Reflecting on International Nursing Programs

Purpose: "Nurses shall engage in critical reflection of their own values, beliefs, and cultural heritage …," states the Expert Panel on Global Nursing.  The evidence is clear.  As Leininger argues in her theoretical framework, self-reflection is an integral part of nursing education as it promotes self-awareness and assists us to gain cultural-based knowledge. Culture influences the manner in which we obtain, process, and conceptualize (i.e., epistemic beliefs) new knowledge. This qualitative study explores the written reflections of international students who worked on surgical units, and illustrates the impact that culture has on the patterns, processes and knowledge development of students placed in a very different international setting.       

 Methods:    Data consist of reflective materials that international students wrote to describe their clinical experience.  Content analysis was used to examine their writings.  Reflective journals (n=30) were analyzed from international students working in surgical rotations.

 Results:   "I am clearly used to a different culture…," wrote one international student.  Two main core categories were identified in the narratives:  patterns and processes. 

Within the patterns, we noted several themes including habits, self-perceptions, impressions and assumptions.  One written impression was, "In the clinic I saw a lot of family members, patients and staff with different skin colors and clothing, and the general atmosphere felt a lot different than a Norwegian hospital."  The students also held many assumptions.  For example, one student queried, "It was clear that they were from different ethnicities.  How can we care for a patient unable to express his own needs?"

Processes included comparisons, interactions and generalizations.  Written in the reflections was, "we didn't have to ask her all the questions we had set up because she answered them before we got to ask her." Introductions in this new culture were very different.  "…we didn't shake hands.  We always do that we present ourselves in Norway."        

 Conclusions:  International students used the frameworks they knew – the ones' from their own culture.  Faced with the Israeli environment, international students struggled to make sense of this dissimilar population, rhythm of clinical practice, atmosphere, and ways of acting and reacting.  This caused dissonance. 

Norwegian students grew up in a homogeneous and collective culture, and consequently, were comfortable learning in that environment.  They relied on their culture to support the development of their knowledge.  They repeatedly spoke about how "we" understand, act or do things.  They expressed themselves as a collective unit.  This contrasted dramatically with the very different heterogonous Israeli population, with strong Jewish and Moslem ethnic groups and idiosyncratic environment.  This different environment colored the lens through which they learned.    

Reflections are a useful and important method for learning; however, the target of the reflections may differ based on culture.  While some students benefit from reflecting on personal experiences in clinical practice, that is not the ideal method of developing transcultural and clinical knowledge for Norwegian students. They benefit more from structured information using established sources to build logical thinking and focusing on evidence-based knowledge would be a better mode of reflection.  Understanding the way that different cultures learn and develop knowledge is vital for teaching international students.