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Nurse educators’ perspectives of teaching culturally diverse nursing students Pastirik, Pamela Jacqueline 1998

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NURSE EDUCATORS' PERSPECTIVES OF TEACHING CULTURALLY DIVERSE NURSING STUDENTS by PAMELA JACQUELINE PASTIRIK B. N., University of New Brunswick, 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (The School of Nursing) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA © Pamela Jacqueline Pastirik, 1998 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada i Date 0*5 , y <? f g l DE-6 (2/88) ABSTRACT Changing demographics in Canadian society are creating an increasingly culturally diverse population. Paralleling these changes is increasing cultural diversity in educational institutions. Educators are challenged with providing education that is culturally sensitive to an increasingly culturally diverse nursing student (CDNS) population. In nursing education and allied health literature insights are given regarding the needs and perspectives of CDNSs, the approaches and strategies to teaching CDNSs and the challenges perceived by educators. In nursing education, there is a dearth of research related to the perspectives of nurse educators regarding teaching CDNSs. The purpose of this study was to explore nurse educators' perspectives of teaching CDNSs. The framework of symbolic interactionism was used as a broad guide to understanding the definitions, strategies and contextual factors related to teaching CDNSs. A generic qualitative design was used to explore these broad theoretical concepts. Seven nurse educators currently teaching in baccalaureate nursing programs were interviewed. Data analysis using the constant comparative method was implemented. Validation regarding the conceptual categories was confirmed through second interviews with the participants. The findings of the study revealed three major categories: 1) Conceptions of Culturally Diverse Nursing Students 2) Challenges to Teaching CDNSs 3) Dealing with Diversity. Teachers generally believed that CDNSs had unique cultural backgrounds, behaviors and beliefs and learning needs that could be uniquely delineated. They believed that language and communication, lack of knowledge and understanding of cultural diversity, lack of resources for teachers and students and a milieu that fostered a pressure to treat students the same, were significant challenges to teaching CDNSs. Approaches to dealing with diversity were identified as examining one's own beliefs and values, considering the influence of culture on the student's performance, and monitoring one's teaching practices. The most significant findings in the study related to the teachers' perceived lack of knowledge, skills and awareness to address the learning needs of CDNSs. The needs of CDNSs, the approaches to teaching CDNSs and the challenges to developing intercultural competency are highlighted. iii TABLE OF CONTENTS ABSTRACT TABLE OF CONTENTS v ACKNOWLEDGMENTS vi CHAPTER ONE: INTRODUCTION 1 Background to the problem 1 Purpose of the Study 4 Research Question 4 Assumptions 4 Conceptual Framework 4 Definition of Terms 7 Significance of Study 8 Organization of Thesis 8 CHAPTER TWO: LITERATURE REVIEW Introduction 10 Concepts and Practices Relevant to Teaching CDNSs 11 Empowerment of CDNSs 11 Bridging Cultures 12 Teaching Strategies 13 Perceptions of CDNSs 16 Educators' Perceptions 19 Nursing 20 Education 24 Anecdotal Nursing Literature ..26 Summary of the Literature 27 CHAPTER THREE: RESEARCH METHOD 29 Introduction 29 Research Design 29 Sample and Setting 30 Data Collection 32 Data Analysis 33 Field Notes 35 Ethical Considerations 36 Methods of Enhancing Rigour 36 Summary 38 CHAPTER FOUR: REPORT OF FINDINGS 39 Introduction 39 iv Conceptions of CDNSs 39 Culturally Diverse Backgrounds 40 Culturally Diverse Beliefs and Values 41 Diverse Learning Needs and Challenges 43 Challenges in Teaching CDNSs 45 Language and Communication 45 Not Knowing or Understanding the Influence of Culture 47 Pressure to Treat Students all the Same 51 Lack of Time and Resources 54 Dealing with Diversity 57 Considering Beliefs and Biases 57 Considering Culture as an Influence on Learning 61 Monitoring Teaching Approaches 64 Summary 66 CHAPTER FIVE: DISCUSSION OF FINDINGS 70 Introduction 70 Perceived Learning Needs of CDNSs 71 Approaches to Teaching CDNSs 73 General Approaches 73 Specific Teaching Strategies 76 Intercultural Competency 77 Knowledge and Awareness 77 Teaching Skills 79 Awareness, Utilization, Accessibility and Availability of Resources 81 Limitations of the Study 82 Summary 82 CHAPTER SIX: SUMMARY, CONCLUSIONS, AND IMPLICATIONS 85 Introduction 85 Conclusions Derived from Findings 89 Implications for Nursing Practice 90 Nursing Education 90 Nursing Research 92 Conclusion 94 REFERENCES 95 APPENDIX A: Participant Information Letter 102 APPENDIX B: Participant Consent Form 103 APPENDIX C: Information Sheet 104 APPENDIX D: Interview Guide 105 v ACKNOWLEDGEMENTS I would like to thank my thesis committee for providing me with the support and critical feedback required to complete this thesis. Their patience throughout this process has been deeply appreciated. In addition, I would like to recognize the support and assistance of the seven teachers who participated in this study. Their insights into teaching culturally diverse students has greatly increased my knowledge and understanding in this area of nursing education. Last, but not least, I would also like to thank my husband Dan and son Michael for waiting so patiently and providing unwavering support throughout this long process. vi 1 CHAPTER ONE: INTRODUCTION Background to the Problem Changing demographic trends in Canadian society continue to foster a rich cultural mosaic. By the turn of the century, it is projected that 46% of the Canadian population will identify themselves as belonging to a distinct cultural group other than EuroCanadian (Census Canada, 1990). Paralleling these demographic changes are growing racial, cultural and ethnic diversity in educational settings (Masi, Mensah & MacCleod, 1992). Educators are challenged with adapting teaching strategies to reflect an eclectic, culturally sensitive approach. Currently, however, it is not known how teachers address culturally diversity in educational settings. In nursing education, issues related to cultural diversity among nursing students have received increased attention. In particular, concern regarding how to retain minority students in nursing programs has been highlighted (Crawford & dinger, 1988; Green, 1987; Holtz & Wilson, 1992; Jones, 1990; Rosella, Regan-Kubinski & Albrecht, 1994; Saucier, 1994). American literature is replete with statistics regarding high attrition rates among minority or culturally diverse students (Allen, Nunley & Scott-Warner, 1988; Boyle, 1986; Reed & Hudepohl, 1986; Tucker-Allen, 1989). Other health professions express similar concerns regarding minority students (Payne et al., 1986; Tyslinger & Whiteside, 1987). It is not known whether these statistics would be similar in a Canadian context. It may be postulated that similar patterns exist given the growing cultural diversity in the Canadian population. Considering that the majority of CDNSs go on to serve diverse populations when they graduate, the development of effective teaching strategies for culturally diverse populations is viewed as a priority for nursing education (McBay, 1992). Factors influencing the educational experience of CDNSs are, not surprisingly, obscure and inherently complex. Some authors suggest that CDNSs are at particular risk for academic difficulty due to differences in learning styles, communication and/or language barriers and previous educational experiences (Bruyere, 1991; Claerbaut, 1978; Rodgers, 1990). Paterson and Hart-Wasekeesikaw (1994a) assert that learning is highly influenced by one's cultural views and ways of knowing. Cultural conflict may arise due to discrepancies between the worldview or ways of knowing of the CDNS and that of nurse educators (Crow, 1993; Rodgers, 1990). Further, nurse educators often possess communication and/or teaching styles that are consistent with a predominantly EuroCanadian perspective (Thorpe & Kulig, 1994). Nurse educators are increasingly cognizant of the multiple challenges that confront many CDNSs when they enter nursing programs. This awareness is reflected in literature related to innovative teaching strategies for CDNSs. For example, mentoring programs have been developed to allow for more individualized teaching (Alvarez & Abriam-Yago, 1993; Paterson & Hart-Wasekeesikaw, 1994). The mentorship approach facilitates the student's use of diverse ways of knowing that are more consistent with the student's cultural 3 orientation (Paterson & Hart-Wasekeesikaw). Other teaching approaches have focused primarily on retention programs; e.g., remedial programs to develop academic skills and computer-assisted instruction have been implemented (Drice, Hunter & Williams, 1978; Goodman, Blake & Lott, 1990). In general, however, very few studies have focused on teaching strategies for CDNSs (Heydman, 1991; Morris & Wykle, 1994). Although the current literature addresses issues related to teaching CDNSs, there is little empirical evidence that provides a clear understanding of the perspective of the nurse educator regarding teaching CDNSs. Cummins (1986) contends that how teachers interact with students is a critical factor determining the extent to which minority students are empowered or disabled in their learning experiences. To date, we know little about how teachers can best teach nursing students in a culturally sensitive manner. In order to teach CDNSs in a culturally sensitive manner, nurse educators must develop intercultural competency. Intercultural competency can be developed in various ways. According to Kurz (1993) this competency can be achieved by communicating with educators who possess experiential knowledge regarding CDNSs. Paterson (1994b) has argued that the practical knowledge of teaching in nursing education is revealed in teachers' thoughts, ideas, and beliefs about their teaching practices. Similarly, other authors contend that research on multiculturalism and teaching should focus on the practice of experienced teachers; specifically, how they practice, their thoughts about their practice and the context in which it occurs (Shulman, 1987b cited in Ladson-Billings, 1992). An understanding of nurse educators' perspectives of teaching CDNSs has great potential to provide both novice and experienced educators with valuable knowledge and understanding regarding culturally sensitive teaching. Purpose of the Study The purpose of this research was to explore nurse educators' perspectives of teaching CDNSs. Research Question The question addressed in this study is "What are nurse educators' perspectives of teaching CDNSs?" Assumptions 1. The experience of teaching CDNSs is a unique experience that can be articulated by experienced nurse educators. 2. The cultural background of the student and the nurse educator uniquely influences the teaching-learning situation. Conceptual Framework Guidance for this research was derived from the theory of symbolic interactionism. The theoretical perspective of symbolic interactionism focuses on how "people define events or reality and how they act in relation to their beliefs" (Chenitz & Swanson, 1986, p.4). The three premises that comprise the theory will provide directives for the research process in this study. 5 The first premise underlying symbolic interactionism is that actions are based on an individual's definition of various objects confronted in daily life. An object can be physical, social (students), or abstract (ideas, principles) and "can be indicated or referred to" by a person or group (Blumer, 1969, p.11). Definitions have individual meaning; as such, it is not possible to understand a person's behavior without exploring the meaning it holds for the person (Blumer; Chenitz & Swanson, 1986). There is a need to obtain descriptive accounts of situations from teachers who are working with CDNSs (Stryker, 1980). The second premise of symbolic interactionism posits that definitions develop through a process of social interaction. By communicating with the self and others, a person creates or constructs definitions of objects in their environment (Blumer, 1969). Through this process, objects come to "have the same meaning for a given set of people and are seen in the same manner by them." (Blumer, p.11). Blumer contends that these shared meanings guide behavior or actions within the group; individuals align their behaviors with that of others. For new situations that arise in group life guidelines may not be present, creating difficulties for the group. " A new form of joint action always emerges out of and is connected with a context of previous action. It cannot be understood apart from the context" (Blumer, p.20). Because the process of social interaction is diverse, ongoing and contextual, the direction of the research reflects a process of discovery rather than fixed, a priori conceptualizations (Blumer, 1969; Stryker, 1980). From the symbolic interactionist perspective, it is necessary not only to explore individual definitions, 6 but the shared meanings of the research participants. This includes, how the person acts in relation to a variety of situations (Blumer; Chenitz & Swanson, 1986). Due to the contextual nature of group life, a priori conceptualizations of the phenomenon are avoided in the literature review. In this way, data is allowed to "emerge from the study" (Denzin, 1970; Sandelowski, Davis, & Harris, 1989). The last premise of symbolic interactionism posits that a person does not merely respond to external stimuli in the environment, but engages in an interpretive process in order to understand the meaning of the situation (Blumer, 1969; Stryker, 1980). The outcome of this process is a conscious action based on the person's interpretation of the situation (Chenitz & Swanson, 1986). Persons exhibit self-directed behaviors that may be observed at both the symbolic and interactional level. Therefore, the researcher must explore these behaviors in order to understand how participants construct their actions (Denzin, 1970; Stryker). This is accomplished by reviewing a person's perception of a situation; that is, according to Stryker, by "including what the actor takes into account and how he interprets what is taken, noting alternative acts that are mapped out, and trying to follow the interpretation that leads to selection of one of these acts" (p. 97). In this study, the theory of symbolic interactionism is employed as a broad framework throughout the thesis. First, it is used as a guide to understanding the definitions or concepts that teachers view as important to the phenomenon of teaching CDNSs, the strategies that teachers implement in relation to teaching CDNSs and the contextual factors that influence teachers' perspectives and actions 7 when teaching CDNSs. Literature related to common themes or concepts emerging from the literature review (empowerment of CDNSs, bridging cultures, teaching strategies, student perceptions) and educators' perspectives (nursing, general education) are reviewed. Second, the theory of symbolic interactionism guides the research design and managing of the interview data. A qualitative design is chosen in order to fully understand both individual and shared meanings of teaching CDNSs. This is accomplished through qualitative data analysis of teachers' descriptive, verbal accounts of teaching CDNSs. The framework of symbolic interactionism provides a broad conceptual guide for initial management of the interview data in relation to definitions pertinent to teaching CDNSs, strategies implemented in teaching CDNSs and factors influencing teaching CDNSs. Definition of Terms Nurse educator: A teacher who has experience in teaching CDNSs for at least two years in an undergraduate degree nursing program. Culturally Diverse Nursing Student: Identified by the nurse educator, these are students enrolled in a baccalaureate nursing education program whose "home language and culture differ from those of the school and wider society (language minority students) and to students whose home language is a version of English but whose cultural background is significantly different from that of the school and wider society" (Cummins, 1986, p. 18). 8 Intercultural Competence: "The ability to deal with diversity in a positive way;...involves skills, attitudes, awareness, and knowledge that foster effective interactions with others across cultures, races, and religions" (Kurz, 1993, p.228) Teaching Strategies: "refers to all methods, techniques, and materials that embody and transmit particular conditions for learning. They are tangible and intangible cues and treatments used by the teacher to facilitate achievement of learning outcomes" (Van Hoozer, 1987, p. 110). Significance of the Study The significance of this study is that it will enhance the body of knowledge in nursing education with respect to teaching CDNSs. As reflected in the previous discussion, a dearth of literature exists to explain how teachers perceive and, subsequently, address issues related to teaching diverse populations. Understanding nurse educators' perspectives has the potential to enhance existing practices related to teaching CDNSs in a Canadian context. In doing so, this may improve the quality of education for students of diverse cultures. Considering that many CDNSs go on to practice in areas with culturally diverse populations, the implications of understanding existing educational practices become far-reaching (McBay, 1992). Organization of the Thesis The thesis is organized into six chapters. Chapter One consists of the background to the research problem, the research question, definition of terms, significance, assumptions and the conceptual framework for this study. Chapter 9 Two contains a review of the related research, organized according to the constructs of symbolic interactionism, pertaining to teaching approaches and culturally diverse nursing students. Chapter Three describes the research design, including a description of a qualitative method of data analysis based on Lincoln and Guba (1985). Chapter Four contains a report of the research findings. Chapter Five includes a discussion of the research findings of the study. Chapter Six provides both a summary and conclusion of the study, including the implications of the study findings for nursing practice, education and research. 10 CHAPTER TWO: LITERATURE REVIEW Introduction The following chapter includes a review of the literature related to teaching culturally diverse students. To complete this literature review, a major search was enacted by means of CINHAL. In addition, ERIC was reviewed for selected articles focusing on general education teachers' perceptions of teaching culturally diverse students. Criteria for inclusion in this literature review include: 1. Qualitative and/or quantitative research articles in nursing and in education that focus on teaching strategies for CDNSs, perceptions of CDNSs and perceptions of nurse educators. 2. Selected educational articles and theoretical literature that contribute to an understanding of the nurse educators' experience of teaching CDNSs. 3. Selected anecdotal, research and theoretical nursing and education literature that include discussion of elements or issues related to the process of teaching culturally diverse students. In addition to the above criteria, the theory of symbolic interactionism is used as a broad guide for the structure of the literature. Definitions or concepts that teachers view as important to the phenomenon of teaching CDNSs, strategies that teachers implement in relation to teaching CDNSs, teachers' perspectives of teaching CDNSs and factors that influence teachers' perspectives are included in the literature review. 11 Concepts and Practices Relevant to Teaching CDNSs Several frameworks in the literature, in both nursing and education, provide various perspectives with respect to understanding how CDNSs interface with teachers and educational institutions. Empowerment of CDNSs Holtz and Wilson (1992) describe a model that focuses on empowering the CDNS through a holistic teaching approach. These authors assert that "students need assistance in the areas of academic readiness for college work, financial resources, social support systems, and ability to deal with the cultural system of the college or university" (p.28). Moreover, the empowerment model stresses the importance of faculty as facilitators to bridge the discrepancies between the students' culture and that of the educational institution. A similar framework by Cummins (1986) purports that relationships between teachers and students play a critical role in the empowerment of culturally diverse students. Cummins asserts that policy reforms in general education with respect to multicultural education are important for change; however, real change depends on whether teachers are able to redefine interaction patterns between themselves and minority students. According to Cummins, the extent to which a teacher incorporates a student's culture, incorporates the community, fosters intrinsic motivation, and becomes an advocate for the student determines whether students are empowered or disabled in the educational setting. "Educators...communicate to students...in a variety of ways the extent to which the minority language and culture 12 are valued within the context of the school" (p.26). Cummins believes that empowerment of culturally diverse students can occur if educators move from a transmission mode of teaching to a reciprocal mode of teaching. The latter allows for more interaction and student control over learning goals; that is, a way of teaching that focuses on interaction as opposed to the traditional "banking" model of education that perpetuates the teacher as transmitter of knowledge (Freire, 1970, 1973 cited in Cummins, 1986). Bridging Cultures The Cultural Bridge Model, described by West (1993), provides an understanding of the interaction between two different cultures. Although the article focuses on nurse-client interaction, the concepts are relevant to understanding the interaction between the student and teacher. The author uses the example of the Native American Indian client in applying the model to nursing situations. For example, a Native American client is posited to be more present-oriented as opposed to future-oriented. According to West, this "cultural gap" prevents the culturally diverse person from fully accessing westernized health care services. In relation to this model and teaching CDNSs, it can be deduced that "cultural gaps" present CDNSs from fully benefiting from westernized educational systems. The Cultural Bridge Model focuses on providing a bridge or understanding between two different cultures without attempting to modify the essence of the culture of the individual. Cultural bridging between two cultures occurs through the processes of "assimilation, integration, education and tolerance" (West, 1993, p. 13 232). For example, the process of education in this model is described as "the moral and mental discipline gained by the study and instruction process that occurs when two cultures interact but this does not necessarily constitute a "conversion" of any cultural traits on the part of any interacting faction, but merely serves to promote a mutual understanding" (Park cited in West, p.232). "The Pathways Model" developed by Rew (1996) outlines a process-approach to affirming cultural diversity in nursing students. Using a travel metaphor, the author discusses the experience of the CDNS in nursing programs. First, the author states that CDNSs have a "diversity of roads" that they have traveled. These roads reflect the various knowledge, skills and attitudes accrued through interaction with the environment. Secondly, there is a "learning landscape" which are resources and interactions shared between the teacher and student that foster success. Thirdly, there are "unique self-built pathways leading to the world of profession nursing practice" (Rew, p.312). Nurse educators, in Rew's view, provide the pathway to student success. Teaching Strategies The strategies that teachers use to assist CDNSs have been studied by nurse educators. Five studies were reviewed that address both the type and effectiveness of various strategies for teaching CDNSs. These approaches include mentoring (Alvarez & Abriam-Yago, 1993), Computer Assisted Instruction (CAI) (Goodman et al., 1990), clinical/interactive learning (Ishida, Inouye & Yoshiko 1994), and group seminar (Malhiot & Ninan, 1979). Another study involved a 14 survey of 21 nursing programs in California to determine effective approaches used for teaching ESL (English as a Second Language) students (Memmer & Worth, 1991). All of these studies were descriptive in nature and focused on the effectiveness of specific teaching/learning strategies. The findings of these studies indicate that CDNSs learn best through interactive methods such as journals, seminar and interactive video. The researchers identified significant differences in learning styles among CDNSs. Specifically, interactive learning was found to be important for establishing relationships between faculty and Asian students (Ishida et al., 1994). Similarly, Goodman et al. (1990) reported that the use of Computer Assisted Instruction improved the mean scores on a medical-surgical unit examination. Memmer and Worth (1991) identified several interesting findings with respect to teaching ESL students. Programs that were successful in retaining these students provided flexible course loads, additional clinical assistance, peer tutorial assistance, academic advising, visiting ESL nursing leaders, content on cultural diversity and stereotyping, faculty workshops and orientation programs. Anecdotal literature offers suggestions for general and specific strategies for teaching CDNSs. Some authors (Saylor & Taylor, 1993: Sturch, 1994) have advocated that the development of culturally sensitive teaching is contingent upon curricular transformation. Transforming education involves making learning experiences culturally relevant to the CDNSs by drawing on the student's own life experiences. Often there is incongruence between Westernized theory and the student's own cultural perceptions of reality (Saylor & Taylor; Sturch). As such, faculty and student sharing of their cultural worldviews is identified as integral to faculty-student relationships (Crow, 1993; Snead, 1982; Gay-Templeton, Edgil, & Stullenbarger, 1993). Interpreting learning objectives in order to be more congruent with the student's learning needs has been suggested as an effective teaching strategy for CDNSs (Sturch, 1994; Wong & Wong, 1982). In this respect, Crow (1993) asserts that it is necessary to adapt teaching approaches in order to assist students to develop the necessary nursing skills without eroding their sense of culture; for example, modifying learning assignments to meet individual needs. Phillips and Hartley (1990) have recommended developing writing labs and providing individual feedback as a means of assisting ESL students with their assignments. A wide variety of teaching approaches have been identified as important when teaching CDNSs (DeTournay & Russell, 1978; Shearer, 1991). Studies from the field of education suggest that effective multicultural teachers are able to modify approaches to ensure success (Larke, 1994). In nursing literature, activities such as peer group learning (Crow, 1993), peer tutoring and CAI (Goodman et al.) reflect such approaches to educating diverse student groups. Literature, both research-based and anecdotal, provides marginal insight into the role of the teacher in addressing the needs of CDNSs. First, the approaches that have been implemented primarily reflect teacher-directed approaches. It is not known what the student's role is in determining various 16 approaches. Secondly, the studies are largely descriptive, thereby limiting their credibility, and consequently, applicability to the education of CDNSs. Thirdly, explanations for why the various approaches are effective are not offered. It is unknown whether similar approaches would be applicable to any student, regardless of their cultural background. Perceptions of CDNSs Ten studies that focus on CDNSs' perceptions of their educational experience were reviewed. All of the studies focus on factors that promote or hinder success in nursing programs. Six studies explored perceptions of designated groups of foreign nursing students in baccalaureate, masters and doctorate programs in the United States (Abu-Saad & Kayser-Jones, 1982a; Abu-Saad, Kayser-Jones & Gutierrez, 1982b; Abu-Saad, Kayser-Jones & Tien, 1982c; Bronner, 1982; Kayser-Jones, Abu-Saad & Akinnaso, 1982a; Kayser-Jones, Abu-Saad & Nichols, 1982b), while the other four studies focused on the perceptions of minority or culturally diverse students in Licensed Vocational Nurse (Anderson, 1991), graduate (Snyder & Bunkers, 1993), and baccalaureate (Kulig, 1987; Thorpe & Kulig, 1994) nursing programs. All of these studies are American-based with the exception of one Canadian article (Thorpe & Kulig). Two of the studies used qualitative designs (Snyder & Bunkers, 1993; Thorpe & Kulig, 1994), while the other studies used descriptive designs. There are several limitations to these studies. First, none of the studies reported measures of reliability or validity of the instruments utilized. Secondly, four studies did not include the sample size (Abu-Saad & Kayser-Jones, 1982a; Abu-Saad et al., 1982b; Abu-Saad et al., 1982c; Kayser-Jones et al., 1982a;, Kayser-Jones et al., 1982b)., thereby creating major limitations in the usefulness of the findings of these studies. In addition, the generalizability of the findings are limited due to small sample sizes. Findings indicate that there are a number of barriers to quality education as perceived by students of diverse cultures. Several of the studies reported that inability to speak English created barriers for nursing students (Abu-Saad et al., 1982a; Abu-Saad & Kayser-Jones, 1982; Abu-Saad et al., 1982b; Bronner, 1982; Snyder & Bunker, 1994). For example, one Latin student stated "I have a language problem...! can't read English very fast to keep up with the rapid pace at school. This puts me behind in my course assignments." (Abu-Saad et al., 1982b, p. 19). Snyder and Bunker reported that student's perceived language as a barrier that interfered with their ability to write papers and communicate effectively. Moreover, it was reported that difficulty in communicating effectively interfered with clinical learning experiences; particularly communication with nursing instructors, physicians and clients (Abu-Saad & Kayser-Jones; Abu-Saad et al., 1982b). Differences in social customs and values were also identified by the students as factors negatively influencing their educational experience (Abu-Saad & Kayser-Jones; Abu-Saad et al., 1982a; Abu-Saad et al., 1982b). For example, one Asian student commented that "different social customs were the most difficult to adjust to...but I learned to change myself...dress like they do, eat like they do, 18 talk like they do...it was hard to change!" (Abu-Saad et al., 1982b). In addition, one study identified racial prejudice (Kayser-Jones et al., 1982a) as a constraint to learning for CDNSs. Another influencing factor identified by students was the perceived inflexibility of nursing programs to address the unique needs of CDNSs (Abu-Saad et al., 1982a; Kayser-Jones et al., 1982b). One middle-eastern student reported, "the program was meant to meet the needs of American students only and is not flexible to foreign students" (Abu-Saad & Kayser-Jones, 1982a, p.24). A final, and probably most significant finding, relates to CDNSs' perceptions of nursing faculty. Lack of faculty knowledge related to various cultures (Abu-Saad et al., 1982b), and faculty bias toward minority groups, or lack of respect for the individuality of the student (Snyder & Bunkers, 1994) were identified as barriers to learning. One study identified lack of minority faculty and students as a hindrance to the CDNS's success (Snyder & Bunkers). Researchers in another study recommended hiring non-Caucasian faculty (Thorpe & Kulig, 1994). The majority of the studies reviewed indicate that helpful or supportive faculty are correlated with a satisfactory educational experience for CDNSs (Abu-Saad & Kayser-Jones; Abu-Saad et al., 1982a; Abu-Saad et al., 1982b; Anderson, 1991; Kayser-Jones etal., 1982a; Kulig, 1987; Snyder & Bunkers, 1994). In addition, one researcher stated that the quality of the nursing education program and well-qualified teachers were important to CDNSs' achievement in the educational program (Kulig). 19 One study included student perceptions regarding specific strategies to improve the education of CDNSs (Snyder & Bunkers, 1982). Student mentorship programs, faculty-student mentorship, tutoring for language deficits, more learning activities that do not require written work, more recruiting of minority students, and respect for both individuality and cultural diversity were identified. The major recommendations arising out of these research articles point to specific teaching strategies for teaching culturally diverse students. First, faculty need to be familiar with the cultural orientation of CDNSs. Secondly, providing cross-cultural courses in the curriculum would allow all students to become familiar with each other's cultures (Abu-Saad et al., 1982a; Abu-Saad et al., 1982c; Thorpe & Kulig, 1994). Thorpe and Kulig have also suggested using culturally diverse role models as guest speakers in the classroom and to increase the number of minority faculty when possible. Third, the use of support and tutoring programs for CDNSs would be useful (Abu-Saad et al., 1982a; Abu-Saad et al., 1982b;). Fourth, diverse teaching strategies should be developed to meet the needs of CDNSs. Lastly, reading and writing courses should be offered to CDNSs to compensate for language difficulties (Abu-Saad et al., 1982a). Educators' Perceptions Literature that has examined teachers' perceptions regarding strategies for culturally diverse students comprises this portion of the literature review. Studies were reviewed that address teacher's perceptions of teaching diverse students: two nursing studies (Bruyere, 1991; Yoder, 1996) and four education studies (Carrington, Millward & Short, 1986; Chen & Goldring, 1994; Gougen, 1993; Rios, 1993). Nursing In Bruyere's (1991) study, written clinical evaluations along with student questionnaires were examined in order to investigate nurse educators' and students' perceptions of clinical learning experiences. Bruyere's (1991) study used a descriptive design. However, a major limitation of the study is that the researcher does not include a sample size, nor is there a description of the reliability and validity of the instrument used. Bruyere's (1991) findings indicated that nurse educators believe that building self-esteem and self-confidence was important in teaching CDNSs. The nurse educators in the study perceived that teachers' and students' conflicting orientations can create uncomfortable tensions between them. Other participants in this study reported that students with English as a second language had multiple difficulties with grammar and oral communication. The researcher did not investigate what the nurse educators perceived as most useful in working with CDNSs. Yoder's (1996) qualitative study explored the processes by which nurse educators teach ethnically diverse students. The sample included 26 American nurse educators and 17 ethnic minority nurses from Asian-American, African-American, and Mexican-American descent. The method of Grounded Theory was applied to elicit and process the data. The findings revealed the process of 21 responding to CDNSs, 5 patterns of responding to CDNSs and positive and negative implications of the patterns of responding (Yoder). The process of responding included the approachability of the teacher, interpreting cues (distinguishing needs of CDNSs compared to students in general) and acting/interpreting cues (in a culturally sensitive manner). Cultural awareness of educators was identified as another category emerging from the data. Specifically, this was described as recognising issues and being sensitive to cultural issues during interaction with CDNSs. Conditions that influenced awareness included "lived experiences, sensitivity training, interacting, and commitment to diversity and equity" (Yoder, 1996, p.318). Exposure to other cultures, exposure to cultural concepts in education, interaction with ethnically diverse faculty, and commitment and respect for equity and diversity were identified as conditions influencing awareness. Broader factors such as international policies, political and legal climate (ie; civil rights), minority access to college, minority student loans and the national controversy over college curriculum diversity content were considered to be influential in the teachers' awareness of cultural issues. Other factors identified were the consciousness in the community of the college, philosophy and mission of the program (re: minority recruitment), student support services, faculty hiring practices, curriculum development, professional norms and values of the discipline and the philosophy mission of the nursing school the nurse educator attended (Yoder). 22 The five patterns of responding described by Yoder (1996) are generic, mainstreaming, non-tolerant, struggling and brokering. For the generic group of educators, there is a low level of cultural awareness. In particular, this group of educators can identify differences between students, however they do not consider culture as an important contributor to these differences. According to Yoder, this is the primary mode of teaching as perceived by the students in the study. The second pattern, mainstreaming refers to teachers that demonstrate a high level of cultural awareness and identify special needs of CDNSs. They assume problems are lack of knowledge about expectation of majority culture. The focus for these teachers is helping CDNSs to assimilate into the mainstream; this is perceived as empowering students. The third pattern identified is the culturally non-tolerant group. For these teachers, cultural differences are not accepted and teaching behaviours create barriers for CDNSs. In this study, both the teachers and the students reported that there was some existence of these practices. The fourth pattern identified, the struggling pattern, refers to teachers are who are aware of the cultural issues influencing their teaching practice. However, they often struggle with their role and often experiment with new teaching approaches to help to meet the needs of CDNSs. The last pattern, bridging, refers to teachers who possess a high level of awareness, knowledge and skills to address the needs of CDNSs. They have a highly positive attitude to teaching diverse learners and help them to bridge the gap between their world view and that of the mainstream institution. The students reported that this was not a common experience for them. Students 23 perceived that in order for bridging to occur, they required educators from minority groups (Yoder). The last category evolving in this study is described as the consequences of the various patterns of responding. The consequences for both teachers and students are outlined. For the generic response, the consequence of this pattern was the perception that there was no need to change. For the struggling response, there is a perceived need to change but it creates a great deal of anxiety. For the bridging response, the result is that more CDNSs make their role more fulfilling. From the students' perspectives, teachers with a generic approach may have a negative impact on their learning experiences particularly for students with high learning needs. Students may feel pressure to conform to mainstream, but are not provided with the resources or assistance to do so. As a result they may have feeling of invisibility, experience cultural isolation, have their needs unrecognised, feel that their cultural perspective is devalued, feel an increased responsibility and feel that the barrier that they confront are being unacknowledged. For the students, the mainstreaming approach was felt to provide more direction as to the expected behaviors, however they still experienced the same kinds of feelings and experiences elicited with the generic approach. For the students, the culturally non-tolerant approach, resulted in "stress and anxiety, loss of confidence, damaged image as an ethnic nurse, feeling devalued because of minority status, and lack of support to deal with barriers" (Yoder, 1989, p.320). For the last pattern , bridging, students perceived that the environment created was more comfortable because of 24 the valuing of their perspectives and the assistance given to overcome the barriers that they confronted. Yoder's study is useful in understanding the various approaches and processes involved in teaching CDNSs. Further, it highlights factors influencing the perspectives and approaches of the teachers. The context of the study is the United States so it is uncertain whether the findings would be similar in a Canadian context. The perspectives of students and teachers provide validation for the effectiveness of the various approaches to teaching (Yoder). Education Six studies from the field of education were reviewed. Heard (1990) explored general educators' perspectives regarding "how teachers identify multicultural learning and teaching problems in their classrooms" (p. 308). Heard used a case study approach. Teachers in the study worked together as a group to discover questions related to teaching culturally diverse students and devised teaching strategies for implementation in multicultural classrooms. Heard (1990) identified six features of an effective multicultural teacher: modifies teaching strategies, expects success, recognizes cultural learning patterns, varies amount of attention, is responsive; and modifies students' grouping pattern. Other education from the field of education has focused on both preservice teachers' and primary and secondary teachers' perspectives of multicultural education and teaching culturally diverse students (Carrington et al, 1986; Chen & Goldring, 1994; Gougen, 1993; Rios, 1993). The four studies reviewed included one quantitative descriptive study (Chen & Goldring), two qualitative studies 25 (Gougen; Rios) and one combined qualitative/quantitative study (Carrington et al). The sample sizes for quantitative studies ranged from 86-370 while the qualitative studies ranged from 4-27. The findings of these studies indicate that teachers perceive lack of resources for assisting culturally diverse students (CDSs) (Gougen, 1993). Further, challenges were reported regarding role expectations in teaching CDSs. These challenges were reported to more significant with higher numbers of CDSs in the classroom (Chen & Goldring, 1994). Other challenges to teaching CDSs included the perception that there were too many things to include in the curriculum and that incorporating diverse perspectives required considerable effort. Further, there was an expressed lack of representation of minority teachers which participants viewed as important to enhancing the quality of education for CDSs (Carrington et al., 1993). The various approaches to teaching CDSs were described in two studies (Chen & Goldring, 1994; Rios, 1993). It was reported that the degree of experience in teaching CDSs influenced the intercultural competency of the educator. Novice teachers in particular were described as approaching cultural diversity in a superficial manner (Chen & Goldring). Rios (1993) reported that approaches to teaching CDSs could be categorized into four approaches. First, the "business as usual" approach involved perceiving language as being the only aspect related to culture. The second approach, a "teaching the culturally different", involved viewing cultural differences as "problems". The third approach, "human relations", involved 26 perceiving role as decreasing prejudice and promoting intercultural communication. The third approach, "education that is multicultural and social reconstructivist" refers to the teacher that views teaching CDSs as complex, involving the culture of the student, the culture of the teacher and the greater social context. Further, the teacher views self and greater institution as deficient in meeting the needs of CDSs. In Carrington et al (1993) the findings revealed that there were a large number of teachers that espouse an assimlationist perspective in teaching CDSs. The usefulness of these studies in understanding the perspectives of CDNSs is limited. It is not known whether similar perspectives exist in a nursing education context. Further, the studies were conducted in primary and secondary schools which may differ from post secondary institutions. Anecdotal Nursing Literature Similar to findings in some of the research literature, anecdotal literature regarding nurse educators' experiences with CDNSs suggests that teaching diverse student populations represents a challenge for educators due to incompatibilities in values, beliefs and language (Holtz & Wilson, 1992; Phillips & Hartley, 1990; Wong & Wong, 1982). Moreover, these authors generally conveyed that most faculty feel ill-prepared to teach diverse populations. It is posited that many of the challenges inherent in teaching CDNSs arise from a difficulty in understanding cultural differences. For example, the North American culture stresses the concept of competitiveness, a notion that might be inconsistent with 27 other cultural groups (Wong & Wong). Wong and Wong contend that such conflicts can create difficulties when the teacher must evaluate students from diverse cultures. Other authors support this assertion (Gay-Tempelton et al., 1993; Snead, 1982). Often, CDNSs are evaluated against "criteria that do not measure their competencies, but how well they have assimilated into Anglo-Saxon culture" (Wong & Wong, p. 258). Summary of the Literature A broad review of literature on nursing education and cultural diversity was provided in order to illuminate the complexities associated with teaching students with diverse cultural backgrounds as well as provide a context for this study. The perspective of symbolic interactionism provided a general guide to the review of relevant concepts, teaching strategies, contextual factors and teachers' perspectives related to CDNSs. The literature review has addressed several theoretical perspectives that are postulated to influence nurse educators' perspectives of teaching students with diverse cultures. Explanations for the interaction patterns between teachers and students with diverse cultural backgrounds are posited. Nurse educators' perspectives were addressed in two studies (Bruyere, 1991; Yoder, 1996). The credibility of the findings in Bruyere's study are questioned due to indeterminate sample size and threats to reliability and validity. Yoder's study is insightful in understanding various perspectives and approaches to teaching CDNSs. In reviewing anecdotal nursing literature, it is evident that the 28 experience of teaching students from diverse cultures presents a challenge to many teachers. Issues such as communication (written and language), conflicting beliefs and values, and difficulties with evaluation are common themes in the literature. Perceptions of CDNSs indicate that faculty support and respect for their culture contribute to student success. However, anecdotal reports do not provide an empirical foundation for understanding of how teachers teach diverse students. The research in both nursing and general education provides a basic understanding of how CDNSs interface with the academic world of nursing. Furthermore, these studies illuminate the myriad of factors that influence the educational experience of CDNSs. There is, however, little empirical evidence to suggest that nurse educators consider the cultural background of a student when developing teaching strategies. The limited number of studies focusing on specific teaching strategies are largely descriptive. Moreover, they do not provide enough depth to understand the complexities involved in teaching CDNSs. An important finding in the literature review relates to the origin of the research and anecdotal publications; the large majority are American-based. It is speculative whether the findings would be similar in the Canadian context. Further, it is not known whether general educators' perspectives' are similar to nurse educators' perspectives. To date, it is not known how increasing cultural diversity in nursing programs in Canada has influenced the perspectives of nurse educators. There is a need to understand what nurse educators' view as important in teaching students with diverse cultures in order to inform existing practices in Canada. 29 CHAPTER THREE: RESEARCH METHOD Introduction This chapter will outline the research design for this study. Procedures for sample selection, data collection and analysis, ethical considerations, and strategies for achieving rigor will be explicated. Research Design The perspective of symbolic interactionism as described in chapter one has implications for the proposed research design for this study. The implications of utilizing this theoretical perspective to direct the research design were three-fold. First, the researcher needs to understand the participants' definitions of the phenomenon under investigation or "see their objects as they see them" (Stryker, 1980, p.97). Secondly, there should be an attempt to explore the perspectives of the participants regarding the context in relation to the phenomenon under study. Lastly, there should be an exploration of how participants interpreted the situations that confronted them and how they constructed their behavior in relation to the phenomenon under investigation (Hammersley, 1990; Stryker). Within the symbolic interactionist perspective, there is "an attempt to analyze, isolate, measure the importance of, and understand meanings arising out of interactions, and in turn relate these meanings to the way in which people construct their behavior" (Hartman & Hedblom, 1979, p. 19). In keeping with these premises, the theory of symbolic interactionism guides the research design and managing of the interview data. A qualitative, eploratory design is chosen in order to fully 30 understand both individual and shared meanings of teaching CDNSs. This is accomplished through qualitative data analysis of teachers' verbal accounts of teaching CDNSs. Further, the framework provides a broad guide for the initial management of the interview data in relation to definitions pertinent to teaching CDNSs, strategies implemented in teaching CDNSs and factors influencing teaching CDNSs. A general exploratory design is further implicated in that the research question has not been explored. Therefore, the goals of this research study are to discover problems in unexplored areas and to define problems associated with the particular phenomena (Brink, 1989). The exploratory design uses "qualitative data collection methods based upon unstructured interviewing techniques, unstructured observations, unstructured available data, small samples, and a variety of forms of content analysis" (Brink, 1989, p. 142). Sample and Setting In exploratory designs, participants are selected according to whether they have experience with the phenomenon being studied (Sandelowski, Davis, & Harris, 1989). Moreover, according to Lincoln and Guba (1985), sampling within the naturalistic paradigm is purposive in order to expose as many realities as possible. With purposive sampling, also known as theoretical sampling (Strauss & Corbin, 1990), it is not possible to stipulate the number of participants required for the study. Ongoing selection of participants depends on whether there are gaps or inconsistencies in the emerging construction of the phenomenon: therefore, 31 participants are selected on the basis of their ability to extend existing categories (Baker, Wuest & Stern, 1992; Lincoln & Guba, 1985). Bowers (1988) suggests that the initial small sample size be five or six with further selection of participants based on the evolving construction. In this study, volunteers were recruited via snowball sampling (Polit & Hungler, 1991). I distributed information to several nurse educators who knew of participants that might be interested in participating (see Appendix A). All volunteers who met the criteria were accepted into the study. However, as the study progressed, participants were selected according to the need to extend or fill the evolving categories. A total of seven nurse educators from four educational institutions were selected. These teachers all taught in baccalaureate and/or collaborative baccalaureate nursing programs and had at least 2 years experience in teaching CDNSs. In order to explore the proposed research question, nurse educators from a baccalaureate degree program were recruited. Criteria for inclusion included: 1. A nurse educator who has taught in a baccalaureate nursing program for at least 2 years. 2. A nurse educator who has experience in teaching culturally diverse students. 3. A nurse educator who is currently teaching in a baccalaureate nursing education program. 32 Following agreement to participate in the study, the researcher requested that a consent form be signed and a demographic sheet be completed (see Appendix B and Appendix C). Data Collection Consistent with the exploratory design is the notion of the researcher as instrument; as such, the interview is a common method of data collection. During the interview, the researcher derives insight from both theoretical and intuitive or tacit knowledge. The complex nature of the interaction between the researcher and the phenomenon under study precludes a prediction of how the research process will unfold. In this sense, the researcher is attempting to derive a construction of the participant's reality, and subsequently reconstruct or synthesize the multiple realities of all the participants to create a new, coherent whole. In order to build a construction of the phenomenon that is truly grounded in reality, data collection and analysis are performed concurrently (Lincoln & Guba, 1985). There are essentially three phases to the data collection process; identifying categories, determining the salient elements of the categories, and member checking (Lincoln & Guba, 1985). Lincoln and Guba contend that the researcher approaches qualitative inquiry "not knowing what needs to be known" about the phenomenon (p.235). Therefore, at the beginning stage of the research, interviews were unstructured; this format allowed for broader exploration of a phenomenon without imposing a priori categories or assumptions (Fontana & Frey, 1994). 33 The first interviews were conducted in two settings (participants' home or office) based on the preference of the participant. The second interviews were conducted by telephone. The interviews ranged from 45 minutes to one and one half-hours. In the initial interviews, general questions were asked to uncover what the participants viewed as important in the exploration of the research area (see Appendix D). Data was audio-taped and transcribed verbatim by the researcher. The transcripts were read several times and then the analytic method of constant comparison, described by Lincoln and Guba (1985), was employed in order to generate categories and subcategories. As the various categories and subcategories emerged, the interview questions became more specific to fill in gaps or inconsistencies in the categories (Catanzarro, 1988; Lincoln & Guba). After the first interview, copies of the participant's transcripts were given to them for review. Second interviews were conducted until categories became saturated and there was a sense of "integration" (Grove, 1988). Data Analysis Qualitative data analysis is inductive. The use of inductive data analysis increases the likelihood of identifying multiple realities and makes the researcher-participant interaction more explicit. During data analysis the researcher "prefers to negotiate meanings and interpretations with the human sources from which the data have chiefly been drawn because it is their constructions of reality that the inquirer seeks to construct" (Lincoln & Guba, 1985, p. 41). 34 The method of constant comparison, delineated by Lincoln and Guba (1985), was used for analyzing the data in this study. These authors have adapted a method originally developed by Glaser and Strauss (1967). Lincoln and Guba's method differs from the latter approach in that the purpose of the method is to process obtained data, not to develop a theory. These authors refer to the end product of data processing as a construction of the phenomenon. There are four stages that comprise this form of constant comparative data analysis. These are explicated by Grove (1988): 1. Unitizing: This method involves extracting small, meaningful excerpts or "incidents" (sentences or paragraphs) from the written transcripts and placing them on index cards. These cards are then coded according to the informant. 2. Categorizing: The coded cards are organized into categories. A number of cards for a particular category are generated based on common units. Following this the category is given a name and specific criteria for inclusion. As categories emerge that do not fit a discrete category, they will be considered miscellaneous or irrelevant. Following this initial process categories are reviewed again to rule out redundancy or conflicts. Lastly, categories are compared with each other to explore possible relationships. Gaps or inconsistencies in the category generate questions that require further investigation. 3. Filling in Patterns: Missing categories are completed through further data collection. Asking questions that either extend existing categories, bridge or subsume categories, or allow new categories to surface are employed in the 35 interviewing process. The research process is halted when categories become saturated and there is a sense of integration. 4. Member checking: Participants are given a reconstruction of the data to see if it is a plausible representation of reality. Furthermore, data is reviewed by an external auditor (Grove, 1988). In this study, an initial analyzed transcripts was reviewed by the researcher's thesis committee to ensure proper interviewing technique and analytic procedures. Following data analysis, the findings were compared with literature (Lincoln & Guba, 1985) to produce a final construction of nurse educators' perspectives of teaching CDNSs. Field Notes Concurrently with data collection, the researcher kept a journal to critically reflect on each interview. The purpose of this journal was to record themes or issues that arose during data collection, as well as personal thoughts and feelings regarding the research process. This process of reflexivity is postulated to promote meaningful research results as well as personal growth of the researcher (Lamb & Huttlinger, 1989). Specifically, the researcher employed a reactivity framework that is explicated by Paterson (1994c). Originally developed by Wiseman (cited in Paterson), the framework consists of five themes that influence the researcher during qualitative inquiry. These themes are "emotional valence, distribution of power, importance of the interaction, goal of the interaction, and the effect of normative or cultural criteria" (Paterson, p.303). The purpose of using this 36 framework was to increase reflexivity throughout the research process (Paterson), thereby enhancing the trustworthiness of the study (Lincoln & Guba, 1985).. Ethical Considerations The inherent nature of qualitative inquiry necessitates an ongoing consent process (Munhall, 1988). Often research problems are emergent in nature and it is not possible to determine the exact course or constituents of the research (Ramos, 1989; Robley, 1995). For this study, several methods were employed to protect the rights of the participants in the study: 1. Approval from the University of British Columbia Behavioral Sciences Screening Committee for Research involving human subjects was obtained prior to the study. 2. Informed consent was achieved by distributing and explaining to the participants the nature of the study, plans for handling and disseminating the data, and the nature of the consent. 3. Audiotapes and transcripts were assigned a code to protect the names of the participants. Audiotapes were only accessible to the researcher. 4. Data was kept for the duration of the research and was destroyed to protect the anonymity of the participants. Methods for Enhancing Rigor Lincoln and Guba (1985) contend that four criteria, credibility, transferability, dependability, and confirmability, judge the trustworthiness of naturalistic research. Credibility is judged by determining whether the experiences 37 of the participants are clearly and accurately described. If this criteria is met, the participants and other researchers are able to grasp the essence of the phenomenon by reviewing the study. Credibility is enhanced in through peer debriefing, member (i.e., participant) checks, and review of data and analysis by the thesis committee members; these processes involved validation and clarification of emerging constructs. In this study, the researcher's thesis committee chairperson reviewed the initial transcript and the evolving analysis. Furthermore, participants were consulted both informally (during the interviews) and formally (after the phenomenon was constructed) to ensure that the interpretation of the phenomenon reflected the reality of the participants (Lincoln & Guba). The second criteria to considered in establishing the trustworthiness of the study is transferability. This criteria is based on the ability of the researcher to provide a "thick" description of the phenomenon under investigation. Thick data is generated when multiple realities are explored. Purposive sampling facilitates the generation of thick data (Lincoln & Guba, 1985). In this study, purposive sampling continued until the data generated was comprehensive and reflective of multiple perspectives. Dependability and confirmability are the last two criteria to consider. This involves critically examining the process of the research and the product or findings of the research. The researcher's thesis committee reviewed both the process and the product of the proposed research. This included all components of the research process and the logistics of data collection, analysis, and congruency between the 38 interpretations and the data (Lincoln & Guba, 1985). Sandelowski (1986) refers to this process as auditability. She asserts that "auditability is achieved when the researcher leaves a clear decision trail concerning the study from its beginning to its end" (Sandelowski, p. 34). Summary The research design for exploring nurse educators' perspectives of teaching CDNSs was reviewed in this chapter. The sampling method, data collection, data analysis, ethical guidelines and guidelines to establish trustworthiness of the study were explicated. The use of a broad exploratory design, guided by the perspective of symbolic interactionism, was employed in this study to ensure that potential insights were not overlooked. It was anticipated that this approach would facilitate an understanding of nurse educators' perspectives of teaching CDNSs. 39 CHAPTER FOUR: REPORT OF FINDINGS Introduction In this chapter, the findings of the research study are reported. The premises of symbolic interactionism infer that understanding behavior entails exploring indvidual definitions or meanings relative to the area of study, ways that definitions are developed and what factors are considered in determining an indviduals' behaviors. Initially, these premises were utilized as a broad framework for categorizing teachers' perspectives of teaching CDNSs. Specifically, initial data analysis involved uncovering nurse educators' definitions of CDNSs, strategies employed in teaching CDNSs and factors that influence the setting and/or strategies used by the educators. By using the method of constant comparison, as outlined by Lincoln and Guba (1985), specific labels were generated for the conceptual categories and subcategories. These conceptual categories represent a synthesis of the participants' perspectives of teaching CDNSs. The three categories identified were: 1) Conceptions of Culturally Diverse Students 2) Dealing with Diversity, and 3) Challenges in Teaching CDNSs. Conceptions of Culturally Diverse Nursing Students Analysis of the data revealed that teachers hold shared conceptions of CDNSs. For the teachers in the study, CDNSs were described as exemplifying diverse cultural backgrounds, diverse behavioral patterns, and diverse learning needs and challenges. 40 Culturally Diverse Backgrounds Throughout the interviews teachers defined CDNSs in terms of their diverse cultural backgrounds. For the teachers in this study, a CDNS was a student that was culturally "different" from mainstream nursing students. In general, CDNSs were viewed as a unique group of students that, as one teacher stated, "swayed from typical nursing students". The cultural differences were attributed to the context in which the student had been brought up. One teacher defined cultural difference in the following way: I think that, you know, we're all different, we're all unique we all have different strengths, we have different weaknesses, we have different likes and dislikes and so I think there's tremendous variation just because we're people. Its more those general kinds of things that you relate to culturally, think and culture I think is often defined by the place where you are, and the place where you grew up and what your parents gave you. More specifically, cultural differences were described in terms of the ethnic background of the student, the length of time living in a Canadian context and the degree of familiarity with the mainstream cultural norms. With respect to ethnicity, teachers used the following terms to reflect the ethnic origin of the CDNS that they taught; "Ukrainian", "Asian", "Chinese", "East Indian", "Ethiopian", "Native" and "Aboriginal." In addition, teachers used terms such as "mainstream", "eurocentric" and "western" to define students who were not generally not defined as culturally diverse. 41 Teachers also described the length of time that the a student had lived in Canada as an important component of the cultural background of a student. Students who were recent immigrants or first generation Canadian students were described as being more culturally diverse while 3rd or 4th generation students were viewed as being similar to "mainstream" Canadian students. Further, the degree of assimilation into mainstream society and the degree of identification with one's own cultural background were describe as influencing the student's cultural diversity. For example, one teacher, described an aboriginal student that had moved from a remote native reservation to attend a nursing program in a large city. She stated: ... she was a native Indian woman from some little island off the northern coast of the island, so she had come to the city to do her nursing education so she was sort of transposed from her own community which was quite a distance away. Culturally Diverse Beliefs and Behaviors In addition to culturally diverse backgrounds, teachers described CDNSs in relation to the diverse beliefs and behaviors that they observed while teaching these students. In particular, language and communication style (ie: student-teacher interaction style, assertiveness, eye contact) were described as being culturally distinct behaviors. With respect to communication style, teachers in the study reported that there were subtle differences in the way that CDNSs communicated within the teacher-student relationship. For example, several teachers talked about Oriental-based cultures and the differences in the way that students interacted in the teacher-student relationship. One teacher stated "Many people coming from the oriental-based cultures have difficulty in dealing with authority, you know, they want to view you as an authority, they want a distance relationship..." Another teacher stated that the idea of "respect" for teachers was particularly evident in some cultural groups. Other teachers suggested that communication differences were evidenced in non-verbal behaviors. As one teacher stated : I guess if I can say anything culturally about those students is that they are generally shy, probably not as confident in their communicating abilities...and probably have a bit more trouble being an advocate both for themselves and their client. Language was another culturally diverse behavior reported as a distinct cultural attribute. Specifically, teachers reported that CDNSs possessed varying degrees of competencies in speaking, writing and understanding the English language. The level of competency of the student in the English language was identified as strongly influencing the CDNSs understanding and application of nursing knowledge. Teachers perceived that students with language barriers often "recite" information and do not totally comprehend the meaning of the words. For example, in relation to knowledge about medications, one teacher stated: I think that with this particular Asian student and some of them, they have a lot of difficulty with English as a second language and so they're not 43 able to express themselves, I think, the way they want to express themselves. They talk really fast and its hard to slow them down, even when they're telling you about a drug they tend to regurgitate like its almost like they've memorized and they're regurgitating sort of thing. Diverse Learning Needs and Challenges Teachers reported that, in general, CDNSs had unique learning needs and challenges when compared to mainstream nursing students. CDNSs, as defined by the teachers, were perceived to be struggling, in varying degrees, to meet program and teacher expectations. Teachers talked about CDNSs as struggling to know what was expected of them as well as how to conform to these expectations. Teachers believed that CDNSs, in general, worked hard to try to adjust to the educational context. As one teacher stated "I feel really sorry for a lot of the students cause I, you know, they're so disadvantaged in some ways and they're so nervous and its hard to be a nursing student anyway." In particular, recent immigrant students with ESL (English as a Second Language) were viewed as having the most learning challenges due to speaking, writing and understanding the English language and, in general, due to unfamiliarity with a different educational system. In referring to a recently immigrated student one teacher stated "that was an adjustment for her to have to make, to come to a western educational institution with a higher set of standards than she was used to... it was a real struggle for her". 44 Learning style as a unique learning challenge was mentioned by one participant in the study. Other teachers in the study believed that learning style was not relevant in teaching CDNSs, but was more an individual characteristic. The teacher who supported learning style as a unique learning challenge discussed an Aboriginal student that had difficulty with sciences and logical/linear thinking. She attributed this struggle to a learning style that was not congruent with mainstream norms. She stated: ...she had struggled through the program off and on. I think that her, the biology/pathology sciences were challenging and I think that seems to be something for that group of students, with the native students, that the sciences were quite difficult for them. In relation to learning needs and challenges teachers believed that CDNSs required more assistance in adapting to the educational institution. The kinds of assistance needed varied with the student, but most often written assignments, tests and verbal communication were areas perceived as a challenge for students. As one teacher stated: "they need, sometimes more direction, from the perspective of understanding exactly what's meant by the assignment." The length of time that the student had been in the program was thought to influence the degree of challenge. In general first year students were perceived as requiring more assistance than third or fourth year students. 45 Challenges in Teaching CDNSs As previously identified, teachers perceived that CDNSs came to the respective nursing programs with a diverse cultural background, diverse beliefs and behaviors, and diverse learning needs and challenges. For all of the teachers in the study, the presence of CDNSs within their classrooms created challenges, in varying degrees, to their teaching role. The wide range of CDNSs in their classrooms contributed to the perceived challenges. As one teacher stated: When you teach culturally diverse groups in a classroom setting, the challenge is often to present material so that everyone understands it and its that salience and nuance and the subtleties of culture that sometimes create difference and distinction for people...so I think that is a challenge to create learning activities so that all students participate and all students can gain some meaning, Four subcategories emerged in relation to challenges: 1) Language and Communication 2) Not Knowing or Understanding the Influence of Culture on the Student's Performance, 3) Pressure to Treat Students all the Same, and 4) Lack of Time and Resources. Language and Communication As defined by the teachers in the study, CDNSs possessed varying degrees of proficiency in the English language. All of the teachers expressed challenges in both providing assistance and evaluating CDNSs in the areas of communication and writing skills. Lack of proficiency in the English language was perceived as an 46 issue for teachers as they felt that some CDNSs with ESL did not possess the minimum competencies upon entry into the nursing program. In reference to the TOEFL (Test Of English as a First Language) test one teacher stated: TOEFL was a really large source of frustration for the faculty not because we didn't believe that the students shouldn't be in the program, but...they had to receive a minimal pass, and that didn't support them in the work that they needed to do within the program, at all. Those CDNSs who had difficulty with speaking and writing English were identified as having difficulty meeting the writing standards set out by the program and/or institution. Teachers expressed difficulty in evaluating the knowledge-base of some ESL students. Further, they expressed that they felt incompetent or frustrated by their inability to assist some of these students with their writing skills. One teacher stated " I am not an ESL teacher and I can't provide that service to the students". Another teacher stated: It's sometimes hard as a clinical instructor to see that when you know that they've probably put more effort into the research of a theoretical paper and yet, even though you know their ideas are there, there not quite coming across the way, coherently, the way they should be. I find it hard, I find it very difficult to mark papers like that... Another challenge identified by the teachers related to communication in the clinical setting. The teachers reported that, for some CDNSs, the use of ambiguous language in both charting and assessments interfered with communication between 47 the student and the teacher, and the student and the health care team. Teachers felt that lack of competency in spoken English language had the potential to interfere with safety and/or quality of care for the client. For example, in referring to CDNSs one teacher stated: I think here, you know, we've had many times faced issues with language where we've said...they could not function in an emergency situation because they cannot understand the words and they misinterpret. And that's been a very difficult issue to deal with. We've had students doing not well in clinical and many times it relates to the fact that it's because they misinterpret and they don't comprehend because the language is so different and they can't concentrate on learning the language and learning what they are doing at the same time. It creates a tremendous struggle, it's hard on the student. It's hard on the teacher. Not Knowing Or Understanding The Influence Of Culture On Performance Teachers reported that, in general, their level of knowledge and understanding regarding the influence of culture on the student's performance was lacking. Specifically, knowledge of cultural beliefs and behaviors of CDNSs and the interaction of these variables on the student performance were cited. The teachers in this study expressed that they felt "disadvantaged" in teaching some CDNSs. As one teacher stated; I think about our different ethnic groups and our different cultures all the time because I feel very much disadvantaged that I don't have a better 48 understanding, especially the Chinese, and East Indian cultures and First Nations students because I think that you need that to develop a really good rapport with students. The teachers in the study perceived that the majority of teachers that they taught with shared similar concerns. They believed that many of the faculty that taught with in their institutions lacked knowledge and sensitivity to issues surrounding cultural diversity. A mainstream perspective was viewed as a significant barrier to understanding diverse cultures. As one teacher stated: I think when we're part of the mainstream majority, the dominant majority, I think we just can't even imagine that culture's an issue if we don't know what it is like to be a minority person. Culture, we just sort of think that we are acultural but of course we're not. For the teachers in the study, coming from a mainstream perspective meant that you had an understanding of, as one teacher stated, the "nuances" and "subtleties" associated with mainstream society. The teachers in the study believed that increasing numbers of CDNSs in their programs sensitized teachers to needs of diverse learners, however, they expressed continued difficulty in interpreting culturally diverse behaviors. Teachers perceived that lack of cultural diversity within the faculty, or not a clear match between percentage of CDNSs and culturally diverse faculty, influenced understanding and sensitivity to cultural behaviors in students. As one teacher stated: 49 ...you know, its just like here with Caucasian people you will do or say certain things and there are nuances and subtleties...that you give to one another that need no explanations, that are understood at almost an intuitive level that you don't share with students who are from China or Japan or Malaysia and that sometimes interferes with some of the rapport that you establish with them. Lack of a shared cultural understanding was perceived as contributing to cultural conflict. For example, several teachers cited incidents where they did not share the perspective of the student and they found it difficult when the student did not have the same expectations of the student-teacher relationship as they did. All of the teachers in the study reported incidents where their philosophy or values had resulted in conflicting expectations between the teacher and the student. For example, five teachers cited incidents where students had different perspectives of authority which conflicted with the teachers expectations of "assertiveness". From their perspectives, they found it difficult to understand what they believed was a culturally prescribed behavior. One teacher stated: I don't want that kind of relationship and I don't want to establish that with them, I want it to be a sharing, and I want it to be open and I want communication going both ways and I want to hear their ideas and what their thinking is and they don't want to tell me, they want to know what mine is so they can go do it. 50 Knowledge and understanding of diversity was felt to be influenced by exposure to diverse cultural groups in one's own life experiences (personal and professional), being a member of a culturally diverse group and/or having extensive experience immersion in a diverse cultural setting. Teachers with more exposure to diverse cultures through these experiences felt that they had greater sensitivity to the needs of CDNSs. For example, one teacher talked about her experience with growing up in a culturally diverse neighborhood: I think I have always been more sensitive to some issues and I've always more accepting of other people, because I never grew up in that sort of middle class, white neighbourhood, so I have a different perspective I think I come with that. In addition to personal and professional experiences, knowledge and understanding of cultural factors were perceived to be influenced by a faculty member's degree of interest in culture as a whole. All of the teachers stated that there were a few faculty that had interest and commitment to cultural diversity. This was evidenced by their research interests and/or involvement in cultural issues in the nursing program and institution. One teacher posited that interest and committment to cultural diversity might be influenced by the educational preparation of teachers related to cultural diversity in their basic nursing programs, however this was not a shared theme. The participants concurred that knowledge of cultural diversity was achieved through their own clinical nursing practice and then translated into the teaching/learning context when they became educators.. The general context in which teachers lived was thought to influence cultural knowledge and understanding at a more global level. For example, one teacher discussed how exposure to culture occurred through the context in which a person lived. She contrasted a primarily eurocentric context with a more culturally diverse context. She stated: Certainly your setting has to be a piece of it and how that influences educators. You know, do you drive through Richmond on your way to work and drive by multiple signs in various languages or do you drive through Oak Bay on your way to work, you know, where it is so British. All of the teachers agreed that context influenced one's perspective on cultural diversity; however, reflection on the meaning of cultural diversity was thought to be the most important factor to enhancing cultural knowledge and understanding. Pressure To Treat All Students The Same Emerging from the interview data was a shared belief that there was a pressure to treat all student the same, the participants concurred that the milieu in which they worked fostered this pressure. The pressure to implement a homogenous approach to student learning challenged the teachers as they lacked the support necessary to implement a more heterogeneous approach. The teachers perceived that students, colleagues, the nursing program (curriculum/philosophy), the institution and society as a whole fostered a homogenous approach to teaching. 52 Certainly our programs are set up to standardize what you learn, to standardize your experiences so at the end we graduated all the same kinds of people who had the same kinds of knowledge with the same kinds of experience so I think that we try to make people the same. Teachers reported that many CDNSs were essentially "lumped" into nursing programs as a continuation of homogenous teaching approaches instituted in their elementary and secondary education. The value that our society, lets say, Caucasian society places on education, formal education, from grade one or kindergarten there is not great emphasis placed on the learning needs of culturally diverse students... then I get them as a nursing student and they just lump them into this nursing program. Values inherent in the Canadian nursing profession were thought to contribute to homogenous teaching approaches for all students. All of the teachers reported that students were expected to meet "standards" and "objectives" as outlined by the nursing program and profession and that, at times, these did not support pluralistic teaching approaches. Demanding that all students be assertive and self-directed were two such values that were believed to be contrary to the needs and values of some CDNSs. According to the teachers in the study, the pressure to treat students the same created tension in teaching CDNSs as they were uncertain as to how adapt their approach to accommodate for diverse learning needs. All of the teachers perceived that adapting their approach to meet the needs of CDNSs was not without risk; that is, being perceived by students and faculty as giving "preferential treatment" or, conversely, "discriminating" was increased with CDNSs. Several participants referred to situations in which a student had accused a faculty member of discrimination because they perceived that the teacher was not culturally sensitive in his or her evaluation of the student. You know, a colleague of mine who was in the situation this spring where she worked with a native student and the native student was unsuccessful in the clinical rotation and it ended up that the student started proceedings against the teacher, sort of that this failure was on the grounds of discrimination. I think that that's going to be something that's more common in that as teachers were actually charged with discrimination because we have not been sensitive to someone's culture The teachers stated that the pressure to treat students the same made it difficult for them to balance acknowledging cultural differences and acknowledging the individual's learning needs because they feared stereotyping students. ...am I stereotyping this person into what I believe is their cultural beliefs where in fact these guys are Canadian-born and 4th generation and all that? Just because the visible minority thing, that, I find is my biggest challenge is to just try not slot them into a predetermined set of rules and regulations with this culture, you know, "Oh, you're Chinese. You obviously believe in the hot and cold thing." 54 All of these teachers had taught in programs with traditional nursing curricula and had recently moved to what they termed the "caring curriculum" They perceived that the new curriculum allowed for more flexibility and creativity in teaching CDNSs. For example, one had allowed a student to complete an assignment on "devil's club" (an aboriginal healing modality) as an attempt to acknowledge and affirm the student's cultural perspective. Further, the philosophy of the caring curriculum was perceived to promote an enhanced awareness (teacher/student) of culture in the classroom context. As one teacher explained: One of the major threads running through is context/culture, we talk about cultural differences and what different cultures mean and how different cultures view things and we try and keep it sort of alive and forefront and I think the students, and teachers, because of that are much more sensitive to cultural issues. Although the teachers stated that the new curriculum enhanced their sensitivity to cultural issues, two of the teachers stated that since the inception of the curriculum, there had been a tendency to revert back to more traditional teaching approaches. Lack of Time and Resources Teachers reported time and resources as barriers to teaching CDNSs. Resources were defined as student, teacher, program and institutional resources that facilitated student learning and promoted teachers' knowledge, skills and understanding of cultural diversity. The teachers perceived that although some 55 institutional resources existed, CDNSs were essentially "on their own" in overcoming learning needs and challenges. In relation to student resources, one teacher stated: There are none, I don't believe, I mean certainly, there are ESL classes and we have English tutoring on site. There's some special support for first nation students, but other than that, I think people are really on their own, it's how much they dedicate themselves to learning. Teachers believed that lack of resources for students created additional challenges to their teaching role as they were not able to compensate for the resources not available. The teachers perceived that they did not have the additional time required to assist students with their language and writing skills. I feel I don't have the time to devote to helping her all the time with that so then I'll refer her to the learning center or whatever it is called, where I used to work, and the, you know, fine, I have a implemented a resource, but then the next week she is back she is not any better...then I am faced with the fact of, you know, what happens now? Although the quality of the resources available were perceived as insufficient for the students who accessed them, several of the participants reported that they could not comment extensively on this issue as they were not familiar with the resources that might be available to assist CDNSs on campus. Other teachers reported that they were aware of the resources for students but did not always access them. They concurred that a lack of knowledge regarding resources for 56 students was common within the faculty. As one teacher stated, "I don't really know of any service that counsels students. Maybe there is, but I don't know of anything." Teachers from larger institutions reported more barriers to both knowing and accessing resources due to the sheer number and location of the resources. Regarding resources for faculty there was a general perception that attaining the knowledge, skills and attitudes necessary for teaching diverse populations was the responsibility of individual faculty members. For the teachers in this study, there were not many formal mechanisms, or at least not to their knowledge, in place to enhance knowledge of diverse groups. Several teachers mentioned the availability of teaching workshops and conferences that might address cultural diversity in the classroom. Further, although they reported that written literature was a potential resource for acquiring knowledge about cultural diversity, they perceived that this was inaccessible to them due to the time constraints created by the day-to-day demands of teaching. All of the teachers reported that there was minimal time to both learn and reflect on issues related to cultural diversity. There's nothing available to help you work with students from other cultures and its not really accessible to us. And you're so busy during the year, just getting your work done, you're not about to forge the library to find articles on culturally diverse students. Faculty knowledgeable in teaching CDNSs as well as culturally diverse faculty and students were identified as a resource by the teachers in the study although these sources were not frequently accessed or perceived as unavailable. Informal discussion with other teachers that they worked directly with were the primary sources of learning about teaching CDNSs; these discussions most often occurred when the teacher was having "difficulties" with helping a student. Informal discussions assisted the teachers in problem-solving as well as provided support in difficult situations. In general, the majority of the participants stated that the area of cultural diversity was not something that was frequently discussed within the general faculty. In discussing a colleague who was having difficulty in meeting the learning needs of a CDNS, one teacher stated: I know she was very frustrated and she didn't know how to deal with this situation and she would come and share it at team meetings and people would offer her what they could, but I don't know that she ever really resolved the issue... or got the support that she need to deal with those students. Dealing with Diversity General strategies for dealing with diversity were identified by the teachers. They fell into three sub-categories: 1) Considering Beliefs and Biases. 2) Considering the Influence of Culture on the Student's Performance. 3) Monitoring Teaching Practices. Considering Beliefs And Biases Teachers in this study discussed the importance of exploring one's own biases and beliefs when teaching a student with a culture different than their own. 58 Reflecting on one's own beliefs and biases in relation to the student's belief system and reflecting on the beliefs and biases embedded in the nursing profession and the institution were cited as ways of dealing with diversity. Teachers reported that there were various ways that they dealt with diverse beliefs and biases in their teaching practice. All of the teachers conveyed that it was important for them to acknowledge that cultural characteristics (behaviors/appearances) did not provide the basis for generalizations and categorization. I don't care whether you're categorizing people, or categorizing concepts or oranges, I think the moment you start to make categories you immediately start to reduce because you start to put boundaries and I think it's very dangerous. I'm really cautious about that. Although the teachers felt that categorization was a practice to be avoided, they believed that an awareness of cultural patterns was important to understanding the beliefs and values of CDNSs. Acknowledging that a student might not come from the teachers' perspective was mentioned. As one teacher stated: I think the bottom line is that all of us, maybe were not racist, but were all ethnocentric, you know, as much as we say we are not I think we all have levels of that in us and we all sort of come from one cultural perspective or another so I think that educators, if were not constantly reflecting on that 59 component of our practice, I think we are really burying our heads in the sand. How teachers reflected on the various beliefs and biases they confronted in their teaching practice varied. Reflecting on one's own beliefs (personal and teaching philosophy) regarding other cultural groups was one way of dealing with diversity. This process involved acknowledging potential areas of cultural conflict; as one teacher stated, reflecting on beliefs or behaviors that she might have difficulty "handling". For six of the teachers they felt that dealing with the conflict meant helping the student change or adapt to their behaviors to reflect the objectives espoused in the program objectives and nursing profession. Teachers believed that they should help the student to convert to mainstream values and practices. ...its the lack of assertiveness sometimes, it's just not something that we can have in this culture. Its almost like, I am sorry but you have to get over that because we cant have that and we certainly have that in nursing, we can't have you doing what you're told and what somebody else said, you have to think for yourself, you must look people in the eye, you must take charge of the situation. For one teacher in the study, dealing with conflicting beliefs and values meant bridging the perspective of the student with that of the values and expectations set out by the nursing program. She questioned whether teachers should expect the student to have to completely adapt to program expectations 60 which were founded on a mainstream perspective. She believed that acknowledging that change has to occur "both ways" was critical to deconstructing the "acultural" attitudes, and sometimes, discriminatory practices that existed within the institution. I guess what I am saying is that the translation just cant go one way. We cant just translate our health care to the student and expect the student to adapt themselves to our health care perhaps the translation has to go the other way as well and maybe not all the change has to be expected from the student, maybe we can teach in different ways as educators, maybe our expectations can be different. For teachers, acknowledging beliefs and biases occurred at a broad level. Teaching diverse groups in the classroom meant that teachers needed to have a general awareness of the beliefs and values of the culturally diverse groups in their classrooms. ...when I look around my classroom I try to remember that I have a Chinese woman there, I have an East Indian woman, I have people from the Philippines and I have first nations people and I have a gentleman from Ireland and I just try to remember that these people bring a background that's different and that we need to acknowledge that and to be sensitive to them as a person and not to think about them as a culture.. Developing an understanding of one's beliefs and biases related to CDNSs students was perceived as a learning process. The teachers in the study reported 61 that as they dealt more with CDNSs, they became more aware of cultural patterns. One participant believed that self-reflection was a necessary component of this experience as sometimes teachers who did not reflect on their behavior and attitudes became "color-blind" or "sensitized" to cultural variations with experience with CDNSs. I think then with more familiarity and more thinking and more working with and more self-awareness I think that you start to see those patterns within, you start to see individual variations within cultural patterns. So I think its sort of almost like a developmental thing in how we think about cultural diversity and whether or not we just come with our stereotypical expectations-this is an Asian student therefore they will do this or do we come with a more sort of informed, but thoughtful perspective where you say "I know a lot of Asian students do this but I need to find out for myself whether this is what its about." So I think its sort of a developmental thing. Considering Culture as an Influence on Learning Considering culture as a factor in the learning process was another category emerging from the interview data. Teachers described ways that they integrated the student's unique learning needs and challenges into the learning experience. Both general and specific strategies were used to address culture in the teaching-learning context. This group of teachers believed that conveying a respect and openness was important in teaching any student, and this was not unique to 62 CDNSs. They felt that these attributes were essential in establishing a rapport, and therefore, to "get to know the student" and "try to get a feel for who they are". Openness and a respect for where they are coming from and to sort of try and elicit that from them, certainly what I said earlier to acknowledge that culture may be a part of what is happening in this rather than just discounting it and blazing ahead and assuming that we are operating from the same premises. Various ways of demonstrating respect and understanding of diverse cultural perspectives were reported. For some of the teachers, incorporating cultural content into their lectures and discussions was a general way of acknowledging diversity within the classroom. For other teachers, encouraging CDNSs to share their perspective in class was important. The teachers perceived that encouraging students to share their perspective fostered respect and understanding for both teachers and students. For example, in referring to an Aboriginal nursing student, one teacher stated: I think some people bring some really unique gifts. We have one young woman, who is a first nations woman and she does a beautiful job of keeping people orientated to first nations culture and not forgetting it and helping people sort of realize that maybe there's a little bit of racism or prejudism, some of what they're saying, she does a lovely job of bringing the first nations culture forward constantly Encouraging the integration of the student's cultural perspective in the clinical setting was described as a strategy to foster cultural sensitivity and respect by two of the teachers in the study. The teachers stated that they talked openly to students about their cultural background and how it might relate to the nursing situation at hand. If a student has a patient who is dying than I talk about with them is how would they handle this in their culture and, sometimes they say the person would be at home and the family would be around or they don't show out emotions. Then, the student and I can talk about what they see and how that's making them feel. Other ways of addressing the cultural influences in the teaching-learning setting were through advocating and bridging the students' perspective with that of other people involved in the education of the students. For example, one teacher described a situation where she helped to "bridge" the cultural perspective of the student and a preceptor who were having difficulty understanding each other. My role was to interpret the culture of the student to the RN and to interpret the culture of nursing to the student and to try and bridge those two differences think that's the most of sort of what I did to facilitate that between those two people was to just to have them both share their perspectives and then talk about what part of this was cultural and then to just come up with a negotiated plan so that they could make this work and to sort of really pull them towards what the common overall goal is. 64 Other strategies used to address the cultural background of the student included pairing students with a similar cultural background for group assignments and assigning students in the clinical setting to clients with a similar cultural background. In these instances, teachers perceived that these strategies helped to lessen the anxiety of the student who was struggling with adapting to different cultural expectations. Monitoring Teaching Approaches For the teachers in this study, monitoring teaching approaches was an important aspect of dealing with diversity. Monitoring entailed being aware of the fairness and sensitivity of teaching practices (specifically assessment and evaluation methods) in relation to teaching CDNSs. Ensuring "objectivity", "fairness" and "equity" were reported as important to teaching students, in general; however, teachers perceived that these concepts were more of a concern in teaching CDNSs, particularly if the student was experiencing difficulties. The teachers reported that the fear of stereotyping or categorizing students existed more with CDNSs because of their lack of knowledge and experience with diverse groups. "I think that what stands out for me is that you have to be very aware that you don't want to be prejudicing them." Teachers in the study reported different ways of monitoring their teaching practices. Teachers questioned themselves as to whether they were accurately assessing the cultural meaning of students' behaviors. Maybe it's not as to the height of awareness where I am monitoring myself even for discrimination, per se, but I would be questioning myself as far as, what am I measuring here? Am I measuring my culture against their culture or am I measuring their nursing practice? So there certainly is that ongoing awareness, I think and sort of self-reflection on your teaching or your practice. For all of the teachers, monitoring entailed comparing their approach with CDNSs to that with mainstream students. Ensuring that students were meeting the "bottom-line" standards of the educational program was described as additional aspect of monitoring. When it comes to looking at people with different backgrounds, I think that we have to look at whether or not they, they're meeting the standards. I think that we still, you know, we can never deny the fact that the pedagogical relationship in nursing education also entails the client and so we always have to be sure that there is competent care happening, For the teachers in this study, monitoring was an important aspect of dealing with diversity. Monitoring teaching approaches meant different things for the participants in the study. For the participants in this study, monitoring meant being aware of their teaching practices (specifically assessment and evaluation methods) in relation to teaching CDNSs. When it comes to looking at people with different backgrounds, I think that we have to look at whether or not they're meeting the 66 standards, I think that we still, you know, we can never deny the fact that the pedagogical relationship in nursing education also entails the client and so we always have to be sure that there is competent care happening. Summary In this chapter, the study findings in relation to the seven nurse educators' perspectives of teaching culturally diverse nursing students were presented. The framework of symbolic interactionism provided a broad guide for initial categorization of the teachers' perspectives. The findings of the study revealed that teachers have shared perspectives regarding their definitions of CDNSs. Further, they reported various challenges related to teaching CDNSs. Lastly, they described various methods of dealing with diversity in their teaching practice. In relation to conceptions of CDNSs, teachers reported that these students were from diverse ethonocultural backgrounds that they perceived as differing from the "mainstream" nursing students. They perceived that CDNS's possessed diverse beliefs and behaviors that made them unique. Beliefs regarding the teacher-student relationship as well as language and behavioral differences were identified as unique to CDNSs. Teachers reported that CDNSs had various learning needs and challenges that often placed them in a disadvantaged position when compared to mainstream students. Students were perceived as struggling to interpret and enact program expectations. Further, teachers reported that ESL students were at risk of having difficulty with academic writing and verbal communication. 67 All of the teachers reported that teaching CDNSs posed some unique challenges. Language and communication barriers appeared to be the most significant issue for teachers in the study. Difficulty in understanding and evaluating the student's learning in the clinical setting and difficulty evaluating written assignment were reported by the teachers. Another challenge to teaching CDNSs was related to lack of knowledge and understanding of diverse cultural practices. The teachers perceived that their own cultural orientation and the faculty cultural orientation was primarily "mainstream" and influenced their degree of knowledge in cultural issues. Difficulty in picking up on cultural cues or patterns was cited as being a challenge for mainstream teachers. Two of the teachers reported that they had significant experiences in cultural diversity that influenced their knowledge around cultural issues. They believed that more exposure to diversity through being a minority person, and being immersed in a diverse cultural background influenced their sensitivity to cultural issues. Nursing education background and clinical experiences with culturally diverse clients were thought to influence overall knowledge according to some teachers in the study All of the teachers in the study reported that knowledge and understanding of diverse cultural groups was not easily acquired. They reported that few faculty were committed/interested in issues around diversity. Those faculty that were interested in cultural diversity demonstrated commitment to understanding cultural issues through research projects or through involvement in program or institutional committees related to teaching diverse 68 students. The nature of the nursing program and curriculum were identified as factors that enhanced or hindered faculty knowledge and sensitivity to cultural diversity. In particular, the use of the "caring curriculum" was perceived as fostering a more pluralistic approach. Teachers reported that inherent in the program and institution was the pressure to treat all students the same. They concurred that various forces in society and the nursing profession fostered this pressure. Using a pluralistic approach was perceived as creating tension for educators as they felt that they did not want to discriminate, or conversely, give "preferential" treatment to students that might have different learning needs. Dealing with cultural diversity in teaching practices was another category that emerged in the data analysis. Teachers reported that they dealt with diversity through examining their own beliefs and biases. Acknowledging and attempting to understand behaviors that were different than their mainstream expectations was one way that teachers dealt with contrasting beliefs and values. For the majority of teachers, dealing with contrasting beliefs and values meant assisting the student to change to more mainstream ways. For one teacher in the study, dealing with contrasting beliefs and values meant adapting the system to account for more diverse perspectives. Teachers reported various teaching strategies that were aimed at acknowledging the influence of culture on the students' performance. All of the teachers in the study reported taking a broad approach to understanding the student's needs and preferences, such as "getting to know the student" and "trying 69 to understand where they were coming from". Other broad approaches included addressing cultural perspectives in the classroom, pairing students with the same cultural background and assigning students to clients with a similar cultural background. Two of the teachers implemented more culturally specific activities which included gaining the perspective of the student and adapting their teaching strategies to include culturally meaningful activities. The last evolving subcategory referred to monitoring one's teaching approach. Teachers revealed that they were aware of the importance of ensuring fairness and equity in their approach to teaching students. They monitored their approach to determine if they were categorizing or stereotyping students into what they believed to be a cultural behavior. Many of the teachers reported that they would compare their approach with how they might react in a situation with a mainstream student. For the majority of teachers in the study, treating students in a similar manner was important to ensure fairness as well as to prevent accusations of discrimination or favouritism. 70 CHAPTER 5: DISCUSSION OF FINDINGS Introduction In this chapter, salient findings of the research study are discussed. The literature reviewed in Chapter Two provided a general understanding of how teachers and CDNSs interface with the academic world. Further, it highlighted strategies that educators use to assist students along with teachers' perceptions of the experience of teaching CDNSs. In this chapter, there will be an in-depth comparison of the current study findings to the study done by Yoder (1996). This was the only known published nursing study located that specifically addresses nurse educators' responses to cultural diversity and, therefore, provides a basis for extending knowledge in the area of nursing education and CDNSs. There will be a brief comparison of the findings to the general education literature. The remainder of the discussion will focus on the concept of intercultural competency. It was decided that a discussion of intercultural competency in relation to the findings would illuminate the significant findings of this research study along with providing significant implications for nursing education. Selected literature in nursing and general education is reviewed in order to illuminate the current study findings related to intercultural competency. The discussion is divided into three areas: 1) Perceived Learning Needs of CDNSs 2) Approaches to Teaching CDNSs 3) Intercultural Competency. Perceived Learning Needs of CDNSs Several findings were consistent with the literature reviewed in Chapter Two. First, in both this study and the literature, teachers and students shared similar views regarding the needs of CDNSs. In Chapter Two, the 10 studies reviewed regarding teacher perceptions revealed that students perceive writing barriers (Snyder & Bunkers, 1994), difficulty in verbally communicating with instructors, health care professionals and clients (Abu-Saad & Kayser-Jones, 1982; Abu-Saad et al, 1982b), and perceive differences in social customs and values (Abu-Saad & Kayser-Jones; Abu-Saad et al, 1982a; Abu-Saad et al, 1982b). In this study, the teachers revealed that language barriers create significant challenges for both CDNSs and teachers. Students were perceived as needing to work harder to both interpret and enact the competencies that were expected of them. Writing, reading and understanding the English language was perceived as critically influencing the student's ability to meet the objectives of the nursing program. Teachers believed that some ESL students did not possess the minimum competencies to meet the learning objectives and that English competency tests did not prepare them for the demands of the program. These findings indicate that teachers believe that students may enter academic institutions without adequate preparation for the demands of the program. Other literature reviewed revealed that CDNSs perceive that programs are inflexible and further, that there is lack of knowledge among faculty regarding their cultural background (Abu-Saad et al, 1982a; Kayser-Jones et al, 1982b). In this 72 study, teachers were able to identify students as being culturally diverse at a general level, however, they stated that they were not always able to identify cultural patterns of specific ethnic groups. With respect to flexibility, the curriculum, program and greater institution were identified as fostering a pressure to treat students in a homogenous manner. Silva (1994) concurs that inflexibility in nursing programs prevents CDNSs from being successful. Further, she asserts that institutions expect students to adapt to the normative ways of being, thereby relinquishing their cultural beliefs and behaviors. Lack of minority faculty was perceived as a barrier to student learning by CDNSs (Snyder & Bunkers, 1994). Several of the teachers in this study cited minority faculty as being important to teaching CDNSs, however this was not a shared belief. One teacher felt that the presence of minority faculty helped to sensitize teachers to cultural issues. She believed that the number of culturally diverse faculty should be representative of the student population. Although all participants did not cite culturally diverse faculty as a necessary resource, they did report that homogeneity among nursing faculty contributed to a lack of knowledge regarding cultural diversity. Therefore, it can be posited that more culturally diverse faculty may enhance sensitivity of faculty to cultural issues. The participants contended that the degree to which the curriculum incorporated cultural content and, further, addressed the individual/personal perspective of the student influenced the cultural knowledge and awareness of the educator. This finding is congruent with those of other studies that found that 73 curricula are influential in fostering the sharing of world-views and are a critical component of faculty-CDNSs' relationships (Crow, 1993; Snead, 1982; Gay-Templeton et al,1993 ). The teachers in this study believed that the "caring curriculum" provided an approach that allowed CDNSs to bring their perspective to the teaching-learning situation, and thus, enhanced the knowledge-base of both students and teachers. This finding suggests that the qualitative nursing curriculum may enhance teachers' knowledge of cultural patterns and foster more pluralistic approaches to teaching CDNSs. Approaches to Teaching CDNSs General Approaches The literature reviewed in Chapter Two provided insight into the various approaches to teaching in a culturally diverse setting. Yoder (1996) identified various patterns of teaching culturally diverse students: generic, mainstreaming, culturally non-tolerant, struggling, and bridging. The teachers in this study did not appear to fall into the same discrete categories as in Yoder's study but comparisons can be made. The majority of the participants enacted a "mainstreaming" pattern when teaching CDNSs. This is reflected by their statements regarding helping CDNSs to change or adapt to meet the program expectations. They viewed CDNSs as having problems in adjusting to a mainstream institution and that their role was to assist them with this transition. The teachers in the study also demonstrated some characteristics of the struggling pattern; that is, they expressed concern for how to adapt their teaching approaches 74 to reflect a more culturally sensitive approach and this created challenge and frustration for them at times. One teacher appeared to approximate the bridging pattern described by Yoder; she defined her role as bridging the student's perspective with that of the greater institution. Several assumptions may be posited in relation to Yoder's (1996) study. According to Yoder, the effect of mainstream and struggling patterns on CDNSs are that they may feel pressure to conform. Consequently, they may experience feelings of invisibility, cultural isolation, devaluing of their perspective, devaluing of the barriers that they confront, and a general sense of being unacknowledged. Mainstreaming assists students with adapting to the institution but the cultural identity of the student is not considered in this teaching approach. According to Yoder, implications of the bridging pattern for students are that students feel their perspectives are valued because barriers are acknowledged and assistance is provided to bridge the perspective of the student and that of the nursing program. The responding process was another category explicated by Yoder (1996). Teachers in this study described interpreting cues as an important process to responding to cultural diversity. The cues that teachers picked up regarding cultural behaviors alerted them to be aware of cultural differences. Following interpretation of cues, teachers reflected upon whether they would use a similar evaluation approach with a mainstream student. The current study supports that personal and professional experience, exposure to other cultures as well as interest and commitment to cultural diversity influence cultural awareness. Interaction with culturally diverse faculty was not generally viewed as a significant factor in increasing cultural awareness in the current study although this was considered critical by Yoder's participants. It is not known how the exposure of faculty in Yoder's study with culturally diverse faculty members compares to that of participants in this study; it may be that this finding is a reflection of the homogeneity of nursing faculty in the programs represented in this study. Other approaches and perspectives to teaching CDNSs were identified in the literature through a review of selected education studies (Carrington et al, 1986; Chen & Goldring, 1994; Gougen, 1993; Rios, 1993). The findings of Rios' study are particularly insightful in relation to the various teacher approaches; that is, "business as usual", "teaching the culturally different", "human relations" and "education that is multicultural and reconstructivist". Similar elements were revealed in the participants' descriptions of their approaches with CDNSs in this study. For example, the majority of teachers perceived that language was the most culturally significant behavior that they dealt with (business as usual) and they perceived that they needed to help CDNSs deal with their "problems" in order to be successful in the program (teaching the culturally different). One of the teachers emphasized promoting intercultural communication and eradication of stereotypes (brokering pattern). She viewed cultural diversity in a global manner and was able to identify the broader influences on teaching CDNSs (education that is multicultural and social reconstrucvist). 76 Specific Teaching Strategies In relation to teaching strategies for CDNSs, the findings of this study were both consistent and inconsistent with the literature. First, the findings were consistent with the anecdotal literature regarding adapting teaching approaches and assisting the student to understand learning objectives (Sturch, 1994; Wong & Wong, 1982) although the way that teachers enacted this strategy varied among the participants. The participants did not identify strategies described in relevant literature, such as mentoring (Alvarez & Abriam-Yago, 1993), Computer-Assisted Instruction (CAI) (Goodman et al., 1990), clinical/interactive learning (Ishida et al, 1994), and group seminar (Malhiot & Ninan, 1979). In this study, the teachers did not define any specific learning strategies or approaches that were most effective with CDNS. They used broad approaches such as getting to know the student, as well as providing individual feedback on writing and language. One teacher did discuss helping CDNS by pairing students or having them work with a client with the same cultural background to assist them with adapting to the clinical context, while another teacher talked about incorporating the student's perspective into the clinical context. The use of resources and/or specific strategies to assist students were viewed as time-consuming and the effectiveness of the various resources were speculative. However, the majority of teachers reported that they were not always aware of the resources that existed nor did they have the time to access resources and, therefore, did not utilize them extensively. This is congruent with the literature that indicates that CDNSs may not always be empowered (Holtz & Wilson, 1992) and may actually become disabled in the educational setting (Cummins, 1986) Intercultural Competency The various approaches to teaching CDNSs provides a lead-in to the discussion of intercultural competency. Intercultural competency is a term that is used interchangeably in nursing and education literature with the terms culturally pluralistic instruction and culturally sensitive teaching. In this section, attributes needed for culturally competent teaching practices as identified in relevant literature are highlighted and compared to the findings of this study. Rew (1996) asserts that intercultural competency is required in order to make teaching meaningful to all students, not just those of the mainstream majority. The majority of teachers in this study exhibited a mainstream approach to teaching (Yoder, 1996); this points to the need for increased intercultural competency. Knowledge and Awareness Knowledge required for intercultural competency includes knowledge of other cultures (Campbell & Davis, 1996; Rew, 1996). For the teachers in this study, knowledge of different cultures was achieved through direct experience as a member of a minority group, by immersion in a culturally diverse setting (i.e., another country), through teaching experiences with CDNSs, and through cultural content in the curriculum. Literature regarding teaching CDNSs was viewed as a potential sources of information but was not generally accessed by the teachers in 78 the study due to perceived time constraints. Informal discussions with colleagues were the most common method of acquiring knowledge. Two of the seven participants had direct experience as a member of a minority group, while one participant had experienced immersion into a different culture. These participants concurred that these experiences had significant meaning for them in terms of understanding CDNSs. The importance of exposure to another culture is highlighted as important in developing cultural sensitivity/competency in nursing literature (Chalanda, 1995; Yoder, 1996 ). Similarly, a qualitative study in education (Taylor, 1994) suggests that having exposure to different cultures through childhood experiences (as a member of a minority group) or significant life experiences in a diverse culture provide a foundation for developing the intercultural competency. In light of the fact that only two of the seven teachers had significant cultural exposure, it is not surprising that teachers cited lack of knowledge or understanding of dealing with CDNSs. Awareness of cultural diversity is another requisite for intercultural competency in teaching. Awareness refers to the awareness of one's own social and cultural biases, opinions and values (Campbell & Davis, 1996; Rew, 1996). According to the literature, awareness means being sensitive to the feelings of minority students (Campbell & Davis, 1996). In this study, teachers were aware of many of the needs and issues confronting CDNSs. Taylor's (1994) study of intercultural competency revealed that there were some teachers that had a reflective approach to cultural issues while others had a non-reflective approach. In 79 this study, several teachers reported that they often did not have time to think about cultural issues, even though they agreed that it was necessary for the development of cultural sensitivity. The study findings suggest that there was a pervasive sense that dealing with difference was difficult because of the fairly homogenous background/perspective of the teachers. Further, there was a sense that the institutional milieu fostered a pressure to treat students in a homogenous way. Failure to do so, according to some teachers, could place them in a position of vulnerability. Specifically, they feared being perceived as being unfair and being charged with discrimination. This issue was not previously addressed in the literature reviewed for this study. Teaching Skills Skills for intercultural competency include the ability to adapt teaching strategies. Some teachers in this study used explicit strategies to address the culture of their students, while others used more generic approaches. Authors have identified various skills necessary for intercultural competency such as role modelling (Campbell & Davis, 1996), effective intercultural communication skills (Campbell & Davis) and brokering to reduce cultural conflict (Chalanda, 1995). A general education study by Hollins (1993) outlines specific'intercultural competencies as: 1) Communication: Communicating effectively with diverse learners means understanding cultural meanings of words. "Theoretically, two distinctly different cultural groups may share the same spoken language, but with 80 varying degrees of comprehension due to differences in cultural meanings" (p.952); 2) Subject Matter: Teachers need to know the subject matter well enough to be able to adapt to differing needs of students thereby helping it make sense to the learner; 3) Reflective Teaching: Teachers should engage in some kind of self-reflection that allows them to see various approaches to teaching CDNSs; what works and what does not (can serve as reference points); 4) Identifying Resources: Teachers need to incorporate culturally responsive material into the curriculum to account for the diverse needs of the learners thereby translating cultural information into appropriate pedacological practices; 5) Creating a Supportive Context: Supporting all kinds of diverse learners and having respect for all opinions; 6) Developing interpersonal relationships; Students do best when they are supported in the classroom; and 7) Promoting Learner Performance: Assessment of where the student is at and helping them to achieve higher levels of competency. In this study, teachers did describe most of these approaches in considering the influence of culture on the student's performance. However, the utilization of resources to assist students was not a common practice. The teachers felt that the available resources for CDNSs were not as effective as they could be. The findings indicate that although the educators have some essential intercultural teaching skills, they require resources to assist them in enhancing their intercultural competency. 81 Awareness, Utilization, Accessibility and Availability of Resources As previously discussed, knowledge, skills and awareness are necessary prerequisites for intercultural competency. Awareness of existing resources was identified as an issue in this study. Some teachers stated that they did not know of existing resources while others stated that they were aware of the resources but did not utilize them. The teachers reported that accessibility and time to use existing resources were constraints to the use of resources. In general, the teachers in the study perceived that there were lack of effective resources to assist teachers in developing knowledge and awareness of cultural diversity. Further, formal mechanisms such as workshops and conferences were not a common source of knowledge for the teachers in this study. Faculty inservices and formal discussion among faculty members were viewed as a potential resource; however, teachers viewed the topic of cultural diversity as an area that was not frequently discussed among faculty members.. Cultural content in the curriculum, along with the philosophy of the curriculum was perceived as contributing to faculty development in knowledge and awareness of cultural differences. According to Yoder (1996) "faculty development is a precursor to changing the curriculum to include multicultural content because if faculty do not understand or respect differences among clients, faculty, and students, the curriculum can not change" (p. 320). As such, Yoder highlighted the importance of having at least one faculty member who was committed to research and knowledge in transcultural nursing. One participant in this study mentioned the 82 importance of faculty who are researching in transcultural nursing as an important resource for the faculty . However, the use of such faculty in enhancing the knowledge of others was not a common practice. With respect to curricula, the study findings suggest that teaching and learning about transcultural nursing can significantly increase the teachers' knowledge and awareness of cultural issues. Limitations of the Study The limitations of the study are several. First, the sample selected in the study was not culturally diverse. All of the teachers reported that they had English as a first language and were at least 4th generation Canadians. Representation of a culturally diverse faculty member would have contributed to the diversity of perspectives in the data. Further, the voluntary nature of the sample could have influenced the sample; that is, people who had an interest in teaching CDNS were likely to volunteer thereby limiting the heterogeneity of the sample. Second, as a novice researcher, I lack experience in conducting nursing research. It can be inferred that more experience in conducting research would enhance my research and analytical skills. Third, the findings of the study are not generalizable which might be perceived as a limitation of the study. However, the intent of the study and the qualitative method selected do not aim for generalizability, but for depth of understanding for a given context (Lincoln & Guba, 1985). Summary In this chapter, the salient findings of the research study were discussed. Literature reviewed in chapter two provided a basis for comparing and contrasting 83 the significant findings in this study. Additional literature in the area of nursing education and general education was reviewed in relation to intercultural competency. According to the findings of the study, teachers and students hold similar perceptions regarding the learning needs and challenges of CDNSs. The teachers in this study were aware of issues such as language and communication, incongruency between the student's cultural perspective and the institutional perspective and the lack of resources to support and assist CDNSs. However, the teachers' knowledge of the kinds of resources for students varied. Some teachers stated that they were not always aware of existing resources. In relation to Yoder's (1996) study, the findings indicate that the majority of teachers in this study exhibit a mainstream pattern in responding to the needs of CDNSs. This kind of approach to teaching CDNSs may leave students feeling vulnerable and feeling that their cultural perspective is not valued. One teacher in the study was found to exhibit a brokering pattern. This approach was posited to have a positive influence on the educational experience of CDNSs (Yoder). Other approaches to teaching CDNSs were postulated in relation to several general education studies. In relation to specific teaching strategies, the findings indicate that teachers utilize a range of approaches in addressing the needs of CDNSs. The strategies identified in the literature, for example, mentoring, were not identified in this study. The findings of the study also revealed that resources for both teachers and students are either insufficient or not utilized by the majority of teachers in the 84 study. It is posited that lack of awareness of existing resources may be influenced by the general program commitment to cultural diversity. That is, more committed institutions would possibly make available resources more visible and accessible to faculty. The degree of intercultural competency among educators was another interesting finding. The findings suggest that, in general, teachers do not have the necessary knowledge, awareness and skills that are required to teach CDNSs. Teachers expressed a lack of knowledge and understanding regarding cultural patterns. Various factors in the faculty cultural make-up, the amount of cultural content in the curriculum and the philosophical underpinnings of the nursing program were though to influence the degree of knowledge among educators. Further, exposure to cultural diversity in both personal and professional realms and reflection on experiences with cultural diverse people were thought to influence awareness of culture in general. 85 CHAPTER SIX: SUMMARY AND CONCLUSIONS Introduction The purpose of this study was to explore nurse educators' perspectives of teaching CDNSs. The need for this study related to the increasingly ethnic and cultural diversity in Canadian society and the lack of empirical research related to the phenomenon of teaching CDNSs. Literature in nursing, other allied health disciplines and the field of education provided insight into strategies for promoting cultural sensitivity in teaching and challenges encountered for both teachers and culturally diverse students. In addition, literature in the field of education provided insight into the various theoretical perspectives and approaches to multicultural education. Only two nursing studies were located that addressed the various perspectives of nurse educators. The theory of symbolic interactionism was employed as a broad framework throughout the thesis. First, it was used as a guide to understanding the definitions or concepts that teachers view as important to the phenomenon of teaching CDNSs, the strategies that teachers implement in relation to teaching CDNSs and the contextual factors that influence teachers' perspectives and actions when teaching CDNSs. Literature related to common themes or concepts emerging from the literature review (empowerment of CDNSs, bridging cultures, teaching strategies, student perceptions) and educators' perspectives (nursing, general education) were reviewed. Second, the theory of symbolic interactionism guided the research design and managing of the interview data. A qualitative, exploratory 86 design was chosen in order to fully understand both individual and shared meanings of teaching CDNSs. This was accomplished through qualitative data analysis of teachers descriptive, verbal accounts of teaching CDNSs. The framework of symbolic interactionism provided a broad conceptual guide for initial management of the interview data in relation to definitions pertinent to teaching CDNSs, strategies implemented in teaching CDNSs and factors influencing teaching CDNSs. Data collection and analysis was accomplished by a method outlined by Lincoln & Guba (1984) in order to address the research question, "what are educators perspectives of teaching culturally diverse nursing students"? Seven nurse educators from Baccalaureate programs in British Columbia participated in the study. Interviews were conducted and data was analyzed according to the method of constant comparison. The findings revealed three categories: 1) Conceptions of CDNSs 2) Dealing with Diversity 3) Challenges in Teaching CDNSs. For the teachers in this study they perceived that their diverse cultural background, diverse behaviors and beliefs and diverse learning needs and challenges were defining features of CDNSs. They perceive that culturally diverse students differed from mainstream nurses due to cultural backgrounds. Further, they believed that CDNSs had unique learning challenges related to interpreting and enacting the expectations of the nursing program. Language and communication were perceived as significant issues for culturally diverse students, particularly students with ESL . 87 Challenges to teaching CDNSs included language and communication barriers, not knowing or understanding the influence of culture on the student's performance, the pressure to treat students the same and lack of time and resources. First, teachers reported that they felt frustrated with their inability to assist some students with writing and communication. They believed that they did not have the skills or resources to assist students with these issues. Further, they perceived lack of effectiveness of existing resources. Second, teachers reported that they did not have an adequate understanding of cultural groups nor did the majority of the teachers that they taught with. Sources of knowledge included informal discussions with colleagues and cultural content in the curriculum. Culturally diverse faculty, literature and workshops/conferences were generally not utilized to enhance knowledge of teaching CDNSs. Third, teachers reported that the institution in which they worked fostered a pressure to treat students the same. Factors fostering this pressure included society and the nursing profession as a whole. Teachers expressed that they feared stereotyping students if they attempted to implement a culturally sensitive approach. Lack of support for pluralistic approaches was perceived as increasing the teacher's chance of student appeals on the charge of discrimination. The curriculum and teaching philosophy were thought to foster or inhibit pluralistic teaching approaches. Specifically, the " caring curriculum" was viewed as allowing more flexibility in teaching CDNSs as well as enhancing both teachers' and students' knowledge regarding cultural diversity. The last challenge identified referred to perceived lack of time and 88 resources. Teachers reported that they believed that resources to assist both teachers and students were unavailable, ineffective and/or inaccessible due to time constraints. Further, some teachers reported that they were not aware of all of the existing resources. Teachers believed that the whole area of diversity was not something frequently addressed in their faculty. The last category, dealing with diversity, included exploring one's own beliefs and biases, considering the influence of culture on the student's performance and monitoring teaching approaches. First, teachers dealt with differing beliefs and biases in teaching CDNSs by exploring behaviors that they might not necessarily agree with or espouse themselves. The majority of teachers dealt with conflicting beliefs and values by assisting the student to adapt to more mainstream values (values embedded in the nursing program) that they felt were necessary for success. One teacher in the study approached conflicting beliefs by assisting the student to bridge her perspective with that of the greater institution. Considering the influence of culture on the student's performance was identified as incorporating both general and specific approaches to addressing the cultural background of the student in their teaching approaches. The majority of the teachers approached CDNSs with general approaches while two of the teachers cited more specific instances of adapting teaching approaches. One approach to dealing with diversity, monitoring, referred to be aware of the importance of fairness in assessing and evaluating students. They reported that they went through a process of comparing CDNSs to mainstream students when evaluating 89 (particularly if the student was having difficulty), to ensure that they were not misjudging or discriminating against the student. Conclusions Derived from Findings The following conclusions are suggested by the participants' statements. Caution must be employed in generalizing these findings beyond the sample studied in this research. 1. Some CDNSs may lack the necessary competency in the English language to meet the requirements of the nursing program. 2. Lack of availability of resources for ESL students may influence their ability to meet the requirement of the nursing program. 3. Nursing programs and institutions may be inflexible in meeting the needs of CDNSs by fostering a homogenous approach to teaching/learning. 4. Teachers may vary in their approaches to diversity. The majority of teachers may expect students to conform to nursing program expectations. 5. Expecting students to conform may negatively influence CDNSs' educational experience. 6. Culturally diverse faculty may enhance the sensitivity of nursing faculty, programs and institutions to cultural issues. 7. Culture addressed as a construct in the curriculum and nursing program philosophy may enhance teachers' knowledge and understanding of the needs of CDNSs. 90 8. Experience as a member of a culturally diverse group and immersion into a diverse culture may positively influence the intercultural competency of the teacher. 9. Resources to assist students with learning needs and challenges may be ineffective. 10. Teachers may lack knowledge, awareness and skills necessary for dealing with CDNSs in their programs. 11. Resources to assist faculty may not be not accessible and/or may not be utilized by the teachers. Time constraints are considered a major barrier to accessing resources as well as lack of faculty and/or program commitment to cultural diversity. Implications for Nursing The findings of the study have implications for nursing education and nursing research. The following section discusses these findings in relation to the study conclusions. Nursing Education The majority of the conclusions have direct implication for nursing education. The findings of the study indicate that there is a pressing need to provide resources to assist CDNSs. The most significant area relates to reading, writing and speaking the English language; however, the study also suggest that preparation for English competency must occur prior to entering the nursing program as well as during the education program. Further, educators need to 91 become aware of the existing resources to assist CDNSs with their English skills. Resources within the institutions must be made explicit to both teachers and students in order for full access and utilization to be obtained. Nursing programs need to make awareness and effective use of resources for CDNSs a priority. For example, a discussion of resources within the institution should be included in both faculty orientation as well as e-mail or newsletters to keep faculty abreast of changes. Further, descriptions of the resources as well as methods of referral should be made explicit and easily accessible so that teachers do not perceive that time is a constraint. Teachers and nursing program administrators need to be sensitive to ethnocentric practices existing in nursing education programs, as well as the expectations and norms that foster homogenous teaching approaches. Awareness discussions and workhops that focus on pluralistic instruction could be helpful in assisting faculty to identify ways in which homogeneity is inadvertently or intentionally fostered. Drawing on the experience of knowledgeable faculty as well as culturally diverse faculty could also be constructive in this regard. The study points to the need for culturally diverse faculty in order to ensure a more equitable ratio of faculty to students with respect to cultural background. The nursing program philosophy as well as a specific review of how culture is presented in the curriculum must be conducted to ensure that pluralism is fostered. The presence of culture and concepts related to culture (i.e.: 92 discrimination, racism) must be integrated in the curriculum to enhance both the teacher and the students knowledge and awareness of cultural concepts. Resources for teachers to acquire intercultural competency must be provided. Teachers must be given an opportunity to participate in cultural awareness workshops to examine the effect of their approach on the learning outcomes of CDNSs. Teachers need to be aware of both the positive and negative results of their various approaches. An example might be providing case studies which allow for demonstration and discussion of various approaches to teaching CDNSs. In this way faculty could explore the implications of, for example, mainstreaming versus bridging approaches. Faculty also need to be provided with opportunities to discuss their approaches to CDNSs in relation to fears of discrimination. Persons knowledgeable regarding human rights and student appeals within educational institutions may be a potential resource for such a discussion. Another resource is to provide cross-cultural experiences for faculty, such as immersion or exchange programs that allow faculty to gain the experience of being in a culture different than their own. Nursing Research The findings of the study support the need for more research in nursing education in a number of areas. First, the findings of the study indicate that the majority of teachers approach CDNSs in a mainstreaming pattern; therefore, the degree to which teachers address the cultural background in their teaching practices must be explored further. It is not known whether the study might yield 93 different results if the sample was more culturally heterogeneous: therefore, the study should be replicated with a more culturally diverse sample. The findings suggested that the presence of culturally diverse nursing faculty would enhance cultural sensitivity among faculty members. Further, as outlined in Yoder's (1996) study, the inclusion of the students' perspectives in such a study has the potential for producing rich data that could illuminate shared perspectives or issues related to cultural diversity in the educational setting. Knowing the perspectives of both teachers and students could provide an empirical basis for developing effective approaches to multicultural education in nursing programs. An exploration of the factors that influence the teachers' perspectives should be included in further research along with the effects of these perspectives on the students that they teach. A second possible research implication relates to the issue of English competency among students entering the nursing programs. Specifically, exploring how the issue of English competency in nursing programs at a teaching level, program level and institutional level. Knowing the scope of the issue as well as possible measures to assist students would reduce some of the challenges and barriers illuminated in this study. A third research implication relates to the accessibility, effectiveness and availability of resources to assist teachers and students. Research regarding the effectiveness of various resources as perceived by students and teachers should be conducted. In addition, an exploration of the factors that foster both bridges and 94 barriers to resource utilization should be explored. A last implication for research relates to exploring the knowledge-base of nurse educators regarding cultural diversity and nursing education and how teachers acquire this knowledge. An understanding of strategies enhance the knowledge, skills and attitudes to address the needs of CDNSs. 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Norwalk, Conn: Appelton-Century Crofts. Vaughan, J. (1997). Is there really racism in nursing? Journal of Nursing Education, 36 (3). 135-39. West, E. (1993). The cultural bridge model. Nursing Outlook, 41, 229-34. Wong, S. & Wong, J. (1982). Problems in teaching minority nursing students. Journal of Advanced Nursing, 7, 255-259. Yoder, M. (1996). Instructional responses to ethnically diverse nursing students. Journal of Nursing Education, 35 (7), 315-321. APPENDIX C: INFORMATION SHEET Demographic Information Name Age Educational Level What level of nursing students do you teach? What content areas do you teach in? Do you teach in both the clinical and classroom setting? How many years have you been teaching? What experiences have you had in teaching a diverse student body? What is your cultural background? APPENDIX D Interview Guide 105 Questions: Tell me about your experiences in teaching culturally diverse students. Prompts: Can you give me an example... What did that mean for you... What were you thinking then... In what way... 

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