Enhancing undergraduate nursing curricula to cultivate person-centred care for culturally and linguistically diverse older people

With an ageing global community and widening socio-cultural diversity, nurse educators are increasingly challenged to align responsive undergraduate nursing curricula to rapidly changing healthcare environments. In future-proofing nurse education, educators need to collectively examine ways of interconnecting and developing gerontological and cultural competence within undergraduate curricula. However, there is limited guidance as to how this can be achieved in already compacted curricula. We suggest that this could be achieved by critically examining undergraduate curricula to make explicit how they can be adapted to educate nurses in the provision of culturally competent person-centred care. This approach could help nurse educators adapt student nurse preparation to meet the needs of culturally diverse older people and their families.


Introduction
Like many countries, Ireland is experiencing a growing inward migration trajectory and a rising ageing population, exceeding any previous trends. Statistics show that net inward migration in Ireland has increased from 59,000 in 2013 to 337,000 in 2019, with non-Irish nationals now representing over 12% of the population (Central Statistics Office, 2019). This aligns with international trends, as migration to Europe has increased from 57million to 82million between 2000 and 2019 (United Nations, 2019). Health care organisations are seeing a broadening socio-cultural diversification of healthcare professionals and patients and their families accessing healthcare services. The challenges with adapting caring practices in response to cultural needs  and working in intercultural healthcare teams are widely reported (Andonian and Rossenblum, 2017).
People are also living longer and culturally and linguistically diverse older adults represent a growing proportion of changing demographics (World Health Organization, 2018). However, deficits in nursing care provided to this cohort (Soderman and Rosendahl, 2016;Gillham et al., 2018) and their families (Johnstone et al., 2016), warrants attention. There is growing evidence to highlight the challenges of caring for older people and their families (Koskinen et al., 2015;Soklaridis et al., 2016) and culturally and linguistically diverse patients (Kouvner et al., 2018;Markey et al., 2020). The term cultural and linguistic diversity (CALD) refers to the diversity of different cultures and language groups represented in the patient population (Department of Health and Human Services, 2014). The need for culturally safe and quality person-centred approaches to care for CALD older people is identified as an urgent necessity (Wang et al., 2018). Person-centred care has been previously advocated by Nolan et al. (2006), who argued for the inclusion of relationship-centred care (RCC) in ensuring both older people and their families' needs are met (Soklaridis et al., 2016). Nolan et al. (2006) draws attention to the importance of everyone feeling a sense of security, belonging, continuity, purpose, achievement and significance. Although the importance of such philosophies of care are clearly identified, student and registered nurses continue to experience difficulties caring for CALD older adults and their families (Soklaridis et al., 2016;Gillham et al., 2018;Wang et al., 2018). This highlights the importance of addressing reported deficits in undergraduate nurse education in the areas of cultural competence (Forss et al., 2019;Hultsjo et al., 2019) and gerontological nursing (Koskinen et al., 2015;Coffey et al., 2017). Aligning nurse education with the changing realities facing nursing practice within a global community is essential. Although beyond the scope of this paper, providing opportunities for students to learn to work within intercultural teams also warrants attention as the nursing workforce is becoming increasingly culturally diverse (Kouvner et al., 2018). Nurse educators must also examine undergraduate curricula and educational pedagogies, making explicit how the capability for cultivating a workforce that can respond appropriately to the needs of CALD older people and their families can be achieved. However, there is limited guidance on how this may be accomplished in an already overloaded curriculum. This paper proposes some practical approaches in preparing nursing students for providing respectful and responsive care for CALD older people and their families.

Culturally competent person-centred considerations
Student nurses' attitudes to nursing older people (Koskinen et al., 2015) and CALD patients and their families (Forss et al., 2019) are dependent on the level of theoretical and practical preparation in the curriculum. Standards for nurse education (European Commission, 2013; Nursing and Midwifery Board of Ireland, 2016), stipulate the need for a more person-centred philosophy when caring for the older person and their families. Nevertheless, nursing students continue to report gaps in the educational preparation received to care for older people and their families (Kydd et al., 2014;Hsieh and Chen, 2018). The ageing process is both 'socially constructed' and 'culturally embedded' (King et al., 2017), highlighting the importance of understanding the diversity of characteristics within the ageing trajectory across CALD communities. However, student and registered nurses experience difficulties when caring for CALD older people (Lood et al., 2014;Wang et al., 2018).
Developing gerontological and cultural competence collectively in nursing curricula is now essential in future-proofing nurse education. Addressing ageist attitudes (Kydd et al., 2014;Wilson et al., 2017) and cultural stereotypes and prejudices (Larson et al., 2017;Hultsjo et al., 2019), within nurse education is core. Although models of care for cultural competence (Papadopoulous et al., 2016) and person-centredness (McCormack and McCance, 2017) are welcome developments, these are often utilised in isolation rather than interconnected elements of curricula. Campinha-Bacote (2011) and Papadopoulos et al. (2016) highlight the need for a culturally competent approach in enhancing the delivery of person-centred and culturally safe care. In comparing conceptual models of cultural competence and patient centeredness, Saha et al. (2008) and Campina-Bacote (2011) argue that despite focusing on different aspects of quality care, seeing the uniqueness of the patient and their needs, is core to both. Approaches to nurse education that examine these constructs together, whilst also nurturing 'age friendly' and 'culturally safe' philosophies of care are essential in preparing students in providing care to CALD older people and their families. Drawing on commonalities between cultural competence and person-centred frameworks informs curricula design and pedagogical approaches that cultivate age-friendly and culturally safe practice (Table 1).

Developing awareness
Developing awareness captures the importance of understanding the self and cultural awareness synchronously. Shepherd et al. (2019) seeks education interventions that acknowledge the value of developing cultural awareness when planning person-centred care. However, the need to address ageist attitudes and cultural stereotyping is paramount (Wilson et al., 2017;Larson et al., 2017). Nursing students need opportunities to think about their personal and cultural values, whilst considering how they affect their understanding of providing culturally safe, respectful and responsive care for CALD older adults and their families. Huang et al. (2011) advocates for a conducive environment that is intolerant to ageism and supports staff in providing age-friendly healthcare. The use of portfolios, reflection and journaling are important strategies for understanding one's values, which helps address ageist attitudes, and cultural stereotyping. However, reflection used in isolation is ineffective in decreasing unconscious biases (Schuultz and Baker, 2017). Facilitating opportunities for students to express their views, attitudes and prejudices in a safe environment, whilst acknowledging how they impact on caring encounters, is paramount. Nurse educators need to appreciate the value of such discussions in engaging students in meaningful and relevant learning, whilst being open and non-judgemental.

Understanding values and beliefs
Nurse educators need to provide opportunities for students to examine their personal and professional values, whilst exploring how they impact on understanding cultural beliefs of others (Markey and Okantey, 2019). Replacing traditional pedagogies with innovative approaches that are more reflective of the changing healthcare environment is essential. The use of art work (De Vecchi et al., 2018) and drama (Arveklev et al., 2018) are effective educational approaches for examining values and beliefs. Providing opportunities for students to explore CALD older adult narratives and co-created practice scenarios is recommended. Engaging with 'culturally diverse age experts' in curricula design can help focus learning and teaching approaches that consider culturally responsive person-centred care (Jansky et al., 2019). Providing opportunities to engage with CALD older adult support groups and clinical placements or opportunities to live in residential aged care facilities, encourages the development of empathy, through intergenerational interaction and intercultural solidarity (Corrigan et al., 2013;Arentshorst et al., 2019). Intergenerational interaction is an approach that can lead to improved understanding, whilst encouraging students to see the older person and their families as active participants in care delivery (Hwang et al., 2013). It is also effective in combating ageism as it gives students the perspective of older adults where the interaction between generations have been minimal (Arentshorst et al., 2019).

Fostering relationships
Fostering trusting and respectful relationships with CALD older people and families is core to developing therapeutic relationships (Nolan et al., 2006). Opportunities for students to consider the influences of ethnicity, gender, class, sexuality and age in how patients engage in therapeutic conversations is needed in respecting individuality. The family plays a crucial role in CALD communities. For example, cultural norms and religious beliefs inform decision making roles within the family, highlighting the importance of ensuring families are integral in planning care. However, the needs of families of CALD older people are often unmet (Schaffler et al., 2019). Family support for older adults varies across cultures, highlighting the importance of educational programmes which address the needs of relatives and staff (Soklaridis et al., 2016). This requires an understanding of the influence of culture in how verbal and non-verbal expressions are communicated. Opportunities must be provided for students to reflect on their own communication style and language and consider how they can impact on developing therapeutic relationships with CALD older people and their families. Educational interventions that encourage simulation, intercultural engagement and role-playing cross cultural caring scenarios, help with understanding and respecting differences with communication styles, modes and language (Chai and Kim, 2018).

Conclusion
Developing gerontological and cultural competence collectively, is paramount in preparing nursing students to provide culturally safe and Table 1 Some commonalities between cultural competence and person-centred frameworks.

Cultural competence
Person-centeredness Cultural awareness Self-awareness Understand cultural beliefs and values (cultural knowledge) Understand personal beliefs and values Intercultural communication (cultural sensitivity) Therapeutic relationships responsive care for CALD older adults and their families.

Contributions
All authors contributed to the drafting and finalising of the manuscript preparation.

Funding
No specific grant from any funding agency in the public, commercial, or not-for-profit sectors was received.