International Preceptorship Training

Preparing Nurses for Preceptoring International
Students: Manual Development
Majumdar, B., Boblin, S., Sheriff, R.
International collaboration
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.
Nurses’ Experiences Preceptoring International Nursing Students
Themes contributed to the rewards and challenges of preceptor
experiences: culture, relationships, knowledge, and expectations.
Preceptoring International Graduates
Building Cross-Cultural Relationships
Preceptoring International Graduates
Building Cross-Cultural Relationships
Preceptoring International Graduates
Expectation to be
culturally sensitive
Expectation focused
on students meeting
their goals
Building Cross-Cultural Relationships
Expectation for students to
adapt to new culture
Expectations differing for
international students
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.
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
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
• 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
Kolb’s experiential learning model, Bastable (2008).
Phase 1
• Content was identified using
expert opinion and evidence based
• 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
• Outcomes evaluated include:
•Perceptions of appropriateness of content
and process
•Increased knowledge and skills
•Cultural communication
•Satisfaction with process
•Perceived impact on future preceptoring
•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,
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
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).
Self awareness
Cultural identity
Heritage adherence
Ethno history
Health beliefs and behaviours
Anthropological, Sociological,
Psychological and Biological
Similarities and differences
Health inequalities
Assessment skills
Diagnostic skills
Clinical skills
Challenging and addressing
prejudice, discrimination and
Interpersonal communication skills
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,
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.,
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
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)
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