Nurse Education in Practice xxx (2013) 1e6
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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study Doris M. Bohman a, *, Gunilla Borglin a, b a b
School of Health Science, Blekinge Institute of Technology, SE-379 71 Blekinge, Sweden Karlstad University, Faculty of Health, Nature and Technical Science, Department of Health Sciences, Nursing Science, SE-651 88 Karlstad, Sweden
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 27 November 2013
With free movement for citizens within the European Union and with distant parts of our globe becoming more accessible, cultural awareness and cultural competence are becoming important skills for nurses. Internationalisation and raising awareness of other cultural contexts are essential elements in Swedish higher education, thus explaining the variety of student exchange programmes that are available. The aim of this study was to explore Swedish nursing students’ perceptions of student exchange and their experiences. Data were collected through group interviews and then analysed following the principles of content analysis. Our analysis resulted in three categories: Preparing to go abroad, Reasons for going abroad and From expectation to experience. Cultural aspects and cultural awareness were emphasised as strong motivational factors, both personal and professional, behind participation in student exchange programmes. Information was also highlighted as a crucial means of reaching potential students as well as the power of knowledge through personal experience. This study highlights the importance of student exchange in expanding the individual student’s personal and professional horizons. It also stresses the importance of including a transcultural nursing element in nursing curricula. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Cultural awareness Internationalisation Student exchange Qualitative study
Introduction The world is becoming smaller and now, more than ever before, cultural competence and cultural awareness are vital skills in the nursing profession (Cowan and Norman, 2006). A changing society with free movement for citizens within the European Union, distant parts of our globe becoming more accessible and an increasingly multicultural population, are factors that are influencing healthcare, highlighting the need for culturally based knowledge among health professionals (Sairanen et al., 2013). Despite 19.6 per cent of the Swedish population having a different background than a Swedish (Statistics, 2010), findings from research studies (Gebru, 1997; Momeni et al., 2008) indicate that nursing students lack the knowledge needed to meet fully the demands that are likely to be presented by multicultural societies, i.e. cultural competence. According to Jirwe (2008), cultural competence in nursing is about the ability to care for patients while taking into account their cultural background. In the present study, cultural competence is
* Corresponding author. School of Health Science, Blekinge Institute of Technology, SE-371 79 Karlskrona, Sweden. Tel.: þ46 (0)455 385404. E-mail address: [email protected] (D.M. Bohman).
viewed as comprising a set of skills and behaviours that enable a nurse to work effectively within the cultural context of a client/ patient (Papadopoulos, 2006). In response to the increase in demand for cultural competence in nursing, a variety of theoretical models have been developed (Purnell and Paulanka, 1998; Brink, 1999; Giger and Davidhizar, 2007), of which Leininger played a central role through the theory of ’cultural care diversity and universality’ (Andrews and Boyle, 1999). The criticism of Leiniger’s model is that it does not take into consideration variations within cultures, such as disability, socioeconomic status, gender, age, religion or education, that influence the way in which people express their cultural orientation (Boyle, 1999; Lipson, 1999; Meleis, 1999). Camphina-Bacote’s model (2002) initiates phases that include cultural awareness and requires healthcare professionals to acknowledge cultural competence as an ongoing process rather than an endpoint. Both these models can be used in nursing education, either as concrete teaching guides and/or as a means of developing curricula that support cultural competence among nursing students (cf. Marcinkiw, 2003). In Sweden, internationalisation and awareness of other cultural contexts are key elements in higher education and are emphasised in the Swedish Higher Education Act (SFS, 1992:1434). To facilitate internationalisation and cultural awareness, a variety of student exchange programmes are also available. Despite this, cultural
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Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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competence in Sweden is a relatively new area of concern for nurse educators and there is limited knowledge and understanding of these skills (Jirwe, 2008). To explore the accuracy of Jirwe’s (2008) findings, this study was preceded by a brief scoping review of nursing curricula. This offered a strong correlation with Jirwe (ibid) by revealing a fragmented, non-consistent approach to the concept. Research findings (Momeni et al., 2008; Petit dit Dariel, 2009) imply that this is not just a Scandinavian problem. European nursing curricula in general are still falling short as they tend to lack detailed transcultural nursing content. One beneficial strategy for developing culturally competent nurses would appear to be the possibility of studying abroad as part of their training (Kokko, 2011). Greatrex-White (2007) suggests that studying abroad deserves more attention in the training of nurses and beyond. The concepts of global communities and a global economy will require employees of the future to have broader experience and understanding of different cultures. Enskär et al. (2011) and Reid-Searl et al. (2011) have highlighted that our knowledge in this area, including student experience of international exchange and the outcomes of such programmes, is relatively limited. Consequently, when developing a nursing programme that actively supports nurses in becoming culturally competent, it is important to take on board the views of the students. Available research reveals positive influences. In a literature review by Button et al. (2005) findings showed that nursing students who had participated in an exchange programme showed a better understanding of cultural differences and grew both on a professional and personal level. The study by Green et al. (2008) also found that students acquired a better understanding of cultural differences. Tabi and Mukherjee (2003) state that the positive effects of a student exchange programme for nursing students seem to extend far beyond the period of time they spend abroad. The opportunity to study abroad expands horizons as it promotes knowledge of a diversity of values, beliefs and practices in a person’s education (ibid). Others confirm that students who study abroad reveal a greater change in their intercultural communication skills than students who remain on campus (Rundstrom Williams, 2005; Johns and Thompson, 2009). Available studies thus imply that nursing students need to experience diversity if they are to embrace it and learn from it. Our literature review indicates that leaving crosscultural and/or transcultural issues and experiences until the students have qualified would be far too late. However, to develop a curriculum based on sound theoretical models, such as CamphinaBacote’s model (2002), it needs to be underpinned by empirical knowledge. This study thus aimed to explore Swedish nursing students’ perceptions and experience of student exchange. Design A qualitative, descriptive design (Polit and Beck, 2012) was adopted to understand the perceptions and experiences of student exchange from the informant’s point of view (cf. Kvale and Brinkmann, 2009). Data were collected through group interviews (Carey, 1994; Morgan, 1997) and the subsequent analysis was inspired by Graneheim and Lundman’s (2004) description of content analysis. Study context The study was performed at a university college in South East Sweden. In Sweden, the training of registered nurses (RNs) is the responsibility of the state and is government-funded. Nursing, with the main subjects caring and nursing science, is a three-year programme (180 ECTS credits). The nursing programme comprises both theoretical and clinical modules and leads to a BSc in Nursing
Science. Within the programme, students are offered the opportunity to participate in student exchange through academic networks in the Nordic countries and the European Union as well as bilateral agreements with non-European HEIs. In the established networks, scholarships are available to finance the exchange. The School offers a university course; Intercultural Perspective on Health Care (7.5 ECTS credits), for nursing students who want to develop and understand cultural competence and for nursing students who intend to participate in the exchange programme, i.e. those aiming to go abroad. Each year, around 13 of the 500 students on the nursing programmes take the opportunity for a student exchange in the Nordic countries, Europe and countries outside the European Union. Students’ time abroad can vary between some weeks up to 12 weeks and they are mainly staying in student accommodation.
Recruitment and informants In this study, a purposive sample (Polit and Beck, 2012) was used. The recruitment targeted students (n ¼ 11) intending to go abroad (pre-exchange study phase) and students who had been abroad (post-exchange study phase) as a part of the college’s exchange programme (Table 1). According to Polit and Beck (ibid), it is important to have as varied a mixture as possible. Consequently, this study included people of different ages and both genders although ensuring that none of the informants had an educational relationship with the researchers. Students were invited by means of an information letter handed out by one of the researchers (DB). All students intending to take part in a student exchange programme or who had been on a student exchange in spring 2011 agreed to participate (n ¼ 11). However, two students failed to attend the scheduled group interview, leaving nine students to participate in the interviews (Table 1).
Data collection In this study group interviews were selected to encourage meaningful discussions (Morgan, 1997). Group interviews also have the advantage of generating considerable quantities of data and the interaction between participants may disclose different opinions and new areas for discussion (Reed and Payton, 1997). During the group interviews, the discussions focused on the students’ their perceptions and experiences of student exchange, i.e. “Can you please tell me about your perception or experience of a student exchange”. A general probing question was used whenever clarification was needed during the interviews (Polit and Beck, 2012). The group interviews were performed at a place and time chosen by the students. Each interview lasted approximately 40 min and was conducted in Swedish. The audio-recorded interviews were transcribed and quotations were translated into English.
Table 1 Characteristics of the participants. Code
Age
Gender
Year of education
A B C D E F G H I
20 19 28 27 28 23 23 32 27
\ \ \ \ \ \ \ \ _
1 1 1 1 1 1 1 3 3
Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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Data analysis The transcribed texts were analysed following the principles of qualitative content analysis, focussing on the manifest level (Graneheim and Lundman, 2004). The texts were read repeatedly to identify parts corresponding to the overall aim. Incidents and discussions not relevant to the aim of the study were excluded. These parts were then analysed and coded. The codes were then grouped into categories based on similarities and differences that were compared and contrasted with the text to ensure credibility. Ethics Under the Swedish Ethical Review Act (SFS, 2003:46), this study does not require ethical clearance by an Ethical Review Board. Despite this, the study was conducted in compliance with established ethical guidelines. Informants received verbal and written information about the study and they were informed of their right to withdraw at any time. To ensure compliance with the Data Protection Act, data were coded and stored securely.
In this category, it also became obvious that ’the first impression is the last impression’, as the informants in the pre-exchange phase stressed that it was not only the type of information that was vital. It should also be possible to have an individual study plan early on in the nursing programme. This could encourage the informants to apply for more than one student exchange scholarship during their three-year nursing programme. The informants in the post-exchange phase also referred to the same three sources of information as the informants in the preexchange phase. However, they also emphasised the power of information. One post-exchange informant stated: Information is crucial. There is always a need for more information about the possibility of participating in an exchange programme. Other sources of importance in promoting participation in student exchange programmes mentioned by the post-exchange informants were the open talks by guest lecturers from visiting exchange universities, presentations by former exchange students, travel reports, blogs etc.
Findings Reasons for going abroad Nine informants participated in this study with a mean age of 27.4 years (range 19e32 years). The majority of the informants were women (Table 1). Our analysis indicated that three categories: Preparing to go abroad, Reasons for going abroad and From expectation to experience could be seen to illustrate their perception and experience of student exchange. Preparing to go abroad In the category Preparing to go abroad the informants in the preexchange study phase acknowledged three important information sources e Internet/web information, information meetings held by an student exchange co-ordinator, and individual consultations with the study co-ordinator. The importance of these depended on where the informant was in the pre-exchange study phase. The Internet was stated to be the main source of information about which Swedish university and/or university college offered student exchange as part of the nursing programme (180 ECTS credits). It became apparent that some of the informants’ applications for nursing studies had been submitted to this particular HEI based purely on the possibility of a student exchange. After being enrolled on the nursing programme, the tendency to seek information on the Internet was maintained. The Swedish education web tool It’s Learning in particular was felt to contain relevant information about student exchanges available at university colleges. As soon as the informants had decided to apply for a student exchange scholarship, the focus shifted from information seeking on the Internet to attending regular information meetings run by the student exchange co-ordinator together with individual consultations with the co-ordinator. Even though the informants felt that participation in an exchange programme was valued and encouraged by the School, they also felt at times that the process of applying for a student exchange was far too complex. A steady and transparent flow of information from the exchange co-ordinator and his/her team stood out as a vital part of the preparation. This appeared to be especially important when it involved applying for scholarships but it was also crucial when deciding to participate in a student exchange programme or not. When you ask questions, it is important to feel that something is possible. Then you continue the process. If not, you will probably just leave it.
The perceptions and experience of the informants in the preexchange phase were highlighted in the category Reasons for going abroad. Here the importance of acquiring an overall cultural insight proved to be the main motivational factor, i.e. driving force, behind applying for a student exchange. Other reasons for student exchanges highlighted by the informants included the opportunity to visit other cultural contexts and be able to go beyond the tourist perspective. The overall cultural insight included being allowed to experience a contextually different healthcare system compared to Sweden. You gain an insight into another culture and realise that not everything is as it is in Sweden. Not everyone responds and thinks as we do. It is an opportunity to experience a different approach. The informants in the pre-exchange phase wanted new knowledge of different technical equipment, facilities, structural organisations and hierarchies. They also wanted to meet patients, care recipients and care providers in a context that was different to Sweden. Student exchanges were also viewed as a possibility to experience a culture from two different perspectives, i.e. as a student and as an RN. Post-exchange informants mainly spoke about the same motivational forces as the pre-exchange informants. This group also spoke about an additional driving force, which reflected ’being prepared’ as an RN for the multicultural society Sweden has become. The category Reasons for going abroad highlighted their insight into requiring additional skills in order to care for all the patients they might encounter as RNs. One student stated: This is a great opportunity to see how it works in reality. Even if it will never be exactly the same in another environment, it’s good to have experienced what ‘different’ means.
From expectation to experience In the final category From expectation to experience the preexchange informants spoke about their expectations of wanting to develop their skill in handling interpersonal relationships. This reflected how they could develop increased cultural sensitivity and how to assess a situation differently based on an alternative
Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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mindset and experiencing different contexts. Informants also expected to be better prepared to develop strategies for handling new and unexpected situations. A recurring perception was the possibility of becoming more flexible, developing heightened selfawareness and growing as a nurse e I want to learn more about myself and gain better insight. A student exchange was also regarded as a platform for future work in an international organisation or abroad. In this category, the post-exchange informants presented different experiences when speaking about attitude-changing moments in South Africa. After spending approximately three months in South Africa, their perception and views on, for example, HIV/AIDS, one of the most common infectious diseases in South Africa, had changed completely. One student stated: Before I left Sweden, it was a huge and very strange matter. Now I have a more relaxed attitude. Now I’ve seen how people actually live with HIV/AIDS and that you can have quite a normal life with the disease. I have learned a lot from meeting people with HIV, which I think will help me in my work as a nurse in Sweden. They also reflected on the fact that they had not brought any previous experience with them from Sweden, as the nursing programme did not include any lectures on HIV/AIDS: We had not touched on the subject at all. In this category, language cropped up as a barrier. It took time to get into a new language. Even if it was a familiar language, i.e. English, they still had to become accustomed to dialects and pronunciations. The informants felt that a lot could be accomplished through body language. Finding other ways to solve situations with patience and acceptance sometimes takes a little longer e that’s life. Travelling alone or in pairs could add to the experience, where those who went alone admitted that it was a little difficult not having someone with whom they could share their experiences and reflections. There was definitely a feeling of safety being two persons on the exchange. It meant that you always had someone with whom you could share your experiences. There are lots of emotions and frustrations. Things perhaps don’t work out as you expect and it’s good to have someone there who actually understands. You can’t discuss things in the same way with someone else. Those who live there don’t understand, as they are part of the system. The post-exchange informants spoke about encountering different ways of thinking. Their experience showed that networking, being part of the group, was important in the educational sphere in terms of sharing information and in the private sphere in terms of deciding where to meet and what to do. Here in Sweden you receive all the information from the university. If something goes wrong, they are responsible and not you. There the university doesn’t provide you with all the information although it’s still not the university that is to blame. They give information to five students in the class who are like class representatives. They’re nice and give you information if you ask but if you don’t know who to ask you don’t receive the information. It’s very complicated, so you need a strong network within the class. Student exchanges could also mirror the experience of being challenged by different education systems. Post-exchange informants experienced the education system as more hierarchical than their own, such as not questioning a lecturer and simply accepting. Not being able to read and understand the non-spoken rules, i.e. the silent codes, also impeded their ability to
understand quickly how ’things work’. One informant exemplified this by describing her struggle to prepare for an exam. They said everything is in the book, so I studied hard, really hard. Then one week before the exam, I heard a rumour that the teacher’s notes were sent to five students in the class. I asked if the notes were important but didn’t really receive an answer. So I decided to focus on the book. Then, when we received the exam paper, the first section was based on the book but the second section was based only on the teacher’s notes! Experiencing challenges when no longer being in a familiar context caused the informants to compare and develop a new kind of appreciation of certain aspects of home. One student stated that it represented a ’born-again’ appreciation of student life at a Swedish university college: Enrolling as a student, for example, is very easy in Sweden but a completely different story there. It takes several days. You’re given a map and then you have to set off in search of different ‘stations’ and get from one place to another. It takes time and it’s a test of your patience. The informants in the post-exchange group stated how being away and taking care of themselves in an environment that was very different to Sweden had led to personal growth and maturity, i.e. returning more self-confident and self-aware. Being away had also led to other things. I feel that I have become a bit tougher. In the category From expectation to experience, the informants shared one general perception e a student exchange is not for the ‘faint-hearted’. Participating meant being prepared, with considerable thought given to the reason for participating, the willingness to take risks, the ability to deal with being challenged and the level of commitment. One informant stated: Even if we assume that people are open-minded and interested in other cultures that is not the case. The course will at least broaden their perspective, which I think is very good. They all spoke about the intercultural course and the preexchange informants stated that the intercultural course should be compulsory. The post-exchange informants revealed that taking the course proved more useful in preparing them for the different healthcare systems and different cultural perspectives than they had initially expected.
Discussion The findings in this study illustrate the perceptions and experiences of student exchange as expressed by a group of students on a Swedish nursing programme. Preparing for and participating in a student exchange programme brought experiences on both a personal and a professional level, as reflected in the three categories: Preparing to go abroad, Motivation for going abroad and From expectation to experience. The main message to emerge from our findings was the fact that ‘the real experience’ seems to be an underestimated resource in developing cultural competence. This is an important aspect to take into account when developing a successful nursing curriculum that supports culturally competent nurses. The transparency and flow in the process of information is particularly important early on in the programme in order to reach potential students and urge them to participate in a student exchange. It is also important later on as a way of preparing the students for the actual exchange. Both Green
Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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et al. (2008) and more recently Reid-Searle et al. (2011) stress the importance of information and thorough preparation of the students. However, a Swedish student mobility report (HSV, 2007:09R) shows a considerably lower percentage (6% of 4.535 students) of nursing students participating in student exchanges than is the case for students from other programmes (range 10.5%e 20.5%). Swedish universities and organisations involved in exchange programmes now have the possibility to draw on UK and Australian experience of how to recruit and prepare the students in the best possible way. According to Randi and Goldstein (2005), interest in international study programmes may also be facilitated in part by interventions that seek to reduce ethnocentrism and apprehension about communicating with culturally different others. One such intervention could be mandatory courses as part of the nursing programme that deals with such topics. International courses also provide educators with a strategy to assist future nurses to become more prepared to provide care across varied population groups (Smit and Tremethick, 2013). Interestingly, our findings indicated that the informants had a clear view that going abroad should not be based on a whim or a woolly notion. The desire for a student exchange needed to be thought through carefully. This issue was not raised elsewhere in the literature. A possible explanation could be that Sweden, rather late in history and particularly compared to certain other parts of Europe, including the UK, has only recently woken up to the fact that almost 20 per cent of the 9.8 million population have an origin other than Swedish. Besides making a deliberate and carefully considered decision, driving forces such as being able to go behind the tourist façade and an opportunity to experience a ’truer’ feeling of the culture and context despite not being ’one of them’ also became obvious. Student exchanges were also seen as an important tool for their future profession as a nurse e as a platform for future work in international organisations, as a means of networking or as a way of finding a job. This is in line with Greatrex-White’s study (2007) and Mohajeri Norris and Gillespie, 2009 and stresses the significant career impact of studying abroad and the continued use of a foreign language. As in earlier studies (Iammarino and O’Rourke, 1999; Reid-Searl et al., 2011; Tabi and Mukherjee, 2003), cultural aspects and cultural awareness were emphasised as strong motivational factors: “It’s good to have experienced what different means.” This applies on both a personal and professional level to participation in an exchange programme. Leaving one’s comfort zone appeared to make it possible to change attitudes. The post-exchange informants’ experiences raised some important issues. These were linked mainly to personal development and their reflections on encounters and a change in attitude towards severely ill patients, such as patients with HIV/ AIDS. Our findings also confirm the possibility of developing increased preparedness for other ways of dealing with and solving situations. As one informant stated: “I have become a bit tougher”. Experience of studying abroad could, as Beacham et al. (2009) stated, help undergraduate nursing students to discover the power of knowledge through experience. The informants’ experience was also reflected in increased self-confidence as well as becoming more self-aware, i.e. ’Who am I?’ Understanding a different pace of life, a new language, different ways of thinking and different ways of being educated resulted in a feeling of personal growth and maturity. The exchange is then linked to the development of interpersonal skills as well as intercultural communication skills (cf. Rundstrom Williams, 2005). Our findings indicate that the students’ experience of studying abroad had impacted on them beyond the goal of the exchange programme, i.e. increased cultural competence. This is consistent with the findings of Smit and Tremethick (2013), who claim that through divergent approaches
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and nursing perspectives, the students gained an understanding of the challenges faced by others and valued their learning experiences linked to international healthcare. An important question remains: Are student exchanges enough to enhance ‘cosmopolitanism’ (cf. Petit dit Dariel, 2009)? An essential aspect of developing cultural competence in nursing education is to acknowledge the impact of existing discourse. As highlighted in Sheets Cook et al. (2012), we are often unaware of the discourses that frame our existence and which constitute barriers in the development of the concept of health/nursing and ultimately cultural competence. Lipson and Desantis (2007) underline that despite progress in incorporating cultural content into nursing curricula, there are several inhibitor issues, including a decline in core courses focussing on culture due to ‘overcrowding’ in required programme content. There could also be a focus on the micro-level of the nurse-patient encounter, with little attention given to the effects of more macro-level system factors with implications for healthcare decisions. According to Lipson and Desantis (2007), and in line with the findings of this study, there are major strengths in an exchange experience, such as increased self-awareness and an enhanced ability to deal with situational, environmental and sociocultural factors, although there are also major weaknesses, such as the limited number of students able to participate. Although an important tool for cultural competence in nursing education exchange, experience needs to be incorporated into a larger educational framework, where the Camphina-Bacote’s model for cultural competence could function as a good introduction. The cultural framework for the enhancement of cultural competence in European health education (Koskinen et al., 2012) has furthered the suggestion of Lipson and Desantis (2007) by introducing a macro-level perspective into the curricula. Within this framework, an exchange period would be seen as an immersive cultural experience that promotes cultural competence. Study limitations Our sampling technique ensured that we captured different perceptions and experiences. The sample was homogenous with regards to gender as the majority of the students were females (Table 1). However the ration female and male students is representative of the nursing profession in Scandinavia. Nevertheless, it is important to recognise that when recruiting students for research, especially as a lecturer, caution is warranted. Students might feel coerced or obliged to participate. To avoid this, the researchers decided not to start recruiting until the course had been completed. There is little consensus as to what sample size is most appropriate (McLafferty, 2004). Mini-groups, as used in this study, are supported by Morgan (1997) and Carey (1994) as they are easy to manage and there is greater likelihood that participants will interact. The content analysis (Graneheim and Lundman, 2004) made it possible to justify the texts by structuring and presenting categories. To reduce the risk of subjectivity (Hutchinson and Wilson, 1994) and to enhance the credibility of the study, the authors worked together throughout the analysis phases to supplement and contest each other’s readings. By providing quotations, we have hopefully enabled the reader to validate the interpretation (Benner, 1985) and assess its trustworthiness. Although this study highlights some valuable findings, it is a small-scale study performed in a specific setting and context and this needs to be taken into account when evaluating the generalisability of the study. Conclusion In this descriptive paper of the virtues of exchange programs being given the opportunity to study abroad, i.e. acquiring
Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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international experience, were found to increase cultural awareness and understanding of underlying behaviour, attitudes and beliefs beyond the student’s own view of the world. However, the findings of this study have left us with a question: Are the students who choose to participate in an exchange programme the ones we really need to reach to stop institutional racism or unequal care? The literature review that preceded this study indicates that cross-cultural courses alone are not sufficient even if they focus on both cultural competence and antiracism. This highlights the fact that we still have some way to go if we are to help nurses to work successfully with populations made up of people from culturally diverse backgrounds. Enhancing cultural awareness and as such a cultural understanding in European nursing education clearly demands curricula permeated by intercultural nursing aspects in combination with immersive student exchanges. Authors’ contributions DMB designed the study and collected the data. GB and DMB analysed and drafted the manuscript. Both authors contributed to editing the final manuscript and approved the submitted version. Conflicts of interest None declared. Ethical approval Not applicable. Acknowledgements and funding We would like to acknowledge the students for their help with this study. We would also like to acknowledge Patrick O’Malley for his help with language revision. DMB was supported by the School of Health Science, Blekinge Institute of Technology, Karlskrona, Sweden. GB was supported by the Department of Health Sciences, Nursing Science, Karlstad University, Sweden. References Andrews, M.M., Boyle, J.S., 1999. Transcultural Concepts in Nursing Care, second ed. J.B. Lippincott company, Philadelphia. Beacham, C., MacDonald, N.M., Yoo, J.J., McFall, B.S., 2009. Design thinking: promoting diversity through global immersion. Family Consum. Sci. Res. J. 37 (3), 344e358. Benner, P., 1985. Quality of Life: a phenomenological perspective on explanation, prediction, and understanding in nursing science. Adv. Nurs. Sci. 8, 1e14. Boyle, J.S., 1999. Transcultural nursing at Y2K: some thoughts and observations. J. Transcult. Nurs. 10 (1), 8. Brink, P., 1999. Trans-cultural versus cross-cultural. J. Transcult. Nurs. 10 (1), 7. Button, L., Green, B., Tengnah, C., Johansson, I., Baker, C., 2005. The impact of international placements on nurses’ personal and professional lives: literature review. J. Adv. Nurs. 50 (3), 315e324. Camphina-Bacote, J., 2002. The process of cultural competence in the delivery of healthcare services: a model of care. J. Transcult. Nurs. 13 (3), 181e184. Carey, M., 1994. The group effect in focus groups: planning, implementing, and interpreting focus group research. In: Morse, J.M. (Ed.), Critical Issues in Qualitative Research Methods. Sage Publications, London, pp. 225e241. Cowan, T., Norman, I., 2006. Cultural competence in nursing: new meanings. J. Transcult. Nurs. 17 (1), 82e88. Enskär, K., Johansson, I., Ljusegren, G., Widäng, I., 2011. Lecturers’ experiences of participating in an international exchange. Nurse Educ. Today 31, 541e546. Gebru, K., 1997. Culture Congruent Nursing Care in Nursing Education. Lund University, Sweden (in Swedish). Licentiate degree dissertation. Giger, J.N., Davidhizar, R.E., 2007. Transcultural Nursing, Assessment and Intervention, fifth ed. Mosby Elsevier, St Louis, Missouri. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24 (2), 105e112.
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The Papadopoulos, Tilki and Taylor model of developing cultural competence. In: Papadopoulos, I. (Ed.), Transcultural Health and Social Care. Development of Culturally Competent Practitioner. Elsevier Limited, Beijing, China, pp. 7e24. Petit dit Dariel, O., 2009. Nursing education: In pursuit of cosmopolitanism. Nurse Educ. Today 29, 566e569. Polit, D.F., Beck, C.T., 2012. Nursing Research: Generating and Assessing Evidence for Nursing Practice, ninth ed. Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia. Purnell, L.D., Paulanka, B.J., 1998. Transcultural Health Care. F A Davis co, Philadelphia. Randi, I.K., Goldstein, S.B., 2005. Intercultural attitudes predict favorable study abroad expectations of U.S. College students. J. Stud. Int. Educ. 9, 265e278. Reed, J., Payton, V.R., 1997. Focus groups: issues of analysis and interpretation. J. Adv. Nurs. 26 (4), 765e771. Reid-Searl, K., Dwyer, T., Moxham, L., Happell, B., Sander, T., 2011. 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Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study Doris M. Bohman a, *, Gunilla Borglin a, b a b
School of Health Science, Blekinge Institute of Technology, SE-379 71 Blekinge, Sweden Karlstad University, Faculty of Health, Nature and Technical Science, Department of Health Sciences, Nursing Science, SE-651 88 Karlstad, Sweden
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 27 November 2013
With free movement for citizens within the European Union and with distant parts of our globe becoming more accessible, cultural awareness and cultural competence are becoming important skills for nurses. Internationalisation and raising awareness of other cultural contexts are essential elements in Swedish higher education, thus explaining the variety of student exchange programmes that are available. The aim of this study was to explore Swedish nursing students’ perceptions of student exchange and their experiences. Data were collected through group interviews and then analysed following the principles of content analysis. Our analysis resulted in three categories: Preparing to go abroad, Reasons for going abroad and From expectation to experience. Cultural aspects and cultural awareness were emphasised as strong motivational factors, both personal and professional, behind participation in student exchange programmes. Information was also highlighted as a crucial means of reaching potential students as well as the power of knowledge through personal experience. This study highlights the importance of student exchange in expanding the individual student’s personal and professional horizons. It also stresses the importance of including a transcultural nursing element in nursing curricula. Ó 2013 Elsevier Ltd. All rights reserved.
Keywords: Cultural awareness Internationalisation Student exchange Qualitative study
Introduction The world is becoming smaller and now, more than ever before, cultural competence and cultural awareness are vital skills in the nursing profession (Cowan and Norman, 2006). A changing society with free movement for citizens within the European Union, distant parts of our globe becoming more accessible and an increasingly multicultural population, are factors that are influencing healthcare, highlighting the need for culturally based knowledge among health professionals (Sairanen et al., 2013). Despite 19.6 per cent of the Swedish population having a different background than a Swedish (Statistics, 2010), findings from research studies (Gebru, 1997; Momeni et al., 2008) indicate that nursing students lack the knowledge needed to meet fully the demands that are likely to be presented by multicultural societies, i.e. cultural competence. According to Jirwe (2008), cultural competence in nursing is about the ability to care for patients while taking into account their cultural background. In the present study, cultural competence is
* Corresponding author. School of Health Science, Blekinge Institute of Technology, SE-371 79 Karlskrona, Sweden. Tel.: þ46 (0)455 385404. E-mail address: [email protected] (D.M. Bohman).
viewed as comprising a set of skills and behaviours that enable a nurse to work effectively within the cultural context of a client/ patient (Papadopoulos, 2006). In response to the increase in demand for cultural competence in nursing, a variety of theoretical models have been developed (Purnell and Paulanka, 1998; Brink, 1999; Giger and Davidhizar, 2007), of which Leininger played a central role through the theory of ’cultural care diversity and universality’ (Andrews and Boyle, 1999). The criticism of Leiniger’s model is that it does not take into consideration variations within cultures, such as disability, socioeconomic status, gender, age, religion or education, that influence the way in which people express their cultural orientation (Boyle, 1999; Lipson, 1999; Meleis, 1999). Camphina-Bacote’s model (2002) initiates phases that include cultural awareness and requires healthcare professionals to acknowledge cultural competence as an ongoing process rather than an endpoint. Both these models can be used in nursing education, either as concrete teaching guides and/or as a means of developing curricula that support cultural competence among nursing students (cf. Marcinkiw, 2003). In Sweden, internationalisation and awareness of other cultural contexts are key elements in higher education and are emphasised in the Swedish Higher Education Act (SFS, 1992:1434). To facilitate internationalisation and cultural awareness, a variety of student exchange programmes are also available. Despite this, cultural
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Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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competence in Sweden is a relatively new area of concern for nurse educators and there is limited knowledge and understanding of these skills (Jirwe, 2008). To explore the accuracy of Jirwe’s (2008) findings, this study was preceded by a brief scoping review of nursing curricula. This offered a strong correlation with Jirwe (ibid) by revealing a fragmented, non-consistent approach to the concept. Research findings (Momeni et al., 2008; Petit dit Dariel, 2009) imply that this is not just a Scandinavian problem. European nursing curricula in general are still falling short as they tend to lack detailed transcultural nursing content. One beneficial strategy for developing culturally competent nurses would appear to be the possibility of studying abroad as part of their training (Kokko, 2011). Greatrex-White (2007) suggests that studying abroad deserves more attention in the training of nurses and beyond. The concepts of global communities and a global economy will require employees of the future to have broader experience and understanding of different cultures. Enskär et al. (2011) and Reid-Searl et al. (2011) have highlighted that our knowledge in this area, including student experience of international exchange and the outcomes of such programmes, is relatively limited. Consequently, when developing a nursing programme that actively supports nurses in becoming culturally competent, it is important to take on board the views of the students. Available research reveals positive influences. In a literature review by Button et al. (2005) findings showed that nursing students who had participated in an exchange programme showed a better understanding of cultural differences and grew both on a professional and personal level. The study by Green et al. (2008) also found that students acquired a better understanding of cultural differences. Tabi and Mukherjee (2003) state that the positive effects of a student exchange programme for nursing students seem to extend far beyond the period of time they spend abroad. The opportunity to study abroad expands horizons as it promotes knowledge of a diversity of values, beliefs and practices in a person’s education (ibid). Others confirm that students who study abroad reveal a greater change in their intercultural communication skills than students who remain on campus (Rundstrom Williams, 2005; Johns and Thompson, 2009). Available studies thus imply that nursing students need to experience diversity if they are to embrace it and learn from it. Our literature review indicates that leaving crosscultural and/or transcultural issues and experiences until the students have qualified would be far too late. However, to develop a curriculum based on sound theoretical models, such as CamphinaBacote’s model (2002), it needs to be underpinned by empirical knowledge. This study thus aimed to explore Swedish nursing students’ perceptions and experience of student exchange. Design A qualitative, descriptive design (Polit and Beck, 2012) was adopted to understand the perceptions and experiences of student exchange from the informant’s point of view (cf. Kvale and Brinkmann, 2009). Data were collected through group interviews (Carey, 1994; Morgan, 1997) and the subsequent analysis was inspired by Graneheim and Lundman’s (2004) description of content analysis. Study context The study was performed at a university college in South East Sweden. In Sweden, the training of registered nurses (RNs) is the responsibility of the state and is government-funded. Nursing, with the main subjects caring and nursing science, is a three-year programme (180 ECTS credits). The nursing programme comprises both theoretical and clinical modules and leads to a BSc in Nursing
Science. Within the programme, students are offered the opportunity to participate in student exchange through academic networks in the Nordic countries and the European Union as well as bilateral agreements with non-European HEIs. In the established networks, scholarships are available to finance the exchange. The School offers a university course; Intercultural Perspective on Health Care (7.5 ECTS credits), for nursing students who want to develop and understand cultural competence and for nursing students who intend to participate in the exchange programme, i.e. those aiming to go abroad. Each year, around 13 of the 500 students on the nursing programmes take the opportunity for a student exchange in the Nordic countries, Europe and countries outside the European Union. Students’ time abroad can vary between some weeks up to 12 weeks and they are mainly staying in student accommodation.
Recruitment and informants In this study, a purposive sample (Polit and Beck, 2012) was used. The recruitment targeted students (n ¼ 11) intending to go abroad (pre-exchange study phase) and students who had been abroad (post-exchange study phase) as a part of the college’s exchange programme (Table 1). According to Polit and Beck (ibid), it is important to have as varied a mixture as possible. Consequently, this study included people of different ages and both genders although ensuring that none of the informants had an educational relationship with the researchers. Students were invited by means of an information letter handed out by one of the researchers (DB). All students intending to take part in a student exchange programme or who had been on a student exchange in spring 2011 agreed to participate (n ¼ 11). However, two students failed to attend the scheduled group interview, leaving nine students to participate in the interviews (Table 1).
Data collection In this study group interviews were selected to encourage meaningful discussions (Morgan, 1997). Group interviews also have the advantage of generating considerable quantities of data and the interaction between participants may disclose different opinions and new areas for discussion (Reed and Payton, 1997). During the group interviews, the discussions focused on the students’ their perceptions and experiences of student exchange, i.e. “Can you please tell me about your perception or experience of a student exchange”. A general probing question was used whenever clarification was needed during the interviews (Polit and Beck, 2012). The group interviews were performed at a place and time chosen by the students. Each interview lasted approximately 40 min and was conducted in Swedish. The audio-recorded interviews were transcribed and quotations were translated into English.
Table 1 Characteristics of the participants. Code
Age
Gender
Year of education
A B C D E F G H I
20 19 28 27 28 23 23 32 27
\ \ \ \ \ \ \ \ _
1 1 1 1 1 1 1 3 3
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Data analysis The transcribed texts were analysed following the principles of qualitative content analysis, focussing on the manifest level (Graneheim and Lundman, 2004). The texts were read repeatedly to identify parts corresponding to the overall aim. Incidents and discussions not relevant to the aim of the study were excluded. These parts were then analysed and coded. The codes were then grouped into categories based on similarities and differences that were compared and contrasted with the text to ensure credibility. Ethics Under the Swedish Ethical Review Act (SFS, 2003:46), this study does not require ethical clearance by an Ethical Review Board. Despite this, the study was conducted in compliance with established ethical guidelines. Informants received verbal and written information about the study and they were informed of their right to withdraw at any time. To ensure compliance with the Data Protection Act, data were coded and stored securely.
In this category, it also became obvious that ’the first impression is the last impression’, as the informants in the pre-exchange phase stressed that it was not only the type of information that was vital. It should also be possible to have an individual study plan early on in the nursing programme. This could encourage the informants to apply for more than one student exchange scholarship during their three-year nursing programme. The informants in the post-exchange phase also referred to the same three sources of information as the informants in the preexchange phase. However, they also emphasised the power of information. One post-exchange informant stated: Information is crucial. There is always a need for more information about the possibility of participating in an exchange programme. Other sources of importance in promoting participation in student exchange programmes mentioned by the post-exchange informants were the open talks by guest lecturers from visiting exchange universities, presentations by former exchange students, travel reports, blogs etc.
Findings Reasons for going abroad Nine informants participated in this study with a mean age of 27.4 years (range 19e32 years). The majority of the informants were women (Table 1). Our analysis indicated that three categories: Preparing to go abroad, Reasons for going abroad and From expectation to experience could be seen to illustrate their perception and experience of student exchange. Preparing to go abroad In the category Preparing to go abroad the informants in the preexchange study phase acknowledged three important information sources e Internet/web information, information meetings held by an student exchange co-ordinator, and individual consultations with the study co-ordinator. The importance of these depended on where the informant was in the pre-exchange study phase. The Internet was stated to be the main source of information about which Swedish university and/or university college offered student exchange as part of the nursing programme (180 ECTS credits). It became apparent that some of the informants’ applications for nursing studies had been submitted to this particular HEI based purely on the possibility of a student exchange. After being enrolled on the nursing programme, the tendency to seek information on the Internet was maintained. The Swedish education web tool It’s Learning in particular was felt to contain relevant information about student exchanges available at university colleges. As soon as the informants had decided to apply for a student exchange scholarship, the focus shifted from information seeking on the Internet to attending regular information meetings run by the student exchange co-ordinator together with individual consultations with the co-ordinator. Even though the informants felt that participation in an exchange programme was valued and encouraged by the School, they also felt at times that the process of applying for a student exchange was far too complex. A steady and transparent flow of information from the exchange co-ordinator and his/her team stood out as a vital part of the preparation. This appeared to be especially important when it involved applying for scholarships but it was also crucial when deciding to participate in a student exchange programme or not. When you ask questions, it is important to feel that something is possible. Then you continue the process. If not, you will probably just leave it.
The perceptions and experience of the informants in the preexchange phase were highlighted in the category Reasons for going abroad. Here the importance of acquiring an overall cultural insight proved to be the main motivational factor, i.e. driving force, behind applying for a student exchange. Other reasons for student exchanges highlighted by the informants included the opportunity to visit other cultural contexts and be able to go beyond the tourist perspective. The overall cultural insight included being allowed to experience a contextually different healthcare system compared to Sweden. You gain an insight into another culture and realise that not everything is as it is in Sweden. Not everyone responds and thinks as we do. It is an opportunity to experience a different approach. The informants in the pre-exchange phase wanted new knowledge of different technical equipment, facilities, structural organisations and hierarchies. They also wanted to meet patients, care recipients and care providers in a context that was different to Sweden. Student exchanges were also viewed as a possibility to experience a culture from two different perspectives, i.e. as a student and as an RN. Post-exchange informants mainly spoke about the same motivational forces as the pre-exchange informants. This group also spoke about an additional driving force, which reflected ’being prepared’ as an RN for the multicultural society Sweden has become. The category Reasons for going abroad highlighted their insight into requiring additional skills in order to care for all the patients they might encounter as RNs. One student stated: This is a great opportunity to see how it works in reality. Even if it will never be exactly the same in another environment, it’s good to have experienced what ‘different’ means.
From expectation to experience In the final category From expectation to experience the preexchange informants spoke about their expectations of wanting to develop their skill in handling interpersonal relationships. This reflected how they could develop increased cultural sensitivity and how to assess a situation differently based on an alternative
Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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mindset and experiencing different contexts. Informants also expected to be better prepared to develop strategies for handling new and unexpected situations. A recurring perception was the possibility of becoming more flexible, developing heightened selfawareness and growing as a nurse e I want to learn more about myself and gain better insight. A student exchange was also regarded as a platform for future work in an international organisation or abroad. In this category, the post-exchange informants presented different experiences when speaking about attitude-changing moments in South Africa. After spending approximately three months in South Africa, their perception and views on, for example, HIV/AIDS, one of the most common infectious diseases in South Africa, had changed completely. One student stated: Before I left Sweden, it was a huge and very strange matter. Now I have a more relaxed attitude. Now I’ve seen how people actually live with HIV/AIDS and that you can have quite a normal life with the disease. I have learned a lot from meeting people with HIV, which I think will help me in my work as a nurse in Sweden. They also reflected on the fact that they had not brought any previous experience with them from Sweden, as the nursing programme did not include any lectures on HIV/AIDS: We had not touched on the subject at all. In this category, language cropped up as a barrier. It took time to get into a new language. Even if it was a familiar language, i.e. English, they still had to become accustomed to dialects and pronunciations. The informants felt that a lot could be accomplished through body language. Finding other ways to solve situations with patience and acceptance sometimes takes a little longer e that’s life. Travelling alone or in pairs could add to the experience, where those who went alone admitted that it was a little difficult not having someone with whom they could share their experiences and reflections. There was definitely a feeling of safety being two persons on the exchange. It meant that you always had someone with whom you could share your experiences. There are lots of emotions and frustrations. Things perhaps don’t work out as you expect and it’s good to have someone there who actually understands. You can’t discuss things in the same way with someone else. Those who live there don’t understand, as they are part of the system. The post-exchange informants spoke about encountering different ways of thinking. Their experience showed that networking, being part of the group, was important in the educational sphere in terms of sharing information and in the private sphere in terms of deciding where to meet and what to do. Here in Sweden you receive all the information from the university. If something goes wrong, they are responsible and not you. There the university doesn’t provide you with all the information although it’s still not the university that is to blame. They give information to five students in the class who are like class representatives. They’re nice and give you information if you ask but if you don’t know who to ask you don’t receive the information. It’s very complicated, so you need a strong network within the class. Student exchanges could also mirror the experience of being challenged by different education systems. Post-exchange informants experienced the education system as more hierarchical than their own, such as not questioning a lecturer and simply accepting. Not being able to read and understand the non-spoken rules, i.e. the silent codes, also impeded their ability to
understand quickly how ’things work’. One informant exemplified this by describing her struggle to prepare for an exam. They said everything is in the book, so I studied hard, really hard. Then one week before the exam, I heard a rumour that the teacher’s notes were sent to five students in the class. I asked if the notes were important but didn’t really receive an answer. So I decided to focus on the book. Then, when we received the exam paper, the first section was based on the book but the second section was based only on the teacher’s notes! Experiencing challenges when no longer being in a familiar context caused the informants to compare and develop a new kind of appreciation of certain aspects of home. One student stated that it represented a ’born-again’ appreciation of student life at a Swedish university college: Enrolling as a student, for example, is very easy in Sweden but a completely different story there. It takes several days. You’re given a map and then you have to set off in search of different ‘stations’ and get from one place to another. It takes time and it’s a test of your patience. The informants in the post-exchange group stated how being away and taking care of themselves in an environment that was very different to Sweden had led to personal growth and maturity, i.e. returning more self-confident and self-aware. Being away had also led to other things. I feel that I have become a bit tougher. In the category From expectation to experience, the informants shared one general perception e a student exchange is not for the ‘faint-hearted’. Participating meant being prepared, with considerable thought given to the reason for participating, the willingness to take risks, the ability to deal with being challenged and the level of commitment. One informant stated: Even if we assume that people are open-minded and interested in other cultures that is not the case. The course will at least broaden their perspective, which I think is very good. They all spoke about the intercultural course and the preexchange informants stated that the intercultural course should be compulsory. The post-exchange informants revealed that taking the course proved more useful in preparing them for the different healthcare systems and different cultural perspectives than they had initially expected.
Discussion The findings in this study illustrate the perceptions and experiences of student exchange as expressed by a group of students on a Swedish nursing programme. Preparing for and participating in a student exchange programme brought experiences on both a personal and a professional level, as reflected in the three categories: Preparing to go abroad, Motivation for going abroad and From expectation to experience. The main message to emerge from our findings was the fact that ‘the real experience’ seems to be an underestimated resource in developing cultural competence. This is an important aspect to take into account when developing a successful nursing curriculum that supports culturally competent nurses. The transparency and flow in the process of information is particularly important early on in the programme in order to reach potential students and urge them to participate in a student exchange. It is also important later on as a way of preparing the students for the actual exchange. Both Green
Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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et al. (2008) and more recently Reid-Searle et al. (2011) stress the importance of information and thorough preparation of the students. However, a Swedish student mobility report (HSV, 2007:09R) shows a considerably lower percentage (6% of 4.535 students) of nursing students participating in student exchanges than is the case for students from other programmes (range 10.5%e 20.5%). Swedish universities and organisations involved in exchange programmes now have the possibility to draw on UK and Australian experience of how to recruit and prepare the students in the best possible way. According to Randi and Goldstein (2005), interest in international study programmes may also be facilitated in part by interventions that seek to reduce ethnocentrism and apprehension about communicating with culturally different others. One such intervention could be mandatory courses as part of the nursing programme that deals with such topics. International courses also provide educators with a strategy to assist future nurses to become more prepared to provide care across varied population groups (Smit and Tremethick, 2013). Interestingly, our findings indicated that the informants had a clear view that going abroad should not be based on a whim or a woolly notion. The desire for a student exchange needed to be thought through carefully. This issue was not raised elsewhere in the literature. A possible explanation could be that Sweden, rather late in history and particularly compared to certain other parts of Europe, including the UK, has only recently woken up to the fact that almost 20 per cent of the 9.8 million population have an origin other than Swedish. Besides making a deliberate and carefully considered decision, driving forces such as being able to go behind the tourist façade and an opportunity to experience a ’truer’ feeling of the culture and context despite not being ’one of them’ also became obvious. Student exchanges were also seen as an important tool for their future profession as a nurse e as a platform for future work in international organisations, as a means of networking or as a way of finding a job. This is in line with Greatrex-White’s study (2007) and Mohajeri Norris and Gillespie, 2009 and stresses the significant career impact of studying abroad and the continued use of a foreign language. As in earlier studies (Iammarino and O’Rourke, 1999; Reid-Searl et al., 2011; Tabi and Mukherjee, 2003), cultural aspects and cultural awareness were emphasised as strong motivational factors: “It’s good to have experienced what different means.” This applies on both a personal and professional level to participation in an exchange programme. Leaving one’s comfort zone appeared to make it possible to change attitudes. The post-exchange informants’ experiences raised some important issues. These were linked mainly to personal development and their reflections on encounters and a change in attitude towards severely ill patients, such as patients with HIV/ AIDS. Our findings also confirm the possibility of developing increased preparedness for other ways of dealing with and solving situations. As one informant stated: “I have become a bit tougher”. Experience of studying abroad could, as Beacham et al. (2009) stated, help undergraduate nursing students to discover the power of knowledge through experience. The informants’ experience was also reflected in increased self-confidence as well as becoming more self-aware, i.e. ’Who am I?’ Understanding a different pace of life, a new language, different ways of thinking and different ways of being educated resulted in a feeling of personal growth and maturity. The exchange is then linked to the development of interpersonal skills as well as intercultural communication skills (cf. Rundstrom Williams, 2005). Our findings indicate that the students’ experience of studying abroad had impacted on them beyond the goal of the exchange programme, i.e. increased cultural competence. This is consistent with the findings of Smit and Tremethick (2013), who claim that through divergent approaches
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and nursing perspectives, the students gained an understanding of the challenges faced by others and valued their learning experiences linked to international healthcare. An important question remains: Are student exchanges enough to enhance ‘cosmopolitanism’ (cf. Petit dit Dariel, 2009)? An essential aspect of developing cultural competence in nursing education is to acknowledge the impact of existing discourse. As highlighted in Sheets Cook et al. (2012), we are often unaware of the discourses that frame our existence and which constitute barriers in the development of the concept of health/nursing and ultimately cultural competence. Lipson and Desantis (2007) underline that despite progress in incorporating cultural content into nursing curricula, there are several inhibitor issues, including a decline in core courses focussing on culture due to ‘overcrowding’ in required programme content. There could also be a focus on the micro-level of the nurse-patient encounter, with little attention given to the effects of more macro-level system factors with implications for healthcare decisions. According to Lipson and Desantis (2007), and in line with the findings of this study, there are major strengths in an exchange experience, such as increased self-awareness and an enhanced ability to deal with situational, environmental and sociocultural factors, although there are also major weaknesses, such as the limited number of students able to participate. Although an important tool for cultural competence in nursing education exchange, experience needs to be incorporated into a larger educational framework, where the Camphina-Bacote’s model for cultural competence could function as a good introduction. The cultural framework for the enhancement of cultural competence in European health education (Koskinen et al., 2012) has furthered the suggestion of Lipson and Desantis (2007) by introducing a macro-level perspective into the curricula. Within this framework, an exchange period would be seen as an immersive cultural experience that promotes cultural competence. Study limitations Our sampling technique ensured that we captured different perceptions and experiences. The sample was homogenous with regards to gender as the majority of the students were females (Table 1). However the ration female and male students is representative of the nursing profession in Scandinavia. Nevertheless, it is important to recognise that when recruiting students for research, especially as a lecturer, caution is warranted. Students might feel coerced or obliged to participate. To avoid this, the researchers decided not to start recruiting until the course had been completed. There is little consensus as to what sample size is most appropriate (McLafferty, 2004). Mini-groups, as used in this study, are supported by Morgan (1997) and Carey (1994) as they are easy to manage and there is greater likelihood that participants will interact. The content analysis (Graneheim and Lundman, 2004) made it possible to justify the texts by structuring and presenting categories. To reduce the risk of subjectivity (Hutchinson and Wilson, 1994) and to enhance the credibility of the study, the authors worked together throughout the analysis phases to supplement and contest each other’s readings. By providing quotations, we have hopefully enabled the reader to validate the interpretation (Benner, 1985) and assess its trustworthiness. Although this study highlights some valuable findings, it is a small-scale study performed in a specific setting and context and this needs to be taken into account when evaluating the generalisability of the study. Conclusion In this descriptive paper of the virtues of exchange programs being given the opportunity to study abroad, i.e. acquiring
Please cite this article in press as: Bohman, D.M., Borglin, G., Student exchange for nursing students: Does it raise cultural awareness’? A descriptive, qualitative study, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.006
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international experience, were found to increase cultural awareness and understanding of underlying behaviour, attitudes and beliefs beyond the student’s own view of the world. However, the findings of this study have left us with a question: Are the students who choose to participate in an exchange programme the ones we really need to reach to stop institutional racism or unequal care? The literature review that preceded this study indicates that cross-cultural courses alone are not sufficient even if they focus on both cultural competence and antiracism. This highlights the fact that we still have some way to go if we are to help nurses to work successfully with populations made up of people from culturally diverse backgrounds. Enhancing cultural awareness and as such a cultural understanding in European nursing education clearly demands curricula permeated by intercultural nursing aspects in combination with immersive student exchanges. Authors’ contributions DMB designed the study and collected the data. GB and DMB analysed and drafted the manuscript. Both authors contributed to editing the final manuscript and approved the submitted version. Conflicts of interest None declared. Ethical approval Not applicable. Acknowledgements and funding We would like to acknowledge the students for their help with this study. We would also like to acknowledge Patrick O’Malley for his help with language revision. DMB was supported by the School of Health Science, Blekinge Institute of Technology, Karlskrona, Sweden. GB was supported by the Department of Health Sciences, Nursing Science, Karlstad University, Sweden. References Andrews, M.M., Boyle, J.S., 1999. Transcultural Concepts in Nursing Care, second ed. J.B. Lippincott company, Philadelphia. Beacham, C., MacDonald, N.M., Yoo, J.J., McFall, B.S., 2009. Design thinking: promoting diversity through global immersion. Family Consum. Sci. Res. J. 37 (3), 344e358. Benner, P., 1985. Quality of Life: a phenomenological perspective on explanation, prediction, and understanding in nursing science. Adv. Nurs. Sci. 8, 1e14. Boyle, J.S., 1999. Transcultural nursing at Y2K: some thoughts and observations. J. Transcult. Nurs. 10 (1), 8. Brink, P., 1999. Trans-cultural versus cross-cultural. J. Transcult. Nurs. 10 (1), 7. Button, L., Green, B., Tengnah, C., Johansson, I., Baker, C., 2005. The impact of international placements on nurses’ personal and professional lives: literature review. J. Adv. Nurs. 50 (3), 315e324. Camphina-Bacote, J., 2002. The process of cultural competence in the delivery of healthcare services: a model of care. J. Transcult. Nurs. 13 (3), 181e184. Carey, M., 1994. The group effect in focus groups: planning, implementing, and interpreting focus group research. In: Morse, J.M. (Ed.), Critical Issues in Qualitative Research Methods. Sage Publications, London, pp. 225e241. Cowan, T., Norman, I., 2006. Cultural competence in nursing: new meanings. J. Transcult. Nurs. 17 (1), 82e88. Enskär, K., Johansson, I., Ljusegren, G., Widäng, I., 2011. Lecturers’ experiences of participating in an international exchange. Nurse Educ. Today 31, 541e546. Gebru, K., 1997. Culture Congruent Nursing Care in Nursing Education. Lund University, Sweden (in Swedish). Licentiate degree dissertation. Giger, J.N., Davidhizar, R.E., 2007. Transcultural Nursing, Assessment and Intervention, fifth ed. Mosby Elsevier, St Louis, Missouri. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ. Today 24 (2), 105e112.
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