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| Teaching and Learning Forum 2004 [ Proceedings Contents ] |
Janet Williams
Auckland University of Technology
There has been an increasing number of foreign born nursing students in New Zealand, and it is important to research ways to help these students cope with the expectations of this training program. The aim of the present study is to explore the ways foreign students adapt culturally to the expectations within the baccalaureate nursing program, and to identify the students' perception of their cultural identity, cultural difficulties and any effects such difficulties have caused. The purpose is to assist students to gain control over their learning and increase their ability to cope with their clinical assessments. The study was based on Cummins (2000) 'interactive/experiential' model, using collaborative critical inquiry, which helped the students to relate the content to their individual and collective experience and to identify individual difficulties, in small co-operative teams. The Cummins model was tested for its usefulness in helping foreign nursing students cope in the nursing course. The model successfully enabled the students to cope better with their clinical nursing experience by facilitating the identification of individual challenges, the planning and actioning of suitable strategies.The study also assessed the students' perceived competence in speaking English, their cultural identity and psychological adjustment and found the model did not affect these factors. The implications for nursing educators is that foreign nursing students could be assisted by Cummins Program to achieve their assessments within the clinical setting, by helping them understand what is expected within this new and different culture. The participants were 21 foreign student nurses, who were divided into two separate groups. One group, of 8 students, underwent an adaptation of the Cummins program, in weekly tutorials, over four weeks, in place of clinical tutorials. A comparison group of 13 students had the usual clinical tutorials. Members of both groups completed a questionnaire, on 3 separate occasions. Interviews were conducted with the 6 lecturers involved with the students who took part in the Cummins Program.
The aims of the study were to explore the ways foreign students adapt culturally and for these students to gain a better understanding of the expectations of the nursing course, control their learning, and find solutions to their difficulties, particularly in the clinical setting. The present study was designed to assist both nurse educators and foreign nursing students by identifying the problems foreign nursing students in the study have experienced, and the effects of these problems. Secondly, the study sets out to evaluate effectiveness of the Cummins Program in helping student nurses cope within the nursing course.
There is almost no research into the difficulties foreign nursing students experience in the clinical area, however theories of the affects of immigration and research involving the challenges faced by foreign university students, have provided relevant information on some the issues. For example, theorists suggest that migrating from ones' native culture into a strange, new, and radically different culture, to live, work and/or study, can cause feelings of helplessness, discomfort and disorientation, as the "outsider" tries to comprehend and adapt to the new culture (Berry, Kim, Minde, & Mok, 1987). Asian students were found to have more difficulty with inter-personal relationships, dealing with people of different status and in establishing friendships than their Australian counterparts, in a large, quantitative study in an Australian university (Barker, Child, Gallois, Jones, & Callan, 1989). A lack of language proficiency has been identified by many authors (for reviews, see Abu-Saad & Kayser-Jones, 1982; Chalmers & Volet, 1997; Kennedy, 1995; Shakya & Horsfall, 2000) as a major factor in learning difficulties for foreign students. Many authors have emphasised that all immigrants experience a process of adaptation as they acculturated to the host environment (Taft, 1989; Asante & Gudykunst, 1989; Kim, 2001; Ward, Bochner & Furnham, 2001). The process has been found to be complex, enduring, and involves multiple factors that can be very stressful for the immigrants (Taft, 1987).
Foreign nursing students also have to deal with the complex and uncertain nature of the clinical setting and being observed closely by the clinical lecturer, which Wilson, (1994) found to be very stressful for the majority of nursing students, regardless of nationality, in a large American study. The specific criteria that the students must meet to pass their clinical experience, creates unique educational needs for the foreign students, as they must be able to demonstrate valuing, respect, advocacy skills, therapeutic touch, non-verbal skills, and communication skills with their patients. It has been suggested that these concepts are interpreted in vastly different ways within different cultures (Novinger, 2001). Examples of how each of the concepts may be viewed in culturally specific ways are well documented in the literature (Andrews & Boyle, 1999; Giger & Davidhizar, 1999; Luckmann, 1999; Nolan, 1999). Novinger (2001) explained that direct eye contact signifies honesty and attentiveness in European culture, and is what is expected within the course, but in some Polynesian and Asian cultures, direct eye contact shows disrespect and boldness, or even aggression. Even a smile, which western cultures would read as showing happiness, may be used by a Japanese person to cover unpleasantness or grief, which should not be inflicted on others. For example, a Japanese student nurse might smile "inappropriately" at a newly bereaved western family, which could be very upsetting for the family. The students are also expected to communicate warmth, closeness and availability or "immediacy behaviours". High-contact cultures, such as Western cultures, value such caring behaviours as being a very important part of nursing care. In low-contact cultures such behaviours may be viewed as being inappropriate, or even be seen as disrespectful or embarrassing for the person who is upset. In Japan, a nurse would leave a patient who was upset and crying, so the patient could compose themselves and not to embarrass them further; an action that would be negatively judged by both staff and patients in western cultures. This raises the question of how aware our foreign students are of their cultural interpretations of the concepts, in contrast to the expected interpretations of the nursing course and the impact of these cultural differences on their ability to acculturate into the course.
The approach recommended by Cummins (1989) to achieve this 'interactive/experiential' model was based on Freire's (1978) pedagogical approach, to achieve what he termed 'Critical Literacy'. It included five phases, that take the students through the Experiential phase (brainstorming what the student knows about the topic to be learnt); the Literal phase (questions such as where, when, how, did it happen, who did it, why?); Personal phase (relate questions to their own experiences and feelings); Critical phase (abstract process of critically analysing the issues or problems raised); Creative phase (translate the results of the previous phases into concrete action).
The Cummins Program was adapted to link to the clinical setting and was designed to "validate students' background experiences" by encouraging them to "express, share and amplify these experiences" (Cummins, 1989, p. 29). The central tenet of the model consisted of guidance and facilitation by the lecturer, genuine dialogue between student and lecturer, and encouragement of student-student talk in a collaborative learning context. This facilitated the use of meaningful language, with conscious integration of curricular (nursing/medical) language and focused on developing a higher level of cognitive skills, such critical analysis, and tasks that produce intrinsic motivation. As Freire (1978, p. 28) argued, "it is only through participation in an educational climate in which open dialogue is fostered that students can develop the skills for critical engagement with their world and a genuine sense of participation in a common life".
In summary, Cummins (2000) recommended having the students in small co-operative teams to engage in collaborative critical inquiry. The aim was to encourage students to relate the content to their individual and collective experience and to discuss ways in which they might take action to change their educational realities.
The following questions were investigated:
The same self-report questionnaire was used on three different occasions during this study. The six-page questionnaire consisted of 5-point Likert scales and some open-ended questions, which were selected and adapted from published research for this study. As the modifications to the questionnaire were very minor, the questionnaire was not trialed before use. All the students in the Program group completed the questionnaire three times (Time 1, before the program commenced, Time 2, when the program was completed four weeks later, and Time 3, two months after the completion of the program). Three students in the Comparison group did not complete the questionnaire at Time 2. All other students in the Comparison group completed the questionnaire on every occasion.
| Program | Comparison | |
| Range of ages | 17-50 years | 17-50 years |
| Length of residency | 2-14+ years | 2-13 years |
| Time in nursing course | 1-3 years | 1-2 years |
Approval to undertake the study was granted by the University of Auckland Human Subjects Ethics Committee and Auckland University of Technology Ethics Committee.
The clinical lecturers supervising the participants' were asked to report on observed changes in attitude or practice in their students twice over the period of the clinical experience.
Quantitative data - The questionnaire included sections for demographic information; Perceived competence in speaking English; Perceived cultural difference; Psychological adjustment; and Coping scale. Statistical analysis was carried out using SPSS 10.1 for Windows 98. Descriptive statistics, reliability analysis, and univariate analysis of variance were generated by SPSS.
Figure 1: Comparison of coping over time
Repeated measures multivariate analysis of variance was performed on the within groups levels of coping, which were statistically significant over time, Time 1, F(20) = 1.76, p <.05, Time 2, F(1,17)= .71, p <.05; and Time 3, F(1,20) = 1.02, p <.05.
There was a main effect for the effect for the differences in the program differences between the Cummins Program and the Comparison groups, F(1,16) = 5.79, p <.05.
Figure 2: Comparison of the perceived competency in speaking English over time
Repeated measures multivariate analysis of variance was performed using SPSS, to compare the mean scores on the perceived confidence in speaking English for all the students at Time 1, Time 2 and Time 3 but this was not statistically significant. Although all students gained in their perceived confidence to speak English over time, as seen in Figure 2, there were no statistically significant change between the group in the Cummins Program and the Comparison group over time with F = 0.27 at Time 1, F = 0.16 at Time 2, and F = 1.57 at Time 3, <.05. Within subjects tests also demonstrated that the students within each group did not change over time, F=.004, at p <.05.
Figure 3: Comparison of maladjustment overtime.
Although all students were low in maladjustment and decreased over time, it can be seen in Figure 3 that the Comparison group were less maladjusted at Time 1 and remained very stable. The Program group were slightly higher in maladjustment at Time 1 and Time 2, but were reducing by Time 3. Multivariate analysis of variance found that there was no difference between the group in the Cummins Program and the Comparison group over time; Time 1, F = .48, Time 2, F = 1.89, and Time 3, F = .82. Within subjects tests also demonstrated that the students within each group showed no statistical significant change over time, F = 2.02, p <.05.
Figure 4: Comparison of ethnic identity
Repeated measures multivariate analysis of variance was performed on the within group ethnic identity, which were not statistically significant over time, Time 1-F(1,20) = 0.004, p = .95; Time 2-F(1,17) = 0.005, p = .94; and Time 3-F(1,19) = 0.67, p = .80. There was not a main effect for the effect for the differences in the program differences between the Cummins Program and the Comparison groups, F(1,19) = 0.14, at p =.71.
When they understood that they also needed to be able to give analysis of their strengths and weakness and to outline strategies for improvement, the students indicated this was not something that they had experienced in the education they had been through in their culture (Kennedy, 1995). As one student said, "In my culture we expect the teacher to evaluate us, it is not something we would do. And I would feel embarrassed to tell her about my weaknesses". It became apparent that the culturally specific definitions contained within the concepts, upon which the students are being assessed, needed to be deciphered with the students, in a safe, supportive and non-judgmental environment, as recommended by Darder, (1991). The students had always had the written assessment criteria, but they had not understood the implications of the requirements of the criteria, from the perspective of the nursing course.
The success of the Cummins Program was evident for one student, who announced after the final session, "This is the best thing I have ever done for myself. I was not sure that it would help me, before it began, I couldn't see how it could work, but now I can see how to control my learning; I feel I have the ability to work through it now. I feel great". This student demonstrated ownership of the changes she had made for herself and she indicated that she now feels she has the power and control over her learning and nursing future.
The findings are consistent with those in an American School of Nursing, which used a similar approach to help minority students identify their major stressors, plan coping strategies, take action, and reflect on which strategies were successful with their academic work (Kirkland, 1998). It also supported previous research findings with first year students across disciplines, that found that a contextually embedded approach, linked to the curriculum, which allowed for interaction between the students and the lecturers and facilitated explicit understanding of the teachers expectations, within a supportive, open and friendly atmosphere, helped new students per se cope with tertiary education (Martin & Ramsden, 1987).
Cummins pedagogical approach, implemented within the Program, was designed to encourage students to assume greater control over setting their own learning goals and collaborating actively with each other in achieving these goals (Cummins, 1989). This seemed to provide a basis for the students to move towards self-regulated learning (Winnie, 1997), an important feature of adult learning, (Brookfield, 1991) in a cycle, similar to Kolb's experiential learning, in that each step depends on completion of the previous step, starting with a concrete experience, reflection from differing perspectives, abstract conceptualisation and active experimentation (Papai, Bourbonnais, & Chevrier, 1999).
Competency in speaking English, Figure 2, was rated at a high level by both the Comparison group (at 3.7 out of a possible 5) and the Program group (at 3.9 from a possible 5) . Overall, 95% of the students rated their confidence greater than 3 (from the possible rating of 5) over the four months of testing. Several of the participants in the focus group, in the present study, indicated that they had difficulties being able to express themselves and feeling that this reflected on judgments of their intelligence, but did not feel that this was a measure of their English speaking ability. This reflected findings of a qualitative study with Hispanic nurses in America (Villarruel, Canales, & Torres, 2001).
The results indicated that both groups were very low in maladjustment (ie. high in adjustment), with mean scores of 2.05 (Time 1), 2.05 (Time 2) and 2.02 (Time 3). This indicates that the students became more adjusted by Time 3, as the score was lower (the lower the score, the higher the adjustment), as seen in Figure 3. The present study supported previous findings that low levels of maladjustment are related to many inter-related factors, such as support, acceptance, self-esteem, equal rights employment prospects, participation, language skills, education, wage employment and ownership (see Berry et al., 1987; Kim, 2001). The students in the Program indicated positive self-esteem, a sense of worthiness, and a feeling of equality and acceptance, which has been found to be consistent with low maladjustment (Wong & Wong, 1982). The majority of the students also reported high levels of support from their families in New Zealand, their ethnic communities, and their friends within the school. This reflected similar findings to a study with Pacific Island university students in New Zealand, where a significant association was found between social support and psychological well being for their participants and low levels of stress and anxiety (Tofi, Flett, & Timutimu-Thorpe, 1996).
The mean scores for the cultural identity questions, Figure 4, indicated that the students were well connected to their own cultural identity, with scores of 3.36 (Time 1), 3.30 (Time 2) and 3.46 (Time 3). The present study revealed that most of the students were well connected to both their own culture and European Kiwi culture. This meant that most of the students were, by Berry and Sam's (1997) definition, "Integrated" in their acculturation process. At the first questionnaire, 81% were Integrated, rising to 95% by the last questionnaire. The present study supported previous findings that English competency and European identity formation were positively correlated, reported in a large study with immigrants in Norway (Sam & Berry, 1995). Eyou (1997) suggested that English competency is vital for effective communications with European Kiwis and that is it associated with greater acceptance by the host community, and becoming integrated within the new culture.
In sum, the students in the Program verified the factors required for successful acculturation were in place for them. They indicated confidence with their English speaking, felt accepted within New Zealand culture and the nursing course, had good connections with and support from their own cultural group and were positive about the changes they had made and their future.
In conclusion, the present study was successful in assisting these foreign nursing students cope with this nursing course using the adapted Cummins model. The students had felt that not understanding what was expected of them within the nursing course, did lead to a feeling of lack of power over their learning and not being able to control their assessment outcomes, which gave rise to a feeling that they were not be able to cope.
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A. Perceived competence in speaking English
Please circle the number that best describes your level of comfort when speaking to the following European Kiwis.
1 = Very Uncomfortable; 2 = Uncomfortable; 3 = Not very comfortable; 4 = Comfortable; 5 = Very comfortable
| 1. | How comfortable do you feel when speaking English to a European Kiwi Lecturer? | 1 | 2 | 3 | 4 | 5 |
| 2. | How comfortable do you feel when speaking English to the staff in the clinical setting? | 1 | 2 | 3 | 4 | 5 |
| 3. | How comfortable do you feel when speaking English to a European Kiwi patient? | 1 | 2 | 3 | 4 | 5 |
B. Ethnic identity scale
Please indicate how much you personally agree or disagree with each statement.
There are no right or wrong answers.
1 = Strongly disagree (SD); 2 = Disagree (D); 3 = Neither agree nor disagree (N);
4 = Agree (A); 5 = Strongly agree (SA).
| 1. | It is important for me to have some friends from my ethnic group. | 1 | 2 | 3 | 4 | 5 |
| 2. | I feel proud whenever people from my ethnic group achieve international success, (for example, in sports, film, or music). | 1 | 2 | 3 | 4 | 5 |
| 3. | I do not like to mix with people from my ethnic group. | 1 | 2 | 3 | 4 | 5 |
| 4. | The values of my ethnic group influence my views on life issues (such as family, education, or work). | 1 | 2 | 3 | 4 | 5 |
C. Please indicate how often each of the following statements is true for you.
Circle one of the numbers next to each statement.
1 = Never; 2 = Rarely; 3 = Sometimes ; 4 = Often; 5 = Always
| 1. | I participate in the cultural practices of my ethnic group (such as food, celebrations or traditions). | 1 | 2 | 3 | 4 | 5 |
| 2. | I'm involved in organisations or social groups that includes mainly people from my ethnic group. | 1 | 2 | 3 | 4 | 5 |
| 3. | I mix with people from my ethnic group. | 1 | 2 | 3 | 4 | 5 |
| 4. | I think about how European Kiwis are different from my ethnic group. | 1 | 2 | 3 | 4 | 5 |
| 5. | I think about why some people from ethnic groups experience racial prejudice. | 1 | 2 | 3 | 4 | 5 |
| 6. | I think about what European Kiwis should do to improve their relationship with my ethnic group. | 1 | 2 | 3 | 4 | 5 |
D. European Kiwi identity scale
Please indicate how much you personally agree or disagree with each statement.
There are no right or wrong answers. Please circle the numbers next to each statement.
1 = Strongly disagree; 2 = Disagree; 3 = Neither agree nor disagree;
4 = Agree 5 = Strongly agree.
| 1. | It is important for me to have some European Kiwi friends. | 1 | 2 | 3 | 4 | 5 |
| 2. | I do not need to know about the history of the European Kiwis. | 1 | 2 | 3 | 4 | 5 |
| 3. | I feel proud whenever European Kiwis achieve international success (for example in sports, films, or music). | 1 | 2 | 3 | 4 | 5 |
| 4. | I do not like to mix with European Kiwis. | 1 | 2 | 3 | 4 | 5 |
| 5. | The values of European Kiwis influence my views on life issues (such as family, education, or work). | 1 | 2 | 3 | 4 | 5 |
Please indicate how often each of the following statements is true for you.
Circle one of the numbers next to each statement.
1 = Never; 2 = Rarely; 3 = Sometimes; 4 = Often; 5 = Always
| 6. | I participate in the cultural practices of European Kiwis (such as food, celebrations, or traditions). | 1 | 2 | 3 | 4 | 5 |
| 7. | I'm involved in organisations or social groups that include mainly European Kiwi members. | 1 | 2 | 3 | 4 | 5 |
| 8. | I mix with European Kiwis. | 1 | 2 | 3 | 4 | 5 |
| 9. | I spend time learning the history of European Kiwis. | 1 | 2 | 3 | 4 | 5 |
| 10. | I spend time learning about the traditions and customs of European Kiwis. | 1 | 2 | 3 | 4 | 5 |
| 11. | I think about how my ethnic group is different from European Kiwis. | 1 | 2 | 3 | 4 | 5 |
| 12. | I think about why some European Kiwis are prejudiced against people from my ethnic group. | 1 | 2 | 3 | 4 | 5 |
| 13. | I think about what people from ethnic group should do to improve their relationship with European Kiwis. | 1 | 2 | 3 | 4 | 5 |
E. Perceived cultural difference
| 1. | In your opinion, how different are European Kiwis from your ethnic group? They are different in: 1 = Every way; 2 = Most ways; 3 = Some ways; 4 = A few ways; 5 = No way. Please circle one number | 1 | 2 | 3 | 4 | 5 |
| 2. | If you think that there are similarities between European Kiwis and your ethnic group, could you please explain how they are similar? | |||||
| 3. | If you think that there are differences between European Kiwis and your ethnic group, could you please explain how they are different? | |||||
F. Cultural identity categories
Please look at the 4 categories below and answer the following questions:
A = people who identify with both their own ethnic culture and European Kiwi culture
B = people who identify with their own culture but have weak ties with European Kiwi culture
C = people who identify with European Kiwi culture but have weak ties with their ethnic culture
D = people who have weak ties with their own ethnic culture and European Kiwi culture
Which of the 4 types of people described above are you most similar to? _____
Which of those 4 types do you think is best? _____
Why?
G. Psychological adjustment
Please indicate how often you fell the way described in each of the following statements.
These questions are about your own PERSONAL FEELINGS. There are no right or wrong answers.
Please circle one of the numbers next to each statement.
1 = Never; 2 = Rarely; 3 = Sometimes ; 4 = Often; 5 = Always
| 1. | I feel that I am useful and needed. | 1 | 2 | 3 | 4 | 5 |
| 2. | I think that I am no good. | 1 | 2 | 3 | 4 | 5 |
| 3. | I feel that I do not have much to be proud of. | 1 | 2 | 3 | 4 | 5 |
| 4. | I feel like a failure. | 1 | 2 | 3 | 4 | 5 |
| 5. | I feel that I have some good qualities. | 1 | 2 | 3 | 4 | 5 |
| 6. | I feel useless sometimes. | 1 | 2 | 3 | 4 | 5 |
H. The depressive tendencies scale
| 1. | I am often sad without seeing any reason for it. | 1 | 2 | 3 | 4 | 5 |
| 2. | Sometimes I think everything is so hopeless, that I don't feel like doing anything. | 1 | 2 | 3 | 4 | 5 |
| 3. | My life is meaningful. | 1 | 2 | 3 | 4 | 5 |
| 4. | Sometimes I think life is not worth living. | 1 | 2 | 3 | 4 | 5 |
| 5. | I have a lot of things to look forward to in the future. | 1 | 2 | 3 | 4 | 5 |
| 6. | I often feel depressed without really knowing why. | 1 | 2 | 3 | 4 | 5 |
| 7. | Sometimes I am just that depressed that I feel like staying in bed for the whole day. | 1 | 2 | 3 | 4 | 5 |
I. The psychological and somatic symptoms scale
| 1. | I get headaches. | 1 | 2 | 3 | 4 | 5 |
| 2. | I get stomach aches. | 1 | 2 | 3 | 4 | 5 |
| 3. | I get backaches. | 1 | 2 | 3 | 4 | 5 |
| 4. | I feel low. | 1 | 2 | 3 | 4 | 5 |
| 5. | I get irritable or bad tempered. | 1 | 2 | 3 | 4 | 5 |
| 6. | I feel nervous. | 1 | 2 | 3 | 4 | 5 |
| 7. | I have difficulties in getting to sleep. | 1 | 2 | 3 | 4 | 5 |
| 8. | I feel dizzy. | 1 | 2 | 3 | 4 | 5 |
J. Coping scale (academic work and clinical work)
Please indicate how much you personally agree or disagree with each statement. There are no right or wrong answers.
1 = Strongly disagree; 2 = Disagree; 3 = Neither agree nor disagree; 4 = Agree; 5 = Strongly agree
| 1. | I do not feel stressed by the university academic work I do. | 1 | 2 | 3 | 4 | 5 |
| 2. | Most of the time I can handle the work load expected at me at university. | 1 | 2 | 3 | 4 | 5 |
| 3. | I have much control over the academic work I do. | 1 | 2 | 3 | 4 | 5 |
| 4. | I usually know what is expected of me when I do my academic work. | 1 | 2 | 3 | 4 | 5 |
| 5. | I plan goals for my academic work. | 1 | 2 | 3 | 4 | 5 |
| 6. | I usually achieve my learning goals. | 1 | 2 | 3 | 4 | 5 |
| 7. | I look forward to the clinical work I do each day. | 1 | 2 | 3 | 4 | 5 |
| 8. | I usually know what is expected of me when I do my clinical work. | 1 | 2 | 3 | 4 | 5 |
| 9. | I do not feel stressed by the clinical work I do. | 1 | 2 | 3 | 4 | 5 |
| 10. | I plan goals for my clinical learning. | 1 | 2 | 3 | 4 | 5 |
| 11. | I usually achieve my goals in my clinical learning. | 1 | 2 | 3 | 4 | 5 |
| 12. | I am a good problem solver in the clinical setting. | 1 | 2 | 3 | 4 | 5 |
| Author: Janet Williams, Senior Lecturer School of Nursing, Auckland University of Technology Jackson Cresent, Martin's Bay, RD2, Warkworth, New Zealand Tel: (09) 425 5969 Email: williamsconsult@big.pl.net Please cite as:Williams, J. (2004). The Cummins Model: Helping foreign nursing students cope in a Baccalaureate course. In Seeking Educational Excellence. Proceedings of the 13th Annual Teaching Learning Forum, 9-10 February 2004. Perth: Murdoch University. http://lsn.curtin.edu.au/tlf/tlf2004/williams.html |