Cultural disadvantage of nursing students.
Dr Don Gorman
This article describes a study carried out by the author to gain insight
into the views and experiences of such student nurses and their teachers.
The study originates from a concern about the ability of the nursing
profession to provide nursing care to patients from a diverse range of
cultural backgrounds, particularly given the relatively small number of
non-English speaking background nurses working in Victorian hospitals
and the apparent lack of university nursing graduates from non-English
The above concerns were recognised by various groups some time ago and
as a result the Multicultural Nursing Workforce Project was established
to explore the issues (Gorman, 1995). Unlike the general population,
the vast majority of nurses in Victoria are from English speaking countries
(Department of Employment Education and Training, 1991). The Multicultural
Nursing Workforce Project identified this failure of the nursing workforce
to reflect the ethnic composition of its patients as a major issue. The
extreme predominance of Anglo-Celtic nurses has a number of consequences
that influence the ability of the health care system to provide a suitable
standard of care to non-English speaking background patients.
Firstly, there is a sense of us and them created when the patient sees
all the nurses as representative of the dominant Anglo-Celtic culture
and cannot identify with them. This lack of identification is exacerbated
by the difficulty the two groups have communicating with each other for
both linguistic and cultural reasons. Once the sense of separateness has
developed the non-English speaking patient is put into a position, of being
subordinate, alienated and marginalised.
Secondly, the lack of non-English speaking background nurses, deprives
the Anglo-Celtic nurses of colleagues with an understanding of the
cultural differences and the experience of being part of a minority
group. Such colleagues would have the potential, not only to teach
their Anglo-Celtic counterparts about specific cultural factors
related to caring for non-English speaking background patients, but
also to give them some insight into the experience of being part of a
minority group and thus help them to become more culturally sensitive.
Thirdly non-English speaking background nurses would have the potential
to act as advocates for non-English speaking background patients on
issues of communication and culture. It was felt that for this issue
to be addressed both recruitment and retention of non-English speaking
background students needed to become a priority issue. This issue is
not unique to Australia and there is considerable literature, especially
from the United States (Grossman et al., 1998).
Clearly, if the nursing profession is to meet the needs of non-English
speaking background clients, there would be benefits in providing a
workforce that more closely approximates the ethnic profile of the
client population and includes nurses who have knowledge, skills and
attitudes that enable them to work effectively with clients from
different cultural backgrounds. This is supported by the National
Agenda for a Multicultural Australia which includes the objective to
reform higher education curricula in all areas to provide the skills
and knowledge needed in a multicultural society (Office of Multicultural
Affairs, 1989). If this is an important goal for all university courses
preparing people to participate in Australian society, how much more
important is it for courses preparing people to care for those members
of society who need the services provided by the health care system.
To achieve this the universities conducting nursing courses must incorporate
the knowledge, attitudes and skills necessary to care for people from
different cultures into their curriculum and must recruit and retain
non-English speaking background students and students with community
This study looks specifically at the area of recruitment and retention
of non-English speaking background students into nursing courses. There
is little current information about the existing nursing courses, but it
would appear that little has changed since D'Cruz and Tham (1992) and
Opit and Martin (1979) showed that the numbers of Non-English speaking
students was minimal and non representative of the general or patient
population. To make the situation worse, the experience of the author
in one institution would suggest that those who are accepted into the
undergraduate course lack the necessary support structure to succeed in
what is essentially an Anglo-Celtic education system. There is clearly
a need for research into these areas, if we are to provide effective,
culturally sensitive nursing care to the Australian public.
The study was a qualitative investigation of the experiences and opinions of
non-English speaking background students and the faculty members who teach
them. It consisted of in-depth interviews of faculty members and non-English
speaking background students to determine their perceptions of what factors
were significant to them. The transcripts from the interviews were
consequently analysed to determine the themes relevant to the study's
As the intention of the interviews was to elicit the personal views of the
students and faculty members about the experiences of being a non-English
speaking background student and of their opinions of why there are less
non-English speaking background students graduating, a nonstandardised,
Free-Response, form of interview was used (Richardson, Dohrenwend, & Klein, 1965).
Open questions (Richardson et al., 1965) were utilised except to clarify
points made by the interviewee or to encourage them to expand on an answer
they had given.
Two universities from quite different locations and with different catchment
areas were approached, given a description of the study and asked for
permission to interview their students and faculty members. This permission
was given on condition that the universities not be identified in the study.
The interviewees consisted of 31 faculty members and students. There were
approximately equal numbers from each university, 16, (nine students and
seven faculty members) at university A and 15, (eight students and seven
faculty members) at university B. All interviewees were volunteers. Students
were approached briefly in class time, given an explanation of the research
and asked to consider volunteering. A letter was then sent to all nursing
students asking them to contact the researcher if they met the criteria of
being from a non-English speaking background and wished to participate in
the research. All students who volunteered where born in countries where
English was not the first language.
Their backgrounds were as follows:
one from Italy, Russia, Poland, Malawi, China, Iran, Romania and Hong Kong;
two from Singapore and Malta; and four from Vietnam. A snowball
technique was used to access faculty members who had experience
teaching non-English speaking background students. While being of
non-English speaking background was not a requirement for the
faculty member interviewees, 8 out of the 14 were from a non-English
speaking backgrounds. Their backgrounds being one from Germany, Sri
Lanka, Denmark, Italy, Albania and Russia; two from Hong Kong ;
and six from Australia.
As the object of the interviews was to determine what the experience of
non-English speaking background students was as perceived by the students
and the faculty members who taught them, qualitative methods were used to
analyse the data collected from the interviews. The interviews, carried
out at the respective universities, were audio recorded and subsequently
transcribed then analysed for themes using the qualitative data analysis
The study only looks at 2 universities, and the data comes from 31 voluntary
students and faculty members. It cannot be claimed that these people are
representative of university nursing faculty members or non-English
speaking background students, therefore the results cannot be generalised
or assumed to apply beyond the people directly involved. The data can
however be used as a starting point for further studies, such as a large
scale survey of non-English speaking background people to determine if
these factors have a widespread effect. Notwithstanding the above the
data could be acted upon if it was believed that the factors identified
were both logical and relevant, and the intervention was considered a
Cultural factors refers to the issues identified in the interviews with faculty
members and non-English speaking background students which the researcher
considered specifically related to differences between the students' culture
and that of Anglo-Celtic Australian society. These factors have the potential
to affect the students' decision to apply for nursing courses in the first
place, the likelihood of them gaining admission into these courses if they
do apply and ultimately their chances of succeeding if they are accepted.
While there has been an attempt to group the factors under headings, these are
not necessarily exclusive and in fact a number of the factors overlap and
relate to each other. However, the groupings do help give some understanding
of the experiences described by the respondents.
The eleven cultural factors identified were:
Asking Questions: Students from non-English speaking backgrounds commonly are
reluctant to ask questions or request help from faculty members, especially
in class or on clinical placement. This issue was also identified by
Jalili-Grenier and Chase (1997) in their study of nursing students with
English as a second language.
As one student reported "...but we would never ask and we'd never know
until like we sort of all sat around and said did you understand that?"
Students from non Anglo-Celtic cultures consider that the lecturer is
responsible for determining what will be learned and at what rate. To seek
clarification is to imply that the lecturer has not explained clearly and
is therefore a criticism and to challenge existing knowledge is to challenge
the lecturer, both behaviours that are highly improper for students from
many non Anglo-Celtic cultural backgrounds.
The act of asking questions, whether to challenge existing knowledge or
to seek clarification, is a critical activity in education systems based
on Anglo-Celtic cultures as it incorporates a number of values considered
to be of importance in the Australian education system. It is critical
because of the value placed on self-direction and assertiveness, and
lecturers tend to depend on student's questions to respond to the specific
needs of individual students.
Status: People from some non-English speaking backgrounds do not
consider nursing to be of sufficiently high status "it was always
looked at as a prostitution thing" and does not demand sufficient
respect for them to approve of their children becoming nurses. The
day to day activities of nurses involve close intimate physical
contact with patient's bodies and bodily fluids and this is considered
by some cultures to be base and unclean, "...it's sort of frowned
upon, especially for the females, in the culture to be exposed to
the human body and that sort of thing ". Those students who do
undertake the course despite their parents' opinion of nursing are
likely to be disadvantaged by a lack of support from their parents,
"...whenever I got problem I wouldn't tell them [parents] because
they say it's your choice, you chose it, I didn't encourage you to
Speaking in Class: Non-English speaking background students are
reluctant to speak in class, even when asked a direct question.
This appears to be related to a cultural belief about the student
role being one of passively accepting the knowledge provided by the
teacher and of avoiding any show of disrespect for the teacher or
others who may be seen as holding a more senior position, "... the
teacher she pass on his or her knowledge to the student and the
student she like a passive learner she receive the information and
I would remember when I studied in Vietnam I just allowed to talk
when the teacher point at me I put the hand up and she say ... you
have the right to talk now and I mean when I allowed I start to talk
and if not I just sitting there quiet".
These non Anglo-Celtic cultural factors are in direct contrast to the
Anglo-Celtic cultural expectations of faculty members who want students
to demonstrate independence and self assurance and expect them to
question and challenge both the lecturer and other students, express
personal opinions and enter into debates. There is also an expectation
that students will make presentations in class as a part of their
assessment and that they will give hand-over to the qualified nursing
staff at the change of shift when on clinical placement. Both
classroom presentations and handover involve the student in being the
centre of attention and expressing their knowledge and opinion to
both their peers and senior staff, something that is culturally alien
and extremely difficult for them to do, "...in our country when you
start in school just sit there and when you got the answer you just
you put your hand up and say something .. didn't stand in front of the
class and you know face-to-face with the other students like we talk
like in Australia so that a big problem...".
Gender Issues: Aspects of the roles of females and males in some
non-English speaking background cultures inhibited their ability
to study nursing. Women are commonly expected to get married and
have children, not to undertake a career, "...decent young Albanian
women waited for someone to come and ask for their hand in marriage
and then got married and had children and fulfilled those roles".
For many cultures it is not acceptable for women to work in close
intimacy with other peoples' bodies, to do so is immodest and only
done by loose women or prostitutes, "...it's sort of frowned upon,
especially for the females, in the culture to be exposed to the
human body and that sort of thing".
Financial Security: Non-English speaking background people preferred
to adopt careers that would ensure a reasonably high income and that
nursing was not considered to be one of these.
Financial security is an issue for people from most cultures, but it
was mentioned as being an issue for non-English speaking background
people in relation to choosing nursing as a career as well as in their
being able to successfully complete the course.
Non-English speaking background people preferred to adopt careers that
would ensure a reasonably high income and that nursing was not
considered to be one of these. This emphasis on income seems to be
closely related to status. Careers with a higher income imply a
higher status and recognition from people from their own cultural
background, "...there's lack of prestige, for example if you're a
doctor there's lots of prestige and respect for your occupation that
you know you are well respected and you have a good salary". It was
also suggested that part of the reason for this interest in income
may be their experiences of poverty and insecurity in their home
country and as migrants in Australia, "...those migrant who come from ..
who leave their country for good to Australia wants to get a better
life, therefore nursing probably can earn not much money for them so
they tend to do business, accounting, computers, something like that,
which is easier to get more money and more job opportunities".
Interpersonal Behaviour: Non-English speaking background people's
interpersonal behaviour differed from that of Anglo-Celtic people,
which resulted in difficulties for them in terms of how they were
perceived by faculty members and nursing staff.
Probably the major area where the differences in cultural beliefs,
values and behaviours was noticed and identified as a problem was
that of interpersonal behaviour. While it was noticed by academics
and clinical staff, it was rarely, especially by clinical staff,
attributed to cultural differences. There were a number of ways in
which non-English speaking background people's interpersonal behaviour
differed from that of Anglo-Celtic people, which resulted in
difficulties for them in terms of how they were perceived by faculty
members and nursing staff. They believed that the non-English speaking
background person was seen as non-assertive, retiring, overly
respectful of authority figures and reluctant to engage with others by
disclosing personal information and sharing experiences. All these were
seen as faulty interpersonal skills which can result in the student
being seen as incapable of functioning competently as a nurse,"...it's
not a western style of communication and clinical teachers pick it up
as they're shy and they're not willing to communicate. Once it gets
picked up as that it's seen as a fault of the student and then the
student does actually go into that sort of self-fulfilling prophecy,
like starting to hide away from teachers and patients so it can be
As interpersonal behaviour is culturally determined, and as it is also
seen as a critical component of nursing care, students have extreme
difficulty trying to meet the expectations of their teachers, especially
when there is little acknowledgment that these behaviours are culturally
determined and therefore students are simply labelled ineffective
Mixing: There is reluctance on the part of non-English speaking
background students to mix with students from other cultures. Partly
because of difficulties communicating but also because it is not
condoned by their families, some non-English speaking background
students are reluctant to mix with people from different ethnic
This is partly due to the desire to communicate with students in
their own language, and a desire to not stand out as different,"...but
I think it's just that coming into a lecture full of what looks like
a homogenous population and you think well I'm the only dark one or
I'm the only yellow skinned one, my eyes tend to be a bit different ..
and you think where do I sit .. I mean we sit together and after that
it's very difficult for you get out of that psyche of okay that's
them and that's us".
It would appear that this reluctance to mix cross-culturally is also
present in the Anglo-Celtic Australians as non-English speaking
background students mentioned the difficulty of trying to get accepted.
This is a particular issue in relation to group work and presentations
where the non-English speaking background students are seen as potentially
lowering the ability of the group to achieve higher grades, "...that girl
was in a group with two other Australian student and she came and said
that the Australian student didn't work with her so well and didn't want
to have the same mark". In situations where students are allocated to
groups (as opposed to being allowed to choose for themselves), the
possibility of being forced to work with people from a different background
creates considerable anxiety, "...every group discussion I'd think oh
who am I going to be with today, I used to worry half the time .. half
the time I worried about that instead of actually enjoying the classroom
Nursing: Some of the requirements of the Australian nursing role while
accepted in an Anglo-Celtic culture are unacceptable to people from a
non Anglo-Celtic culture. This would make people from such a culture
reluctant to apply to nursing courses or if they did start the course
they could find it difficult to comply with the expectations made of
them or invoke the disapproval of lecturers and nursing staff. This is
especially so as the nursing profession is seen as being very rigidly
ethnocentric, '...in nursing we justify that by saying this is for the
best for the patient so therefore we can be ethnocentric 'cos it's the
right way to do it and the patient's well-being is at stake'. There
is no recognition that the values and rules of nursing are culturally
determined, such as promoting independence in patients, '...you know,
asking them [patients] to do things by themselves whereas in my culture
if the person is old you would say sit there, you don't have to do
anything, I do it for you'. In Western nursing it is considered poor
practice to encourage dependency in patients, as this undermines their
autonomy and independence, so they are encouraged to do everything for
themselves that they can.
Values: There is a conflict between the values of non-English speaking
background people and the expectations of the course. A great deal of
self-esteem and pride not only of the student but of the family also,
is linked to performance and there are very high expectations from the
student's families, not only to succeed, but also to get high grades.
This valuing of the family group and the pride of the group means that
failure of an assessment appears to have a much greater effect on their
self esteem than on Anglo-Celtic Australian students whose Anglo-Celtic
culture is more pragmatically related to the ultimate success of the
individual and therefore sees low grades as a relatively minor hurdle
to overcome. "...they get a hell of a lot of pressure from home for
good results, not just a pass, very good results";
"...we have had one suicide, that was last year ... this person did
perform quite well but not well enough for what she considered to be
good grades, and unfortunately we lost her ... student failed first
year three times and unfortunately she hadn't told her family that and
they were expecting to come to her graduation".
Family roles: Non-English speaking background people had expectations
of their student children or spouses to fulfil certain roles at home
that Anglo-Celtic students do not usually have to do and that may place
an additional burden on the student or prevent them from even applying.
The expectations held by the families of students from non Anglo-Celtic
cultures tend to have a much greater impact on students from non Anglo-Celtic
cultures than do those of students from Anglo-Celtic cultures.
Non-English speaking background students appear to put the needs of the
family before their studies. The students (especially female students),
are commonly required to undertake housework and care for siblings
"...the girls .. I don't know, they're encouraged to stay home and keep
the house clean ... the girls they're not encouraged to go and be educated
do anything other than looking after the house". These roles and
expectations are related to the fact that non Anglo-Celtic cultures tend
to place a high emphasis on membership of social groups, especially the
family, and the preservation of that group rather than of the individuals
as the preservation of the individual is dependant on the group. This
contrasts strongly with the Anglo-Celtic cultural values of Australia's
Anglo-Celtic society, where the rights of the individual and promotion of
autonomy and independence are highly valued. Anglo-Celtic Australian
students tend to see their studies as a priority, and this value is fostered
by the family who may then make sacrifices to help the student.
Cultural knowledge: Not only do non-English speaking background students
have difficulty socialising because of different cultural beliefs, values
and rules, but they are often disadvantaged by subjects that assume
a sound knowledge of Australian culture.
This is especially true of subjects such as Sociology, Psychology, Philosophy
and Nursing Issues, but it probably applies to some extent with all subjects.
This knowledge is unstated and therefore students are never informed of what
they do not know and cannot find it in reference books. This lack of knowledge
can result in content being misunderstood or simply not making sense, "...rules,
regulations are that much more difficult for people who don't have that sort of
immersion in the English culture". A major area of difficulty that arises for
non-English speaking background students in this area is when they are expected
to participate in discussions or debates. "... you're not like you are not
familiar with the system how can you share your ideas on issue. [Australian
students] when they get into nursing issues that involves debates . they know
how the law is, they know what nurses should do but we don't have the idea
so ... we don't have a clue". Each of the factors identified has the potential
to have quite a devastatingly negative effect on the students' ability to
succeed in the course. While any given student may not be affected by all
of the factors, it is highly likely that they would be affected by some of
them. In many cases the effect of one factor may well increase the effect
of others for example reluctance to ask questions can make the lack of cultural
knowledge far more serious and difficult to overcome. The themes identified
by the participants, especially when combined, make the task of succeeding
extremely difficult if not impossible.
This study was able to identify quite specific issues and their potential
effects on students as perceived by the interviewees. These factors,
especially as they appear to be rarely identified, can play an
extremely important role in disadvantaging students from non Anglo-Celtic
cultures. The students come to the course with expectations of what they
will be required to do and of what the university will provide, based on
their previous experience of education and their own cultural values and
beliefs. They have little understanding of the cultural basis of the
university system as it is not overtly acknowledged or described. The
student has no means to prepare for, or understand, the culture shock to
follow. Even if assimilation were an acknowledged goal and the student
could reasonably be expected to adopt the Anglo-Celtic cultural values of
the university, the fact that they are not explained makes such an assimilation
very difficult for them. While there are faculty members who are concerned
at the disadvantage experienced by non-English speaking background students,
they often do not understand the basis of the students' disadvantage.
The degree to which students are disadvantaged depends on how much their
cultural background differs to that of the university. Clearly the degree
cultural difference of each individual student will vary, not only because
of their ethnic background, but because as individuals they will vary from
others of the same background. There is also variation within the components
of the university. Some faculty members are themselves relatively non
Anglo-Celtic in their cultural background and thus when they are the point
of contact for students there may be a much closer fit of cultures.
Consequences of/Reactions to, the Cultural Gap
The non Anglo-Celtic characteristics of the students are seldom seen as
culturally appropriate. It was reported that the behaviours of specific
students were judged in a negative way, as would Anglo-Celtic students
with the same characteristics. There was little recognition of the fact
that these behaviours were culturally appropriate. When the behaviours
were acknowledged as culturally based, the culture was considered wrong.
This was reported as being especially strong in the clinical areas.
There was little recognition that valuing assertiveness for example
is culturally determined. It was seen as a universal truth, and any
culture that did not value it was wrong. There is also a very strong
educational belief that the right way to teach is to encourage students
to challenge and develop the ability to be autonomous self directed
learners. These values are seen as unquestionable facts and therefore
cannot be accepted as being culturally relative. Another factor that
increases the belief on the part of nurses that their values should not
be compromised is fear that to do so would put patients at risk. While
students are expected to challenge the university faculty members at a
theoretical level, the belief in the clinical area is that best practice
involves compliance to professional norms. This increases the intolerance
of different behaviour and reduces the likelihood of any re-evaluation
of what is considered normal.
Interviewees indicated that non-English speaking background students
were commonly seen as being ineffective; excessively shy; non-assertive;
lacking initiative; impersonal; distant; non-communicative; excessively
modest; introverted; disinterested; lacking intelligence; untrustworthy;
lacking knowledge, skill, or confidence; and having a tendency to curry
favour. This causes them to be judged as having a serious problem which
would affect their ability to communicate and relate to others and they
were therefore considered unsuitable for nursing.
Their unwillingness to ask questions resulted in greater difficulty
for them understanding what was expected of them. In the clinical area
they missed out on opportunities to observe or participate in particular
procedures, or worse, failed to carry out instructions correctly. This
sometimes caused anger and frustration on the part of clinical staff who
judged the student as lacking English skills or as incompetent. The
student then became even more reluctant to approach staff and a vicious
cycle developed. Non-English speaking background students were also
reluctant to ask for help with assignments or for extensions thus making
it more difficult for them to pass.
While unable to identify them for reasons of confidentiality, the author
wishes to thank the universities, students and faculty members who
participated in this study. Their willingness and efforts are evidence
of their concerns about the difficulties experienced by NESB students.
D'Cruz, J., & Tham, G. (1992). Nursing and nursing education
in a multicultural Australia: A Victorian study of some cultural,
curriculum and demographic issues. Melbourne: David Lovell
Department of Employment Education and Training. (1991).
National nurse labour market study: Volume one; summary report.
Canberra: Department of Employment, Education and Training.
Gorman, D. (1995). Multiculturalism and nursing in Australia.
Journal of Transcultural Nursing, 6 (2), pp.27-33.
Grossman, D., Massey, P., Blais, K., Geiger, E.,
Lowe, J., Pereira, O., Stewart, A., Taylor, R., Filer, V.,
Nembhard, J., & Tally-Ross, N. (1998). Cultural diversity
in Florida nursing programs: A survey of deans and directors.
Journal of Nursing Education, 37(1), pp.22-26.
Jalili-Grenier, F., & Chase, M. (1997). Retention of
nursing students with English as a second language. Journal
of Advanced Nursing, 25, pp.199-203.
Office of Multicultural Affairs. (1989). National agenda
for a multicultural Australia. Canberra: AGPS.
Opit, L., & Martin, P. (1979). Student general nurse
applicants in Victoria (1978) with particular reference
to their ethnic origin and language skills. Melbourne:
Richardson, S., Dohrenwend, B., & Klein, D. (1965).
Interviewing: Its forms and functions. New York: Basic Books.
DR DON GORMAN
RN(End M H), DipNEd, BEd, MEd, EdD
University of Southern Queensland
Toowoomba, Qld. 4350
Telephone: (07) 4631 2976
Fax: (07) 4631 1653