Nurse teacher ’ s perceptions on teaching cultural competence to students in Finland: a descriptive qualitative study Nurse Education Today

Background: Cultural diversity in healthcare settings requires that care professionals are able to provide culturally competent care. This means that educational institutions have a crucial role to play in equipping students with the skills to deal with diversity in cross-cultural and multicultural contexts. Ensuring that cultural competence is part of the educational curriculum is therefore essential. Purpose: This study aims to examine what elements influence the implementation of cultural competence content in nursing education from a nurse teacher ’ s perspective. Methods: A descriptive qualitative design was used consisting of semi-structured interviews with nurse teachers ( n = 12). Inductive content analysis was applied to explore their perceptions on teaching cultural competence at a University of Applied Sciences (UAS) in Southern Finland. Results: Analysis from the open coding of interviews indicated that there are three main categories of importance regarding students ’ cultural competence education: exposure to diversity in the teaching environment; teacher ’ s experience and understanding of cultural competence; and integrating cultural competence into the curriculum. Conclusions: The findings suggest that more transparency and cooperation between nurse teachers and the university administration is necessary to ensure the inclusion of cultural competence in nursing education. For instance, teachers should receive training related to cultural competence and evidence-based teaching methods. The curriculum should include a course or workshop about cultural competence with clear learning objectives and evaluation criteria for the purpose of grading. Finally, the educational institution should commit to devel- oping a culturally competent organisation through internationalization and the maintenance of a diverse environment.


Introduction
Increased migration trends have significantly diversified European societies in the past few decades. The majority of all international migrants end up in Asia or Europe (International Organization for Migration, 2017) and between 2000 and 2015 the European population size would have dropped by 1% if there was no net inflow of migrants (United Nations, 2017). These changes are particularly noticeable in the sphere of public health, where healthcare faces increasing complexity in dealing with patients from different cultural backgrounds (Farber, 2019;Flood and Commendador, 2016;Lin et al., 2015). Therefore, cultural diversity in healthcare settings requires all care professionals to be able to provide culturally competent care.
By including culture in care education we can foster the creation of healthcare systems that are culturally competent and able to integrate and interact with health beliefs and behaviours of different patient populations (Betancourt et al., 2003). Furthermore, cultural competence skills are necessary to ease cultural barriers between health personnel and patients; reduce racial and ethnic disparities; develop culturally sensitive communication; and improve patient outcomes (Anderson et al., 2003;Beach et al., 2005;Douglas et al., 2018). In turn this means that educational institutions have a crucial role to play in equipping students with the skills to deal with diversity in cross-cultural and multicultural contexts once they enter the health workforce (Salminen et al., 2010).
Cultural competence can be defined as a set of beliefs, attitudes, knowledge, and skills that can be adapted to manage cultural differences in work settings (Bernhard et al., 2015;Douglas et al., 2018). It is especially important for frontline healthcare workers, such as nurses, to develop these skills in order to work effectively with diversity and provide high quality of care. As stated above, educational institutions play a crucial role in developing a culturally competent health workforce. For this reason guidelines have been developed in European nursing practice for implementing cultural competence in the educational curriculum (Sairanen et al., 2013). These guidelines support the premise that creating culturally competent healthcare systems starts at the level of education. However, existing evidence shows that despite cultural competence being a recognised and essential part of nursing education, difficulties in integrating cultural competence into curricula have been identified in several countries (Montenery et al., 2013;Morton-Miller, 2013). Moreover, there are still large differences in terms of harmonising educational programs across the EU (Sorensen et al., 2019). In fact, very few nursing programs evaluate cultural competence or provide staff with sufficient training and resources (Farber, 2019;Sorensen et al., 2019).
It has become clear that changes need to be made to implement this skill in nursing educational frameworks in order to reap the potential benefits (Green et al., 2017;Salminen et al., 2010). In nursing education, nurse teachers play a key role in developing cultural competence in their students (Flood and Commendador, 2016). In order to create evidencebased strategies on how to facilitate the integration of cultural competence in nursing curricula, it is important to identify those factors that may support or hinder the implementation and the development of students' cultural competence. Hence, the aim of this study was to examine what elements influence the implementation of cultural competence content in nursing education from a nurse teacher's perspective.

Design
This study employed a descriptive qualitative design with single interviews (Denzin and Lincoln, 2018) in order to understand nursing educator's perspectives on elements that impact teaching cultural competence. Subsequent analysis of the interviews was done using principles of inductive content analysis (Elo and Kyngas, 2008). This method for data analysis was chosen because it is commonly used in nursing studies (Vaismoradi et al., 2013). The "Consolidated criteria for reporting qualitative research" (COREQ) checklist was used to ensure comprehensive reporting throughout this study (Tong et al., 2007).

Study context
Nursing education in Finland is organised at Universities of Applied Sciences, which are multi-field institutions known as polytechnics (Salminen et al., 2010). Programs have a strong clinical focus, they last 3.5 years and consist of 210 European Credit Transfer and Accumulation System (ECTS) which is in accordance with European standards (Kaihlanen et al., 2019). Multicultural nursing is included as a core competence although there is no national standard in the curriculum that indicates how this skill should be taught (Repo et al., 2017).

Data collection
Qualitative data was collected through individual interviews with nurse teachers (n = 12) working in a large University of Applied Sciences (UAS) in Southern Finland. This UAS was selected because it offered both a degree program in English as well as a native Finnish program in nursing. Participants were selected from two different campuses through convenience sampling. Only participants currently working in the program were approached. All participants were recruited through email. An interview guide with open ended questions was developed in collaboration with the research group and pilot tested prior to the interview with one nurse teacher so questions could be adjusted (Table 1). Interviews lasted between 30 and 45 min and were conducted on campus in the English language (thus not in participants' mother tongue) as the lead researcher did not speak Finnish. Transcribed interviews were sent back to the participants for comment and/or correction. Only one participant commented and whished for corrections to the interview through email. It was not necessary to repeat any interviews.

Data analysis
Inductive content analysis was used to interpret the study results as transcribed interviews were analysed line by line in order to move from specific to more general data (Elo and Kyngas, 2008). The unit of analysis consisted of expressions where the teacher described elements that influenced their ability to teach about cultural competence. First, the research team conducted line by line open coding. During this process essential expressions were extracted from the transcripts and abstracted into codes without altering too much of their original content. Finally, the codes were grouped into subcategories based on similarity of content, which were further classified into three main categories ( Table 2). The research aim and interview guide were used to help identify these categories. Two researchers were involved in the categorisation and abstraction of codes.

Ethical considerations
A research permit was granted in April 2019 by the UAS where the study took place. All participants received oral information about the study and signed an informed consent form. Any identifying data was removed during transcription of the interviews, prior to data analysis. The research team tried to minimise their impact on the course of the interviews or subsequent analysis by becoming aware of their own perceptions on the topic. In case of differing opinions the researchers sought consensus.

Findings
A total of twelve nurse teachers participated in this study. The majority of the participants were female (n = 11) and had between 1 and 20 years of experience as an educator in nursing, with a mean experience of 8 years. Participants taught in the English program (n = 3), the Finnish program (n = 5), or both (n = 4). Only one participant came from a migrant background, the rest were from various parts of Finland. All participants had received a teacher's training course from the UAS in which cultural competence was briefly addressed as part of the international environment at the UAS. No additional training in cultural competence was received, with the majority of participants (n = 9) stating they had never received training on this subject throughout their career. There seemed to be no clear consensus on a definition of cultural competence although none of the participants were completely unaware of the meaning.
The three main categories describing the elements that impacted cultural competence teaching were: exposure to diversity in the teaching environment, teacher's experience and understanding of cultural competence, and integrating cultural competence into the curriculum.

Category 1: exposure to diversity in the teaching environment
In this category teachers acknowledged that being exposed to diversity was essential to developing cultural competence. They noted that teaching cultural competence in international settings was preferable as students more frequently encountered cultural differences. For this reason, many participants stated that the integration of international students should be encouraged and further internationalization promoted.
"I think it's in the university strategy to aim for internationalization, but somehow it seems that it is viewed very narrowly, that it mainly has to do with the exchange, like Erasmus programs, things like this, or certain projects. But it should be much more" Organising cultural activities, theme days, or creating electives open to all, provide opportunities for different students to meet and were seen as ways to further internationalize the UAS. Participants indicated that a more systematic approach to organising such activities would be desirable in order to help their students experience contact with diversity and gain better understanding. However, they noted that this is a commitment that requires strong organisational support and understanding of cultural competence at the level of administration, for instance by providing training to teachers: "At least at the moment, I feel it would be easier for me if I could first educate myself" Such a commitment could also include ensuring diversity in hiring practices or encouraging staff to go abroad as is the case in this UAS. For instance, by implementing teacher exchange programs, teachers have the opportunity to see how other UASs "do things" (A12). Participants indicated that this practice ensures that there is a knowledge exchange  between different institutions which offers an opportunity to reflect on how nursing education is organised.
Additionally, a few participants commented that exchange students add much-needed diversity to Finnish programs, which are generally more homogeneous in their cultural make-up than the English programs: "Each semester there's at least a couple of [exchange] students who come and actually study with the Finnish students so that they all have an exchange" (A2) Diversity on campus carries over into the classroom, where teachers can encourage discussion among students on cultural matters. A few participants remarked that cultural competence is easier to take into consideration in the English program "where we have it more naturally" (A4). Participants agree that openness to sharing experiences and perspectives is necessary to engage with students: "When you're studying in an English-speaking program, like the degree program of nursing, I feel like that's one good example of a multicultural environment. So almost every day, you're dealing with situations where people are sharing their different perspectives or different opinions" (A5)

Category 2: teacher's experience and understanding of cultural competence
Participants were asked to reflect on what makes them culturally competent and qualified to teach this skill to students. Personal experience with diversity or being a minority, such as living or studying abroad, were quoted as important life events that enhanced perceptions of cultural competence. All participants had such experiences and reflected on its importance. Also mentioned was that teaching international students gave teachers the opportunity to learn about different cultures. Similarly, having a multicultural staff allows colleagues to share different perspectives.
"When we are having different projects, or planning something, for instance, it could be a module or a course, or an implementation. I always bring that aspect to it, you know, because I'm an immigrant" Participants felt it was important to understand that there can be differences within a culture, that "there can be many cultures within one person" (A2). Therefore, acknowledging difference within culture and understanding how it can influence patient care was seen as necessary, and as a goal of developing cultural competence in their students: "So, I think the only way to teach cultural competency is to teach the nursing students to be flexible, ask questions and assess the situation, find out what that particular patient wants or needs, requires, or what that particular family needs" (A7) The participants found it important to teach students that their role as nurses expands beyond curative care. That care is also about understanding individual patient needs in terms of culture, and recognizing when there is a need to advocate for patients or help them navigate the healthcare system: "Because the system is so that if the nurse is not culturally competent and does not know which kind of difficulties this patient has, then they do not know, for example, how to offer different social benefits" Understanding the background of patients, even if it is sensitive and difficult to ask about, was noted to be essential to providing appropriate care. Participants thought that using concrete examples made it easier to teach this aspect. For instance, in light of the refugee crisis, an additional learning module was developed which focused on the needs of refugee patients: "For example, if patients are coming from Syria, they lived in [refugee] camps. And what this means for example, for their nutrition, they may have malnutrition, suffer things like that. … To give good advice, and good nutrition and good medicine, and vitamins for example" (A12)

Category 3: integrating cultural competence into the curriculum
Finally, participants believed that there is need for a systematic approach to implementing cultural competence in the curriculum by using evidence-based teaching strategies. During the interviews it became clear that implementing cultural competence in the curriculum had been discussed, but how it is taught depended on the teacher's preference. Regrettably this meant there was little coordination between teachers:

"It has to do with the teacher. If I want to include it, it's not a problem. But for teachers who don't think about it and don't want to include it maybe, it would be a problem"
(A3) This lack of transparency was believed to lead to confusion concerning where in the curriculum cultural competence is implemented, in what manner, and what plans were made to ensure this skill development. Without a clear strategy in place, teachers became unaware of who was ultimately responsible for ensuring students were properly instructed: "It's not a living thing. There may be some courses, which contain elements, or maybe even theory, but they are like… it's not systematic" However, participants expressed that cultural competence was not missing from the curriculum. One participant described it as being part of the "hidden curriculum", meaning that it is not something explicitly mentioned and evaluated in the curriculum, but it is a skill that is implied throughout the entire program and can be observed "in our actions" (A8).
Additionally, teachers pointed out that there is pressure to develop study materials by themselves to incorporate into the curriculum, as there is not enough space to include a ready-made course on this subject: "There is, for example, this very nice online course, about culture, differences and so on. … I think: how we could put it in our module four? But it seems to be impossible! Because it's so big material. And we have so little time. So, we have to give them only one-hour lesson" On the other hand, participants highlighted that researching what teaching methods suit the development of cultural competence best needs to be addressed. Gaining knowledge on evidence-based teaching methods and pedagogies was seen as beneficial to improve their cultural competence teaching:

"I don't know if it needs like lecturing, or if it needs my role as a pedagogue, or if it requires my role more as a facilitator or listener. I do feel that it requires a little bit of resources as well to really focus on this issue,
so that everyone has time to really discuss, reflect, ask" Participants explained that current teaching methods consist of: encouraging discussion, self-reflection, and group work in the classroom; using examples from culturally diverse patients; and organising simulation exercises. Having extensive theoretical and cultural knowledge was not considered necessary for providing culturally competent care. Far more important was to encourage students to understand their patients as individuals first and be aware of culture second.
Participants reported that learning outcomes were currently not measured, nor were there any specific evaluation criteria or learning objectives in place. One participant stated there was no "explicit systematic way of evaluating our students" (A6) in cultural competence. Even when looking at graduation transcripts, cultural competence was not a skill specifically mentioned or visible in study units. Another participant explained that cultural competence was difficult to grade: "Because let's be honest, sometimes it's very difficult to assess cultural concepts. So that's something from within, people develop it. And it has to come from the willingness, it has to come from that individual" (A8)

Discussion
According to the study findings, three main elements stand out: exposure to diversity in the teaching environment, teacher's experience and understanding of cultural competence, and integrating cultural competence into the curriculum.
The conclusion based on these interviews is that by utilising cultural differences on campus, among students and staff, the university administration can enhance the teaching environment in such a way that students have opportunities to engage with and reflect on cultural difference. Other studies have similarly found that developing cultural competence in nursing students requires faculty commitment and the intent to create a culturally competent organisation (Beard, 2016;Morton-Miller, 2013). Research has shown that increasing exposure to diversity is tremendously important for creating situations where cultural experience can be gained (Choi and Kim, 2018). Having such experiences outside of the classroom is meaningful because it encourages interactions in more natural settings and provides possibilities for further internationalization (Repo et al., 2017). Educational institutions have an essential role to play as they can invest in expanding international cooperation, experiences abroad for students and faculty members, and ensuring diversity among staff (Farber, 2019). Making use of the different cultures on campus and providing opportunities for integration among diverse students can only be done successfully with support from the organisation. The findings in this study support these claims as teachers desire a more systematic approach to cultural competence in the nursing programme which goes beyond only including it in classroom settings.
Secondly, the findings indicate that the teacher's experience and understanding of cultural competence greatly influences how it is included in their teaching. Teachers form their views about the topic in different ways, often based on their own experiences, knowledge, or level of comfort. Creating a common strategy and getting staff equally familiarised with the concept is paramount for developing cultural competence in the curriculum. This is in line with earlier studies showing that teachers often lack skills to include this topic adequately in the curriculum due to lack of consensus on the definition of cultural competence, teaching methods, and pre-prepared materials (Liu et al., 2018;Montenery et al., 2013). The results indicate that creating opportunities to learn from each other, being open minded, and having a desire to learn about culture, are elements of personal attitudes and convictions that enable teachers to reflect on their positionality in regards to cultural competence. Nevertheless, research recommends that staff should be encouraged and be provided the resources (and training) to continuously improve their knowledge and skill (Sealey et al., 2006). Creating opportunities for international experience, like having a teacher exchange, is important for continued growth (Farber, 2019) which is also reflected in the findings. Creating self-aware teachers with the ability to reflect on their own positionality and on the cultural backgrounds of their students requires awareness, coordination and support from university administration. Once this is achieved teachers can function as role-models for their students (Flood and Commendador, 2016) and act as leaders to help their organisations become culturally competent. Interestingly, participants indicated that gaining knowledge about different cultures is less important than teaching students how to be an advocate for patients, particularly concerning their individual and cultural needs. One can speculate this indicates a preference towards a more practice-based understanding of cultural competence rather than theoretical.
Finally, this study found there was no systematic approach to cultural competence in the curriculum even though this was considered important. Participants agreed on the need to develop and evaluate learning objectives in order to facilitate a faculty wide commitment. Although this study observed a commitment to teaching cultural competence throughout the nursing program, there was no clear implementation strategy beyond encouraging teachers to incorporate this individually. Resources like creating time for this subject in the curriculum or ensuring teachers receive training were desirable but absent. These results are consistent with broader literature which similarly shows that evaluation of cultural competence is often not systematic and ongoing, tied to learning objectives, graded, or presented on graduation transcripts, which makes it difficult to assess skill development (Flood and Commendador, 2016;Lin et al., 2015;Salminen et al., 2010). Nonetheless, having a course dedicated to exploring cultural competence is proven to be effective (Noble et al., 2014). Doing so creates a space to assess the competency and includes it to the curriculum in a clear manner. Introducing a more structured preparation, follow-up and evaluation during clinical placement should also be considered (Boyer et al., 2019). In fact, having a multitude of teaching strategies and pre-prepared material greatly improves the development of cultural competence (Liu et al., 2018). Ensuring that evidence-based teaching strategies are discussed with teachers and utilised in the program, including ways to grade and evaluate students, will greatly improve the quality and standard of instruction.
Despite previous research illustrating the importance of teaching cultural competence to nursing students (Green et al., 2017), no standardised European educational frameworks are available and implementation seems to remain difficult (Sairanen et al., 2013;Sorensen et al., 2019). Yet this Finnish study shows that cultural competence is not overlooked by teachers, given that it is included throughout the entire curriculum where appropriate in the form of patient examples, classroom discussions, and simulation exercises. Unfortunately, however, there was no specific course dedicated to exploring the concept and educators are left to include it in their teachings as they see fit. This had resulted in a teaching environment that lacks coordination, transparency, and dedicated resources. Overcoming this barrier is an important lesson to take home and should be a priority of faculty staff and administration worldwide.

Limitations
There are several features that limit the results of this study. The relatively small sample size is insufficient to be properly representative of Finnish nursing programs as data was collected at only one, albeit large UAS. It is possible that some concerns related to implementing cultural competence in nursing education may have been overlooked. Furthermore, because interviews were conducted in English and none of the participants were native English speakers, this might have limited participants' abilities to adequately express their thoughts on the subject. Despite these limitations the teachers' views on the topic were quite similar and the findings were consistent with the larger body of literature.

Conclusions
Results from the interviews with nurse teachers showed that a longterm commitment from faculty and university administration is necessary to free up much-needed resources to create a conducive learning environment for developing cultural competence in students. Equipping students with the skills to provide culturally competent care is important for the development of a European health workforce and improving patient outcomes. To achieve this, not only do teachers themselves require training, but the institutions they work for also need to show support for cultural diversity. Due to lack of clear evaluation criteria and standardised educational frameworks, there is need for careful coordination and leadership from faculty members. It is recommended that future studies focus on developing such frameworks and guidelines which can be used as suggested implementation strategies in European educational institutions.
Based on results from this study, the following recommendations for implementing cultural competence teaching in nursing education can be made -Cultural Competence incorporation into the curriculum needs to be discussed by faculty members, this includes making agreements on learning objectives and criteria for evaluation. -There should be a course or workshop dedicated to cultural competence in the curriculum focusing on exploring the concept. -Staff should receive training in cultural competence and be introduced to evidence-based teaching methods and pedagogies. -Cultural competence should be supported by the entire organisation through internationalization and the maintenance of a diverse environment.
Simply implementing cultural competence content in the curriculum is not enough to ensure sufficient skill development in students, rather, developing a shared strategy among faculty members is needed to realise a curriculum wide commitment. The main message that emerges from this study is that developing an international and culturally competent teaching environment should be high on the agenda of teachers.

Declaration of competing interest
None declared.