Preparing Nurses for Preceptoring International Students: Manual Development Majumdar, B., Boblin, S., Sheriff, R. Introduction International collaboration - Globalization Clients of multicultural backgrounds (Halabi, 2011). Nurses of multicultural backgrounds In response, nurses of all cultures must develop cultural sensitivity, competence and knowledge. One way that this can be achieved is through international nursing collaboration (Halabi, 2011). Preceptoring and working alongside international students promotes acquisition of cultural knowledge. Benefits international students. Background Nurses’ Experiences Preceptoring International Nursing Students (2010) Themes: -Culture -Relationships -Knowledge -Expectations Themes contributed to the rewards and challenges of preceptor experiences: culture, relationships, knowledge, and expectations. Preceptoring International Graduates Preceptor Building Cross-Cultural Relationships Student Preceptoring International Graduates Culture Preceptor Building Cross-Cultural Relationships Knowledge Student Preceptoring International Graduates Expectation to be culturally sensitive Preceptor Expectation focused on students meeting their goals Culture Building Cross-Cultural Relationships Knowledge Expectation for students to adapt to new culture Student Expectations differing for international students Purpose The purpose of this project was to develop and test a manual that could be used to support registered nurses in their role as preceptors of international learners. This manual is created to address identified themes and is aimed at reducing factors that are barriers to the experience of preceptoring international students. The intent is that the manual, as well as a complementary orientation session will result in preceptors experiencing increased cultural knowledge and consequently a more favourable and successful experience preceptoring international students. Significance Using the information provided in this manual, preceptors will gain awareness of the impact of culture in healthcare and nursing education, thus facilitating better relationships and communication. As such, this will enhance the international students’ educational experience and the preceptor’s professional development. Quality patient care will be enhanced when the preceptors and learners have more positive experiences. Phase 1 • Content was identified using expert opinion and evidence based literature • Content addressed themes identified by Majumdar et al. (2010): culture, knowledge, expectations and relationships • Development was based on Kolb’s Experimental Learning Model • Feedback was obtained from nursing faculty and clinical staff and revisions were made accordingly Phase 2 Processing Continuum Perception Active Experimentation Doing Continuum Concrete Experience Feeling Abstract Conceptualization Thinking Kolb’s experiential learning model, Bastable (2008). Reflective Observation Watching Phase 1 • Content was identified using expert opinion and evidence based literature • Content addressed themes identified by Majumdar et al. (2010): culture, knowledge, expectations and relationships • Development was based on Kolb’s Experimental Learning Model • Feedback was obtained from nursing faculty and clinical staff and revisions were made accordingly Phase 2 • Implementation and evaluation of orientation session and materials • Sample: 8 registered nurses •Recruitment: posted flyers and snowball sampling • Outcomes evaluated include: •Perceptions of appropriateness of content and process •Increased knowledge and skills •Cultural communication •Satisfaction with process •Perceived impact on future preceptoring experiences •Focus group to gather qualitative data on nurses’ feelings, perceptions and experiences •Data analysis: template strategy Manual Components 4 major themes Communication Description of importance Objectives Key points Tips for Preceptors “Did you know?” Example scenario Suggested orientation activities Manual Component - Culture International students face a unique set of challenges related to learning and living in a different culture, learning in a foreign health care context, and learning while developing English language proficiency (Arkoudis, 2006). Studies have found that international nurses working in a different country experienced feelings of being strangers, communication difficulties, professional negation, and ignorance by peers. Having a common language, understanding, and knowledge in the health care setting is important for creating a sense of belonging for international nurses (Jose, 2011). As such, preceptors should develop an understanding of their international student’s cultural background and direct them to community resources and university groups that consist of members and activities of their specific culture. In this way the preceptor can extend support toward their student and decrease feelings of isolation in a new and unknown environment. The purpose of international nursing collaboration is to create closer relationships and interactions between nurses, that will encourage dialogue leading to deeper understanding of each person’s culturally unique participants’ values, beliefs, and traditions about nursing, caring, and leadership and management. (Halabi, 2011) Keep in mind that different cultures have their own assumptions regarding patient care. Sunrise Enabler by Leininger (2008). CULTURAL AWARENESS Self awareness Cultural identity Heritage adherence Ethnocentricity Stereotyping Ethno history CULTURAL KNOWLEDGE Health beliefs and behaviours Anthropological, Sociological, Psychological and Biological understanding Similarities and differences Health inequalities CULTURAL COMPETENCE Assessment skills Diagnostic skills Clinical skills Challenging and addressing prejudice, discrimination and equalities CULTURAL SENSITIVITY Empathy Interpersonal communication skills Trust, Acceptance Appropriateness Respect Tips for preceptors Ask international students how situations would be considered from their experiences (Arkoudis, 2006) Keep in mind that students do not necessarily represent the views of their culture or country (Arkoudis, 2006) Discuss with your students how their culture views patient care and how it may be similar or different from the Canadian culture. Learning about other cultures makes us more aware of our own, sometimes implicit, cultural values (Lamiani, 2008) Attempt to accommodate the student’s cultural preferences in whatever way possible so long as it does not compromise patient safety (CNO, 2009) Reflect on your own culture, including the importance of factors such as work, family, religion, and ethnicity in your life (CNO, 2009) Reflect on the differences and similarities between your ethnic background and the mainstream Canadian culture (CNO, 2009). How are aspects of both of these cultures integrated into your lifestyle? Did you know? The thumbs up gesture is a common way of expressing approval in Canada; however, such a gesture is extremely rude in Brazil, Australia, Spain and Middle Eastern countries (Morrison & Conaway, 2005). Example Scenario Aamir is an international nursing student from Saudi Arabia. Upon meeting Aamir, you discover that he is a pleasant and polite young man. Since you will be his preceptor for his clinical placement in Canada, you decide that it would be a good idea to find out his expectations for the placement and his level of education.You suggest to Aamir that you could use the conference room to help him develop a list of goals. Aamir appears embarrassed by your proposal and politely informs you that it is against his religion to be in a room alone with a woman.You are surprised to hear this as you did not know that about Aamir’s culture. As a preceptor who is striving to facilitate Aamir’s learning, why would it be important take into account your student’s culture? What actions would you take to find out more about Aamir’s culture? How would you accommodate these cultural considerations in order to help Aamir achieve a positive learning experience? Manual Component - Knowledge It is equally important for preceptors to have knowledge about the Canadian Health care system and culture as it is for preceptors to have knowledge about the student’s culture. Having this knowledge will facilitate a broader understanding of the student’s context, thereby allowing preceptors to tailor the teachinglearning process to the individual needs of the student. Internationally recruited nurses may experience tremendous language difficulties and ongoing cultural learning (Sochan & Singh, 2007). It is important to remember that it is not the international students’ knowledge that is in question; rather their English language ability that can influence reading, understanding, interpretation and evaluation of information that is communicated (Arkoudis, 2006). Knowledge about how norms and values of various cultures influence behaviours related to health, illness and suffering can assist nurses in developing cultural sensitivity (Tailor et al., 2011). By helping internationally trained nurses and students develop cultural sensitivity, preceptors can better prepare them to work with the diverse patient population within the Canadian health care system as well as their own. Tailor et al. (2011), also found that international students expressed interest in educational initiatives such as study days, short courses, and national seminars. These students were open to opportunities to test their own professional practice with supervision and guidance within a safe environment, and followed by subsequent reflection. Manual Component -Expectations Core values of nursing are universal, but the delivery and quality of nursing care depends on contextual factors such as the collective skills, language, and shared understanding of professional nursing practice (Jose, 2011). In addition, scope of practice of the nurse differs in different countries (Xu, 2007). Therefore, it is important to discuss legal practices in Canada to increase students’ awareness. For example, personal care of the patient is solely the responsibility of the family rather than the nurse in Asian cultures such as India, China, Nigeria, and the Philippines (Jose, 2011; Xu, 2007). In these cultures, it is considered a privilege for families to be able to care for their family members in this way (Xu, 2007). Furthermore, in collectivist countries, it is unacceptable to challenge someone of higher authority; however, in Canada, it is our legal and professional responsibility as nurses to challenge physicians’ orders when necessary (Xu, 2007). As such, international nursing students may come to Canada with a number of preconceived expectations regarding Canadian culture. Also, international students often enter overseas placements expecting that their experience from their homeland will be valued only to find that it is ignored (Allan, 2007). Therefore, when reality contradicts a student’s expectations, the international students’ experiences and ability to achieve their educational goals may be impacted. Manual Component - Relationships The concept of international nursing collaboration is to create closer relationships and interactions (Halabi, 2011). This will encourage dialogue leading to deeper understanding of the culturally unique students’ values, beliefs, and traditions about nursing, caring, leadership, and management (Halabi, 2011). Although the preceptor may be focused on his/her own difficulties when communicating with international students, it is important to remember that they are not the only ones experiencing frustrations. Difficulty understanding spoken language can lead to frustration and stress because students may feel inadequate and unable to provide care (Xu, 2007). The preceptor’s role is to address these difficulties by establishing supportive relationships and fostering a comfortable learning environment for students. Preceptors should encourage students’ to express their frustrations and reflect on their experiences. Supportive leadership is crucial for a successful experience for the student because internationally educated nurses can be psychologically strained, which negatively impacts their self confidence (Chege & Garon, 2010; Sherman & Eggenberger, 2008). This may impair their problem solving ability in a unfamiliar and confusing setting, leading to poor performance (Chege & Garon, 2010). If the preceptor works closely along with students and takes on leadership roles to advocate for their learning, it may empower the student to succeed. Strategies - Communication Communication has very important implications during transcultural interactions. What may be acceptable in one culture may be rude or insulting in another (Morrison & Conaway, 2004). Below are some key points to keep in mind when interacting and communicating with individuals of diverse cultures: Strategies- Be Mindful Be receptive to new information and different perspectives (Samovar, Porter, & McDaniel, 2009). Remember that using a second language requires greater cognitive capacity than using a native language (Samovar et al., 2009). Inaccurate or variations of pronunciations and accents may create a communication gap (Chege & Garon, 2010). Remember that difficulties in communication do not necessarily reflect incompetency's in practice (Xu, 2008; Chege & Garon, 2010) Strategies - Speech Rate Make an effort to speak slightly slower and more clearly (Samovar et al., 2009) Monitor the individual’s response, taking note of how quickly he or she responded and at what rate. Then, adjust your speech rate accordingly (Samovar et al., 2009) Strategies -Vocabulary Avoid the use of metaphors, slang, or colloquialisms (Samovar et al., 2009) Be cautious of the use of medical acronyms or jargon and do not assume that all medical terms translate across all cultures (Samovar et al., 2009). For example, “appy” is commonly used to abbreviate “appendectomy” in Canada; however, this abbreviation is not used in the Philippines (Chege & Garon, 2010) Use humour with caution, as some cultures differ drastically in their perceptions of a joke (Samovar et al., 2009) Strategies - Monitor nonverbal feedback Nonverbal language is an important tool that can help you gain perspective about whether the individual is understanding what you are saying or whether he or she is comfortable in the situation. For example, giggling as a response to a serious statement may indicate that the individual did not comprehend what was said to them (Samovar et al., 2009). Take note that nonverbal cues in one culture may not translate equally in another. For example, nodding in Canadian culture is a way of expressing agreement; in Ethiopia, the same message is sent by throwing the head back (Samovar et al., 2009). Strategies - Checking It is important to ensure that the individual has comprehended what you have said and in the correct context (Samovar et al., 2009). Rephrase your statement using other words if you sense the individual is having difficulty with comprehension (Samovar et al., 2009). Avoid phrases that put pressure on the individual, such as “Do you understand?” (Samovar et al., 2009). It may be helpful, if interacting with an individual who is less fluent in English, to write down some of the pertinent words in the discussion, as the individual’s reading skills may be better than auditory skills (Samovar et al., 2009) References Allan, H. (2007). 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