International Education -ej

Volume 3, Number 4 (December 1999) ISSN 1327-9548

 

IE-ej IE-ej index CRIE Faculty of Education University of Canberra

Cultural disadvantage of nursing students.

Dr Don Gorman

Introduction

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 speaking backgrounds.

Background

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 language skills.

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.

METHODOLOGY

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 questions.

Interviews

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.

Analysis

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 software NUD*IST.

LIMITATIONS

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 reasonable one.

Cultural Factors

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:

  1. 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.

  2. 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 choose it".

  3. 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...".

  4. 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".

  5. 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".

  6. 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 very problematic".

    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 communicators.

  7. 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 backgrounds.

    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 sessions".

  8. 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.

  9. 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".

  10. 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.

  11. 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.

Discussion

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.

Acknowledgements

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.

References

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 Publishing.

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: Monash University.

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
Associate Professor
University of Southern Queensland
Toowoomba, Qld. 4350

Telephone: (07) 4631 2976
Fax: (07) 4631 1653
Email: gorman@usq.edu.au


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