Learning to Nurse in a Multicultural Society – The Experiences of Nursing Students in Sweden

Introduction: Transcultural nursing education is often neglected within nursing curricula and inclusion within curricula may be haphazard. Little is known about nursing students’ views on transcultural nursing education. There is a lack of research examining how nursing students are prepared in university and practice settings for nursing in a multicultural society. Objective: To examine nursing students' preparation for and experience of cross-cultural encounters. Method: Semi-structured interviews were undertaken with a purposive sample of 10 final year students from one university in Sweden: 5 participants were from a Swedish background and 5 from an immigrant background. Interviews explored participant’s experiences of preparation for and experience of nursing in a multi-cultural society. Interviews were audio recorded, transcribed and analysed using ‘framework’ approach. Results: Three themes were identified in the analysis: experiential learning through life experience, educational preparation for practice, and learning in clinical education. Students from an immigrant background emphasized the importance of their life experiences while ethnic Swedish students emphasized education in equipping them to meet patients from another culture than their own. In clinical settings students used their skills of self-awareness to reflect upon their response to cross-cultural encounters as well as critical reflection on practice. In clinical placements, students were inadequately prepared to deal with negative attitudes, racism and discrimination towards patients and in some instances towards themselves. Conclusion: Although nursing students felt nursing education had equipped them with the necessary selfawareness, knowledge and skills to face cross-cultural encounters, nursing education had failed in preparing students to deal with negative attitudes, racism and discrimination. Nurse educators need to place greater emphasis on preparing students deal with difficult situations arising from racism and discrimination that they may experience in clinical practice. Students need to understand why racism and discrimination may occur and also how to respond and act appropriately.


Introduction
According to the International Council of Nurses ethics code [1] nurses are not only responsible for promoting health, prevent illness, restoring health and relieving suffering but also for respecting human and cultural rights [1]. In order to meet these demands, nurses need to be self-aware and have the knowledge and skills to provide appropriate care for all patients. They need to provide nursing care unrestricted by considerations of age, colour, sexual orientation, nationality, politics, race or social status i.e. to be culturally competent [1]. Transcultural nursing is the field of study enabling nurses to provide culturally competent care [2]. Cultural competence is an important component to be included in nursing curricula [3]. Although it is often included, transcultural nursing education is frequently haphazard and lacks integration [4,5], a view endorsed by an international project undertaken by a group of educators from five EU countries conducting a review of the nursing education at the eight institutions they were representing [6]. Furthermore, a study conducted by Momeni et al. [7] analysing the curricula in all 26 nursing programs in Sweden identified a lack of structure for students to become culturally competent [7]. A national study undertaken by Schüldt Håård et al. [8] found that only 41% of 1110 nursing students felt their education had equipped them with adequate understanding of people from other cultural backgrounds.
The need to prepare nursing students for international exchange programs has been acknowledged and described by several researchers [6,[9][10][11]. However, the need for this preparation holds true for all nursing students due to the challenge many nurses face when caring for immigrant patients who are from a different cultural background to their own. According to the Institute of Medicine [12] cultural competence is essential for providing high quality care to diverse populations and for providing patient-centered care that identifies, respects and addresses differences in patients' values, preferences and expressed needs. This statement highlights the importance for nurse educators to develop nursing curricula and nursing education in a way that enables all nursing students to become culturally competent in order to provide nursing care to diverse populations.
Integrating cultural competence training into the nursing curricula in order to reach an effective outcome is challenging [13]. Different learning activities can be used to facilitate the development of cultural competence among nursing students [13,14]. International exchange programs that provide the opportunity for students to study in a different country are one successful learning activity (c.f. [9][10][11]. However not all nursing students have the opportunity to take part in an international exchange program and therefore other learning activities that enable similar learning opportunities are necessary. Simulation games e.g. Barnga [15,16], BaFá BaFá [15][16][17][18], Culture Copia [19] and High-fidelity patient simulation [13] are other forms of effective learning activities which can be used to enable students to develop culturally competence, either as a single method or in combination with other learning activities.
Little is known about nursing students view on transcultural nursing education. To date, the focus has mainly been on nursing students' experiences of specific learning activities such as exchange studies and simulation games. There is a lack of research examining how nursing students are prepared in university and practice settings for nursing in a multicultural society.

The Study Aim
The aim of the study was to examine nursing students' preparation for and experience of cross-cultural encounters.

Method
An exploratory qualitative study was undertaken with semistructured interviews using a purposive sample of 10 nursing students who were in the final year of a three year education programme in a Swedish University. The university was located in a city with a multicultural population drawn from over 180 countries so it was anticipated that students would gain experience of cross-cultural encounters during their clinical practice.

Participants
Five students with an ethnic Swedish background and five students from different immigrant backgrounds were recruited. Biographical details of the participants are provided in Table 1. All students with an immigrant background had migrated to Sweden during their childhood and were fluent in Swedish. All students had undertaken a 5 week course in transcultural nursing (Table 1).

Data collection
The students received an interview guide in advance asking them to reflect upon how they had been prepared for cross-cultural encounters in clinical practice and to bring appropriate examples to the interview to discuss.
Interviews lasted between 20 to 45 minutes and were audiorecorded and transcribed verbatim. Interviews took place at a location convenient to the student. Six interviews were undertaken in the university and four by telephone.

Data analysis
The interviews were analysed using the five steps in the Framework approach developed by Lewis and Ritchie [20]. The steps involve: • familiarisation with the richness, depth and diversity of the data. • identification of a thematic framework • indexing whereby the thematic framework is systematically applied to individual transcripts • charting, whereby indexed data from different transcripts are grouped into common themes • mapping and interpretation involves identifying the key characteristics of the data as a whole, and systematically examining the relationships between different themes.
The familiarization step began when transcribing the interviews as the researchers started to immerse themselves in the issues that participants raised. Each transcript was then read several times in order to become familiar with the data, gain an understanding of the breadth and depth of the data and identify key issues.
A thematic framework based on the key issues identified from the previous step was constructed. The thematic framework was used initially to code four transcripts and additional issues that were not included in the framework were identified. These additional issues were then incorporated into a revised thematic framework and codes identified for each theme and sub-themes: code 1 for the first theme (Educational preparation for practice), 1.1 for the first sub-theme (Nursing school), 1.2 for the next (Literature) and so on.
During the indexing step, the coding framework was systematically applied to individual transcripts. Summarized data from each participant's transcript were then brought together in order to chart the data as a whole. This involved constructing tables for each theme and sub-theme which included a summary of what each participant had said about the specific sub-theme, and specific quotes from the transcripts were also included. This process enabled the research team to gain an understanding of the extent to which different participants contributed data to the various themes and sub-themes.
The final step involved mapping the themes and sub-themes across the whole data set and interpreting the data in relation to nursing students' preparation for and experience of cross-cultural encounters. Interviews were analysed initially by one researcher and the interpretation validated by the other members of the research team.

Ethical considerations
Ethical approval was obtained from the Ethics Committee at the Karolinska Institutet (Dnr 03/550) and the study was conducted in accordance with the University's requirements. Potential participants were given information about the aims of the study and what their involvement would entail as part of the recruitment process. Verbal consent was obtained at the time of interview. Participants were assured that the information they provided would be treated confidentially and would not be disclosed to people outside the research team, and that their anonymity would be ensured in any publications arising from the study.

Findings
All students, irrespective of their ethnic background, referred to cross-cultural encounters in terms of their interaction with patients and relatives who were from an immigrant (i.e. non-ethnic Swedish) background. Interestingly, students who were themselves from an immigrant background did not conceptualise their interactions with ethnic Swedish patients as cross-cultural, rather they interpreted 'cross-cultural' in terms of encounters with other immigrant groups in Sweden.
Three themes relating to students' educational preparation to engage in cross-cultural encounters were identified, namely; (i) experiential learning through life experience, (ii) educational preparation for practice, and (iii) learning in clinical education. Each of these themes will be discussed in turn.

Experiential learning through life experience
Whereas all students had lived in a multi-cultural city in Sweden for a number of years, only students from an immigrant background saw life experience as meaningful in terms of their preparation to nurse in a multi-cultural society. Immigrant students drew attention to how their experiences of living in Sweden post-migration had shaped their understanding and receptiveness to cultural diversity.
Yes, I think it's due to immigration that I've developed as a person. You see and experience a lot during that time (P2) Immigrant students perceived that their personal biography and their interactions with other immigrant communities in the neighborhoods where they grew up enabled them to be more attuned to the needs of patients and relatives from culturally diverse backgrounds.
I grew up in (suburb) and still live there. I speak some Somali, some Arabic, and some Turkish. I come from a Muslim family and I have Muslim relatives …. I've grown up in (suburb) where more than half the population is Muslim, so I understand Islam (P9).
Immigrant students also perceived that their life experiences of interacting with people from different immigrant communities enabled them to be confident in their interactions with patients from different cultural backgrounds. Rather than be concerned with potential cultural difference, they felt better able to focus on the needs of the individual patient.
I've had so many experiences in my past. It comes automatically in a way… you cross over a line, and finally you don't see cultural differences anymore, you see the person. It's the person that's important, not the culture, the religion or the background. I've reflected on whether it could be due to my background, my openness, that I am myself (P2).
In addition to influencing how students responded to cultural diversity, life experiences enabled immigrant students to develop skills and confidence in responding to racism.
I grew up in a neighbourhood where racism was common and I learnt how to confront it (P10) By contrast, students with a Swedish background did not provide illustrations of how their life experiences had helped equip them to engage in cross-cultural encounters in nursing practice.

Educational preparation for practice
Students were generally positive about the contribution that formal education in the university had made to developing knowledge and skills to support cross-cultural encounters. Whereas immigrant students emphasized the contribution that life experiences made to helping them interact with patients from different cultural backgrounds, ethnic Swedish students placed more emphasis on the learning that had taken place within the university. The university provided a 5 week full-time course in transcultural nursing which introduced students to relevant theories from sociology and anthropology which helped inform their understanding of cultural diversity in relation to nursing practice and develop skills in intercultural communication.
The course in transcultural nursing increased my awareness about cultural differences, what is normal for me is not necessarily normal for others (P6) Understanding the cultural practices of people from different cultural backgrounds enabled students to become more accepting of cultural difference and have greater confidence in their interactions with patients: (It's about) how to encounter a person when it's normal for them but not for us. (P4) Students perceived that their educational preparation had also enabled them to develop self-awareness in relation to cultural diversity. By developing greater awareness of their own cultural identity they felt better able to understand the patient's perspective.
You start to think about who you are and what cultural background others are from and what it is that affects their reactions… And then you look back on yourself. What is it that makes me react in the way I do or why do I handle the situation in the way I do? (P6) You've learned how to put yourself in the situation, to handle cultural differences… to think in a different way (P8) I learned some words in Arabic. It came from what we have learned about cultural meetings, and I thought that this could help. I showed that I wanted to meet her, to understand (P1) The opportunity to participate in overseas educational exchange visits was also seen by students to be beneficial in helping to raise their awareness of their own cultural identity.
Exchange studies helped further with the knowledge to know yourself... It feels more like I'm starting to understand who I am and beginning to accept that I cannot put myself in a box, I fit like a bit of everywhere. It is an advantage, not a disadvantage. (P9) Whereas the majority of students were positive about the contribution that university-based education had made to equip them with the knowledge and skills for cross-cultural encounters, one student felt that the emphasis on cultural differences could result in stereotypical assumptions about different cultures developing.
I think in terms of cross-cultural care encounters, nursing education was rather problematic… to learn about this culture, read this book, it's a bit cookbook-like (P7).
In summary, students generally felt that their university-based education had developed their self-awareness and made them aware of cultural diversity in relation to patients they may encounter in clinical practice. Moreover, communication skills training had equipped them with techniques to facilitate communication across language barriers.

Learning in clinical education
The students' descriptions were quite similar when they shared their experiences about how clinical education in practice settings prepared them for their cross-cultural encounters. Students found themselves utilising their skills in self-awareness in order to reflect upon how they responded to cross-cultural encounters.
When you enter an unfamiliar situation, (you ask yourself) 'why is it like this?' 'what is it that stops me from acting properly?' (You think) 'well you are like this'… then you have a better understanding of why the patient acts in the way he does, if it is part of the culture or religion or whatever... (P6).
Critical reflection on practice was another means whereby students learnt in practice. One student recounted on how when faced with a potentially challenging cross-cultural encounter she had not engaged fully with the patient in ascertaining her needs but had made assumptions based on cultural stereotypes. Through reflection on practice she gained new insights into how stereotypical assumptions could influence her practice inappropriately.
It was really an eye-opener, I took for granted that she was very different, I probably became afraid of her and avoided her. Instead I could have just talked to her even if it would have been more demanding than if I'd have spoken to a Swedish woman (P7).
University-based education had provided students with a knowledge base to inform cross-cultural encounters. Although communicating with patients and relatives from different cultural backgrounds, especially where there were language barriers, was challenging students perceived that they could try different techniques to facilitate interaction.
It felt like it was another climate for communication (at the clinical placement). No one (the staff) assumed they would understand each other at once. It was almost as if they assumed there would be problems communicating with each other but that you could solve it somehow (P8) However, although students felt that they had had received some useful preparation for cross-cultural encounters, they experienced additional challenges in clinical practice for which they felt inadequately prepared. Several students were exposed to negative attitudes, racism and discrimination towards patients and in some instances towards themselves during their clinical placements which they found distressing and were inadequately prepared to deal with. Some students reported instances where nursing staff had expressed prejudicial views towards specific patients. One student gave an example of a young immigrant female patient who had migrated to Sweden following an arranged marriage. The woman had subsequently felt socially isolated and was hospitalised following a suicide attempt. The student considered that both medical and nursing staff viewed arranged marriages as 'abnormal' and they did not want to understand the woman's situation.
The problem was that she (the patient) had problems with the staff who didn't take her seriously. They had some kind of prejudice towards her -'you are so stupid to agree to get married'. They didn't want to understand her, but it was her culture and for her it was normal. They (the staff) looked upon it as unnatural; she (the patient) felt that she wasn't taken seriously… It didn't feel right with these prejudices that they (the staff) didn't even consider to think differently. (P10).
Other students provided illustrations of where they had observed other staff show unwillingness to engage fully with patients from a different culture to their own. I don't know what causes it, but they'll go into a patient and come out again saying 'I have not been able to talk to him, it did not work, I can't, end of story.' (P2).
Alternatively, they found that staff expressed more general negative attitudes towards a specific culture. One student recalled that when she shared the focus of her final year project on cultural diversity, it promoted staff to voice their own prejudices.
When I said that I wrote about culture, the people (staff) individually began to say 'Yes, I think the worst cultures are Gypsies.' (P7).
Some students from an immigrant background had experienced disparaging attitudes in relation to their own ethnicity from patients and relatives.
A patient made some comments about not wanting dark skinned persons (looking after them), I am light brown (P9).
He says he doesn't want a 'wog'. Then he continued to call me 'wog', 'Negro', all kinds of things (P10).
Some students also interpreted patient or relatives behavior as disparaging, even when they could not fully understand the language.
I suspect that they were saying condescending things about me when I was in the room. I can't say it for sure (relatives were speaking in another language that the student did not understand) but it felt like it. I tried to be as professional as possible and do as a good job as possible (P1). Immigrant students who had experienced prejudices suggested that if they were exposed to this directly they acted upon it but if it was second hand information they ignored it.
Nursing students emphasised that they had not learnt how to deal with racism during their university education. Whereas students from an immigrant background felt that their life experiences had helped them to deal with such situations, students from a Swedish background were less confident. Irrespective of ethnic background, students found their experiences of racism a cause of considerable distress and felt inadequately supported by other staff.
Several students expressed concern that if they witnessed racist comments from patients directed towards students from an immigrant background they experienced a lack of support from their clinical supervisors. The lack of active intervention meant that patients were able to continue their racist behaviours unchecked. A student from an Iranian background recounted a situation when a patient's behaviour was effectively condoned by a lack of intervention from a nursing assistant.
A man in his eighties came for a blood pressure check-up and he did not want me. He called me all sort of names. I told him that he can go somewhere else for a check-up and he says 'no I want someone else'. Then a nursing assistant came in and said 'I can take the blood pressure' and she did… I stayed in the room and watched and he was sitting there with a big smile looking at me. Afterwards I told the nursing assistant that I was disappointed at her and that she had allowed racism to continue due to her actions. She just said 'no, no, come on it wasn't like that, all old people are like that, it's normal' (P10) Students also drew attention to instances where they would have valued the opportunity to observe and learn how more experienced staff dealt with difficult situations where patients expressed racist views.
I was in there by myself with the patient… It was good in one way but I think that I would have preferred to have someone with me a bit more often, and right then in this meeting I would have wanted my supervisor with me. I would have wanted to see how she would have handled the situation (P5) In summary, it was evident that students were able to apply learning gained as part of formal university education in cross-cultural encounters in clinical practice, however they also experienced racism in clinical settings which they felt inadequately prepared to deal with.

Discussion
According to the literature (c.f. [21][22][23]) cultural awareness is an essential step towards developing cultural competence and thereby being able to provide cultural sensitive care to patients from diverse ethnic backgrounds. When it comes to developing cultural awareness, nursing students with an immigrant background appeared to be at an advantage compared to nursing students with an ethnic Swedish background, irrespective of whether nursing students with immigrant background came to Sweden at a very young age or as an older child closer to becoming an adult. It could be argued that their cultural awareness is due to the surrounding area in which they reside (usually living in multi-cultural suburbs since arriving in Sweden) as well as their own earlier experiences of not being able to communicate in Swedish. Not being able to understand others or being able to make oneself understood is an useful life experience to bring to cross-cultural encounters [24]. The findings from this study indicate that immigrant students and ethnic Swedish students i.e. students from the majority population have different life experiences and perspective when entering nursing education and this may be why Swedish nursing students emphasized the importance of the theoretical university-based education to a greater extent than immigrant nursing students. Ethnic Swedish nursing students appear to have a greater need to develop cultural awareness through different educational activities such as exchange programs [9,25], simulation games [16] and immersion with specific cultural groups [26,27] compared to students with an immigrant background. The benefit of having an immigrant background was also identified in a Swedish study of health care workers in elderly care settings where first generation immigrants reported being more cultural aware than ethnic Swedes, even though the differences were not significant [28].
Transcultural nursing models highlight the importance of understanding cultural differences in order to be able to deliver cultural competent care (c.f. [2,29]). Cultural understanding was also emphasized by nursing students in this study. Nursing students highlighted that being able to understand cultural differences was something they had been prepared for during their nursing education. Whereas nursing students with an immigrant background emphasized the impact of the education, they also stressed that their experience as immigrants had enhanced their understanding of cultural difference. However, the education program had not prepared them to be able to handle negative attitudes, racism and discrimination, whether it was towards themselves, patients or other students/colleagues. Other research studies [28,30,31] have identified that minority ethnic healthcare staff perceive more discrimination than healthcare workers from the majority population. In this study, several nursing students were, in relation to ethnicity, exposed to prejudices, discrimination and racism or witnessed it from staff towards minority ethnic patients during their clinical placements. Nursing students emphasized that they were inadequately prepared during their nursing education to address prejudices, discrimination and/or racism, whether it was directed towards themselves or towards patients. Being able to address inequalities and discrimination is an important part of being culturally competent [4,21,29]. Students in this study had been taught how prejudices and racism occur, but not how to address it. Tilki, et al [32] emphasize that racism in nursing curricula is often neglected as nursing lecturers are not well equipped for this due to problems at both on an organisational level and an individual level. This may be the case in the present study. However, the failure to address racism and discrimination could also be related to the theoretical frameworks that Swedish nursing curricula usually draw upon. In Sweden, North American transcultural nursing models are often used and these models do not emphasise racism and discrimination to the same extent as transcultural nursing models from the United Kingdom and New Zealand [21].

Limitations
The findings from this study are based on interviews with ten nursing students who reflected on how their life experiences, their university education and their experiential learning in clinical education had prepared them for engaging in cross-cultural encounters. The small sample size which was drawn from one university in Sweden means that caution needs to be exercised in assuming that the findings are transferable. Nevertheless, the fact that some of the issues raised in this study are reflected in the wider literature suggests that the findings are relevant to other contexts. The study has also identified the different experiences of nursing students with ethnic Swedish and immigrant backgrounds. However, further research is required to ascertain where such differences exist more widely in Sweden and in other countries where people from immigrant backgrounds are recruited into nurse education. The findings in this study are based on interviews with nursing students reflecting over their experiences of cross-cultural encounters during clinical placements and their educational preparation for these encounters.

Conclusion
Although nursing education had equipped nursing students with the necessary tools, such as increased self-awareness, and the knowledge and skills, to manage cross-cultural encounters, it had failed to prepare students to deal with negative attitudes, racism and discrimination. Nurse educators need to place greater emphasis on preparing students deal with difficult situations arising from racism and discrimination that they may experience in clinical practice. Students need to understand why racism and discrimination may occur and also how to respond and act appropriately. Conclusively, this study provides important information about nursing students' experience of cross-cultural encounters that needs to be addressed in nursing education. Students need to be provided with educational opportunities to develop the necessary tools to care for patients from different cultural backgrounds as well as the tools to respond to negative attitudes, racism and discrimination. The findings from this study can therefore be used to inform the development of preregistration programs and continuing professional development for registered nurses.

Ethical Approval
Ethical approval (Dnr 03-550) was obtained from the Ethics Committee at the Karolinska Institutet and the study was conducted in accordance with the University's requirements.