Art & science. Developing cultural sensitivity and awareness in nursing overseas

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1 Art & science If you would like to contribute to the Art & science section, The synthesis of art and science is lived by the nurse in the nursing act Josephine G Paterson Developing cultural sensitivity and awareness in nursing overseas Norton D, Marks-Maran D (2014) Developing cultural sensitivity and awareness in nursing overseas. Nursing Standard. 28, 44, Date of submission: October ; date of acceptance: March Abstract Many nurses are choosing to work in other countries, providing an opportunity to broaden their experience and knowledge. However, it is important that nurses who have the opportunity to work overseas develop cultural awareness and sensitivity before arriving. This article provides a reflective account of the experiences of one of the authors of working overseas. From the reflective account and evidence available in the literature on cultural sensitivity, insights are offered to nurses who may be considering working overseas to ensure they are adequately prepared. Authors Diane Norton Senior lecturer, School of Nursing, University of Greenwich, London. Diane Marks-Maran Honorary research fellow, University of Greenwich, London. Correspondence to: marksmaran@btopenworld.com Keywords Cultural awareness, cultural competence, cultural sensitivity, nursing overseas Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online Guidelines on writing for publication are available at For related articles, visit the archive and search using the keywords above. WORKING OVERSEAS IS becoming an attractive option for nurses in many different roles, providing personal, professional, institutional and societal benefits (Button et al 2005). The British Council (2013) suggests that working internationally is beneficial when competing for future employment. The Royal College of Nursing (RCN) (2007) and the Department of Health (DH) (2003) have identified the desired skills and qualifications required by agencies who send healthcare professionals to other countries. These skills include cultural sensitivity and interpersonal skills to live and work together with people of all nationalities and cultures (RCN 2007). In addition, the RCN (2007) highlights the need for cultural preparation and states that a well-prepared and trained volunteer is a valuable asset in the humanitarian sector whereas well-meaning but poorly prepared volunteers can be a liability to both themselves and those they are trying to help. The majority of studies on the benefits of working in a different country in terms of cultural understanding and/or sensitivity have been undertaken with nursing students who have experienced elective placements overseas, and many of these studies are dated. Button et al (2005) found that nursing students on placement overseas reported a better understanding of cultural differences and of the need to acknowledge them in the delivery of health care. Thompson et al (2000) undertook a study of 74 students who had been on an elective placement overseas and reported that nursing students identified cultural learning as one of the major benefits of international experience. Cultural learning was described by these students as challenging their existing values and beliefs, leading to in depth reflection on the concept of NURSING STANDARD / RCN PUBLISHING july 2 :: vol 28 no 44 ::

2 Art & science cultural competence BOX 1 culture. Scholes and Moore (2000) found that students needed to unlearn their own cultural value and belief system to become sensitive to the culture of the country they were studying and working in. Kokko (2011) found that nursing students who participated in exchange placements overseas developed cultural competence as a result of the experience. This process of developing cultural competence consisted of increased cultural knowledge, personal growth and a change in practice as a result of the nursing student s experiences. Jones et al (2012) also reported that nursing students who practised nursing overseas demonstrated a significant change in cultural attitudes as a result of the experience. Reflecting on the experiences of working overseas A reflective account of the experiences of one of the authors of working overseas is provided in Box 1, emphasising the need to prepare for working with people from different cultures. This author prepared for her first nursing experience overseas by researching the country and region to which she was travelling and the related healthcare system. The World Health Organization (WHO) A reflective account of working overseas I first visited the Himalayas as an 18-year-old nursing student, and ten years later I returned to Nepal to work as a volunteer. During the intervening years, I qualified as a nurse and midwife and specialised in children s nursing. My first post in Nepal was in a hospital for patients with leprosy and, to prepare, I attended a tropical nursing course in London. This provided essential knowledge of illnesses not commonly encountered in the UK, such as leprosy. While in Nepal, I learned about the culture and people, a process that was necessary to provide appropriate care for these patients. After two years, I transferred to a clinic in a remote mountainous region to work with colleagues from Nepal and to establish a tuberculosis treatment centre. A three-month course at the National Institute for Research in Tuberculosis in India provided me with the necessary knowledge and skills, which were further enhanced by working with medical colleagues in Nepal. I then became involved in maternal and child health clinics, drawing on previous experience, and began to teach healthcare students. Following academic studies in the UK, I worked as a nurse tutor, teaching midwifery and children s nursing at a university in a larger town in Nepal. This involved working with nursing students in the hospital and supervising their practical nursing care, including the delivery of babies, and undertaking antenatal and postnatal care and clinics. After 12 years I returned to the UK to live and work, and since then I have taught nursing students in India, Nepal, Uganda, Cambodia, the Czech Republic and Finland. Throughout that time, I have drawn on my earlier experiences of the need to develop cultural sensitivity and awareness to help me prepare for these visits and to inform my practice in the UK. and Global Health Workforce Alliance (2008) suggest that integral to successful working overseas is careful personal and professional preparation. The author worked as a nurse and nurse teacher in several countries, and learned that cultural sensitivity and awareness are equally important in both roles. It is important to note that not all nurses will have the same moral and ethical outlook as each other. Moral codes are culturally determined; people see the world in many different ways, and understanding this can be helpful. For example, one culture s value placed on personal honesty can be at odds with another culture s value placed on the need to save face. This is part of cultural acclimatising learning about the values and practices of a particular culture. In addition, people from different cultures value different personality traits. In the West, for example, individuals may be deemed to be achievement and goal-orientated. This may be at odds with the view in many cultures, in which relationships rather than goals are more highly valued. It is vital that anyone considering working overseas should develop cultural awareness and sensitivity, and should be aware that nursing overseas can be challenging but rewarding. There will be many similar traits among people from different cultures, and these outweigh any differences. It is important to focus on the positives rather than the negatives and enjoy exploring the diversity of life found in the many different societies worldwide. Defining culture The word culture is commonly used, but there is little nursing literature that explores the relationship between culture and care. Watt and Norton (2004) argued that, without a sound understanding of the relationship between the two, care could be compartmentalised and fragmented by focusing only on areas of difference such as dress, food or religion. Instead, it is suggested that more attention should be paid in nursing as to how culture and care link together to form an integrated and meaningful whole. Culture is a system of shared ideas, rules and meanings that inform individuals how to view the world and how to act or behave (Watt and Norton 2004). People within a culture usually interpret the meaning of symbols and behaviours in the same or similar ways (Banks and Banks 1989). Helman (2007) referred to culture as the lens of society, or how life is viewed. Andrews and Boyle (2007) described culture as having four main characteristics: 40 july 2 :: vol 28 no 44 :: 2014 NURSING STANDARD / RCN PUBLISHING

3 It is learned from birth through the process of language acquisition and socialisation. Socialisation is the way culture is passed down and determines how an individual fits into the organised way of life of the cultural group. It is shared by all members of the same cultural group. The sharing of cultural beliefs and behaviours is what binds people together under one identity as a group, even if individuals are not consciously aware of this. It determines the pattern through which people undertake roles and responsibilities related to family, friendships and work. It is an ever-changing and dynamic process. Cultural awareness, sensitivity and competence A lesson learned by one author when reflecting on her experiences of working overseas is the importance of cultural awareness. This understanding came about as a result of learning the culture of the people in Nepal, as well as working in other countries and seeing how different cultures affect caregiving. This message is also reflected in the literature. Quappe and Cantatore (2011) suggested that cultural awareness exists at four levels, as shown in Box 2. These levels suggest that, when nurses arrive in a new country or are exposed to a different culture, there is an inherent danger of perceiving that their way of doing things is the only way. However, this assumption should be tackled. Many healthcare professionals, with or without international experience, have a desire to share their knowledge and expertise. Merely imparting this knowledge and way of doing things is not necessarily sufficient to be either useful or worthwhile to someone whose cultural background is different. The challenge is to make this knowledge and expertise beneficial for those who are the recipients. Cultural awareness includes, but goes beyond, merely being aware of different cultures. Ramsden (2002) suggested that cultural awareness is a first step towards understanding that there is a difference between cultures and seeking to find out what this difference is. In the literature, the terms cultural awareness, cultural sensitivity and cultural competence are often used interchangeably. Cultural sensitivity is described by Fleming and Towey (2001) as an awareness of the nuances of one s own and other cultures. The authors also describe cultural competence as the knowledge and interpersonal skills that allow healthcare providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences, self-awareness, knowledge of a patient s culture and adaptation of skills. Developing cultural sensitivity is an important element of pre-registration nurse education in the UK, and all nurses who are educated in the UK are expected to demonstrate cultural sensitivity. One of the essential skills clusters indicates that: People can trust a newly qualified graduate nurse to engage with them and their family or carers within their cultural environments in an acceptant and antidiscriminatory manner free from harassment and exploitation (Nursing and Midwifery Council 2010). Therefore, at the end of the pre-registration nurse education programme, newly qualified nurses should be able to demonstrate cultural sensitivity when they care for patients in the UK who are from different cultural backgrounds. However, the continued development of cultural sensitivity is necessary as nurses choose to work in countries and with people from different cultures. Cultural competence is defined as understanding the importance of social and cultural influences on patients health beliefs and behaviours; considering how these factors interact at multiple levels of the health care delivery system (eg at the level of structural processes of care or clinical decision-making); and, finally, devising interventions that take these issues into account to assure quality healthcare delivery to diverse patient populations (Betancourt et al 2003). BOX 2 Levels of cultural awareness My way is the only way (level 1) people are aware of their culture and way of doing things, and perceive that their way is the only way. This is the parochial stage, and is the level of cultural awareness where people ignore the effect of cultural differences. I know their way, but my way is better (level 2) people are aware of other s cultures and ways of doing things, but still perceive their way as the best way. This is the ethnocentric stage, and at this level cultural differences are seen as a problem and people will try to ignore them or play down their significance. My way and their way (level 3) people become aware of their own way of doing things, as well as other people s. They tend to choose the best way depending on the situation. This is the synergistic stage, and at this level people recognise that cultural differences can lead both to problems and benefits, and start to use cultural diversity to create solutions and alternatives. Our way (level 4) this is the highest level of cultural awareness. This level brings people from different cultural backgrounds together to create a culture of shared meanings. This is the participatory stage, and at this level people continually discuss with others and create new understandings and rules to meet the needs of a particular situation. (Quappe and Cantatore 2011) NURSING STANDARD / RCN PUBLISHING july 2 :: vol 28 no 44 ::

4 Art & science cultural competence Working as a nurse successfully in a different country requires cultural competence. Campinha-Bacote (2002) explored five components of cultural competence: Cultural awareness the exploration of one s own cultural and professional background. This involves recognising one s biases, prejudices and assumptions about individuals who are different. Cultural knowledge obtaining cultural knowledge about people s beliefs and values about health and health behaviour involves understanding their world view. This explains how they interpret their illness and how this guides thinking and behaviour. Cultural skill being able to collect relevant cultural information about people s presenting health problems and learning how to conduct cultural assessments and culturally based physical assessments. Cultural encounter the process through which the healthcare provider engages directly in interactions with people from culturally diverse backgrounds. Cultural desire the healthcare provider wants to, rather than has to, engage in the process of becoming culturally aware, knowledgeable and skilful, and familiar with cultural encounters. Cultural desire involves the concept of caring. What appears to emerge from Quappe and Cantatore s (2011) framework (Box 2) is that the first and second levels can be described as becoming culturally aware, while the third and fourth levels describe the process of becoming culturally sensitive and culturally competent. For the person planning to work in another country, culture shock can be minimised by embarking on the journey from cultural awareness to cultural sensitivity, as described by both Quappe and Cantatore (2011) and Campinha-Bacote (2002), before leaving the UK. Preparing to work overseas There are several steps nurses can take to ensure that, when working in another country or with people from different cultural backgrounds, they demonstrate cultural competence. Advice is provided here based on what one author has learned from her experiences of nursing overseas, as well as from the literature. Nurses should prepare in advance to work overseas and should be ready for the unexpected. It may be that different preparation is needed for different types of employment overseas, such as working for a salary, or undertaking voluntary or humanitarian work. It is important to research the country and/or culture before arrival. For example, there are many national and local training programmes that can prepare individuals for the demands of a particular location, and an appropriate course should be undertaken. Nurses should request or seek detailed information about the nursing work or teaching that they are expected to undertake. They should become familiar with the job and/or role description or, in the case of teaching, the intended content or learning outcomes. For teachers, this can provide a stimulus to consider learning materials that might be needed. In doing this, nurses will begin to move to the second level of cultural awareness (Quappe and Cantatore 2011) (Box 2). However, flexibility is integral to successful working overseas. Advanced preparation for working overseas is useful and important, but until a nurse or nurse teacher immerses him or herself in the new culture it is likely that his or her own cultural assumptions may influence pre-prepared learning materials. It is important to allow developing cultural awareness and sensitivity to lead to changes in original perceptions about practising or teaching overseas. As previously mentioned, nurses should be aware that not everyone has the same moral and ethical outlook as themselves. It is vital that nurses do not make assumptions about what is right and wrong in a new culture this process is part of cultural acclimatisation. Nurses are advised to read as much as they can about the country to which they are travelling and about nursing there. If possible, they should speak to people who have worked in the same country. It may be beneficial to request a period of time after first arriving in the country to either visit or work temporarily in the clinical area. Spending this time acclimatising to the culture enables nurses to better understand the local culture. The UK is a multicultural society and provides many opportunities to meet people from diverse backgrounds. Nurses considering working overseas or with a particular ethnic group, should find out as much as they can about customs, beliefs and celebrations by talking to individuals from that culture. It may be helpful to find an individual who can teach some of the language, because a few phrases such as hello, please, thank you and how are you? can mean a lot to an individual and help to develop a positive therapeutic relationship. On arrival in the country, learning the local language will enable nurses to succeed in developing relationships with patients or nursing students. In doing so, they will begin to move to the third level of cultural competence (Quappe and Cantatore 2011) (Box 2). To demonstrate cultural competence, nurses should reflect on and recognise their own biases 42 july 2 :: vol 28 no 44 :: 2014 NURSING STANDARD / RCN PUBLISHING

5 and be open to other perspectives, rather than trying to persuade others to see things their way. An understanding and appreciation of the culture, a working knowledge of the local healthcare system, the humility to accept that what the nurse has to offer may not be wanted or needed and the recognition that the nurse has something to learn are also required. This is significant in achieving the fourth level of cultural awareness (Quappe and Cantatore 2011) (Box 2). The process is exemplified in a quotation with a nurse teacher who worked overseas: When I started my travels, I believed that UK nurses could show others the way the job should be done. By the time I returned, I had learned just how global nursing is and how much other countries can teach us. It is important for the nurse to begin to develop cultural sensitivity and cultural competence by recognising his or her own biases. If the nurse takes the time to prepare and acclimatise to the culture, he or she is likely to become culturally aware, culturally sensitive and culturally competent. Conversely, inadequate preparation and poor cultural acclimatisation can result in culture shock and a disappointing experience of working in another country and/or with people from different cultural backgrounds. Conclusion Working as a nurse in a different country or with individuals from different cultural backgrounds can be beneficial to all, in terms of sharing ideas and experience. Indeed, research shows that evidence of working internationally is beneficial in terms of competing for future employment. However, cultural preparation and professional skills preparation are mandatory for successful working overseas. The issues raised and advice offered in this article can be applied to nursing students undertaking elective experience or placements in a different country. With an increasing nursing student population, including individuals from other cultures, universities should consider providing guidance to enable these students to develop the cultural competence they require to succeed in nursing in the UK and elsewhere NS References Andrews M, Boyle J (2007) Transcultural Concepts in Nursing Care. Fifth edition. Lippincott, Williams & Wilkins, Philadelphia PA. Banks JA, Banks CAM (1989) Multicultural Education. Allyn & Bacon, Needham Heights MA. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O (2003) Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports. 118, 4, British Council (2013) Culture at Work: The Value of Intercultural Skills in the Workplace. British Council, London. Button L, Green B, Tengnah C, Johansson I, Baker C (2005) The impact of international placements on nurses personal and professional lives: literature review. Journal of Advanced Nursing. 50, 3, Campinha-Bacote J (2002) The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing. 13, Department of Health (2003) International Humanitarian and Health Work: Toolkit to Support Good Practice. The Stationery Office, London. Fleming M, Towey K (2001) Delivering Culturally Effective Health Care to Adolescents. American Medical Association, Chicago. Helman CG (2007) Culture, Health and Illness. Fifth edition. Hodder Arnold, London. Jones AM, Neubrander J, Huff M (2012) A cultural immersion experience for nursing students. Global Partners in Education Journal. 2, 1, Kokko R (2011) Future nurses cultural competences: what are their learning experiences during exchange and studies abroad? A systematic literature review. Journal of Nursing Management. 19, 5, Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education Annexe 3: Essential Skills Cluster and Guidance for Their Use. NMC, London. Quappe S, Cantatore G (2011) What is Cultural Awareness, Anyway? How Do I Build It? com/kxogodh (Last accessed: June ) Ramsden I (2002) Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu. PhD Thesis. Victoria University of Wellington, Wellington. Royal College of Nursing (2007) Working with Humanitarian Organisations: A Guide for Nurses, Midwives and Health Care Professionals. RCN, London. Scholes J, Moore D (2000) Clinical exchange: one model to achieve culturally sensitive care. Nursing Inquiry. 7, 1, Thompson K, Boore J, Deeny P (2000) A comparison of an international experience for nursing students in developed and developing countries. International Journal of Nursing Studies. 37, 6, Watt S, Norton D (2004) Culture, ethnicity, race: what s the difference? Paediatric Nursing. 16, 8, World Health Organization, Global Health Workforce Alliance (2008) Scaling Up, Saving Lives. Task Force for Scaling Up Education and Training for Health Workers, Global Health Workforce Alliance. WHO, Geneva. NURSING STANDARD / RCN PUBLISHING july 2 :: vol 28 no 44 ::