|Year : 2009 | Volume
| Issue : 3 | Page : 303
Communicating Across Cultures: Suggested Teaching Strategies
L Slimmer1, D Highland1, M Stout2
1 University of Illinois at Chicago College of Nursing, Chicago, Illinois, USA
2 DePaul University College of Nursing, Chicago, Illinois, USA
|Date of Submission||18-Jan-2009|
|Date of Acceptance||07-Jul-2009|
|Date of Web Publication||20-Nov-2009|
845 S. Damen (MC 802), Chicago, IL 60612
Source of Support: None, Conflict of Interest: None
Context: Quality healthcare for diverse populations requires providers that understand the impact of culture on health and health seeking behaviors. Recruiting individuals from diverse cultures into healthcare professions facilitates this understanding. Although nursing education programs have been successful in recruiting such individuals, they often experience difficulties communicating with faculty and patients, which contributes to attrition from their first clinical course. Communicating Across Cultures is an innovative learning experience at our school to facilitate achievement of clinical competencies in the first nursing course. The purpose of this paper is to describe the teaching strategies used in this course that have increased achievement of clinical competencies and decreased the attrition rate of students from diverse cultures at our school.
Suggested Teaching Strategies: First, assessing the students' specific communication difficulties guides what learning objectives and content are appropriate. Second, an immersion experience immediately before students begin their first clinical course provides experiential learning suited to acquiring new communication styles. Third, the experience and subsequent reinforcement are facilitated by faculty with expertise in teaching communication skills and with guiding the learning experiences of students from diverse cultures. Fourth, delineation of eligibility criteria allows students to self-identify their need to participate. Finally, an evaluation plan provides information to help make decisions about subsequent implementation of the learning experience.
Keywords: Cultural diversity, nursing education, communication, teaching strategies
|How to cite this article:|
Slimmer L, Highland D, Stout M. Communicating Across Cultures: Suggested Teaching Strategies. Educ Health 2009;22:303
Quality healthcare for diverse populations requires providers that understand the impact of culture on health and health-seeking behaviors (Amaro et al., 2006). Recruiting individuals from diverse cultures into healthcare professions facilitates this understanding (Choi, 2005). The University of Illinois at Chicago College of Nursing in the midwestern portion of the United States has been successful in recruiting such individuals. However, students who have immigrated to the U.S. within the last five years from a culture or country other than North America or Western Europe have often been unable to achieve the competencies of the first clinical course. Academic ability was not the reason for the students’ difficulties. From approximately 800 applicants to the College’s upper division undergraduate nursing program which leads to licensure as a registered nurse (RN), these students were among the 100 selected because of their stellar academic record during their first two years of college. The issue was a broader communication difficulty rooted in cultural values and perceptions.
As faculty members interacted with students during the first clinical course, they documented the students’ communication patterns with patients and faculty. After reviewing the previous three years’ evaluation reports of students who had not achieved the first clinical course competencies, faculty identified six culturally related communication difficulties impacting the ability to achieve the clinical course objectives:
- Interviewing and asking sensitive questions when assessing patients.
- Facilitating patients’ expression of feelings.
- Being assertive with patients, clinical agency staff, and/or faculty.
- Speaking with vocal intonation and/or speech volume appropriate to patient understanding.
- Initiating conversation with patients.
- Requesting faculty assistance.
Using the keywords ESL (English as Second Language), Nursing Education, and Teaching Strategies in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), a review of the literature indicated that difficulty retaining students from diverse cultures is a problem shared by other nursing education programs (Jalili-Grenier & Chase, 1997; Malu & Figlear, 1998; Abriam-Yago et al., 1999; Klisch, 2000; Yoder, 2001; Bosher & Smalkoski, 2002; Guhde, 2003; Choi, 2005; Amaro et al., 2006; Caputi et al., 2006). Culturally related communication difficulties often contribute to attrition of these students from the first clinical nursing course (Guhde, 2003). Successful completion of the first clinical course is necessary in order to progress in the program. Therefore assessment of the communication difficulty needs to occur prior to enrollment in this course.
In response to this instructional challenge, a College workgroup consulted with the following University resources: International Program, TESOL (Teachers of English to Speakers of Other Languages) Program, Academic Center for Excellence, College of Allied Health Sciences English Enrichment Tutoring Program, and Tutorium in Intensive English Program. The workgroup also had conversations with the nursing students who were experiencing the identified communication problems to elicit their perceptions.
Two actions resulted from the assessment of the factors contributing to the students’ communication difficulties and the teaching strategies needed to address the difficulties. First, the College initiated two faculty workshops on 1) teaching strategies for those for whom English is not their primary language and 2) avoiding linguistic/cultural bias on examinations. Second, the College’s Associate Department Head of Biobehavioral Health Science, the Director of the Tutorium in Intensive English, and a nursing faculty member designed a communication learning experience for nursing students from a country or culture other than North America or Western Europe: Communicating Across Cultures. In 2007, fourteen students from Nigeria (5), Algeria, the Philippines (2), Mexico, China, India (2), and Iran (2) participated in the experience. Twelve students from China (3), Korea, India, the Philippines (4), Israel, and Mexico (2) participated in 2008. The purpose of this paper is to describe the teaching strategies that have increased achievement of clinical competencies and decreased the attrition rate of students from diverse cultures from their first clinical nursing course.
Suggested Teaching Strategies
Learning Objectives and Content
To ensure that a learning experience meets student needs, it is essential to identify learning objectives based on a comprehensive assessment. The objectives for this learning experience were derived from the review of past clinical evaluation reports, consultation with University departments working with diverse students, perceptions of students experiencing communication difficulties, and a review of literature documenting the learning needs of nursing students from diverse cultures (Jalili-Grenier & Chase, 1997; Yoder, 2001; Bosher & Smalkoski, 2002). The identified needs were not associated specifically with spoken language proficiency, but with cultural values and perceptions about health/illness, appropriate communication styles, faculty/student interactions, and studying strategies. In addition, after the 2007 student evaluations of the experience indicated that they would benefit from a peer support system, this was added as a learning objective to the 2008 experience.
The following objectives have been designated for this learning experience:
- Compare and contrast definitions of health, illness and expectations of healthcare providers from various cultural perspectives.
- Practice specific communication techniques that allow nurses to meet patients’ expectations of healthcare providers and result in quality healthcare.
- Discuss how to work with nursing faculty to further develop the ability to communicate across cultures in the practice of nursing.
- Explain ways to effectively manage time, cope with stress, and implement studying strategies that will promote achievement of nursing learning objectives and competencies.
- Develop a peer support group to decrease feelings of isolation common to students from diverse cultures.
Content is chosen to provide knowledge and skills toward achievement of designated learning objectives. The following four content modules in this learning experience were developed based on the communication needs identified by faculty and the recommended content noted in the review of literature (Yoder, 2001; Bosher & Smalkowski, 2002; Choi, 2005):
- Cultural Perspectives on Health and Healthcare
- Assertiveness Skills
- Therapeutic Communication Skills
- Academic Skills
Placement and Format
Students transfer as college juniors (i.e. third year of education after completion of high school/secondary education) into our College of Nursing from a large number of other academic institutions to complete a baccalaureate degree in nursing during the final two years of college. Students with other degrees who desire to change careers also enter the College to complete a degree in nursing. Therefore, it is necessary to offer this experience during the summer prior to entering the College or during the first semester of the nursing program. The first semester includes 16 semester hours of coursework including 10 hours of classroom courses and a six-hour clinical course. Because the goal of the learning experience is to facilitate successful achievement of the first semester clinical competencies, the optimal time for the experience is during the summer before fall semester classes begin.
Learning outcomes related to values clarification, communication skills, and interpersonal relationships are best achieved through experiential experiences including group work, active learning techniques, and guided reflection (Kolb, 1984). Such experiential learning is facilitated through immersion experiences. Therefore, Communicating Across Cultures is a three-day, six-hour per day immersion experience which includes health and healthcare values clarification exercises, self-assessment of assertiveness and interpersonal relationship styles, and communication role-playing.
Although the range of participants’ cultural backgrounds makes it difficult to provide faculty for the experience from the same cultural traditions as the students, facilitation of the experience is enhanced by having the participation of faculty with expertise in teaching communication skills and with expertise in guiding the learning of students from diverse cultures. The Communicating Across Cultures facilitators include the Associate Department Head of Biobehavioral Health Science who has extensive experience in teaching communication skills, the Director of the Tutorium in Intensive English who has been an educator in several non-Western countries, and a nursing faculty member with experience in counseling students from diverse cultures. The facilitators serve as a resource to the participating students and their clinical faculty throughout the first clinical practicum. Learning that occurs during the immersion experience is reinforced as the students interact with faculty and patients. Moreover, faculty are guided in applying culturally sensitive, evidence-based teaching strategies provided to them in faculty development workshops.
Selection Criteria and Process
Identifying students who will benefit from the learning experience before they enroll in the College is a difficult task. In order to not pre-judge and/or discriminate in deciding who will benefit, this College of Nursing allows students to self-identify for participation. All new students are sent a letter in the spring prior to enrollment explaining the purpose of the Communicating Across Cultures learning experience. At the students’ summer orientation, a more detailed explanation is provided and students who answer “yes” to at least one of the following questions and are able to attend all three days of the experience are invited to participate:
- Do you speak a non-English language more than 50% of the time in your home?
- Have you attended primary and/or secondary school in a country other than the
- Do you identify yourself as being a member of a country or culture other than North America or Western Europe?
These eligibility criteria are derived from the Cummins Model describing language development in promoting educational success for students for whom English is not their first language (Abriam-Yago et al., 1999).
It is important to implement a program evaluation plan to assess the students’ satisfaction with the learning experience and outcome measures documenting their ability to achieve the first clinical course competencies after participating in the learning experience. Unlike a research study which compares the outcomes of two of more teaching strategies, program evaluation documents how well a specific teaching strategy addresses the identified instructional challenge for purposes of decision-making related to the implementation of the teaching strategy (Popham, 1975). The evaluation plan for this learning experience includes four components:
- Evaluation of Experience Survey completed immediately after the immersion experience (Items listed in Table 1)
- Student Evaluation: Impact of Experience on Clinical Performance completed by the student at mid-term during the first clinical nursing course (Items listed in Table 2)
- Faculty Evaluation: Impact of Experience on Clinical Performance completed by the clinical instructor at mid-term during the first clinical nursing course (Items listed in Table 2)
- Clinical Competency Evaluation completed for all nursing students at the end of the first clinical nursing practicum
Table 1 describes the results of the Experience Survey and Table 2 describes the results of the student and faculty evaluation of Impact of Experience on Clinical Performance completed at mid-term.
Table 1: Students’ Evaluation of Experience Mean Scores (1 = strongly disagree; 4 = strongly agree)
Table 2: Mid-term Evaluation of Communication Skills Mean Scores (1 = strongly disagree; 4 = strongly agree)
Data from the Experience Survey indicate a high level of satisfaction with the objectives, content, activities, and facilitators of the learning experience. Data from the Impact of Experience show that faculty and students agree that students demonstrate required communication behaviors at mid-term. However, it is evident that the 2007 Impact of Experience ratings are higher than the 2008 ratings. Although participants in the 2007 and 2008 learning experiences successfully achieved clinical competencies in the first nursing course, clinical evaluation outcomes indicate that the three Chinese students and one Korean student from 2008 who demonstrated more limited English language proficiency had greater difficulty and required more faculty support to achieve those competencies than the other participants. Therefore, subsequent Communicating Across Cultures learning experiences will include an English language proficiency assessment. Students with limited English language proficiency will be invited to attend the eight week Tutorium in Intensive English course, Conversation and Vocabulary Skills Builder, during the first semester.
Although the specific objectives and content of this Communicating Across Cultures learning experience may not be appropriate to all health profession educational programs, culturally related communication difficulties are a common instructional challenge and the teaching strategies used to design and implement this experience are relevant. Based on the positive results of the Communicating Across Cultures learning experience, five teaching strategies are suggested to increase achievement of clinical competencies and decrease the attrition of students from diverse cultures from their first clinical nursing course. First, an assessment identifying students’ communication difficulties guides what learning objectives and content are appropriate. Second, an immersion learning experience immediately before students begin their first clinical course provides experiential learning suited to acquiring new communication styles. Third, the experience and subsequent reinforcement are facilitated by faculty with expertise in teaching communication skills and with guiding the learning experiences of students from diverse cultures. Fourth, delineation of specific eligibility criteria allows students to self-identify their need to participate. Finally, an evaluation plan provides information that informs decisions about subsequent implementation of the learning experience.
Funding for the Communicating Across Cultures learning experience is provided by the University of Illinois at Chicago Council for Excellence in Teaching and Learning and the College of Nursing Collaborative for Learning Excellence.
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