The LEARN process is demonstrated in the students’ descriptions of their personal development up to the point of acknowledging persons with a different cultural background. Through their personal experiences, reflections and dialogues with people, they developed new understandings and attitudes, and an acknowledgement of the differences in the cultures.
However, they did not develop competence that enabled them to make recommendations and negotiate with the people they met in the clinical situations. This was partly because the role of student was limited in terms of responsibility and opportunities for following up patients or service users. Another reason was that they did not have sufficient professional competence to ask critical questions in the dialogues they had with people in clinical situations.
A third factor that restricted the students’ ability to be involved in the last two elements of LEARN was their lack of language skills in Swahili. Language has a large impact on human interaction, and the students described how they often used nonverbal communication or a supervisor and interpreter when there were language barriers.
Nonverbal communication is not always sufficient when interacting with patients and assessing their situation in cases where making recommendations and negotiations are essential elements for achieving patient satisfaction, for example (7). Some interpreters were qualified healthcare workers and supervisors with extensive clinical experience, but they were not responsible for patient care.
In cases where patients only spoke Swahili, the students were not proficient enough in the language to interact with the patients without an interpreter. In view of this and the role of student in a foreign culture, the students’ contribution to assessing patients was therefore limited. Developing cultural competence takes time (2). The students’ development of cultural competence and ability to carry out a professional assessment in a different culture must therefore be considered in light of the short time they participated in the culture.
A desire to develop cultural awareness
A desire to develop cultural awareness is a key factor in developing cultural competence (5, 21), and the students expressed this desire, partly through their open attitude in cultural encounters with people. This mindset contributed to personal development, and strengthened their confidence in their abilities. Personal development and a sense of mastery are essential learning outcomes of student exchanges (10, 22, 23).
In her review article on how nursing students benefit from student exchanges, Kelleher (22) concludes that ‘participation in a study abroad experience is associated with many benefits for nursing students, including various forms of personal and professional growth, cultural sensitivity and competence, and cognitive development’ (p. 690).
Several studies (10, 22, 23) do not describe what level or degree of competence the students have achieved after taking part in a student exchange. The students in our study did not mention this either, but several of them stated that they had a greater learning outcome from the exchange in Tanzania than from their clinical placements in Norway.
Culture needs to be an integral part of the education
In order for nursing students to develop cultural competence as part of their nursing education, the cultural aspect should be an integral part of the learning process and not something that is only brought up in some university classes. One measure that has proven to be effective is to conduct workshops for staff and students (24, 25). More research is also needed on what factors impact on the students’ learning outcomes from student exchanges (11, 22, 26).
In addition to the importance of language skills and personal development, the development of cultural competence can be linked to the content of the partnership between the institutions, the organisation of the exchange programme, the student role, the duration of the exchange and the process that takes place when the students interact with people in the local community (27–29).
Strengths and weaknesses of the study
This study presents the development of cultural competence from the student’s perspective; something that has not been studied previously as far as we are aware. A further strength of the study is that the experiences we present in this article are from students from three different learning institutions in Norway. The students had a common understanding of the process of developing cultural competence, and the findings concur with earlier research.
The focus group was an appropriate method because it created opportunities for dialogue, and several students said that sharing their experiences with fellow students gave them valuable feedback. It is open to debate whether we could have learned about other experiences by using a theory-driven interview guide with points from the theory of cultural competence.
The study only covers the experiences of Norwegian students in one exchange country. Several of the studies we refer to were conducted in the USA, but we have not discussed differences in culture and education systems. The students in this study lived with up to 70–80 other Norwegian students in a centre founded and run by Norwegians.
In addition, the centre is physically isolated from the local community. It would have been useful to explore the importance of exchanges between Tanzanian and Norwegian culture in more depth in the interviews. The exchange between two cultures and the degree of proximity to the local culture can impact on the benefits and level of cultural competence gained from the exchange.
The students strengthened their cultural competence during the exchange period. Communication and interaction with people who had a different cultural background to their own supported this process. Receiving explanations of aspects they found difficult to understand contributed to the development of their cultural competence. The students emphasised that the ability to maintain an open attitude and go outside their comfort zone was essential for developing cultural competence.
It was crucial for them to have the opportunity for organised reflection on their personal experiences in order to strengthen their cultural competence. The student exchange did not, however, contribute to developing competence that enabled the students to make recommendations and negotiate with people they met in the clinical placements.
It takes time to develop cultural competence, and language skills, the role of student as well as the length and content of the exchange programme are some of the factors that impact on the process. There is therefore a need for more research on teaching programmes that strengthen students’ cultural competence.
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