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Being the stranger: Comparing study abroad experiences of nursing students in low and high income countries through hermeneutical phenomenology
Nurse Education Today 45 (2016) 114–119
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Being the stranger: Comparing study abroad experiences of nursing students in low and high income countries through hermeneutical phenomenology☆ Hendrika J. Maltby a,⁎, Joy M. de Vries-Erich b, Karen Lund c a b c
College of Nursing and Health Sciences, University of Vermont, 106 Carrigan Drive, Rowell 208, Burlington, VT 05405, USA Center for Evidence Based Education, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands Health Sciences, International University of Business Agriculture and Technology, Bangladesh
a r t i c l e
i n f o
Article history: Received 12 May 2016 Received in revised form 8 June 2016 Accepted 23 June 2016 Keywords: Cultural competency Nursing education Study abroad Hermeneutical phenomenology
a b s t r a c t Aim: To understand the experience of American nursing students who complete a study abroad trip to a low-income country, Bangladesh, versus a high-income country, the Netherlands in the development of cultural consciousness. Methods: Hermeneutic (interpretive) phenomenology was used to explore the journals of 44 students' experiences and reflections. Results: The comprehensive understanding of the naïve and structural analysis revealed that, no matter where these students travelled, they increased their cultural consciousness. Conclusions: We need to revise curricula to create ‘change from the familiar’ experiences for all students (many cannot afford study abroad) to move students to cultural consciousness on their journey to cultural competency that may improve client health outcomes. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction Cultural competency is a program outcome for baccalaureate nursing education internationally (American Association of Colleges (AACN), 2008; Canadian Nurses Association, 2010; International Council of Nurses, 2013). If nursing students are to become competent, curricula need to provide sufficient opportunities to learn culturally appropriate care, increase awareness of other ways of being, and enhance understanding of themselves in an ever expanding world (Carpenter and Garcia, 2012; Curtin et al., 2015; Edmonds, 2011; Kulbok et al., 2012; Larsen and Reif, 2011; Kent-Wilkinson et al., 2015; Maltby and Abrams, 2009). A study abroad trip does not make students culturally competent but can raise consciousness to an extent that they realize that there are multiple ways of providing care to diverse individuals, families and communities. Cross et al. (1989) developed a cultural competency continuum to describe the process of becoming culturally competent (Table 1). Although not part of their continuum, we feel that the term ‘cultural consciousness’ bridges cultural pre-competence and cultural competence. Cultural consciousness is defined as accepting that there are
☆ This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. E-mail addresses: [email protected] (H.J. Maltby), [email protected] (J.M. de Vries-Erich), [email protected] (K. Lund).
http://dx.doi.org/10.1016/j.nedt.2016.06.025 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
differences but not knowing yet how to respond appropriately to those differences. We believe that this is where many of the nursing students are: they know there are differences and the study abroad experience highlights these differences. The purpose of this hermeneutic phenomenological study was to understand the experience of students when completing a study abroad trip to a low-income country (LIC), Bangladesh, versus a high-income country (HIC), the Netherlands. In other words, does socio-economic circumstance impact students' cultural consciousness? 2. Literature Review There is abundant research and case study literature of the impact study abroad has had on nursing students' personal and professional lives. Many are either about experiences in HICs such as Europe and the United States (Carpenter and Garcia, 2012; Green et al., 2008; Maas and Ezeobele, 2014) or on experiences in LICs located in South America, Asia, or Africa, (Bentley and Ellison, 2007; Charles et al., 2014; Curtin et al., 2015; Kirkham et al., 2009; Larson et al., 2010; Maltby and Abrams, 2009; Wros and Archer, 2010). Kulbok et al. (2012) reviewed the nursing education literature and found that international experiences continue to be created for students with the goal of responding to diverse populations. There has been, however, little in the literature that compares student learning between those who travelled to a LIC and HIC. Edmonds (2011) conducted a literature review of study abroad programs for
H.J. Maltby et al. / Nurse Education Today 45 (2016) 114–119 Table 1 Cultural competency continuum. Cross et al. (1989). Element
Characteristics
Cultural destructiveness Cultural Incapacity Cultural blindness
Bigotry, racism, hatred; one race is superior Bias; discrimination
Believe that everyone is the same; approaches used by dominant culture works for everyone Cultural Knowing there is a difference and may be marked by pre-competence ‘tokenism’, that is, one person from the minority represents all Cultural Acceptance and respect for difference; tailored approaches competence Cultural Holding culture in high esteem; advocate for cultural proficiency competence
American nursing students. She found no comparative studies between those who travelled to developed and developing countries as “findings from studies on travel to both types of countries are usually reported collectively rather than by type of destination” (p. 32). The qualitative study by Thompson et al. (2000) assessed the differences in the experiences of Irish nursing students who had travelled to either a developed, i.e. HIC, (Australia, Canada, New Zealand, Spain, Sweden, USA) versus a developing, i.e. LIC (Brazil, Gambia, India, Kenya, Malawi, Tanzania, Uganda, Zambia) country. Using Zorn's International Education Survey, and a response rate of 84.1% (n = 74), the researchers found that all students benefited from international experiences although they felt that those who travelled to developing countries “had gained significantly more in relation to international perspectives, personal development and intellectual development” (p. 489). They surmised that the contrast with their own lives stimulated a re-evaluation of personal and professional values. They also found that students had a better understanding of their own country context no matter if they travelled to a LIC or a HIC. The current study addresses the gap of qualitative studies with American nursing students in the literature identified by Edmonds (2011). It also builds on the work of Thompson et al. (2000) of a comparative analysis between students who travelled to either a LIC or a HIC. The reflective journals of American nursing students who travelled to either a LIC or a HIC were analyzed to understand their experience.
3. The Immersion Experience A three-week study abroad experience for public health nursing had been established in Bangladesh in partnership with [International University of Business Agriculture and Technology] since 2008. During the planning for 2013, an election season in Bangladesh became very violent. In consultation with university risk management and Bangladeshi colleagues, we decided that the trip would be cancelled for security reasons. Instead, as we had an established relationship with universities in the Netherlands, we were able to arrange a study abroad trip there on short notice. The following year, continuing security issues cancelled the trip to Bangladesh again (there are no future trips planned). We were again able to travel to the Netherlands. The students completed their Public Health Nursing course (theory and clinical) during the study abroad trips. In both countries, classes were held almost daily; students spent time in health care institutions, completed community assessments, went on field visits, and learned about the culture. They were able to visit historical sites and experience the life in various communities.
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4. Method 4.1. Design Hermeneutic (interpretive) phenomenology was used for this study as the students' experience and reflections of cultural consciousness in Bangladesh or the Netherlands were being explored. This design was deemed appropriate for the study as we wanted to move beyond description of the experience to understanding and constructing what it meant for the students. The lived experience of the students was expressed through their narratives in their reflective journals so that the “essential meaning [was] studied and revealed in the interpretation of the text” (Lindseth and Norberg, 2004, p. 147). We were involved in the experience with them, meaning that the bracketing of our assumptions and beliefs was impossible (Lopez and Willis, 2004; Reiners, 2012). Students were required to keep a reflective journal of their experiences within the framework of culture and public health nursing. As well, they included their own thoughts, feelings, and meanings throughout the trip which became the data for the study. 4.2. Participants There were 45 undergraduate nursing students who participated in study abroad programs over four years: 21 to Bangladesh and 24 to the Netherlands. Participants were 93% female, 95% White with an average age of 22 years (Table 2). All but one were fourth year nursing students who were going to graduate within four months of the trip. One was a registered nurse student who did not provide her journal for the study and therefore was not included. 4.3. Setting In Bangladesh, 43.3% of the population live below the international poverty line of US$1.25 per day (UNICEF, 2015). This percentage is zero in the Netherlands. Table 3 provides further comparisons between the two countries. 4.4. Procedure The University's Institutional Review Board granted ethical approval for the study prior to departure. Students were invited to participate in the study via e-mail, approximately four weeks after returning home. It was anticipated that students would be more open if they did not know about the study until the experience had concluded. All but one student (n = 44; 97.7%) gave permission for their de-identified journals to be included in the study once final grades had been submitted. Journals were photocopied, de-identified, and scanned to make them available electronically to the research team members. The original journals were returned to the students. 4.5. Data Analysis Data were analyzed using Lindseth and Norberg's (2004) phenomenological hermeneutical methodology of text interpretation. All researchers read the journals several times during the naïve reading of the text to find meaning as a whole and provide the “first conjecture” Table 2 Demographic Characteristics of participants. Year
Participants by country Bangladesh
Number Gender: female Age range: years
Total The Netherlands
2012
2013
2014
2015
10 100% 21–30
11 90.9% 22–29
14 100% 21–58
10 80% 21–35
45 Mean: 93% Mean age: 22
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about the price of dinner in America. That really struck me (B-13-4). [1000 taka could purchase food for the week for the worker.]
Table 3 Comparison of Bangladesh and the Netherlands. Central Intelligence Agency (2016). Bangladesh
The Netherlands
Land area
143,998 sq. km; terrain: mainly flat alluvial plain
Population
169 mil. (growth rate 1.6%); infant mortality rate (below 1) – 44.9/1000; life expectancy – 70.9 years (2015) Bangla (official), English
41,543 sq. km; terrain: mostly coastal lowland and reclaimed land 16.9 mil. (growth rate 0.41%); infant mortality rate – 3.62/1000; life expectancy – 81 years (2015)
Languages
Ethnicity/race Bengali 96%; tribal groups; non-Bengali Muslims Religion Muslim 89%; Hindu 10%; other 1% Education Primary school attendance – 92%; adult literacy rate – 61.5% (2015)
Dutch (official) but many people also speak English, French, and German Dutch 78.6%, EU 5.8%, other 15% Catholic 28%; Protestant 19%; other 11%; none 42% Attendance (primary school enrolment) – 100%. Literacy rate – 99%
(p. 149). In structural analyses, researchers divided the text into meaning units from which themes and sub-themes emerged. We reflected on the themes and subthemes, resorted, condensed and at times, reformulated themes. These were examined in relation to the naïve understanding of the whole which was validated through this process. Finally, the themes/sub-themes and the naïve understanding were further interpreted and discussed in relation to the literature to provide a comprehensive understanding of whether the socio-economic circumstance of the study abroad country impacted cultural consciousness. Excerpts from the journals were coded as location (B-Bangladesh; N-Netherlands), year, and participant number. 5. Results and Discussion 5.1. Naïve Understanding The nursing students on both the Bangladesh and Netherlands trips began to develop a sense of themselves as the ‘other’ particularly in relation to being Americans. They discovered that there were other ways of being in the world: the American way was not necessarily the best way for everyone. This was a revelation for them leading to a beginning cultural consciousness being developed. 5.2. Structural Analysis The structural analysis revealed themes unique to each travel group. For the Bangladesh group, the two themes were ‘they are poor/I am wealthy’ and ‘I am a minority’. In the Netherlands group, the focus on ‘primary care’ was paramount. Additionally, there were two themes common to both groups. ‘Public Health’ was the first theme with the environment, status of women, health promotion, and the health care system as the subthemes. The second theme was ‘Stranger in a Strange Land’, with the following subthemes: culture shock, language barrier, and myself as the foreigner. 5.3. Themes Unique to the Bangladesh Group The first theme in this group was They are poor/I am wealthy. This was a theme that came through in all the journals and in many of the entries in each journal. A worker downstairs admired her [a student's] new bracelet and [the student] said it was 1000 taka [about $12.00 US] and the woman said she'd never be able to afford that. That's incredible, because it's
Students had their idea of ‘wealth’ changed when they were confronted with those who had nothing. There was little realization, however, that similar conditions face many in the United States. The second theme in the Bangladesh group was the recognition that they were a minority group. Not only were they wealthy, but they were mostly White. As a white person I am a minority that sticks out as different from the norm. I have been stared at, had my picture taken, and received undue attention for the color of my skin … I didn't realize how much I would stick out (B-12-6). Often, when out in the community, a small group of students would stop to look at a stall or try to determine where they were going next and within minutes, there was a group of people (mostly men) around them, just looking, maybe taking pictures. Students felt very unnerved by the experience. A number of the students took a ‘mental health day’ when they did not go out into the community just to have a day to themselves, using withdrawal to cope with the experience.
5.4. Themes Unique to the Netherlands Group The unique theme to this group was the realization that primary care is the central focus of the health care system in the Netherlands. I think we should adopt their general practitioner (GP) system to save money on ED [Emergency Department] visits and hospital stays that could absolutely be prevented. It seems much easier to access their GP (free at any point 24/7) instead of wasting ambulances and ED services (N-15-8). In most cases, the GP visits people at home day or night to determine diagnosis and treatment and whether or not the person needs to be in hospital. The students were amazed how well the system worked.
5.5. Themes Common to Both Groups The first common theme is Public Health. There were comments and observations throughout all of the journals about public health and health in general; both of the community and the people. This theme has four subthemes: environment, status of women, health promotion, and the health care system. The environment was very evident in both countries but at opposite ends of the scale. In Bangladesh, Unsafe driving and pedestrian conditions (overcrowded cars, lack of use of traffic lights, poor sidewalks, no crosswalks)…wires in the streets…trash piles in the streets…all concerns to be addressed by public health officials (B-12-6). In the Netherlands, many of the comments were about the public transportation system and the number of bicycles. There is very accessible/clean public transportation, very safe bike routes (at times it seemed like there were more bikes/mopeds on the road than cars) (N-14-9). I … wish there was a feasible way to have a system like this in the States. Unfortunately environment certainly influences the system. The Dutch train system benefits from a dense population a small land mass. With all the rural areas at home, such an extensive system seems economically impossible to me (N-15-1). In both cases, students became very conscious of the differences between the country they visited and home.
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The status of women is the second subtheme. A number of countryspecific readings featured the status of women. In Bangladesh, women do not have many rights (although this is changing). Students also felt restricted by the rules that govern women's behavior. We are unable to go out at night without a man accompanying us. This is difficult for me as a woman who is used to having independence (B-12-1). While the status of women in the Netherlands is high, students had been eager to see the Red Light district in Amsterdam, until they learned about human trafficking. At night my group visited and walked through the Red Light District. I felt a tad (well honestly a lot) uncomfortable with the objectification of the female body…Do they feel safe? (N-14-11). The third subtheme was health promotion. This was related to both observed dangers as well as what worked well. In the Netherlands, the students became very troubled with the number of people who bicycled without helmets (although motorcyclists did wear them). The students did not understand why people were not concerned about this issue. Their other observation has to do with restaurant portions and the size of the people. I am concerned with the lack of helmet wearing. With the large biking culture there is in the Netherlands, I am shocked at the lack of bike safety advocacy (N-14-3). There were much smaller portions than at home, fast food available but not as much as in America with less morbid obesity (N-14-9). In Bangladesh, students felt that there was a large role for injury prevention policies, not realizing at the time that enforcement was more the problem. For example, the traffic is very risky … as an outsider I could suggest changes, like saying that people need more regulation for traffic violations and safety. People should be required to wear seatbelts (B-12-1). The final subtheme is the health care system. Students in both groups toured a variety of health care institutions as part of learning about public health. The hospitals here [in the Netherlands] make it an inviting place (and not one of death and sickness). The colors were bright, there was actual art on the walls, a daycare, hairdresser and open squares with greenery. This is such a great opportunity to seize because making the hospital a more interesting place to go, can lead to education opportunities and encourage people to be more open to the idea. I hope the US will change to this system of setup, because I believe it will make a difference” (N-15-4). In Bangladesh, the students commented on one of the hospitals in Dhaka, the capital city: There was a long line out the entrance of people waiting to get in. Right inside the door there is a desk where a nurse sits and assesses the dehydration status. If the patients were severely dehydrated, they were weighed and then an IV is started within 2 min of the assessment. They are very efficient (B-13-7). One visiting resident from the US said that this hospital [ICDDR,B] is as good if not better than any hospital in the US at curing diarrhea quickly, and using much less resources (B-12-1).
ICDDR,B is the International Centre for Diarrheal Diseases Research, Bangladesh (the locals call it the cholera hospital) and receives considerable international support. Many hospitals in Bangladesh are not well resourced.
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The second theme common to both travel groups was the realization that I am a Stranger in a Strange Land. Students became aware that they were far from home. This theme included the following three subthemes: culture shock, language barrier, and myself as the foreigner. Culture shock, the first subtheme, refers to the “multiple demands for adjustment that individuals experience at the cognitive, behavioral, emotional, social, and physiological levels, when they relocate to another culture” (Chapdelaine, 2004). Food and water tended to be the topic of many conversations as it is a visible aspect of different cultures. Familiar food is related to their sense of wellbeing. The students also had a definite appreciation of the term: ‘rice is a staple in the diet’. “I'm so sick of rice and just want American food. I am craving cheese and crackers, turkey burger and a big salad” (B-13-6). In the Netherlands, students were more worried about the access to drinking water. We've noticed here that drinks are extremely costly, including water. The bottles come in such small portions and cost so much that a lot of us feel like we've been dehydrated since we've been here. N-14-9. They had become so used to buying bottled water at every corner at home that even though we told them to bring fillable drinking bottles, they did not fill them as often as they should. Students also became homesick, missing their friends and familiar places. “As I become less homesick, the more I'm loving it here” (N-14-5). “I miss the ‘cushy’ luxuries of home – I miss showers, washing machines, and such. And then the little things, like being able to wear the clothes I want, putting my toothbrush under the [tap], not having people gawk at me wherever I go, knowing the local language” (B-12-7). Part of the issue in both countries was not being able to use their cell phones and not having instant access to the internet which may have created a sense of loss of personal connections with family and friends. The language barrier, the second subtheme, frustrated the students in both countries. For a couple of seconds I'm like, living here [the Netherlands] would be so easy, I already feel like a citizen and then every time I walk into [the grocery store] my dreams are shattered as I struggle to even pronounce what I'm possibly reading about a very questionable meal that I later find surprise ingredients in that may or may not be a foreign animal (N-14-5). I have never talked to someone who didn't speak my language. I felt embarrassed and awkward (B-136). It frustrated me personally seeing a room full of [lay health] workers who benefit so many communities by teaching, and me being unable to do the same, because of a language barrier (B-13-10). In the Netherlands, we toured the government buildings in The Hague. The tour was in Dutch and we had audioguides in English. The guide would speak in Dutch, telling stories, the group would laugh and the students looked at one another. As one student stated. I felt isolated not being able to understand the tour and a lot of personal communication. The American people tend to feel entitled and expect to be catered to. By not being able to hear what everyone else was hearing, I felt disadvantaged and alienated. Intentional or unintentional, it was a great exercise and I will be cognizant of this from now on (N-15-8). The final subtheme is myself as the foreigner. The students made comments on the overall learning that took place while they were abroad. The students began to understand and empathize with immigrants/refugees to the US.
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It's hard for me to think of life back home and how unfriendly and unwelcoming people are, especially toward foreigners. It makes me want to do more to help the refugees and immigrants in the US. It showed me just how difficult it must be for them whether it's buying groceries, catching a bus, finding a job etc.” (B-12-1). Today the tour guide spoke in Dutch a lot and would only speak to us in English a little every once in a while …. We compared the experience and feelings we had today with how it must feel for foreigners or refugees moving to our country – and they don't even get little headsets to walk around with in their native language! (N-15-2).
5.6. Comprehensive Understanding All of the nursing students in this study were in their final semester of a four year baccalaureate program, looking forward to graduation and employment. The naïve understanding and structural analysis revealed that, no matter where these students travelled, they increased their understanding of public health nursing and their cultural consciousness. Similar to the work of Thompson et al. (2000), the students in this study learned much about themselves as American nursing students in the global context. They made judgments about the country they visited as well as their own. The students in our study were affected by the poverty they witnessed, so much so that when they returned home, several of them gave away many of their possessions as they felt they had too much. Discussions about the hidden poverty in the United States needs to occur where “approximately 1 in 5 children live below the official federal poverty level and almost 1 in 2 are poor or near poor” (Dreyer et al., 2016, p. S1). There was no commensurate reaction from the students who went to the Netherlands. Does this mean that the students in the Netherlands group did not learn as much? They did note how nice it was that most stores and shops were closed by five o'clock in the afternoon most days of the week which gave families time to be together. We do believe that these students too, had a transformative experience albeit differently. The students who went to the Netherlands did increase their “awareness of socioeconomic relations, structural oppression, and human connectedness” (Foronda and Belknap, 2012, p. 157) even though they travelled to a HIC. The comparison of health insurance costs and the basic right of everyone to health care was an eyeopening one. In discussion with hospital staff, health insurance in the Netherlands was 60 euros (about $70 US) compared to one student's brother who paid $600 a month. Learning about human trafficking prior to visiting the Red Light District in Amsterdam raised their awareness of oppression. In fact, students had wanted to hold up signs to the women in the windows to ask if they felt safe. As Greatrex-White (2008) states “we can learn through new experience to expect people to behave differently [from us]. The crux is that we need to acquire the experiences that will bring about this change” (p. 536). The results of this study suggest that all of the students changed their world view and developed their cultural consciousness no matter if they travelled to a LIC or a HIC. In both socio-economic situations, they experienced being ‘the other’, how language barriers affected them, and how culture in general, defines who we are and how we act. Similar to Greatrex-White (2008) the “uncovering of study abroad as ‘foreigner’ although sometimes accepted is often underestimated: the influence it exerts…profoundly affects cultural perspectives” (p. 537). Structuring the learning experiences to address the various public health nursing concepts as well as providing prompts for the reflective journaling was essential to the enhancement of cultural consciousness. We need to determine the true reason to travel to a LIC. Woolf (2013) has termed the travel to LICs as “a new orthodoxy … built out of a misplaced and sometimes condescending enthusiasm for regions and nations in the developing world that are seen through a Western lens as ‘exotic’ others” (p. 1). He calls this ‘politics-and-poverty tourism’. Study in these countries should be based on partnership principles,
benefitting both countries; activities should be part of local integrated and sustainable initiatives. Perhaps, as Kushner (2016) states “the first step toward making the world a better place is to simply experience that place” (p. 4/5). It takes considerable reflection to realize that effective change requires time and understanding. Students need to become the ‘other’, a stranger in a strange land. Future research can investigate revising curricula to create ‘change from the familiar’ experiences for all students, rather than a select few, as many cannot afford study abroad. To facilitate the move to cultural consciousness on their journey to cultural competency that may improve client health outcomes, Fischer (2015) argues, this may mean not crossing national borders at all. It is often possible to be the ‘other’ in your own country. Additional research is also needed to support the findings from this study. 6. Conclusion This study adds to the sparse literature that compares student cultural learning between a LIC and a HIC. Cultural consciousness changes regardless of where students travel. They reflected not only on their experience of being abroad but also on what that meant to professional identity. They experienced what it is like to be a stranger. Nurse educators need to develop the course objectives first, and determine the reason for travel to a specific country. We need to ask ourselves if ‘place’ truly matters to meet course objectives. This study supports that travel in any country can develop cultural consciousness. As one of the students stated: I have been a foreigner and therefore have a greater, although incomplete, understanding of what it is like for someone who is in that position. Because of this, I believe I will be able to perform better culturally sensitive care than I would have before this experience (N15-10).
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Lopez, K.A., Willis, D.G., 2004. Descriptive versus interpretive phenomenology: their contributions to nursing knowledge. Qual. Health Res. 14 (5), 726–735. Maas, L.G., Ezeobele, I.E., 2014. Reflections from Dutch advanced nursing practice students on psychiatric mental healthcare in the United States. Arch. Psychiatr. Nurs. 28 (2014), 357–361. Maltby, H.J., Abrams, S., 2009. Seeing with new eyes: the meaning of an immersion experience in Bangladesh for undergraduate senior nursing students. Int. J. Nurs. Educ. Scholarsh. 6 (Article 33). Reiners, G.M., 2012. Understanding the difference between Husserl's (descriptive) and Heidegger's (interpretive) phenomenological research. J. Nurs. Care 1 (5). http://dx. doi.org/10.4172/2167-1168.1000119. Thompson, K., Boore, J., Deeny, P., 2000. A comparison of an international experience for nursing students in developed and developing countries. Int. J. Nurs. Stud. 37 (2000), 481–492. UNICEF, 2015. Bangladesh statistics. http://www.unicef.org/infobycountry/bangladesh_ bangladesh_statistics.html (The Netherlands statistics: http://data.worldbank.org/ country/netherlands). Woolf, M., 2013. Politics-and-Poverty Tourism: The Lure of Study in Developing Countries. The Chronicle of Higher Education (http://chronicle.com/blogs/worldwise/ politics-and-poverty-tourism-the-lure-of-study-in-developing-countries/32799). Wros, P., Archer, S., 2010. Comparing learning outcomes of international and local community partnerships for undergraduate nursing students. J. Community Health Nurs. 27 (4), 216–225. http://dx.doi.org/10.1080/07370016.2010.515461.
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Being the stranger: Comparing study abroad experiences of nursing students in low and high income countries through hermeneutical phenomenology☆ Hendrika J. Maltby a,⁎, Joy M. de Vries-Erich b, Karen Lund c a b c
College of Nursing and Health Sciences, University of Vermont, 106 Carrigan Drive, Rowell 208, Burlington, VT 05405, USA Center for Evidence Based Education, University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands Health Sciences, International University of Business Agriculture and Technology, Bangladesh
a r t i c l e
i n f o
Article history: Received 12 May 2016 Received in revised form 8 June 2016 Accepted 23 June 2016 Keywords: Cultural competency Nursing education Study abroad Hermeneutical phenomenology
a b s t r a c t Aim: To understand the experience of American nursing students who complete a study abroad trip to a low-income country, Bangladesh, versus a high-income country, the Netherlands in the development of cultural consciousness. Methods: Hermeneutic (interpretive) phenomenology was used to explore the journals of 44 students' experiences and reflections. Results: The comprehensive understanding of the naïve and structural analysis revealed that, no matter where these students travelled, they increased their cultural consciousness. Conclusions: We need to revise curricula to create ‘change from the familiar’ experiences for all students (many cannot afford study abroad) to move students to cultural consciousness on their journey to cultural competency that may improve client health outcomes. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction Cultural competency is a program outcome for baccalaureate nursing education internationally (American Association of Colleges (AACN), 2008; Canadian Nurses Association, 2010; International Council of Nurses, 2013). If nursing students are to become competent, curricula need to provide sufficient opportunities to learn culturally appropriate care, increase awareness of other ways of being, and enhance understanding of themselves in an ever expanding world (Carpenter and Garcia, 2012; Curtin et al., 2015; Edmonds, 2011; Kulbok et al., 2012; Larsen and Reif, 2011; Kent-Wilkinson et al., 2015; Maltby and Abrams, 2009). A study abroad trip does not make students culturally competent but can raise consciousness to an extent that they realize that there are multiple ways of providing care to diverse individuals, families and communities. Cross et al. (1989) developed a cultural competency continuum to describe the process of becoming culturally competent (Table 1). Although not part of their continuum, we feel that the term ‘cultural consciousness’ bridges cultural pre-competence and cultural competence. Cultural consciousness is defined as accepting that there are
☆ This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author. E-mail addresses: [email protected] (H.J. Maltby), [email protected] (J.M. de Vries-Erich), [email protected] (K. Lund).
http://dx.doi.org/10.1016/j.nedt.2016.06.025 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
differences but not knowing yet how to respond appropriately to those differences. We believe that this is where many of the nursing students are: they know there are differences and the study abroad experience highlights these differences. The purpose of this hermeneutic phenomenological study was to understand the experience of students when completing a study abroad trip to a low-income country (LIC), Bangladesh, versus a high-income country (HIC), the Netherlands. In other words, does socio-economic circumstance impact students' cultural consciousness? 2. Literature Review There is abundant research and case study literature of the impact study abroad has had on nursing students' personal and professional lives. Many are either about experiences in HICs such as Europe and the United States (Carpenter and Garcia, 2012; Green et al., 2008; Maas and Ezeobele, 2014) or on experiences in LICs located in South America, Asia, or Africa, (Bentley and Ellison, 2007; Charles et al., 2014; Curtin et al., 2015; Kirkham et al., 2009; Larson et al., 2010; Maltby and Abrams, 2009; Wros and Archer, 2010). Kulbok et al. (2012) reviewed the nursing education literature and found that international experiences continue to be created for students with the goal of responding to diverse populations. There has been, however, little in the literature that compares student learning between those who travelled to a LIC and HIC. Edmonds (2011) conducted a literature review of study abroad programs for
H.J. Maltby et al. / Nurse Education Today 45 (2016) 114–119 Table 1 Cultural competency continuum. Cross et al. (1989). Element
Characteristics
Cultural destructiveness Cultural Incapacity Cultural blindness
Bigotry, racism, hatred; one race is superior Bias; discrimination
Believe that everyone is the same; approaches used by dominant culture works for everyone Cultural Knowing there is a difference and may be marked by pre-competence ‘tokenism’, that is, one person from the minority represents all Cultural Acceptance and respect for difference; tailored approaches competence Cultural Holding culture in high esteem; advocate for cultural proficiency competence
American nursing students. She found no comparative studies between those who travelled to developed and developing countries as “findings from studies on travel to both types of countries are usually reported collectively rather than by type of destination” (p. 32). The qualitative study by Thompson et al. (2000) assessed the differences in the experiences of Irish nursing students who had travelled to either a developed, i.e. HIC, (Australia, Canada, New Zealand, Spain, Sweden, USA) versus a developing, i.e. LIC (Brazil, Gambia, India, Kenya, Malawi, Tanzania, Uganda, Zambia) country. Using Zorn's International Education Survey, and a response rate of 84.1% (n = 74), the researchers found that all students benefited from international experiences although they felt that those who travelled to developing countries “had gained significantly more in relation to international perspectives, personal development and intellectual development” (p. 489). They surmised that the contrast with their own lives stimulated a re-evaluation of personal and professional values. They also found that students had a better understanding of their own country context no matter if they travelled to a LIC or a HIC. The current study addresses the gap of qualitative studies with American nursing students in the literature identified by Edmonds (2011). It also builds on the work of Thompson et al. (2000) of a comparative analysis between students who travelled to either a LIC or a HIC. The reflective journals of American nursing students who travelled to either a LIC or a HIC were analyzed to understand their experience.
3. The Immersion Experience A three-week study abroad experience for public health nursing had been established in Bangladesh in partnership with [International University of Business Agriculture and Technology] since 2008. During the planning for 2013, an election season in Bangladesh became very violent. In consultation with university risk management and Bangladeshi colleagues, we decided that the trip would be cancelled for security reasons. Instead, as we had an established relationship with universities in the Netherlands, we were able to arrange a study abroad trip there on short notice. The following year, continuing security issues cancelled the trip to Bangladesh again (there are no future trips planned). We were again able to travel to the Netherlands. The students completed their Public Health Nursing course (theory and clinical) during the study abroad trips. In both countries, classes were held almost daily; students spent time in health care institutions, completed community assessments, went on field visits, and learned about the culture. They were able to visit historical sites and experience the life in various communities.
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4. Method 4.1. Design Hermeneutic (interpretive) phenomenology was used for this study as the students' experience and reflections of cultural consciousness in Bangladesh or the Netherlands were being explored. This design was deemed appropriate for the study as we wanted to move beyond description of the experience to understanding and constructing what it meant for the students. The lived experience of the students was expressed through their narratives in their reflective journals so that the “essential meaning [was] studied and revealed in the interpretation of the text” (Lindseth and Norberg, 2004, p. 147). We were involved in the experience with them, meaning that the bracketing of our assumptions and beliefs was impossible (Lopez and Willis, 2004; Reiners, 2012). Students were required to keep a reflective journal of their experiences within the framework of culture and public health nursing. As well, they included their own thoughts, feelings, and meanings throughout the trip which became the data for the study. 4.2. Participants There were 45 undergraduate nursing students who participated in study abroad programs over four years: 21 to Bangladesh and 24 to the Netherlands. Participants were 93% female, 95% White with an average age of 22 years (Table 2). All but one were fourth year nursing students who were going to graduate within four months of the trip. One was a registered nurse student who did not provide her journal for the study and therefore was not included. 4.3. Setting In Bangladesh, 43.3% of the population live below the international poverty line of US$1.25 per day (UNICEF, 2015). This percentage is zero in the Netherlands. Table 3 provides further comparisons between the two countries. 4.4. Procedure The University's Institutional Review Board granted ethical approval for the study prior to departure. Students were invited to participate in the study via e-mail, approximately four weeks after returning home. It was anticipated that students would be more open if they did not know about the study until the experience had concluded. All but one student (n = 44; 97.7%) gave permission for their de-identified journals to be included in the study once final grades had been submitted. Journals were photocopied, de-identified, and scanned to make them available electronically to the research team members. The original journals were returned to the students. 4.5. Data Analysis Data were analyzed using Lindseth and Norberg's (2004) phenomenological hermeneutical methodology of text interpretation. All researchers read the journals several times during the naïve reading of the text to find meaning as a whole and provide the “first conjecture” Table 2 Demographic Characteristics of participants. Year
Participants by country Bangladesh
Number Gender: female Age range: years
Total The Netherlands
2012
2013
2014
2015
10 100% 21–30
11 90.9% 22–29
14 100% 21–58
10 80% 21–35
45 Mean: 93% Mean age: 22
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about the price of dinner in America. That really struck me (B-13-4). [1000 taka could purchase food for the week for the worker.]
Table 3 Comparison of Bangladesh and the Netherlands. Central Intelligence Agency (2016). Bangladesh
The Netherlands
Land area
143,998 sq. km; terrain: mainly flat alluvial plain
Population
169 mil. (growth rate 1.6%); infant mortality rate (below 1) – 44.9/1000; life expectancy – 70.9 years (2015) Bangla (official), English
41,543 sq. km; terrain: mostly coastal lowland and reclaimed land 16.9 mil. (growth rate 0.41%); infant mortality rate – 3.62/1000; life expectancy – 81 years (2015)
Languages
Ethnicity/race Bengali 96%; tribal groups; non-Bengali Muslims Religion Muslim 89%; Hindu 10%; other 1% Education Primary school attendance – 92%; adult literacy rate – 61.5% (2015)
Dutch (official) but many people also speak English, French, and German Dutch 78.6%, EU 5.8%, other 15% Catholic 28%; Protestant 19%; other 11%; none 42% Attendance (primary school enrolment) – 100%. Literacy rate – 99%
(p. 149). In structural analyses, researchers divided the text into meaning units from which themes and sub-themes emerged. We reflected on the themes and subthemes, resorted, condensed and at times, reformulated themes. These were examined in relation to the naïve understanding of the whole which was validated through this process. Finally, the themes/sub-themes and the naïve understanding were further interpreted and discussed in relation to the literature to provide a comprehensive understanding of whether the socio-economic circumstance of the study abroad country impacted cultural consciousness. Excerpts from the journals were coded as location (B-Bangladesh; N-Netherlands), year, and participant number. 5. Results and Discussion 5.1. Naïve Understanding The nursing students on both the Bangladesh and Netherlands trips began to develop a sense of themselves as the ‘other’ particularly in relation to being Americans. They discovered that there were other ways of being in the world: the American way was not necessarily the best way for everyone. This was a revelation for them leading to a beginning cultural consciousness being developed. 5.2. Structural Analysis The structural analysis revealed themes unique to each travel group. For the Bangladesh group, the two themes were ‘they are poor/I am wealthy’ and ‘I am a minority’. In the Netherlands group, the focus on ‘primary care’ was paramount. Additionally, there were two themes common to both groups. ‘Public Health’ was the first theme with the environment, status of women, health promotion, and the health care system as the subthemes. The second theme was ‘Stranger in a Strange Land’, with the following subthemes: culture shock, language barrier, and myself as the foreigner. 5.3. Themes Unique to the Bangladesh Group The first theme in this group was They are poor/I am wealthy. This was a theme that came through in all the journals and in many of the entries in each journal. A worker downstairs admired her [a student's] new bracelet and [the student] said it was 1000 taka [about $12.00 US] and the woman said she'd never be able to afford that. That's incredible, because it's
Students had their idea of ‘wealth’ changed when they were confronted with those who had nothing. There was little realization, however, that similar conditions face many in the United States. The second theme in the Bangladesh group was the recognition that they were a minority group. Not only were they wealthy, but they were mostly White. As a white person I am a minority that sticks out as different from the norm. I have been stared at, had my picture taken, and received undue attention for the color of my skin … I didn't realize how much I would stick out (B-12-6). Often, when out in the community, a small group of students would stop to look at a stall or try to determine where they were going next and within minutes, there was a group of people (mostly men) around them, just looking, maybe taking pictures. Students felt very unnerved by the experience. A number of the students took a ‘mental health day’ when they did not go out into the community just to have a day to themselves, using withdrawal to cope with the experience.
5.4. Themes Unique to the Netherlands Group The unique theme to this group was the realization that primary care is the central focus of the health care system in the Netherlands. I think we should adopt their general practitioner (GP) system to save money on ED [Emergency Department] visits and hospital stays that could absolutely be prevented. It seems much easier to access their GP (free at any point 24/7) instead of wasting ambulances and ED services (N-15-8). In most cases, the GP visits people at home day or night to determine diagnosis and treatment and whether or not the person needs to be in hospital. The students were amazed how well the system worked.
5.5. Themes Common to Both Groups The first common theme is Public Health. There were comments and observations throughout all of the journals about public health and health in general; both of the community and the people. This theme has four subthemes: environment, status of women, health promotion, and the health care system. The environment was very evident in both countries but at opposite ends of the scale. In Bangladesh, Unsafe driving and pedestrian conditions (overcrowded cars, lack of use of traffic lights, poor sidewalks, no crosswalks)…wires in the streets…trash piles in the streets…all concerns to be addressed by public health officials (B-12-6). In the Netherlands, many of the comments were about the public transportation system and the number of bicycles. There is very accessible/clean public transportation, very safe bike routes (at times it seemed like there were more bikes/mopeds on the road than cars) (N-14-9). I … wish there was a feasible way to have a system like this in the States. Unfortunately environment certainly influences the system. The Dutch train system benefits from a dense population a small land mass. With all the rural areas at home, such an extensive system seems economically impossible to me (N-15-1). In both cases, students became very conscious of the differences between the country they visited and home.
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The status of women is the second subtheme. A number of countryspecific readings featured the status of women. In Bangladesh, women do not have many rights (although this is changing). Students also felt restricted by the rules that govern women's behavior. We are unable to go out at night without a man accompanying us. This is difficult for me as a woman who is used to having independence (B-12-1). While the status of women in the Netherlands is high, students had been eager to see the Red Light district in Amsterdam, until they learned about human trafficking. At night my group visited and walked through the Red Light District. I felt a tad (well honestly a lot) uncomfortable with the objectification of the female body…Do they feel safe? (N-14-11). The third subtheme was health promotion. This was related to both observed dangers as well as what worked well. In the Netherlands, the students became very troubled with the number of people who bicycled without helmets (although motorcyclists did wear them). The students did not understand why people were not concerned about this issue. Their other observation has to do with restaurant portions and the size of the people. I am concerned with the lack of helmet wearing. With the large biking culture there is in the Netherlands, I am shocked at the lack of bike safety advocacy (N-14-3). There were much smaller portions than at home, fast food available but not as much as in America with less morbid obesity (N-14-9). In Bangladesh, students felt that there was a large role for injury prevention policies, not realizing at the time that enforcement was more the problem. For example, the traffic is very risky … as an outsider I could suggest changes, like saying that people need more regulation for traffic violations and safety. People should be required to wear seatbelts (B-12-1). The final subtheme is the health care system. Students in both groups toured a variety of health care institutions as part of learning about public health. The hospitals here [in the Netherlands] make it an inviting place (and not one of death and sickness). The colors were bright, there was actual art on the walls, a daycare, hairdresser and open squares with greenery. This is such a great opportunity to seize because making the hospital a more interesting place to go, can lead to education opportunities and encourage people to be more open to the idea. I hope the US will change to this system of setup, because I believe it will make a difference” (N-15-4). In Bangladesh, the students commented on one of the hospitals in Dhaka, the capital city: There was a long line out the entrance of people waiting to get in. Right inside the door there is a desk where a nurse sits and assesses the dehydration status. If the patients were severely dehydrated, they were weighed and then an IV is started within 2 min of the assessment. They are very efficient (B-13-7). One visiting resident from the US said that this hospital [ICDDR,B] is as good if not better than any hospital in the US at curing diarrhea quickly, and using much less resources (B-12-1).
ICDDR,B is the International Centre for Diarrheal Diseases Research, Bangladesh (the locals call it the cholera hospital) and receives considerable international support. Many hospitals in Bangladesh are not well resourced.
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The second theme common to both travel groups was the realization that I am a Stranger in a Strange Land. Students became aware that they were far from home. This theme included the following three subthemes: culture shock, language barrier, and myself as the foreigner. Culture shock, the first subtheme, refers to the “multiple demands for adjustment that individuals experience at the cognitive, behavioral, emotional, social, and physiological levels, when they relocate to another culture” (Chapdelaine, 2004). Food and water tended to be the topic of many conversations as it is a visible aspect of different cultures. Familiar food is related to their sense of wellbeing. The students also had a definite appreciation of the term: ‘rice is a staple in the diet’. “I'm so sick of rice and just want American food. I am craving cheese and crackers, turkey burger and a big salad” (B-13-6). In the Netherlands, students were more worried about the access to drinking water. We've noticed here that drinks are extremely costly, including water. The bottles come in such small portions and cost so much that a lot of us feel like we've been dehydrated since we've been here. N-14-9. They had become so used to buying bottled water at every corner at home that even though we told them to bring fillable drinking bottles, they did not fill them as often as they should. Students also became homesick, missing their friends and familiar places. “As I become less homesick, the more I'm loving it here” (N-14-5). “I miss the ‘cushy’ luxuries of home – I miss showers, washing machines, and such. And then the little things, like being able to wear the clothes I want, putting my toothbrush under the [tap], not having people gawk at me wherever I go, knowing the local language” (B-12-7). Part of the issue in both countries was not being able to use their cell phones and not having instant access to the internet which may have created a sense of loss of personal connections with family and friends. The language barrier, the second subtheme, frustrated the students in both countries. For a couple of seconds I'm like, living here [the Netherlands] would be so easy, I already feel like a citizen and then every time I walk into [the grocery store] my dreams are shattered as I struggle to even pronounce what I'm possibly reading about a very questionable meal that I later find surprise ingredients in that may or may not be a foreign animal (N-14-5). I have never talked to someone who didn't speak my language. I felt embarrassed and awkward (B-136). It frustrated me personally seeing a room full of [lay health] workers who benefit so many communities by teaching, and me being unable to do the same, because of a language barrier (B-13-10). In the Netherlands, we toured the government buildings in The Hague. The tour was in Dutch and we had audioguides in English. The guide would speak in Dutch, telling stories, the group would laugh and the students looked at one another. As one student stated. I felt isolated not being able to understand the tour and a lot of personal communication. The American people tend to feel entitled and expect to be catered to. By not being able to hear what everyone else was hearing, I felt disadvantaged and alienated. Intentional or unintentional, it was a great exercise and I will be cognizant of this from now on (N-15-8). The final subtheme is myself as the foreigner. The students made comments on the overall learning that took place while they were abroad. The students began to understand and empathize with immigrants/refugees to the US.
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It's hard for me to think of life back home and how unfriendly and unwelcoming people are, especially toward foreigners. It makes me want to do more to help the refugees and immigrants in the US. It showed me just how difficult it must be for them whether it's buying groceries, catching a bus, finding a job etc.” (B-12-1). Today the tour guide spoke in Dutch a lot and would only speak to us in English a little every once in a while …. We compared the experience and feelings we had today with how it must feel for foreigners or refugees moving to our country – and they don't even get little headsets to walk around with in their native language! (N-15-2).
5.6. Comprehensive Understanding All of the nursing students in this study were in their final semester of a four year baccalaureate program, looking forward to graduation and employment. The naïve understanding and structural analysis revealed that, no matter where these students travelled, they increased their understanding of public health nursing and their cultural consciousness. Similar to the work of Thompson et al. (2000), the students in this study learned much about themselves as American nursing students in the global context. They made judgments about the country they visited as well as their own. The students in our study were affected by the poverty they witnessed, so much so that when they returned home, several of them gave away many of their possessions as they felt they had too much. Discussions about the hidden poverty in the United States needs to occur where “approximately 1 in 5 children live below the official federal poverty level and almost 1 in 2 are poor or near poor” (Dreyer et al., 2016, p. S1). There was no commensurate reaction from the students who went to the Netherlands. Does this mean that the students in the Netherlands group did not learn as much? They did note how nice it was that most stores and shops were closed by five o'clock in the afternoon most days of the week which gave families time to be together. We do believe that these students too, had a transformative experience albeit differently. The students who went to the Netherlands did increase their “awareness of socioeconomic relations, structural oppression, and human connectedness” (Foronda and Belknap, 2012, p. 157) even though they travelled to a HIC. The comparison of health insurance costs and the basic right of everyone to health care was an eyeopening one. In discussion with hospital staff, health insurance in the Netherlands was 60 euros (about $70 US) compared to one student's brother who paid $600 a month. Learning about human trafficking prior to visiting the Red Light District in Amsterdam raised their awareness of oppression. In fact, students had wanted to hold up signs to the women in the windows to ask if they felt safe. As Greatrex-White (2008) states “we can learn through new experience to expect people to behave differently [from us]. The crux is that we need to acquire the experiences that will bring about this change” (p. 536). The results of this study suggest that all of the students changed their world view and developed their cultural consciousness no matter if they travelled to a LIC or a HIC. In both socio-economic situations, they experienced being ‘the other’, how language barriers affected them, and how culture in general, defines who we are and how we act. Similar to Greatrex-White (2008) the “uncovering of study abroad as ‘foreigner’ although sometimes accepted is often underestimated: the influence it exerts…profoundly affects cultural perspectives” (p. 537). Structuring the learning experiences to address the various public health nursing concepts as well as providing prompts for the reflective journaling was essential to the enhancement of cultural consciousness. We need to determine the true reason to travel to a LIC. Woolf (2013) has termed the travel to LICs as “a new orthodoxy … built out of a misplaced and sometimes condescending enthusiasm for regions and nations in the developing world that are seen through a Western lens as ‘exotic’ others” (p. 1). He calls this ‘politics-and-poverty tourism’. Study in these countries should be based on partnership principles,
benefitting both countries; activities should be part of local integrated and sustainable initiatives. Perhaps, as Kushner (2016) states “the first step toward making the world a better place is to simply experience that place” (p. 4/5). It takes considerable reflection to realize that effective change requires time and understanding. Students need to become the ‘other’, a stranger in a strange land. Future research can investigate revising curricula to create ‘change from the familiar’ experiences for all students, rather than a select few, as many cannot afford study abroad. To facilitate the move to cultural consciousness on their journey to cultural competency that may improve client health outcomes, Fischer (2015) argues, this may mean not crossing national borders at all. It is often possible to be the ‘other’ in your own country. Additional research is also needed to support the findings from this study. 6. Conclusion This study adds to the sparse literature that compares student cultural learning between a LIC and a HIC. Cultural consciousness changes regardless of where students travel. They reflected not only on their experience of being abroad but also on what that meant to professional identity. They experienced what it is like to be a stranger. Nurse educators need to develop the course objectives first, and determine the reason for travel to a specific country. We need to ask ourselves if ‘place’ truly matters to meet course objectives. This study supports that travel in any country can develop cultural consciousness. As one of the students stated: I have been a foreigner and therefore have a greater, although incomplete, understanding of what it is like for someone who is in that position. Because of this, I believe I will be able to perform better culturally sensitive care than I would have before this experience (N15-10).
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