Cultures apart but learning together

There are important strategies that clinical supervisors can use to support culturally and linguistically diverse students while on clinical placement, writes Joan Deegan.

In Australia, international student education is a significant part of the economy. It is the third most valuable export after coal and iron ore and the largest export industry for the state of Victoria, worth more than $5.5 billion annually.

However, students from culturally and linguistically diverse (CALD) backgrounds face some significant challenges during the clinical education component of their undergraduate nurse education.

At the same time, clinical supervisors often require support to help make the clinical experience meaningful for the student and an enjoyable professional experience for themselves.

The following are strategies that may provide a useful reference point for clinical supervisors to help facilitate learning for CALD students.

As there are various models of clinical supervision, the titles of clinical supervisors vary across organisations, with terms such as preceptor, educator and facilitator frequently used. The term clinical supervisor will be used here to encompass all of those titles.

Clinical supervision is an opportunity for a registered nurse to facilitate learning and reflection on clinical practice with the specific aim to assist the student to develop and sustain high-quality knowledge and skill. It is time consuming and professionally engaging for the student and supervisor alike. In addition, the process can be more complicated when the student is from a cultural and linguistic background that differs from that of the supervisor.

Culture is defined as a complex frame of reference that consists of patterns of traditions, beliefs, norms, values, symbols and meanings that are shared to varying degrees by interacting members of a community.

Through communication culture is passed down, created and modified. It provides a set of ideals on how social interaction can be accomplished, and binds people via shared linguistic codes and scripts. In a multicultural environment such as the clinical education space, however, codes and scripts can be a potential source of confusion and even conflict.

In contrast to classroom teaching, clinical education takes place in a dynamic social context where a supervisor, in order to secure appropriate learning opportunities, needs to have a working knowledge of the needs of patients, students and clinician colleagues in the clinical unit. The supervisor then becomes a significant variable in establishing the learning environment, and therefore has the potential to be the key support or the chief barrier to the student’s success.

However, the activities of the clinical environment are complicated by additional factors such as clinical speciality, knowledge, rules (formal and informal), cultural norms, power relationships and mediating artefacts such as technology and language, that it uses to pursue an outcome. In fact many practices, ideas and routines that students experience on clinical placement may be accepted as natural when in fact they are culturally specific to that environment.

In the clinical environment international students traditionally report difficulties associated with various aspects of language and prejudice because of their accents, with many encountering prejudicial behaviours from staff and patients. Other factors that inhibit learning are fear of making mistakes, difficulty understanding and speaking English, necessitating translation from English back to their first language to facilitate comprehension.

Learning a new vocabulary, and understanding new concepts have the potential to impede academic achievement with communication anxiety impacting on learning behaviour, a student may avoid participating in learning activities, particularly if it involves speaking to a group, for example in nursing handover.

It follows then that for meaningful learning to take place in the clinical context a number of factors other than the students’ level in the course and associated knowledge-base need to be considered; the most important being, how to overcome cultural and linguistic barriers in the teaching learning and assessment process.

Intercultural communication takes place when cultural group membership factors (norms and scripts) affect communication processes. In this situation it is important to remember that bilingual students process information more slowly in their less familiar language. This may account for their slower speed of response in some situations. Similarly, in order to achieve communicative competence they need to achieve interactional competence; for example, when and how to respond to questions and seek clarification; as well as, understanding organisational norms around authority figures and communication processes.

As socio-cultural adaptation is strongly affected by the quantity and quality of the relationship with the host community, institutions can either help or hinder the adaptation process through the support that is provided to students.

The quality of this relationship can be improved in a number of ways such as individual awareness of our own culture, both personal and professional; as well as, awareness of factors that impact on learning and adaptation.

Facilitating learning

The student’s access to appropriate learning experiences, are largely dependent upon inclusion in the everyday practice of the clinical unit. The first priority then is providing a clear orientation that is not too complex, and does not involve areas outside of the immediate learning environment to start with. In other words, small increments of information will be more meaningful to a student who is faced with interpreting large amounts of contextual and discipline knowledge complicated by an overlay of linguistic and cultural uncertainty.

Although scholarly independence is to be encouraged at all times, structure is important for most international students of nursing. This is particularly important at the second-year level, as it is most likely their first clinical learning encounter and therefore their first contact with the Australian health system and associated ethical and legal frameworks. It is important to develop a realistic learning plan incorporating the students’ learning objectives (provided they are realistic) with outcomes that are clearly aligned with the subject outcomes and the Australian Nursing and Midwifery (ANMC) Council Competency Standards.

Students are likely to need assistance to make links between theory and practice, for example, a student may go all day seeing examples of informed consent, and regulations associated with drug administration and storage, but not necessarily link that to the application of knowledge about the legal system as it relates to the provision of patient care.

Regular concise factual and constructive feedback, one message at a time, delivered by one person, is vital to help students to understand their progress and areas requiring improvement.

Beware of abbreviations, context specific medical terminology, pronunciations and slang.

The tension between service delivery and teaching is recognised as a persistent challenge in a cash-strapped clinical environment and there are times, when the former is under pressure, the latter can be overlooked. It is worth pointing this out to the student at the beginning of the placement, with a view to considering how such pressure can add rigour to the learning experiences rather than being perceived as an isolating experience.

A student journal can provide a useful means to document issues, reflect and seek clarification either through questioning and debriefing or other self-directed approaches to learning as well as encouraging them to observe practice, develop independence and critically appraise the complexity of the learning environment.

Mindful communication is an important element of student supervision; that is focusing attention to the process of communication between ourselves and dissimilar others, as distinct from habitual ways of thinking and behaving without conscious awareness of our underlying intentions or emotions.

Listening

Active listening can greatly reduce the tendency for CALD students to feel marginalised, and it provides an opportunity for students to voice concerns and seek clarification.

Assessment

Assessment in the clinical setting is an important part of nurse accreditation, a powerful motivator and an integral part of the learning process. It has formative and summative components, and is guided by the Australian Nursing and Midwifery Accreditation Council (ANMAC) National Competency Standards. Even for novice supervisors these standards provide a sound framework from which to develop the students’ learning plan and assessment process.

Formative assessment should commence ideally on the second or third day of placement. This is important as many nursing placements particularly at the second-year level are very short, e.g. two weeks in some cases. It was mentioned earlier that the student learning plan should be closely aligned with the competency standards and the subject outcomes. This provides a structure for learning, feedback and a plan for future learning activities leading to the summative assessment.

Learning in the clinical environment above all should be focused on knowledge acquisition to support skill development; as it is knowledge that guides practice and makes safe practitioners.

This is important to emphasise as the view that clinical skills are more important than knowledge is widespread and misleading amongst students of nursing. Motor skills are important; but, students need to make connections between the patient’s diagnosis and current clinical status, and their decision to carry out an intervention involving a clinical procedure. It is important to remember that some positive feedback is a powerful motivator.

Working with the tertiary provider

Clinical education is an integral part of the course curriculum, and will be either a stand-alone subject or a component of a theory-based subject. Either way it will be co-ordinated by a faculty- based academic responsible for monitoring the students overall progress in the course.

For this reason close collaboration between the clinical supervisor and the subject co-ordinator or their designated representative is a vital link in monitoring student learning. If there are questions and doubts about student learning it needs to be discussed with the co-ordinator at the earliest signs of risk. This enables the supervisor to gain valuable support in their role and to initiate a rigorous learning plan to enable the student to focus their efforts on subject outcomes and competency standards and work towards a successful outcome.

The education of CALD students in the clinical environment is both a challenging and rewarding experience for the student and the supervisor.

Many of the strategies advocated in this article are applicable to any student in the clinical learning environment. However, the key strategies associated with facilitating learning for CALD students is, mindful communication including active listening, understanding the complexities imposed on the student by cultural and communication differences in terms of personal interaction and expectation.

Finally, the key to successful supervision is clear understanding of subject outcomes, competency standards, a learning plan that is closely aligned with both, and collaboration with the subject academic at the earliest signs of risk to the student’s learning and academic progress.

Dr Joan Deegan is the development manager of the Central Western Region Clinical School Network with La Trobe University.

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