The impact of short term clinical placement in a developing country on nursing students_ A qualitative descriptive study
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Nurse Education Today
journal homepage: www.elsevier.com/locate/nedt
The impact of short term clinical placement in a developing country on
nursing students: A qualitative descriptive study
Ingeborg Ulvund⁎, Elin Mordal
Molde University College, Specialized University in Logistics, Bj. Bjørnsonsvei 100B, 6410 Molde, Norway
A R T I C L E I N F O
Keywords:
Cultural competency
International clinical placement
Nursing students
Developing country
A B S T R A C T
Background: Offering nursing students' international clinical placement during the educational program is one
esponse to meet the need of cultural competence among nurses. This paper provides insight into the impact of
clinical placement, in a developing country, on third year nursing students. In the study we investigated how
short term international clinical placement impacted Norwegian nursing students' development of cultural
competency.
Design and Methods: In this study we utilised a qualitative descriptive design and used individual interviews with
eighteen Norwegian nursing students who had all participated in an international clinical placement. The data
were analysed using the principles of systematic text condensation.
Results: In spite the international clinical placement only was four weeks, the findings suggested that real life
experience culturally awakened the students and forced an ongoing process developing cultural competence.
However, it is important to give students time to reflection.
Conclusions: Although increased cultural awareness and a growing cultural competence was identified by the
students undertaking international clinical placement, further research is required. It is important to investigate
the best methods to support the students' reflection such that the experiences lead to learning.
1. Introduction
Immigration and the growth of multicultural societies highlight the
need for cultural competence in healthcare. The lack of this competence
may cause deficits in practice and hinder nurses from providing quality
nursing. One strategy for developing cultural competence in nursing is
to offer nursing students international clinical placements (ICPs)
(Browne et al., 2015; Kokko, 2011; Long, 2014; Taylor et al., 2011).
Different models of ICPs have been used within undergraduate nursing
programs, and there is a need for research on international experiences
in nurse education (Alpers and Hanssen, 2014; Kokko, 2011; Taylo
et al., 2011).
Cultural competence is a set of congruent behaviours, attitudes and
policies that enable professionals to work effectively in cross-cultural
situations. A variety of theoretical models define and explain how
professionals develop cultural competence (Campinha-Bacote, 2002;
Leininger, 2002; Taylor et al., XXXXXXXXXXAfter analysing the data, we
decided to base the cu
ent study on Papadopoulus, Tilki and Taylor's
Model for Developing Cultural Competence (PTT model)
(Papadopoulos and Lees, 2002).
In the PTT model cultural competence is acknowledged as an
ongoing process and includes four stages. The first stage, cultural
awareness, is an awareness of one's own cultural background and
cultural identity and begins with an examination of one's own culture,
personal value base and beliefs. By becoming aware of one's own norms
and values, one becomes aware of preconceived attitudes and pre-
judices. Cultural awareness must be supplemented with the second
stage, cultural knowledge. Meaningful contact with people from different
ethnic groups and theoretical studies can enhance one's knowledge of
the health beliefs and behaviours of different groups and provide a
etter understanding of the problems faced by different cultural groups.
The third stage, cultural sensitivity, enhances the development of
interpersonal skills with regard to working with people from different
cultures. Important elements are empathy, solidarity, trust, acceptance
and respect. Clients must be considered true partners, if nurses are
culturally sensitive. The fourth stage, cultural competence, represents the
synthesis of the preceding stages. This stage requires the application of
previously developed awareness, knowledge, sensitivity and culturally
appropriate caring skills (Papadopoulos, XXXXXXXXXXCulturally competent
nurses must develop both culture-specific and culture-generic compe-
tence. Culture-specific competence is defined as the knowledge and
skills related to a specific ethnic group that enables the nurse to
http:
dx.doi.org/10.1016/j.nedt XXXXXXXXXX
Received 3 June 2016; Received in revised form 20 April 2017; Accepted 15 May 2017
⁎ Co
esponding author.
E-mail addresses: XXXXXXXXXX (I. Ulvund), XXXXXXXXXX (E. Mordal).
Nurse Education Today XXXXXXXXXX–100
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understand the values and cultural prescriptions within that specific
culture. Culture-generic competence is defined as the knowledge and
skills that are applicable across ethnic groups (Ge
ish and
Papadopoulos, 1999).
The literature primarily describes ICP as a beneficial teaching and
learning method for developing cultural competency in nurses. As
shown in empirical studies, international experiences increase the
students' understanding of the complex dynamics of culture and nursing
in foreign cultures (Bohman and Borglin, 2014, Kohl
y, 2016, Reid-
Searl et al., XXXXXXXXXXStudents have evaluated the impact of ICPs on thei
personal and professional development beyond what they might have
learned in a theoretical way (Bohman and Borglin, 2014; Edgecombe
et al., 2013; Kokko, XXXXXXXXXXA systematic thematic synthesis of the
literature identified five primary impacts of ICPs within nursing: 1)
developing cultural awareness and competence, 2) providing a global
perspective on health care, 3) growing personally, 4) moving theory
into practice and 5) successfully meeting challenges (Browne et al.,
2015). These findings are consistent with other studies (Kokko, 2011;
Long, 2014; Taylor et al., XXXXXXXXXXThere are risks associated with ICPs
(Egenes, 2012, Hovland and Johannessen, 2015, Morgan, 2012, Reid-
Searl et al., XXXXXXXXXXSeveral studies emphasize the importance of
ensuring that differences do not lead to ethnocentric attitudes
(Hovland and Johannessen, 2015; Reid-Searl et al., XXXXXXXXXXThe litera-
ture proposes guided and shared reflection of the experience in a
foreign country to avoid ethnocentric attitudes (Kohl
y, 2016; Kokko,
2011).
According to the literature, it is a need for research on the methods
nursing students use to develop cultural competency and the benefits
and challenges involved in their participation in ICPs (Kokko, 2011;
Browne et al., XXXXXXXXXXThe objectives of the cu
ent study was to
investigate how short-term international clinical placement impacted
Norwegian nursing students' development of cultural competency.
2. Methods
This study utilised a qualitative descriptive design and was based on
eighteen individual interviews of nursing students who have all
participated in an ICP in Ethiopia (Malterud, 2001, XXXXXXXXXXUtilised a
qualitative descriptive design, provided us with the ability to analyse
complex textual descriptions of how an experience is understood from
the perspectives of the participants and we used a semi-structured
interview guide to explore the nursing students' experiences and the
meaning they attributed to the ICP (Malterud, 2001, 2012; Patton,
2015).
2.1. Setting
Ethiopia is one of the poorest countries in the world; more than 80%
of the population lives in rural areas. According to the UN, 30% of
Ethiopia's population lives below the national poverty line, 35% are
malnourished, and the infant mortality rate is 64 per 1,000 live births.
Life expectancy is 60 years, and 39% of the population is illiterate
(Globalis, 2015).
Once a year, a group of six students from the Norwegian University
College Bachelor's Programme in Nursing spend four weeks in an ICP in
Ethiopia during their final semester. Prior to travel, the students
complete their theoretical studies in reproductive health, paediatrics,
global health challenges, and knowledge of the culture, population and
health systems in Ethiopia.
The clinical placement is organized to provide a wide range of
cultural encounters for the students and includes Ethiopian students
and staff, patients and their relatives, and women and children living in
ural areas. During the first three weeks, the students' are placed in
clinics in a hospital, in a maternity ward and in a children's ward. The
School of Nursing and Midwifery at the university is responsible for the
programme and classes. During the final week, a voluntary organization
provides students an opportunity to learn about the everyday life and
the common health challenges of women and children in underserved
ural areas. Supervised by nurses from the voluntary organization, the
students participate in a health promotion programme targeted to those
women.
English is spoken at the hospitals and universities in Ethiopia. Both
Ethiopian nurses and Norwegian students speak English as a second
language. In Ethiopia, there are many different languages, and many
inhabitants do not speak either English or the official language
Amharic. Nurses at the hospital translate for the nursing students.
When students participate in health programmes in rural areas, they use
interpreters to communicate with the local women and children.
2.2. Participants
The target population of this study was undergraduate nursing
students who experienced four weeks of clinical placement in Ethiopia.
All students who participated in the exchange programme from 2012 to
2014 received a letter of invitation that explained the study and a
consent form. All 18 students who were enrolled in this ICP participated
in this study and were interviewed 3 months after the ICP.
2.3. Data Collection
The first author conducted semi-structured interviews with the
students. The interview occu
ed three months after the students
a
ived home. During the interview, the informants were encouraged
to reflect on their learning outcomes and experiences during the ICP.
The semi-structured interview guide encouraged the students to speak
openly regarding their experiences. The interviewers' intention was to
elicit the informants' own opinions and explanations as much as
possible and then ask follow-up questions. The interviews lasted
25–60 min and were digitally recorded.
2.4. Data Analysis
All interviews were transcribed ve
atim. The analysis followed the
principles of the four phases of Malterud's systematic text condensation
(Malterud, 2001, 2011, XXXXXXXXXXIn the first step, we obtained an overall
impression of the data. By listening to audio files and reading the text,
we extracted some preliminary themes from the data that could
illuminate the research question. In the second step the coding started.
Coding includes identifying, classifying, and sorting themes in meaning
units related to the previously negotiated themes and implies decon-
textualization and temporarily removing parts of the text. The third
step implies a systematic abstraction of meaning. We reduced the data
to a decontextualized selection of meaning units sorted across indivi-
dual participants. The fourth and final step represents the “contextua-
lization” and synthesis. Follow Malterud it includes a summary in the
form of retellings, and conveys loyalty towards the informants' voices
(Malterud, 2011, XXXXXXXXXXBoth authors participated in all steps of the
analysis process to increase validity. First, the researchers separately
analysed the interviews, and then meaning units and codes were
discussed until a consensus