnic,
cultural, religious and language background. Even though the Danish National Board
has the responsibility for ensuring pre-registration programs provide student nurses with
cultural understanding, it does not provide curriculum guidelines for how the school
should implement these. It is up to the individual nursing school to determine the course
content and methods to achieve cultural sensitivity.
5
Lack of cultural sensitivity by nurses and other health care professionals can alienate the
very people whom nurses purport to help ( Mitchelson & Latham,2000). During my
experience as a nurse teacher with students in the clinical area in Denmark, informal
comments expressed by registered nurses who acted as the student nurses clinical
supervisors/mentors were that they lacked understanding of cultural diversities,
knowledge, and were ethnocentric, as well as lacked educational preparation. They also
stated they felt inadequate in helping students, as they lacked multicultural skills
themselves.
During my involvement with international students I became interested in exploring
how living and studying in another culture may encourage the development of cultural
sensitivity. During the student’s international experience they spent a week in Poland
and were asked to keep a diary, comparing the health care system of their host country
that is Denmark, their own country and the health care in Poland, including their
subjective experiences. In addition, the students were required to keep a reflective
journal of their clinical experience in Denmark. In their reflective journal, many of the
student nurses wrote they had become more aware of the dominant culture, and sociopolitical factors that influenced the health care in each country. In addition they
expressed greater awareness of their role, when interacting with clients who had a
different cultural background and language to their own. They stated that living and
studying in another country had increased their awareness of their own culture, feelings
of being different and feeling that they were part of a minority. These student’s
comments stimulated my interest in exploring whether student nurses develop cultural
sensitivity as a consequence of an international learning experience, as seen through
their eyes.
6
Aim:
The aim of this study is to explore whether student nurses develop cultural sensitivity as
a consequence of living and studying in a culture that is different from their own.
Rational and importance of the study:
With the increase of culturally diverse people residing in Denmark as previously
discussed, comes an imperative for student nurses to develop knowledge about other
cultures and to acquire skills that will enable them to interact with clients from
culturally diverse backgrounds. A serious conceptual problem exists within nursing in
Denmark, in that nurses are taught in the mono-cultural western paradigm, yet still are
expected to meet the health needs of clients from diverse cultural backgrounds.
Currently there is no research that has explored the impact of student nurses from
Denmark participating in international education. With the increased cultural diversity
in Denmark and the need for culturally relevant care, it is clear there is a need to
identify how students become culturally sensitive, in order to inform nursing education
and improve practice. It is proposed that this phenomenological study will explore if
student nurses who have engaged in overseas study programs develop cultural
sensitivity.
Research approach and limitation of the study:
A qualitative research methodology was utilized, based on Gadamer’s hermeneutic
phenomenology (Gadamer, 1989). Open ended dialogical in depth interviews were
used to collect data. The purpose of the interviews was to explore the student nurses’
7
reflections of whether study abroad enhanced their development of cultural sensitivity.
The texts generated from the interviews were the source of research data.
Data analysis was undertaken using a hermeneutic approach to guide the interpretation
of meaning (Norris 2002; Turner 2003). Further elaboration regarding the study
methodology and methods are provided in Chapters 3 and 4 of this thesis.
The study was limited to a homogenous small sample of seven student nurses from a
School of Nursing located in Viborg County. Even though the findings may be of
interest to other schools of nursing, no attempt will be made to generalize the results.
This chapter has provided some background information regarding this study and an
overview of the thesis and rational for the study. Chapter 2 provides an historical
account of culture in nursing in general and the historical context of international
education. Also a discussion will be provided on related literature on international
education, with particular reference to Bennett’s model of cultural sensitivity, which
reviews some studies in international education. This is followed by a discussion on
culture, cultural sensitivity and cultural sensitivity and nursing. Chapter 3 describes the
research methodology and Chapter 4 the method. Chapter 5 presents the findings.
Chapter 6 presents a discussion. Chapter 7 provides a conclusion to the study and will
address the implication of the findings and areas for further research.
8
Chapter 2: Review of Related Literature
Introduction
To accomplish the literature review a variety of search techniques and approaches were
used. These included searching using electronic bibliographic data bases such as
CINAHL Pubmed, ERIC and PsychINFO. Search terms which were combined with
each other included, cultural sensitivity, cultural congruent care, nursing education and
culture, cultural sensitivity and student nurses, cultural competency and nursing
education, international education and culture, study abroad and student exchanges,
globalization and nursing. Reference lists from identified studies were also used. These
search techniques produced a wealth of material and laid the foundation and conceptual
framework for exploring the impact of internationalization to the development of
cultural sensitivity in student nurses.
Internationalizing of the nursing curriculum is essential to help student nurses develop a
global perspective as they prepare to practice in a world of interdependent nations with
increasing cultural diversity. It is therefore important that they develop an
understanding of culture, its relationship to illness, and health, and the context in which
culturally sensitive care is delivered. This literature review comprises a historical
perspective of culture in nursing, the reasons for the development of cultural sensitivity,
and historical contexts for the development of international education. It includes an
exploration of international education, culture, cultural sensitivity, as well as cultural
sensitivity and nursing.
9
Historical Perspectives of culture in nursing
Traditionally within Denmark nursing education utilizes a biomedical model, which is
focused on providing care within a diagnostic and treatment regime for patients, without
consideration of a cultural perspective. Nurses’ values are a product of their own
cultural background and a product of the nursing culture, as well as the culture of the
Western model of health and illness care. Nurses who are not knowledgeable about
cultural influences on health and illness are unaware that differences exists and use their
own familiar value-based intervention when dealing with diverse population group
( Lynam, 1999; Ramsden, 1993).
Lack of cultural sensitivity can lead to misunderstanding and treatment, which is not in
the best interest of the patient, where health professionals do not understand the
patient’s values and health-related beliefs. For example, ethnocentrism by health care
professionals has resulted in failure to provide adequate pain relief due to a lack
understanding about the cultural expression of discomfort ( Durie, 1985; Ramsden,
1993). A study conducted at the University of Alberta concluded that the culturally
insensitive individual is a person who believes that people are the same everywhere
(Reagan, 1966). Deagle (1986) has claimed that people who do not comply with the
conventional Western system of health care are often considered ignorant, superstitious
and non-compliant. Physicians and nurses are often unaware that non-compliance from
clients occurs because health professional lack knowledge of the clients’ beliefs and
values related to this illness and disease. The climate of mistrust and misunderstanding
that can occur often leads to paternalistic and coercive behaviour on the part of the
health professional who is unable or unwilling to consider the patient’s values and
health related beliefs. Deagle (1986) gives an illustration of what can happen when
10
health care professionals fail to provide culturally sensitive care that demonstrates
understanding of the relationship of culture to illness and care giving.
A twenty year old native Haida patient delivered her third
normal child after a long labour. The baby was large and
required a difficult forceps extraction. Since the women had
two previous children, it was recommended to her that in view
of her stressful delivery, that she should have a postpartum
tubal-ligation. This procedure was done. Within one year the
patient presented in the office stating that she now wished to
have more children. Surgical reconstruction of her tubes was
not possible, and the patient remains chronically depressed.
This is an example of mono-cultural health care. The physician
showed great concern for the future welfare of his patient, but
the Haida patient was not as concerned about or aware of the
future implication of her actions, since in her culture, the future
is not as important as the past. In addition the physician asked
the young women to make the decision on her own, as he
considered it was her individual responsibility to do this, while
the Haida patient would have preferred to discuss the issues
with her extended family and friends, since a collateral
decision is often seen as more desirable in her culture, p.1317).
In a study conducted by Murphy and MacLeod (1993) in depth interviews with nurses
revealed that registered nurses experienced difficulties in intercultural communication
with clients and a lacked knowledge about cultural differences. One nurse from the
study reported:
I always remember that the relatives didn’t communicate with
the staff. They would not ask thing. They probably didn’t think
they were supposed to. I felt like they didn’t care or were not
interested. Usually with the relatives you discuss things but
they just sat there (p 446).
An insidious form of coercion or lack of intercultural communication can occur in
contexts where health care providers are culturally insensitive to the patient. That is,
intercultural communication difficulties occur when conflicting values or meanings are
not identified due to lack of understanding of differences. This results in ethnocentric
11
care wherein nurses practise with the belief that the western biomedical model is
superior to other forms of health care.
Some reasons for ethnocentric behaviour by registered nurses were cited as lack of
knowledge about cultural differences, poor communication skills, stereotyping,
unawareness of their own attitudes, and lack of educational preparation (MacLeod &
Murphy, 1993). These authors concluded that the skills and knowledge needed to care
for the ethnic minorities should be addressed in pre and post basic registration courses.
There are however, some examples of early nursing pioneers in community health who
recognized the importance of culture in nursing. Nightingale’s work in the Crimean war
and her concern with the Australian Aboriginal people made her the first transcultural
and international nurse in modern history ( Hagey, 1988; Morse, 1988). In 1980, Linda
Richards became the first international American nurse, when she established a school
of nursing in Japan (Masson, 1981). In the 1900’s public health nurses Wald and Dock,
recognized the importance of being sensitive to individual attitudes, values and beliefs
about health, illness when caring for the health needs of the European immigrants
(Hagey, 1988).
Leininger (1978), purported to be the founder of transcultural nursing, stated that
content regarding cultural awareness and cultural knowledge have been inadequate in
nursing education. The lack of these concepts in nursing practice have led to health care
providers imposing their own cultural views on clients, with the belief that the nurses
values premised in the bio-medical were more correct. This ethnocentric view inhibits
nurses from interacting sensitively to the needs of clients from diverse cultural
12
backgrounds. In 1978 Leininger developed the sunrise model of transcultural care,
which demonstrated her theory of cultural care and diversity. She defined transcultural
care as a formal area of study of cultures and subcultures in the world, with respect to
cultural care, health and illness.
For nurses to be transcultural, they must be able to momentarily step out of their own
tradition, in order for them to perceive and understand different cultural perspectives
(De Santis, 1988). Knowledge and skills needed for student nurses and nurses to
become transcultural are not only theoretical, but require experience in interacting with
people from diverse cultural backgrounds. Furthermore, student nurses need opportunity
to reflect on these experiences. In order to achieve this, the student needs to acquire an
understanding of inherent biases within themselves and care organizations, and how
these may limit the efficacy of the care provided (Lynam,1992; Bartz,1993;
Ramsden,1993; Mitchelsen & Latham,2000).
Lindquist (1990) stated that international education is the preparation for social and
economic realities that humans experience in an interdependent culturally diverse and
competitive world. Meleis and Trangenstein (1994) have suggested that such an
experience provides nursing students with an opportunity to reflect on their transitions
from their home culture to the host culture. This experience has the potential to increase
the nurses’ awareness of what it means to be in a foreign environment. As a result of
this experience, it is anticipated that they will become more sensitive to the patients
needs as they try to adapt to a new culture. Furthermore, reflecting on this experience
provides the student nurse with an opportunity to view their own experience from a new
vantage point, as well as develop understanding of the socio-political structures that
13
affect health care. This argument is supported by Perry (1970) who stated that when
students are confronted with experiences that do not fit their worldview, they adapt their
thinking by moving from simple concrete thinking patterns to relativistic ones. Bennett
(1986) used Perry’s model of relativity as a basis for the developmental model of
cultural sensitivity. He suggested that the development of cultural sensitivity demands
attention to the subjective experience of the learner. The key to such sensitivity is the
way in which the student construes cultural differences. However, it is not the events
the students respond to, it is the meaning they attach to these events (Kelly, 1963). For
this reason, Bennett (1986) stated the development of cultural sensitivity requires new
awareness and attitudes, and a movement through a continuum of stages. The
developmental continuum moves from ethnocentric orientations to ethno relative
orientations. Earlier stages define denial and minimization of differences and the later
stages define acceptance, adaptation and integration of differences into one’s
worldview. He goes on to say, cultural sensitivity can be developed in contact with new
and unfamiliar persons and places.
There is general agreement that international education is likely to expose students to
their own prejudices and biases, which in turn can make the student more aware of their
own culture. It is also suggested that interpersonal skills and reflective skills are
enhanced by this experience (Perry, 1970; Paige, 1990; Lindquist, 1990; Bennett, 1993;
Martin, 1993).
International Experience - Definition and History
In 1997 The Global Alliance for transcultural/international education (GATE) defined
international education as any teaching or learning activity in which the students are
14
located in a different country to that which the institution providing the education is
based. International education began in the 1940’s in USA in order to design crosscultural education for the employees of the Foreign Service institute (Martin, 1993).
The focus was the study of interaction of individuals from different cultures and the
beginning of intercultural communication (Hall, 1966); Martin, 1993). Another program
that provided grants and scholarships was the Fullbright Program, which commenced in
1946. Its purpose was to promote mutual understanding, with the view that nations
would learn to live in peace and friendships (Bureau of Educational and Cultural affairs,
2004). American secondary schools and universities have had exchange programs for
the last thirty years. However these are sporadic and dependent on finance from the
individual institutions and individuals (Lindquist, 1990).
The historical context of the single European market provided a need for European
nursing education to implement curriculum changes that enabled student nurses to
undertake overseas exchanges for both theory and clinical experiences. Such
experiences empower student nurses to become sensitive and receptive to other cultures
and behaviours, and to embrace cultural diversity in health care, as well as preparing
students for working across borders when they graduate (Caligiuri, Jacobs & Farr, 2000;
Lee, 1997). The development of educational programs such as Erasmus, Leonardo de
Vinci encourages student and teacher mobility in international exchanges, as well as the
co-operation of educational institutions within Europe (Jensen, 1999; Hansen, 2001).
These study abroad programs provide an opportunity for student nurses to participate in
international education in order to learn about diverse cultures and how these effect
health status and lifestyles.
15
International education
According to Heidemann (1999), Martin (1994), and Bennett (1993), international
education provides students with an opportunity to live and study in a culture different
to their own. This experience has the potential for affirming their self-identity, and for
exploring sources of bias within themselves and the structures of societies that influence
their socialization process. Martin (1994), and Bennett (1993), have stated that adaptive
processes occur during the student exchange, which involve cognitive, affective and
behavioural dimensions. These scholars have advocated that the goal of international
education is for students to develop an understanding of their own/other cultures, race,
gender, politics and economics, and to understand the effect this has on their perception
of the world. This understanding will hopefully enable diverse cultural groups to coexist within and across borders in the global village. This experience is psychologically
intense for a number of reasons. For example it requires the student to reflect upon
situations and experiences with which they have little experience. While adapting to
their host country, many students experience culture shock and as a consequence may
view this experience negatively. According to Bennett (1993) however, culture shock is
a transition experience that can enhance psychological growth, as long as the students
recognize this state as a defence response to cognitive dissonance. Adler (1975) has
described the concept of culture shock in terms of personal growth. He wrote:
cross- cultural learning experiences is a set of intensive and
evocative situations in which the individual experiences
him/herself and other people in a new way distinct from
previous situations and is consequently forced into new levels
of consciousness and understanding p.13.
Brueggemann (1987) supported Adler’s view and suggested:
that changes in individuals occur in periods of transition of
discontinuity disjunction and displacement and new insights
16
and revelation occur at points of harsh displacement and not in
situations of equilibrium p.36.
Theoretically this experience then forces the student to step out of the self and view all
previous experience from a truly critical vantage point. This promotes understanding,
recognition and acknowledgement of differences. These differences may be viewed as
resources rather than obstacles and openness to the development of respect and
receptivity of the culturally diverse.
Therefore international education may be a relevant approach for the development of
cultural sensitivity. According to Meizrow (1994), critical reflection and self reflection
on the different situations provide the context for transformation. In addition Gray, the
president of the United Negro College Fund (2002), stated that as globalisation
continues to shrink borders, cultural, financial, religious and cultural challenges must be
met by international education.
However it is necessary to look at the specific factors that promote adaptation, and the
development of cultural sensitivity, as there may well be individual variations among
students and the host environment that may encourage or impede the development of
cultural sensitivity. Kim (1988) has suggested that successful adaptation to the host
culture, with the ensuing growth in interpersonal skills and cognitive growth, is affected
by a number of factors. These factors are identified, as the student’s own cultural
background, their value differences and, characteristics, as well as their characteristics
of openness, flexibility, age and gender. Further, preparation for the intercultural
experience by the students own school; the students own attitudes, motivation, language
competence and expectations for the intercultural experience, also influence adaptation
17
to the host culture. In addition factors such as receptivity, openness, acceptance of the
students by the host culture and potential for interaction in the host culture all encourage
adaptation and sensitivity to other cultural groups. Active involvement by the student in
the host culture provides the students with information about the host country and
understanding of different patterns in communications and relationships. This
involvement provides the students with feedback about their interaction in the host
environment, and helps to reduce stress, thereby encouraging openness and acceptance
of cultural differences between the student’s own and the host culture (Cross, 1995;
Searle & Ward, 1990). According to Torbiorn (1982) and Storti (1990), it is important
for students to interact with both people from their own culture, as well as people from
their host culture, to promote adjustment to the host culture. Torbiorn (1982) and Stort
(1990) claimed that interaction with people from one’s own cultural background helps
to confirm one’s identity, provides support for dealing with new experiences, and
encourages openness to differences between cultures.
Studies in international Education
Reports and research on the outcomes for international study in general education have
been published for the last 40 years. Studies from general education in North America
have reported perceived benefits from studying abroad. These were increased
confidence in the self, personal development, a less ethnocentric outlook and,
consciousness of learning as an object of reflection rather than something taken for
granted (Kaufman, Weaver & Weaver, 1992). In addition, students reported beneficial
outcomes from exposure to other worldviews, such as increased global understanding,
greater self-awareness and changes in attitudes (Nisbet & Scuckssmith, 1984; Widaman
& Carlson, 1988; Cushener,1989; Straffon, 2003).
18
Only two studies on high school and tertiary student exchanges in Denmark have been
located, and no Danish studies have been found that looked at the impact of overseas
studies in nursing education in Denmark. Jensen (1998) used a qualitative approach to
explore intercultural communication among high school and tertiary students,
concluding that this was a new concept in Denmark and tertiary institutions. Jensen
further alleged that undergraduate programs in teaching and nursing education, as well
as law faculties, continued to prepare students for a mono-cultural society.
Heidemann (1997) used a quantitative and qualitative approach to investigate the extent
of international education within secondary education and business schools in tertiary
education. She found that an international experience encouraged openness and more
flexible attitudes amongst students. A number of research studies from Europe, North
America and Australia, have reported on the exchange experiences of student nurses.
Common to these reports are gains in personal development, coping skills and cognitive
growth, a greater understanding of cultural diversity, heightened feelings of what it
meant to be different, as well as an increased global understanding. However, many of
these studies have also highlighted that students experience culture shock during their
exchange ( Bond & Jones, 1999; Fritsch,1990; Zorn,1995; Haloburton & Thompson,
1998; Pross, 2003).
Most of the above studies have explored the outcome of learning from the international
experience, that is, what students learned rather than how they acquired transcultural
skills. Meleis and Trangenstein (1994), in their studies with immigrant women found
that that transition experiences of another culture is concerned with the process. They
19
note that a successful transition is characterized by both process and outcome indicators.
According to these authors, process indicators involve confronting differences,
interacting, developing confidence and coping. An outcome indicator is reflected by the
mastery of the new environment. To understand the transition experience, it is necessary
to confront the differences between the new and old environment. Feeling different,
being perceived as different by the host culture, or seeing the world and others as
different can lead to periods of uncertainty, disconnectedness or culture shock (Meleis
& Trangenstein, 1999). According to Meleis, Sawyer, Messias and Schmacher (2000), it
is during a period of discontinuity from their own culture that people become more
aware of their own culture biases, prejudices and assumptions about individuals who are
different. These authors go on to say that levels of awareness influence interactions with
people from the different cultures and lead to increase in self-confidence and coping in
the new environment.
In summary, it would therefore be valuable to explore the exchange process as seen
through the eyes of student nurses, of whether learning about culture, and cultural
diversity during a student exchange develops cultural sensitivity.
Definition of Culture
Keesing (1981) noted that culture refers to patterns of behaviour. He restricted culture
to mean systems of shared ideas, systems of concepts and roles and meanings that
underlie values and beliefs and are expressed in the way humans live. Leininger (1985)
defined culture as the values and beliefs, norms and practices of another group, which
are learned and shared to guide decisions and actions in patterned ways. Culture then
can be understood as patterns of learned perceptions, behaviour, attitudes and beliefs by
20
either individuals or a group of individuals. Individuals learn about their culture during
the process of language learning and being socialized.
According to Mead ( 1972); Durie (1989); and Leininger (1995), parents and family are
the most important sources for the transfer of traditions and teach both explicit and
implicit behaviour of cultures. Explicit behaviours include language and interpersonal
distance, whereas implicit behaviour are less visible and include the way individuals
perceive health and illness, body language, differences in language expressions and the
use of titles. Furthermore, each culture has an organizational structure that distinguishes
it from another, which provides the structure that members of cultural groups use to
determine appropriate and inappropriate behaviour. Such organizational elements
include child rearing practices, religion, family values and attitudes, education and
health care systems (Battle, 1998; Leininger, 1995). During the socialization process,
certain patterns of thinking and behaving are acquired unconsciously. In this way we
may develop perceptions of something, which may lead to stereotyping of other people
and groups. In fact, discrimination may stem from our upbringing, education, the
history of our country, history lesson, schoolbooks, songs or jokes (Brislin, 1993).
Prejudice may lead to hostile acts, such as discrimination and generalisation. This
results in marginalizing of groups, who differ from the dominant culture. Marginalizing
of people who look and think differently has a high cost to the individual, groups and to
society, in terms of ill health, especially poor mental health and social problems (Mead,
1972; Durie, 1989).For these reasons it is important for student nurses and nurses to
learn about cultural diversity. When addressing cultural diversity it is important to
consider the many faces of diversity. According to Singer (1987) and Campina-Bacote
(2003), cultural diversity is no longer conceptualized as applying only to national or
21
ethnic/racial groupings but is expanded to include religious affiliation, language,
physical size, gender, sexual orientation, age, disability and socio-economic status.
Nurses, who are educated in the Western tradition, have learned certain values about
health and illness. When biological information is of primary concern, cultural
differences may not be attended to, resulting in nurses imposing their value system on
their clients (Leininger, 1978; Lynam, 1992). For example a nurse may not appreciate a
family’s reliance on a spiritual healer. It is essential to remember that a patient’s and
family’s perception and understanding of well-being, illness and recovery can be major
factors in the health care process. Kleinman (1978) has described the folk domain as the
health care that take place outside the dominant organized professional health care
system. In this domain nutritional practices, such as the importance of balance in the
body in the form of yin and yang are used. The Chinese diet is based on the yin-yang
balance. By eating the right combination of foods, the correct balance can be maintained
or restored. Thus yang (hot) foods including meats, seafood, tonics and fried foods are
eaten with yin (cold) foods, such as vegetables and fresh fruits. Excesses of yin or yang
foods could result in various illnesses; yin excess results in fever and dehydration while
gastric disorders can be attributed to an excess of yang. For example a blood deficiency
has been considered as a yin condition and requires special yang foods, such as ginger
and soups containing pork liver. Moreover high blood pressure, resulting from an
excess of yang, can be treated with garlic or celery porridge (Chen-Louie (1983), other
ways are use of spiritual healers and prayer.
The popular domain also takes place outside the dominant organized health system.
This form for health care may use over the counter medicine, advice from family and
22
friends, herbal medication, alternative medicine for example zone therapy, massage and
social network. In addition to the folk domain, Kleinman (1978) has described the
professional domain, wherein health professionals make the decisions about treatment
and care of the individual, according to the bio-medical model of care. These domains
are similar to Leininger’s folk or generic form of health care, which take place outside
the dominant organized professional health care system and the professional form,
which encompasses the Western biomedical model (Leininger, 1978).
Acknowledgement of the different domains of health care is essential for nurses, if they
are to meet the health care needs of the diverse cultural groups. Similarly, nurses need
to understand and use different communication styles during their interaction with
clients from various cultural and social groups. According to Gudykunst and TingTooney (1988) and Hall (1976), communication in Western culture is described as low
context. That is, people of Western cultures use explicit communication, characterized
as being linear and open, which is direct, to the point and goal-oriented. Additionally,
within this culture, silence is viewed as positive. In contrast, other cultures such as
Japanese, Asian and Latin America use high context communication, wherein implicit
communication is used (Olguri & Gudykunst, 2002). High-context communication is
characterized as contextual, and emphasizes the reciprocal roles of the people
communicating, and the status relationship between them. Further, people who use high
context communication use a narrative form in their conversation.
Eye contact to people from the western culture is considered polite and a sign of
attentiveness. However, this may be viewed as intrusive and disrespectful in other
cultures. For example, when gathering data from a Hispanic woman, the nurse should
23
be aware that the woman’s communication style may be low keyed and she may avoid
eye contact or be hesitant to respond to questions. This behaviour should not be
interpreted as a lack of interest or inability to relate to others (Randall-David, 1989).
Further, people from western cultures value time efficient behaviour, reflecting a belief
that time is saved, lost, or wasted. Within Western culture there is a strong emphasis on
being on time (Rundle, 1999; Giger & Davidhizar, 1999; Ramsden, 1993). Western
thinking is often future oriented. People can plan for the future in many aspects of their
lives, believing that they, not fate, control the environment, and that they can determine
the direction of many areas of their lives (Giger & Davidhizar, 1999).
In many other cultures, time is present or past oriented. Taking time to build personal
relationships is more important than being on time. Therefore, stopping to talk to a
neighbour could be more important than arriving on time for a clinic appointment.
While preventative medicine is an important aspect of health care in Europe and North
America, it is not practiced in many other countries (Rundle, 1999). For example, a
Latin American parent may not give preventative asthma medicine when the child is not
exhibiting symptoms at the moment.
In high context cultures, society is group oriented. The welfare of the group and cooperation, rather than competition, is primarily valued, as seen in African, Arabic,
Asian, and Latin countries (West, 1993). Many cultures from the non-western world
believe in less control over the future, and more in the role of the fate. It is therefore
important that student nurses learn about these organizational elements and patterns of
24
behaviour and communication, in order to provide culturally sensitive care to clients
from diverse cultural backgrounds
Cultural Sensitivity:
Developing cultural sensitivity is an ongoing process. It is challenging and at times
painful, as nurse struggles to break with old and adopt new ways of thinking (Lindquist,
1990; Styles, 1993). Cultural sensitivity has been defined by Bennett (1986, 1993) as
the appreciation for and receptiveness to another’s cultural heritage and values. He has
also suggested that cultural sensitivity can be developed in contact with new and
unfamiliar persons and places. The development of cultural sensitivity is a process of
moving through ethnocentric and ethno-relative stages. Bennett’s model is a
developmental model of personal growth. It is based on the concept of difference, in the
sense that people differentiate phenomena in a variety of different ways. The goal is to
develop self-awareness, other cultural awareness, and skills in intercultural perception
and communication (Martin, 1994; Paige 1993; Bennett 1993). These authors hold the
view that experience is constructed according to variable structural patterns and that
these differences are the crucial factors in our attempts to understand and communicate
experiences inter-culturally.
Cultural sensitivity then, is a developmental process that includes cognitive, affective
and behavioural dimensions. The cognitive dimensions include the ability to understand
that knowledge arises from the shared world of history, culture and traditions, resulting
in the norms and values displayed by a cultural group. Subsequent appreciation of
cultural differences is affective, in the sense of feeling a threat to one’s worldview. This
is followed by an appreciation of cultural differences, followed by behavioural
25
applications of building intercultural communication skills (Bennett, 1996). According
to Bennett’s six stage model of developing cultural sensitivity, the student progresses
from ethnocentrism to increased cultural sensitivity in the ethno-relativistic stages.
Ethnocentrism includes stage one, two and three. The ethnocentric stage includes denial,
defence and minimization. In stage one denial, there is no recognition of cultural
differences, which may result in the student nurse labelling the client non-compliant,
resistive, or demanding. In stage two, the defence stage, differences are recognized, but
the student feels their culture is superior to the client’s and may stereotype their client.
In this phase the positive aspects of one’s own group is exaggerated, demonstrating an
allegiance to an ethnocentric view. In stage three, trivialisation of differences,
characterises the minimization stage. The ethnorelative part includes stage four, five and
six. During the ethno-relative stages, the student nurse acknowledges the existence and
validity of other cultural beliefs and practices. In stage four, acceptance is an aspect of
cultural relativism whereby one embraces a belief that one culture is not inherently
better or worse than another. Differences are no longer judged by the standards of one’s
own group difference, but are examined within their cultural context. This is the first
step in which effective transcultural nursing care can be delivered.
In stage five, adaptation occurs as a result of extensive exposure to another culture.
Adaptation to differences involves the dimension of empathy and pluralism. Empathy
refers to the ability to shift perspectives into alternative cultural worldviews. Pluralism
means the internalization of more than one competing paradigm. In this stage, the
students can communicate and interact effectively with people from other cultures and
shift their frame of reference. In stage six, integration occurs as the students move
comfortably among cultures, recognizing variations in cultural practice. In this stage,
26
students are able to internalize more than one cultural worldview. In other words, the
students are able to transcend the cultures of which they are part. They see themselves
as persons in process and as facilitators of cultural transition (Bennett, 1986). The
development of cultural sensitivity then facilitates the communication process between
the student nurse and the client.
In the interpersonal relationship, both the client’s and student nurse’s values come into
play, as both are members of cultural groups. When these values differ, it is important
for the student nurse to perceive the clients values as a variation rather than a deviation
from their espoused values. If the student nurse is able to affirm their own identity, it
becomes easier to show acceptance, respect and interest and to learn more about the
client’s culturally based needs. The ethno-relative stage allows the student to be
receptive to the clients’ perspective and to appreciate the meaning of life processes from
their clients’ perspective.
It is generally agreed that acquiring cultural sensitivity is a developmental process.
Campina-Bacote (2003) agrees with Bennett (1993) that cultural awareness of self and
others, through cultural encounters, are essential in becoming culturally competent.
However, it is acknowledged that this is a life-long process, to which nurses
continuously strive. Bennett’s model of intercultural sensitivity emphasizes
acknowledgement of difference and the relativity of one culture to another. Unlike the
claims of Bennett (1993), Campina-Bacote (2003) claims nurses must acknowledge
both differences and similarities in people, in the sense that we all belong to the same
human race, with the same basic needs. The difference however, it is the way these
27
needs are expressed. It is therefore important to include client’s health related beliefs
and values in order to provide culturally competent care.
It would seem that Bennett’s (1986) model of intercultural development, described in
terms of affective, cognitive and behavioural constructs, as well as in response to
cultural differences, would apply to all students participating in international exchanges.
However Black (1990); Hammer, Gudykunst and Wiseman (1978); Kim (1988); and
Kelly and Myers (1992), have suggested that specific characteristics such as flexibility,
openness, autonomy, comfort with differences, emotional resistance and cultural
knowledge facilitate coping with culture shock, differences and adaptation. These
characteristics also help facilitate acceptance of cultural diversity.
Ishiyama (1989), and Hammer, Gudykunst and Wiseman (1978) have identified other
factors necessary to consider in intercultural contacts. These factors are how to help the
student to establish interpersonal relations with mainstream students, teachers, and the
community in which they live. In addition, the student will benefit from learning
appropriate ways of conducting social exchanges, useful for a variety of interpersonal
situations, such as seeking information and help, making social contacts and
conversation, participating in group discussion, receiving and giving feed back.
Satisfactory social relationships with host cultural members are important for general
social purposes in daily living, as are confronting differences in order to gain
acceptance, adapt and integrate more than one cultural worldview into their own.
Cultural sensitivity and nursing
28
Lynam (1992) claims that giving culturally sensitive care requires both the nurse and
the health care system to be culturally sensitive. For this reason, it is essential that
nursing curricula prepare students to critically examine the historical, political, social
and cultural factors that contribute to the health care system, which are responsible for
health policies. Lynam further discusses challenges for nursing education, with one of
these being to achieve a balance between cultural/ethnic specific content, and develop
an understanding of concepts that are applicable across cultural settings.
An approach that assigns particular practices to particular groups, and makes
assumptions about individuals’ health based on the cultural group (for example
Leininger’s [1978] sunrise model), can lead to categorizing groups and making
assumptions about individual health based on their group membership. One criticism of
this approach is that it can lead to generalising and stereotyping, resulting in failure to
meet the needs of the individual client. Campinha-Bacote (2003) has suggested it is
important to acknowledge that there may be more variation within cultural groups than
across cultural groups. No individual is a stereotype of one’s culture of origin. Rather,
individuals have a unique life experience and individual experience during the process
of acculturation to other cultures.
According to Lynam (1992), cultural knowledge needs to be supplemented with
intercultural communication skills. This necessitates the student’s understanding of their
own culture, sources of bias, and their acculturation into the nursing and biomedical
model. It is important to explore our own values, attitudes and biases, because the
attitudes the student holds as an individual can impact upon their behaviour towards
people who are perceived to be different. In order to provide culturally sensitive care, it
29
is necessary that the student nurse identifies and acknowledges differences, as well as
seeking out ways of working within these differences. When considering differences,
the student needs to recognize that culture is not static, but a dynamic process (Mead,
1972; Lynam, 1992).
People continue to be influenced by the people and institutions with whom they interact.
It is therefore important for the student nurse to understand the transition phases that
refugees and immigrants pass through when they move to another country, and to
explore such questions as what happens to the culture of refugees and immigrants when
moving to another country. Do they transfer their own culture? How do they integrate
their values, the norms and practices of health care to the new country or do they? For
example, has immigration altered how a family defines itself, how their family is
organized, whether they experience economic difficulties, or have diminished or
increased their social networks? Further considerations are the impact of interaction
with other people, systems, what culture they identify with, and familiarity with the
health care system (Anderson, 1990; Jensen 1998). It is important for the student nurse
to deeply contemplate what culture their clients identify with. For example, children of
immigrant families may identify with their new culture and may experience
considerable cultural conflict between their parents and peers (Norbeck & Tilden,
1988).
Another imperative in establishing intercultural communication is developing a
meaningful relationship, by creating a dialogue with the client. The purpose of the
dialogue is to discover differences, transition stages and stress factors of refugees and
30
immigrants and to consider their health practices in partnership, with the view of
reaching a common goal and plan (Lynam 1992; Mitchelson & Latham, 2000).
In New Zealand, nursing education has adopted a culturally safe approach (Ramsden,
1997). This approach requires student nurses to examine their own cultural identity and
beliefs and to explore ways in which these issues might impact on the nurse- patient
relationship. It incorporates inclusion about the historical and social processes involved
in the causation of health problems, as a way of encouraging student nurses to reflect
carefully on their experiences with individuals from different cultural groups (New
Zealand Nursing Council, 1996).
Leininger (1995) has argued that nursing is essentially a trans-cultural phenomenon,
that is, culturally congruent nursing care requires knowledge about patients’ cultural
values, beliefs and practices, as integral to providing holistic care. Her sunrise model
demonstrates her theory of Cultural Care Diversity and Universality. This model
identifies a range of issues, which together create the context of environment, language
and cultural background, major influences on patients, their expression of need and the
provision of care. According to Leininger, there are three dominant actions that are
essential in providing culturally congruent nursing care. These are: culture care
preservation and maintenance; care accommodation or negotiation and; culture care
restructuring and repatterning. The goal of cultural preservation is to support the use by
clients, of those aspects of the client’s culture that promote healthy behaviours. Cultural
accommodation means that the nurse negotiates with clients to include aspects of their
folk practices within the traditional system, to implement essential treatment plans.
31
When using this model, it is important that the nurse views the client as an individual
and works in partnership with the client, in order to avoid categorizing the client as, for
example, an Asian. The action of restructuring or repatterning requires the nurse to
work with the client to make changes in health practices when these behaviours are
harmful or decrease the client’s well-being. Bartz (1993) has suggested that student
nurses must be given the opportunity to practice transcultural nursing and not simply be
taught the theory underpinning culture. These approaches suggest a holistic perspective
to nursing that considers individuals, groups and institutions involvement in interacting
systems of folk, popular or professional domains.
Campinha-Bacote (2003); Leininger (1995) and Lynam (1992) agree that sensitivity to
clients with other cultural backgrounds require that the nurse is aware of their own
personal values and biases. Cultural awareness then enables nurses to understand the
basis for their own behaviour and how it helps or hinders the delivery of holistic care to
persons from cultures other than their own. Further, culturally aware nurses recognize
that health is expressed differently across cultures and that culturally sensitive care can
be delivered in a variety of ways consistent with the client’s health. In addition,
development of cultural sensitivity occurs mainly through experiences with clients of
other cultures through the nurses’ awareness of this experience.
Conclusion
Cultural sensitivity is a personal development process that requires students to reflect on
their own culture and values, their acculturation into nursing and the bio-medical
cultures, as well as to explore their own biases, to avoid ethnocentric behaviour. In
order to interact effectively, student nurses must acknowledge differences in values
32
systems and the reasons for differences, so they can provide nursing care that is
sensitive to their clients’ health needs.
Studies in general education showed that participating in international education does
promote the development of cultural sensitivity (Bennett, 1993).The reason for this was
that international education heightens the students’ awareness of their own cultural
identity and promotes an understanding of cultural differences during the process of
transition. In addition, an international exchange prompts an understanding of political
and social factors that affect organizational structures.
Anecdotal and subjective description of international experience in nursing have
identified that characteristics such as openness, flexibility, and the importance of
acknowledging cultural differences are essential, when working with diverse cultural
groups. Reports lend support to a belief that student nurses should be given the
opportunity to practice knowledge and skills required to meet the health care needs of
people from different cultures. Clearly there is a need to explore the effects of
international experiences on student nurses in Denmark, to determine if such an
experience promotes cultural sensitivity.
33
Chapter 3 Methodology
Introduction:
This chapter describes the methodology used to conduct the study. It includes the
philosophical underpinnings of Gadamerian hermeneutic phenomenology on which this
qualitative research is based. A Gadamerian hermeneutic phenomenological approach
has frequently been used within nursing research, as it focuses on understanding and
interpreting the phenomenon of understanding, what it is and how it comes into being,
and the interpretation of the text (Heidegger, 1962; Gadamer, 1979).
The methodological approach to the study and reasons for choosing this approach:
A qualitative phenomenological design was considered to be ideal to explore whether
nursing students develop cultural sensitivity as a consequence of living and studying in
a culture that was different from their own. This study was guided by the philosophy of
Gadamerian hermeneutic phenomenology and key concepts of Gadamer’s
phenomenology that were used included Bildung or openness to meaning, preunderstanding and fusion of horizons.
A phenomenological approach was selected for the conduct of this study because a
phenomenological approach proposes to describe the meaning of the lived experience
for individuals, in order to understand their perspective. In this way, human experience
is inductively derived and described with the purpose of discovering the essence of
meaning (Morse and Field, 1995). Further, phenomenology focuses on lived experience
and is both a philosophy and research method. An underlying assumption that underpins
a phenomenological approach is that a person must communicate their experience,
whilst the researcher attempts to understand this experience.
34
Hermeneutics is concerned with the task of understanding and interpreting. Gadamer
(1989) advocated that interpretation involves ontology and language and must include
pre-understanding, which is a necessary condition for understanding. The underlying
assumptions that underpin a Hermeneutic approach are as follows: The researcher, on
the basis of common meanings given by culture and language, has a preliminary
understanding of the human experience being studied. Interpretation occurs through
analysis of the whole in order to gain new perspectives and depth of understanding. This
is achieved by examining parts of the whole and then re-examining the whole in relation
to the insight gained from the parts. Also there is no Archimedean worldview that is
atemporal and ahistorical (Palmer, 1969). Thus understanding occurs as the researcher
reflects on their own point of view while at the same time remaining open to the
similarities and differences of another’s subjective understanding of their experience.
A hermeneutic phenomenological approach has been chosen for this study, as the
research methodology was suitable for this study. The aim of this research was to
explicate and illuminate the essence of whether participation in an international learning
experience promoted the development of cultural sensitivity in student nurses, as seen
through their eyes. An open dialogical conversation, consistent with the hermeneutical
approach, was used to explore this experience, to discover the inter-subjective meanings
they attached to the development of cultural sensitivity and the intent of the
conversation – understanding the phenomena of the international learning experience as
the context for the development of cultural sensitivity, was the focus of the
conversation.
35
According to Gadamer (1986) the human capacity for understanding was believed to be
related to culture and history and is therefore not value free. Therefore objectivity is not
relevant when the focus of the enquiry is on understanding the meaning of people’s
lived experiences. Further this approach is consistent with the researcher’s belief that
one cannot remain neutral when studying other people’s lived experience, in the sense
that the history and culture of the researchers own experience will merge with the
perspectives of the participants. For this reason, an interpretative methodology is
relevant for exploring the inter-subjective phenomena of development of cultural
sensitivity, situated in a different cultural context. It is therefore appropriate to use a
phenomenological hermeneutic philosophy because it enables the researcher to explore
a phenomenon by clarifying the conditions in which understanding takes. That is, in this
study it sought to interpret the meaning of the participants’ experience through
exploring whether cultural sensitivity developed in student nurses as a consequence of
their international learning experience. This experience of learning in a culture different
from one’s own is contextual, dynamic and inter-subjective.
Phenomenology: Edmund Husserl
Phenomenology is concerned with the understanding what it is like to be human and
what meanings people attach to events of their lives (Grant & Giddings, 2002),
Phenomenology has its origins in the work of the German philosopher Edmund Husserl.
Husserl’s understanding of consciousness as an object was derived from the mind-body
split of Cartesian duality. For Husserl, human beings were subjects in a world of objects
and it was the study of the consciousness of those objects that he called phenomenology
(McKee, 1987). He claimed if consciousness was objective, it would be possible to look
at it in an objective way, hence he advocated bracketing as a fundamental movement
36
towards eliminating one’s bias whilst exploring phenomenon. By eliminating
prejudices about the world (bracketing) it is possible to describe the fundamental
structures of the world of lived experiences (Draucher, 1999). Husserl’s work was
placed within the framework of traditional logic and supported a reductionistic scientific
approach with its associated assumptions of objectivity and neutrality (Husserl, 1993).
While Husserl was purely descriptive in his exploration of a phenomenon, Heidegger
moved phenomenology into the interpretative area. He replaced the concept of knowing
within that of understanding. He believed that understanding included awareness of
one’s being, belonging to the world and relating with others (Leonard, 1989; Heidegger,
1994). The next section will briefly describe Hermeneutics, followed by an exploration
of Heideggerian and Gadamerian phenomenology.
Hermeneutics
The discipline of hermeneutics can be traced to the early Greeks. Early Greek root
words of Hermeneutics suggest the idea of understanding through language (Palmer,
1969). Further Phillips claimed that Schleiermacher redefined hermeneutics as the study
of understanding itself. This was followed by the work of Dilthey who saw
Hermeneutics as the core for disciplines such as the humanities and social sciences,
which interpret experiences and the inner life of human beings (Turner, 2003).
In the early 20th century Heidegger’s analysis suggested that interpretation is the
foundational mode of being. Heidegger’s Being and Time is referred to as an
hermeneutic, an interpretable effort that illuminates what it means to be a person in the
life world (Heidigger, 1962). Thus the relevance of hermeneutics in this study is its
37
concern with understanding human beings and the clarification of the conditions in
which understanding takes place (Gadamer, 1976).
Hermeneutics has been described as an encounter with being through language and
raises question as to the relationship of language to understanding, history, existence
and reality (Gadamer, 1975). The purpose of hermeneutical description is to achieve
understanding through interpretation of the phenomena under study. It is the written
description of the phenomenon (text) that is the object of interpretation (Palmer, 1969).
Hermeneutics then provides an effective interpretative strategy for a deeper
understanding of the people in the situation and for preserving the meaning and the
context of the experience, an important focus in this study.
Heideggerian phenomenology.
Heidegger, a student of Husserl reacted against the notion that we are observing subjects
separated from the world of objects. He believed that presupposition cannot be
bracketed or suspended, as people cannot be in the world without reference to their
background understanding. According to Heidigger (1962) human beings cannot
experience the world without pre-understanding. It is given in our culture, language and
history. While Husserl was purely descriptive in his exploration of a phenomenon
Heidigger moved phenomenology into the interpretative area. He replaced the concept
of knowing with that of understanding. Heidegger (1993) represented understanding in
his main work Sein and Zeit as a mode of being which makes knowing possible. He
referred to being in the world as Dasein. He believed understanding included awareness
of one’s being, belonging to the world and relating with others (Heidegger, 1962). He
argued that humans are self-interpreting, finding significance and meaning in their
38
world, which can only be understood in terms of people’s history or background and the
social context of the experience (Draucher, 1999). Because people are self-interpreting
they cannot be completely understood, therefore understanding others requires openness
toward an understanding of their interpretation of their reality and situation.
Gadamerian Phenomenology.
Gadamer, a student of Heidegger extended his existential ontological exploration of
understanding by providing an emphasis on language (Koch, 1996) Like Heidigger, he
refuted the notion that experiences could be studied from a neutral observer’s position,
that is detached or removed from the experience, and advocated that understanding
occurs as a consequence of a fusion of horizon. He argued that a value oriented
approach to understanding is unavoidable, because each person in interacting with
another has some pre-understanding of that which they are seeking to explore. Gadamer
(1990) considered it is only through pre-understanding that understanding is possible.
That is to say, if one does not recognize one’s pre-understanding, there is a risk that one
will fail to understand or will misjudge meaning.
Gadamer (1979) claimed that knowledge is always shared, that is, it is inter-subjective
and resides within traditions. Tradition is the shared culture, history and language
handed down to us from the past, it forms the present in which we live and shapes the
future (Gadamer, 1979). In other words, traditions and understanding are thereby
inherited through language and the unconscious processes of socialization. For
Gadamer then, we are all part of history and it is not possible to step outside history to
look at the past objectively. He saw understanding as being the fusion of the
individual’s horizon within the prejudices of history. Because Gadamer believed that
39
understanding could only be possible with historical awareness, it therefore carried
certain prejudices (Gadamer, 1990). The term prejudice refers similarly to background
horizons or frames of references, and Gadamer (1996) acknowledges:
that long before we understand ourselves through processes of
reflection we understand ourselves in a self-evident way in the
family, society and the state we live (p.276).
A Gadamerian approach then excludes the concept of bracketing, which when applied
to a research claims that the researcher must maintain a neutral stance and remove the
self from the seat of inquiry. Gadamer suggested that the knower brings background,
fore-projections, pre-understanding and prejudice to bear in the reciprocal act of
understanding, also known as the fusion of horizon (Turner, 2003; Draucher, 1999).
According to Gadamer (1990), understanding is both a process and a mode of being.
Therefore the research process is a journey, wherein the aim of the experience is not to
understand better, but to understand differently (Kvale, 1996: Koch, 1996). The
transformative effects of the research process are called a bildungsreise and includes
Gadamer’s principles that understanding is an interpretative act, that is bound up in
language. This understanding is dependent on the tradition of shared language, history
and culture and is therefore inter-subjective (Gadamer, 1979, 1989). Furthermore
understanding is not an epistemological problem but an ontological one
(Turner, 2003).
Interpretation then, is a way to grasp and recreate meaning, by being open to one’s preunderstanding and prejudices, in order that more complete or different understanding
may be clarified and reveal hidden meaning ( Allen, 1995). In addition, it illustrates
how a particular understanding comes into being ( Geanello,1998). For these reasons,
40
the hermeneutic phenomenological method used in this study acknowledged that the
phenomenon of whether students develop cultural sensitivity as a result of participating
in an international learning experience could best be understood in the context of the
participants being in the world.
The concepts used for interpretation of the text, consistent with the hermeneutic
philosophical method, include the concepts of “Bilding” or openness to meaning, preunderstanding, prejudices and fusion of horizon. “Bilding” or remaining open to
meaning facilitates the exploration of the ways in which particular pre-understanding
and prejudices come about (Kvale, 1979). The concept of pre-understanding relates to
one’s frame of reference, knowledge, personal and professional experience, as well as
the socio-political and cultural contexts in which one lives.
Gadamer (1993) claimed that understanding may only be possible through dialogue,
with one being open to the opinion of the other. In this sense, the notion of dialogue
includes the conversation between two people, as well as a dialogue between the reader
and the text. This requires awareness of one’s own bias or prejudice in order to be open
to the other’s point of view. The concept of “bildung” or openness to meaning is
important in this study as it facilitates exploring hidden meaning and unexamined
prejudices, by being open to the researcher’ own bias and prejudices, as well as being
open to the participants perception of the effects of their international experiences on
the development of cultural sensitivity. During the processes of open dialogue or
conversation and interpretation of the texts, consideration of other values and prejudices
recognizes the potential for increased or different understanding. The movement of
41
understanding is constantly from the whole to the part and back to the whole again
(Gadamer, 1989).
Prejudice/Pre-understanding:
Prejudice, a condition of understanding, determines what we understand in any given
situation (Koch, 1995). According to Gadamer (1996), there is a need to remain open to
‘the hidden prejudices that makes us deaf to what speaks through tradition’ (p.270). For
Gadamer, the notion of tradition comprises the shared understanding that is implicit in
our language, history and culture. In this way, unexamined prejudices limit our horizon
of understanding. The art of interpretation is in seeing what can be questioned and then
questioning it further (Koch, 1995). Gadamer’s interpretation therefore, enables
exploration of the ways prejudices come about. Prejudice relates to the researcher’s
value position, that is the unconscious judgement and prior understandings that
influences interpretation. Before we can understand another, we must first understand
ourselves. When encountering differences, contact with “other breaks my egocenteredness and gives me something to understand” (Gadamer 1986, p 46). Thus
openness to different understandings makes possible a movement on the part of the
participants and researcher towards ways of knowing that extends beyond their current
understanding. Reflecting upon our prejudices will enable the researcher to move
beyond pre-understanding or prejudices.
It also encourages the consideration of other possible prejudices and recognises the
potential for understanding to change and increase. In this study, the process of
interpretation is the identification of similar and different prejudices. During the
interpretative process, the researcher becomes a mediator between the text and all the
42
text implies, but not the interpretation of what the research participant meant. That is,
the text should be understood on the basis of its own frame of reference (Kvale, 1996,
Geannellos, 1999). These concepts constitute an understanding process or a fusion of
horizon.
Fusion of horizon:
A horizon, which is in continuous development, forms a transformative process. It is
comprised of things that are part of our understanding, such as our point of view, which
consists of everything that can be seen to form one perspective (Gadamer, 1990). Fusion
of horizon refers to the coming together of different vantage points through language
and conversation. This occurs when our own horizon is understood in order to
understand another, that is the points where multiple thoughts and realities of the
various participants, and the researcher intersect and draw apart (Turner, 2003). It is at
this point that the understanding of the participants and the researcher merge, and
understanding comes about, through a conscious attempt to fuse our horizon with
another. In this study, fusion of horizon is shown through explication of the researcher’s
understanding of the phenomena of development of cultural sensitivity, merged with
each participant’s conversation, as well as across their conversations. These
conversations create the texts for interpretation. The only way to reach interpretative
understanding and allow the text to reveal its truth is by the hermeneutic circle.
In this circle, the understanding of the text is the movement between the parts and the
whole. Understanding of the whole presupposes understanding of the parts, in the same
way that understanding of the parts presupposes understanding of the whole. In
principle, such a hermeneutical explication of the text is an infinite process. That is,
43
interpretation depends on the way the interpreter approaches and questions the text.
Therefore, the text may be understood and interpreted differently by the interpreter at
another time. This process however ends in practice when one has reached a sensible
meaning which is free of inner contradictions, which are referred to as a fusion of
horizons (Kvale, 1996).
Conclusion:
Hermeneutics and phenomenology is not one and the same thing. Husserl’s
phenomenology considered consciousness as an object making it therefore possible to
look at experience in an objective way. He believed that in order to understand
phenomenon, all prejudices must be eliminated. This process involved the researcher
assuming a neutral detached position. Heidegger, on the other hand, proposed that there
is no Archimedean point, no privileged position for objective knowing, but rather that
knowledge emanates from persons who are already in the world and seeking to
understand other people who are also already in the world. One is therefore always
within the hermeneutic circle of interpretation. For Gadamer, people are all part of
history and it is not possible to step outside of history to look at the past objectively. He
saw consciousness as being interpreted by the fusion of horizon within the prejudices of
history, including those provided by people and texts. Understanding therefore contains
prejudices.
A Gadamerian hermeneutic approach is therefore relevant for this study, as it allowed
the researcher to openly and deeply probe the phenomena and the meaning the
participants attributed to their understanding of the effect of their international
experience on the development of cultural sensitivity. Further pre-understanding
44
enhanced the researcher’s role as interpreter, as it enabled the researcher to explore her
own bias about the nature and understanding of the phenomenon, while at the same time
remaining open to what the literature and participants had to say throughout the study.
In this way, the researcher became a participant in the study. In addition, listening in an
open way to the participants’ stories provided them with an opportunity to express their
ideas and thoughts about the meaning of their experience. As such, the experiences of
the participants will be examined through the interpretation of the language presented in
the interviews. The method of gaining understanding and analysis of texts is discussed
in the following chapter.
45
Chapter 4 Method.
Introduction:
The philosophical underpinnings and rational for using a hermeneutic
phenomenological approach was explained in chapter 3. This chapter describes methods
employed to undertake this study. Research carried out in the Gadamerian tradition was
selected because the purpose of the research study was to achieve a deeper
understanding of the phenomenon of whether student nurses developed cultural
sensitivity as a consequence of participating in an international educational. For this
reason interviews that enabled the opening of possibilities were used. These were
conversational in nature to facilitate a contextualised portrayal of the depth and
complexity inherent in an international exchange for student nurses. The interviews
were transcribed verbatim and created the texts for analysis. The study findings have the
potential to articulate common meaning from student nurses’ experience and the
researcher’s pre-understanding of whether the context of international learning
experience developed cultural sensitivity in student nurses; and thereby extend
knowledge regarding nurses and student nurses in their interactions with patients who
are from a different cultural background.
The study participants:
The study participants were seven students who were enrolled in an undergraduatenursing course, at a school of nursing in a county in Denmark. As part of their
educational experience, they participated in an international exchange. The principal of
the school of nursing had given permission to do the study (appendix B). The eighth
participant was the researcher. To access these participants, the study’s plain language
statement and consent form (appendix C) was given to the international exchange co-
46
ordinator, asking her to disseminate it to all students who had undergone an
international exchange. The co-ordinator was asked to mail out the plain language
statement in increments of twenty until notified that a sample of seven participants,
which was deemed adequate for this study, had been obtained. The plain language
statement invited student nurses to contact me directly, if they were interested in
participating in the study. When the students contacted me, I established a date, time,
and location for us to meet, that was mutually convenient. At this meeting I answered
all questions related to the study and asked each participant to fill in a consent form and
established a date for the interview.
The participants:
Patton (2002) recommends specifying a minimum sample that would be adequate for
understanding any phenomenon. In this study, consistent with advice given by Morse
(1994), it was deemed that seven students would be an adequate number of participants.
The eighth participant was the researcher, as a Gadamerian hermeneutic
phenomenological design requires the researcher to identify how pre-understanding
influences the research. For as Gadamer (1989) explained, it is only through one’s preunderstanding that understanding is possible.
The seven student participants of this study were Danish student nurses enrolled as
nursing students in an undergraduate nursing program. A brief description and
designation of the placement where they undertook their experience follows. The brief
description is given in the order the participants were interviewed, concluding with the
researcher as the final participant.
47
Lone was a 28-year-old female student nurse enrolled in her seventh and final semester
in a bachelor of nursing program. Lone had spent a month holidaying in England two
years ago. At the time of this study she was living in the nursing residence. Lone had a
younger brother. Her international study experience took place in Jamaica and she
travelled alone. Lone was the first student nurse from Denmark to participate in a
student exchange in Jamaica.
Lena was a 25-year-old female nursing student enrolled in her fifth semester in a
bachelor of nursing program. Lena travelled with her parents in England for a one
month vacation a couple of years ago. Lena had an older sister. Lena also lived in the
nursing residence. Her international experience was in Jamaica. Lena travelled with two
other students from her class in Denmark. Lena was in the second group of student
nurses who participated in a student exchange to Jamaica. Lena travelled with Inge who
was also a participant in this study.
Bent was a 29-year-old male nursing student enrolled in his seventh and final semester
in a diploma of nursing program. He had previous experience as an exchange student in
his senior year in high school. He was the youngest of four children. His international
study experience took place in Australia.
Signe was a 27-year-old female student nurse enrolled in her seventh and final semester
in a diploma of nursing program. She had no siblings. She also lived in the nursing
residence. Her international experience took place in Australia.
48
Inge was a 29-year-old female student nurse enrolled in her fifth semester in a bachelor
of nursing program. Inge had never travelled outside the Scandinavian countries. Inge
had a younger sister. Her international experience took place in Jamaica. She travelled
with two other students from her class in Denmark. Inge was in the second group of
student nurses who participated in a student exchange to Jamaica
Jette was a 24-year-old female nursing student enrolled in her fifth semester in a
bachelor of nursing program. Jette spent many 3 week vacations with her parents in
other European countries. She had no siblings. She also lived in the nursing residence.
Her international experience took place in Malta.
Susanne was a 26-year-old female nursing student enrolled in her seventh semester in a
diploma of nursing program. She also lived in residence. She did not have any siblings.
Her international experience took place in Greenland.
Heidi was employed as a lecturer in an undergraduate-nursing program in Denmark. I
have had experience with the transition to another culture three times. The first was to
Canada where I finished secondary and tertiary education. The second transition was in
New Zealand, where I completed a university education, and taught in an undergraduate
nursing program. My final experience was the transition or re-patriation to my birth
country. In Both Denmark and New Zealand I have been involved with international
students in both the theoretical component and clinical experiences in undergraduate
nursing programs.
49
Data Collection: Gaining understanding:
In my role as course co-ordinator in the international module I had been privy to the
growth and development that occurred in students during their international experience.
As such, I brought to this study some pre-understanding about student nurses’
experience in the development of cultural sensitivity in an international context.
According to Gadamer (1990) there is no understanding without questioning. For this
reason, it was necessary for me to question my own understanding in order to be open to
what others had to say. For Gadamer (1989) asserts that in order to understand another
we must first understand ourselves. Therefore a journal describing my own
understanding was the first step in the data collection process, followed by a dialogical,
in depth interview that was conversational in nature, which was used to gain an
understanding of each participant’s international experience as seen through their eyes.
The final step in data collection was the verbatim transcription of the interviews for
interpreting the data.
The goal of the interview was to obtain a description of whether the experience of living
and learning in another culture affected the participant’s development of cultural
sensitivity. The initial question that was asked was: What was it like to live and learn in
another culture? Subsequent questions probed the verbal expressions of each
participant’s experiences and sought clarification of the meanings that they attached to
their experience. The participants were invited to reflect on aspects of their personal and
educational experience that they believed might influence the way in which they nursed
people from another culture. The questions that were asked at interview related to the
researcher’s experience and reading of the literature, the intent of this study, which was
to determine whether participating in an international experience influenced the
50
participant’s development of cultural sensitivity, and responses given by participants
during their interview. Probes were used to maintain the focus of the interview, to seek
clarification of meanings, and to probe for deeper explanation to determine the course of
the conversation (Turner, 2003; Koch, 1996: Kvale 1997; Gordon 1998).
See appendix D for sample questions.
Throughout each interview, I maintained a warm, non-judgemental attitude towards the
participants, taking care to be responsive to the participants, and concentrate on what
was said. I adopted an active listening stance, and encouraged the participants to be
reflective. These actions demonstrate an attitude of “bildung” or being open, which
encouraged movement toward understanding and interpretation.
I used a reflective journal to record nonverbal aspects of the interview, immediately
following each interview. Non - verbal communication was observed as the participants
smiling, maintaining eye contact, head nodding, and leaning forward. In addition, I used
a reflective journal to record my own thoughts and feelings about the research process
(Koch, 1996: Draucher, 1999; Turner, 2003). In this journal I recorded my own ideas,
attitudes and understanding about the development of cultural sensitivity. That is, I
described my pre-understanding, fore-projections and prejudices. These actions were
necessary to enable me to understand my own horizons about my understanding of the
development of cultural sensitivity, which was a crucial step towards understanding the
horizon of the participants (Turner, 2003; Koch, 1996). Furthermore it was important to
acknowledge that insights derived from journaling influenced the interpretative process
(Drauchen, 1999). Data obtained from the interviews, reflexive journal and ongoing
51
review of the literature created texts from which analysis of the phenomenon under
exploration was made.
Ethical Considerations
The codes of Ethics described in the Declaration of Helsinki, ethical guidelines of
Deakin University and the School of Nursing in Denmark were adhered to.
The principle of beneficence acknowledged that the participants would not be harmed in
any way. As the interview focused on the student nurses’ experiences, it is
acknowledged that sensitive issues may have arisen in the course of their conversation.
Fog (1995), states that an interview allows privileged access to a person’s lived world
and this access can be a potential source of stress. As the researcher, I was aware of this
possibility and therefore developed mechanisms in advance of the interview on how I
would handle such situations, should they arise. As part of the study method, I decided
that should the participants show sign of stress, which as an experienced comprehensive
registered nurse with skills in mental health assessment and counselling I was
competent to recognize, I would suspend the interaction, until such a time as the
participant indicated they were ready to resume. In the event the participant did not wish
to resume, for any reasons whatsoever, it was planned that they would be withdrawn
from the study without penalty and data collection to that point would not be used. It
was also planned that should stress reactions be prolonged that the participant would be
referred, at no cost to the individual to the school guidance counsellor, who would refer
for ongoing counselling, with no cost to the participants if needed. Despite these
considered measures, there were no occasions during which the participant’s
experienced stress and hence these strategies did not need to be activated.
52
The rights to self- determination and full disclosure were firstly observed through
providing to all potential participants a plain language statement that detailed
requirements of participation. After having read this statement, those who indicated
that they wished to be involved were asked to voluntarily sign an informed consent
form. Participants were informed of the aim of the research and that their participation
was entirely voluntary and that they were free to withdraw at any time. Participants
were also advised that should they choose to withdraw from the study at any time and
for any reason that they were free to do so and that any information given by them up to
that point in time would not be used.
All participants were asked to choose a pseudonym to ensure confidentiality. The
audiotape was given a separate code from the pseudonym to maintain anonymity. None
of the participants were identified personally in any manner during or following
completion of the research. The tapes and transcripts while not being used were kept in
a locked cabinet at the County School of Nursing in Denmark for six years where they
will be stored and then destroyed. Finally, ethics approval was sought and given from
the County School of Nursing’s ethics committee and Deakin University Human
Research and Ethics Committee.
Data Analysis:
Analysis of the data of this study utilized Gadamer’s philosophy of understanding the
concepts of pre-understanding, prejudice, horizon and fusion of horizon were applied in
undertaking the analysis of data. (See appendix A ). According to Turner (2003),
understanding begins with an assumption of familiarity and proceeds to listening with
openness to the unexpected and readiness to revise our preconceptions. For this reason,
53
the achievement of understanding required me to get in touch with my own
understanding about the development of cultural sensitivity prior to interacting with the
participants. In this way I became part of the whole, listening to what the participants
had to say and questioning my own and their understanding. This led to formulating and
reformulating the early ideas (fore-projections) that emerged as part of considering the
wholeness of what the participants had to say about their international experience and
its effect on the development of cultural sensitivity (Turner, 2003).
In addition, prejudices that emerged throughout the analytic process were identified and
finally the development of cultural sensitivity as a consequence of international
experience was explicated as a fusion of horizon between the researcher and the
participants of the study.
Following each interview I transcribed the audio tape(s) verbatim, to create the text for
analysis. The transcription of the texts created an overview and was in itself a beginning
of analysis (Kvale, 1996). Texts here refer not only to the written transcripts, but also to
my reflexive journal. Analysis of these texts was undertaken using an iterative process
described by Turner (2003), which is described in a further section of this chapter.
During this process, the texts and audiotapes were read and listened to over and over
again, enabling identification of prejudices and horizons that distilled the essence of
whether the participants developed cultural sensitivity as a consequence of living and
studying in a culture that is different from their own.
In analysing the data, the aim was not to understand better, but to understand differently
(Turner, 2003). To be consistent with the philosophical underpinnings of Gadamerian
54
hermeneutic phenomenology, the hermeneutical circle guided the interpretation of
meaning. “The hermeneutic task becomes of itself a questioning of things, whereby
early understanding or fore-projections become replaced by more suitable projections,
as it become clear what the meaning is.”(Turner, 2003, p10). Thus within the context of
the hermeneutic circle, understanding moves as we circle from the whole to the parts,
and back to the whole, continually revising our understanding, as more parts of the
whole come into view (Turner, 2003). During this process the purpose is not to
eliminate prejudices, but to identify our pre-understanding, as well as discriminate our
horizon and the horizon of others through the process of questioning of our beliefs and
values. Understanding will appear through the fusion of horizon by the participants and
researcher, where horizon is defined as the field of vision, which includes and
comprises everything that can be seen from one perspective (Gadamer, 1990). Because
the horizon of the present is in continuous development, understanding of the
participants and researcher will merge into new understanding.
According to Kvale (1996) analysis ends in practice when no new meaning emerge
from the texts, that is, when a valid unitary meaning, free of inner contradictions is
reached. During the process of interpretation the researcher interacts with the text by
asking questions of what it means. At the same time the researcher questions their
beliefs and values to uncover hidden meaning and contradictions in the researcher’s
understanding.
The texts generated from the reflexive journal were used as a filter to understand and
interpret meaning during the interaction with the participants, exploration of the
literature and interaction with the texts generated from the interviews. At the same time
55
the interviewer remained open to different meanings of the development of cultural
sensitivity as seen through the student nurses eyes, based on their experience of living
and learning in another culture.
Turner’s (2004) method of analysis was used to interrogate the data and this process
was as follows:
1. Before I undertook my interviews I deeply contemplated what I believed about
whether being involved in an international exchange will help to develop cultural
sensitivity. I journalled my thoughts about this, which enabled me to become clear and
to identify my own unique reflections and pre-understanding, prejudices and horizons of
this phenomenon.
2. I began the interviews and listened attentively to what the participants had to say. I
did not draw conclusions, but I did note when things were said that resonated with my
own prior beliefs. I also noted when things were said that were different to what I
expected. At this stage I made a conscious decision to not form opinions or draw
conclusions about what I was hearing, because I was prepared for each person’s story to
reveal something new to me. In other words, I allowed my understanding of the
phenomenon being explored to be influenced by what each participant shared with me.
However, as the participants shared their ideas, I probed these ideas with them, through
asking them questions that would enable me to become clear about what they were
expressing. At this stage I was mindful that the intent of probing was not to draw
conclusions, but to achieve understanding. This demonstrated an attitude of Bildung, or
being open to meaning.
3. When the interviews were completed, I transcribed them verbatim, to create the text
for analysis. I then read and listened to the texts and audiotapes over and over again, to
56
gain a sense of the whole of each participant’s story as well as its parts. I noted
similarities and differences in expressions, both across and between participants, and I
listed ideas each participant’s expressed ideas, that is their prejudices, or the ways they
understood the phenomenon of developing cultural sensitivity.
4. Having identified the prejudices of the participants, myself included, I then began the
process of grouping and re-grouping their prejudices in meaningful ways. This enabled
me to identify the various horizons that expressed each participant’s unique experience
of developing cultural sensitivity. At this point, I considered a variety of words of
phrases that could identify their horizons and encapsulate the phenomenon under
consideration. Although there were some similarities in the horizons of each
participant, there were also some differences, and I was conscious of the need to not
lose these. In this sense then, analysis was an additive process.
5. Having identified the horizons of this phenomenon across each participant, I then
began to pull them together in meaningful ways, to create a fusion of horizons, leading
to the development of a succinct statement that described the phenomenon of
developing cultural sensitivity following an international exchange.
Trustworthiness of the study:
Trustworthiness (rigour) is dependent on the ontological and epistemological
assumptions underpinning the study. Lincoln and Guba (1985) have suggested four
criteria to establish trustworthiness or validity of qualitative data. These are credibility,
dependability, confirmability and transferability. These are built into the process of the
study and as such criterion strategies were part of the iterative process of the study.
Credibility refers to the confidence to the truth of the data and its interpretation. In this
study strategies for achieving credibility were methodological coherence, and
57
researcher’s responsiveness. Methodological coherence is part of the process of the
study. That is, it is iterative rather than linear, wherein the researcher moves back and
forth between design and implementation to ensure congruence among question
formulation, literature, recruitment, data collection and analysis. This is supported by
Kvale (1996) who stated that the purpose of validity was to discern truth and he also
argued for coherence. He stated that coherence provided logic and consistency,
reflecting the intent of exploring the unique and context dependent experience of the
participants. Researcher responsiveness was achieved by the researcher maintaining
integrity, mutual trust and respect by being open, remaining sensitive while listening to
each participant’s story to ensure the participants’ perspectives were represented as
clearly as possible. Use of direct quotes maintained from the text enable the reader to
participate in the validation of the data.
Dependability according to Guba and Lincoln (1985) refers to the stability of data over
time and over conditions. Description of theoretical and methodological decisions was
explicated throughout the study. This included the journal of the researchers own preunderstanding of the phenomenon, as the hermeneutic inquiry is affected by the
researcher’s own values (Kock, 1996). For Gadamer understanding can only be
achieved by consensus of the whole and part of the text. This offers a standard for
trustworthiness related to the processes. It is however questionable whether the criterion
of dependability can be attributed to this study as my horizons and those of the
participants has and will change, therefore, interpretation of data will change over time.
Confirmability refers to the objectivity or neutrality of the data. Consistent with the
hermeneutic study, the researcher did not assume a detached, objective position, but
58
included her own prejudice as part of the data. Therefore although confirmability is
pertinent to this study, it incorporates the notion that confirmability includes the
researcher’s own bias and understanding was part of the data. This study acknowledged
that multiple realities were possible as well as dynamic and changing, depending on the
time and person reading the text.
Objectivity in hermeneutic research can be understood as being open and listening
faithfully to the audiotapes to create the text from the interviews and this was achieved.
Transferability according to Lincoln and Guba (1985) refer to generalizability of the
data, that is the extent to which the findings can be transferred to other settings or
group. In this study the sample size was only seven participants. It was acknowledged
from the outset that the intent of this study was not to generalize; but rather to provide a
rich and deep description of the phenomenon of developing cultural sensitivity from the
limited perspective of the shareholders of this experience. Therefore, although the
findings of this study will definitely have relevance and meaning to the participants of
this study, I cannot say with certainty that they will resonate with others who have
undertaken an undergraduate educational exchange.
Conclusion:
In this chapter the methods used to conduct this research were explained, as were the
reasons for choosing a Gadamerian phenomenological hermeneutical approach to
conduct the study. Furthermore, the identification of the way the participants were
recruited laid the foundation for the conditions for the researcher and the participants to
establish rapport and build a relationship. A brief description of each participant, with
focus on the destination of their international experience was given, to provide the
59
reader with an appreciation of the context in which each participant reflected on the
development of cultural sensitivity.
The use of open dialogical interviews provided the means for the researcher and
participants to interact with each other, to explore the participants’ perception of
whether the international experience affected their development of cultural sensitivity..
Ethical issues of maintaining confidentiality, support for the participants and ethical
approval were described. Finally the importance of establishing congruence between
the study methodology and methods, in order to maintain rigour as part of the process of
the study was identified
60
Chapter 5: Findings
This chapter presents the findings of the qualitative study undertaken to understand the
student nurses’ perception of the development of cultural sensitivity in the context of an
international learning experience. Cultural sensitivity is described as an individual’s
responses to cultural differences and perspectives of people from other cultures
(Bhawuk and Brislin, 1992; Bennett, 1986). It is developmental in nature, implying that
cultural sensitivity is a gradual process of personal maturation from ethnocentrism
towards ethnorelativism (Bennett, 1986), which might lead to enhanced client care in
nursing practice.
As described in the methodology and method chapters the findings are presented in a
manner consistent with the methodological approach. According to Gadamer (1989) it
is only through one’s pre-understanding that understanding is possible. Therefore this
chapter begins with my pre-understanding about international education as the context
for developing cultural sensitivity. This provides the vehicle for reflecting on my
presuppositions as well as an opportunity to question the data to reveal early
understanding or fore structures. This is followed by identification of prejudices or
projections of the whole. Finally a fusion of horizon of the participants of the
phenomenon of international education as a context for developing cultural sensitivity
are explicated (Turner, 2003)
Pre-understanding
When I first started this study I was of the opinion that immersion in another culture
enhanced culture sensitivity, but as I began writing my journal I became unsure of my
assumption. The following is an excerpt from my journal:
61
As I began to write my journal I began to question myself in regards to my
assumption. I thought living and learning in a foreign environment would
increase the students’ awareness of differences and therefore make them
more sensitive to other people who are different. As I thought about this
assumption I began to realize how superficial it was. This led to my
reflection on my times as an immigrant. I remember immigrating to
Canada as a teenager. I remember the Canadians as being very open,
friendly and interested in you as a person and I adapted quickly. Then I
began to compare this experience to immigrating to New Zealand as a
young adult. It took me a while to adapt. I can remember New Zealanders
at that period in time as being more closed and more interested in how I
liked their country… or could it be that I wasn’t as open to new experience
at this time in my life? These experiences have highlighted for me that my
initial assumption was very narrow…I began to wonder about the
students’ process in adjusting to a different learning environment… What
were the factors, that facilitate their process of adjusting from their home
to the host culture …How do these factors play a part in their
understanding and respecting differences among people from diverse
cultural backgrounds?
In my work with international students during these last four year I have
always been impressed with the students’ enthusiasm, tolerance and
interest in each other. I write that that because one of the assignments was
group work and they were graded as a group. Each group consisted of
differences in gender, age or culture where possible. Although some of
the students had never written an assignment as a group let alone get the
same grade they worked well in these groups…I guess some of the
characteristics they displayed were openness, caring for each other,
frustration and anger at times as the level of motivation among the
students varied, they managed to support and challenge each other
effectively. Teaching methods also varied. We used a lot of discussion and
working in groups during class time… one day an angry outburst came
from one of the Australian students in relation to the Danish press and
other Danish student referring to immigrants’ children as second and
third generation immigrants. This really affected this student as her father
came from Italy and as she said that would make her a second generation
immigrant and she had never thought of herself as anything but an
Australian. This led to a discussion in class about how different cultures
view immigrants and refugees who settle in their country. I guess I learn a
lot from the students. The discussion about the way we perceive
differences and treat immigrants in different countries made me aware of
how important it is for me as a teacher to reflect with the students about
their experiences.
Further journal entries revealed:
Additional thinking about my experience with international students made
me realize how fortunate I was in my interaction with the international
students. We were only a small group of maximum 12 students. Many field
trips were included in the course and it was often during these trips that
students reflected on their experiences and some of the differences they
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encountered. One thing I noted was the need to compare cultures
throughout the course…I wondered if the students of this study had similar
experiences… I can remember my parents comparing Denmark and
Canada on a regular basis. I began to wonder if exchange students shared
some of the similar experiences immigrants have.
Some of the frustrations the international students experienced in
Denmark were in clinical. Some clinical places were not as open and
accommodating as expected. Other placements allowed the students to
observe but not participate…In reading the students’ reflective journals I
was amazed at one comment about the experience of being a foreigner and
not speaking the language could be very isolating. This student further
commented, this experience made her more aware of her own
culture…Unfortunately she didn’t elaborate more…. And I was left
wondering what that statement meant for her….and I began to wonder if
feeling different to the majority culture enhances your understanding of
what it means to be marginalized in a minority group in your home
culture.
Further journal entries expressed the following thoughts and questions:
Through the four years I have been involved with international students I
noted a great deal of variability in the students’ attitudes and motivation.
Some students have clearly stated that this course was a way of seeing
Europe and having a good time. Other students were more serious and
wanted to understand the Danish health care system. Still other students
wanted to experience a different dimension of nursing. Some students were
outgoing, and open to new experiences, others were shy and some very
critical of some of the differences in teaching style. I wondered how the
students’ attitudes and motivation influenced their understanding of
diversity and realized I had some gaps that needed to be filled.
I reasoned that:
Study abroad provides the students with an opportunity to experience
diversity. I believe this has the potential to challenge the student’
established perspectives and thereby enable them to shift their frame of
reference to the perspective of someone from another culture, but what is
the process that encourages the students to step out of their own world
view and embrace multiple points of view?
My understanding of international education influenced my interaction with the
participants. I also used this understanding as a background to ask questions of the
literature and the texts created from the interviews, as I interacted with both. This
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enabled me to look for the meaning the participants attributed to their international
experience in order to expand my understanding.
Foreprojections or early understandings
After reflecting and questioning my pre-understanding, at the same time considering
their influences on myself and the data, I came to an early understanding of what the
participants were telling me about their international experience as a context for
developing cultural sensitivity. The next step of the analytic process was to allow the
participants’ expectations or projections known as prejudices (see Appendix A) about
the whole of the experience to surface and to discriminate among them. This step
considered each data set as a whole, while questioning how these ideas could be
understood in a meaningful way. This step involved considering each interview or data
set as a whole, while questioning how these prejudices or expectation reflected the
essences of what a participant was telling me. This process required movement from the
whole of the data set to the parts and back to the whole repeatedly, in order to identify a
number of prejudices or horizons; that is the participants’particular viewpoints, which
are constantly in the process of formation and are shaped by the participants’ past and
present (Gadamer, 1989; Turner, 2003) experiences . These prejudices or horizons will
be presented under the names of each participant.
Lone
Lone was enthusiastic about the opportunity to reflect on her international experience as
a process for the development of cultural sensitivity at a psychiatric state hospital in
Jamaica. Lone undertook this experience alone.
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As I considered the totality of the conversation I shared with Lone, four dominant
horizons or prejudices emerged. They were:
∙ Experiencing transition as a bit of a shock
∙ Gaining insight into socio-political influences on health care
∙ Feeling different, noticing differences and crossing barriers
∙ Transforming
Experiencing transition as a bit of a shock
Lone described transition as a bit of a shock during the first few days. It began at the
airport, followed by her own admission to a hospital and her initial experience in a
psychiatric ward as a student nurse,
I was really looking forward to the experience. I went alone ready for a
totally new experience. I had been promised that I would be picked up at
the airport, but no one came. I had to use my own initiative and problem
solve on my own and find my own way in a country where I had no idea of
their transport and buses. I felt scared and rejected at first. It made me
realize I could cope in a new environment.
When Lone spoke of her hospital admission she said:
There was a different hospital structure from home. The accident and
emergency department was one big room. There were no dividers. It was
very primitive.
When I asked Lone how she felt, she said:
I felt very alone. The nurses didn’t show caring in the same way they do at
home…they did not talk to you. It is not that they were cold; in fact they
are very warm people. They were just very active.
In relation to her own discharge from the hospital, she said:
They discharged me too soon. That wouldn’t have happened in Denmark.
You had to pay for your hospital stay here.
When Lone spoke about her first impression of the psychiatric hospital she said
It was a shock the first few days; I asked myself where am I? Is this year
2003? I had read about Jamaica and their welfare system, which isn’t a
welfare system.
When I asked Lone how she felt about those conditions, she reflected:
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I felt very frustrated. I was in acute psychiatric ward where we admitted
patients in acute psychosis. We gave them medication and send them
home. They were readmitted quickly because either they hadn’t taken their
medicine. They had no money…psychiatric patients are labelled and
marginalized. I wondered why the treatment wasn’t more advanced.
Lone talked her experience on a psychiatric ward in general and said:
The patients were given their medicine and meals at specific times, then
the patients went back to a room that housed 20 patients. They had an old
iron bed with two mattresses. You didn’t sit down and talk to them…That
surprised me. In Denmark we know the importance of talking to and being
with the patients…I felt very frustrated about the poor conditions and the
smell of urine.
Gaining insight into socio-political influences on health care
Lone reflected on the reasons for the differences in health care and how it motivated her
to talk with a nurse to understand the differences and in relation to this, she said.
There was huge poverty and the very rich…There were many who got sick
unnecessary. The state paid for hospitalization, but on discharge the
patients got a lot of prescriptions they did not fill and then they didn’t get
the medicine they needed… If that had been in Denmark the patients could
go to their own G.P and get free healthcare and some financial assistance
with their medication.
She also said:
It is a huge problem; there is a lot of violence, readmissions and overbookings in the psychiatric services. It made me understand the
importance of the structure of society and its impact on health care as
reflected by the lack of resources.
On further reflection she explained:
Having the opportunity to experience a different health care system made
me realize the influences of social structures and economy on health care.
It was not until this experience that I understood why we learned about
health structures and health budgets in class in Denmark. Before this trip I
thought it was a waste of time and couldn’t see its relevance to nursing.
Now I understand that nursing is more than one to one nursing care and
that politics influence the way health care is resourced
Feeling different, noticing differences and crossing barriers
Throughout our conversation Lone spoke about her experience of feeling different, of
what it feels like to be part of a minority from the others in the Jamaican society. She
revealed:
The psychiatric patients refused to talk to me at first because I looked
different It is the first time in my life I am the one who is different 24 hours
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in a day. It was difficult to gain the patients trust, and when it happened
they couldn’t understand I continued to talk to them.
When I asked Lone how she coped with being different, she replied:
It gave me some insight into what it is like to feel different and gave me a
deeper understanding of the different experiences people have and that it
takes time to adapt to a new situation. It also made me more aware of my
own behaviour and the importance of being non-judgemental toward
people who are different from oneself. I will give you an example. During
the first week I overtook everyone. It was not until one of the other nurses
asked me why I walked so fast, did I have an appointment. I wasn’t even
aware that I walked faster than the others. I didn’t think I walked very
fast. I just walked in my own tempo. But all of a sudden I walked slower
and no longer noted the stench of urine. I laughed several times about my
hurry in the beginning of my stay.
Lone described other differences she encountered in relation to their use of time when
going on duty:
When I meet on duty I always arrive 10 minutes before to be ready for
report. I was always the first one there. They sometimes come half an hour
to an hour later than designated time. The night staff did not go before
someone had arrived. My first morning I thought I was in the wrong place
and got quite nervous… the staff told me if I wanted to go home before the
staff met just to go home. I could not do it. I realized meeting late for duty
was not acceptable for me. Being on time was so entrenched in my culture
that I could not break this pattern. When I talked with the nurses about
that they could not understand such a rigid timetable.
Later on she talked about her reaction to medicine not being given on time:
When I asked them if they should not have their medicine at 10 o’clock,
they laughed and said they were just going to finish eating. At first I
thought how uncaring they were, but after a while I just adapted to their
ways by understanding the nature of the medicine. It made me think about
how relaxed they were compared to the stress we experience at home, and
perhaps we could learn something from their culture.
Further on in the conversation Lone talked about the ways barriers were overcome. She
said:
It was about me getting used to being there, especially visually, as I was
so different in appearance. The registered nurses called a meeting and
invited me to tell the patients and the staff why I was there, that I was a
student nurse on a learning exchange. When the patients realized I was
not a white spirit, that would harm them, some of patients began to accept
me. Those, who accepted me I got close to.
She relayed:
I really tried to understand their ways and not impose mine. I did not want
to give them the impression that their ways were wrong. Their nursing
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education is quite different to ours. They begin at 16 and the students were
treated differently to me. The nursing students had to sit in the back and I
got to sit with the registered nurses, as I was considered a nurse because I
was doing a bachelor degree in nursing.
Lone talked about other factors that helped her adjust outside the hospital environment.
She described a situation with a taxi cab driver:
When people found out I was not a tourist I was treated with respect and
he showed a lot of interest in me and wanted to learn about Denmark. I
even got the taxi fare to half price. The Jamaicans showed outsiders such
as my-self interest, engagement and hospitality. Although I don’t want to
generalize I don’t feel we are as open and hospitable at home to outsiders.
She later revealed:
Because I was a white girl I could not travel freely on my own, without
being harassed. One of my teachers on campus became my mentor and he
looked after me and ensured I got home safe when I went out. That is so
different from Denmark where you can go anywhere freely.
When Lone spoke of her life at campus where she lived, she said:
Life at campus was tremendous. It was very lively. Other students came
over to me asked who I was and invited me to parties. They asked me if I
knew how to get there and offered me help and assistance. They were very
interested in me and very helpful. I didn’t even need to ask for help.
Transforming
Lone had a sense of how the experience made her more aware of her values and the
need to accept the values of others
Living the experience gave me much more then reading and talking about
it, it made me feel what it was like to be the outsider, it made me question
my own values and gave me a new understanding of what it is like to be
in a different situation and that it takes time to adapt to a new
environment.
Further on in the conversation she reflected:
After this experience I take more time to listen to patients from other
cultures and different backgrounds by showing an interest in them and
what they have experienced, and spend more time with them. I now
question the difference between their values and my own.
Later on she added:
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This experience has made me reflect on how open, spontaneous and
interested the Jamaicans were in me and how closed we may appear to
people from other cultures. It made me think what it is like for a registered
nurse that comes from another country working in a hospital ward. After
this experience I would be more open and welcoming and invite her home
for dinner.
Lena
Like Lone, Lena expressed excitement and thanked me for the opportunity to reflect on
her international experience in a hospice in Jamaica. Unlike Lone, Lena travelled with
two other classmates from Denmark. One of the other classmates Inge, also
participated in this study. Through the analysis of the international experience as a
context for development of cultural sensitivity four dominant horizons and prejudices
emerged. They were:
∙ Inner feeling of chaos
 Broadening my horizon
∙ connecting with others
∙ Growing personally
These horizons and prejudices will now be discussed.
An inner feeling of chaos
Lena talked about her initial feelings of excitement, curiosity and impressions about
participating in an international experience. She said:
I was really looking forward to go to Jamaica to meet different people and
another culture. It was a strange feeling landing in Kingston with two of
my classmates. It was full of people who looked different from us. People
were so helpful and our mentor met us and helped us find our
accommodation and ensured we got settled at the campus. She was so
friendly. We were given accommodation with our own kitchen. The other
students just had a room…At first we felt a little unsure and kept together
and did not really mix with the others…it was very different and very
interesting. Nursing practice was much broader than I had experienced in
Denmark. The nursing staff had more responsibilities and tasks than
Danish Nurses…the country I was in seemed much poorer than Denmark
and there were not the same resources to practice nursing, which made
me think of the conditions in Denmark and how lucky we are.
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Later on in the conversation Lena said:
It was not until we started classes that we began to interact more with the
Jamaican students…that was regrettable but we needed the reassurance of
each other in the beginning to talk about the differences.
In relation to this, she said:
It was very different and exciting, but sometimes frustrating. I was really
glad that I come away with Danish girls, because sometimes I did not
understand the meaning of what was said. We were able to help each
other with the meaning… but generally I did not feel the language a
hindrance…there are many ways of communicating, body language,
singing together and sign language
Further in the conversation Lena reflected:
After I came home I had an inner feeling of chaos, I think it was because
of so many new impressions. I couldn’t understand I was back in
Denmark, mentally I was still in Jamaica
When I asked her why she felt that way. Lena said:
I think it was because I wanted to be there longer and I didn’t feel I was
finished with the experience and I became so involved with the people and
probably because I am very emotional person and then had to end it
suddenly. Immediately I arrived home I had to start clinical in Denmark
Broadening my horizon
Lena spoke about how she became her more aware of her own culture in the context of
another culture while perceiving the differences in her host culture. This was
particularly clear when she reflected on lifestyles:
Meeting people who live different with limited economic resources, made
me more aware that I am privileged living in Denmark where education is
free; I can participate in a student exchange. I talked to some student
nurses there who would like to come to Denmark, but they couldn’t afford
it. We told them they could stay with us, free room and board, but they
simply didn’t have the resources… It made me feel very humble.
And in relation to this she said:
I wondered why they weren’t stressed about their lack of money, but
interpersonal relationships seemed more important than money, family
support and extended family made them more relaxed and they didn’t
worry about money. Their pace of life was much slower. They were more
spiritual. They believed their spiritual faith could make them well…I
wondered how I could learn to change and take things less serious and not
stress about life.
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Later on she revealed:
Their spiritual faith broadened my horizon as I reflected on my own faith.
I considered myself a Christian. I have always attended church, but I feel
the meeting with the Jamaicans made me more aware of my own faith, and
I attended church with them because the patients needed prayer.... it
broadened my vision of the different ways people live their lives and how I
could learn from them … think I have a better understanding of people
who are different.
Lena also talked about some differences that really impressed her. She said:
In the hospice where I had my clinical they had a Zone therapy centre,
where they used alternative treatment. Care was focused on the spiritual
dimension. It was a very important part of caring for patients and staff
and the whole population…and I become convinced it is very essential
part of nursing
When I asked Lena if she become more open to differences because of this experience,
she replied:
I don’t think I am more open, I always considered myself open to changes,
and I have always accepted people who are different, but now I spent time
with people who are different and show more understanding of their
differences.
Lena also talked about what cultural sensitivity meant to her and how this experience
had made her more aware to acknowledge difference. She said:
Before the trip I have met people from other cultures in clinical practice,
but I now I realize that I didn’t really consider the differences, and what it
means to adapt to a new environment…I think I now have a better
understanding of what it means to be different and be more aware of their
life style and their social background and what it means to them and that
people’s culture is important to peoples health…I think of how the
Jamaicans used prayer to make them better…that is so different from the
technology we use here to make people better.
Connecting with others
Throughout the interview Lena revealed it was important to feel connected to the other
two Danish students;
It was important to talk about our feelings, share the different experiences,
and talk to someone with a similar cultural background and language and
relax together…Being in another country made me realize how important
a support group from your own background is.
Later in the interview, she said:
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All three of us had to acknowledge, we found strength in each other at
different times during our stay, especially in the beginning
When I asked Lena to reflect on an incident when she cared for a Jamaican patient she
relayed an experience with a 22 year old Jamaican girl with AIDS:
It was a hard situation, it has affected me there and after I came home. It
was very fulfilling to be with her and I could feel she was pleased for me
to nurse her. We connected …it felt that it was more than a nurse/client
relationship, we got really close … she asked about my life and my family
and what it was like to live in Denmark and then she told me about her
own life ……that was quite rough compared to mine.
.
I asked Lena how she managed that situation. She reflected:
That situation demanded I was present, listening to her, and finding a way
to make her comfortable…. she liked me to massage her feet.
She later said:
It was a hard experience…it helped to talk to the other girls about the
situation to help me deal with it effectively
Later in the interview, she reflected:
In the beginning of our stay we remained close together, but after we
began attending classes with the other students, we began to talk with
them, and interact more with them in the student residence. They plaited
our hair and we listened to their music and they listened to ours. I
regretted that didn’t happen earlier there was no limitation to their
hospitality and interest in our background and us. One gave us massages
when we came back from clinical.
Growing personally
Lena expressed how this student exchange had challenged her to confront uncertainty in
new situations. She reflected:
I can remember one situation in class. The students were asked to stand
individually and talked about their philosophy on life. I remember being
really impressed and wondered why we didn’t do that in Denmark. When
the other students were finished, the teacher turned to us and asked us
what our philosophy on life was... at first we froze, we hadn’t expected to
be involved and I don’t think we as Danes place as much emphasis on our
life philosophy in comparison to the Jamaicans. Anyway I stood up and
at the spur of the moment talked about what I believed in… in English,
and the other two followed suit. Then we had to explain what it was like to
be a student nurse in Denmark. Following this episode I told myself if I
can manage this, I can manage my oral exam at the end of the semester in
Denmark. It gave me some self-confidence and belief in myself that I can
manage new situations.
Later on Lena said she had begun to question some of her values that had led to some
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changes inside her. She said
After I came home I began to interact more with some of the girls in
residence, now I knock on their doors instead of just going to my room.
She later added:
I think it is important to accept differences, but I also believe it is
important to be able to cope with being different
I think it would be useful if more people had some cultural experience
outside their normal existence
Bent
I would describe Bent as very enthusiastic as he shared his ideas about his international
experience at a University in Australia in relation to the process of development
of cultural sensitivity. Four dominant horizons and prejudices emerged from the
conversation. They were:
∙ Confronting differences
∙ Developing social networks
∙ Seeing the world differently
∙ Developing confidence and coping
These horizons and prejudices are now discussed.
Confronting differences
Throughout his conversation with me Bent spoke about unmet or divergent
expectations, respecting and appreciating differences.
When I asked Bent what it was like to live and study in another country, he said
It was all that I expected to be. It was nice to live in another country and
breathe the experience. You are there and your taking it all in and it is not
just for two weeks, you experience the good and the bad…going abroad is
very different everyday is a new experience, I was there for five months
there was something new I learned every day
Bent revealed his feelings of frustration and disappointment with the different teaching
styles:
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The relationship to teachers were not as close as in Denmark…and what
disappointed me the teachers attitudes were not open to discussion, even
though I had a good argument
I asked Bent how he managed that difference. He said:
I pretty much had to walk away from the situation…whereas at home if I
have a problem they are open to my suggestion………I was disappointed
that in a place where I actually thought they were more advanced, I felt it
was a backward step, if there is no room for dialogue. I don’t agree with
this. You lose something in the relationship with the teacher. They are just
going to tell me what I need to know - You lose the motivation
to learn
He later said:
In the school we did not have a lot to do with the teachers, we came in and
they taught us what they wanted to teach us… continually tried to get this
dialogue going if not with the teachers, then with the students…only to be
told by the students that because I am from Denmark and not Australia I
had to realize that is not the way we do it here
In relation to this he said:
There were 150 to 200 students in class looking down at a teacher with a
power point presentation. The shock was there was so many people in the
class and there was no place for single student…we had these other
classes that were more focused on discussion and they were pretty
interesting…we got to talk and they were pretty interesting, but they were
only a few per week it didn’t add up. I would have preferred more of them
than the lectures.
Bent also revealed his feelings of anxiety about the lack of support in writing
assignments:
I couldn’t find any teacher to help with the assignments, like they do at
home… had lots of problems with writing assignment,..another reason
was the timing of clinical and theory did not link…….I was doing two
courses one in clinical and one in theory…so after clinical I had to bike 12
km. to attend classes, so I was pretty exhausted
Later on in the conversation, he reflected
I tried to solve the problem my asking his room mates from other countries
how they dealt with assignment writing and the Australian students
Developing social networks
Bent spoke about the importance of the relationship with other exchange students
helped him to adjust:
I lived with 2 other Danish guys, 2 Americans and two Australians in a
house we rented together…That was different, having to be responsible
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for lease was a big responsibility…we talked about differences in food,
cooking and shared recipes… I even had to taste vegemite.
Later he added:
I could talk with these guys…they could identify with my problems and
gave me advice and support and helped me figure it out…it helped me to
have other people around who could see the problem from both sides
Seeing the world differently
Bent spoke of his excitement about meeting different people in his clinical experiences,
and the different opportunities clinical offered; it was unlike any education he had ever
undertaken:
It was really a very good experience out there…that was probably the
biggest experience being and working in places where nobody else gets to
go unless you go as a student where you get to be on a ward and do the
things that happen, that was the best part of…The nurses and patients that
you meet are open and interested in your background… there were so
many cultures, Iris, English and Aborigines…when you meet people from
the first time it wasn’t long before we found something to relate to because
we all came from somewhere else.
Further on in the conversation he said:
You want other people to accept you…that made me think that other
people from other countries want me to accept their values…unless it
involves hurting people…there are limits to my acceptance
I asked Bent to tell me what cultural sensitivity meant to him, he said
Acknowledge other cultures…we need to have respect and acceptance for
what we believe in, and the way we want to do things and not judge
cultures as being right or wrong… Once in a while you don’t have to
accept it …there are some situations like circumcision in Africa that is
disgusting and shouldn’t take place, but then again that has taken place
for hundreds of years
He also spoke becoming more aware of his own culture:
I like the values I grown up with all my life and I realized it was for
important for me for people to accept me as I am…that has helped me
understand that people from other countries may feel insecure in their new
environment… I now spent more time when I give them information in
clinical and feel more confident to ensure there is no misunderstanding
…just because they say yes does not necessarily mean they understand
and they may need more information.
He later said:
My first clinical was in a general ward with burn trauma victims
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You get out there and you get to see and experience the difference…what
surprised me was the build up of this hospital and facilities. I am used to
vinyl floors … here some of the floors were carpeted, I wandered how they
kept them clean…and uniforms were all different…The nurses wore their
uniforms home and some took public transport home with their uniforms
on… I asked the nurses why they didn’t have a uniform that is given to
them and laundered by the hospitals…the nurses were open and willing to
discuss this issue.
He later reflected:
I was wondering if we were too cautious at home…I heard someone say
there was no proof that wearing uniforms home affected the risk of
infection…another difference that made me wonder was the how easy it
was to get antibiotics…There was a campaign asking parents not to ask
for antibiotics…there was a problem with resistance to antibiotics… that
made me wonder.
When he spoke of his clinical teacher, he said:
I was also very impressed with the clinical teacher the school hired to
follow us in the weeks we were there…also the room we had as students to
take time out to reflect…the clinical teacher arranged for me to go and see
things in our clinical practice time…as part of my clinical I spent two
weeks at a national workshop demonstrating the most advanced prosthesis
for burns victims who had lost limbs.
Developing confidence and coping
Bent spoke about how participation in the international experience had increased his
self confidence and help him cope and be more accepting in new situations:
I was not the same when I came back, something happens to you when you
are away on your own
In relation to this he said
When you leave everything behind you treasure and you go away for five
months in a foreign country you have to figure out ways…it is different
from being a tourist… you are alone a lot, you have to be open and you
will get someone to talk to and by doing that you grow up and learn
things…I am more open. …and not afraid to do new things…for example
….yesterday I had to tell a dying patient’s mother that it would be fairly
soon…It was sad…but going in there and asking her to sit down and talk
with her was a skill in confidence that I learned from going out and having
to cope on my own
Signe
Like the other participants, Signe expressed gratitude for the opportunity to relive her
international experience. For Signe the essence of the international experience as a
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context for the development of cultural sensitivity revealed four horizons and prejudices
emerged. They were.
∙ Experie cing differences
∙ Dealing with stress and disappointment
∙ Getting support from other students
∙ Becoming more accepting of multiple points of view
These horizons and prejudices will now be discussed.
Experiencing differences
Signe spoke about being nervous and excited about the opportunity of learning another
dimension of nursing at an Australian university. She said:
Before leaving home I worried about travelling alone…what if I didn’t
make any contacts or friends…two students collected me at the airport
and showed me to my accommodation…that was a house with seven
Australian students and myself…Here 4 other students received me well…
I will give you an example…I had no cash only my visa card that showed
no available funds …that was scary… and I thought what if I don’t get any
money…immediately one of the students gave me a fifty dollar note with
the comment that I could use this to get started and pay him back when I
sorted my visa account… that was really trusting and gave me some
confidence…I was very excited and I was going to have half a year
experiencing new and exciting things…I was full of positive
thoughts and feelings.
When Signe spoke about meeting other exchange students she said:
We were two hundred exchange students who participated in a three day
introduction …that was really exciting to find out and talk about their
lives and studies in their own countries… you had to be really open and
non judgemental and interested in their life styles to learn more…I talked
with students from Malaysia and Hong Kong…I can remember one night
when we had dinner with a student from Hong Kong…He ate with his
bowl right up to his mouth, slurping and burping while he was eating…at
first I thought he was rude…and I started to laugh …he just kept eating
and didn’t even register that I was laughing…I thought about it and
realized that may have been his normal way of eating. I also met two other
Danish and Swedish Students whom I maintained contact with during my
stay.
Later on in our conversation, Signe talked about the hospitality of the Australian
people:
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One of the Australian students invited us to his home. We rented a car and
his mother made up the beds, ran a bath for us and gave us great food and
really made a fuss…they were much more hospitable than the Danes… we
could learn something from them
When she talked about classes, she said the following:
The first 14 days were difficult, getting used to language and the
Australian accent, and sometimes I didn’t understand everything…all in
all it was very interesting…they had a totally different way of doing things
compared to home…it was very exciting being at the university there were
so many different people and we took different classes …my course was in
psychiatry. The way of teaching was totally different… they had sessions
where they used an actor to demonstrate a psychiatric illness…This way
of teaching was a great way to prepare for clinical experience.
Dealing with stress and disappointment
Signe talked about the stress of dealing with new situations. She expressed frustration
and uncertainty in regards to completing her assignments:
I had no idea what their expectations were regarding assignments. Their
assignment writing style was very different to ours I asked a teacher, but
didn’t really understand. I wasn’t allowed to use my own personal ideas
but needed to search for articles and journals …The different process was
challenging and interesting, although frustrating.
When I asked how she dealt with this challenge, she said:
I asked one of the students to see one of her old assignments to get an idea
of the format and structure. I then tried to forget the way I wrote
assignments at my school and focus on the task at hand to minimize my
confusion…It was not easy to stop comparing…it made me feel
insecure…I talked to another Danish girl who had the same problem….a
teacher gave us a couple of pages on assignment writing…we just had to
get on with it
Further on when Signe talked about her clinical experience she revealed disappointment
and frustration with the type of clinical experience she encountered:
I really wanted to go out and experience how to work with psychotic
patients, instead I was sent to a private hospital that appeared as a
convalescent centre…a couple really sick people came…we were told the
students had to keep away from them…us students only observed that was
frustrating…we were three students, one Australian, one Malaysian and
me as a Danish student…we talked about our frustrations…The Australian
student felt like me but The Malaysian student seemed relieved that we
didn’t get our own patients and that the place was peaceful…The only
interaction we got with the patients were in the cafeteria…I could have
done that at home…I didn’t learn much from this experience and felt it
was a waste of time… frustrated in relation to developing competence
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in psychiatry
Reflecting on her frustration, she said:
It could have happened at home…we had reflection with the clinical tutor,
and we talked little it about it, but I talked more about my frustrations per
phone with the students back in Denmark…it was really disappointing but
I tried to fill the weekends with new experiences…I also met with the
Australian student for a cup of coffee in the evening to talk about it and
other things…and thought classes were exciting.
Getting support from other students
Signe talked about how she found the Australian students very supportive:
Living in a house with seven Australians was very interesting and helped
me adjust to the Australian way of life…it was good to live with other
Australian students … they were interested in me, invited us out and that
incident with the student lend me a fifty dollar made me feel welcome and
accepted
When I asked Signe why she maintained contact with the other two Danish and Swedish
students she said:
It was a form of security, we understood each other in the way we reacted
and experienced new situations. We also had a similar humour,
understood each other better and helped each other make sense of new
situations
Becoming more accepting of multiple points of view
Signe relayed that she had developed some skills in reflection and an ability to see
things from different perspectives, she said
Because of my experience I se things from more perspectives and I am
more tolerant of different life styles … realizing there are so many
different ways you can do things I wouldn’t have considered before and
their ways can be just as good as ours…just different…for example when
people from a different country are admitted to a Danish hospital and the
relatives don’t speak Danish I can appreciate how frustrating that can
be…and I can try to be more tolerant and provide them with information
in a way they can understand
When I asked Signe to elaborate, she said:
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I think I become more open to different ways of doing things… being in a
different environment makes you realize you don’t have the network you
have at home, you have to be open and seek out new relationships, you
can’t sit back… that has made me want to make an extra effort with the
international students when I come home…one of my roles at my school is
being an international mentor for the international students…the
experience of being away from my own friends and family in another
culture, where they speak a different language has made me realize how
important it is to spent more time and appear interested in the students
from the international module and students from other European countries
who participate in clinical experience in Denmark …after I come back
from my student exchange I have arranged social events with students in
the international module and take time to listen to their stories … other
ways this experience has made me more aware and changed my behaviour
relates to when I hear people speaking a different language and appear
lost I now have a greater tendency to approach these people and offer my
help.
When I asked Signe to define cultural sensitivity, she said
You have to be open and non-judgemental …its about finding out what
people from different backgrounds are like as people and not put them into
categories based on their physical appearance and culture, but to meet
them where they are and listen to their stories, because prejudging them
could lead to a lot of wrong information.
When Signe talked about re-entry to her home culture, she said:
I had to adapt to some situations, where I reacted different than before...I
am more sure of myself…more tolerant in new situations….sometimes a
feeling of being able to manage the whole world
Inge
Inge was very passionate about understanding and respecting differences when caring
for people from other cultures. Inge relayed she was happy that she undertook this
journey with her classmate Lena. As I considered the totality of our conversation, four
dominant prejudices emerged. They were:
∙ Experiencing cultural differences
∙ Appreciating and accepting differences
∙ Connecting with others
∙ Growing in awareness and independence
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Experiencing cultural differences
Inge, who had never travelled outside the Scandinavian countries shared some of her
anxieties:
Travelling to a country, where I couldn’t use my own language was a huge
challenge for me… a culture shock…I had to speak English not only to the
locals… but to the patients…that was a huge challenge… I didn’t know if
they would understand me or if I would fit in, the other two Danish
students spoke a much better English than me, but I was very excited
about being in Jamaica…I was also glad I had two of my classmates with
me.
She spoke of her first impressions after arriving in Jamaica
A teacher from the school of nursing met us at the airport ...she was very
friendly...she took us to the nursing residence...It was separated by huge
iron fence...that was scary...at the same time reassuring when we were
told of the high crime rate... felt bad that we got an apartment to share
when the Jamaican students just had a single room....what shocked me
was the Jamaican students’ attitude...to them it was natural we should
have the best…if that had been in Denmark we would have been resentful
and complained, because we would think we all should have the same
facilities.
Inge also spoke of culture shock in relation nursing practice:
The hardest thing about being a student nurse was that I couldn’t use
some of the teachings from my home school…we emphasized the
individual and pharmacology and here they didn’t have the
resources…nursing care was very old fashioned…they used team nursing
at the expense of the individual…Even though the student nurses read
American text books…they couldn’t implement what they read…..that was
a real culture shock and the lack of money…we were told we could not
participate in the washing and showering of the patients…because that
was the job of the nurse aides…if we took that from them …they would just
sit and be lazy…in Denmark we would have participated in the total care,
including giving the prescribed medication.
In relation to this, she said:
At first I felt really helpless and angry about the way they medicated their
patients…The patients said several times they had pain, but the doctor
only came once a month...they were given a sleeping pill…there was no
morphine... was at a hospice with aids patients...it was really difficult to
see them lie there and suffer, the sleeping tablet helped a bit...but not
much.
When I asked Inge how she provided nursing care under these conditions, she said:
I came to value other ways of caring…use of yourself… the thing is not
just to give medicine, use of touch such as massage, and being there
holding their hand and spending time with them made a difference…I had
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to come to terms with my prejudices in relation to A.I.D.S and death and
came to the realization it is not the disease but the person you are
nursing…In Denmark we don’t talk about death…but her they had a really
open relationship to death … one person was drawing a picture of death
and they had a prayer session with the minister every Tuesday morning…I
wish we could implement that in Denmark
Later on in the conversation Inge talked about some of the frustrations and rewards
about participating in the local community:
Sometimes I felt the local people were discriminatory toward us …they
talked about us as the rich white people...it can be really difficult being in
a different society, not just having a different skin colour but also the lack
of familiar things...it made me think how people from other cultures in
Denmark feel when we talk about them...going to the local shops was a
challenge in the beginning…the shopkeeper would be sitting on the steps
while I would stand in the shop by the counter rattling my change…she
just kept talking…if that behaviour had happened in Denmark the
shopkeeper would have been verbally abused…generally people were
interested in us and wanted to hear about our background. People in town
would always smile at me. We became known as the runners from
Denmark because I used to jog with my Danish classmate.
Appreciating and accepting differences
When I asked Inge how she felt about the differences, she reflected:
It made me more aware of the importance of money and its influence on
the type of health care in a country…after a few weeks I wondered if we
had lost some fundamental values in palliative care….at first I was angry
about their lack of medical care and pain medication but their attitude to
death was impressive... still think the patients should be given adequate
pain medication... They didn’t have the money for our ways ...it made me
more aware of how lucky we are in Denmark…it made me appreciate our
welfare system…we have food on the table every night, and we can be
admitted to hospital when we are sick…we give medicine when patients
experience pain… we shouldn’t complain about our health care system in
Denmark.
She recounted other differences:
Their sense of timing was different… I could get quite annoyed when they
came to work late…they looked at me strangely for being on time. I had to
get used to their very relaxed attitude of tomorrow is another day...but
after a while I began to appreciate their relaxed ways… and thought we
could use more of that attitude in Denmark...they also had a sofa on the
ward where could lie for an hour and relax I asked one of their nurses
why they didn’t stress…She didn’t really understand the concept of stress
and was shocked when I told her that people get sick from stress in
Denmark.
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Connecting with others
Inge talked about a very humbling incident when she connected with a patient:
I nursed a 19 year old lady with three children in the terminal stage of her
illness with A.I.D.S. This lady was just skin and bone and very weak...she
had been given some nice postcards from the A.I.D.S. support group I
asked where I could buy some. At the same time I bought a very colourful
Jamaican bracelet from her and paid her more than its value, not a lot
more by our standards. The next day she wanted to get up and have a
shower, although she had only been given a bed bath for the last two
weeks. I asked for permission to give her a shower, it took one and a half
hour and then she wanted to sit in the sun on the terrace. Again she hadn’t
done that for a long time, as she had been bedridden. When I came on
duty the next day, she called me in to give me some post cards…she had
taken a cab to town, gone to A.I.D.S. support shop and bought those cards
with the money I had paid for the bracelet…I could feel the tears in my
eye…two weeks later she was dead… that really affected me…I don’t
know where she found the strength….It made me realize the little things in
life matter
Later on Inge explained why the three Danish students kept to themselves in the
beginning:
We needed the support from each other, to talk about clinical and some of
the differences…to make sense of it…that support really helped me to
adjust…we also reflected about what it must be like to be live in a poor
country and about their health care system and our attitudes to dying…it
wasn’t until we started classes that we really began to socialize with the
other student nurses…they were very friendly and showed us around
wanted to involve us in everything…They liked to touch our skin and plait
our hair…they were very proud of their country…sometimes that got a bit
much and we needed some space.
Growing in awareness and independence
Inge revealed that learning and being in another place made her question some of
beliefs, attitudes and values:
Before this experience I tended to be very outgoing and could be loud,
although I am still out-going I become more aware that being loud can be
intrusive and it is important to match your behaviour to the people and the
context you are in…it has made me more independent …going to a new
clinical has become easier as I adapt easier and believe in myself and
realize that I know more than I thought I did before I went. It has been a
real confidence builder…I am more conscious of why people from other
cultures appear nervous or negative at times, having experienced that
myself enables me to recognize it in others. I have given a talk in clinical
after I come home about being a stranger in another country.
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Jette
In her very quiet and soft spoken manner, Jette showed an eagerness to talk about her
experience abroad as a process for the development of cultural sensitivity. As I
considered the totality of what she shared with me three dominant horizons and
prejudices emerged.
They were as follows:
∙ Feeling alone and left to our own devices
∙ Having a network
∙ Expanding one’s world view
These will now be discussed
Feeling alone and left to our own devices
Jette described the beginning of the student exchange at Malta as a shamble. It was
fraught with uncertainty, nervousness and disappointments:
In the beginning I was very unsure and self- conscious when I spoke
English…There were no other Danish people besides a classmate I
travelled with. I was forced to speak…After the first few weeks it became
much easier.
When I asked Jette to elaborate on her uncertainty, she said:
It was everything. I think I got a culture shock, there was no structure, no
one knew what to do with us at first, and many of the locals only spoke
Maltese,…we looked different…people stared at us…it was weird to feel
like the outsider…because we had blonde hair and looked very different,
some people would come over and talk to us and touch …that was scary
and uncomfortable…and we kept to ourselves in the beginning.
In relation to the host school, Jette added:
The teacher from the host school who was supposed to co-ordinate our
clinical was very disorganized…he couldn’t find the papers relating to our
stay…we only saw him that one day and then to a farewell dinner at the
end of trip…we were disappointed as we had hoped for an introduction
together with other exchange students…we felt really alone.
Jette described her first meeting in the clinical are:
When we met on duty, we weren’t expected they didn’t know what to do
with us…at the beginning they kept their distance…we were the
foreigners…we had to take the initiative
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She later revealed:
We were also in one ward, where they ignored us the whole time… that
was terrible
Jette recounted an incident about an elderly patient she nursed with her Danish
classmate:
At first we were really unsure and worried whether we could communicate
with the patients….We had to wash and help an elderly lady who did not
speak and understand English. She was in a two bedded room, her
roommate spoke English but was hard of hearing….but she tried her best
to translate… our patient spoke to us in Maltese and her room mate would
translate when she could hear…consequently there were a lot of
misunderstandings….which made us all laugh…..that seemed to be
universal…we resorted to a useable sign language … That seemed to
work…our Maltese patient was so gentle and tolerant.
Having a network
When Jette spoke about support, she revealed:
I was really glad I had a Danish classmate with me, we did everything
together, and we worked together in the hospital…it helped with the
feelings of strangeness and isolation. .. we could talk about feelings and
the differences we met…talking with each other helped made sense of the
many new things … we lived at a hostel, where they were other European
students,…there was a girl from Portugal we used to go to town with
her…that was really good….We would only go to town or clubs with other
students, because we stood out because of our blonde hair and fair
complexion. When we went out with the Portuguese students we wouldn’t
be harassed.
Jette revealed how she began to adjust when she felt supported and accepted in clinical:
In one ward the registered nurses were really helpful. They apologized for
not receiving us better, but they had no idea we were coming. They were
very caring and spoke English. Because Malta is a British colony quite a
few of the staff spoke English as many of them were married to an English
person. After that they included us as part of the team …showed us respect
by allowing us to make our own roster and choose patients according to
our needs…they gave us more responsibility and independence than we
had at home…they also asked the other staff to speak English with us…
There were three types of nurses…registered staff …nurse aides and
helpers …it was a little confusing …but once we became part of the
team…and told them we were Danish student nurses who spoke English …
their attitudes changed to openness and caring and we began to feel
comfortable.
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Expanding one’s world view
Jette spoke about gaining insight and understanding of cultural difference and how
feeling different has made her more aware of herself, her culture and that it has given
her more courage to be different and try to do things differently. She said:
Now I know what it must feel like to come to Denmark and hope that I can
be more receptive to immigrants and refugees….I didn’t really think about
their feelings before…just thought it was the newcomers’ responsibility to
fit in….being ignored in one ward has really affected me….I came home
feeling sad and hoped I didn’t behave like that……
Later she reflected about her own culture. She said:
We are very closed as Danes…we needed our own space….and be by
ourselves…we weren’t as open as the other students we met …we are
more quiet and reserved
In relation to religion and gender differences, she said:
We are not as religious in Denmark …down there they are Roman
Catholics and their crucifixes were everywhere in the hospital……they
had separate wards for men and women….male nurses or helpers looked
after the men……they couldn’t visualize it different, even though we talked
to them about it, they couldn’t understand it.
Later, she said:
We need to consider that in our hospitals,
When I asked her to elaborate, she said:
Religion is part of their thinking and feeling…it gives them strength …I
think it is important that we ask patients from other cultures if they have
special needs … and try to accommodate them where we can ….because
culture affects their thinking and feeling about illness, healing and health
Further on in the conversation she said:
It was really important that we show interest in people who come from
other places …I think in Denmark we are terrible busy the whole
time…over there they have time for each other, talk to the patients,
give them cuddles, and kiss each other and the patients on the cheek…I
can’t do that, but for them it is so natural… talk to each other…they don’t
worry about time or getting things done in the right order…that was
hard… I missed the structure of home…I guess that order and structure is
so much part of me and my culture…for example breaking for siesta …in
the beginning we didn’t know what to do with two hours in the middle of
the day…it was really boring….but after a while we discovered it was
really nice to sit and talk with the staff, relax and not worry about time.
When she spoke about some personal changes as a result of the experience
she said:
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It has really made me think about doing things different…having the
courage to be different …talking with people who are different has made
me more open and outgoing…I am better at setting boundaries and have
a bit more courage to express my point of view…I hope I continue to be
more open.
Susanne
Susanne expressed enthusiasm and excitement with the opportunity to reflect on her
overseas student exchange in Greenland. As I considered the totality of what she shared
with me three dominant horizons and prejudices emerged. They were:
∙ Open-mindedness
∙ Confronted by differences
∙ Moving between the familiar and the unfamiliar
Open-mindedness
Susanne talked about her desire to learn more about other people, other cultures,
different ways of doing things in cross-cultural situations. She shared:
I went up there with an open attitude and embracing the opportunity to
experience new and different things…I had read a lot about Greenland
before I went up there…I was met at the airport by a Danish teacher who
showed me my accommodation…that was my first challenge …the window
on my room was covered with thick ice and the room was not well
insulated…my second challenge occurred with the introduction or lack of
it…I was a little disappointed…but learned that you didn’t question things
or ask for explanations you just accepted things as they were…that was
challenge number three as I normally ask for explanations.
Later on Susanne talked about being non-judgemental and flexible in communicating
with the young people:
My clinical was in an obstetric ward and part of the work was teaching
about prevention, because they didn’t take their birth control and there
were many therapeutic abortions….before I came, I thought the young
people could speak Danish and hadn’t anticipated the language to be a
problem….I quickly learned different …we used sign language and an
interpreter.
Susanne revealed that she needed to modify her own feelings:
I didn’t always feel that I met their needs and went home from clinical
feeling frustrated, but I learned that if they said shu meaning yes it was
87
okay and began to question whether my frustrations arose from my needs
to feel good about myself rather than meeting the patients’ needs
Confronted by differences
Susanne spoke of the need to maintain flexible attitudes to demonstrate cultural
sensitivity as some of the norms and beliefs held by the Greenlanders were very
different to her own. She said:
The team assessed an 18 year girl with abdominal pain. The scan
confirmed she was 19 weeks pregnant. The young house surgeon
confirmed with his registrar only to discover that she was 21 weeks
pregnant. The doctors informed the girl, mother and boyfriend of the news
and at the same time gave them the opportunity to think about an
abortion… they were offered an appointment with the senior obstetric
consultants the following Monday to give them time to think about their
options…they went outside the room for a smoke and 10 minutes later they
had a made a decision to have the baby… The 19 year old girl said that
the mother and her boyfriend would support her… I was shocked by their
quick decision.
Further on in the conversation she said:
There is quite a cultural difference. In Denmark we start sex education in
the fifth grade. In Greenland it is the parents or a teacher that randomly
informs the young people…One Wednesday morning we had a young girl
who came for her fourteenth therapeutic abortion. …on discharge she was
told to use prevention, but just shrugged her shoulders … at first that
attitude appeared shocking by my standards…this wasn’t Denmark …it is
important not to judge and to look at their history and context they grow
up in … it is an old catching (sealing) community there is a lot of incest
and rape and often the girls don’t react to the cessation of menstruation
until the twelfth week…the parents encourage the girls to sleep with their
male cousins as a normal part of growing up…their living accommodation
is extended family with aunts and uncles in the same household….it is
hard not to be judgemental….you can’t change thing,…but you can make
a difference by being there.
Later on in the conversation she revealed she became increasing comfortable with
differences as she began to understand the norms and values in the context of their
history and understood why she was met with some hostility, she said:
I never understood why some of the Greenlanders resented me because I
was Danish ….it wasn’t until one of the nurses I had become friendly with
explained that although they became independent in 1976, Greenland still
depends on Denmark for economic support, consequently the hospital is
staffed by a lot of Danish doctors who implement a lot of their policies,
because they think they know better…same in the school system….there
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are a lot of Danish teacher, teaching our children……yet we still have a
lot of unemployment.
Susanne talked how living in another country had challenged some of her beliefs and
values. She shared:
I learned to become more tolerant…no one stresses or seem to in a hurry
…not even in traffic…I soon learned not to get irritated with their very
relaxed way…for example… if you ask a Greenlander to hurry… they do
the opposite…. I became much better at reading non-verbal
behaviour…having to cope in a new culture without my family and friends
has giving confidence to deal with new situations… knowing that I can,
has made me more independent…when I start in a new ward I take more
initiative.
Moving between the familiar and unfamiliar
Susanne talked about how she sought contact with Danish teacher and the local people
when she was of duty:
I talked a lot with the Danish teacher, I used to discuss some of the ethical
dilemmas I was confronted with…that was really helpful…there was
another Danish student from another ward…she stereotyped
Greenlanders as being lazy and alcoholics…that needed to get off their
feet…I was very embarrassed and didn’t understand why she was there if
that was her attitude…I didn’t spend a lot of time with her.
Further on in conversation she talked about a family she visited, she had the following
to say:
They can manage on very little …they often bought a huge bag of prawns
for five kroners…that would be an evening meal for the whole family
…then they might know someone who had killed a reindeer, which they
shared among the families. They made earrings from the horn, which they
sold…the families helped each other.
She talked of a young patient she got very involved with:
I nursed a 19 year old patient with pre-eclampsia who was bedridden and
talked very little Danish. I would use my electronic encyclopaedia to talk
with her. We laughed at the many misunderstandings in the
translation…we became really close, a month and half before she was due
there was no amniotic fluid…after a videoconference with a hospital in
Copenhagen, it was decided to fly her there, she squeezed my hand and
asked me to go with her …I was thrilled with the way she trusted me.
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Fusion of horizons
The next step in the data analysis was to gain understanding through the fusion of the
multiple horizons of whether cultural sensitivity developed as a consequence of the
participants’ experience in international education as expressed by the participants.
Horizon is the field of vision, which includes and comprises everything that can be seen
from one perspective (Gadamer, 1990). However, as our horizon is not static, but moves
with us the task is to illuminate the situation or the events (Gadamer, 1989).
Thus engaging reflexively with my own, the participants’ understanding and the
literature enabled different vantage points to come together through language and
conversation. Gadamer (1989) called this the fusion of horizon. However the
understanding achieved by the fusion of horizon is not closed but continues to be
refined and extended. Therefore the understanding developed from reading the literature
and the stories told by the participants represents my understanding at this point in time.
This is consistent with Gadamer’s philosophy of understanding that espouses that
understanding is never entirely finished, because we have an infinite capacity to refine
and extend our understanding (Gadamer, 1989; Turner, 2003).
This phase of the analysis involved questioning of my pre-understanding along with the
horizons identified from the texts. This was followed by grouping and regrouping the
prejudices of all the participants, while considering the totality of what was shared by
all the participants. This was necessary to clarify how the participants’ prejudices could
be understood in the light of each other. The horizons that emerged from the process of
grouping and regrouping the multiple ideas expressed by the participants were not
separated by rigid boundaries but taken together as a whole to explicate the essence of
whether cultural sensitivity developed as a consequence of the student nurses
90
participating in the international experience as seen through their eyes. The horizons
identified were: experiencing transition from one culture to another, adjusting to cultural
differences and developing cultural sensitivity and growing personally. These horizons
will now be presented and discussed.
Table 1 highlights the horizons emerged from the multiple ideas across the participants.
The lack of lines between the horizons indicates that there are no rigid boundaries
between the horizons.
Table 1. Horizons emerged from multiple ideas across the participants
Experiencing transition
from one culture to
another
Adjusting to cultural
differences
Developing cultural
sensitivity and growing
personally
experiencing transition as a
bit of a shock
feeling different/crossing
barriers
Transforming
inner feeling of chaos
developing social networks
broadening my horizon
confronting differences
openness to differences
seeing the world through
different eyes
dealing with stress and
disappointment
getting support from other
students
becoming more accepting of
multiple points of view
experiencing different
cultures
connecting with others
appreciating and accepting
differences
feeling alone and left to
own devices
having a network
expanding one’s
world view
openmindedness
moving between the
familiar and unfamiliar
confronted by differences
Experiencing transition from one culture to another
Each of the participants of this study experienced the transition of moving from one
culture to another in different ways, and yet there was some commonality across their
experiences. For instance, a number of participants expressed that their transition led to
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some experiences which were for them quite strange. This was particularly evident
when Lone spoke about not being able to travel on her own even though this was
normal for her in her country of origin; it was further highlighted by Lone who openly
questioned where she was and if she was really experiencing life in the year 2003; it
was expressed in the dialogue of Lena, who found the inclusion of alternate therapies
and spiritual care quite somehow strange but refreshing.
Susanne revealed she had to shift from her familiar frame of reference in her
intercultural encounter. This was illustrated when she spoke about accepting things as
they were without being able to ask for an explanation, which is something she would
normally do in new situations. For Jette the initial transition to the host culture was
experienced as a time of disorientation. This was expressed when she told me about the
lack of preparation by the host school and feeling unwelcome in the clinical area in the
beginning. Inge on the other hand expressed feeling angry in the beginning. This was
illustrated when she spoke about the AIDS patients not getting adequate pain relief, but
were given sleeping medication instead. She said this was very different to the hospitals
in her home culture where the terminally ill were given adequate pain relief. Like Lena
she found the inclusion of spiritual care refreshing. The dialogue of these participants
clearly revealed that their transition was anything but ordinary.
For other participants the transition to a new culture was characterized by
disappointment and uncertainty. Bent revealed this when he spoke about not being able
to participate actively in discussion during class. Further he expressed anxiety and
frustration relating to him coping with a different way of writing assignments. Unlike
Bent, Signe expressed excitement about the different approach to teaching. This was
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illustrated when she spoke of actors being used to play psychiatric patients. However
she shared Bent’s feelings of frustration and uncertainty relating to her ability to meet
the different expectations in writing assignments.
When I looked for a common thread among these diverse expressions, I realized this
horizon of experiencing transition from one culture to another was characterised by
experiences of uncertainty precipitated by a change in the participants familiar
environment that required adjustment Furthermore the feelings the participants
associated with this transition were excitement , frustration and disappointment . In
addition an attitude of openness by the participants facilitated accommodating to the
strangeness of the experience.
Adjusting to cultural differences
Each of the participants expressed adjusting to cultural differences in a variety of ways,
but there were some similarities across the participants. Adjustment to differences was
expressed by Lone when she spoke about the interest and openness in her as a person,
when she mixed with the local people. She told the story about the taxi cab driver who
treated her with openness and interest in her background when he found out she was not
a tourist. She revealed that by living on campus the other students involved her in their
activities and ensured her safety. Furthermore she spoke about the support she received
from the registered nurse in clinical that helped the patients to accept her and thereby
facilitated her adjustment to a strange environment in her clinical experience. Bent
highlighted this when he spoke of the openness and interest in him and his background
by the patients from diverse cultural backgrounds in his clinical experience. He further
spoke of the support from the clinical teacher that made this experience invaluable and
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unlike any learning experience he had encountered before. Students he shared
accommodation with facilitated Bent’s adjustment to the cultural differences. He
revealed that students with a similar background to himself helped him make sense of
some of the difficulties as they understood his problems from both perspectives.
Like Bent, Signe reflected on her experience in living with other Australian students.
She said the support she received from the students helped her adjust to the cultural
differences. Also being invited home to one of the Australian student’s home made her
feel accepted and involved with Australian people. She also spoke of the importance of
connecting with two other Scandinavian students. She said sharing her experiences with
students from a similar background, comparing the host culture with her own helped her
make sense of many of the new experiences she had in a different culture.
Other participants expressed that travelling with Danish classmates helped them to
adjust to the cultural differences. This was particularly evident when Lena
spoke about the way they supported each other in filling in the gaps when they didn’t
understand everything that was said in the beginning of their stay. Furthermore, she
spoke of the importance of how sharing their feelings and reflecting on their clinical
experiences helped her make sense of a very different health care system. Lena said that
the strength they found in each other helped her adjust to the cultural differences. Inge
highlighted this when she spoke of the need to support each other. She added together
they gained insight by reflecting on what it must be like to live in a poor country and the
local people’s different attitudes to dying, quite different to people’s attitudes to dying
in their home country. For Inge and Lena comparing the two cultures helped them to
adjust.
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Like Lena and Inge, Jette identified the importance of travelling with a classmate in
adjusting to the cultural differences. She said it helped with the feelings of strangeness
and isolation in the beginning. She revealed that reflection about their experiences,
comparing cultures and sharing feelings helped her make sense of the many new things
she encountered. She said after they became accepted as part of the team, they received
a lot of support from the registered nurses. She identified that being involved in caring
for their clients and interacting with the other staff helped her adjust to the cultural
differences.
Like the other participants, Susanne revealed that reflecting about her experiences with
a Danish teacher helped her cope with the many new situations. She also said this
support helped her to be open and flexible in her attitudes to the cultural differences and
ethical dilemmas she met during her clinical experience. Unlike the other participants,
Susanne did not find support in a student from her own background. She revealed the
other student had a negative attitude towards the Greenlanders by referring to them as
lazy and alcoholics. Susanne expressed embarrassment by the other student’s attitude.
Furthermore she expressed that her interactions with patients and staff at the hospital, as
well as the local people helped her gain insight and understanding of cultural
differences.
When I asked myself what the stories had in common, I learned that interest, openness
and acceptance from the local people and the participants interaction with helped them
to cope with a strange environment. In addition, openness and flexibility by the
participants enabled them to compare the different health care, educational and nursing
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care systems with each other, other students, registered nurses and teachers, to enable
understanding and appreciation of differences. Support from nursing staff, getting
involved in nursing patients made the participants feel part of the new environment. In
addition reflecting on their experiences with other students, especially students from
their own culture helped the participants to put things into perspective facilitating
adjustment to the cultural differences.
Developing cultural sensitivity and growing personally.
Each of the participants expressed the horizon of developing cultural sensitivity and
growing personally in a variety of ways. Yet there was some commonality across the
experiences and ways, in which, the participants became sensitive to the influence of
culture within health care. They learned to relate to patients with empathy, respect and
understanding as part of the process of adjusting to the host culture. During this process,
the participants reported personal and professional maturation. This was revealed by
some of the participants as insights and growth from the experience of being a
foreigner, a broadening of their horizon as they reflected about what it must be like for
patients who come to Danish hospitals with a different cultural background to the
majority culture. This was particularly evident when Lone revealed that living the
experience made her more aware of her own values and the need to accept the value of
others. She talked about the importance of being non-judgemental and open toward
people who are different from oneself. This was illustrated when she compared the
Jamaicans more relaxed and flexible attitude to time, for example being late for work
was a normal event for the Jamaicans. She acknowledged that being late for work was
not an option for her, and that there are aspects of one’s own culture that are impervious
to change.
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Lone reflected on the importance of not forcing one’s beliefs on people from another
culture and being sensitive to cultural differences. Like Lena, Jette revealed the
experience of being different from the majority made her more aware of her own
culture’s emphasis on structure compared to the more relaxed ways of the people in her
host culture. She also acknowledged that some parts of one’s culture is part of one’s
identity and not open to change. Jette illustrated this when she spoke of structure as
integral to her way of coping with life. She reflected on the importance of religion in her
host culture’s way of life and its influence in health and illness. She expressed this
experience had increased her self-confidence and independence as well as enhanced her
awareness of the importance of being more open to health beliefs and values to people
from other countries who come to live in Denmark. This was highlighted by Inge, when
she spoke of the importance of prayer in caring for young Jamaicans afflicted with
A.I.D.S. For Inge being present and spending time with her patients enhanced her focus
on the holistic aspect of nursing where it is the person that is in centrum. She said she
had become more aware of her self, grown in self confidence and independence, as well
as more adaptive in new situations. Inge revealed she had become more appreciative of
the relaxed way of caring where the use of self as a therapeutic tool as the essence of
nursing. She compared this to the more stressful way at home, where the emphasis is on
pain medications as the predominant way of caring for the terminally ill.
Like Inge, Lena also reflected on the difference in caring for the clients and reflected on
spiritual care as a core in nursing as opposed her own culture’s reliance on technology
in health care. Lena also reflected on the how the social background and culture
reflected the Jamaicans’ view on health care. Furthermore she identified that
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communication was much more than language. She spoke of touch, music and being
present as important aspects in caring for your patients. Lena also acknowledged that as
well as appreciating differences, it was also important to be able to cope with being
different.
These participants came to appreciate a different dimension in nursing and expressed
that the technological approach to nursing could be enhanced by adding the spiritual
dimension in health care. Furthermore connecting with people involved using
themselves in a therapeutic way that included emotional presence, openness, genuine
concern and respect and acceptance of cultural differences. For Signe development of
cultural sensitivity as a consequence of living in a different culture meant that she
became more tolerant of different life styles. She clearly conveyed there were so many
different ways you could do things. She spoke of the relativity in different values. This
was clearly conveyed when she said no ways of life are better…just different. This was
emphasized by Susanne when she revealed that living in another culture gave her a
different perspective. She spoke of the importance of understanding the history, norms
and values and how this helped her understand and appreciate a different way of life.
For Susanne this understanding helped her to adopt an open attitude and flexibility in
her interactions with her young clients who had a very different attitude to therapeutic
abortions. She revealed this experience meant an increase in her self-confidence in new
situations.
Unlike the other participants, Bent expressed a negative point of view in his encounter
with a different educational system. This was illustrated when he talked about the
different teaching styles and teachers’ attitudes to students as being superior in his home
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culture. It was not until Bent was met with openness and interest by patients from
different cultural backgrounds that he expressed an appreciation of different values. He
revealed that acceptance by other people was essential to being culturally sensitive. This
was illustrated when Bent spoke of how this experience had made him more aware of
the importance of being accepted and people being interested in him and his background
while living in a different culture.
In considering the commonalities of this horizon, it became clear that attitudes towards
cultural differences, such as openness, respect, and flexibility enabled the participants to
appreciate and accept cultural differences. Furthermore an increased awareness and
appreciation of their own culture, along with personal growth and adapting to a new
culture reflected the horizon of developing cultural sensitivity and growing personally.
Conclusion
The findings of this study involved journaling and reflecting on my pre-understanding
or initial ideas about the experience of international education on the development of
cultural sensitivity. This was done in order to acknowledge how they influenced my
interaction with the participants and interrogation of the data. This is consistent with
Gadamer’s writing about the need for reflection on pre-understanding prior to textual
interpretation. In addition I explicated how my early understandings began to reveal
themselves by looking at the whole, by moving to the parts and back to the whole in
order to begin my journey beyond my pre-understanding towards an expansion of my
understanding of the phenomena. Thereafter the prejudices of whether the participation
in international education of each participant was identified. Finally similarities and
differences from the prejudices of the participants were fused and three horizons
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emerged. These were: experiencing: transition from one culture to another, adjusting to
cultural differences and developing cultural sensitivity and growing personally. These
horizons must be understood in relation to each other as interwoven aspects of the
meaning of the whole of the experience as expressed by the participants. Incorporating
the horizons of the development of cultural sensitivity as a consequence of participating
in an international exchange revealed an ongoing circular process consisting of
experiencing transition from one culture to another, adjusting to cultural differences and
developing cultural sensitivity and growing personally
In the next chapter these horizons are discussed.
Chapter 6 Discussion
Introduction
This study explored undergraduate nursing students experience in international
education in countries such as Australia, Jamaica, Malta and Greenland. The purpose of
this research was to determine whether student nurses develop cultural sensitivity as a
consequence of living and studying in a culture that is different from their own. The
horizons identified were experiencing transition from one culture to another; adjusting
to cultural differences; developing cultural sensitivity and growing personally. These
horizons helped to extend my understanding of the essential nature of the development
of cultural sensitivity in the context of a different culture as seen through the eyes of the
participants in this study. These horizons are relational in nature in the sense that there
are no rigid boundaries that define the development of cultural sensitivity in an
international exchange, rather they are complex ideas that when taken together provide
meaning of the whole from the perspective of the participants’ understanding of their
experience. For example a nursing student may be participating in an international
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education experience preparing to participate in classes or provide nursing care, while
adjusting to an unfamiliar educational facility or practice area, while being present and
caring in relationship with other students, staff and/or patients in a different culture.
This study has the potential to provide some understanding of ways in which student
nurses can learn to become culturally sensitive in order to provide culturally appropriate
care to clients from diverse cultural backgrounds. As identified in the literature review it
was evident that Denmark is becoming increasingly more diverse requiring nurses to
consider the needs of the culturally different in their health care practice to avoid
culturally insensitive practice.
The discussion starts with the researcher’s expanded understanding of the phenomena
resulting from the merging of the three horizons identified in the study and from reading
the literature. The differences and similarities of each horizon are merged with the
vantage points from the literature.
Journey towards expanded understanding
Philosophical hermeneutics takes the view that understanding is both a process and a
mode of being (Gadamer, 1996). The process of this study has been an illuminating
journey that began with the researcher identifying her pre-understanding prior to
engaging in an open dialogue with the participants. The interview situations were
marked by an openness and interest by the researcher in the participants’ perception of
their experiences. The journey continued as the dialogues were recorded on tape and
transcribed verbatim.
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The defining features in this journey were being open to the experiences of the others
without putting ones self in their shoes. Gadamer(1990), argued that to do that would be
to withdraw from the situation of understanding, because one’ own pre-understanding
would be ignored during the process of moving to a shared understanding. The journey
was also marked by the reciprocal openness between the participants and the researcher.
This was reflected by the participants opening up, expressing delight in sharing their
experiences, as reflected by their smiles, leaning forward and total involvement in their
stories. They felt valued and safe throughout the interview as evidenced by surprise
when the interview was over. It was as if they were reliving their experiences. I felt they
were as excited in telling me their stories as I was in hearing them. This was
highlighted by the participants’ comments after the tape was turned off. Most of the
participants thanked me for listening to their experiences and revealed this was the first
time since they had returned home anyone had listened to the whole of their experiences
in another culture. These comments made me reflect on the need to set aside time for
reflection on re-entry to their home culture. As I read the texts one at a time, listening to
the tapes, bringing the texts together I began to relive their experiences, as I visualized
their faces when they told their stories. I interacted with the texts by asking questions,
writing and rewriting and teasing out differences and similarities as I moved from the
whole, to the parts and back to the whole again. It was through this process the
interpretation developed. Then moving between the transcripts, the literature, and my
interpretation of the texts, completed the journey at this moment in time. The movement
between the researcher’s pre-understanding and the merged horizons of the participants
led to a shared understanding that expanded the researcher’s horizon and formed a
different understanding of the phenomenon.
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Prior to undertaking this study my understanding was that the experience of
participating in an international learning experience would provide the student nurses
with an opportunity to develop cultural sensitivity. After my involvement in this study it
has become clear that other factors during the intercultural experience influenced the
development of cultural sensitivity. Factors such as motivation, that is wanting to learn
about another culture, personality characteristics such as openness and flexibility,
interaction with people in the host culture, connecting with teachers, staff and patients
in the educational institutions and clinical settings, were vital in adjusting to cultural
differences. These factors were reinforced by the literature most notably by Kim (1988)
who indicated that successful adaptation to the host culture were influenced by the
students’ own attitudes, motivation, openness and flexibility.. Other authors maintained
that involvement in the host culture promote adjustment to the host culture (Cross,
1995; Searle and Ward,1990). This is congruent with findings from student nursing
exchanges conveying the importance of support from clinical teachers and registered
nurses (Koskinen and Tossavainen, 2003: Pross ,2003).
. In addition comparing and reflecting on the differences with students or teachers from
their own background fostered an appreciation and acceptance of cultural differences.
This was highlighted by Bennet (1986): DeSantis(1991) who claimed that development
of cultural sensitivity is based on acknowledging and accepting differences .Further
Torbiorn (1982); Storti (1990); Haloburton and Thompson (1998) claimed that
interaction with people from their own background helped to make sense of unfamiliar
experiences
. Considering these factors, the development of cultural sensitivity is a process that
begins in the home culture, preparing for the exchange, transition to the host culture and
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adjusting to the cultural difference, re-entry to the home culture and interacting with the
culturally different in the home culture, and not an end product that occur as a result of
the experience.(again there is a need to weave the literature into this discussion or else
what you are doing is just rehashing the findings of the study, which is not what you are
supposed to do in the discussion chapter. In the discussion you must provide tight
connections between what you learned about the development of cultural sensitivity
from the literature, what your study revealed, with particular emphasis on the gaps)
The process of developing cultural sensitivity from an international exchange:
The process of developing cultural sensitivity as a consequence of participating in an
international experience consisted of the three interdependent or merged horizons
identified in the introduction of this chapter. Meleis, Sawyer, Hilfinger and Schumacher
(2000) suggested that central to the process of adjusting to cultural difference is the
familiar being rendered strange by a new culture and communicating in a new language.
According to these authors, this creates dysjunction and triggers transformative
learning.The horizon of adjusting to cultural differences revealed exposure to an
alternative culture created disjuncture, as the participants had to reconsider what had
been taken for granted in their own culture as well as consider and analyse a context that
was novel. They were challenged by having to communicate in a different language,
confronted by cultural differences in health and educational practices, experienced
minority status, as well, as lived and learned in an environment that was strange to
them. The participants reported feeling stressed in response to the unfamiliar, as they
became increasingly aware of their own personal beliefs and different cultural value in
the host culture. However the participants dealt with stress differently in this initial
transition period. Some considered it to be exciting and challenging, and dealt with it by
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being open and flexible to the differences they encountered. This is in line with
Campinha- Bacote’s (2003) view that desire is a precursor to being open and flexible
when meeting people from a different cultural background. (This was revealed by Lone
as she expressed that although she felt alone and frustrated with the cultural differences
in the beginning, she saw it as a challenge and it was up to her to seek new
understanding by being open and interested in the different ways of doing things. Lena
revealed she was usually open and excited about new experiences. Like Lena and Lone,
Susanne expressed she came with an open mind and felt excited about new experiences
in a different culture. Others expressed feelings of disappointment, frustration,
loneliness and varying degree of cultural shock to the differences when confronted by
the differences between the home and host cultures’ health care and educational system
during the initial transition. This was evident when Bent talked about the teachers being
more supportive at home. Jette spoke of the isolation and frustration at being ignored in
the beginning of the experience. Inge reported feelings of anxiety and uncertainty in
relation to the language barrier and ability to cope. She also revealed feelings of
helplessness and anger in relation to some of the nursing care she saw in Jamaica during
the initial period of disjuncture). Please note that what I have highlighted in red is not
discussion, it is the findings of this study repeated. You must avoid this because you
defeat the purpose of the discussion chapter, which is to highlight what you found as it
relates to what is already know, and to identify what you found that is not present in the
literature. The different ways of coping with stress during transition from the home to
the host culture is consistent with Lazarus’ and Folkmann’ (1998) view that stressful
situation may be evaluated as challenging, threatening or harmful. A challenging
situation taxes personal resources but holds the potential for growth and mastery and is
associated with feelings of excitement and enthusiasm. On the other hand, threat and
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harm–loss appraisal are associated with defensive behaviours.(whilst these are good
observations it is not entirely clear how this discussion relates to your study findings.
Can you take care here to weave a tight argument which is very much in line with your
study findings?
Generally it was clear that participants were stressed or found it difficult to make sense
of their initial experience, because as they voiced, they were expecting that the
situations they would encounter during their exchange would be similar to the way they
were at home. Participants dealt with the way they approached stressful situations in
different ways (name some of them here without mentioning the specific person).
Clearly this placed some responsibility with teaching staff in the home culture in
helping the students prepare for the exchange. Providing the students with information
about the host culture may help to minimize stress as well as provide them with
valuable insights into how to deal with stress or problem when confronted with cultural
differences.
The centrality of the horizon of adjusting to cultural differences was seen to be
facilitated by interacting and connecting with people in the host culture and living
within a supportive environment, that is receiving support from teachers, registered
nurses, feeling accepted and support from students with a similar background as
themselves. In addition critical reflection and comparing the cultures enabled the
participants to reconcile personal beliefs and conflicting values. This is in line with
Bennett’s (19939; Adler’s (1975) Brueggemenn’s (1987) view that students’ experience
of psychological stress in the host culture occurred because of cognitive dissonance and
a transition of discontinuity. These authors suggested reflection and self–reflection on
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the differences can help the students adjust by leading to grow in self-awareness,
awareness of own culture, openness, respect and acceptance of differences.
According to Oguri and Guykunst (2002) adjusting to the host culture is dependent
upon the sojourner’ interacting and getting involved with people in the host culture.
This provides the students with information about the host country and understanding of
different patterns in communication and relationships (Cross, 1995; Searle and Ward,
1990). The findings in this study revealed getting involved with patients and staff in
clinical practice and educational institutions helped the participants obtain direct
knowledge of cultural differences in learning about alternative health care practices. In
addition the participants gained an awareness and appreciation for their own health care
and educational systems, as well as alternative nursing care practices. This expanded
their understanding of how culture is a component of all human life, in the sense that
health care, educational institutions and families are created by the culture of a country
and forms the basis for people’s attitudes and beliefs to health, illness and death.
(What I would like you to do here is contrast this discussion with the fact that the
students used a technique of “drawing in and drawing back” (you will probably need to
find your own words to describe this) as their patterns of behaviour whilst they were
developing cultural sensitivity. That is, they were willing to get involved and be with
others, and get to know them (drawing in) but they also voiced that at times they just
needed to be with those who were familiar and hence comfortable to help them make
sense of what was going on around them (drawing back). By having this sort of
discussion you add to the literature of the development of cultural sensitivity in unique
ways, which is essential to your thesis.
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Connecting with the patients’ situation influenced the participants’ construct of the
nurse patient relationship. Being or becoming open- minded and flexible helped the
participants communicate with the patients. They became more aware of the importance
of laugher, nonverbal communication as the essence of crossing cultural barriers. They
learned how to convey meaning beyond the spoken word, connect in a therapeutic way
to demonstrate emotional presence, genuine concern and respect for the cultural
differences. (again, you don’t need to rehash the findings ehre. Just trust that your
reader will remember the story of Inge and will understand the points that you are
raising. So, get on with the discussion) This was evident when Inge talked about the
importance of being present and just being there, and Lena talked about the importance
of massage. Both Lena and Inge learned to appreciate prayer meetings and the
importance of religion in caring for their patients. Jette revealed how laughter helped
her connect with the patient. Susanne said learning about the culture from the locals
helped her understand why the young girls in Greenland had so many therapeutic
abortions even though it conflicted with her own beliefs regarding this issue.) These
examples of connecting within an intercultural context are evident in the literature, with
Campinha-Bacote (2003) and Lynam (1999) claiming that interaction in local contacts
and interacting with patients from other cultural groups will modify existing beliefs
about a cultural group and will prevent stereotyping.
Heidi, I am going to stop here and ask you to do a bit more work on your discussion
chapter. I think you are on the right track but I run the risk of taking over and not
allowing you to re-shape your work, which I don’t want to do. Whilst you are almost
there, you are not quite there and a bit more work is in order.
A supportive environment that enabled the participants to be open to differences,
compare and critical reflect on their experiences was connecting with other students,
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teachers, staff, patients and local people helped the participants adjust to the cultural
differences. This is in line with French’s (1999) view that a mindset of openness and
enable us to function effectively in a culturally diverse health care environment. To
become aware of these differences the participants reflected on their values and beliefs
in order to compare those with the values they shared with the patients. This reflection
included own personal beliefs and values; their professional beliefs and values in the
context in which the interaction took place that is the institution, the politics of the
country and the health care system. Lena and Inge expressed that living in a poor
country made them aware and more appreciative of a health care system that was free
and accessible to all. However they did recognize the value of an alternative health care
system where decisions were not dominated by the biomedical model but that other
professionals such as the minister had a prominent role in caring for the dying. They
were also impressed by their different sense of timing that reflected a more relaxed
attitude to their patients and practice. Like Lone, Inge and Lena became aware that
some aspects of one’s culture cannot be changed . Although they appreciated the more
relaxed way, being late for work was not an option for them. In a similar way Jette
appreciated that order, structure and social distance was an integral part of her and her
culture that was not amenable to change. She did however learn to appreciate the more
chaotic and relaxed ways the wards were run in Malta and the way the nurses cuddled
their patients. They reported it was important to reflect on their experiences together, to
consider what was happening around them, listen, question, take time to compare, be
analytical in order to adjust and accept the cultural differences they had experienced. It
was clear that reflection occurred with the students of similar background and clinical
mentors. Boyd & Fales (1993) described reflection as an active learning process,
wherein the students use their cognitive and affective abilities that allows them to
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emerge from the process with a changed perspective. It is through reflection the
participants became more aware of themselves, their culture, and the host culture’s
religious, cultural, political and economic factors that affect people’s views on health
and illness and their health care practices. Sharing a common language and cultural
background helped them become more aware of their own culture in the context of a
different culture, as well as helped them with feelings of loneliness and frustration. This
is in line with the view advocated by Leininger, (1995); Ramsden (1999); Mitchelson
(2000); Campinha-bacote (2003) Locke (1982) McMurray(2003) and Meleis (2000) that
awareness of self and one’s culture; openness to differences facilitate respect and
accept of cultural differences. This is supported by ( DeSantis 1988) who claimed that
in order to appreciate cultural differences it is necessary to recognize one’s own values
and be open to cultural differences.
Although Signe and Bent didn’t travel with students from their home school they
teamed up with students from other Scandinavian countries. They revealed the
importance of sharing the same humour; language to explore some of the differences
with some one from their own background made them feel more secure and helped them
adjust. Although Susanne also had an opportunity to connect with a Danish student, she
did not do so, because they did not share the same value system. Conflict in values with
people from one’s own ethnic background may not enhance support in an unfamiliar
environment. Susanne did however connect with a Danish teacher who helped reflect
over some of the ethical dilemmas she was confronted with in her clinical practice. The
importance of support from each other, that is students with similar background is in
line with Torbiorn’s (1982) and Storti’s (1990) view that interacting with people from
one’s own cultural background help to confirm one’s identity, provides support for
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dealing with new experiences and encourages openness to differences between cultures
This is consistent with Ryan and Twibell (2000) who claimed that the ability to
communicate with fellow students was essential in adaptating to cultural differences in
a strange environment. However there is no mention in the literature of the effects when
students from similar backgrounds differ in attitudes toward the cultural different.
The findings of this study also indicated that support from mentors in the clinical area
and the teachers in the classrooms were some of the key persons to provide support and
give encouragement. This is clearly evident in Lone, Jette’s and Susanne’s discussion
about the importance of being supported by the registered staff in clinical practice. It
was revealed in Bent’s discussion about the importance of the clinical mentor
facilitating new learning experiences. In addition Bent reported it was very important
for him to feel accepted. He talked about the acceptance he felt from clients from
different cultural background during his clinical practice. This was highlighted by Lena
and Inge who indicated that their class teacher interest in their background made them
feel supported
These findings were supported by (Koskinen & Silen-Lipponen, 2001; Haloburton and
Thompson; Pross, 2003) who suggested intercultural mentorship was a very rewarding
experience that offered opportunities for mutual learning. The mentors promoted the
students’ team membership and encouraged learning. In addition social support from
teachers and mentors in the clinical area helped students make sense of the dilemmas,
and social frustrations the students encountered during their exchange.
This has expanded my understanding of the development of cultural sensitivity as a
consequence of international education. Prior to my engagement in this study I thought
111
immersion in anther culture would develop cultural sensitivity. Now I come to
understand that the international co-ordinator or teachers and registered nurses involved
in this practice need to consider the following questions:
How do we prepare students prior to their departure? Do we assess the students attitudes
of openness and flexibility? Do we advise the students to travel with other students
from their own culture? What about the students who lack motivation to experience
other dimension of nursing and goes on the trip for the fun of it? What do these students
learn in such an exchange, does the experience support the negative stereotypes? And
what are the responsibilities of the international co-ordinators?
Gudykust (1989); Wiseman an Koestler (1993) suggested that intercultural encounters
can be confusing due to group differences, and different communication styles. This can
result in misunderstandings and failure to adjust resulting in an unpleasant intercultural
exchange resulting in negative evaluation and stereotyping of the cultural different.
The horizon of development of cultural sensitivity and growing personally was clearly a
consequence of the impact of social dislocation. This enabled the participants to develop
sensitivity to the influence of culture within health care. Because of this experience they
were able to relate to patients with greater respect and empathy in caring for the
culturally different.
Experiencing minority status in the sense of communicating in a different language,
living in a strange environment away from their family and friends heightened the
participants’ awareness of what it feels like to be away from home without relations and
friends in a new environment. Furthermore they reflected about what it must feel like to
112
be a patient in a Danish hospital, and the need to empathize with people who are
adapting to change. Feeling marginalized was an overwhelming factor in development
of cultural sensitivity as the participants integrated new perspectives into old values and
views that were transforming. The participants stated that awareness, acknowledgement
of cultural differences, the importance of being non-judgemental, recognition that there
is no right or wrong culture only differences, respect and acceptance of these differences
were essential in integrating new perspectives. Broadening their horizons enhanced the
participants understanding and use of non- verbal communication in acknowledging and
accepting people who are different, along with an appreciation of the impact culture has
on health care systems, clients’ beliefs regarding health and illness. These findings are
compatible with intercultural awareness at the stages of acceptance and adaptation in
Bennett’s model,. as well as the view outlined by De Santis (1988) and CampinhaBacote(2003) that acknowledgement and acceptance of cultural differences enable
nurses to act as cultural brokers and advocates for the culturally diverse clients.
This was clearly evident in Lone’s discussion of what it means to be a minority,
acceptance of the importance of acknowledging and respecting differences by
modifying her behaviour in clinical and an appreciation of the influence of sociopolitical factors on health care, as well as empathy for foreigners in Denmark. This was
heightened by Lena’s, Inge’s and Jette’s appreciation for the less stressful lifestyle and
recognition of the role of spirituality in health care and empathy for people from
different backgrounds living in her home culture. Susanne spoke of the importance of
understanding the norms and values of the different cultures in the context of their
history in order to appreciate and respect the cultural differences. Unlike the other
participants Bent was defensive and emphasized the superior ways of his education
system. Bent’s initial attitude was compatible with Bennetts’ stage of defence on the
113
developmental continuum in developing cultural sensitivity. He did however become
more open and reflexive when he felt accepted and valued by the host culture reflecting
a movement to the acceptance stage.
Confronting the intensity and challenge of the international experience enabled the
participants to grow personally and gain personal insights. They learned to cope in new
and stressful situations which brought about increased self-confidence and
independence, as well as being more reflective about their practice
The participants in this study revealed that the context of an international experience
had been a process of learning to adjust to cultural differences. Reflecting about their
experiences with other students and clinical mentors facilitated the development of
cultural sensitivity to different lifestyles and health care practices.
Conclusion
This chapter revealed some insight into the effect of international education as a context
for the development of cultural sensitivity. It became clear that the development of
cultural sensitivity is an ongoing process that continued on re-entry as evidenced by
openness and interest in people from other cultural backgrounds. Reflecting about their
experiences enabled the participants to view cultural differences from different
perspectives. Support from other students, especially students from the participants own
background as well as clinical mentors facilitated this process. Furthermore, personal
characteristics of openness and flexibility and willingness to modify one’s behaviour
promoted adaptation into another culture. The findings in this study are reflected in the
literature and raise some questions regarding preparation and planning between the
home and host culture.
114
.
Chapter 7 Conclusion (Heidi, can you look at what you are saying in your
conclusion with “fresh eyes” because it occurs to me that some of what you are
saying can go into your discussion chapter because it does not appear to be there)
The findings from this study and the literature suggest that an international exchange
opportunity is a suitable learning method for developing cultural sensitivity in student
nurses. Participating in an international experience had a profound influential impact on
the participants. Challenged by differences in their values, beliefs and communicating in
a different language enabled them to increase cultural self and other awareness, as well
as gain insight into their nursing practice beyond that experienced within their own
culture.
Development of cultural sensitivity as a consequence of participating in an international
experience was seen to be an ongoing circular process in this study. This process
consisted of three merged horizons with no rigid boundaries between them. These were
experiencing transition from one culture to another, adjusting to cultural differences and
developing cultural sensitivity and growing personally. Central to this process was
adjusting to an unfamiliar environment where the participants had to speak another
language. This created stress and varying degrees of culture shock. The participants
115
learned to adjust to cultural differences by interacting with local people, staff, and
patients, taking on the ways of the host culture and letting go of some of their Danish
ways. Having a secure environment provided by students with similar backgrounds,
teachers, and clinical mentors enabled them to compare and critically reflect on their
experiences in the host culture Through this process, the participants learned to
appreciate, respect and accept cultural differences that transformed their understanding
of the influence of culture on politics, health care systems, people’s beliefs about health
and illness. This is consistent with Campinha-Bacote’s (2003) claim achieving cultural
sensitivity is an ongoing process and not an end product. As a consequence of this
process the participants became more open and flexible, with growth in self confidence
and independence when confronted with new situations .This was evident as the
participants now realized the importance of being more open, and interested in people
from other cultural backgrounds because adapting to a new culture with different norms
and values can be difficult.
Furthermore the participants revealed changes in behaviours. Upon their return to their
own country they voiced that they now spent more time interacting with and listening to
clients from other cultural background, than they did before their overseas exchange.
One of the participants gave a talk in her clinical of what it meant to be a stranger in a
different culture. The benefits of increased sensitivity appreciation and respect for the
culturally different, along with personally and professional growth are consistent with
the findings from other studies (Lee,1997; Haloburton & Thompson,1998 and
Pross,2003).
116
My involvement in this study has made me more aware of other important factors such
as motivation, personality characteristics of the students who participate in an
international learning experience. Prior to undertaking this study I was of the opinion
that participating in an international experience and travelling alone would promote
cultural sensitivity A changed understanding of the importance of travelling with other
students and active involvement, interest and acceptance of the participants by the
clinical mentors and people in the host culture raises some important issues for me as an
international co-ordinator in planning student exchanges.
The participants in this study were a small homogenous sample and the findings cannot
be generalized to other students. The study findings however have the potential to
inform nursing educators planning international student exchanges. This study
highlighted the need for preparing the students prior to their student exchanges. It is
important to talk with the students about their expectation and attitudes toward their
student exchanges and it may be a valuable strategy to encourage students to travel
abroad with another student from their own school if this is possible. . In addition
information about the norms and values of the host culture could be valuable for the
students Other factors to consider are close liaison with the host school and clinical
mentors, and visits to the host schools and clinical areas the students will be placed in. It
is also important that the students get experiences in direct clinical contacts with the
patients and have the opportunity to feel part of the health team.
As development of cultural sensitivity is an on-going process, it is necessary to schedule
reflection time when the participants return home. In these sessions the participants
could share and critique their experiential knowledge with each other, other students
117
and nurses from the clinical areas. These sessions could be scheduled regular as the
development of cultural sensitivity is an on going process and not an end product that is
mastered.
Recommendation for further study
Participants in this study were described as homogenous, six female students and one
male student enrolled in an undergraduate-nursing program in Denmark. It would be
valuable to replicate this study with other students from diverse backgrounds, socioeconomic backgrounds as they may experience international education differently.
Follow–up studies to determine how transformations change over time would be
beneficial. Finally integrating international education into the curriculum can be a way
to prepare student nurses for the global village
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Appendix A: Glossary of terms
Bildung
Bildung means openness to meaning- Bildung leads beyond what one knows and
experiences immediately. It consists in learning to affirm what is different to oneself
and to find a universal viewpoint from which one can grasp things (Gadamer,1993,p14)
Bildung means being open to the experience of others and embrace other perspectives
Pre-understanding
A condition and necessary part of understanding that give rise to thought, a pre.condition of understanding- such as our history and traditions that influence our
thinking.
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Fore-projection
Early understandings, pre-conceptions or presuppositions that are constantly brought
into play as a basis for new understanding
Prejudice
Refers to prior understanding that encourage consideration of other perspectives in
order for understanding to change and increase.
Horizon
Horizon comprise pre-understanding, worldview or perspective that enable us to
understand or make sense of new situations or events, that are constantly being shaped
by our past and awareness of the present.
Fusion of horizon
A process that occurs when different vantage points merge and new understanding
occurs
Appendix B
Consent form to conduct study: Head of School
127
Appendix C
Student consent form.
128
Appendix D
Some sample questions and probes used were as follows:

What was it like to live and study in another country?

Try to think of an incident and experience when you nursed a client with a
different cultural background to your own. Select one situation and describe
your experiences.
129

What does cultural sensitivity mean to you? Can you tell me about that? As a
result of your experiences how would you incorporate cultural sensitivity in
your interaction with clients from other cultural backgrounds?

What skills do you feel you have developed as a consequence of living and
studying in another country?

How can you use those skills when you return home? What was it like to study
in a country where they spoke another language?

Tell me about some of your experiences in speaking a second language? Can
you tell me how you felt about some of your experiences speaking a second
language?
The order of questions varied from one participant to the other, and other questions
which are not listed but were pertinent to exploring each participant’s perception of
their experience were asked during the
130