A tailored program of support for culturally and linguistically diverse ...

Nurse Education in Practice 10 (2010) 355e360

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A tailored program of support for culturally and linguistically diverse (CALD) nursing students in a graduate entry Masters of Nursing course: A qualitative evaluation of outcomes Maureen A. Boughton, Lesley E. Halliday*, Lynne Brown Sydney Nursing School, University of Sydney, 88 Mallet Street, Sydney, Australia

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 1 May 2010

This paper aims to firstly explain why a support program is necessary and describe briefly the support program for culturally and linguistically diverse (CALD) nursing students enrolled in a two year accelerated Master of Nursing program at the Faculty of Nursing and Midwifery, the University of Sydney. Secondly, it aims to address the underpinning pedagogical approach to delivery of the program and finally this paper reports the findings of a qualitative evaluation of the program. The program was introduced in semester 1, 2008 and aimed to facilitate improved student satisfaction by addressing the academic, communication and relational challenges identified as having a significant impact on both CALD students’ academic achievement and their performance on clinical placement. Teaching and support strategies included interactive delivery, activities in small groups and the use of video clips, reflective feedback sessions, and open discussions. An evaluation, based on 13 semi-structured interviews explored the consequences of the program on student satisfaction and to determine whether the student learning experience had been enhanced. Crown Copyright Ó 2010 Published by Elsevier Ltd. All rights reserved.

Keywords: Nursing Education Students Support Program CALD

Introduction Recruiting and retaining nursing students from CALD backgrounds is important to increase the diversity of the nursing workforce in Australia and to enable the provision of culturally specific care that Australia’s multicultural society requires (Davidhizar and Shearer, 2005; San Miguel et al., 2006; Shakaya and Horsfall, 2000). This need for culturally competent care, alongside a general increasing nursing shortage, has prompted universities to create alternative pathways into the nursing field (Steib, 2005), especially for students from overseas. One such pathway e the two year Master of Nursing (Graduate Entry) (MN (GE)) program e was introduced into the Faculty of Nursing and Midwifery, at the University of Sydney, in 2006. The MN (GE) is an accelerated program that enables individuals with non-nursing degrees to fulfill the requirements for registration as a registered nurse in Australia. Like many other condensed programs that are available worldwide, this professional degree requires the students to complete an accelerated and intensive academic work load,

* Corresponding author. Tel.: þ61 424 102505. E-mail addresses: [email protected] (M.A. Boughton), lesley. [email protected] (L.E. Halliday), [email protected] (L. Brown).

communicate to a high standard both written and verbally, as well as participate in clinical placements. Condensed or accelerated programs have been offered for more than 20 years in the United States at the Baccalaureate level (Walker et al., 2008) and the situation is similar in the UK (Halkett and McLaffetry, 2006). Singapore Ministry of Health introduced a Strategic Manpower Conversion Programme (Healthcare) that was an accelerated nursing course in preparation for registration as a nurse in the last decade. Canada also has offered accelerated programs for many years. The accelerated programs were first considered as a means to increase the number of people entering nursing but increasingly they have been used as a strategy to cope with the global shortage of nurses (Obermann, 2004; Cangelosi and Whitt, 2005). Walker et al. (2008: p. 348) refer to the diversity of the cohorts in terms of ethnicity but they do report any focus on supporting the learning needs of this group specifically. Students in the MN (GE) 2006 cohort were culturally and linguistically very diverse, with almost 50% from countries whose first language was not English. During 2006 it became evident that many CALD students enrolled in the MN (GE) needed a high level of support to enable them to effectively meet the academic demands of the course as well as perform to the expected levels whilst on their clinical placements.

1471-5953/$ e see front matter Crown Copyright Ó 2010 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2010.05.003

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M.A. Boughton et al. / Nurse Education in Practice 10 (2010) 355e360

Recent studies have identified a number of perceived barriers that can hamper CALD students’ progress including different expectations of teaching styles to those experienced within the Australian system, difficulties with language and communication styles, lack of confidence to speak out and ask questions and approach teaching staff, as well as difficulty establishing peer relationships and experiencing loneliness and a feeling of isolation (Amaro et al., 2006; Davidhizar and Shearer, 2005; Gardner, 2005; Gunn-Lewis and Smith, 1999; Jeon and Chenoweth, 2007; Omeri et al., 2003; San Miguel et al., 2006; Villarruel et al., 2001; Wilson et al., 2006). Consequently, CALD students often find academic expectations and clinical placement difficult as they have to adapt quickly to the learning environment, while embracing a different language and culture and they must do this at a higher academic level compared to those accelerated programs referred to in the US and UK. It became apparent that many of these students needed additional support in developing and clarifying the necessary skills and abilities to integrate successfully into this environment and achieve academic success (Brown and Anema, 2007). Given the multitude of issues that can affect the educational experience of CALD students, as well as the enhanced academic pressure prevalent on post graduate ‘accelerated’ nursing courses, the faculty decided to implement a tailored program, to execute strategies such as academic and communication support, mentoring, and clinical orientation and preparation that have been suggested in the literature to enhance overall student satisfaction and success and also to facilitate maximum student retention (Kilstoff and Baker, 2006; Merrill, 1998; Wilson et al., 2006; Yoder, 2001). The program The CALD program was executed during semester 1, 2008 by three academics from within the faculty and consisted of a series of workshops specifically developed to address the unique needs highlighted in the research literature, and drawing upon a similar program (focusing on undergraduate students) that had been undertaken and favorably evaluated within the School of Nursing and Midwifery, at the University of Tasmania during 2006. Our program commenced with a 5-h introductory workshop then nine subsequent sessions lasting for 1.5 h and aimed to: facilitate overall improvement in students’ experience and satisfaction with the course; enhance CALD nursing students’ academic capability through greater participation in learning; improve retention in and progression through the course; and prepare/equip CALD students for clinical nursing placements by minimizing the stress associated with clinical placement and enhancing clinical safety and competence.

Invitation to participate in the program As this was a voluntary program, information about the program and invitation to participate flyers were sent to students from CALD backgrounds who had indicated their intention to enroll in the Master of Nursing (GE) and others were approached individually and invited to participate at the time of enrolment. Who participated e group profile In total, the group consisted of 3 males and 14 females. 3 students were from Korea, 2 students were from the Philippines, 2 from Tanzania, 2 from the USA, and one each from Singapore, China, India, Laos, Romania, Nigeria, Kenya and Zimbabwe. The average

time that students had been living in Australia was 6.4 years, with a range of between one week and 29 years. Of the 17 students who completed a questionnaire, 15 were full time, 2 were part time, and 11 considered English to be their main language. The majority of students (n ¼ 9) who attended the program were over 40 years old. Eleven were married, and 12 had at least one child. In line with the admission criteria of the course, all the students were post graduates, and first degree types were varied (engineering, science, health, law, agriculture, zoology). Seven of the students already possessed postgraduate qualifications at Masters level. Sessions e underpinning pedagogical approach The pedagogical underpinning of the program is participatory learning. The rationale for this approach is based on research that identifies reluctance to participate actively in class as a common issue negatively impacting learning for CALD students (Gardner, 2005; Sanner and Wilson, 2008) as well as our experience of teaching the 2006 students who were reticent in class despite the adoption of several strategies to increase participation. Effective communication is pivotal to safe nursing practice (Garling Report, 2008) hence some priority is placed on involving participants in role playing communication in a supportive environment. The group dynamic was built on respect for each other’s culture, freedom to speak and raise any issues of concern that may be impacting their ability to learn effectively. One such issue the participants highlighted was their struggle to read and comprehend the journal articles and other resources required for tutorial sessions. The students subsequently formed learning groups of 3e5 people and shared the preparatory reading. This strategy enhanced their understanding of the articles and their communication skills as they wrote summaries for fellow group members and/or scheduled a meeting to discuss the readings prior to the tutorial. This strategy led to increasing levels of confidence, academic writing practice and greater engagement in the tutorials as reported by both the students and tutorial staff who noticed a significant difference in participation. A second valuable outcome of forming learning groups is the potential for the naturally forming social support networks. As we report later in the paper this outcome was highly valued by the participants and it impacted significantly on the retention of CALD students in the course as they felt supported in their challenges. Sessions were mixed, with some emphasizing relationship building to promote social support, friendship and peer relationships, whilst others focused on academic requirements of the course. Students received sessions involving the use of the library and student web pages, critical reading skills, referencing conventions and avoiding plagiarism, examination and revision preparation, communication skills for clinical placement, the use of Australian colloquialisms, common terms and expressions for body parts, and other phrases encountered in the healthcare environment. Within a participatory learning framework the teaching and support strategies for all sessions mentioned above, included interactive delivery, activities in small groups, video clips with role play, reflective feedback sessions, and open discussions. A major objective of the MN (GE) is preparation for competence to practice safely as a registered nurse in a variety of health care settings. As such we identified challenges for CALD students such as ineffective communication with colleagues and patients and their family members. Situations in which communication is ineffective can result in risk to patient safety and compromise the quality of care (Garling Report, 2008). Further issues that we had identified related to difficulties with pronunciation, telephone communication, the


use of colloquial expressions and semantic differences as well as dealing with nursing/medical jargon. In addressing these potential situations we used video clips in which misunderstanding of communication between the nurse and a patient occurs. This is used as a trigger to discuss the scenario and problem solve the situation. We invited a previous student from a CALD background to participate and share her personal experiences of communication difficulties and how she had resolved them. Students learn how to avoid similar situations from participating in the discussion. Another strategy we used to assist the transition to the clinical area from the classroom was to discuss the various colloquialisms and terms for body parts. For example terms used by individuals to express a need to ‘empty their bladder’ were discussed and the group found this somewhat amusing. The humour contributed to student engagement and enhanced student learning. Students are invited to actively participate in sharing the expressions used for emptying the bladder in their country of origin.

Evaluation of the effectiveness of the CALD program Ethics At the outset we intended to evaluate the effectiveness of the CALD program in terms of outcomes for students. During 2007 the program was prepared and also ethics approval gained through the University of Sydney Human Ethics Committee to conduct an evaluation of the effectiveness of the program. Interviews with consenting participants were undertaken to determine their views/ perceptions on the effect of the program upon them in relation to our aims. At the outset it was a conscious decision to evaluate the program outcomes and effectiveness in a rigourous manner and hence the research approach was adopted in terms of ethics, delivery of the program, collection of evaluation data and content analysis of the transcripts of interview. We qualitatively evaluated the effectiveness of the program by using end of semester semi-structured interviews with 13 participating female CALD students that lasted between 20 min and 45 min. Two members of the CALD program team who did not have teaching/coordination responsibilities within the course conducted the interviews. The interviews were digitally recorded and transcribed verbatim and a descriptive analysis (Holloway, 2005) of the data was undertaken to determine common responses that would indicate positive as well as potential negative effects of the program.

Evaluation e findings The evaluation of the program was overwhelmingly positive. The responses from the interviewees were categorised relating to the benefits of participating in the CALD support program in enhancing academic potential, the initial experience of clinical placement and the student learning experience. Enhancing academic potential The program gave the students an ‘extra boost to do well’ by instilling confidence and information to enable them to move forward with their studies. It was reported to be ‘of great benefit’. In relation to enhancing academic potential, the interviews demonstrated that the program broke down perceived barriers between academic staff and students through the development of relationships, which in turn gave students the confidence to approach staff directly for help, speak out in larger group sessions (lectures) and ask questions.

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.it was something that gave us the boost to be more like assertive in class like when we have to ask questions but we are not hesitant to say that I don’t understand this can you please explain it to us. cause its if we are thinking it then ok maybe someone else from CALD has the same question too and we might as well ask it so that its clear and then he’d ask even if its another person from CALD like did you understand and such and such and its like yeah.. this and that’s and its like ok . (P1, 75) It also provided invaluable information and advice relating to computer use/resources and more practical skills such as essay writing, referencing and critical reading. Being a group member gave participants a sense of ‘privileged’ access to peer support with other CALD students, which in turn maximized opportunities to clarify coursework requirements, share resources, and study as a group outside the scheduled CALD meetings. This not only enhanced understanding, but also gave the students access to a large variety of shared resources sourced by individual group members. One student referred to the group as an extra ‘learning tool’. Students told how they checked each others work for grammatical errors, helped each other to interpret assignment questions, and utilized available supplementary lab sessions with other CALD students to check that procedures they were using were being undertaken correctly. The students reported a sense of ‘friendly competition’ amongst the group members, which again spurred them on to do well. Participation in the program was also reported to have diverted a number of the interviewed students from ‘quitting’, with one claiming that: .the program it has really supported me to you know survive in this place so far otherwise if this support is not in here, definitely I couldn’t go on I am telling you I couldn’t because the support that is given by the lecturers in the CALD program is very so supportive morally and everything (P11, 11) Another quite succinctly voiced her “vulnerable determinism” (Di Gregorio et al., 2000) and the importance of CALD in maximizing the potential of students to successfully complete their studies: .I really want to be a nurse so if staff help a little bit why quit I am not going to quit because I am strongly determined so if CALD help the people it will help the student to stay I think (P6, 122) Enhancing the experience of clinical placement Students indicated they felt well prepared for their first placement. They also said they felt less nervous or anxious, more comfortable and relaxed, and generally more confident as a consequence of having clear expectations of their role and responsibilities within the clinical environment. I went there prepared and I was more comfortable I mean if I didn’t have that information [from the CALD program] I would have been scared and confused not to understand but that session gave me. it was a kind of a preparatory talk for me to go out in the field (P10, 64) The students particularly valued the opportunity to learn about effective communication and colloquial language that would potentially be encountered in the clinical environment. One student spoke of her “CALD note book” (in which she had taken personal notes from every session) as a source of comfort, which she kept in her pocket while on placement and referred to at various times as required. Although handouts of words were supplied, the students reportedly liked the discussions carried out in the group sessions. They felt

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supported, confident and empowered as they had talked through various scenarios, and discussed different terminology to enable them to better understand various colloquialisms used by patients. They appeared to view this strategy particularly positively. They claimed that had they not been prepared, they would have felt anxious as they would not have understood what the patient was referring to. These students also valued the continuing assistance received and the post-placement reflection sessions where they had the opportunity to listen to, and talk about their experiences. As well as sharing their own experiences, they also appreciated having the opportunity to learn about less positive experiences. Through group discussion including session facilitators, they were able to talk through and formulate strategies to deal effectively with such situations, should the need arise in their own future placements. The chance to talk through various coping strategies and ways of resolving potential difficulties e who their first point of call should be, where they could find help, the best way to handle issues e this all reportedly added to their confidence levels. I think it will help me to tackle the situation better compared to if I don’t really. haven’t heard or talked to anyone about the situation that happened to them.you know..in any thing in life I guess if you have information from other people you go oh at least I know what to do next time or next you know when it comes over and although its your first time to experience it yourself you can always pool the information you know.behind somewhere in your brain and then go oh I think that’s what she did you (P7, 88) The reflective feedback session was also viewed as a place to talk through their problems and gain valuable moral support for students whose experience had been less than positive: I had some problems with my clinical placement [but] at least I was able to talk with others even though the problem wasn’t solved fully. At least I feel very relieved and I fell like, I feel like I have someone at least I have someone who is ready to listen to me (P13, 15) Enhancing the student’s learning experience The program provided students with an important source of support by fostering a sense of belonging, providing an identity, and facilitating the development of cherished friendships, which in turn made the students feel valued and important. This sense of affiliation alleviated the feelings of isolation and loneliness reportedly experienced by several students, while others commented on how being involved gave them reassurance and a confidence boost through the realization that they shared similarities with many other students in the course- something that many had preciously perceived would not be the case. I met all these different people who have the same goal and another thing is they are all from different backgrounds and that makes you immediately feel at ease e that I am not alone, I am not the only second English as a second language doing this so just because of that that is a lot of uhmm confidence that you gain straight away (P12, 8) It appeared that the students had such a low expectation of help and co-operation from peers and staff, that when help was offered, it was received with gratitude and often disbelief. They reported feeling ‘blessed’ that someone had actually taken the time to help them. They appreciated this help, and acknowledged that academic staff were actively trying to help them achieve their potential. This appeared to instill a sense of feeling valued and respected as a student within the faculty.

The opportunity to meet and talk with others ‘in the same boat’ who understood and shared common problems, issues and challenges was particularly appreciated, as was the opportunity to speak out, share and express themselves in what they considered to be a safe, friendly non-judgmental environment. Having a place to discuss and share problems was also considered a main source of support, especially as many of the students involved in the group had no immediate family in Australia. I feel people are.uhmm.we have same problem and same stress and want to support each other because we want to be a nurse we have to look after each other I think but under stress we have no space I think I feel yes kind of not much interaction with the other students so that’s changed everything’s changed (P6, 74) Being part of the CALD program was referred to by one student as like ‘being at home’. In my background we are very sort of that kind of gathering like we are always together its not separate everyone doing his or her own things so when we gather like that I feel at home (P2, 69) The opportunity to clarify issues was also appreciated as several students reported being hesitant to ask questions, and speak out in larger group sessions, such as lectures for fear of not being understood or feeling ‘stupid’ because of their accents. Perceived communication difficulties also seemed to act as a barrier to successful integration with peers who were Australian. As a consequence, the friendships developed with other CALD students were particularly valued especially as many of the students had embarked on the course with no expectations that they would develop connections and bonds with other students. All talked with animation about the friendships they had formed with others in the CALD program. Several of the women interviewed became emotional as they portrayed what a difference the CALD program had made to them, and talked of the group as a ‘nucleus’, enabling them to acquire much needed support. .we got on really well especially among the females you know we all have different skin colours but we [are] all really working well together uhmm I think I mention that to the room [in a CALD session] I am looking after [my] clinical really really sick mum and I couldn’t do something, and all of a sudden there’s a chain of events that all these other ladies were helping me out you know getting information to me and not only for that aspect with my studies but I was in tears like today and they were there to help so its not only the academic side but the social side as well (P12, 36) Discussion The purpose of this program was to provide support to CALD nursing students by addressing several previously identified challenges and barriers to their learning and academic achievement. The evaluation findings highlight the benefits of implementing a program such as this for CALD students in accelerated nursing courses, with the program appearing to be successful in several areas; firstly, it provided students with the necessary academic resources and support to maximize their chances of success. Secondly, it enabled the students to make cultural adjustments, develop additional knowledge and necessary skills that set them in good stead for their first experiences within a clinical nursing environment. Finally, the program provided much needed support from peers, and avenues for friendship and social support alleviating feelings of isolation and some students claimed it contributed significantly to their decision to remain in the course.


As a consequence of participation, the students had the opportunity to develop relationships and speak with staff, and ask questions outside the typical academic environment (i.e. lectures/ tutorials). This appeared to serve two purposes for the participants in this program. Firstly it instilled them with the confidence to directly approach staff with issues relating to coursework and assessment, something that they reportedly would have been reluctant to do previously, and secondly it made them more comfortable and willing to speak out in lectures if clarification of certain points was necessary. Several authors have reported on the benefits of developing strategies to overcome the barriers relating to achieving more interaction from CALD students to encourage students to ask questions during academic sessions especially in light of suggestions that both nursing students and nurses from CALD backgrounds may be prone to silence through incomplete or imperfect communication often choosing not to speak out in class because of being self conscious (Sanner and Wilson, 2008), or perceive non-CALD students/academic staff as not having the patience to listen to someone with an accent (Lacina, 2002). In addition the benefits of developing relationships and rapport between staff/students include instilling a sense of student empowerment, value and importance (Holtz and Wilson, 1992) as well as perhaps coaxing a struggling student to remain on a course (Christie, 2004). The participants in the program reported to have particularly enjoyed belonging to a small group of students with similar issues, concerns and challenges, which appeared to foster their sense of affiliation, appeared to raise their self esteem, decreased their isolation and provided mutual support as well as fulfilled their need for social acceptance and group membership. It has been suggested that the need for social belonging- for seeing oneself as socially connected- is a basic human motivation (Walton and Cohen, 2007). Being in the presence of students who share characteristics is reassuring and fulfills a need to feel affiliated to a group who understands specific issues that often arise for students (Kevern and Webb, 2004). The ability to openly ‘speak out’ or communicate in a safe place and to discuss issues relating to academic study, clinical placement, or more generic challenges in a ‘friendly’ and ‘non-judgmental’ environment was particularly valued and reflected previous findings (e.g. San Miguel et al., 2006). As was the opportunity to build networks, form friendships and utilize various support pathways offered by other group members, which led to a level of support that exceeded that initially offered by the program. Furthermore, the finding that participation virtually eliminated the sense of loneliness and social isolation in this group attributed to the group’s facilitatory aspect of maximizing the students exposure to similar others with whom they could develop deep social bonds, is encouraging, especially as both loneliness and isolation have been identified as a persistent theme for both CALD nursing students and overseas qualified nurses (Omeri et al., 2003; Rogan and San Miguel, 2006). This social support acted as a buffer against potential mental health problems (i.e. anxiety, stress) which in turn maximized the students’ potential for academic success. The notion that overseas students value the opportunity to study in small groups has been demonstrated in the literature (Ramburuth and McCormick, 2001; Shakaya and Horsfall, 2000). The students enrolled in the program formed their own ‘small’ study groups outside the scheduled CALD program sessions. This had far reaching benefits in terms of sharing resources, informal peer instruction and frequent clinical practice sessions in the labs. This use of available additional resources appears to have assisted these students with many academic aspects of the course, as well as provided them with ‘healthy competition’. It has been suggested that ‘students who are pro-active about their learning and who take

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advantage of every support opportunity may be more likely to succeed than students who do not access all available support’ (Bretag et al., 2002, p.11). Communication difficulties often impact on the clinical placement experiences of CALD nursing students (Rogan and San Miguel, 2006). In addition to this, CALD students often report very little, if any, prior experience of health care (or hospitals) before their first clinical placements, which leads to heightened stress and anxiety levels because of lack of clear expectations (Timmins and Kaliszer, 2002). This program addressed these challenges by providing students with the opportunity to practice Australian colloquialisms and common ‘slang’ which they were likely to be faced with on placement. It also provided them with opportunities to discuss video vignettes of role played that developed their confidence to deal with various scenarios in a clinical setting and provided clear expectations of their role and responsibilities. This reportedly modified their anxieties and provided reassurance to enable them to develop the knowledge and skills needed to make the cultural adjustments, communicate effectively and undertake their role in a competent and confident manner. Conclusion Given the growing importance of a CALD nursing workforce in Australia, it is essential that to maximize the success of CALD nursing students, nursing faculties conduct programs of support that not only enhance academic potential, but also address problematic aspects of clinical placements and the social needs of these students. This evaluation of a tailored program for CALD students has demonstrated clearly that the challenges CALD students face are multifaceted and complex. However, given the fact that this project involved a small number of students and was a pilot program carried out during one semester, it is clearly not possible to make generalisations, nonetheless, the evaluations of the program were extremely positive which suggested there is a need for ongoing program development and evaluation to enhance the student learning experience within the faculty whilst at the same time maximizing student potential for future success as registered nurses within Australia’s multicultural health care system. Acknowledgements This study was supported by a University of Sydney Teaching Improvement and Equipment Scheme (TIES) grant. References Amaro, D.J., Abriam- Yago, K., Yoder, M., 2006. Perceived barriers for ethnically diverse students in nursing programs. Journal of Nursing Education 45 (7), 247e254. Bretag, T., Horrocks, S., Smith, J., 2002. Developing classroom practises to support NESB students in information systems courses: some preliminary findings. International Education Journal 3 (4) Education Research Conference 2002 Special Issue. URL: http://www.flinders.edu.au/education/iej. Brown, B.E., Anema, M., 2007. The road to excellence for minority graduate students. Nurse Educator 32 (6), 234e235. Cangelosi, P.R., Whitt, K.J., 2005. Accelerated nursing programs what do we know? Nursing Education Perspectives 26 (2), 113e116. Christie, H., 2004. Leaving university early: exploring the differences between continuing and non-continuing students. Studies in Higher Education 29 (5), 617e636. Davidhizar, R., Shearer, R., 2005. When your nursing student is culturally diverse. The Health Care Manager 24 (4), 356e363. Di Gregorio, K.D., Farrington, S., Page, S., 2000. Listening to our students: understanding the factors that affect Aboriginal and Torres Strait Islander students’ academic success. Higher Education Research and Development 19 (3), 297e309. Gardner, J., 2005. Barriers influencing the success of racial and ethnic minority students in nursing programs. Journal of Transcultural Nursing 16 (2), 155e162.

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