- Email: [email protected]
Teaching and learning about culture: A European journey
Nurse Education Today (2005) 25, 398–404
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Teaching and learning about culture: A European journey Peter Wimpenny *, Barry Gault, Vivienne MacLennan, Lesley Boast-Bowen, Patricia Shepherd School of Nursing and Midwifery, The Robert Gordon University, Garthdee Road, Garthdee, Aberdeen AB10 7QG, United Kingdom Accepted 15 March 2005
KEYWORDS
Summary This paper explores the evolving nature of an understanding of culture through attendance on an Intensive Programme (IP) funded by ERASMUS–SOCRATES. Aims: The purpose of this paper is to report a journey of learning about culture through attendance on a ERASMUS–SOCRATES funded Intensive Programme (IP) for nurses in Hasselt, Belgium. Method: This paper seeks to describe the process and experience of our involvement through an examination of the authors’ participation as teachers and students. This was undertaken using serial taped group and individual interviews. The metaphor of the IP as a journey is described and used as the vehicle for data collection and analysis. Findings: The key findings were the development of key themes relating to: Personal Values and Culture, Engagement and Culture, Personality and Culture and Physicality and Culture. Discussion of these findings raises issues of language and language skill, communication and listening skills, stereotyping, personal awareness, cultural awareness, sensitivity and competence. Conclusions: It is proposed that direct engagement through programmes, such as the reported IP, with other nurses and nurse educationalists in Europe is an essential part of any modern nursing curriculum and aids the development of internationalisation. Without such direct engagement there is potential for a narrower, limited view of culture and a lack of sensitivity in understanding our own and other cultures. c 2005 Elsevier Ltd. All rights reserved.
Europe; Culture; Cultural awareness; Nursing education
* Corresponding author. Tel.: +44 1224 262650; fax: +44 1224 262630. E-mail address: [email protected] (P. Wimpenny).
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.03.009
Teaching and learning about culture: A European journey
Introduction Background Developing a greater understanding of cultural issues in nursing and health care education is imperative due to increasing diversity and mobility. The likelihood of caring for people from other cultures is highly probable for all nurses and also working outside national boundaries, particularly within the EU, a possibility based on the free movement of labour. In addition Gilroy (1997) uses the term ‘diaspora’ to illuminate the modern tendency towards forced dispersal and reluctant scattering of populations resulting from such forces as war, ethnic cleansing and political repression. Polaschek (1998) believes that a concept of cultural safety is required to ensure that nursing delivers a service, which does not diminish, demean or disempower the cultural identity and well being of an individual. In Scotland, a small scale qualitative study has indicated the need for adaptation and development of nursing education curricula to promote knowledge and understanding regarding the experience of patients from diverse cultures, and advocates an approach which engages people from a range of backgrounds in the learning process (Leishman, 2004). As Canales and Bowers (2001) highlight, practicing with ‘‘cultural competence’’ is an essential and core requisite for nursing and nursing education. However, they indicate that there is little available on how to teach cultural diversity and competence and also how to evaluate such learning. This difficulty is echoed in earlier work by McGee (1992), although she does provide strategies for curriculum building and teaching. One key aspect that McGee does raise in this work is the distinction between understanding other cultures and developing a greater understanding of one’s own cultural attitudes, values and beliefs. When this is considered in a European context it may be that similar western health care attitudes, values and beliefs apply and differences in nursing care may be less than similarities (Tadd, 2004). However, this reported Intensive Programme was attempting to introduce students and teachers to these differences and similarities, whilst at the same time asking the question of how we care for people from other cultural groups. As Duffy (2001) highlights such programmes are essential in a world where culture is constantly shifting and changing (Leininger, 2001). This paper reports on a SOCRATES funded Intensive Programme (IP) undertaken in Hasselt,
399
Belgium from 16th to 29th March 2003 and entitled; Cultures in European Nursing. The programme was attended by teachers and students from nine European countries: Sweden, Italy, Netherlands, Belgium, Finland, Spain, Czech Republic, Turkey and Scotland. The focus for the IP was ‘‘Cultures in European Nursing’’. The programme was organised through the European Network of Nurse Educators (ENNE). SOCRATES has for many years funded student and teacher exchange in higher education and a range of other activities including Intensive Programmes (IP). (www.europa.eu.int/comm/education/erasmus. html). Although small in number there have been reports of nursing related activity undertaken through SOCRATES; from student and teacher exchange (Lee, 1998; Koskinen and Tossavainen, 2003), Intensive Programmes (Kotzabassaki et al., 2003) to the development of European nursing modules (Watt et al., 2002). One factor which connects all the activities in nursing is that of culture and cultural diversity. The intention is to describe our own journey (Benner-Carson, 2000) of discovery as participants in a programme which involved encounters with other cultures, and to consider whether the themes that emerged could be used as a road map or metaphor for the wider encounter between particular cultural groups and nurses. At this point the aim of this paper is not to be prescriptive about the manner in which culture is taught and learned about; it is rather to examine a number of themes that arose during a particular course, and to speculate as to their wider relevance, particularly in terms of personal and professional transformation (Duffy, 2001).
The structure of the IP The IP was structured around a series of tasks which had been sent to each participating institution prior to the programme. These tasks covered: introductions and setting objectives; describing a typical and migrant family; presenting issues around becoming a nurse, particularly if they were a migrant to that country; what happens when a health problem occurs; and what happens if the family needs care for an elderly person? The process for the IP was: Three groups containing a mixture of nationalities of both teachers and students in which all the tasks were discussed and contrasted.
400 Clinical visits to support the perspective of Cultures in European Nursing. These were undertaken to hospital, nursing homes and community settings. Social aspects to encourage group process and understand the social and political life of Belgium as our host. Students from each group had to make a presentation to summarise and evaluate their experiences.
Method Tape recorded group meetings of the journey: at the start of the educational process whilst still ‘‘at home’’ (Int 1), at the commencement of the IP (Int 2), midway through (Int 3) and end of the IP itself on the return journey home (Int 4). The process attempted to mirror the metaphor of the journey with all participants as fellow ‘‘travellers’’ (Kvale, 1996) and the interviews themselves informal (Chenitz and Swanson, 1986). In addition individual interviews lasting for approximately 45 minutes were carried out with the three students within three weeks of returning home (Int 5, 6 and 7). The group interviews lasted for approximately 30–45 min and commenced with an opening question about how we felt at that time and developed from this. Often issues from previous group meetings were raised and discussed further at subsequent meetings. Such on-going linkages between interviews can be valuable (Seidman, 1991). Analysis of the tapes was undertaken by PW and BG through an iterative process of repeated listening and noting of significant statements (Denzin and Lincoln, 1998). The narrative created from interpretations, themes and factual data from the programme were then shared with LB, VMcL and PS and discussed as a group. Such an approach can be a means by which the authenticity and trustworthiness of findings in qualitative research are endorsed (Guba and Lincoln, 1989).
Findings The journey From the beginning of this IP we considered that it was a journey. Firstly, because it took place in another country, and therefore demanded a physical journey and secondly it involved engagement with other cultures and was a journey of personal and
P. Wimpenny et al. professional discovery. This metaphor surfaced throughout the preparation, undertaking and return periods of the IP. The preparation period or ‘‘starting out’’ brought with it a personal review of the present nursing curriculum and the identification that overt content covering cultural diversity and competence were not strong in the main undergraduate programme in the School. This was reinforced at the end of the IP when such content was considered as essential to our own curriculum. However, it was considered that learning about other cultures should not be a passive process and it should be active rather than academic. The experience of all of the authors validated the power of the central metaphor of a journey (Benner-Carson, 2000). ‘‘Making the physical journey – it started the journey for me’’ (Int 2) In both teaching and learning about culture the key point is that the journey never reaches an end point. Our perception of present experience is always coloured by the experience of what has gone before, and there are always new points on the horizon to journey towards. This may seem to be a commonplace, but like Leininger (2001) the authors would seek to dispel the notion that practitioners can ever say that they have reached a point of knowing enough about the culture of their patients/clients. It is a requirement of a people based, inside culture approach, that the development of cultural knowledge continues to be both a dynamic and an interactive process. The journey through the Intensive Programme illuminated this process. Some key themes were identified from the group and individual data: Physicality and culture. Personal values and culture. Engagement and culture. Personality and culture.
Physicality and culture The three students (LB, VMcL PS) gathered material about the Scottish culture to take with them, including overt cultural symbols of Scotland such as tartan, salmon, whisky, haggis, oatcakes, shortbread, Edinburgh rock and porridge! However, collecting such artefacts raised awareness of the question, how do we show our culture to others? What do we take? Even at this stage it was already being recognised that you are ‘‘bringing your own culture with you’’ (Int 1) and that culture was not something that could be solely represented in symbols but was also part of our own ‘‘personal
Teaching and learning about culture: A European journey value systems, and that is why it’s difficult to take on new cultures’’ (Int 1). Physical differences were apparent on reaching Hasselt. Noticing physical surroundings: ‘‘what we take for granted’’, normality (our own and others), everyday life and objects. For example, there was table beer at lunch time, it is weak and considered as far as could be ascertained a ‘‘normal’’ part of Belgium lunch times. Our own cultural overlay was startled by having this available at lunch time. We reflected that we seem to have an issue about alcohol in Scotland that would prohibit this, as alcohol = drunkenness. We noticed the light switches, the food at breakfast time, the lack of privacy for men’s toilets, the art and architecture. As the IP progressed we began to ‘‘get used to the physical space and stopped noticing these things’’ (Int 3). It was also the case that aspects of health care were noted, such as the hospital we visited in the Netherlands which incorporated art into the building (a Dutch requirement for public buildings). Whilst not an unusual feature of hospitals in the UK it was the manner in which it was incorporated through sculpture, poetry and pictures. ‘‘I felt if I was working on the ward I could buy nice things to eat – walk through the art and then you could go and study – why aren’t all hospitals built like that?’’ (Int 4) However, the physical nature of hospitals, even though in a different country, did not give sufficient indication on the care in that culture. We considered the building as a reflection of the care, for example a large hospital/nursing home for those with Dementia created discussion of ‘‘large institutions’’ (Int 3) and how we now consider that this is not appropriate and how it ‘‘makes you question your practice’’ (Int 3). The considerable workshop space in the mental health hospital challenged our views on ‘‘work therapy’’ and mental health.
Personal values and culture In explaining to others about family life, health care and health problems it was inevitable that some personal values in respect of these were exhibited by all participants. This mixture of personal values about our own worlds and listening actively to others created a situation where we were always ‘‘readjusting and sifting and sorting’’ (Int 5), personal and professional perspectives. Without previous exposure one of us noted that they ‘‘felt quite ignorant about the different countries’’ (Int 6) and the engagement at a per-
401
sonal level within the groups revealed many similarities and differences. However, in post IP discussions it was appreciated that the key learning was that we ‘‘wouldn’t be able to take on the world view but could get an insight’’ (Int 6). This was illustrated in a visit to a community health care group where nurses had devised practical ways of relating to the local Turkish/Muslim community. They had prepared a list of key words to use with clients and often attended ‘‘coffee mornings’’ and other local community events to establish insight. This seemed to work well without infringing or demanding change to their personal values in both cultures. A local hospital had a well developed programme for supporting immigrants, using ‘I’-workers. These ‘I’-workers had language and cultural understanding and became part of the multidisciplinary team for an immigrant admitted to hospital. However, reaching some understanding of other cultures through engagement of the self could leave us ‘‘feeling vulnerable without the normal cultural supports’’ (Int 5) we would be used to being ‘‘at home’’. It was suggested that we needed to lose some of these supports and therefore go away ‘‘from home’’ before we could learn. The metaphor of the journey remains a strong influence as both physical, personal and professional movement were undertaken. Prior to and after the IP the Johari window (Luft, 1969) was mentioned as a way of explaining this opening out of our personal selves into these unknown areas. But we also examined the nature of our engagement with others and noted that we ‘‘. . .didn’t get on with everybody’’ (Int 7) it wasn’t just a cultural thing, there was a personal/self component operating within the cultural surround.
Engagement and culture Language, listening actively and responding appropriately, was a major issue for engagement with others. We joked that we were learning Finnish English, Turkish English, etc. ‘‘We had to listen very carefully’’ (Int 2) as though we hadn’t done this before when engaged with others in our own institutions/health care settings. The activity of listening was, to our surprise, tiring. Engagement was not passive. We experienced immersion in group work through the tasks. It was easier to ask for clarification, as you could not make assumptions about meanings. Engagement with other cultures reinforced that we ‘‘can’t assume’’ (Int 4) in whatever situation we are in. ‘‘You take things for granted’’
402 (Int 6) when in your own culture and meeting other cultures raises questions about own meanings. One participant ‘‘had been told that English people weren’t very helpful in terms of learning their language’’ (Int 2) and was surprised to find us helpful when she engaged with us. Cultural stereotypes were operating for all of us.
Personality and culture Personality and culture illuminated, for us, the differentiation between the person and the culture. Is there a Scottish personality or a Swedish personality, where are the boundaries? This led to the exploration of stereotypes: were the Finns quieter, the Italians late for sessions, the Belgians organised and punctual? (Int 3) Did we notice these individual traits more because of their nationality? The question arose of ‘‘What are the boundaries between personality and culture?’’ (Int 3). At the outset we had considered that we would be ‘‘Bringing our own culture with us’’ (Int 1). We were focused on the physicality of culture but reached the conclusion that ‘‘culture is what you are’’ (Int 4). One of the students suggested that the groups were like Russian Dolls. At the centre was the person, around that person was their own national group, then the multinational group, the teachers group, the student group. The person was central to this and shifted between groups. At first there was safety in the national group but as the IP progressed the groups or the student or teacher groups became more active. The ease of shifting between groups seemed to depend on the person, rather than their nationality.
Discussion The importance for all the authors of the personal experience of physicality shows that learning about culture always takes place within a context. Theoretically, this has been well represented by Thompson (1993) whose model utilises three levels of analysis, Personal, Cultural and Structural which are interlinked, and constantly interact with one another. However, if we are to get beyond an ‘‘additive’’ approach to the web of social relations (Dominelli, 2002) then we must acknowledge the complexity within which the IP was taking place. In their teaching around the issue of communication BG and PW had often emphasised the importance of ‘‘active listening’’; but the emotional engagement and fatigue derived in our view from a much wider context. Dominelli urges
P. Wimpenny et al. us to examine closely what we bring with us to interaction: In this they do not negotiate with one another as purely autonomous beings without a social context, but as contextualised beings who carry with them as an integral part of their being ontological realities such as skills, knowledge, values and social resources which they use in the hopes of influencing and changing their world (Dominelli p10, 2002). She goes on to describe alternative strategic responses which can be characterised as acceptance, accommodation and rejection. In order to do the necessary work and make a choice to resist stereotypical relationships with others the critique has to be informed by both individual and structural knowledge. This is all the more difficult because there is a temptation to work on the basis of a totalising and static view of cultural identity. The authors became aware of the necessity to avoid teaching programmes which promise to give students all the knowledge they require to enable them to understand (Belgian, Swedish, Scottish, etc.) culture. The impact of the IP rested both on an understanding of the history and development of the cultures represented, as well as an experience of face to face interaction, which gave staff and students the chance to understand how individuals working in the health service, situate themselves. The boundaries between the personal and the cultural levels were continually being patrolled during the fortnight, and only afterwards was it possible with the aid of hindsight to see how the intensity of engagement at a personal level, along with a concomitant feeling of vulnerability had led to some significant individual change and development. Despite the fact that we had set out on our journey armed with a commitment to explore cultural difference, it was thus small wonder that we brought with us from Scotland a discourse derived both from the media, and wider sources of influence which sought to locate our fellow participants within a simplistic and stereotypically derived context (Helman, 2000). The experience of taking part in the IP soon demolished this simplicity, as work within the groups led to personal contact and friendship across boundaries, nationalities and language. There was a grappling with the language idea that there were many versions of English. This range of ‘‘Englishes’’ didn’t initially fit to any prior understanding of native language, despite having a range of different regional variations within our own group. We failed, initially, to listen to what was being said and instead were concerned with how it
Teaching and learning about culture: A European journey was being said. Our own education and culture led us to compare our colleagues English to some ‘‘standard’’ form (Conteh-Morgan, 2001). Such an approach is consistent with cultural immersion and understandings of English as a spoken and written language (Decke-Cornhill, 2002). However, for collaborations like the IP we would suggest that there must be a valuing of other ‘‘Englishes’’ and not a conservative view based on linguistic purism. Furthermore, the need for active listening, as already suggested, is imperative so that words and meanings could be questioned and explored. Language teaching was, and possibly still is, inextricably bound with culture of the country. The same, it is assumed would be the case for our colleagues from across Europe where English would be taught with a cultural backdrop. However, this may not now be British English but a form of American English. The connection between our own personal identity, culture and language is an area of some debate, although Adams (2003) argues that we are bounded by our culture and language albeit not exhaustively. The room for manoeuvre and flexibility may be increasing as globalisation reshapes much of modern life. In the future we may see separation of language from culture and it may be that English becomes the Lingua Franca (Decke-Cornhill, 2002) of Europe. However, it would appear there is a tension in this proposal, for the EU whilst seeking such a common language for integration also supports multilingualism and diversity. Nursing benefits from sharing ideas, concepts, theories, and skills, which, adds to an internationalisation agenda. Having some common language for this is helpful, although the diversity and language of nurses from across Europe adds a richness that we would not achieve if we adopt a globalisation or ‘‘MacDonaldisation’’ (Risager, 2000) approach to developing nursing and nursing knowledge. English language could itself have been a barrier to learning on the Intensive Programme, as English as a Second Language (ESL) students and teachers may be reluctant to speak if the level of language skill was felt to be insufficient (Jackson, 2001). Development of relationships in small groups does allow students, who have English as a second language to feel more comfortable and to participate. In addition, for us, there was a feeling of frustration in our own inability to speak other languages, a factor affecting European collaborators at all levels (Marinker, 2002). Walford (1991) bemoans the level and scope of foreign language skills in the UK. It has, it might be assumed, worsened since 1991. Our experience suggests that those who enter nursing have limited language skills. Whilst we would, following this IP, argue that language is only
403
one aspect of developing cultural awareness and moving to cultural sensitivity (Lonergan, 2000) there is a concerning lack of language provision in schools and also language provision in Higher Education that should be addressed. Our meetings with colleagues in this European context allowed us to move on from our initial limited view to one where we began to listen to what was being said and analysed and interpreted this in the light of our own understandings. We were beginning, as Duffy (2001) highlights to move beyond the stereotypes and confronting our own cultural norms and also our own personal meanings. Whilst it cannot be claimed that this was transformative in the Mezirow (1990) life world transformation sense, it did change us all in some way. Perspectives on caring for other cultures and also an examination of our own cultural perspectives were heightened. Furthermore, the need to consider how culture is incorporated into the curriculum in an attempt to prepare nurses for caring for patients and clients from other cultures was discussed. The consideration of whether we are preparing nurses to practice within national frames of reference is a moot point and one not readily addressed by national bodies (NHS Education for Scotland, 2004). It may be wholly appropriate that such bodies focus on local and national perspectives, as standards for nursing education are important in this context. However, it may also be possible and most valuable to consider how internationalisation of nursing curricula can be achieved through incorporation of cultural awareness and cultural sensitivity. There is, we believe, a need to prepare students to work in an increasingly international society and workplace (Ka ¨lvermark, 1997). Although, as Duffy (2001) has pointed out, this needs to be undertaken through personal engagement with others through international experiences involving risk and self-reflection, rather than just teaching ‘‘monolithic descriptions’’ of other cultures. This paper has attempted, in an introspective manner, to report on the impact of such engagement. In addition the presentation about the use of I workers as cultural intermediaries in a palliative care programme in Belgium showed that it is not enough to study culture as an ‘add on’ or option, it needs to be an integral part of education and practice.
Conclusion The overall effect of this very intensive experience was to convince all the authors of the centrality of
404 the importance of learning about culture. Working together with other European teachers and students learning about both individual and institutional development has led to the belief that teaching and learning about culture is central to the development of modern and relevant practice in a multicultural world. Schools of Nursing and Midwifery in the UK need to consider how they can facilitate such face to face exchange within their programmes through joining intensive programmes, thematic networks and exchange agreements.
References Adams, M., 2003. The reflexive self and culture: a critique. British Journal of Sociology 54 (2), 221–238. Benner-Carson, V., 2000. Mental Health Nursing: the Nurse– patient Journey. WB Saunders, London. Canales, M.K., Bowers, B.J., 2001. Expanding conceptualizations of culturally competent care. Journal of Advanced Nursing 36 (1), 102–111. Chenitz, C.W., Swanson, J.M., 1986. From Practice to Grounded Theory: Qualitative Research in Nursing. Addison Wesley, Menlo Park, CA. Conteh-Morgan, M., 2001. (M)other tongue: a selected annotated bibliography of world ‘‘Englishes’’. Collection Building 20 (2), 73–79. Decke-Cornhill, H., 2002. We would have to invent the language we are supposed to teach: the issue of English as Lingua Franca in language education in Germany. Language, Culture and Curriculum 15 (3), 251–263. Denzin, N.K., Lincoln, Y.S. (Eds.), 1998. Collecting and Interpreting Qualitative Materials. Sage, Thousand Oaks. Dominelli, L., 2002. Anti-oppressive Social Work. Theory and Practice. Palgrove MacMillan, Basingstoke. Duffy, M.E., 2001. A critique of cultural education in nursing. Journal of Advanced Nursing 36 (4), 487–495. Gilroy, P., 1997. Diaspora and the detours of identity. In: Woodward, K. (Ed.), Identity and Difference. Sage, London. Guba, E., Lincoln, Y., 1989. Fourth Generation Evaluation. Sage Publications, Newbury Park, CA. Helman, C.G., 2000. Culture, Health and Illness. Butterworth Heinemann, Oxford. Jackson, J., 2001. Reticence in second language case discussions: anxiety and aspirations. System 30, 65–84. Ka ¨lvermark, T., van der Wende, M. (Eds.), 1997. National Policies for the Internationalisation of Higher Education in Europe. National Agency for Higher Education, Stockholm.
P. Wimpenny et al. Koskinen, L., Tossavainen, K., 2003. Relationships with undergraduate nursing exchange students – a tutor perspective. Journal of Advanced Nursing 41 (5), 499–508. Kotzabassaki, S., Alabaster, E.S., And, K., Larsson, U., deVree, W., 2003. Care of older people in nursing homes: an intensive programme as an educational activity within Erasmus– Socrates. Nurse Education Today 23 (2), 138–145. Kvale, S., 1996. Interviews: an Introduction to Qualitative Research Interviewing. Sage, Thousand Oaks, CA. Lee, N., 1998. What do they think of us? Perceptions of Nursing in England. European Nurse 3 (4), 238–243. Leininger, M.M., 2001. Culture Care Diversity and Universality: A Theory of Nursing. Jones and Bartlett Publishers, London. Leishman, J., 2004. Perspectives of cultural competence in health care. Nursing Standard 19 (11), 33–38. Lonergan, J., 2000. Graduateness, transferable skills and employability. In: King, A. (Ed.), Languages and the Transfer of Skills, The Relevance of Language Learning for 21st Century Graduates in the World of Work. Centre for Information on Language Teaching and Research, London (Chapter 15). Luft, J., 1969. Of Human Interactions. The Johari Model. Mayfield, Palo Alto. Marinker, M., 2002. Health Targets in Europe. Polity, Progress and Promise. BMJ Books, London. McGee, P., 1992. Teaching Transcultural Care. Chapman and Hall, London. Mezirow, J., 1990. Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. JosseyBass, San Francisco. NHS Education for Scotland, 2004. Themes and Issues 2002– 2004. Quality Assurance and Professional Regulation. NHS Education for Scotland, Edinburgh. Polaschek, N.R., 1998. Cultural safety: a new concept in nursing people of different ethnicities. Journal of Advanced Nursing 27 (3), 452–457. Risager, K., 2000. Globalisation and internationalisation: two conflicting discourses? Towards a multilingual, ethnically reflective intercultural competence. Internationalising vocational education and training in Europe: prelude to an overdue debate. In: Proceedings of the Conference on Internationalising Vocational Education and Training in Europe, Thessalonika, Greece, 25–27 May, 2000. CEDEFOP, Panorama Series. Seidman, I.E., 1991. Interviewing as Qualitative Research. Teachers College Press, NY. Tadd, Win (Ed.), 2004. Ethical and Professional Issues in Nursing, Perspectives from Europe. Palgrave MacMillan, Houndmills, Hampshire. Thompson, N., 1993. Anti Discriminatory Practice. MacMillan, Basingstoke. Walford, A.J. (Ed.), 1991. The Working Languages of the European Community. The Library Association, London. Watt, S., Law, K., Ots, U., Waag, K., 2002. Reflections across boundaries: the European nursing module. Journal of Transcultural Nursing 13 (4), 318–324.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Teaching and learning about culture: A European journey Peter Wimpenny *, Barry Gault, Vivienne MacLennan, Lesley Boast-Bowen, Patricia Shepherd School of Nursing and Midwifery, The Robert Gordon University, Garthdee Road, Garthdee, Aberdeen AB10 7QG, United Kingdom Accepted 15 March 2005
KEYWORDS
Summary This paper explores the evolving nature of an understanding of culture through attendance on an Intensive Programme (IP) funded by ERASMUS–SOCRATES. Aims: The purpose of this paper is to report a journey of learning about culture through attendance on a ERASMUS–SOCRATES funded Intensive Programme (IP) for nurses in Hasselt, Belgium. Method: This paper seeks to describe the process and experience of our involvement through an examination of the authors’ participation as teachers and students. This was undertaken using serial taped group and individual interviews. The metaphor of the IP as a journey is described and used as the vehicle for data collection and analysis. Findings: The key findings were the development of key themes relating to: Personal Values and Culture, Engagement and Culture, Personality and Culture and Physicality and Culture. Discussion of these findings raises issues of language and language skill, communication and listening skills, stereotyping, personal awareness, cultural awareness, sensitivity and competence. Conclusions: It is proposed that direct engagement through programmes, such as the reported IP, with other nurses and nurse educationalists in Europe is an essential part of any modern nursing curriculum and aids the development of internationalisation. Without such direct engagement there is potential for a narrower, limited view of culture and a lack of sensitivity in understanding our own and other cultures. c 2005 Elsevier Ltd. All rights reserved.
Europe; Culture; Cultural awareness; Nursing education
* Corresponding author. Tel.: +44 1224 262650; fax: +44 1224 262630. E-mail address: [email protected] (P. Wimpenny).
0260-6917/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2005.03.009
Teaching and learning about culture: A European journey
Introduction Background Developing a greater understanding of cultural issues in nursing and health care education is imperative due to increasing diversity and mobility. The likelihood of caring for people from other cultures is highly probable for all nurses and also working outside national boundaries, particularly within the EU, a possibility based on the free movement of labour. In addition Gilroy (1997) uses the term ‘diaspora’ to illuminate the modern tendency towards forced dispersal and reluctant scattering of populations resulting from such forces as war, ethnic cleansing and political repression. Polaschek (1998) believes that a concept of cultural safety is required to ensure that nursing delivers a service, which does not diminish, demean or disempower the cultural identity and well being of an individual. In Scotland, a small scale qualitative study has indicated the need for adaptation and development of nursing education curricula to promote knowledge and understanding regarding the experience of patients from diverse cultures, and advocates an approach which engages people from a range of backgrounds in the learning process (Leishman, 2004). As Canales and Bowers (2001) highlight, practicing with ‘‘cultural competence’’ is an essential and core requisite for nursing and nursing education. However, they indicate that there is little available on how to teach cultural diversity and competence and also how to evaluate such learning. This difficulty is echoed in earlier work by McGee (1992), although she does provide strategies for curriculum building and teaching. One key aspect that McGee does raise in this work is the distinction between understanding other cultures and developing a greater understanding of one’s own cultural attitudes, values and beliefs. When this is considered in a European context it may be that similar western health care attitudes, values and beliefs apply and differences in nursing care may be less than similarities (Tadd, 2004). However, this reported Intensive Programme was attempting to introduce students and teachers to these differences and similarities, whilst at the same time asking the question of how we care for people from other cultural groups. As Duffy (2001) highlights such programmes are essential in a world where culture is constantly shifting and changing (Leininger, 2001). This paper reports on a SOCRATES funded Intensive Programme (IP) undertaken in Hasselt,
399
Belgium from 16th to 29th March 2003 and entitled; Cultures in European Nursing. The programme was attended by teachers and students from nine European countries: Sweden, Italy, Netherlands, Belgium, Finland, Spain, Czech Republic, Turkey and Scotland. The focus for the IP was ‘‘Cultures in European Nursing’’. The programme was organised through the European Network of Nurse Educators (ENNE). SOCRATES has for many years funded student and teacher exchange in higher education and a range of other activities including Intensive Programmes (IP). (www.europa.eu.int/comm/education/erasmus. html). Although small in number there have been reports of nursing related activity undertaken through SOCRATES; from student and teacher exchange (Lee, 1998; Koskinen and Tossavainen, 2003), Intensive Programmes (Kotzabassaki et al., 2003) to the development of European nursing modules (Watt et al., 2002). One factor which connects all the activities in nursing is that of culture and cultural diversity. The intention is to describe our own journey (Benner-Carson, 2000) of discovery as participants in a programme which involved encounters with other cultures, and to consider whether the themes that emerged could be used as a road map or metaphor for the wider encounter between particular cultural groups and nurses. At this point the aim of this paper is not to be prescriptive about the manner in which culture is taught and learned about; it is rather to examine a number of themes that arose during a particular course, and to speculate as to their wider relevance, particularly in terms of personal and professional transformation (Duffy, 2001).
The structure of the IP The IP was structured around a series of tasks which had been sent to each participating institution prior to the programme. These tasks covered: introductions and setting objectives; describing a typical and migrant family; presenting issues around becoming a nurse, particularly if they were a migrant to that country; what happens when a health problem occurs; and what happens if the family needs care for an elderly person? The process for the IP was: Three groups containing a mixture of nationalities of both teachers and students in which all the tasks were discussed and contrasted.
400 Clinical visits to support the perspective of Cultures in European Nursing. These were undertaken to hospital, nursing homes and community settings. Social aspects to encourage group process and understand the social and political life of Belgium as our host. Students from each group had to make a presentation to summarise and evaluate their experiences.
Method Tape recorded group meetings of the journey: at the start of the educational process whilst still ‘‘at home’’ (Int 1), at the commencement of the IP (Int 2), midway through (Int 3) and end of the IP itself on the return journey home (Int 4). The process attempted to mirror the metaphor of the journey with all participants as fellow ‘‘travellers’’ (Kvale, 1996) and the interviews themselves informal (Chenitz and Swanson, 1986). In addition individual interviews lasting for approximately 45 minutes were carried out with the three students within three weeks of returning home (Int 5, 6 and 7). The group interviews lasted for approximately 30–45 min and commenced with an opening question about how we felt at that time and developed from this. Often issues from previous group meetings were raised and discussed further at subsequent meetings. Such on-going linkages between interviews can be valuable (Seidman, 1991). Analysis of the tapes was undertaken by PW and BG through an iterative process of repeated listening and noting of significant statements (Denzin and Lincoln, 1998). The narrative created from interpretations, themes and factual data from the programme were then shared with LB, VMcL and PS and discussed as a group. Such an approach can be a means by which the authenticity and trustworthiness of findings in qualitative research are endorsed (Guba and Lincoln, 1989).
Findings The journey From the beginning of this IP we considered that it was a journey. Firstly, because it took place in another country, and therefore demanded a physical journey and secondly it involved engagement with other cultures and was a journey of personal and
P. Wimpenny et al. professional discovery. This metaphor surfaced throughout the preparation, undertaking and return periods of the IP. The preparation period or ‘‘starting out’’ brought with it a personal review of the present nursing curriculum and the identification that overt content covering cultural diversity and competence were not strong in the main undergraduate programme in the School. This was reinforced at the end of the IP when such content was considered as essential to our own curriculum. However, it was considered that learning about other cultures should not be a passive process and it should be active rather than academic. The experience of all of the authors validated the power of the central metaphor of a journey (Benner-Carson, 2000). ‘‘Making the physical journey – it started the journey for me’’ (Int 2) In both teaching and learning about culture the key point is that the journey never reaches an end point. Our perception of present experience is always coloured by the experience of what has gone before, and there are always new points on the horizon to journey towards. This may seem to be a commonplace, but like Leininger (2001) the authors would seek to dispel the notion that practitioners can ever say that they have reached a point of knowing enough about the culture of their patients/clients. It is a requirement of a people based, inside culture approach, that the development of cultural knowledge continues to be both a dynamic and an interactive process. The journey through the Intensive Programme illuminated this process. Some key themes were identified from the group and individual data: Physicality and culture. Personal values and culture. Engagement and culture. Personality and culture.
Physicality and culture The three students (LB, VMcL PS) gathered material about the Scottish culture to take with them, including overt cultural symbols of Scotland such as tartan, salmon, whisky, haggis, oatcakes, shortbread, Edinburgh rock and porridge! However, collecting such artefacts raised awareness of the question, how do we show our culture to others? What do we take? Even at this stage it was already being recognised that you are ‘‘bringing your own culture with you’’ (Int 1) and that culture was not something that could be solely represented in symbols but was also part of our own ‘‘personal
Teaching and learning about culture: A European journey value systems, and that is why it’s difficult to take on new cultures’’ (Int 1). Physical differences were apparent on reaching Hasselt. Noticing physical surroundings: ‘‘what we take for granted’’, normality (our own and others), everyday life and objects. For example, there was table beer at lunch time, it is weak and considered as far as could be ascertained a ‘‘normal’’ part of Belgium lunch times. Our own cultural overlay was startled by having this available at lunch time. We reflected that we seem to have an issue about alcohol in Scotland that would prohibit this, as alcohol = drunkenness. We noticed the light switches, the food at breakfast time, the lack of privacy for men’s toilets, the art and architecture. As the IP progressed we began to ‘‘get used to the physical space and stopped noticing these things’’ (Int 3). It was also the case that aspects of health care were noted, such as the hospital we visited in the Netherlands which incorporated art into the building (a Dutch requirement for public buildings). Whilst not an unusual feature of hospitals in the UK it was the manner in which it was incorporated through sculpture, poetry and pictures. ‘‘I felt if I was working on the ward I could buy nice things to eat – walk through the art and then you could go and study – why aren’t all hospitals built like that?’’ (Int 4) However, the physical nature of hospitals, even though in a different country, did not give sufficient indication on the care in that culture. We considered the building as a reflection of the care, for example a large hospital/nursing home for those with Dementia created discussion of ‘‘large institutions’’ (Int 3) and how we now consider that this is not appropriate and how it ‘‘makes you question your practice’’ (Int 3). The considerable workshop space in the mental health hospital challenged our views on ‘‘work therapy’’ and mental health.
Personal values and culture In explaining to others about family life, health care and health problems it was inevitable that some personal values in respect of these were exhibited by all participants. This mixture of personal values about our own worlds and listening actively to others created a situation where we were always ‘‘readjusting and sifting and sorting’’ (Int 5), personal and professional perspectives. Without previous exposure one of us noted that they ‘‘felt quite ignorant about the different countries’’ (Int 6) and the engagement at a per-
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sonal level within the groups revealed many similarities and differences. However, in post IP discussions it was appreciated that the key learning was that we ‘‘wouldn’t be able to take on the world view but could get an insight’’ (Int 6). This was illustrated in a visit to a community health care group where nurses had devised practical ways of relating to the local Turkish/Muslim community. They had prepared a list of key words to use with clients and often attended ‘‘coffee mornings’’ and other local community events to establish insight. This seemed to work well without infringing or demanding change to their personal values in both cultures. A local hospital had a well developed programme for supporting immigrants, using ‘I’-workers. These ‘I’-workers had language and cultural understanding and became part of the multidisciplinary team for an immigrant admitted to hospital. However, reaching some understanding of other cultures through engagement of the self could leave us ‘‘feeling vulnerable without the normal cultural supports’’ (Int 5) we would be used to being ‘‘at home’’. It was suggested that we needed to lose some of these supports and therefore go away ‘‘from home’’ before we could learn. The metaphor of the journey remains a strong influence as both physical, personal and professional movement were undertaken. Prior to and after the IP the Johari window (Luft, 1969) was mentioned as a way of explaining this opening out of our personal selves into these unknown areas. But we also examined the nature of our engagement with others and noted that we ‘‘. . .didn’t get on with everybody’’ (Int 7) it wasn’t just a cultural thing, there was a personal/self component operating within the cultural surround.
Engagement and culture Language, listening actively and responding appropriately, was a major issue for engagement with others. We joked that we were learning Finnish English, Turkish English, etc. ‘‘We had to listen very carefully’’ (Int 2) as though we hadn’t done this before when engaged with others in our own institutions/health care settings. The activity of listening was, to our surprise, tiring. Engagement was not passive. We experienced immersion in group work through the tasks. It was easier to ask for clarification, as you could not make assumptions about meanings. Engagement with other cultures reinforced that we ‘‘can’t assume’’ (Int 4) in whatever situation we are in. ‘‘You take things for granted’’
402 (Int 6) when in your own culture and meeting other cultures raises questions about own meanings. One participant ‘‘had been told that English people weren’t very helpful in terms of learning their language’’ (Int 2) and was surprised to find us helpful when she engaged with us. Cultural stereotypes were operating for all of us.
Personality and culture Personality and culture illuminated, for us, the differentiation between the person and the culture. Is there a Scottish personality or a Swedish personality, where are the boundaries? This led to the exploration of stereotypes: were the Finns quieter, the Italians late for sessions, the Belgians organised and punctual? (Int 3) Did we notice these individual traits more because of their nationality? The question arose of ‘‘What are the boundaries between personality and culture?’’ (Int 3). At the outset we had considered that we would be ‘‘Bringing our own culture with us’’ (Int 1). We were focused on the physicality of culture but reached the conclusion that ‘‘culture is what you are’’ (Int 4). One of the students suggested that the groups were like Russian Dolls. At the centre was the person, around that person was their own national group, then the multinational group, the teachers group, the student group. The person was central to this and shifted between groups. At first there was safety in the national group but as the IP progressed the groups or the student or teacher groups became more active. The ease of shifting between groups seemed to depend on the person, rather than their nationality.
Discussion The importance for all the authors of the personal experience of physicality shows that learning about culture always takes place within a context. Theoretically, this has been well represented by Thompson (1993) whose model utilises three levels of analysis, Personal, Cultural and Structural which are interlinked, and constantly interact with one another. However, if we are to get beyond an ‘‘additive’’ approach to the web of social relations (Dominelli, 2002) then we must acknowledge the complexity within which the IP was taking place. In their teaching around the issue of communication BG and PW had often emphasised the importance of ‘‘active listening’’; but the emotional engagement and fatigue derived in our view from a much wider context. Dominelli urges
P. Wimpenny et al. us to examine closely what we bring with us to interaction: In this they do not negotiate with one another as purely autonomous beings without a social context, but as contextualised beings who carry with them as an integral part of their being ontological realities such as skills, knowledge, values and social resources which they use in the hopes of influencing and changing their world (Dominelli p10, 2002). She goes on to describe alternative strategic responses which can be characterised as acceptance, accommodation and rejection. In order to do the necessary work and make a choice to resist stereotypical relationships with others the critique has to be informed by both individual and structural knowledge. This is all the more difficult because there is a temptation to work on the basis of a totalising and static view of cultural identity. The authors became aware of the necessity to avoid teaching programmes which promise to give students all the knowledge they require to enable them to understand (Belgian, Swedish, Scottish, etc.) culture. The impact of the IP rested both on an understanding of the history and development of the cultures represented, as well as an experience of face to face interaction, which gave staff and students the chance to understand how individuals working in the health service, situate themselves. The boundaries between the personal and the cultural levels were continually being patrolled during the fortnight, and only afterwards was it possible with the aid of hindsight to see how the intensity of engagement at a personal level, along with a concomitant feeling of vulnerability had led to some significant individual change and development. Despite the fact that we had set out on our journey armed with a commitment to explore cultural difference, it was thus small wonder that we brought with us from Scotland a discourse derived both from the media, and wider sources of influence which sought to locate our fellow participants within a simplistic and stereotypically derived context (Helman, 2000). The experience of taking part in the IP soon demolished this simplicity, as work within the groups led to personal contact and friendship across boundaries, nationalities and language. There was a grappling with the language idea that there were many versions of English. This range of ‘‘Englishes’’ didn’t initially fit to any prior understanding of native language, despite having a range of different regional variations within our own group. We failed, initially, to listen to what was being said and instead were concerned with how it
Teaching and learning about culture: A European journey was being said. Our own education and culture led us to compare our colleagues English to some ‘‘standard’’ form (Conteh-Morgan, 2001). Such an approach is consistent with cultural immersion and understandings of English as a spoken and written language (Decke-Cornhill, 2002). However, for collaborations like the IP we would suggest that there must be a valuing of other ‘‘Englishes’’ and not a conservative view based on linguistic purism. Furthermore, the need for active listening, as already suggested, is imperative so that words and meanings could be questioned and explored. Language teaching was, and possibly still is, inextricably bound with culture of the country. The same, it is assumed would be the case for our colleagues from across Europe where English would be taught with a cultural backdrop. However, this may not now be British English but a form of American English. The connection between our own personal identity, culture and language is an area of some debate, although Adams (2003) argues that we are bounded by our culture and language albeit not exhaustively. The room for manoeuvre and flexibility may be increasing as globalisation reshapes much of modern life. In the future we may see separation of language from culture and it may be that English becomes the Lingua Franca (Decke-Cornhill, 2002) of Europe. However, it would appear there is a tension in this proposal, for the EU whilst seeking such a common language for integration also supports multilingualism and diversity. Nursing benefits from sharing ideas, concepts, theories, and skills, which, adds to an internationalisation agenda. Having some common language for this is helpful, although the diversity and language of nurses from across Europe adds a richness that we would not achieve if we adopt a globalisation or ‘‘MacDonaldisation’’ (Risager, 2000) approach to developing nursing and nursing knowledge. English language could itself have been a barrier to learning on the Intensive Programme, as English as a Second Language (ESL) students and teachers may be reluctant to speak if the level of language skill was felt to be insufficient (Jackson, 2001). Development of relationships in small groups does allow students, who have English as a second language to feel more comfortable and to participate. In addition, for us, there was a feeling of frustration in our own inability to speak other languages, a factor affecting European collaborators at all levels (Marinker, 2002). Walford (1991) bemoans the level and scope of foreign language skills in the UK. It has, it might be assumed, worsened since 1991. Our experience suggests that those who enter nursing have limited language skills. Whilst we would, following this IP, argue that language is only
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one aspect of developing cultural awareness and moving to cultural sensitivity (Lonergan, 2000) there is a concerning lack of language provision in schools and also language provision in Higher Education that should be addressed. Our meetings with colleagues in this European context allowed us to move on from our initial limited view to one where we began to listen to what was being said and analysed and interpreted this in the light of our own understandings. We were beginning, as Duffy (2001) highlights to move beyond the stereotypes and confronting our own cultural norms and also our own personal meanings. Whilst it cannot be claimed that this was transformative in the Mezirow (1990) life world transformation sense, it did change us all in some way. Perspectives on caring for other cultures and also an examination of our own cultural perspectives were heightened. Furthermore, the need to consider how culture is incorporated into the curriculum in an attempt to prepare nurses for caring for patients and clients from other cultures was discussed. The consideration of whether we are preparing nurses to practice within national frames of reference is a moot point and one not readily addressed by national bodies (NHS Education for Scotland, 2004). It may be wholly appropriate that such bodies focus on local and national perspectives, as standards for nursing education are important in this context. However, it may also be possible and most valuable to consider how internationalisation of nursing curricula can be achieved through incorporation of cultural awareness and cultural sensitivity. There is, we believe, a need to prepare students to work in an increasingly international society and workplace (Ka ¨lvermark, 1997). Although, as Duffy (2001) has pointed out, this needs to be undertaken through personal engagement with others through international experiences involving risk and self-reflection, rather than just teaching ‘‘monolithic descriptions’’ of other cultures. This paper has attempted, in an introspective manner, to report on the impact of such engagement. In addition the presentation about the use of I workers as cultural intermediaries in a palliative care programme in Belgium showed that it is not enough to study culture as an ‘add on’ or option, it needs to be an integral part of education and practice.
Conclusion The overall effect of this very intensive experience was to convince all the authors of the centrality of
404 the importance of learning about culture. Working together with other European teachers and students learning about both individual and institutional development has led to the belief that teaching and learning about culture is central to the development of modern and relevant practice in a multicultural world. Schools of Nursing and Midwifery in the UK need to consider how they can facilitate such face to face exchange within their programmes through joining intensive programmes, thematic networks and exchange agreements.
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