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Nursing and Health Sciences (2015), 17, 181–187
Research Article
Experiences of undergraduate African health sciences students: A hermeneutic inquiry Davis Inyama, RN, MN, Allison Williams, RN, PhD and Kay McCauley, RN and RM, PhD School of Nursing and Midwifery, Monash University, Frankston, Victoria, Australia
Abstract
While efforts have been made to understand the experiences of African students in predominantly white environments, the experiences of African students in clinical placement areas have rarely been explored. This paper is a report on a study designed to address the gap in educational research on the experiences of African health sciences students in clinical placements in predominantly white environments. Interviews adopting an open approach to conversations were conducted with nine African students from three health disciplines at one metropolitan university in Australia between 2012 and 2013. Interview transcripts were analyzed using philosophical hermeneutics, where shared meanings were arrived at by employing key Gadamerian hermeneutic components. Findings revealed a number of factors that had a direct effect on the meaning students derived from their clinical placement experiences. These, as revealed in the interlinked domains of body, space, relationships, and time included difference, acceptance, resilience, and cultural sensitivity. Insights from this study may lead to the adoption of strategies designed to improve the experiences of African students studying health sciences in predominantly white environments.
Key words
African students, clinical placements, experiences, health sciences, hermeneutics.
INTRODUCTION Clinical placements serve as the link between theoretical knowledge and real patient situations (Coyne & Needham, 2012). Students are exposed to a variety of clinical situations that laboratory or classroom settings cannot provide (Fahy et al., 2006; Coyne & Needham, 2012). They enable students to communicate and interact with patients and their families, learn from the healthcare teams through their interactions, achieve skill competence through supervized practice, and acquire the ability of dealing with the complex nature of competing needs (Fahy et al., 2006). Students are able to receive feedback on real world performance and are individually guided in their reflection on their lived experiences (Fahy et al., 2006). The experience of clinical placements as being anxiety provoking has been reported in early nursing literature (Kleehammer et al., 1990). The personal and unparalleled nature of clinical learning was brought to the fore in a study by Midgley (2006) exploring the perception of 67 nursing students in regards to clinical placement in the United
Correspondence address: Davis Inyama, School of Nursing and Midwifery, Monash University, Frankston, Vic 3199, Australia. Email: [email protected] Study conducted in Melbourne, Victoria, Australia utilising the interpretive phenomenological approach. Research project approved by Monash University Research Ethics Committee (MUREC). Received 18 August 2013; revision received 27 March 2014; accepted 29 April 2014
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Kingdom. Similarly, Grealish and Smale (2011) revealed the anxiety suffered by the students in their “intimate” journey while on clinical placement in the Australian system. With the concern about high anxiety levels on clinical placement, it is important to explore the journeys of potentially “vulnerable” students in a bid to improve their overall clinical placement experience. This paper reports a study to understand meanings derived from the experience of the Australian clinical placement setting by black African health sciences students. “Health sciences” was operationalized to indicate courses that require clinical placements, that is, medicine, nursing, and radiography and medical imaging. The research explored the education journey of the nine African students in their clinical placement experiences in Australia, employing an interpretive phenomenological approach.
Literature review Before commencing the study, it was essential to establish previous research that had been conducted in regard to African health sciences students’ experience of clinical placements in predominantly white environments. Omotosho (1998) conducted a phenomenological study to explore the experiences of African nursing students in the American context. In adapting to the American culture, Omotosho (1998) reported that the students experienced detachment from home, a place where they felt comfortable and secure. doi: 10.1111/nhs.12153
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The students were also faced with language difficulties, issues related to being different, new assessment methods, and unfamiliarity with cultural practices. In a study conducted by Sanner et al. (2002) on the experiences of international students to whom English was a second language, eight Nigerian nursing students were interviewed.While trying to integrate into the academic and social components of the institution, the students reported feeling that they were not accepted. The researchers reported that the participants felt that American students, both Caucasian and African-American were not keen to listen to them, something that made their attempts to join study groups or nursing student organizations difficult (Sanner et al., 2002). Mattila et al. (2010) investigating the experiences of international nurses in the Finnish education system indicated that 14 students of African and Asian origin had both positive and negative experiences adapting to the new system. Semistructured interviews were used to collect data where the students reported that while adjusting to the Finnish healthcare system, they felt appreciated in the way that they were introduced to the clinical environment, staff members, patients, and the daily routines on the wards. Mattila et al. (2010) asserted that the orientation program aided the students’ adjustment to the new system as it gave them an understanding of how they could involve themselves in the activities in their new environment. As regards negative adjustment experiences, Mattila et al. (2010) reported that a key hindrance for the students’ adaptation was the foreign language: the students had a major problem communicating in Finnish, thereby making it difficult for them to adapt to Finnish hospital work culture (Mattila et al., 2010). With the above-mentioned studies reporting the challenges faced by African students in predominantly white environments in the United States and Europe, it was evident that there is a dearth in recent studies exploring the clinical placement experiences of African students in Australia. It for this reason, and due to the lead researcher’s (an African health science student) experience of difficult transition into the Australian education system, as well as other preconceived ideas about African student experiences, that the study was conceived.
METHODS Study design This research employed an interpretive phenomenological approach to derive meanings rooted in the experiences of African health sciences students within Australian clinical settings. The research made use of the main tenets proposed by the Gadamerian school of interpretive phenomenology. The goal of interpretive phenomenology is to go beyond face-value description of major concepts and intrinsic properties that characterize a phenomenon (essences) to investigate and interpret meanings rooted in every-day practices (Lopez & Willis, 2004). Gadamer, whose focus and cardinal concern was understanding, proposed that as an event, understanding is dialectic, linguistic, and historical (Pascoe, 1996). He further identified the key concepts for understanding the © 2014 Wiley Publishing Asia Pty Ltd.
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human experience as pre-understanding, Bildung or openness to meaning, fore-projection, prejudice, and fusion of horizons (Walsh, 1996). Overall, the researcher endeavored to become immersed in the participants’ “world,” with an aim of “mixing” his prior knowledge and experiences as an African student (his view/ horizon) with what the participants narrated or what their spoken words portrayed as their experiences, so as to develop meanings that make sense to both parties (fusion of our horizons). Through this, all the parties in the research would enter a common “circle” of understanding (hermeneutic circle).
Participants African health sciences students were recruited from a large metropolitan Australian university using “snowballing” or networking, a technique where one participant is used to find another (Speziale & Carpenter, 2003). Networking was set in motion after the first two participants had been purposefully recruited between September 2012 and December 2013. The initial recruitment came by the way of an acquaintance of the researcher who informed two potential participants at the study site. The inclusion criteria stipulated that participants should have born in Africa, or shared and subscribed to given African beliefs, culture, or upbringing. They were also required to have a health sciences background, for example, undergraduate medicine, nursing, paramedic, radiography and medical imaging, and to have undertaken at least two clinical placement rotations. Information about the study was made available to potential participants on initial contact and follow-up calls were made to confirm their participation. Overall nine students were recruited: two nursing, two radiography and medical imaging, and five medical students, in a 4:5 male to female ratio.
Data collection Interviews were conducted in the participants’ place of choice to allow for free sharing of information and to gain an in-depth understanding about the clinical placement “world” of the participants. As the research intended to explore the participants’ “life world” as they undertook clinical placements, the interview questions were structured along the elements of the existential framework: lived body, lived space, lived relationships, and lived time (Munhall, 2007). These elements denote the various “entities” through which humans experience life (Munhall, 2007). As Gadamer noted, the work of a question is to place the subject of inquiry in the intended perspective (Binding & Tapp, 2008). The approximately 40-min conversations began with queries related to participant’s general international travel experience and proceeded to more focused questions, such as “What can you say about working in the hospital as an African student?” All the interviews were conducted by an African health science student, which cemented the choice of Gadamerian philosophical hermeneutics as the preferred study methodology due to the interviewer’s “close connec-
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tion” with the participants. Interviews were recorded with consent from the participants and were later transcribed verbatim prior to analysis.
RESULTS
Data analysis
Understanding the “life-world” of black African health sciences students was the primary focus of this study. Humans experience the world through the physical self (lived body), in the environment lived in (lived space), through the associations forged (lived relationships), or the quality of life at a particular point (lived time) (Van Manen, 1990). The experiences of the participants were therefore placed in the aforementioned categories (i.e. lived body, lived space, lived relationships and lived time).
The transcripts were read to establish an overall impression and to focus the interviews to provide a deeper and richer understanding of the experiences. As the study sought to investigate the “lived experience” of the participants, the researchers, in reading the transcripts tried to locate statements that lay within the elements constitutive of the “life world” or the existential framework (Munhall, 2007). In-depth reading and re-reading further identified experiences and statements that were harmonious with the researchers’ prior understanding. It also unearthed unexpected or unique information (Koch, 1996; Turner, 2008). The central concerns and unique information from each of the participants’ transcript was allocated under each element of the life world to form 1–2 page summaries, providing a platform on which interpretations were to be built. The overall summaries, developed and agreed on by the researchers, were then compared against each other in a bid to identify common patterns in the participant experiences. Common patterns were clustered under units of similar meanings (subthemes). The subthemes were grouped under the four elements of the existential framework, that is: body, space, relationships, and time (Munhall, 2007).
Rigor In using the Gadamerian approach, it was essential to establish the trustworthiness of the research process and achieve truthfulness in analysis. Adherence to the trustworthiness criteria as outlined by Guba and Lincoln (1985) as cited in Koch (2006) was utilized in this study.According to Guba and Lincoln, the key to establishing authenticity is the credibility, transferability, dependability, and confirmability of the study findings (Koch, 2006). To make the study credible and confirmable, the views of the participants were clearly represented. The principal researcher kept a reflective journal throughout the interview process in the spirit of phenomenological inquiry. Attempts at contacting the participants during various stages of data analysis to clarify, validate, and further explore their experiences were made but not achieved as they declined citing busy schedules. The co-researchers randomly checked the transcripts against the audio files and agreed upon the final analysis.
Ethics The study was approved by the Monash University ethics committee. Participants were issued with an explanatory statement that clearly informed them of their rights and outlined the principles guiding the study in order to enable them to make an informed decision and provide a written informed consent. Confidentiality was protected by allocating pseudonyms to interview data.
Interpreting the meanings within African student experiences
Lived body Interpretation of the lived body experiences of the African student required careful regard to how feelings and representations of internal, external, and psychological experiences were brought to the fore. One major aspect running through the transcripts was the relay of “difference” as exhibited in the conversations of the participants. There was general consensus among the participants that they were considered “unique” in the areas where they were assigned for clinical placements, something they believed drew attention to them. Participants related this to the color of their skin. Jabali, a male final year medical student from Botswana shared: “For me I don’t know if it’s because I have a bit of an attitude problem or what. But . . . because it seems like all the placements I go to I am usually the only African person, the black person in any group.And that, honestly speaking, just you being the only black person in a group, it just puts a lot of attention on me.” However “difference” was described not only in relation to the participant’s skin color. Participants mentioned other aspects such as their accents, confidence levels, and their apparent difficulties in articulating ideas in English, which was their second language. This, they believed was misinterpreted as inferiority by some of the patients that they provided care to. Orji, a male second year nursing student from Sierra Leone shared: “. . . . there have been so many times when I have been faced with that dilemma where a patient will tell you I don’t want that black guy. “Reason?” “Well, I just don’t feel confident with him.” Being viewed as “different” elicited various psychological and emotional responses from the participants. Several relayed the anger, frustration, and awkward moments in their clinical placement areas. Participants spoke of statements and treatment directed at them by some patients and staff members due to perceived “difference.” For example, frustration was conveyed by Jabali’s utterances and voice tone as he shared; “. . . . I would be more happy if you know I walked into a place and didn’t have to think about the fact that I’m © 2014 Wiley Publishing Asia Pty Ltd.
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different and just walk in there, sit in with the whole team and not worry about being asked about where I’m from . . . and every time talk about tropical diseases, HIV. People look at me, you know, yeah. But I guess it’s only natural. . . .” The frustration experienced for being “different” still acknowledged that while not able to change their appearance, the participants needed to accept and live with it. Jabali summed the experience of living in an African body, saying, “. . . and you just got to put up with it. . . . like just not think about it and just move on.”
Lived space The “lived space” is a representation that people are linked to environments and places, in the case of participants in this study, their clinical placement locations. The key meanings of the “lived space” experiences of the participants were based on their unfamiliarity in a new place. While the participants revealed their initial elation at the opportunity to undertake clinical placements in a western healthcare system, the majority reported the many challenges faced, particularly fitting in at the placement areas. For instance, the lack of knowledge about the culture of people in places where they were assigned for clinical rotations elicited feelings of “being out of place.” Participants reported difficulties interacting with both staff and patients. Sade, a female third year radiography and medical imaging student from Botswana shared: “. . . . obviously when I was starting . . . like I didn’t know much, like I think one of the things that found really hard was interacting with both staff and the patients because like there was just a lot of difference. I didn’t know like, you know, what they found offensive or what they didn’t find offensive, just because of the difference in the cultures and all that.” The participants further revealed that it was particularly difficult for those African students living or undertaking their clinical placements in rural areas that were not as culturally diverse as the cities. Ayanna, a third year medical student, while acknowledging that she had relatively good experiences during her placement in a hospital located close to the city, identified that was not the case for her other African friends who went to rural hospitals. She linked these experiences to the multicultural nature of the city hospitals, which was not replicated in the rural hospitals. She explained: . . . . some of my friends in rural areas, they have been placed in areas where they were only black person in the community for example. And that was like a big deal for everyone. Like people would stare . . . some would just ask them so many million questions because they are black. And at the hospital clinical placements they found it difficult to interact with some patients . . . some patients would behave weird-ish because they haven’t seen black people and they were like . . . “Oh! So there is a black medical student!” While the participants reported becoming accustomed to their new environment with time, it was evident that the © 2014 Wiley Publishing Asia Pty Ltd.
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African healthcare context would still be the preferred practice setting for most once studies were completed. For example, one participant shared that he would go back to his country, a decision he attributed to the confidence he felt when he was undertaking his elective program in a hospital in his home country. Ultimately, the participants felt that they would make better healthcare professionals in their home countries than they would in the context where they were currently undertaking clinical placements.
Lived relationships The concept of “lived relationships” was representative of the meaning attached to associations or interactions between the participants and people at their clinical placement areas: staff and patients. From the participant responses, it was inferred that there existed “unique” social dynamics and ways of relating in clinical placement areas that were distinct from previous experiences and which had to be learned. One such aspect was the “impersonal” nature of relationships that existed between people in the Australian healthcare context. Participants noted that patients and care providers in the clinical placement areas appeared detached and “caught up” in their own worlds and did not seem to care much about one another beyond professional boundaries. Sade, shared, “I don’t want to be judgmental. But it’s like . . . I don’t know . . . most people just . . . even patients; they are just caught up in their own things.” Participants further described experiencing a cultural clash between their norms and those evident in the Australian culture, for example, ways of interacting with older patients and the provision of care to older people. For the participants, the African culture dictated that older people should be “revered.” Participants stated that this was not the case in the current clinical setting where interactions were casual and somewhat “equal.” Therefore, the participants encountered challenges in interacting and providing care to older patients in ways that were customary and the norm in the Australian clinical placement areas. For instance, Orji disclosed the difficulty he faced with accepting the fact that he had to provide personal care to older female patients, an aspect that is “taboo” in his culture: “Yes, that day that was the first day I actually assisted an elderly (female) person with a shower because it is unacceptable in my culture. In my culture if an elderly person is sick, the elderly person will be looked after by the elderly people or an adult in the family.” The exploration of “lived relationships” for the participants highlighted the reality that culturally sensitive practices are frequently absent in some clinical settings in Australia.
Lived time The experiences linked to “lived time” displayed the progressive change in the quality of the participants’ lives over the clinical placement period. Most of the participants became accustomed to life in their new environments with each passing day. The participants attributed this to increased
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knowledge of the culture of people at clinical placement areas and the influence of local Australian friends who helped in demystifying aspects that had initially seemed “alien.” Amani shared: “At this point in time I think I am now used to it. I can just go to the patient and talk to them and I can. . . . I just feel like I’m getting there . . . I’m a doctor now. Yeah, it’s fine. All these two years of transition, I think now it’s fine.” In further exploring the aspect of “lived time,” the resilience of the participants was brought to the fore. While identifying experiences participants wished they had never had during their time in clinical placement, most recognized that dealing with the various difficulties enlightened them and strengthened their resolve to complete their course. Mvumilivu, a second year nursing student from Ethiopia, when referring to abuse he received from a patient which he believed was racially instigated, noted: “. . . for me, I know everything is for my own good. Even the bad thing which is happening to me, as I mentioned here . . . turned out to be my . . . turned out to be good because I learn from those offences and I learn from all the situations that happen to me. It gives me a lesson so that I’ll be prepared in future when things like that come into my life.” Summarily, the journey of the participants as they adapted, integrated, and conditioned themselves to life in Australia has been seen to have various challenges. Quoted interview excerpts have elucidated major factors that influenced the lives of the participants as they adjusted to the Australian healthcare system.
DISCUSSION: THE INTERLINKED DOMAINS While exploring the “world” of the participants, the associations that existed between their experiences, specifically in the clinical placement “world,” pointed to the Heideggerian assertion about the integrated and interrelated nature of the world we live in (Dreyfus, 1991). There was therefore interplay in the way the participants experienced their clinical world, with body, space, relationships, and time being seen to influence each other. The interplay between the domains was essential in providing an understanding of the whole participant experience of clinical placement. The interlinked domains were part of a “hermeneutic circle,” a component expounded by Gadamer (1975) to elucidate the back and forth movement between parts essential in arriving at a shared understanding. In exploring the four core themes, it became clear to the researcher that “lived body” was the central construct due to the influence it exerted across the whole spectrum of participant experiences. In the case of participants in this study, their lived body was the perception and reality for themselves and others that they were of a different skin color. It was noted that the “body” in which the participants lived subjected them to various physical and psychological challenges related to looking and feeling different within the Australian society and the healthcare system. This domain
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also influenced their experiences in regard to the domains of space, relationships, and time. For example, most participants would opt to go back to practice in Africa (their space) on completion of their studies partly due to the negative bodily occurrences during their clinical placements in Australia (current space) and their desire to be part of the “norm” rather than being seen as different. Nash et al. (2009) in a study examining a transition model for final year nursing students to graduate nursing revealed that the “sense of belonging” in clinical placement areas has a direct effect on student career decisions. Of interest is the connection between body and space in the way some participants reacted to racially directed comments made by some patients about Africa, the related misconceptions and their view that being black relegated them to a lesser standard. The participants’ anger and dismay is understandable given the multicultural nature of Australia where these experiences are not expected. These findings were also in contrast to those by Webster et al. (2010) in a study examining the experiences of eight nursing students from a city university who undertook a four-week placement program at a rural facility in an Aboriginal community in Australia. While Webster et al. (2010) did not provide details about the racial make-up of the eight students, all participants in that study attested to having positive experiences during their stay at the facility. The above differences raise the question whether the participants’ experiences in their respective placement areas are linked to “place of origin” and color of their skin. The link between “relationships” and the other domains was evident mainly in the reaction of the participants to the nature of relationships between staff and patients that were seen to exist in the Australian context and which did not occur in their countries of origin (in Africa). The participants, apart from being “different” in body, came from Africa (known space), a context where relationships between people are heavily linked to given cultural inclinations. For this reason, they initially found it challenging to nurture relationships with the patients in their early days in the clinical context. The findings are a corroboration of those in studies by Lee and Opio (2011) and Constantine et al. (2005), in which the culture of African students made it difficult to relate to people in predominantly white settings. The experiences which participants in the current study narrated regarding other African students undertaking clinical placements in rural areas in Australia also alluded to the nature of relationships that existed in those contexts. Conversely, the “lived relationships” of the participants can be used to epitomize the conflict that has existed between the European and African cultures since the colonial era. When European nations colonized African countries, they brought with them elements in their culture that eroded or threatened to erode various aspects of the African culture (Traoré, 2004). In discussing the “cultural bomb,” Traoré (2004, p. 353) notes that Africans still subscribe to cultural and educational domination served to them by white colonial masters. The findings of the current study are an indication of the colonial trends of cultural and educational domination that were imposed on African students by European © 2014 Wiley Publishing Asia Pty Ltd.
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educators during the colonial era. The above analogy is perhaps reflective of the experiences of participants as they try to nurture relationships in clinical placement areas governed by “norms” different to what they were initially exposed to. The above-mentioned matrix represents the complex interlinks the participants experienced in their clinical placement settings, providing insight on the meaning of being an African student in a predominantly white environment. By carefully examining the participants’ language, the analysis linked the experiences of the participants in each domain of the existential framework leading to the arrival at a shared understanding. The study unearthed various cultural and psychosocial challenges that participants faced. Specifically, the nature of patient–participant relations as cardinal in shaping overall student experiences and culture-linked clashes during care delivery and ways of relating between the various age groups, especially between the young and the old were some of the findings not identified in the literature.This therefore calls for measures that can help to address the challenges, allowing for a harmonious interlink between space, body, relationships, and time for the students in clinical placement areas.
Implications and recommendations Considering that some participants faced challenges interacting with some patients – from rejection of care services, to patients being outspoken as regards to participants’ skin color – the “life” of African students would perhaps be improved if more efforts we made to educate Australians on cultural acceptance. This would perhaps help eliminate the stigma associated with “being different” and issues evident in the provision of cross-gender care. Lack of knowledge of and understanding of the Australian culture and healthcare organizations/systems raised many challenges for the participants on clinical placement, as they were unprepared for what to expect. It would therefore be beneficial if institutions of higher learning carried out thorough briefings with African and other minority population students on issues potentially expected on clinical placement.
Limitations In conducting the study, several factors that may have limited the study findings have been acknowledged. The study had the intention to include African students from all health disciplines. This was considered a limiting factor as the study could perhaps have benefitted from the input of students from other health disciplines, such as paramedics and physiotherapy or instead provided an in-depth exploration of one particular discipline. Nevertheless, this study has highlighted specific difficulties faced by African students as regards to completing a health sciences degree in Australia in addition to those revealed in studies conducted in other countries such as the United States.
CONCLUSION This study has brought to the fore important aspects as regards to understanding of the experiences of African health © 2014 Wiley Publishing Asia Pty Ltd.
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sciences students in predominantly white clinical placement areas by revealing new findings and perspectives that had not been identified in the reviewed literature. The research has provided several recommendations based on the study findings such as the need for proper orientation and mentorship for the students. It would be of benefit to education stakeholders if the findings from this study were used to survey a larger African student population to obtain information that is generalizable for policy development. Meanwhile, the dissemination of these findings is likely to improve the experiences of African students on clinical placement in Australia and possibly in other multicultural settings such as the United States.
ACKNOWLEDGMENTS The authors wish to thank the research participants for their time and dedication during the study.
CONTRIBUTIONS Study Design: DI, AW, KM. Data Collection and Analysis: DI, AW, KM. Manuscript Writing: DI, AW, KM.
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Mattila L-R, Pitkäjärvi M, Eriksson E. International student nurses’ experiences of clinical practice in the Finnish health care system. Nurse Educ. Pract. 2010; 10: 153–157. Midgley K. Pre-registration student nurses perception of the hospital-learning environment during clinical placements. Nurse Educ. Today 2006; 26: 338–345. Munhall PL. Nursing Research: A Qualitative Perspective (4th edn). Boston: Jones & Bartlett, 2007. Nash R, Lemcke P, Sacre S. Enhancing transition: an enhanced model of clinical placement for final year nursing students. Nurse Educ. Today 2009; 29: 48–56. doi: http://dx.doi.org/10.1016/ j.nedt.2008.06.004. Omotosho SA. Becoming a stranger: the experience of African students’ transformation in a baccalaureate school of nursing. 1998; Ph.D., University of Maryland, Baltimore. [Cited July 2013.] Available from URL: http://search.ebscohost.com/login.aspx?direct= true&db=jlh&AN=2004118126&site=ehost-live Available from EBSCOhost jlh database. Pascoe E. The value to nursing research of Gadamer’s hermeneutic philosophy. Journal of Advanced Nursing. 1996; 24: 1309–1314. doi: 10.1111/j.1365-2648.1996.tb01039.x.
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Sanner S, Wilson AH, Samson LF. The experiences of international nursing students in a Baccalaureate nursing program. J. Prof. Nurs. 2002; 18: 206–213. Speziale JH, Carpenter DR. Qualitative Research in Nursing: Advancing the Humanistic Imperative (3rd edn). Philadelphia, PA: Lippincott Williams & Wilkins, 2003. Traoré RL. Colonialism continued: African students in an urban high school in America. J. Black Stud 2004; 34: 348–369. doi: 10.1177/ 0021934703258986. Turner DS. Horizons revealed: from methodology to method. Int. J. Qual. Methods 2008; 2: 1–17. Van Manen M. Researching Lived Experience: Human Science for an Action Sensitive Pedagogy. London: Suny Press, 1990. Walsh K. Philosophical hermeneutics and the project of Hans Georg Gadamer: implications for nursing research. Nurs. Inq. 1996; 3: 231–237. doi: 10.1111/j.1440-1800.1996.tb00046.x. Webster S, Lopez V, Allnut J, Clague L, Jones D, Bennett P. Undergraduate nursing students’ experiences in a rural clinical placement. Aust. J. Rural Health 2010; 18: 194–198. doi: 10.1111/ j.1440-1584.2010.01153.x.
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Nursing and Health Sciences (2015), 17, 181–187
Research Article
Experiences of undergraduate African health sciences students: A hermeneutic inquiry Davis Inyama, RN, MN, Allison Williams, RN, PhD and Kay McCauley, RN and RM, PhD School of Nursing and Midwifery, Monash University, Frankston, Victoria, Australia
Abstract
While efforts have been made to understand the experiences of African students in predominantly white environments, the experiences of African students in clinical placement areas have rarely been explored. This paper is a report on a study designed to address the gap in educational research on the experiences of African health sciences students in clinical placements in predominantly white environments. Interviews adopting an open approach to conversations were conducted with nine African students from three health disciplines at one metropolitan university in Australia between 2012 and 2013. Interview transcripts were analyzed using philosophical hermeneutics, where shared meanings were arrived at by employing key Gadamerian hermeneutic components. Findings revealed a number of factors that had a direct effect on the meaning students derived from their clinical placement experiences. These, as revealed in the interlinked domains of body, space, relationships, and time included difference, acceptance, resilience, and cultural sensitivity. Insights from this study may lead to the adoption of strategies designed to improve the experiences of African students studying health sciences in predominantly white environments.
Key words
African students, clinical placements, experiences, health sciences, hermeneutics.
INTRODUCTION Clinical placements serve as the link between theoretical knowledge and real patient situations (Coyne & Needham, 2012). Students are exposed to a variety of clinical situations that laboratory or classroom settings cannot provide (Fahy et al., 2006; Coyne & Needham, 2012). They enable students to communicate and interact with patients and their families, learn from the healthcare teams through their interactions, achieve skill competence through supervized practice, and acquire the ability of dealing with the complex nature of competing needs (Fahy et al., 2006). Students are able to receive feedback on real world performance and are individually guided in their reflection on their lived experiences (Fahy et al., 2006). The experience of clinical placements as being anxiety provoking has been reported in early nursing literature (Kleehammer et al., 1990). The personal and unparalleled nature of clinical learning was brought to the fore in a study by Midgley (2006) exploring the perception of 67 nursing students in regards to clinical placement in the United
Correspondence address: Davis Inyama, School of Nursing and Midwifery, Monash University, Frankston, Vic 3199, Australia. Email: [email protected] Study conducted in Melbourne, Victoria, Australia utilising the interpretive phenomenological approach. Research project approved by Monash University Research Ethics Committee (MUREC). Received 18 August 2013; revision received 27 March 2014; accepted 29 April 2014
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Kingdom. Similarly, Grealish and Smale (2011) revealed the anxiety suffered by the students in their “intimate” journey while on clinical placement in the Australian system. With the concern about high anxiety levels on clinical placement, it is important to explore the journeys of potentially “vulnerable” students in a bid to improve their overall clinical placement experience. This paper reports a study to understand meanings derived from the experience of the Australian clinical placement setting by black African health sciences students. “Health sciences” was operationalized to indicate courses that require clinical placements, that is, medicine, nursing, and radiography and medical imaging. The research explored the education journey of the nine African students in their clinical placement experiences in Australia, employing an interpretive phenomenological approach.
Literature review Before commencing the study, it was essential to establish previous research that had been conducted in regard to African health sciences students’ experience of clinical placements in predominantly white environments. Omotosho (1998) conducted a phenomenological study to explore the experiences of African nursing students in the American context. In adapting to the American culture, Omotosho (1998) reported that the students experienced detachment from home, a place where they felt comfortable and secure. doi: 10.1111/nhs.12153
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The students were also faced with language difficulties, issues related to being different, new assessment methods, and unfamiliarity with cultural practices. In a study conducted by Sanner et al. (2002) on the experiences of international students to whom English was a second language, eight Nigerian nursing students were interviewed.While trying to integrate into the academic and social components of the institution, the students reported feeling that they were not accepted. The researchers reported that the participants felt that American students, both Caucasian and African-American were not keen to listen to them, something that made their attempts to join study groups or nursing student organizations difficult (Sanner et al., 2002). Mattila et al. (2010) investigating the experiences of international nurses in the Finnish education system indicated that 14 students of African and Asian origin had both positive and negative experiences adapting to the new system. Semistructured interviews were used to collect data where the students reported that while adjusting to the Finnish healthcare system, they felt appreciated in the way that they were introduced to the clinical environment, staff members, patients, and the daily routines on the wards. Mattila et al. (2010) asserted that the orientation program aided the students’ adjustment to the new system as it gave them an understanding of how they could involve themselves in the activities in their new environment. As regards negative adjustment experiences, Mattila et al. (2010) reported that a key hindrance for the students’ adaptation was the foreign language: the students had a major problem communicating in Finnish, thereby making it difficult for them to adapt to Finnish hospital work culture (Mattila et al., 2010). With the above-mentioned studies reporting the challenges faced by African students in predominantly white environments in the United States and Europe, it was evident that there is a dearth in recent studies exploring the clinical placement experiences of African students in Australia. It for this reason, and due to the lead researcher’s (an African health science student) experience of difficult transition into the Australian education system, as well as other preconceived ideas about African student experiences, that the study was conceived.
METHODS Study design This research employed an interpretive phenomenological approach to derive meanings rooted in the experiences of African health sciences students within Australian clinical settings. The research made use of the main tenets proposed by the Gadamerian school of interpretive phenomenology. The goal of interpretive phenomenology is to go beyond face-value description of major concepts and intrinsic properties that characterize a phenomenon (essences) to investigate and interpret meanings rooted in every-day practices (Lopez & Willis, 2004). Gadamer, whose focus and cardinal concern was understanding, proposed that as an event, understanding is dialectic, linguistic, and historical (Pascoe, 1996). He further identified the key concepts for understanding the © 2014 Wiley Publishing Asia Pty Ltd.
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human experience as pre-understanding, Bildung or openness to meaning, fore-projection, prejudice, and fusion of horizons (Walsh, 1996). Overall, the researcher endeavored to become immersed in the participants’ “world,” with an aim of “mixing” his prior knowledge and experiences as an African student (his view/ horizon) with what the participants narrated or what their spoken words portrayed as their experiences, so as to develop meanings that make sense to both parties (fusion of our horizons). Through this, all the parties in the research would enter a common “circle” of understanding (hermeneutic circle).
Participants African health sciences students were recruited from a large metropolitan Australian university using “snowballing” or networking, a technique where one participant is used to find another (Speziale & Carpenter, 2003). Networking was set in motion after the first two participants had been purposefully recruited between September 2012 and December 2013. The initial recruitment came by the way of an acquaintance of the researcher who informed two potential participants at the study site. The inclusion criteria stipulated that participants should have born in Africa, or shared and subscribed to given African beliefs, culture, or upbringing. They were also required to have a health sciences background, for example, undergraduate medicine, nursing, paramedic, radiography and medical imaging, and to have undertaken at least two clinical placement rotations. Information about the study was made available to potential participants on initial contact and follow-up calls were made to confirm their participation. Overall nine students were recruited: two nursing, two radiography and medical imaging, and five medical students, in a 4:5 male to female ratio.
Data collection Interviews were conducted in the participants’ place of choice to allow for free sharing of information and to gain an in-depth understanding about the clinical placement “world” of the participants. As the research intended to explore the participants’ “life world” as they undertook clinical placements, the interview questions were structured along the elements of the existential framework: lived body, lived space, lived relationships, and lived time (Munhall, 2007). These elements denote the various “entities” through which humans experience life (Munhall, 2007). As Gadamer noted, the work of a question is to place the subject of inquiry in the intended perspective (Binding & Tapp, 2008). The approximately 40-min conversations began with queries related to participant’s general international travel experience and proceeded to more focused questions, such as “What can you say about working in the hospital as an African student?” All the interviews were conducted by an African health science student, which cemented the choice of Gadamerian philosophical hermeneutics as the preferred study methodology due to the interviewer’s “close connec-
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tion” with the participants. Interviews were recorded with consent from the participants and were later transcribed verbatim prior to analysis.
RESULTS
Data analysis
Understanding the “life-world” of black African health sciences students was the primary focus of this study. Humans experience the world through the physical self (lived body), in the environment lived in (lived space), through the associations forged (lived relationships), or the quality of life at a particular point (lived time) (Van Manen, 1990). The experiences of the participants were therefore placed in the aforementioned categories (i.e. lived body, lived space, lived relationships and lived time).
The transcripts were read to establish an overall impression and to focus the interviews to provide a deeper and richer understanding of the experiences. As the study sought to investigate the “lived experience” of the participants, the researchers, in reading the transcripts tried to locate statements that lay within the elements constitutive of the “life world” or the existential framework (Munhall, 2007). In-depth reading and re-reading further identified experiences and statements that were harmonious with the researchers’ prior understanding. It also unearthed unexpected or unique information (Koch, 1996; Turner, 2008). The central concerns and unique information from each of the participants’ transcript was allocated under each element of the life world to form 1–2 page summaries, providing a platform on which interpretations were to be built. The overall summaries, developed and agreed on by the researchers, were then compared against each other in a bid to identify common patterns in the participant experiences. Common patterns were clustered under units of similar meanings (subthemes). The subthemes were grouped under the four elements of the existential framework, that is: body, space, relationships, and time (Munhall, 2007).
Rigor In using the Gadamerian approach, it was essential to establish the trustworthiness of the research process and achieve truthfulness in analysis. Adherence to the trustworthiness criteria as outlined by Guba and Lincoln (1985) as cited in Koch (2006) was utilized in this study.According to Guba and Lincoln, the key to establishing authenticity is the credibility, transferability, dependability, and confirmability of the study findings (Koch, 2006). To make the study credible and confirmable, the views of the participants were clearly represented. The principal researcher kept a reflective journal throughout the interview process in the spirit of phenomenological inquiry. Attempts at contacting the participants during various stages of data analysis to clarify, validate, and further explore their experiences were made but not achieved as they declined citing busy schedules. The co-researchers randomly checked the transcripts against the audio files and agreed upon the final analysis.
Ethics The study was approved by the Monash University ethics committee. Participants were issued with an explanatory statement that clearly informed them of their rights and outlined the principles guiding the study in order to enable them to make an informed decision and provide a written informed consent. Confidentiality was protected by allocating pseudonyms to interview data.
Interpreting the meanings within African student experiences
Lived body Interpretation of the lived body experiences of the African student required careful regard to how feelings and representations of internal, external, and psychological experiences were brought to the fore. One major aspect running through the transcripts was the relay of “difference” as exhibited in the conversations of the participants. There was general consensus among the participants that they were considered “unique” in the areas where they were assigned for clinical placements, something they believed drew attention to them. Participants related this to the color of their skin. Jabali, a male final year medical student from Botswana shared: “For me I don’t know if it’s because I have a bit of an attitude problem or what. But . . . because it seems like all the placements I go to I am usually the only African person, the black person in any group.And that, honestly speaking, just you being the only black person in a group, it just puts a lot of attention on me.” However “difference” was described not only in relation to the participant’s skin color. Participants mentioned other aspects such as their accents, confidence levels, and their apparent difficulties in articulating ideas in English, which was their second language. This, they believed was misinterpreted as inferiority by some of the patients that they provided care to. Orji, a male second year nursing student from Sierra Leone shared: “. . . . there have been so many times when I have been faced with that dilemma where a patient will tell you I don’t want that black guy. “Reason?” “Well, I just don’t feel confident with him.” Being viewed as “different” elicited various psychological and emotional responses from the participants. Several relayed the anger, frustration, and awkward moments in their clinical placement areas. Participants spoke of statements and treatment directed at them by some patients and staff members due to perceived “difference.” For example, frustration was conveyed by Jabali’s utterances and voice tone as he shared; “. . . . I would be more happy if you know I walked into a place and didn’t have to think about the fact that I’m © 2014 Wiley Publishing Asia Pty Ltd.
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different and just walk in there, sit in with the whole team and not worry about being asked about where I’m from . . . and every time talk about tropical diseases, HIV. People look at me, you know, yeah. But I guess it’s only natural. . . .” The frustration experienced for being “different” still acknowledged that while not able to change their appearance, the participants needed to accept and live with it. Jabali summed the experience of living in an African body, saying, “. . . and you just got to put up with it. . . . like just not think about it and just move on.”
Lived space The “lived space” is a representation that people are linked to environments and places, in the case of participants in this study, their clinical placement locations. The key meanings of the “lived space” experiences of the participants were based on their unfamiliarity in a new place. While the participants revealed their initial elation at the opportunity to undertake clinical placements in a western healthcare system, the majority reported the many challenges faced, particularly fitting in at the placement areas. For instance, the lack of knowledge about the culture of people in places where they were assigned for clinical rotations elicited feelings of “being out of place.” Participants reported difficulties interacting with both staff and patients. Sade, a female third year radiography and medical imaging student from Botswana shared: “. . . . obviously when I was starting . . . like I didn’t know much, like I think one of the things that found really hard was interacting with both staff and the patients because like there was just a lot of difference. I didn’t know like, you know, what they found offensive or what they didn’t find offensive, just because of the difference in the cultures and all that.” The participants further revealed that it was particularly difficult for those African students living or undertaking their clinical placements in rural areas that were not as culturally diverse as the cities. Ayanna, a third year medical student, while acknowledging that she had relatively good experiences during her placement in a hospital located close to the city, identified that was not the case for her other African friends who went to rural hospitals. She linked these experiences to the multicultural nature of the city hospitals, which was not replicated in the rural hospitals. She explained: . . . . some of my friends in rural areas, they have been placed in areas where they were only black person in the community for example. And that was like a big deal for everyone. Like people would stare . . . some would just ask them so many million questions because they are black. And at the hospital clinical placements they found it difficult to interact with some patients . . . some patients would behave weird-ish because they haven’t seen black people and they were like . . . “Oh! So there is a black medical student!” While the participants reported becoming accustomed to their new environment with time, it was evident that the © 2014 Wiley Publishing Asia Pty Ltd.
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African healthcare context would still be the preferred practice setting for most once studies were completed. For example, one participant shared that he would go back to his country, a decision he attributed to the confidence he felt when he was undertaking his elective program in a hospital in his home country. Ultimately, the participants felt that they would make better healthcare professionals in their home countries than they would in the context where they were currently undertaking clinical placements.
Lived relationships The concept of “lived relationships” was representative of the meaning attached to associations or interactions between the participants and people at their clinical placement areas: staff and patients. From the participant responses, it was inferred that there existed “unique” social dynamics and ways of relating in clinical placement areas that were distinct from previous experiences and which had to be learned. One such aspect was the “impersonal” nature of relationships that existed between people in the Australian healthcare context. Participants noted that patients and care providers in the clinical placement areas appeared detached and “caught up” in their own worlds and did not seem to care much about one another beyond professional boundaries. Sade, shared, “I don’t want to be judgmental. But it’s like . . . I don’t know . . . most people just . . . even patients; they are just caught up in their own things.” Participants further described experiencing a cultural clash between their norms and those evident in the Australian culture, for example, ways of interacting with older patients and the provision of care to older people. For the participants, the African culture dictated that older people should be “revered.” Participants stated that this was not the case in the current clinical setting where interactions were casual and somewhat “equal.” Therefore, the participants encountered challenges in interacting and providing care to older patients in ways that were customary and the norm in the Australian clinical placement areas. For instance, Orji disclosed the difficulty he faced with accepting the fact that he had to provide personal care to older female patients, an aspect that is “taboo” in his culture: “Yes, that day that was the first day I actually assisted an elderly (female) person with a shower because it is unacceptable in my culture. In my culture if an elderly person is sick, the elderly person will be looked after by the elderly people or an adult in the family.” The exploration of “lived relationships” for the participants highlighted the reality that culturally sensitive practices are frequently absent in some clinical settings in Australia.
Lived time The experiences linked to “lived time” displayed the progressive change in the quality of the participants’ lives over the clinical placement period. Most of the participants became accustomed to life in their new environments with each passing day. The participants attributed this to increased
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knowledge of the culture of people at clinical placement areas and the influence of local Australian friends who helped in demystifying aspects that had initially seemed “alien.” Amani shared: “At this point in time I think I am now used to it. I can just go to the patient and talk to them and I can. . . . I just feel like I’m getting there . . . I’m a doctor now. Yeah, it’s fine. All these two years of transition, I think now it’s fine.” In further exploring the aspect of “lived time,” the resilience of the participants was brought to the fore. While identifying experiences participants wished they had never had during their time in clinical placement, most recognized that dealing with the various difficulties enlightened them and strengthened their resolve to complete their course. Mvumilivu, a second year nursing student from Ethiopia, when referring to abuse he received from a patient which he believed was racially instigated, noted: “. . . for me, I know everything is for my own good. Even the bad thing which is happening to me, as I mentioned here . . . turned out to be my . . . turned out to be good because I learn from those offences and I learn from all the situations that happen to me. It gives me a lesson so that I’ll be prepared in future when things like that come into my life.” Summarily, the journey of the participants as they adapted, integrated, and conditioned themselves to life in Australia has been seen to have various challenges. Quoted interview excerpts have elucidated major factors that influenced the lives of the participants as they adjusted to the Australian healthcare system.
DISCUSSION: THE INTERLINKED DOMAINS While exploring the “world” of the participants, the associations that existed between their experiences, specifically in the clinical placement “world,” pointed to the Heideggerian assertion about the integrated and interrelated nature of the world we live in (Dreyfus, 1991). There was therefore interplay in the way the participants experienced their clinical world, with body, space, relationships, and time being seen to influence each other. The interplay between the domains was essential in providing an understanding of the whole participant experience of clinical placement. The interlinked domains were part of a “hermeneutic circle,” a component expounded by Gadamer (1975) to elucidate the back and forth movement between parts essential in arriving at a shared understanding. In exploring the four core themes, it became clear to the researcher that “lived body” was the central construct due to the influence it exerted across the whole spectrum of participant experiences. In the case of participants in this study, their lived body was the perception and reality for themselves and others that they were of a different skin color. It was noted that the “body” in which the participants lived subjected them to various physical and psychological challenges related to looking and feeling different within the Australian society and the healthcare system. This domain
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also influenced their experiences in regard to the domains of space, relationships, and time. For example, most participants would opt to go back to practice in Africa (their space) on completion of their studies partly due to the negative bodily occurrences during their clinical placements in Australia (current space) and their desire to be part of the “norm” rather than being seen as different. Nash et al. (2009) in a study examining a transition model for final year nursing students to graduate nursing revealed that the “sense of belonging” in clinical placement areas has a direct effect on student career decisions. Of interest is the connection between body and space in the way some participants reacted to racially directed comments made by some patients about Africa, the related misconceptions and their view that being black relegated them to a lesser standard. The participants’ anger and dismay is understandable given the multicultural nature of Australia where these experiences are not expected. These findings were also in contrast to those by Webster et al. (2010) in a study examining the experiences of eight nursing students from a city university who undertook a four-week placement program at a rural facility in an Aboriginal community in Australia. While Webster et al. (2010) did not provide details about the racial make-up of the eight students, all participants in that study attested to having positive experiences during their stay at the facility. The above differences raise the question whether the participants’ experiences in their respective placement areas are linked to “place of origin” and color of their skin. The link between “relationships” and the other domains was evident mainly in the reaction of the participants to the nature of relationships between staff and patients that were seen to exist in the Australian context and which did not occur in their countries of origin (in Africa). The participants, apart from being “different” in body, came from Africa (known space), a context where relationships between people are heavily linked to given cultural inclinations. For this reason, they initially found it challenging to nurture relationships with the patients in their early days in the clinical context. The findings are a corroboration of those in studies by Lee and Opio (2011) and Constantine et al. (2005), in which the culture of African students made it difficult to relate to people in predominantly white settings. The experiences which participants in the current study narrated regarding other African students undertaking clinical placements in rural areas in Australia also alluded to the nature of relationships that existed in those contexts. Conversely, the “lived relationships” of the participants can be used to epitomize the conflict that has existed between the European and African cultures since the colonial era. When European nations colonized African countries, they brought with them elements in their culture that eroded or threatened to erode various aspects of the African culture (Traoré, 2004). In discussing the “cultural bomb,” Traoré (2004, p. 353) notes that Africans still subscribe to cultural and educational domination served to them by white colonial masters. The findings of the current study are an indication of the colonial trends of cultural and educational domination that were imposed on African students by European © 2014 Wiley Publishing Asia Pty Ltd.
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educators during the colonial era. The above analogy is perhaps reflective of the experiences of participants as they try to nurture relationships in clinical placement areas governed by “norms” different to what they were initially exposed to. The above-mentioned matrix represents the complex interlinks the participants experienced in their clinical placement settings, providing insight on the meaning of being an African student in a predominantly white environment. By carefully examining the participants’ language, the analysis linked the experiences of the participants in each domain of the existential framework leading to the arrival at a shared understanding. The study unearthed various cultural and psychosocial challenges that participants faced. Specifically, the nature of patient–participant relations as cardinal in shaping overall student experiences and culture-linked clashes during care delivery and ways of relating between the various age groups, especially between the young and the old were some of the findings not identified in the literature.This therefore calls for measures that can help to address the challenges, allowing for a harmonious interlink between space, body, relationships, and time for the students in clinical placement areas.
Implications and recommendations Considering that some participants faced challenges interacting with some patients – from rejection of care services, to patients being outspoken as regards to participants’ skin color – the “life” of African students would perhaps be improved if more efforts we made to educate Australians on cultural acceptance. This would perhaps help eliminate the stigma associated with “being different” and issues evident in the provision of cross-gender care. Lack of knowledge of and understanding of the Australian culture and healthcare organizations/systems raised many challenges for the participants on clinical placement, as they were unprepared for what to expect. It would therefore be beneficial if institutions of higher learning carried out thorough briefings with African and other minority population students on issues potentially expected on clinical placement.
Limitations In conducting the study, several factors that may have limited the study findings have been acknowledged. The study had the intention to include African students from all health disciplines. This was considered a limiting factor as the study could perhaps have benefitted from the input of students from other health disciplines, such as paramedics and physiotherapy or instead provided an in-depth exploration of one particular discipline. Nevertheless, this study has highlighted specific difficulties faced by African students as regards to completing a health sciences degree in Australia in addition to those revealed in studies conducted in other countries such as the United States.
CONCLUSION This study has brought to the fore important aspects as regards to understanding of the experiences of African health © 2014 Wiley Publishing Asia Pty Ltd.
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sciences students in predominantly white clinical placement areas by revealing new findings and perspectives that had not been identified in the reviewed literature. The research has provided several recommendations based on the study findings such as the need for proper orientation and mentorship for the students. It would be of benefit to education stakeholders if the findings from this study were used to survey a larger African student population to obtain information that is generalizable for policy development. Meanwhile, the dissemination of these findings is likely to improve the experiences of African students on clinical placement in Australia and possibly in other multicultural settings such as the United States.
ACKNOWLEDGMENTS The authors wish to thank the research participants for their time and dedication during the study.
CONTRIBUTIONS Study Design: DI, AW, KM. Data Collection and Analysis: DI, AW, KM. Manuscript Writing: DI, AW, KM.
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