Practice supervision of minority language nursing students requires more time and adaptation

Nurses have a professional, ethical and personal responsibility for patients and their relatives (1) as well as responsibility for teaching and supervising nursing students (2). This can be particularly challenging when the students are minority language speakers, i.e. their mother tongue is not Norwegian. They often need additional support during work placements (3). With this in mind, our focus in this study is to direct attention to practice supervisors’ experiences of supervising minority language students in hospital work placements.

Nursing education is complex and the combination of theoretical knowledge and practical skills is particularly challenging for minority language students. They represent diversity but have in common that they speak two languages (3). It can take from five to eight years to acquire both linguistic and communicative competence, which constitutes a major challenge for many of them (3).

Education is an important goal for integration and it is challenging for educational institutions to differentiate individual supervision needs through good pedagogical programmes that are perceived as inspiring (4). The prerequisite must be that students have an understanding of the language that enables them to derive benefit from supervision.

We need minority language nurses

Norway has become a pluralistic society (5). According to Magelsen (6), there is a growing need to provide health assistance to minority groups. It is therefore important and valuable to educate nurses with a minority language background who can meet health challenges in Norwegian society (7). Research also confirms that such knowledge is important in order to better safeguard the health needs of minority groups (8–10).

Many minority language nursing students terminate their education before they graduate (11). According to Lauglo (12), social satisfaction and zest for life are lower among minority language nursing students than Norwegian students. In order to promote good integration processes, the programme of study must meet the needs of minority language students by adapting the study situation so that they complete their education and experience well-being and security (11, 13).

Practice supervisors must have intercultural skills

The national framework curriculum for the bachelor’s degree in nursing (14) states that practice supervisors should have pedagogical competence in order to assess the professional development of students. Supervisors who are to supervise minority language nursing students need to have special competence in intercultural knowledge (3). According to Boruff (11), both teachers and practice supervisors need to develop positive strategies and interventions that can conceivably influence minority language students to complete their education.

Fillingsnes and Thylén’s study (15) reveals that practice supervisors often feel professionally inadequate in their interaction with nursing students. The authors assert that it is vital to cooperate with the educational institution (15). The teaching principles are the same for all students but Boruff (11) claims that minority language students have a greater need for supervision and follow-up due to their lack of language skills.

Both national and international research has had little focus on practice supervisors’ experiences of supervising minority language nursing students. The objective of this study is to shed light on practice supervisors’ experiences of supervising minority language nursing students in a hospital context.

Method

Design

The study has a qualitative design with individual interviews of nurses who have supervised minority language nursing students at a hospital trust under the South-Eastern Norway Regional Health Authority. We conducted the study in spring 2017.

Sample

The inclusion criteria for participating in the study were: being an employee of the regional health trust, having at least two years’ experience as a nurse and experience in supervising a minimum of one minority language nursing student. The nurse with responsibility for work placements at the relevant hospital recruited informants for the study.

All relevant wards received the request. Ten practice supervisors with between 5 and 25 years experience were asked and agreed to take part in the study. Six of the practice supervisors had supervised one minority language student and four had supervised two students. All were women and they represented the surgical ward, medical ward, post-operative ward and paediatric ward, as well as the emergency ward and the medical and surgical outpatient clinic.

Data collection

The informants were contacted in order to schedule a time for the interview. We interviewed eight practice supervisors on the hospital’s premises and two at the nearby educational institution. The first author conducted individual, semi-structured interviews.

The practice supervisors were asked about their experiences of supervising minority language students, what challenges they had encountered, what the practice institution could do to improve the study situation and what measures the educational institution could introduce. In order to obtain more detailed answers, we asked follow-up questions. The interviews lasted from 20 to 50 minutes, and we audiotaped them. An external transcriber transcribed the data material.

Context

The bachelor’s degree in nursing at the educational institution in question includes 18 weeks’ practice in a somatic hospital during the second or third year of study, with a focus on surgical and medical studies. According to the national framework curriculum for the bachelor’s degree in nursing (14), the practice supervisors are responsible for ensuring that the learning situation is in accordance with the learning outcomes. The practice teacher must inform the practice institution about the requirements and goals in the programme description, and facilitate cooperation with the practice supervisor.

In situations in which the student has experienced challenges in connection with an earlier work placement, a conversation will take place prior to the start of the work placement between the student, the practice teacher and the practice supervisor. This is termed a transition conversation. The suitability of all students is assessed on an ongoing basis throughout the course of studies and this forms part of the overall evaluation of the student’s professional and personal aptitudes for working as a nurse (16).

Analysis

We analysed the data using manifest content analysis (17). The whole text was read several times and divided into meaning-bearing units. These units were condensed, abstracted and coded. Based on the codes, the condensed and abstracted meaning units were gathered in the following three categories:

• Uncertain about language understanding
• Need more time
• Need for cooperation

Table 1 shows examples of the process of analysis.

Ethics

We conducted the study based on research ethics guidelines in accordance with the Declaration of Helsinki (18). We applied for permission to carry out the study via the hospital’s research unit. The project was approved by the Norwegian Centre for Research Data (NSD) (project number 52027).

The practice supervisors received oral and written information about the study, and gave written consent to participation. During the interview situation and in the analysis process, we took care to prevent identification of any informants by a third party.

Results

In the results section, we present the findings in relation to the three categories.

Uncertain about language understanding

The practice supervisors stated that they found it challenging to supervise minority language students because they were often uncertain about whether the students understood what was said. They found that the students worked hard to master the subject of nursing and they were often unsure whether the students had understood information and messages correctly: ‘I don’t know if they know what they don’t understand.’

They described how busy their daily work was. The students struggled to keep up with what was going on at the nurses’ station and in the break room when instructions were given quickly. This could result in some students failing to understand what had been said, and backing away.

When the students were unable to understand the communication, the practice supervisor believed that this could lead to the students feeling inadequate. The supervisor believed that this feeling could be reinforced when she had to monitor the student closely: ‘It’s not good to hang over the student all the time. It can make them feel even more inadequate.’

Several supervisors brought up the point that students apparently got little language training: ‘They seemed to have little contact with Norwegians or any social life at university.’ When the supervisors were unsure about the students’ understanding, this affected the opportunity to delegate tasks. As a result, it could take time before the students were given the chance to work independently compared with Norwegian students: ‘I had to tag along with the student because I wasn’t sure if she had understood the instructions.’

The supervisors felt that they showed the same respect for all the students, i.e. treating everyone equally, but they needed more time to feel secure about the minority language students. This need to spend more time on establishing trust led to a fear of being perceived as prejudiced.

It also transpired that when students struggled to master the language, it affected their self-confidence. The practice supervisors believed that minority language students were more vulnerable than Norwegian students: ‘The students are vulnerable regardless of background, but minority students are much more vulnerable than I thought. Comments from others were very hurtful as they made her feel that she wasn’t good enough because she spoke differently. It shook her self-confidence.’ However, the supervisors clarified that there were weak and strong students among both minority language students and Norwegian students.

Need more time

The supervisors said that it was more time-consuming to supervise minority language students than other nursing students: ‘Minority language students need more supervision and you need more time to adapt things and make sure that they’ve understood the instructions.’ More detailed planning was needed as well as more time to evaluate the work afterwards: ‘It takes time, and I wish I had more time in the morning for planning, and more time in the afternoon for summing up to make sure that the student has understood.’

The practice supervisors felt that spending more time on supervision meant that the students had better opportunities to achieve the learning outcomes in the work placement. However, it was challenging for the practice supervisors to set aside enough time for the students due to work pressure in connection with patients and their relatives: ‘It’s a challenge to set aside enough time in the hope that the student will achieve the goals.’

This could result in some practice supervisors being over-lenient rather than strict because they saw that many of the students were in a difficult social situation. The supervisors could also find it challenging to set limits for what could be expected and the amount of supervision to which the students were entitled: ‘A lot of time is consumed by uncertainty as to where to set the standard.’

Need for cooperation

The practice supervisors felt that having open and frank cooperation with the educational institution was crucial for a good learning environment. Most supervisors were of the opinion that there was positive cooperation between the educational institution and the field of practice. They stressed that the practice teacher and the practice supervisor must jointly assume responsibility for supervising and following up the students during the work placement. The practice supervisor has daily responsibility for following up the students in the department and the practice teacher must maintain a close dialogue with the practice supervisor and the student: ‘We must be united as a learning institution and field of practice. That is absolutely essential.’ Similarly, ‘The university must provide close follow-up, and it must be easy to get in contact.’

The practice supervisors found that there was more need for good cooperation when a student experienced challenges. They highlighted situations where the students had not gained a pass mark for an earlier work placement, but the educational institution had not informed them about this before the start of the current placement. The practice supervisors wanted more transparency in this situation about earlier challenges: ‘If you have problems with Norwegian, a transition conversation takes place almost automatically.’

When such a conversation did not take place beforehand, this meant that the supervisors got off to a bad start with the student: ‘It’s challenging to be unable to meet the student at their current level.’ One practice supervisor expressed this as follows: ‘It took a long time for me to find out this student’s professional level.’

The supervisors generally perceived there to be an inadequate exchange of information in between the various work placement periods as regards the professional level of weak students. They felt that students with major language problems should get help at an early stage of their education: ‘Extra resources should be allocated as early as the first year. It’s terrible that they get to the third year and their Norwegian is really bad and no one has told them properly.’

They described situations where the supervisor and the teacher disagreed about the student’s professional level: ‘I felt that the teacher did not share my opinion of the student, and that meant cooperation was difficult.’ It was described as very unfortunate when disagreement led to the teacher correcting the supervisor while the student was present: ‘I don’t want to be corrected by the teacher when the student is listening.’

Discussion

The purpose of the study was to shed light on practice supervisors’ experiences of supervising minority language nursing students in a hospital context. The practice supervisors often felt uncertain about the students’ language understanding, and found this a major challenge.

Daily life at the hospital is characterised by considerable work pressure and quick decisions. The supervisors became insecure when they were uncertain about whether the students had understood instructions. Hanssen and Helleland (3) assert that acquiring linguistic and communicative skills takes time because it is difficult to learn a foreign language. Minority language students must practice Norwegian and get a grounding in attitudes, values and customs in order to understand the society they live in and will work in (3).

When the practice supervisors were uncertain about whether students understood what had been communicated, it was difficult for them to allow students to work independently. A lack of language understanding can give rise to risky situations for patients, and this gives the practice supervisor additional challenges. It is vital, therefore, to use simple language when conversing with the students in order to avoid misunderstandings (3).

Important to be part of a community

For students to develop their professional identity it is essential to interact with others in a professional context (7). This requires the practice supervisor to trust the students and delegate relevant work tasks that the students can master. When the students feel this sense of mastery, they will acquire greater self-confidence, more motivation and a feeling of responsibility. Furthermore, mastering work tasks will enable students to feel that they have control of the situation (19).

The practice supervisors found that the students withdrew from social situations at the hospital when a lot of information was communicated in a short period of time. According to Sedgwick et al. (20) and Bekkeli (4), it is vital that students feel that they are part of a community in order to be able to develop their knowledge. In this process, the practice supervisors found it was important to spend more time during supervision helping students understand communication in the hospital context. This is in line with the findings of Bolderston et al. (21), who state that communication in context is a key learning arena.

A lack of time can limit supervision

Our findings showed that minority language students needed more time in respect of practice supervision. A hectic daily life in the ward and little time posed a strong challenge to the supervisory function. A lack of time was often identified as the reason for limited supervision (22, 23). The practice supervisors expressed a need to be informed about students who needed extra supervision before the start of the work placement.

It is important to be well-informed in order to be able to employ pedagogical strategies that suit the individual student (13). The practice supervisors strove to have realistic expectations, and deciding where to set the standard was challenging. It was difficult to know how much time should be set aside for supervision when there were considerable language challenges. How supervision should be structured and how much time should be set aside are well-known challenges in the supervision of minority language students (22, 23).

The supervisors wanted to have more time both in the morning to check that the student had understood what had been reported and at the end of the day to sum up. In the future, the population will change and become more multicultural. Consequently, nursing education must include a study programme that can educate students from all cultures. Implementing such a programme will take time (13).

Practice supervisors must be given information about the students

The practice supervisors emphasised that good cooperation between the educational institution and the field of practice was crucial. It was particularly challenging if they had not received information about the students before the placement started. To achieve good-quality supervision, it is essential that the educational institution and the practice institution cooperate well (2).

If the practice supervisors are to give useful feedback to the students, they must have knowledge about the students and the study programme’s progression, requirements and learning outcomes (19). For this reason, the teacher, practice supervisor and student must take part in a conversation before the start of the work placement if the student has language difficulties or other challenges.

The students must feel secure and experience a good atmosphere when they start in the department. If the practice supervisor has no information about the student’s professional and language-related level, a considerable part of the work placement will be spent on establishing the student’s professional level. 

According to Boruff (11), minority language students spend considerable energy on creating good strategies to master the study situation (11). It is vital that students receive help in learning to interpret signals mediated through body language and behaviour. They gain such knowledge via social arenas where they speak Norwegian (24).

The practice supervisors stated that they were reliant on mutual respect in difficult situations and found situations where the practice supervisor and the teacher had opposing views extremely taxing. Feeling responsible for a student who has not achieved the learning outcomes can be stressful.

Sometimes practice supervisors felt that their responsibility for minority language students was very heavy, since the students work hard and often have obligations both in Norway and their country of origin. It is challenging when they fail to achieve their professional and personal goals for a hospital work placement, and the supervisors find that the students become disheartened (13). Students who are training to become nurses must have good language skills and the ability to expand their cultural understanding.

Strengths and weaknesses

The strength of our study was that it fills a knowledge gap where there is little research both nationally and internationally on practice supervisors’ experiences of supervising minority language nursing students. Moreover, the findings are in accordance with similar research and with the authors’ experiences as nursing education teachers.

A weakness of the study is that the practice supervisors had only supervised one or two minority language students. None of them had experience of supervising many. Another weakness was that some interviews lasted only 20 minutes because the supervisors had little experience of supervising minority language students. Despite this, we gathered a rich data material.

Conclusion

It is challenging to supervise minority language students in hospital work placements because the practice supervisors often feel uncertain about the students’ language understanding. More time is needed for supervision and better cooperation between the educational institution and the field of practice.

The education plan must be adapted to the individual in order to ensure that minority language students will be better able to complete their education. Practice supervisors should be offered courses in intercultural communication and cultural understanding.

Research going forward should focus on minority language nursing students’ experiences of being a student as well as teachers’ experiences of supervising these students.

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