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Nursing students’ understanding of the concept of culture Aluwihare, Dilmi S. 1998

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NURSING STUDENTS' UNDERSTANDING OF THE CONCEPT OF CULTURE B y D i l m i S. Aluwihare B S c . N . (Hons)., University of Manchester, 1995 A THESIS S U B M I T T E D I N P A R T I A L F U L F I L M E N T O F T H E R E Q U I R E M E N T S F O R T H E D E G R E E O F M A S T E R OF S C I E N C E I N N U R S I N G in T H E F A C U L T Y OF G R A D U A T E S T U D I E S The School of Nursing We accept this thesis as conforming totke required standard T H E U N I V E R S I T Y O F B R I T I S H C O L O M B I A October, 1998 © D i l m i . S. Aluwihare 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 Kl U£5 IKJOi The University of British Columbia Vancouver, Canada Date IS ^ O C T O S e & DE-6 (2/88) A B S T R A C T Using a critical ethnography design, the investigator foregrounds nursing students understanding of the concept of culture, how they learn about the concept of culture, and apply what they learn in providing care for a culturally diverse population. Eight students from diverse ethnic, cultural, and educational backgrounds, with varying lengths of clinical experience voluntarily participated in the study. Data were collected through access to two students' reflective journals and in-depth interviews with students using open-ended questions, which were audiotaped and transcribed verbatim. Socio-demographic data were also collected. The data were analysed using narrative analytical techniques. The findings from this study suggest first, that students hold diverse perspectives on the concept of culture. A t the same time, it is also crucial to value and respect the perspectives of others and recognise the implications of particular ideological stances toward the concept of culture. Second, the process of learning and understanding about culture involves giving voice to multiple representations of realities, and cannot be isolated from socio-cultural, historical, economic, and political contexts. Third, inequalities and oppression that result from particular perspectives on culture can only be overcome when nursing students and nurses engage in a continuous discourse and problematise culture and bring critical perspectives to the processes of learning about culture. In addition, learning about culture must be ongoing and must draw from academic, personal and nursing experiences. Fourth, there is a dialectic relationship between culture and life experiences. The research indicates that the perception of culture influences values and beliefs, and these values and beliefs are rooted in their life experiences, whether they be of a personal, academic, and nursing nature. TABLE OF CONTENTS Page A B S T R A C T i i T A B L E OF C O N T E N T S iv LIST O F F I G U R E S v i i i A C K N O W L E D G E M E N T S ix CHAPTER 1 1 Introduction to the Problem . . . . . . 1 Background and Statement of the Problem . . . . 2 Purpose of the study . . . . . . . 3 Significance of the Study . . . . . . 3 Nursing Education . . . . . . 3 Nursing Practice . . . . . . 4 Assumptions . . . . . . . . 4 Summary . . . . . . . . 4 CHAPTER 2 6 Review of the Literature . . . . . . 6 Culture. . . . . . . . 7 Culture and the Provision of Health Care. . . . 15 Culture and Nurse Education . . . . . 23 Culture and Learning . . . . . 28 Caring for an Ethnically Diverse Client Population . . 32 Clients Perspectives on Health and Illness . . . 38 Increasing Cultural Awareness . . 41 Gender Issues and Student Nurses . . . . 4 8 Recruitment and Retention of Minority Students . . 52 V Summary of State of Knowledge . . . . . 57 Research Questions . . . . . . 61 Definition of Terms . . . . . . . 61 Summary . . . . . . . . 62 CHAPTER 3 63 Research Methodology . . . . . . 63 Critical Ethnography . . . . . . 63 Selection of Participants . . . . . 69 Sample Selection . . . . . . 69 Selection Criteria . . . . . . 69 Selection Procedure . . . . . . 70 Data Collection and Analys i s . . . . 71 Data Collection . . . . . . 71 Data Analysis . . . . . . . 73 Issues of Validi ty and Reliability . . . . . 80 Credibility and Fittingness. . . . . . 81 Auditability . . . . . . . 82 Confirmability. . . . . . . 83 Limitations . . . . . . 83 Ethical Consideration . . . . . . . 84 Summary . . . . . . . . 85 CHAPTER 4 87 Presentation and Discussion of Meaning Reconstruction's. . . 87 The Processes of Learning about Culture . . . . 89 Personal Life Experiences . . . . . 94 vi Seeing the world . . . . . 95 Tension between what is shared and what is different. 98 The quagmire of understanding culture . . 106 Nursing Experiences . . . . . . 113 Confronting values, beliefs, assumptions, and bias 114 Power of language . . . . . 122 Academic Experiences . . . . 125 Importance of learning about culture . . . 125 What to learn about culture . . . . 126 Ways of learning about culture . . 129 Politics of learning about culture . 131 A time to learn . . . . . 133 Isomorphic Relations . . . . . 133 Understanding Culture . . . . 134 Learning about the Concept of Culture . . 136 How Students Apply what is Learned in Providing Care . 137 Summary . . . . . . . . 138 C H A P T E R 5 140 Summary, Conclusions, and Implications for Nursing . . 140 Summary of the Study . . . . . 140 The Processes of Learning about Culture . . 143 Personal Life Experiences . . . 143 Nursing Experiences . . . . . 145 Academic Experiences . . . . 146 Conclusions . . . . . . . . 148 Implications for Nursing . . . . . 149 Practice . . . . . . . 149 Education . . . . . . . 151 vii Research . . . . . . . 152 R E F E R E N C E S 155 A P P E N D I C E S 165 Appendix A : Tentative Interview Guidelines. . 165 Appendix B : Socio-Demographic Information Form. . 167 Appendix C: Ethical Review Board Letter of Permission . 168 Appendix D : Letter of Information about Participation . 169 Appendix E : Participant consent form . . 171 L L I S T O F F I G U R E S Figure 1 A woman sitting in a wheel chair Figure 2 Explanatory model framework Figure 3 Analytical structure . Figure 4 The processes of learning about culture A C K N O W L E D G E M E N T S I would like to acknowledge all the contributions of the participants of this study, for taking time from their very busy and demanding lives to relate their stories. I thank you all for your trust in me. Then I must thank the members of my thesis committee, Prof. Joan Anderson, Prof. Judy Lynam, and Prof. Sonia Acorn for their excellent guidance and support. In particular, Dr. Joan Anderson, chair of the committee, whose advice was always very timely and succinct, and always imbued with personal concern. I would like to thank the Open University of Sri Lanka, the University of Athabasca, and the Canadian International Development Agency, for giving me the opportunity to study for a Master of Science in Nursing. I would also like to thank the School of Nursing, University of British Colombia for their support. Finally, I would like to thank my parents, many friends, both nursing and non-nursing for their encouragement, support, and forbearance. To all above: Thank you. Concept of Culture 1 CHAPTER 1 Introduction to the Problem Canada is a multicultural society (Masi, 1993); approximately 10% of the total population or 2.5 mil l ion people represent ethnic minorities (Shareski, 1992). B y the year 2000, an 80% increase in the present ethnic population, to 18% of Canada's total population, is projected (Shareski). Previously, the majority of immigrants were from Europe, whereas recently, significant numbers of immigrants are from Asia , Central, and Latin America (Ministry for Multiculturalism and Immigration ( M M I ) , 1991). These figures illustrate the reality for nurses providing care to individuals from ethnic and cultural backgrounds different from their own (Lea, 1994). Nardi and Rooda (1996) advocate that nurses need to increase their cultural awareness in order to maximise their therapeutic competence for patients of diverse cultural backgrounds. To ignore this responsibility is to deny the fact that the cultural backgrounds of both nurses and patients can and do affect the attitudes and responses toward treatment (Rothenburger, 1987). Providing culturally sensitive care can be a difficult process for nurses who are unaware of cultural meanings: meanings such as those that patients may attach to health, illness and health care. Lack of awareness of cultural meanings may result in stress and frustration for nurses and families, as wel l as inadequate care for clients (Chrisman, 1991). The lack of understanding of the concept of culture, cultural knowledge and sensitivity may result in "inappropriate Concept of Culture 2 judgement, leading to ineffective and unsafe practice" (Orque, Block & Monroy, 1983, p. 393-394). Background and Statement of the Problem In the nursing literature it is argued that an individual's culture influences how illness events are perceived, and the need for nurses to provide culturally sensitive care is identified (Dobson, 1991; Lea, 1994; Leininger, 1988; Lipson & Steiger, 1996; Lynam, 1992; Porter-O'Grady, 1996; Wilkins, 1993). The concept of 'culture' in the nursing education literature is identified with issues related to gender (Kelly, Shoemaker & Steele, 1996; Paterson et al., 1996), ethnicity, minority groups (Campbell & Davis, 1996; Yoder, 1996), retention and recruitment of nursing students' (Dowell, 1996), and the need for increasing cultural awareness and sensitivity (Culley, 1996; Haloburdo & Thompson, 1998; Lynam; Murphy & Clark, 1993). In the step toward preparing nurses to provide culturally sensitive care, a range of approaches is addressed in the literature (Chrisman, 1991; Lynam, 1992; Lipson & Steiger, 1996; Porter-0'Grady, 1996; Waxier-Morrison, Anderson & Richardson, 1990; Wright, 1991). For example, advocating that nurses acquire skills in dealing with patients on a one-to-one level as wel l as skills to work with and within organisations (Coeling, 1990) and communities, and focusing on health beliefs and practices of a particular cultural or ethnic group are some of the approaches mentioned. Moreover, providing students with opportunities to explore their own belief system, and appreciate why a client's perspective is important (Anderson, 1990; Smith, Col l ing, Elander & Concept of Culture 3 Latham, 1993), develop communication skills (Waxier-Morrison et al.), examine issues effecting care to people of different cultures (Anderson; Smith, 1997), and develop skills in the identification of cultural bias (Lynam; Spitzer et al., 1996), are some of the other approaches adopted in preparing nurses to provide culturally sensitive care. However, a gap exists in the nursing literature that is important to address. This gap relates to nurses' understanding of the concept of culture; how they learn about the concept of culture; and how they apply what they have learned to provide care for a culturally diverse population. Purpose of the Study In this study, I explore nursing students' understanding of the concept of culture. In particular, I examine how they learn about the concept of culture, and how they perceive their understanding of the concept of culture w i l l influence their values, beliefs, and behaviours in providing nursing care for a culturally diverse population. Significance of the Study Nursing Education The study w i l l provide an explanation of the patterns of values and beliefs of nursing students' perceptions related to learning about the concept of culture. In addition, the study w i l l provide direction for those planning, developing, and revising nursing curricula in schools of nursing. Concept of Culture 4 Nursing Practice Nursing students' understanding of the concept of culture may affect their ontology (way of being in the world), and their epistemology (knowledge derived from their way of being in the world). This study w i l l provide an explanation of how students' understanding of the concept of culture influences their values, beliefs, and behaviours in providing care for a culturally diverse population. Assumptions This study is based on the following assumptions: • Students are from diverse cultural backgrounds. • Students share a culture that is not static but continually evolving. • Socio-cultural, historical, political, and economic contexts affect students' understanding and learning of the concept of culture. • Students have clinical experiences, and have the ability to reflect on those experiences. • Students are able to describe their perceptions and reflections on the concept of culture. Summary In this chapter, the problem of the paucity of information about nurses' or nursing students' understanding of the concept of culture has been introduced. The background to the problem has also been introduced, the purpose of the study identified, and the significance of this topic to nursing Concept of Culture practice and nursing education has been explicated. In the next chapter, relevant literature is reviewed. Concept of Culture 6 C H A P T E R T W O Review of the Literature The literature review for the study begins with an exploration and discussion of the definitions of the concept of culture as understood in the nursing, education, sociological, and anthropological literature. The review then focuses on how the concept of culture is understood in literature relating to the provision of health care, and the delivery of nursing education. In addition, I examine theoretical and research literature about the relationship between culture and learning, particularly as it pertains to nursing education. There are numerous articles, and papers written that identify the need for inclusion of culture related topics in the nursing curricula. The concept of 'culture' in the nursing education literature is generally aligned with issues related to gender, ethnicity, minority groups, and retention and recruitment of students. In the general nursing literature, discussions of the concept of culture focus on the need for nurses to develop the knowledge and skills to provide culturally sensitive care. However, there is a paucity of general nursing research literature related to several key topics: nurses' or nursing students' understanding of the concept of culture, how nurses learn about the concept of culture, and the understanding that nurses bring about culture to the practice of nursing. Finally, this literature review places this research project in the context of the current literature available on the topic of nursing students' understanding and reflections on the concept of culture. Concept of Culture 7 Culture There are many diverse definitions of the term culture in the theoretical and research literature, reflecting diverse theoretical concepts (Masi, 1993). Culture is a capacious construct understood in terms of age, gender, sexual orientation, cultural identity, ethnicity, and religious or philosophical orientation. Therefore a melange of definitions is introduced and discussed in the following paragraphs. Anthropologist E . B . Tyler, in 1871, defined culture as "that complex whole which includes knowledge, belief, art, morals, law, customs and any other capabilities and habits acquired by man as a member o f society" (cited by Helman, 1990, p. 2). Similarly, Spector (1991) suggests that culture includes the interrelationship of beliefs, values, and language, modes of dress, social relationships, rules or norms of behaviour, economics, politics, law, and social control, artefacts, technology, dietary practices, and health care. These perspectives reflect an understanding of culture as a discrete entity, something that can be seen and described. In contrast to the rather static views of culture as described by Tyler and Spector, Bullivant (1981) stresses the evolving nature of culture. Bullivant defines culture as a "patterned system o f knowledge and conception, embodied in symbolic and non-symbolic communication modes, which a society has evolved from the past and progressively modifies and augments to give meaning, and cope with the present and anticipated future problems of its existence (p. 3)." Concept of Culture 8 Similar to this notion of pattern, Couclelis (1995) introduces the idea of culture as schema. He develops an understanding of culture as schema by considering what it is not. It is a coherent pattern rather than a thing, a state rather than stored in memory; it is recreated rather than re-called; it changes through re-structuring rather than accretion; it is holistic rather than an atomistic concept. Bullivant 's (1981) reference to pattern draws attention to the wholeness of culture and the sharing of beliefs, values and practices. He asserts that the past, present, and future strongly suggest a requirement to transmit the culture to the next generation, while his use of the term 'progressively modifies' implies that what is transmitted is not static, but continually evolves (Burtonwood, 1988). Mention of communication modes draws attention to the relationship between language and culture. Finally, his definition signals culture as a problem-solving approach (Burtonwood). Marxist social scientists introduce a hegemonic 1 dimension to the concept of culture, by seeing culture as a set of behaviours imposed on the majority by a dominant class (Burtonwood, 1988). From this view, culture is seen to be responsible for reproducing inequality as wel l as being a site for class struggle. Inequality and struggle are created and sustained by a strong version of economic determinism which explains society and culture in terms of the need to improve productivity (Burtonwood). The oppressed are required 1 Hegemony refers to the ability of a dominant class or culture to exercise social and political control, and to legitimise that control, through influencing the consciousness of people to accept its particular world-view as common sense (Boggs, 1976, as cited by Clare, 1993). Concept of Culture 9 to think, act, and live in ways that take this economic determinism (capitalism) for granted, and to end capitalism the oppressed groups are required to understand work and politics in socialist, rather than capitalist terms (Aune, 1994; Burtonwood). On reflection, perhaps an indictment of Marxism is that its "economic determinism" excludes other stories about human beings (Aune); stories related to exploitation and oppression. Consistent with the Marxist view of culture, Friere (1997) paints a picture of ways in which oppressed minorities live "inside" a socio-cultural, political and economic structure, a hegemonic structure, that makes them "being for others" since they do not conform to the norms of the dominant culture. These individuals are treated not as ends in themselves but rather as means to someone else's end - that is, objects of exploitation and oppression. Friere suggests that the solution is not to completely absorb or assimilate minorities into the dominant social structure but to transform that structure so that people within minority groups are "being for themselves." To do this a society must provide equality of opportunity that enables individuals to develop their capabilities to the fullest (Koggel, 1998). Towards this end, 'culture,' when identified as a pluralist concept recognises that within any society there is a multiplicity of distinctive value 2 Capitalist exploitation includes the time expended by workers at a socially prevailing rate of efficiency to produce raw materials and percentage of tools and machinery used in producing the commodity. Although, the worker is politically, though not practically free to work or not as she chooses and is paid for her work, the wage is less than the value of what the worker produces (Gottlieb, 1992). Concept of Culture 10 systems (Trend, 1995). Cultural pluralism is based on values of equality 3 for all people, and respect for human dignity. Cultural pluralism leads to a conviction that no single pattern of living is good for everyone, and to be different is not to be inferior (Pai, 1990). Sharing in different socio-cultural patterns and practices enriches the lives of individuals. Notwithstanding the views of culture already addressed, 'culture' as a term is frequently misused to refer only to the life patterns of people who are racially different from the majority 'white' population (Chrisman, 1991; Krieger, Rowley & Herman, 1993). Paradoxically, believing that only "other" people have culture may help direct attention toward people whose distinctive behaviours have been ignored or misunderstood for decades. However, this narrow perspective reduces the opportunities to understand that all humans are similar and that all people have cultural needs (Chrisman). Furthermore, this view promotes stereotyping, and racism 4 . Racialisation based on a notion that cultures are static and homogeneous (Ahmed, 1993), and that cultures directly determine attitudes, 3 In reference to equality, "the right to equal treatment concentrates on equality as sameness on treatment" (Koggel, 1998, p. 168). In a world where able-bodied people are the norm, a person in a wheelchair, for example, has her right to equal treatment respected even if nothing is done to accommodate her difference (Koggel, 1998). The right to treatment as an equal, on the other hand, focuses on the differential effects her disability has on her opportunities. Treating her as though she is the same as the able bodied person creates unequal opportunities. For example, she cannot get into a building that has only stairs and may not be able to take notes in the class the "same" way able-bodied people can. 4 Racism is defined "as an oppressive system of racial relations, justified by ideology, in which one racial group benefits from dominating another and defines itself and others through this domination. Racism involves harmful and degrading benefits and actions expressed and implemented by both institutions and individuals, as linked to their membership in racially defined groups" (Krieger, Rowley & Herman, 1993, p. 85). Racism as a concept "has enabled such institutions as slavery to flourish and has allowed for attacks on religious groups, such as the holocaust, to be justified" (Shapiro, Sewell & Ducette, 1995, p. 43-44). Concept of Culture 11 expectations, and behaviours (Donald & Rattansi, 1992). From this view, cultures take on a rigid and constraining shape in which issues of power, deprivation and racism are ignored, rather than being seen as nurturing and sustaining forces (Ahmed). Therefore, understanding the dynamics of 'race' 5 , racism and antiracism could mean studying an ever-changing nexus of representation, discourse 6 and power. Although the concept of race invokes "biologically based historical characteristics, selection of these particular human characteristics for purposes o f racial significance is always and necessarily a social and historical process" (Omi & Winant, 1994, p. 55). In addition, race is linked to the evolution of hegemony, the way in which "society is organised and ruled" (Omi & Winant, p. 55). From this view, race is linked to biological determinism and social construction, whereas 'culture' is a vinculum to social construction. Donald and Rattansi advocate a critical return to the concept of culture, because it is around the definition and significance of culture that some of the disagreements and disputes relating to racism have been expressed. A return to this discussion w i l l facilitate understanding of contemporary controversies and dilemmas involving race, 5 'Race' is conceptualised as "an unstable and ' decentred1 complex of social meanings constantly being transformed by political struggle" and defined as a "concept which signifies and symbolises social conflicts and interests by referring to different types of human bodies (Omi and Winant, 1994, p. 55). 6 Discourses can be thought of as "multiple, discontinuous conversations, mediated by written, spoken, and enacted texts and separated by time and space" (Foucault, 1977, as cited in Allman, 1992, p. 35). Concept of Culture 12 including the nature of racism, the relationship of race to inequalities, oppression, and identity (Omi & Winant, 1994)7. The construct of 'culture', as understood in the nursing, education, sociological, and anthropological literature, encompasses the notion that values and beliefs are shared and patterned systems o f knowledge. Leininger (1988), one of the early nurse theorists in the area of cultural care nursing, defines culture as: "learned, shared, and transmitted values, beliefs, norms, and lifestyle practices of a particular group that guides thinking, decisions and actions in patterned ways" (p. 156). Leininger (1996) writes that "culture is the broadest and most holistic construct one can use in order to know and understand societies, groups, individuals, and communities" (p. 229). Largely derived from anthropology, the holistic view o f culture stresses the wholeness of a way of life and the sharing of understandings within social groups (Burtonwood, 1988). In addition, the concept of culture is tied in with numerous related concepts, for example, race, class, gender, ethnicity, equality, respect, oppression, exploitation, and stereotyping. This implies that people's behaviours are not casual in character. Rather, an individual's culture or personal values, beliefs and ontology, are socially constructed. Individuals develop or acquire a cultural perspective in response to what they perceive to be important and of value (Pai, 1995). 7 The issues around 'race' and 'racism' are complex and the emphasis of this thesis constraints me from exploring and doing justice to discussing the issues to a greater length. However, I suffix that what is important is to be vigilant to the use and abuse of the construct of culture. In that, just as race has been co-authored in the oppression of people, the potential for the Concept of Culture 13 A s individuals encounter new experiences, their minds construct representations8 o f those experiences that are structured by their own previous knowledge and beliefs (Schwandt, 1994). These individually constructed representations interact with each other in the production of new knowledge and beliefs. New knowledge or experience either finds a place within an existing scheme or forces us to modify our picture of how things are in order to take account of it. The representations are different with each social and cultural context (Schwandt). To explicate, representation, is broadly defined as the process by which members of a culture use language (verbal and/or non-verbal in the forms of art, signs and/or symbols) to produce meaning (Hall , 1997). This definition carries the important axiom that things, objects, people, and events in the world do not have any final or true meaning; meaning is contextual and through language and discursive practice, changes from person to person, one period to another, and from one culture to another. Ha l l asserts that it is "us" 'in society' who make and re-make meanings by forging links between people, events, experiences, the mental concepts we carry in our heads, communication, and the interpretation and deconstruction of those meanings. Consequently, because meanings shift and slide, representations of these meanings are always in the process of evolution (Hall). same political co-authorship to support social construction of the concept of culture exists. Please see Donald & Rattansi, (1990), and Omi & Winant (1994) for in-depth discussions. 8 Representation.. ."speaks to such topics as voice, audience, and the 'Other', and the author's place in the reflexive texts that are produced" (Denzin, 1994, p. 503). Concept of Culture 14 Hal l (1992) argues that, on the one hand, representation is a way of viewing a reality that exists 'outside' the means by which things are represented. On the other hand, the term representation can also stand for "a radical displacement of that unproblematic notion of the concept of representation" (p. 253). Deconstructing this quotation, I learnt from H a l l that events, structures, and relations have conditions of existence outside the sphere of the discursive. However, it is within the discursive, subject to context and language that those events, structures, and relations have meaning. To illustrate, I reflect on Clemence (1966), who notes that existentialism 9 emphasises the value of the individual, and is extremely wary of anonymous and amorphous abstractions as groups, classes and categories. However, she suggests that the objective realm is difficult to avoid, for it dominates health care in countless ways, for instance, diagnostic categorisations, patient classifications, expectations, institutional regulations, and the nurse and client cultural backgrounds. For example, see the picture of woman sitting in a wheel chair, and the quote "For one [nurse], I am a presence; for the other, I am an object" (Clemence, p. 503) (See Figure l ) 1 0 . Thus, "while not wanting to expand the territorial claims of the discursive 9 Existentialism is "a philosophical theory emphasising existence of the individual person as a true and responsible agent determining his own development" (The Concise Oxford Dictionary, 1982). 1 0 On reflection, I believe this picture of an elderly woman sitting in a wheel chair elucidates • the two ways in which Stewart Hall presents the term representation. Imagine the picture depicts reality and in observing the picture, you may interpret the unproblematic - what are immediately observable... elderly women sitting in a wheel chair, an object. However, as the quotation suggests, on the other hand, through language and discursive practice you may see the woman as a presence, a person, and the meaning of representation will go beyond what is immediately observable. Concept of Culture 15 infinitely, how things are represented in a culture plays a constitutive, and not merely a reflexive, after-the event, role. This gives questions of culture and ideology, and the scenarios of representations - subjectivity, identity, politics - a formative, not merely an expressive - place in the constitution of social and political life" (Hall , 1992, pp. 253-254). In terms of research, the researcher moves between what is learned from participants, the interpretation1 1 of what was learned (through his or her cultural lens), and the articulation of what was learned. Thus, the researcher is required to address issues closely related to multiple representations o f reality and to the interpretations of that reality (Denzin, 1994). Representation.. ."is always self-presentation. That is, the other's presence is directly connected to the writers' self-presence in the text. The other who is presented in the text is always a version of the researcher's s e l f (Denzin, p. 503) . Culture and the Provision of Health Care Culture plays a vital role in how we define and seek to attain health (Leininger, 1996). Leininger suggests that care and cultures are linked and should not be separated in nursing care actions and decisions (Leininger, 1988, 1991, 1994, 1996). She contends that cultural care focuses on beliefs, 1 1 "Interpretation is an art: it is not formulaic or mechanical. It can be learned, like any form of storytelling, only through doing...writing is interpretation, or storytelling." One ..."can neither make sense nor understand what has been learned until they.. .write the interpretive text, telling the story first to themselves and then to their significant others, and then to the public" (Denzin, 1994, p. 502). 1 2 Representation is always through the writer's cultural lens. So for instance, although I may disseminate what I learn from the participants' after 'member checks' and the use of quotations Concept of Culture 16 "For the one [nurse], I am a presence; lor the other, I am an object." Figure 1 A woman in a wheel chair From: Clemence, M . (1966, p. 503). Existentialism: A philosophy of commitment. American Journal of Nursing, 66(3), 500-505. for examples, when I present what they (the participants) say, I wil l always be presenting through my cultural lens. Concept of Culture 17 values, and life styles of diverse cultures and on the use of this knowledge to provide culture-specific or culture-universal care to individuals, families, and specific cultural groups. Further, she advocates that quality of life is a culturally constituted holistic phenomenon that provides a broad but specific way to know and understand human conditions and expressions. In addition, she expresses the view that quality of life needs to be understood from an emic (inside) culturally patterned viewpoint, and an etic (outsider's) professional viewpoint. Wilkins (1993) believes, and I concur, that Leininger's focus neglects variables such as class, gender, race, racism, religion, politics, employment and unemployment, and individual beliefs and values since diversity also exists within a culture and between generations. Moreover, I suggest that it is imperative that nurses have the ability to develop an awareness of the different cultures, cultures within cultures, and cultures within institutions (Habayeb, 1995; Rosenbaum, 1991; Suominen, Kovasin & Ketola, 1997). Conversely, on rhetorical reflection, by suggesting that it is imperative that nurses have an ability to develop an awareness of different cultures am I reducing culture to a residual category that may invariably cause collateral damage... 1 3 1 3 Reducing culture to a residual category may constrain nurses into stereotyping individuals from particular cultural groups. Stereotyping differs from generalising in that it involves making assumptions about a person based on group membership without bothering to learn whether or not the individual in question fits that assumption (Lipson & Steiger, 1996). Generalising also begins with an assumption about a group, but it includes seeking further information to see whether the assumption fits the individual. Thus, in making a cultural assessment, it is important to learn whether the person being assessed considers himself, or herself, typical of or different from others in his or her cultural group. Moreover, stereotyping comes from jumping to premature conclusions based on insufficient data or experience with a cultural group. It is useful for those making cultural assessments to suspend judgements as Concept of Culture 18 Chrisman (1991) considers an expansionist perspective of cultural care that originates with the client and expands to all relevant aspects of the client's context. He suggests that to understand the role of socio-cultural knowledge in patient care is to view the history of health care and nursing as a series of eras in which the focus on the patient has shifted. The first era, ensuring that the patient's biomedical needs were satisfied, the second era, recognising the patient as having psychological and interpersonal characteristics, and the third focusing on the socio-cultural factors of patient as parts of the health care equation. Although Chrisman recognises the direction in which patient care has shifted, he concentrates on core concepts found in all cultures rather than those which are culture specific - cultural beliefs and practices, and examines care-seeking behaviour rather than caring behaviour. However, in focusing on core concepts found in all cultures there is a danger that the meaning of cultural sensitivity w i l l be restricted to culture-specific nursing care, and divert attention away from the uniqueness of the individual. On reflection, I argue that Leininger (1988, 1991, 1994, 1996) and Chrisman essentialise culture: they see culture as a fixed attribute. Kleinman (1978) argues that client-health care practitioner interactions constitute transactions between explanatory models (EM) . To explicate, Kleinman's explanatory model conceptualises three interacting structural domains of health care, the popular (family, social network, community), folk long as possible. However, the paradox is that the more a person learns about a cultural group other than his or her own, the more that person learns how much there is to learn... Concept of Culture 19 (non-professional healers) and professional sectors (nursing, medicine, and other professions). Figure 2 presents a schematic representation o f the structural domains of health care adapted by Anderson (1985) from Kleinman. The explanatory models of both the professional and popular sectors are culturally shaped. Kleinman's framework provides direction for researchers to examine issues that arise when the professional E M collides with the popular E M , and to find ways of facilitating the process. I introduced the work of Kleinman because Anderson's 1985 work builds on that of Kleinman and examines the socio-cultural context of health and illness. Anderson holds that the perception of health and illness are related to the individual's subjective experience as well as cultural context and social organisation. The structural features of the health care system and the interactions with health care professionals help determine the client's health care experiences. Therefore, it is valuable to examine the context of providing care, and to look more closely at the interactions between the client and the health care system. On reflection, Anderson does not essentialise culture but sees culture as negotiated and in process rather than as a fixed attribute. Culture is more than concrete forms of social structure such as ethnicity and social class, it reflects "origins, beliefs, and values" (Waxier-Morrison et al., 1990, p. 9). Culture is not static, but involves processes by which beliefs are constructed and maintained (Anderson, Blue, & Lau 1991, p . l l l ) . A n individual's concepts of health and illness are formed through personal experiences, social context, and the ethno-cultural group with which Concept of Culture 20 they identify (Mensah, 1993). Cultural influences on a person's concept of health and illness influence the ways in which that person manages health and illness, including accessing health care services. When a health care system is built within a particular cultural context and is accessed by people from other cultural contexts, barriers to access emerge. The British Columbia Royal Commission on Health Care and Costs (1991) reports that individuals' from ethno-cultural minority groups experience difficulty accessing appropriate health care services. Some barriers include limited language ability, cultural practices unfamiliar to health care workers, limited awareness of rights and entitlements, and limited knowledge of available services. Health care that is not culturally responsive is l ikely to be ineffective (Masi, 1993), and nurses who are not sensitive to cultural issues provide less than optimal care (Rothenburger, 1990). Several authors have conducted studies 1 4 that revealed that nurses experienced difficulties in providing care to clients from ethno-cultural groups different from their own (Murphy & Clark, 1993; Rooda, 1993; Spitzer et a l , 1996). The difficulties experienced included problems communicating with both the client and family, and a lack of knowledge about the client's culture which then resulted in stress and frustration for the nurses and perceived lower standard of care for the client. If culture is fluid and evolving, and if, as I have suggested, there is 1 4 Studies are reviewed under section entitled 'caring for an ethnically diverse client population.' Concept of Culture 21 Figure 2 Explanatory Mode l Framework: Sociocultural context of Health Adapted by Anderson (1985) from: Kleinman, A . (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science & Medicine. 12. 85-93 Concept of Culture 22 benefit in adopting a pluralistic perspective on culture, culturally sensitive nursing care emerges as a complex practice. In recent years, attempts to redress the identified difficulties have resulted in a wealth of research and theoretical literature exploring the cultural aspects of caring (Lipson & Steiger, 1996; Spector, 1991; Waxier-Morrison et al., 1990), and advocating the use of various models and conceptual approaches in the process of providing culturally sensitive care (Anderson, 1985, 1990; Kleinman, Eisenberg & Good, 1978; Lipson & Steiger). Despite the existing information and identified resources many nurses continue to experience difficulty working with clients from cultures different from their own. Two decades ago, Leininger (1978) identified a gap between what is known about providing culturally sensitive care, and what is actually practised. She advocated eliciting from nurses themselves the issues they face in caring for clients they perceive to be from other cultures. Since then, many researchers and theorists have sought to address issues around culture and nursing practice. In spite of all this, a gap exists between theory and practice. A s Leininger suggests, we may need to revisit the perspectives of nurses on providing care to people from other cultures. This, in conjunction with our theoretical and philosophical understandings of culture, w i l l provide the foundation for research in a very important and, as yet underdeveloped aspect of providing culturally sensitive care: teaching and learning about culture. Concept of Culture 23 Culture and Nursing Education The need to incorporate cultural concepts into nursing education is evident in the papers reviewed in this section. Lynam (1992), writing from the premise that negotiation with all clients is foundational to successful nurse-client relationships, outlines how to address culture in nursing education. There is wide agreement that ethnospecific knowledge balanced with general concepts and strategies is needed to enable nurses to provide culturally sensitive care (Jeffreys & O'Donnell , 1997; Mas i , 1993; Murphy & Clark, 1993; Papadopoulos, T i l k i & Alleyne, 1994). Lynam believes that nurses should be aware of their own culture and belief system. In addition, nurses must have an appreciation for and be knowledgeable about the client's perspective. Communication skills to facilitate effective negotiation with clients must be learned, and an awareness of the issues which affect the delivery of care to their clients must be encouraged. These knowledge and skills must be conveyed to practising nurses, but literature describing nurses' awareness of these skills cannot be located. However, there are a few articles in the literature that pertain to describing approaches for integrating general transcultural nursing concepts and skills in the nursing education curricular (Cannon et a l , 1984; Eliason & Macy, 1992; Jeffreys & O'Donnel l ; Smith, 1997). Theoretical and empirical knowledge related to culture and health has tended to focus on either the client's perspective of health and illness and/or processes for applying the knowledge and skills needed in practice. One Concept of Culture 24 source of information related to the client's perspective is the wealth of anecdotal, descriptive, and research literature 1 5 devoted to describing, exploring, and documenting the beliefs, values and health practices of diverse cultural groups (Anderson, 1991; Anderson, Blue & Lau, 1991; Duh Chen, 1996; McAll i s ter & Farquhar, 1992; Spector, 1991; Waxier-Morrison et al., 1990; Wilkins, 1993). A s Lynam (1992) has argued, there is variation within cultural groups, so to limit our knowledge to such information can lead to cultural stereotyping. Instead, she argues that ethnospecific knowledge must be balanced with knowledge of concepts and processes that enable the provision of culturally appropriate care for all clients. Lock (1993) argues that the development of a sophisticated understanding of culture entails a radically new way of thinking about and representing the body. She says that it is not sufficient to regard culture as simply an extra variable when using a scientific analytic approach to the body, rather the analytic approach is one that is inherently contradictory to the idea that recognition of cultural variation is important. Lock argues that it is imperative to incorporate these fundamental points into every aspect o f health care education beyond the teaching of basic sciences. She addresses the difficulties in defining concepts such as culture, race, and ethnicity. Finally, she discusses the relationship of culture to the body in health and illness and Please see section titled 'Clients perspective on health and illness' for a brief review of two of the research studies. Concept of Culture 25 how the significance of this relationship is best taught as part of health care education. Lock ' s comments are valuable as she cautions that there is a danger of "jumping into a culturally sensitive approach to health education without first examining what is meant by the concept of culture and, even more important what our own values are with respect to the culture of the Other" (1993, p. 145). Similarly, from a broader perspective, Lock raises the concern of the concept of culture being seised on as a panacea, as the key to open a treasure chest, a trouble-free health care system, while there are more persistent problems lying at the root of i l l health. In reflection, Lock identifies that the concept of culture is complex, and that it must be seen in its historical context. In spite of this broad perspective, she appears to relate the concept of culture primarily to issues of ethnicity and race. Culley (1996) notes that issues of race and health have been ignored or played down in discussions about the health status of people from minority ethnic groups and the delivery of health care to such groups. She argues that the experience of l iving in a society which is structured by gender, socio-economic and racial inequalities and the inter-relation between the l iving and working conditions of minority groups has been given less prominence. She maintains issues of cultural difference and problems related to communication receive greater distinction. Culley (1996) theorises that the "dominant way of conceptualising issues of'race' and health has serious drawbacks that may serve to obstruct the Concept of Culture 26 attainment of equitable health and health care" (p. 564). She identifies the need for health professionals to be more sensitive to cultural differences and provide 'care' that takes into account the cultural background o f the patient/client. Further, she stresses the need for nursing and nursing education to address the institutionalised racism and discrimination faced by clients and/or health professionals from minority ethnic groups inside the health service and/or in society in general. She recommends re-assessing the learning needs of health workers and educators in the light of a critique o f an analysis based on 'cultural pluralism' and 'ethnic sensitivity'. In conclusion, she suggests that the inclusion of social scientific concepts and analysis into the nurse education curriculum w i l l provide an opportunity to discuss the more complex ways in which social relations and social structure impact upon minorities. Culley (1996) identifies the need for nurse educators to go beyond cultural essentialism and reductionism and entertain discourse on the ways in which social and political structure impact on minorities. She offers some useful comments, however; like Lock (1993) her use of the word 'culture' primarily focuses on issues of race and ethnicity - which I believe is a narrow and constricted view of the concept of culture. In discussing the need to incorporate cultural concepts into nursing education, the above papers concentrate on 'ethnospecific knowledge' required for nurses to provide culturally sensitive care. Apart from 'ethnospecific knowledge,' providing culturally competent care necessitates Concept of Culture 27 consideration of knowledge of other social constructions that individuals may or may not be a part of, for example, sex or gender 1 6. Gender is a broad concept encompassing "complex political, economic, psychological, and social relations between men and women in society" (Andersen, 1988, p. 76). Societal awareness of gender bias in health has been heightened by the knowledge that biomedical studies having used men for the prototypical study population applied the results to women as i f gender conditions have the same history or response (G. Morse, 1995) 1 7. In the context of teaching about women's health, G . Morse (1995) discusses how feminist beliefs and values might influence nursing education by increasing sensitivity to cultural issues. She discusses the bio-psychosocial perspectives guiding health and feminist pedagogy in nursing education. In particular, nurses have begun to challenge traditional patriarchal values and to view nursing and women health consumers from a feminist perspective (Chinn & Wheeler, 1985). Feminists argue that women are oppressed or dominated by men and that patriarchy is constituted by the structural arrangements that initiate, support, and legitimate this systematic oppression (Warren & Rheingold, 1993). G . Morse suggests that the objective o f feminism is to constitute itself as a social and political movement to undo this patriarchal 1 6 According to Andersen (1988), "sex refers to the genetic and physical identity or the person and is meant to signify the fact that one is either male or female. One's biological sex usually establishes a pattern of gendered expectations" (p. 75). Andersen, when describing gender, says, "Gender refers to the socially learned behaviours and expectations that are associated with the two sexes. Thus, whereas 'maleness' and femaleness' are biological facts, masculinity and femininity are culturally constructed attributes" (p. 75). 1 7 Please see page 40-41 for further discussion. Concept of Culture 28 domination. Moreover, she says that feminist theories have advanced an epistemological challenge by placing gender front and centre, by integrating women into discourses of social and political theory, and by bringing women's needs into the public policy sphere. In theoretical terms, feminism wants to make gender as important as class, to explain the world and relationships in the world in terms of gender (G. Morse; Warren & Rheingold). In this article, G . Morse appears to spell out a theory of social change in terms o f gender, and writes of gender's convergence with race, class and sexual preference. She advocates that concepts that centre on oppression of women health care consumers consist of equity, dominion and diversity. B y dominion, she refers to "women having the same rights over their bodies as men" and by diversity she writes that "points to the recognition of diverse experiences of women and minorities" (p. 275). Curriculum development in nursing courses must reflect these concepts, as it would provide students with the opportunity to examine the societal effects of racism, sexism and class. In conclusion, G . Morse writes that nursing education is in a unique position to use feminist teaching strategies for increasing sensitivity to gender and minority issues among students. Culture and Learning Pai (1990), hooks (1994) and Hones (1997) have argued that educators need to realise that processes of learning are influenced by the core values, beliefs, and attitudes as well as the predominant cognitive and communication styles and linguistic patterns of a culture. Further, the education process, Concept of Culture 29 whether formal or informal, is equally affected by the socio-economic status of the learner, peer pressures, the nature of the relationship between dominant and minority groups, and the impact of technology on the society. Pai and Hones stress that because education is a socio-cultural process, critical examination of the role of culture in human life is indispensable to the understanding of education processes. The large volume and quality of experiences individuals have determines how they w i l l learn. Learning is on a continuum, which, i f reinforced over time, may lead to permanent changes in behaviour (Bruner, 1996). Because of the differences in educational preparation and experiences of the students and educators, each person's contribution in the classroom must be valued (hooks, 1994). Indeed, the strengths of each person need to be maximised to enhance the broad cultural base. In reflection, it is not possible to further address learning without, at least implicitly, adopting some view of knowledge or 'personal epistemology'. Yet as Candy (1991) says, "When authors advocate a particular approach to learning (or teaching), only rarely do they make explicit their view of what constitutes valid knowledge, of how it is created, shared or reproduced" (p. 262). Schwandt (1994) argues that there are two fundamentally different views of knowledge related to perspectives on learning. The one view holds that knowledge exists independent of the learners' interest in it, or awareness Concept of Culture 3 0 of it (objectivism). The other view holds that knowledge is something intimately determined by the learner (subjectivism). Objectivism assumes that people can rationally come to know the world as it really is. In other words, that the physical and social worlds are essentially there for study, and exists independent of the people who study it. Therefore the object of teaching, is to provide a literal account of what the world is like. On the other hand, the notion of subjectivism holds that knowledge and truth are created, not discovered; the world is only known through people's interpretation of it (Schwandt, 1994). Smith (1989) suggests that the world of teaching, "is a constructed reality, the product of the meaning people give to their interactions with others...." (p. 8). Therefore, knowledge is neither a copy nor a mirror of some external reality, but rather a construction of the individual experiencing it. People (learners) do not merely respond to the world; they impose meaning and value upon it and interpret it in ways that fit, or make sense to them. Culture plays a crucial role in determining what meaning people assign to their experiences, the contents of what is learned, as well as how learning occurs (hooks, 1994). Acknowledging, respecting, and reflecting on an individual's past and present experience is imperative as learning is a life long interactive process. This in turn, preserves the student's sense of individuality and suppresses the eventual desire to conform to other individuals' ways of learning. Reflection is described as a process whereby individuals respond to a Concept of Culture 31 lived experience and cognitively review and explore the experience in such a way as to create and clarify meaning in terms of self (Boyd & Fales, 1983). Reliable knowledge about learning, perception, and cognition, and the roles of ethnic, language, gender, religion and value differences in these processes would inform the development of strategies to enable support for students learning (Baldwin & Nelms, 1993; Hones, 1997; hooks, 1994; Pai, 1990). Learning is not purely a psychological phenomenon because it always takes place in some social and cultural setting (Bruner, 1996; Pai). In addition to the individual characteristics of students' and teachers' gender and ethnic orientation, the classroom and institutions themselves represent a culture with deeply embedded values and beliefs. Accordingly, regardless o f one's own conception of learning, any attempt to understand how students learn must deal with questions about the relationships between the learner, the teacher, and the context, and the purposes of learning certain knowledge and skills (Lynam, 1992). Learning in a formal or informal educational setting involves other people (Pai, 1990). Hence, the learner's ability to maintain complex relationships with others influences how he or she learns. Such an ability, as well as the learner's own sense o f personal identity and roles, is developed through social experiences of associating with people. A s social experience is an essential aspect of learning so is social conflict. Through encounters with interpersonal conflicts an individual may learn to work co-operatively with others to resolve various problems stemming from aggression, competition, Concept of Culture 32 and struggle for power. These interpersonal dynamics, so important to learning, take place in the social and political context of the institution and society where the learning takes place. The dominant values held within the institution add another layer of complexity to the process of learning. Caring for an Ethnically Diverse Client Population. Murphy and Clark (1993) explored the experience o f nurses caring for 'ethnic minority clients' in England, and identified problems nurses encounter when caring for these clients. The study was a "small-scale" (p. 449) exploratory study and a descriptive approach to qualitative data collection and analysis was utilised. 'Focused' interviews were conducted with 18 nurses. Respondents were asked to discuss a particular client for whom they had provided care. Areas such as the nurse-client relationship, problems they may have encountered, and the extent to which their training had prepared them for providing care in a culturally diverse setting were discussed. The results of their exploratory descriptive study indicated that many nurses shared common experiences when caring for these patients. Issues related to communication difficulties with both patient and family and a lack of knowledge about cultural differences were two of the most prevalent issues identified by the nurses. Difficulties were also associated with the nurses' relationships with extended families and the perceived disruptions in ward routines. These problems resulted in stress for all 18 nurses. Furthermore, many identified that the lack of time and resources to provide care resulted in substandard care. A l l o f the respondents in the study felt their basic education had not adequately Concept of Culture 33 prepared them for caring for an ethnically diverse client population. H o w nurses addressed these difficulties and the availability and use of institutional resources, either concrete or philosophical, was not explored in this study. Murphy and Clarke's (1993) study is valuable in documenting that problems do exist for nurses caring for culturally diverse clients. The study does not provide direction for supporting the nurses in practice. Little is known about the setting in which Murphy and Clark's study occurred except that it had a high number of 'ethnic minority' clients. Whether or not there was institutional support for culturally sensitive care was not addressed. In critique of the methodology for this study, Murphy and Clark (1993) fail to provide information about the descriptive approach to data collection, analysis, and focussed interviews that they used. On reviewing the paper describing the study, I postulate that Murphy and Clark used content analysis for analysing the data. They state that "quantifying the responses o f respondent enabled (p. 444)" them to categorise the data. On reflection, because the study calls for an interpretive approach with greater emphasis on emergent meanings, I suggest a grounded theory approach rather than content analysis may have been more suited to the data analysis process. Stubbs (1993) argues that 'with greater knowledge o f different cultures, with improved skills in cross-cultural communication, and through the creation of particular ethnic specialisms, services w i l l be improved. Therefore, using the 'ethnic sensitivity model, the emphasis within educational programs, should be on teaching health professionals about 'ethnic minority Concept of Culture 34 cultures' and encouraging health education programmes aimed at ethnic minority communities. Nevertheless, despite the popularity of an educational prescription of a curricula dose of knowledge about other cultures, and an introduction to cultural empathy, Rattansi (1992) suggests that there is very little consideration about how 'cultural understanding' might actually occur. What form cultural understanding might take, what its limits are and indeed i f such teaching actually has any significant impact on reducing prejudice is not known or considered. In concurrence with Rattansi (1992), and based on the critique of the study by Murphy and Clark (1993), I suggest that although an increased knowledge base of the different cultures w i l l contribute to furthering cultural sensitivity, it is not possible to know all that there is to know about the different cultures that exist. Nevertheless, I submit that it is pertinent to have awareness and respect for cultures that are different from one's own, and an awareness of crucial issues within the concept of culture. I believe that the starting point for nurses, as they begin to develop an understanding o f cultures different from their own, is to develop an appreciation for the complexity of the concept of culture. Rooda (1993) conducted an exploratory study to examine the knowledge and attitudes of nurses toward patients from culturally diverse backgrounds through a cultural fitness survey (CFS). The paucity of research and programs on multiculturalism in nursing education provided the basis for Concept of Culture 3 5 the study. It was based on the premise that concepts of cultural diversity related to health care must be understood and incorporated into nursing practice on a systematic basis. A random sample of 319 nurses practising in nine acute care hospitals was selected. The sample was predominantly female (96.6%). Both male and non-white people were excluded from the analysis because the researcher believed that their numbers precluded meaningful analysis. Additionally, the sample was limited to nurses practising in acute care hospitals and did not include nurses from other health care settings. In critique, I suggest that a main limitation of this study is that in the concluding paragraph, the author of the exploratory study recognised the need to include nurses from a variety of ethnic identities and cultural backgrounds working in diverse health care settings. The C F S is a self-administered questionnaire. Two sections were developed by the researcher, and the third was an adaptation of a 34-item Likert-type attitude scale, developed by Bonaparte (1979), as cited in Rooda (1993, p. 210). The sections of the C F S developed by Rooda dealt with knowledge of cultural diversity, including questions about culturally specific disease and symptoms, values, and issues related to disease symptoms, values and issues related to family orientation of specific cultural groups, and demographic information. I argue that the nature of the C F S may have invited the respondents to stereotype individuals and essentialise culture. Concept of Culture 36 The researcher appears to have used multiple statistical methods to analyse the data, but does not provide any explanation or justification for the use of these methods. In critique, I submit that the researcher presents the results in a manner that is lacking in clarity and succinctness, making it difficult to grasp the essence of the findings. The results of the investigation, however, appear to suggest that nurses' knowledge of the various ethnic groups vary, and they have different attitudes toward the culture and health practices of ethnic groups. In addition, nurses' knowledge of culture and health practices is related to their level of educational preparation. Another limitation of this study is that the survey dealt with attitudes. There may be existing biases and prejudices among the respondents, and these biases could have unduly skewed, either positively or negatively the results obtained. Rooda sought to explore the knowledge and attitudes of nurses toward culturally different patients, however, focuses primarily on nurses' knowledge and attitudes toward three ethnic minority groups (Black Americans, Hispanics, and Asian Americans). Spitzer et al. (1996) describe a cross-cultural educational project which was designed as a pilot for a new baccalaureate program in nursing, in which faculty and students collaborated in the care provided to Ehiopian Jews who had immigrated to Israel. Interestingly, before beginning the study the investigators conducted a preliminary survey that revealed significant deficiencies in the knowledge of health care professionals concerning the needs of the population. There was a tendency for nurses to feel suspicious of Concept of Culture 3 7 their "foreign clients " (p. 323) and to avoid caring for them. Moreover, the nurses indicated that their lack of knowledge and culturally adequate social communication skills fed into their fears and led to stereotyping Ethiopian Jews. In this collaborative study, Spitzer et al. identified important aspects to include in projects directed toward enhancement of cultural competence. Among these were: (a) emotional as well as cognitive preparation for working with clients from a different culture, (b) controlled contact with gradual exposure to the community, (c) flexible organisation of experiences, in recognition of disparate cultural expectations, (4) faculty and students learning as equals, with faculty modelling "respectful consideration of unfamiliar realities", (5) an interpretive stance to learning, demanding that learners question their own assumptions about reality, and (f) that clients' interpretations of their situation become "key content." I argue that although this study is aimed at improving nurses' cultural competence, overall, it is unsuccessful. The study focuses on race and ethnicity, which implies and essentialised the concept of culture and does not fully explore the concept of culture. The researchers provide a detailed description of the study, and write about three phases of the study: preparation, collecting data and nursing interventions. However, it is unclear as to what methodology the researchers used for the study as there is no mention or description of the methodology used to guide the study. The only information provided is that data was collected through individual and group interviews and by observation, and that Concept of Culture 38 data was analysed concurrently. I posit that the paucity of information provided about the methodology leaves the project open to questioning. Clients Perspectives on Health and Illness Two important studies about clients' perspective on health and illness, one by Anderson, Blue, and Lau (1991), the other by Duh Chen (1996), contribute a cultural perspective to our understanding of clients' perspective on illness. Each of these studies approaches the topic in a different way - one is a phenomenologic study and the other grounded theory study. From a phenomenological perspective, Anderson, Blue and Lau (1991) describe an inquiry into the existential experience of women with chronic illness and the context in which experiences took place. The analysis is a product of a three-year study examining how Chinese and White women living with diabetes construct chronic illness, and the circumstances shaping their illness experiences. Data collected from 15 immigrant Chinese and 15 Anglo-Canadian women with diabetes were used to show that illness is constructed in a complex social, political and economic nexus. When the circumstances of women's lives were examined, styles of managing illness that could be attributed to ethnicity became recognisable as pragmatic ways of dealing with the harsh realities of material existence. The authors submitted that "the trends toward individualising social problems, and shifting the responsibility for care-taking from the state to the individual, obfuscate the social context of illness, and exclude the socially disadvantaged from adequate healthcare" (p. 101). Concept of Culture 39 Anderson, Blue and Lau (1991) revealed that "treating culture as static, as an 'objective fact' that determines illness meanings and the restructuring of life, glosses the harsh reality of poverty and oppression" (p. 102). Anderson, Blue and Lau cautioned against creating a catalogue o f assumed beliefs of people from different groups, and basing the provision of health care on these assumptions. They stressed the need for health care professionals to examine the context in which belief systems are constructed, and the social inequity within the society that impinges upon illness management. The researchers obtained access to participants through personnel from health care and community agencies. A limitation of this process, identified by the researchers, was the inability to gain access to women who were not in contact with health care providers or other community personnel. Letters of information describing the research and informing the voluntary nature of their participation were made available in Chinese and English, and the women were given the choice of consenting in the preferred language. Methods of data collection, data analysis, socio-demographic characteristics o f the women, and the process of interpreting the qualitative data is described clearly by the authors. In the following study, Duh Chen (1996) describes a substantive theory that explains the worldview of health and illness and the beliefs and behaviours with respect to health promotion and illness prevention among Chinese elders in the United States. Symbolic interactionism provided the underlying theoretical foundation for the study, and grounded theory method Concept of Culture 40 was used to understand how people defined reality through social interactions. Theoretical and convenience sampling were used to select 21 Chinese elders aged 60 to 90 years. The author clearly describes the selection criteria o f participants. Data were collected through two interviews, 2 weeks apart, with each participant, observations during interviews, personal health diaries of one week's duration, and the researcher's memo's and journal. K e y questions that guided the first interview, and an example of what was observed is provided, however, the researcher has omitted to mention what sort of information the clients included in their health diaries. The interviews were conducted in Mandarin Chinese, translated into English, and validated by a second nurse also fluent in Mandarin Chinese, and later clarified with the participants. Dreher (1994) suggests that it is important that the investigator take precautions to ensure that the interpretation is truly a reflection of experience and not simply differences in the capacity to use language and discourse. The results of this study indicated that conformity with nature, the substantive theory held by Chinese elders, promotes health and prevents illness. The researcher suggests that "the theory of conformity with nature provides nurses a subjective and philosophical basis for understanding Chinese elders' worldview, beliefs, and practices regarding health promotion and illness prevention" (p. 25). The findings suggest that to achieve harmony with the environment: Chinese elders prefer to obtain and use natural resources. Chinese elders usually do not argue with health care providers and value consideration of other people and w i l l withdraw their ideas i f they believe they Concept of Culture 41 would inconvenience others. In critique of this study, I posit that the researchers have described the research process well , however, I argue that, by creating a generalisable picture of health and illness beliefs of Chinese elders the researchers run the risk of essentialising the culture of these people. Reviewing these studies provides a glimpse of the impact of the researchers philosophical orientation and consequent choice o f methodology in conducting research about people's experiences of health and illness. Anderson, Blue, and Lau (1991) are seeking to uncover the experience of the people they study in order to increase sensitivity to the issues people of diverse cultures face. On the other hand, Duh Chen (1996) is seeking to create a theory explaining the way the people she studied experienced health and illness. The grounded theory methodology she chose, while congruent with her philosophical orientation and research question, w i l l necessarily tend to essentialise understandings. Increasing Cultural Awareness Although the following study is from another discipline, occupational therapy, it is valuable as the authors Fitzgerald and Mullavey-O'Byrne, (1996) explored definitions of culture offered by occupational therapy (n = 274), diversional therapy (n = 43), and physiotherapy (n = 398) students in Australia. This study was conducted as "a prelude to looking at the use of the concept among practising health professionals being conducted as part of the Intercultural in Rehabilitation Practice Project. The purpose of the Intercultural Project was to explore cultural issues specific to rehabilitation Concept of Culture 42 practice and therapists' strategies for addressing them" (Fitzgerald & Mullavey-O'Byrne, p. 69). The interview data were collected from occupational therapists and physiotherapists in collaboration with students enrolled in a subject called "Culture and Communication in Occupational Therapy" (Fitzgerald & Mullavey-O'Byrne, p. 69). The material presented in this article is a content analysis on written definitions of culture collected over a period of three years from 715 students. The students were given five minutes to write the definitions and were asked not to dwell on the definition, which is interesting considering the complexity of the concept of culture. The findings suggest that the students tended to use a totalist or materialist view of culture and often confounded the concept of culture with issues of race and ethnicity. Fitzgerald and Mullavey-O'Byrne cite Tylor 's , 1871 definition of culture and suggest that the totalist view presents a definition that describes observed "patterns of behaviour", while the mentalist view suggests "a system of rules or a pattern for behaviour." In critique of the above study, I posit that the approach used to explore students' definitions reduces the phenomenon to a set of de-contextualised variables. I argue that such an approach does not do justice to the complexity of the students' definitions and understanding of the concept of culture. However, Fitzgerald, and Mullavey-O'Byrne (1996) suggest that the definitions provided clues as to the definition students may take into practice, for instance that students appeared to confound race, ethnicity, and culture. These researchers did not discuss their findings with the students that Concept of Culture 43 participated in the study. However, they acknowledge that their study would only provide thought-provoking data and recommend further explorations of students understanding. The data collection methods used by Fitzgerald and Mullavey-O'Byrne (1996) suggest they were able to collect qualitative and quantitative data. The richness of qualitative data, however, is invisible. Morse (1995) suggests that when conducting a content analysis, the researcher must read the entire interview and identify the important topics. However, in this study the researchers appear to have entered the definitions on to a Lotus-123 spreadsheet and then converted the spreadsheet into a WordPerfect table before reading and becoming familiar with the data. Smith et al. (1993) write that in preparing students to give culturally sensitive care nursing educators must help students to examine values, beliefs, and lifestyles as well as myths, stereotypes, and stigma regarding many groups and personal characteristics. In other words, the authors suggest that nurse educators must help students move beyond their own ethnocentric world-views. This implies that Smith et al. assumed that all students come into nursing with ethnocentric views. In this article, these authors describe the results of a curricula analysis to determine the inclusion of multicultural concepts in baccalaureate nursing curricula. Reviewing the article, the authors did not provide an operational definition for multiculturalism. They identified the definition of multiculturalism as being inclusive of the following variables: ethnicity, race gender, sexual orientation, spirituality/religion, family Concept of Culture 44 style/makeup, ability, age regionalism, language, physical appearance, and socio-economic status. Impediments to appropriate inclusion of diverse cultural content were identified as stereotyping, bias, insensitivity, phobia, omission, and inappropriate commission. The results of the analysis indicated that faculty valued individuality and were reluctant to make generalisations regarding populations for fear that this would lead to stereotyping. Faculty became aware that "individuals have their own monocultural perspectives that need expansion to function in a pluralistic society. Moreover, anxiety was experienced with regards to the amount of time that would be necessary to become informed regarding culture specific content" (Smith et al., p. 206). The curricula analysis revealed that some 'multicultural content' was addressed (ethnic groups, stigma of unpopular diseases) while others (non-heterosexual orientation, specific information about cultures, and power relations) were not. The students that were interviewed by Smith et al. (1993) perceived that faculty were either open or closed to discussions of sensitive multicultural issues. Moreover, in the students' clinical learning experiences male students experienced difficulties in providing care and in relations with members of staff because of their gender, and students with a different skin colour to the majority experienced being stereotyped. Faculty were given feedback about their courses in terms of identified multicultural content that might be added. Moreover, seminars were held on specific topics identified to increase culture-specific knowledge and Concept of Culture 45 multicultural awareness. Appropriate persons were asked to address concerns identified by students which included socialisation of males into the nursing profession. Each of 14 required and 10 elective undergraduate courses were studied, and faculty were interviewed. The four students who volunteered to work with the committee verbalised their own and others' experiences of bias that occurred during learning experiences. A limitation of this analysis is that there is no mention of the number of faculty interviewed, and the results are based on an ' x ' number of faculty, four students and the courses studied. Moreover, Smith et al. (1993) identified that the curricula analysis was limited by traits of the committee members, as the faculty component of the committee consisted of "third-generation Euro-American, non-obese, heterosexual females in their 40s. Students were all under 25 years o f age. Neither faculty nor student members were disabled" (p. 207). On reflection, I concur with Smith et al. (1993) that valuing multiculturalism is essential in education i f we wish to incorporate knowledge of and respect for cultural values in nursing care. However, in critique, I suggest that the data collection would have been richer and the curricular analysis would have been strengthened i f faculty and students were given an understanding of the particular concepts used in the framework to analyse the curricula. There is no indication that the participants of the analysis were permitted to discuss their understandings of the concepts included in the model. Concept of Culture 46 The following study describes the experiences of student nurses who had the opportunity to travel to another country and encounter different health care systems, thus returning with an understanding of a culture different from their own. Haloburdo and Thompson (1998) conducted a grounded theory study to explore the meaning of an international experience for nursing students, as well as to discover what community health nursing concepts were reinforced as a result of the experience. Furthermore, the study analysed the similarities and differences in learning outcomes among students who had t travelled to developed versus developing countries and those who had or had not participated in direct patient care during their trip. Fourteen students, who participated in one o f three international trips, (Dominican Republic, Netherlands, and Nicaragua) as part of a community health-nursing course, were invited to participate in the study on their return. Haloburdo and Thompson (1998) identified three major themes from the student interviews. The first theme, personal and professional growth, describes the struggles and rewards faced by students as they learned about cultural sensitivity, the recognition of universal characteristics, communication, caring, and use of self. The second theme, empirical knowledge, included the attributes of socio-political resources influencing health care, population-based problems, and attitudes towards their own country, the United States (appreciation versus criticism). Finally, the third theme, learning experience, incorporated the properties of motivation for participation, benefits of the experience, and teaching and learning strategies. Concept of Culture 47 Students were interviewed only once, and were not given the opportunity to clarify and elaborate on their initial responses. The time available for the trips was a major limitation. Haloburdo and Thompson (1998) argued that a longer time would have precluded students from gaining international learning experiences because o f family or job obligations as well as other program courses. This study, however, suggests that effective learning outcomes for baccalaureate nursing students may be achieved through international experiences. In this study, the researchers did not discuss the students' values and beliefs related to culture before their international experience. However, in the conclusion of the paper they acknowledge the importance of identifying students' pre-trip values and beliefs. From personal experience, I suggest that, for international learning experiences to be beneficial, a time period of over two weeks is necessary, given the time required to become somewhat familiar with the new environment. In critique of the methodology, I note that Haloburdo and Thompson (1998) describe their use of grounded theory methodology for sample selection and data collection. However, they provide limited information on how the data was analysed, making it problematic to review the methodology of the study. Concept of Culture 48 Gender Issues and Student Nurses. A t this juncture, I introduce 'gender' 1 8 because it is an integral part of any social group's structure of domination and subordination and division of labour. Gender shapes the individual's opportunities for "education, work, family, sexuality, reproduction, authority, and the chance to make an impact on the production of culture and knowledge" (Lorber & Farrell, 1991, p. 2). Sex and gender are quite distinct, although 'things feminine' are associated with females, and 'things masculine' are associated with males (James & Saville-Smith, 1994). Gender is a categorisation based not on physiological but on social attributes. Sex, that is the categories 'female' and 'male' are purely physiological (Allen, 1990; James & Saville-Smith; Lorber & Farrell, 1991). Individuals may be born female or male but the degrees of masculinity or femininity are socially defined. Societies socialise their members into gender roles and expectations and they associate various traits and qualities with gender categories (Allen, 1990; James & Saville-Smith). The very fact that these roles, expectations, traits, and qualities vary from society to society and over time, indicates the real but often hidden disjunction between sex and gender (James & Saville-Smith). In the social construction of gender there appears to be a marked tendency for masculinity to be rewarded more highly than activities and qualities associated with femininity. Therefore, The concept of gender "refers to qualities, traits, and activities collectively deemed to be masculine or feminine in any particular society" (James & Saville-Smith, 1994, p. 10). Concept of Culture 49 inequalities between those of the female sex and those with male physiology also tend to be a phenomenon of human societies (James & Saville-Smith). In this subsection, two qualitative studies (Kelly et al., 1996; Paterson et al., 1996) about the experience of male nurses are reviewed in some depth. These studies do not address how students learn about the concept of culture. However, the studies are relevant to the literature review, because the researchers in the following studies look at the experiences of male students and how these students perceive the influence of their gender on nursing care. Parallels to the influence of culture in nursing education will require further exploration. Paterson et al. (1996), guided by the tenets of interpretive phenomenology in the tradition of Benner (1984, 1988), describe one aspect of a research study designed to investigate the lived experience of male nursing students as they learned to care as nurses. Twenty male students, aged 18 to 34, representing each year of a four-year baccalaureate-nursing program, participated in the study. The researchers obtained the participants' stories by means of paradigm cases and interviews. The participants were asked to relate a story about an incident or situation during the academic year that taught them about the nature of caring. The participants were asked to describe the context of the incident or situation, describe the emotions felt during and after the incident or situation, and continue until incident/situation was discussed as fully as possible. Concept of Culture 5 0 The researchers found that the experience of learning to care as male nursing students was perceived by the participants as unique to their gender. The participants described learning to care as a complex entity that incorporates the gender of the student, the patient, the teacher, and the nurse. Students' experience of gender issues in learning to care was shaped by personal experiences, the expectations of a predominantly female faculty and nursing staff, and their evolving understanding that the ways of caring that are gender based (Paterson et al., 1996). Interestingly, the students in the study revealed that there was a difference between female caring as a nurse and male caring, in that "male caring was perceived.. .as being 'less touchy' and as more of a friendship than female caring" (Paterson et al., p. 32). Apart from this difference rejection by patients, being a visible minority, and being unprepared for the gender issues that may arise in their clinical learning experiences were some of the issues raised by the students. Students in the study expressed a desire for additional opportunities within the educational program to continue exploration of gender issues in nursing. Paterson et al. suggest that gender issues should be addressed as part of the curriculum for all students as this would serve to heighten the awareness o f students of both genders regarding the influence o f gender on caring within nursing. The authors have described one part of the study clearly; however, it would have been useful to have a summary of the whole study to provide a complete picture. The findings are dependent on 20 students. The students interviewed in the study are at different stages of the nursing program. Concept of Culture 51 Variation in clinical experience between the first year students with no clinical experience and other students who began the clinical experience in the second year may have affected the results of the study. The following study is also related to 'gender' but differs from the previous study, because Ke l ly et al. (1996) describe a study conducted to identify male students' perceptions of the motivational factors, barriers, and frustrations encountered in becoming a nurse. The researchers found that the students' belief that society' perceived of nursing as a feminine profession was an underlying thread to many of their perceptions and feelings. The students indicated that nursing was attractive because of the job opportunities, security and flexibility of the jobs, as well as scientific technology, diversity, their desires to help people, and the team orientation of health care. Some of the barriers identified were a lack of encouragement from high school counsellors to pursue nursing as a career, and feeling overwhelmed in the educational setting. The students' perception of being treated differently from females contributed to frustration and feelings of isolation and exclusion. In conclusion, the authors suggested that i f the administration and faculty are aware of the tendency to isolate male students by identifying them as different the retention of minority students w i l l be enhanced. Culley (1996) suggests that the experience of l iving in a society which is structured by gender, socio-economic, and racial inequalities, and the inter-relation between the l iving and working conditions of minority groups has been given less prominence than the issues of 'cultural difference and Concept of Culture 52 problems of communication.' The information from the study by K e l l y et al. (1996) addresses some issues faced by male nursing students in choosing nursing as a career. Furthermore, these authors identified a need for increased societal and institutional awareness and inclusion of discussions of issues relating to gender in the nursing curricular. Recruitment and Retention of Minority Students I reviewed the following studies in brief, because in perusal of the nursing education literature, I learned that it was important to reflect on issues related to recruitment and retention of nursing students from diverse cultural backgrounds. Hesser, Pond, Lewis and Abbot (1996) conducted a study to evaluate a supplementary retention program established for African-American students enrolled in a southern state health sciences baccalaureate nursing program. The retention program was developed to address specific problems that negatively influence minority student retention. The program used a variety of activities to bolster black student retention. These activities consisted of advising on and discussing issues related to family, friends, finances, career, and racial prejudice with students. Other supplementary activities included provision of reading and communication skills, orientation to the program, meetings to discuss retention-related concerns, a newsletter, and presentations on numerous issues. The evaluation method merged a quasi-experimental with a time-series design. A group of 114 black students was included in the study. A comparison (cohort) group o f 608 nursing students, predominantly white, was incorporated for control purposes. The cohort group Concept of Culture 53 was incorporated to minimise potentially confounding effects and events. Statistical methods were employed to analyse the findings. The overall findings of the study suggested that the program was useful in bolstering black student retention. The study refers to measures that may be utilised to influence minority student groups' retention and recruitment. This study is about African American baccalaureate nursing students, however, in criticism of the study it is arguable that the terms used to describe the subjects of the study 'black and white students' invites racial discrimination. The program evaluated provides discussion of issues related to racial prejudice. But, the program does not appear to address other issues related to culture such as, issues related to gender, sexual orientation, and religion, which suggests that the discussions only included issues related to ethnicity. Nurses from a variety of cultures and backgrounds are needed to provide health care to a culturally diverse population. Phillips and Hartley (1990) reported that English as a second language (ESL) students' difficulties in the classroom and clinical areas lead to frustration on the part of both students and faculty. Because of the frustrations, these students often leave the nursing programme or are forced out by course failures. Jalili-Grenier and Chase (1997), describe a descriptive survey study involving 160 first year students and 11 second year students. The purpose of the study was to determine nursing students' perceptions of the learning activities that contribute the most to their knowledge and skills, and to determine students' perceptions of their learning difficulties. In addition, the study intended to Concept of Culture 54 compare the perceptions of E S L and non-ESL students, determine nursing faculty perceptions of E S L students' learning difficulties, and identify needs for educational and /or supportive programmes for faculty and students. The study revealed that the E S L students found asking questions in the lab, first year clinical courses, and English courses significantly more difficult than non-ESL students (Jalili-Grenier & Chase, 1997). The perceptions relating to learning difficulties and language needs was different between students and faculty. Faculty rated students' needs in the areas of writing skills, fluency in speaking English, specialised vocabulary, and projects and assignments as significantly greater than did the students. The researchers indicate there is a lack of understanding from faculty of E S L students and their cultures. For example, "students may not ask questions because they believe it is not necessary or, according to their cultural beliefs, it is not appropriate to question authority while faculty perceive it as being a difficulty" (Jalili-Grenier & Chase, p. 202). Jalili-Grenier and Chase suggest that further research is essential in the areas of required ski l l , learning styles in various cultures, and the relationship between language and culture to plan and evaluate interventions. Both the above studies identify the need for programs to facilitate the retention of students to exist within the institutions, to support students from a diverse backgrounds or students who have English as a second language. Guided by principles of naturalistic research and grounded theory, Yoder (1996) explores the complex issues facing nurse educators and Concept of Culture 55 ethnically diverse nursing students. The research questions guiding this study are as follows: How do nurse educators manage teaching students from diverse ethnic groups? What are the conditions, strategies, and consequences of the process of responding to ethnically diverse nursing students? What are the patterns of variation in the processes of responding? What are ethnic nurses' perceptions of the actions/interactions they experienced as students? Twenty-six nurse educators from nine nursing programs participated. While the majority of programs enrolled over 45% ethnic minority students, approximately 90% of the students in two programs were ethnic students. The researcher writes that 46% of the faculty informants were ethnic minority educators - but does not identify their specific ethnicity. Seventeen "ethnic nurse informants" (Yoder, 1996, p. 316) participated in the study - the researcher identified their ethnicity, writing that the informants were chosen from "groups that are under-represented in nursing education programs including five Mexican-American, five African-American, and seven Asian-Pacific Island nUrses. The Asian/Pacific Island group included three Vietnamese-Americans, one Korean-American, one Taiwanese-American, and one nurse who was born in Palau" (p. 316). In so identifying the informants, Yoder appears to negate the fact that everyone is from an ethnic group. Graduate nurses were chosen because it was assumed that graduates have a more realistic perspective about the content and experience required for preparing nurses than undergraduate students. However, in the study the Concept of Culture 56 nurses were referred to as 'students' because their reflections were o f the time when they were undergraduate students. The concept that emerged was identified as the interactive process of responding to ethnically diverse students in culturally sensitive ways. Cultural awareness was identified as a major condition influencing this process. Conditions that affect the teachers' level of cultural awareness include lived experiences, sensitivity training, interacting, and commitment to diversity and equity. Other broader structural conditions that bear upon and impinge on an educator's level of cultural awareness include the following: international policies surrounding immigration and assimilation ideologies, the national, political, and legal climate surrounding issues such as c iv i l rights legislation, minority access to college, community consciousness, and philosophy of the institution (Yoder, 1996). The above study generated a beginning substantive grounded theory about the process of responding to ethnically diverse students. Five distinctive patterns were identified: the responding process, the cultural awareness of the educators, patterns of responding to student ethnic diversity, conditions influencing students' perceptions, and consequences of patterns of responding. Although the above components of the process have been identified other linkages have yet to be substantiated. Another limitation identified by Yoder (1996) is that the theory pertains to one particular situational context. Yoder (1996) suggests that defining the terms and concepts related to cultural and racial diversity is problematic since transcultural nursing theorists, Concept of Culture 57 anthropologists, and educators use the terms differently. However, I suggest that, as the purpose of the study conducted by Yoder was not to define the above concepts, providing a working grounding definition would have added strength to the study. Campbell and Davis (1996) suggest that minority students are at risk in major institutions because they face personal, academic, and institutional barriers to their success. They suggest that commitment o f both minority and majority faculty is the primary factor in promoting minority student success. Further, such commitment can lead to increased involvement of faculty in the success of minority students and to the establishment of organised programs and services that facilitate minority student success (Dowell , 1996). The study by Yoder (1996) is reviewed under the subsection recruitment and retention of minority students, as the retention of students can also be affected by instructional responses (Dowell, 1996). Summary of the State of Knowledge Canada's current demographic profile indicates a society that is ethnically, culturally, and racially plural and trends in health care are creating an urgency for providing culturally competent care. Providing health care to populations with a range of needs and expectations requires that nurses be able to participate in providing culturally competent care. The concept of culture is a complex and capacious construct represented by matrixes of historical, socio-cultural, political, and economic contexts. It is inseparable from numerous related concepts: race, class, gender, Concept of Culture 5 8 religion, ethnicity, respect, equality, equity, oppression, exploitation, and stereotyping. On the one hand, culture is perceived as a construct that is fixed and identifiable, and on the other hand, it is portrayed as a construct that evolves, and is embodied in language and given meaning by society through discursive practices. Marxist social scientists introduce a hegemonic dimension to this concept by viewing culture as a set of behaviours imposed on the majority by a dominant class. From this perspective, culture is responsible for reproducing social injustices, such as inequality, oppression, and exploitation. In contrast, cultural pluralism embraces the belief of equality of opportunity for all people, and respect for human dignity. Notwithstanding these perspectives, 'culture' as a term is also frequently misused to refer only to the life patterns of people who are racially different from the majority 'white' populations, promoting racism and stereotyping. These perspectives on culture, and the philosophical underpinnings of each, have implications for nursing practice, nursing education, and nursing research. A n y clinical nurse, nurse educator, or nurse researcher exploring the concept of culture w i l l be influenced by their implicit or explicit beliefs about this construct. For a researcher, the stance assumed w i l l shape the questions asked, sample selection, the process of data collection, and the process of data analysis. Because I come to this research project believing in the rights of all humans to dignity and equality, and because I believe culture is a fluid and evolving construct that shapes every human interaction, I approached this research with a non-essentialised, pluralistic perspective on culture. Concept of Culture 59 In reviewing the literature for this study, it becomes evident that culture plays a role in how individuals define and seek to attain health. I argue that health care that is not culturally responsive is l ikely to be ineffective, and that nurses who are not sensitive to cultural issues provide less than optimal care. Attempts to redress difficulties nurses' experience in providing care, have resulted in a wealth of information, which exploring the cultural aspects of caring. Numerous scholars have developed models and frameworks for health care professionals to participate in providing care to a culturally diverse population. However, I posit that, some of the frameworks, essentialise culture and portray culture as a fixed attribute, an 'objective fact'. (Campinha-Bacote, 1995; Chrisman, 1991; Leininger, 1988). I argue a limitation of these frameworks is that they neglect variables such as class, gender, race, racism, religion, politics, employment and unemployment, and gloss over the realities and social injustices such as poverty, oppression, and exploitation. They are incongruent with a nonessentialised, pluralistic perspective on culture. From a more critical perspective, others, theorists and researchers (Allen, 1990; Anderson, 1990; Anderson, Blue and Lau, 1991; Kleinman, 1978) suggest that a culturally sensitive care can be achieved only through a process of discourse and negotiation that takes into account the wider socio-cultural, political and economic contexts in which nurse-client interactions take place. They caution against essentialising culture and urge health professionals to examine the social construction of belief systems, bringing to Concept of Culture 60 light the ways in which the values embedded in the health care system shape the health and illness experiences of individuals. Rather than focusing on the socio-cultural, political, and economic contexts in which nurse-client interactions take place, most theoretical and empirical knowledge related to culture and health has tended to focus either on the difficulty nurses' experience in providing care or on the clients' perspective of health and illness. A wealth of anecdotal, descriptive and research literature devoted to describing, exploring, and documenting beliefs, values, and health care practices of diverse cultural groups exists in the literature. However, I note that the majority of authors when discussing 'cultural groups or cultural differences' refer primarily to race, nationality and ethnicity. This language points to an essentialised perspective on culture which fails to account for factors outside a particular relationship, such as, gender differences, or the social injustices imposed by political structures. The concept of 'culture' in the nursing education literature is identified with issues related to gender, retention and recruitment of minority nursing students', and the need for developing programs to facilitate retention of minority students. In discussing recruitment and retention o f minority students, I note that authors refer primarily to students from ethnic minorities. The need to incorporate a balance between ethno-specific knowledge, general cultural concepts and strategies into nurse education is also evident from this literature review. Nurses are encouraged to be aware of their own culture and belief system, have an appreciation for and be knowledgeable about the Concept of Culture 61 client's perspective, and develop communica t ion sk i l l s to faci l i tate effect ive communica t ion w i t h cl ients. In addi t ion, nurses are encouraged to have an awareness o f issues that affect the de l ivery o f health care to their c l ients, but literature that identif ies nurses' awareness o f these sk i l l s , and h o w understanding o f culture might actual ly occur cannot be located. Research Quest ions The f o l l o w i n g research questions were raised as a result o f the literature rev iew: 1. H o w do nurs ing students understand the concept o f culture? 2. H o w do they learn about the concept o f culture? 3. H o w do they apply what they have learned i n p rov id ing care to a cu l tura l ly diverse populat ion? B y e l i c i t ing the experiences o f students, I obtained a comprehensive and va l i d account o f students' understanding o f the concept o f culture and the perceptions o f learning about the concept o f culture. De f i n i t i on o f Terms Cul ture I d iscussed a melange o f def ini t ions for the concept o f culture i n the literature rev iew. Howeve r , a s ingle def in i t ion is not predetermined for this study because the students' focus ing on their be l ie fs , values, behaviours , and ref lect ions on the concept o f culture w i l l explore def in i t ions o f culture. W h i l e a single def in i t ion o f culture cannot be created, a cr i t i ca l perspect ive on culture, one that values divers i ty i n perspectives and that sustains awareness o f dominat ing structures and practices in forms this research project. Concept of Culture 62 Nursing Student A student in a baccalaureate nursing program or graduate nursing program in a major Canadian university, who has been introduced to the concept of culture and related concepts and issues in a particular class or in his or her experience as a student. Summary In this chapter, literature concerning the concept of culture in nursing, education, sociology, and anthropology has been reviewed. The current state of knowledge has been summarised, research questions identified, and definitions of terms delineated. The methodology I used to guide the study is discussed in the following chapter. Concept of Culture 63 CHAPTER3 Research Methodology The nature o f the questions to be addressed determined the design I selected for the study. Qualitative research methods are employed to gain knowledge about phenomena from an inductive approach (Morse & Field, 1995). These methodologies are suited to research questions that seek to explore the real world o f persons through the insights and meanings they find in their own experiences, rather than through statistical analysis and empirical truths. In this study, I sought to interpret, first, nursing students' understanding of the concept of culture, second, how they learn about the concept of culture, and third, how they apply what they have learned in providing care to a culturally diverse population. In this chapter, I w i l l provide an account of how I implemented the study, including how I learned and how I was affected. Critical Ethnography Throughout this research project, I maintained the position that culture, as discussed in chapter 2, is fluid and dynamic rather than static. It creates the social context in which it exists and is fully implicated in the notions of power and oppression. Viewed in this way, the relevance of the concept of culture for nursing education calls for particular attention to issues o f social context and power relations. Whether we look at the concept of culture and its impact on nursing education or at the concept in the context of nursing practice, issues of context and power lead to critical questions. In this discussion, power relations refer to the inherent power relationships between majority and minority groups Concept of Culture 64 within the health care system and within educational institutions. Although the description of power in the cultural context would be important, the focus of this study is on how an inadequate understanding of the concept of culture leaves unchallenged practices that lead to oppression, stereotyping, inequality, and inadequate care. Ethnography is a social research method that has extensive, though controversial traditions and is meant to study social contexts (Hammersely & Atkinson, 1995). Various forms of ethnography have evolved over the past century, as philosophies of science have developed and various disciplines have adopted ethnographic techniques. During the modern era, ethnography was born of cultural anthropology, which studied tribal societies and followed colonialist expansion (Cole & Phillips, 1995). Ethnography served colonialism by rendering primitive societies more open to scrutiny. The term, "ethnography" refers to the tradition of cultural description and analysis that uses interpretation to unfold meaning (Thomas, 1993). "Critical ethnography," on the other hand, is a style o f inquiry, analysis, and discourse embedded in conventional ethnography (Thomas, 1993), that attends particularly to the issues of power and equality. A s a reflective process, this research process asks researchers to choose between "conceptual alternatives and value-laden judgements of meaning and method to challenge research, policy, and other forms of human activity" (Thomas, p. 4). M y conceptualisation of culture is value laden. Values o f equality, human respect, dignity, and freedom from oppression guide my thinking. Concept of Culture 65 Reflexivity is crucial in the process of critical ethnography. It allows the researcher to explore the agendas, assumptions, and power relations in the construction of the research project, in the research data, and in the constructs of participants through a dialectical process. It includes examining the structural and historical forces that inform the social construction being studied (G. Anderson, 1989). Critical ethnography is distinguished from traditional ethnography by its description, analysis, and scrutiny of hidden agendas, power relations and taken-for-granted assumptions that inhibit or constrain (Carspecken, 1996; Thomas, 1993;). Conventional ethnography describes "what is," whereas critical ethnography asks, "what could be" (Thomas, p. 4). This approach is appropriate in this study because the method aids the emancipatory 1 9 goals of reconstructing the conception of culture in nursing education. It also provides a means to minimise the repressive 2 0 influences such as influences determined by unexamined conceptualisations of culture (Thomas), that lead to unnecessary social domination of groups. A critical ethnographic approach supports the development of new ways to think about how students understand and learn about the concept of culture, and the implications o f this learning for their nursing practice. 1 9 Emancipation refers to "the process of separation from constraining modes of thinking or acting that limit perception of and action toward realising alternative goals" (Thomas, 1993, p. 4). 2 0 Repression is "the condition in which thought and action are constrained in ways that banish recognition of these alternatives" (Thomas, 1993, p. 4). Concept of Culture 66 In critical ethnography data collection generally includes systematic or participant observation (Clarke, 1997; Resnick, 1995; Thomas, 1993). Some theoretical literature advocates participant observation as a primary means of collecting data in ethnographic studies (Hammersely & Atkinson, 1995; Morse & Field, 1995). Participant observation, as a primary means of data collection for this project, is both impractical and of questionable value. The purpose of this study was to interpret students' understanding of the concept of culture and the ways in which they develop this concept. Imposing participant observation on the data collection process would have only served to maintain methodologic orthodoxy, appropriating the purpose of this research into the methodology (Thomas, p. 10). Spradley (as cited in Thomas, 1993) has a broader perspective on critical ethnography, one that expands access points into culture by supplementing participant observation with additional data sources, strengthening the researchers' ability to bring different analytic approaches on their topics (p. 10-11). Carspecken, (1996) claims that there are some ethnographic studies that study attitudes, beliefs, and experiences o f individuals through qualitative interviews alone. Such studies are addressed to social action while seeking information about the cultural schema that shape the practice of participants in social situations (Carspecken). Students participating in this study were encouraged to reflect on their understanding of 2 1 Both traditional and critical ethnography involve the "ethnographer participating, overtly or covertly, in people's daily lives for an extended period of time, watching what happens, listening to what is said, asking questions..." (Hammersely, & Atkinson, 1995). Concept of Culture 67 the concept of culture, their-experiences of learning about the concept of culture, participation in class discussions, personal experiences, clinical learning experiences, and field note journals (that include data related to their learning and reflections on the concept of culture). Carspecken notes that as .. .as a subject starts to talk about an experience, cultural schema are inevitably employed. Such activities are related to activities that the subject takes part in, or could in principle take part in. There is no such thing as a pure representation of subjective experience: schema must always be used, and such schema will be closely tied to contexts of social action (p. 39). For these reasons, participant observation has not been used in this research, while other data sources have been used to access and interpret students' schema in relation to cultural practices. The critical ethnography methodology of this study was intended to assist the participants to uncover and reflect upon their concept of culture and to examine the consequences of the perspective for the nurse-client relationship. It was also intended to assist participants to learn about the context in which their ideas about culture are formed and challenged. The findings from this inquiry can also inform the practice of nursing education. The overall goal is to illuminate assumptions, taken for granted beliefs, and educational practices related to culture that serve to maintain the status quo and sustain oppression. As such, the goals of the study are compatible with the critical theory perspective. One of the central tenets of critical theory is a commitment to penetrate the world of objective appearances, and to expose underlying social Concept of Culture 68 relationships and the power structures within them. The overall goal of critical theory is to liberate individuals from conscious and unconscious constraints by nullifying the effects of dogma and ideology (Allen, 1990; Brent, 1993; Wilson-Thomas, 1995). The premise is that once people's perceptions and experiences are freed, they are able to see beyond the taken-for-granted realities by which they are oppressed (Stevens, 1989). The focus o f critical theory is to liberate people from unacknowledged circumstances of domination and to transform constraining conditions. The emphasis is on consciousness raising which occurs through the processes of critically questioning the "taken-for-granted " and reflective participatory dialogue in order to redress power imbalances and end oppression (Friere, 1997). Critical theorists maintain that reality is historically and socially created (Allen, Benner & Diekelmann, 1986), taking into account larger social, political, cultural, and economic factors (Thomas, 1993). Methodologically, critical theorists take a dialogic and dialectical approach, illuminating false consciousness, energising and facilitating transformative practices (Guba, 1990). This transformation is based upon non-hierarchical, free, and undistorted communication between the researcher and subject. A s Bernstein (as cited in Schwandt, 1990) explains, "participants achieve self-knowledge and self-reflection which are therapeutic and effect a cognitive, affective, and practical transformation moving toward autonomy and responsibility" (p. 269). Concept of Culture 69 Selection of Participants Sample Selection The aim of sampling participants in a qualitative study is to select people who are qualified in terms of experience, receptivity and trust to represent the phenomena under investigation (Morse & Field, 1995). The task with critical ethnography is to identify the best sources that bear most directly on the topic. In addition, "it is crucial to identify the types of informants most likely to posses an "insider's knowledge" of the research domain" (Thomas, 1993, p. 37). Sampling included Baccalaureate 2 2, Masters, and Doctoral nursing students in a major Canadian university who had completed a course on culture and health or had otherwise explored this topic. Selection Criteria A sample of eight participants for this study was expected to be an adequate number to achieve a degree of representativeness o f concepts and applicability of re-constructed meanings that would be acceptable for the level of a master's thesis. Initially, I invited participants to volunteer who met the following criteria: • Are undergraduate nursing students Rationale: Nursing students have completed education programs whose requirements are such that the students can be expected to have some 2 2 Initially I decided to focus on undergraduate students. However, as only three students volunteered, with approval from the thesis committee chair-person, and a letter to the Director of the following School of Nursing, and to the Ethics Review Board, on my behalf an Associate Director approached masters and doctorate students to request their participation for the study. Concept of Culture 70 understanding of nursing knowledge, have been introduced to the concept of culture, an ability to think reflectively about their clinical experiences, and an ability to articulate those experiences in a way that would benefit the research. • Are wi l l ing to share their reflective journals and share their perceptions and experiences in interviews with the researcher. Three undergraduate nursing students volunteered for the study (two students submitted reflective journals). Following consultation with my thesis supervisor, and letters to the School of Nursing, and the Ethics Review Board, I extended the invitation to graduate nursing students to participate in the study. The masters and doctorate-nursing students who participated were qualified in terms of experience, receptivity, and trust to represent the phenomena under investigation. Selection Procedure Upon approval from the University Behavioural Research Ethics Board, and with permission from the Director of the School of Nursing, I met with an Associate Director of the School of Nursing to explain the study, selection criteria, and recruitment strategies. Recruitment strategies included the Associate Director approaching the students on my behalf to provide the students with a letter of information about the study. I left my telephone number and that of my thesis chairperson to encourage the students to call my thesis chairperson or myself i f questions arose. The students let me know of their interest in participating by calling me directly. Concept of Culture 71 Data Collection and Analysis Data collection and analysis occurred simultaneously. Data collection was over a period of one month. I was sensitive to fieldwork issues relating to gaining access to gatekeepers and key informants. Data Collection Data collection for the study was comprised of students' reflective journals, interviews, and socio-demographic data. Although data collection in critical ethnography usually includes participant observation, in this study it did not. Reflective journals. Throughout an academic term during a nursing program, undergraduate nursing students gathered data on their learning and reflections on the concepts introduced in the context o f a course. The concepts introduced and discussed included the concept of culture, related concepts and issues related to the concepts. A s part of the course assignment, the students kept observations, thoughts, and reflections in a field note journal. I requested access to the journals from the students who consented to participate in the study. Although, only two students submitted their reflective journals, I did not dismiss the journals, as the reflections in the journals were rich and complemented the data derived from interviews with each of the participants. Interviews. Lincoln and Guba (1985) note that interviews can be used for such things as here-and-now constructions of participants' perceptions, reconstruction's of past perceptions, projection of beliefs about the future, and verification of other sources of data as wel l as verification of constructions Concept of Culture 72 developed by the inquirer (p. 268). Therefore, data collection included audiotaped interviews. Over a period of one month I interviewed the once for for approximately one to one-and-a-half hours, at a time and location mutually convenient to the participant and me. Wi th the exception of three students, who were interviewed in a quiet room at the School of Nursing, four were interviewed in their homes and one student was interviewed at my home. A t the beginning of each interview, I reviewed the purpose of the study, encouraged and answered any questions. I drew up a number o f open-ended questions based on the literature and the reflective journals (the interview guidelines were tentative because they changed upon analysis of the reflective journals and the progress of the interview, see Appendix A, for tentative interview guidelines). The interview progressed from open listening on my part to increasing clarification and exploration of themes arising from what was learned from analysing the reflective journals and socio-demographic data. I was alert for informants' answers that were contradictory, that did not correspond to other informants' answers, or indicated gaps (Thomas, 1993). Due to time constraints and personal commitments of three students, I discussed and shared the meaning re-constructions with five participants. Time committed to these discussions was approximately one to one-and-a-half hours and conducted at a time, and place that was mutually convenient for the students and me. Concept of Culture 73 Socio-demographic data . I collected the data upon access to students before the interviews. Demographic data tabulated were age, sex, ethnicity, cultural identity, religious, spiritual, or philosophical orientation, education before entering the nursing program, and length of experience in clinical areas (see Appendix B, for socio-demographic data form). Data Analysis Data analysis in critical ethnography is discussed in terms of interpretation (Thomas, 1993) and reconstructive analysis (Carspecken, 1996). The interpretation of the data is the de-familiarisation process in which the researcher revises what is revealed during the interviews (and reflective journals submitted by two undergraduate students), and translates it into something new (Thomas). De-familiarisation is a way of "distracting ourselves from the taken-for-granted aspect of what we see and allowing us to view what we have seen more critically" (Thomas, p. 43). In relation to the study this involved stepping aside from what was revealed about the concept of culture in the literature to enable a critical reflection of the data collected from the participants. Analysis involved looking for non-literal meaning in the data collected from the participants (Carspecken; Thomas). There is a growing body of epistemological and methodological analysis in writing on critical ethnography but there is little practical advice (G. Anderson, 1989). Thomas (1993) provides a brief description of the 2 3 The socio-demographic data of the investigator are as follows: Age - 29, Gender - Female, Ethnicity/ Cultural identity - Sri Lankan, Religion - Anglican. Concept of Culture 74 analytical process but the practical side of analysing data is not particularly well explicated. Therefore, being a neophyte, I used the analytic approach described by Carspecken (1996), and Lincoln & Guba (1985), augmented by perspectives in critical theory (Campbell & Bunting, 1991). Re-constructing meanings. The data analysed in the study were interview transcripts and reflective journals, therefore I employed narrative-analytical techniques (Carspecken, 1996; Lincoln & Guba, 1985). Preliminary reconstruction 2 4 was initiated by becoming familiar with the data and noting thoughts and reflections associated with possible underlying meanings revealed in the reflective journals submitted by two undergraduate students and the interview transcripts. Carspecken (1996) suggests beginning with low level coding, "which is coding that falls close to the primary record (reflective journals and interview transcripts) and requires little abstraction" (p. 143), and keeping initial meaning construction on relatively low levels of inference. Apart from saying that low level coding is coding that falls close to the primary record Carspecken does not clearly delineate what to encompass in "low level coding." Therefore to avoid fragmenting the meaning of what participants said to me, I borrowed some terms from Lincoln and Guba (1985), who in endeavouring to be more explicit in data processing activities, posit a number of operational refinements (pp. 344-351). 2 4 Reconstructive, in that I will "reconstruct" through my cultural lens into explicit discourse, cultural and subjective factors the participants revealed in the two reflective journals and interviews." Concept of Culture 75 They organise their refinements in terms of unitising and categorising 2 5. Similar to low level coding as described by Carspecken (1996), they write that unitising involves delineating "units of information that w i l l , sooner or later, serve as the basis for defining categories" (Lincoln & Guba, 1985, p. 344). Lincoln and Guba note that the units should be heuristic, "that is, aimed at some understanding or some action that the inquirer needs to have or to take" (p. 345). Secondly, each unit "must be the smallest piece of information about something that can stand by i t s e l f (p. 345), and suggest that such a unit may be "a simple factual sentence" (p. 345) or "as much as a paragraph" (p. 345) 2 6 . Reflecting on what I learned from Carspecken (1996) and Lincoln and Guba (1985), rather than calling the initial meaning reconstruction low level coding or unitising, I decided to call the initial part of meaning reconstruction low level units. Upon identifying the "low-level units" Caspecken suggests adding, "discursive articulations of tacit modes of meaning.. .that underlie the 27 interactions recorded" (p. 95), that is creating a meaning field Although I "hovered close to the data", I viewed constructing a meaning field (the initial reflections and impressions of meaning) as preliminary and subject to my interpretations. I was cognisant that the re-2 5 As I would like to walk the reader through the process of analysis, I will discuss categorising as identified by Lincoln and Guba (1985) in a later paragraph. 2 6 Lincoln and Guba (1985) suggest erring "on the side of over inclusion" during the unitising phase of data processing. They say "it is easier to reject what later appears irrelevant material than to recapture information suddenly realised to be relevant but discarded earlier" (p. 346). Concept of Culture 76 constructed meaning field may not be the same as the meaning field experienced and/or articulated by the participants. Initial meaning reconstruction involves a circular process: "movement from the tacit (intuitive and undifferentiated) toward the explicit (delineated 28 and differentiated) and then back to the holistic" (Carspecken, 1996, p. 95) . However, to make explicit the process of analysis I adapted what I learned from Carspecken and Lincoln and Guba (1985) for a regular word-processing program on a computer 2 9, and used it for the reflective journals and interview data that I obtained through audio-tapes and subsequent transcriptions. Categorising is the second process for data analysis (Lincoln & Guba, 1985, pp. 347-352). It involves bringing together "into provisional categories those [units] that apparently related to the same content" (p. 347). Using the method of constant comparison, it involves a careful construction of a category set by looking for units that provide extension, bridging, suggestions, or new categories (p. 347). Carspecken (1996) uses the term "high level coding" to describe a similar process of categorising as described by Lincoln and Guba (1985). I choose to name what Carspecken calls "high level coding" high level categorising as he does not clearly delineate what he means by high level 2 7 A meaning field is a range of possibilities/ interpretations articulated because the researcher cannot know for certain what the participant intended with an act, or the meanings people might infer, either overtly or tacitly (Carspecken, 1996). 2 8 Although I have described the process in discrete steps the process of analysis was circular. 2 9 There are a number of computer programs for use in qualitative data analysis. I made a conscious decision not to use such a program as I did not have the expertise or time to master a program. Concurrently, I felt that such a program would take me away from the meanings of Concept of Culture 77 "codes." Moreover, "high level categorising" seemed more consistent with the low level units developed and used to select segments of the interview transcripts and reflective journals for intensive analysis (Carspecken). This phase (higher level categorising) was based on explicit meaning reconstruction and pragmatic horizon analysis. Carspecken writes, "analysis o f interview transcripts w i l l require attention to the contextual nature of any particular statement" (p. 162) made by the participant. I learned that Carspecken (1996) coined the phrase "pragmatic horizon analysis" 3 0 by borrowing the term horizon from phenomenology, it "comes from regarding action rather than perception 3 1 to be most primary in experience" (p. 103). He states that "an object takes on a distinctive form within perceptual experience only against a background horizon that is apperceived at the same time" (p. 103). For instance, metaphorically, the appearance of a tree depends upon passing beyond the tree to the field or horizon which places the tree before us (Caputo, 1987). Carspecken says that we w i l l only understand an idea against the horizon from which that idea is brought forth, and a "structure of background contrasts works to constitute the idea in the foreground" (p. 103). Carspecken points out that "you cannot re-construct every possible reference in a set of data - any effort to try to accomplish this would lead to endless work and a smothering amount of the participant's stories. In addition, Sandelowski (1995) cautions that such a program "may transform and even adversely influence qualitative work" (p. 207). 3 0 Please see Carspecken, (1996, pp. 103-120). Concept of Culture 78 detail" (pp.119-120). Therefore, though I created initial meaning fields for each individual low-level unit, pragmatic horizon analysis took place following the pooling of units into categories. From a practical point of view, pragmatic horizon analysis involved searching for meaning in the horizon structure (the pooled low-level units) constituted by inter-subjective interpretations (Carspecken & Apple, 1992). Carspecken and Apple (1992) and Carspecken, (1996) suggest that the next stage of reconstructing meanings begins with examining relationships between social sites and social groups, because the comparison of these cultures may display isomorphic 3 2 relations between them. I conducted the study on the one site, and with a particular social group - nursing students. Reflecting on what I learned from Carspecken and Apple and on what I learned from the participants, I identified three metaphoric sites that I used as an analytical structure to guide me in unearthing possible isomorphic relations 3 3. A s the last phase 3 4 o f the research process, Carspecken and Apple, and Carspecken advocate making an effort to relate the re-constructed meanings to a broad view of society as a whole. With this in mind, in Chapter 3 1 A "perceptual horizon is understood to be a special case of a pragmatic horizon".. .because a perceptual object only becomes fully foregrounded when it is symbolised and therefore located within generalised contexts of possible communication (Carspecken, 1996, p. 103). 3 2 "Isomorphism used in this context refers to similarities between the cultures of each site" (Carspecken & Apple, 1992). 3 3 Please see Chapter 4 where I will present the reconstructed meanings. 3 4 By identifying this as the last phase of the analysis, I am not intending the reader to interpret this as the final stage of my learning. I see my learning as an on-going process of critical reflection and re-construction of meanings. Concept of Culture 79 5 I w i l l address the implications of the re-constructed meanings for nursing 35 practice, nursing education and nursing research . Here is how I proceeded in meaning re-construction: • Audio-tapes were listened to until I became familiar with the participants tone of voice. Transcripts were re-read making mental note of underlying meanings 3 6. • I opened a new, blank file and split the screen so that I could see the primary data file and the blank screen 3 7. Whenever a sentence or a paragraph in the primary record struck me as worthy of being a low-level unit 3 8 ,1 toggled to the blank screen and pasted the unit. In an indented section below the unit, I wrote the participant number, interview number and line number for reference. • Then, within brackets, I inserted initial meaning re-constructions 3 9 with the letters M F (meaning field) placed in front. See example of low level unit, with participant number, interview number, line number, and meaning field. I'd say ideas related to culture need to be woven throughout the curriculum.. .1 think that looking at issues about culture provides a way for students to examine their own perspective, worldviews.. . Please see Chapter 5. 3 6 Carspecken (1996) suggest that "several readings will begin to suggest patterns as well as highlight unusual events that may be important to .. .the.. .analysis" (p. 95). 3 7 Adapted from Carspecken, (1996), please see p. 149. 3 8 1 selected low level units on the basis of either what I felt was most relevant and/ or on the basis of what the participant emphasised. 3 9 Initial meaning reconstruction's were constructed on a relatively low level of inference, and consisted of "meanings that other people in the setting might themselves infer, either overtly or tacitly" Carspecken, 1996, p. 95). On the hard copy (printed copy) of the transcripts I noted relationships to other interviews, theoretical ideas, comments on reflexivity and flagged particular pithy quotes for future retrieval. Concept of Culture 80 P 6 , I 1 , L N , 807-814 [MF: ideas related to culture need to be woven throughout the curriculum, as it provides a way for students to examine their own perspectives and worldview]. • A s I continued to read, I continued to construct new low-level units, and create sub-units when I felt I identified an important distinction within an already established unit 4 0 . The low-level units and initial re-constructions were organised into categories for each individual. • The low level units from each individual were pooled and sorted into pragmatic categories. Initial-re-constructions were collapsed into more abstract themes and pragmatic horizon analysis was carried out to identify high level categories. • Analytic structure was organised and elements pulled out for exploration. The exploration included data from interviews, excerpts from the reflective journals, meaning re-constructions, related theory or concepts, and links to other empirical and theoretical work. I sought peer de-briefer dialogues with my thesis committee chair to check the process o f analysis. In addition, I clarified the meanings re-constructed meanings with the participants (Carspecken, 1996). Issues of Validi ty and Reliability Research conducted using qualitative methods requires different criteria to assess validity and reliability than those applied to quantitative 4 0 Carspecken differs from Lincoln and Guba at this point as he advises creating a hierarchical structure of categories from when the first unit is identified, and subsequent sub units are identified. Concept of Culture 81 methods. Sandelowski (1986) recommends that the criteria of credibility and fittingness be used instead of internal and external validity. Likewise, auditability and confirmability replace the criterion of reliability. Efforts to ensure rigor during the proposed research project included several strategies that are grouped under the headings of credibility and fittingness, auditability, and confirmability. Credibility and fittingness Credibility is concerned with the lived experience as perceived by the participants and is achieved when the participants are able to recognise themselves and their experiences in the descriptions and interpretations of re-constructions. Fittingness addresses the ability to fit the data into the re-constructions from which they are derived. That is, re-constructions must be well-grounded in the reflections of the life experiences of participants or, as in this study, the participant's reflections. Credibility and fittingness for this study was achieved in several ways. First, after I identified the relationships among the themes, according to the above paradigm, I verified these relationships against statements in the interview data. In other words, data sources (making comparisons of the interview data) and data collection procedures (interviews, students reflective journals, my personal journal, and theoretical memos) were triangulated to determine congruence among them (Sandelowski, 1996). Participants were asked to comment on the descriptions and impressions derived from the interviews and reflective journals in order to Concept of Culture 82 equalise the power relations of the data analysis 4 1. Credibility was also based on the processes of self-reflection and analysis built into the written work, reflective journals, and on the discussion and mutual construction of meanings with participants during interviews. These steps were used to contribute to the "trustworthiness" o f the research (Lincoln & Guba, 1985). Auditabilitv Auditability refers to the "decision trail" (Sandelowski, 1986) used throughout the research process. A s such, I strove to present the situation and data in enough detail so that others are able to arrive at similar conclusions. Accordingly, in this report I have described: (a) how I became interested in examining nursing students understanding of the concept of culture; (b) the purpose of the proposed study; (c) how I invited participants to volunteer in the study; (d) how I collected the data; (e) the length of time for data collection procedures; (f) the setting of the data collection; (g) the data analysis process; including, (h) excerpts o f the data in the research report. Additionally, I made assumptions about the subject matter explicit in order to interpret my own behaviour in relation to the participants (Carspecken, 1996). Furthermore, I shared all the steps of the decision trail with the thesis committee both verbally, and in the final report. 4 1 Carspecken (1996) writes that it is "essential to share explicitly.. .(the ).. .meaning constructions with the subjects (participants) of the study" (141). When the participants disagreed with the re-constructions I reflected on the re-constructions, and included their views as alternatives to what I have written, to enable the reader to compare my interpretations with those of the participants and decide for themselves. Concept of Culture 83 Confirmability Confirmability or freedom from bias replaces the quantitative criterion of objectivity (Sandelowski, 1986). I sought dialogues with my peer de-briefer (thesis committee chairperson) to check the process of reconstructing meaning. I did become involved with the participants and the subjective data gained from them. Sensitivity to context begins to attend to what Sandelowski (1993) describes as the need to practice good science in order to ensure rigor. "Trustworthiness becomes a matter of persuasion whereby the scientist is viewed as having made those practices visible and, therefore, auditable; it is less a matter of claiming to be right about a phenomenon than of having practised good science" (p. 2). Limitations (1) The undergraduate students participating in the proposed study kept a heavy school work schedule and were reluctant to commit to two, one-to-one-and-and-a-half interviews. In addition, as mentioned previously, due to the reduced number of undergraduate students who volunteered to participate in the study, I extended the invitation to graduate students to participate in the study (this was not viewed as a limitation, but I was aware that they were also constricted by time to participate). A t the outset, I viewed the number of undergraduates that volunteered to participate in the study as a limitation. However, on reflection, I believe extending the invitation to the masters and doctoral students contributed to a rich data set Concept of Culture 84 (however, this is not to imply that, had it only been undergraduate students, the data set would not have been as rich). (2) The timeframe for the research was a limitation because the project was conducted within the confines of a graduate program, and other commitments of all involved. I committed the necessary time and effort to the study to allow the data collection and analysis to be done efficiently, while simultaneously ensuring a good quality of work. Ethical Consideration There were no anticipated risks or direct benefits for the participants in this study. Because the participants shared personal and confidential information with me they were given assurances that their identities would not be revealed and their rights as human subjects would be protected. To ensure this I adhered to the following protocol: 1. Ethical approval for the study was obtained from the University of British Columbia Behavioural Research Ethics Board and permission was obtained to conduct the study at a major Canadian university. For reasons of ensuring confidentiality I have not enclosed the letter received from the university. A copy of the letter received to conduct the study from the Behavioural Research Ethics Board is appended - see Appendix C, as ethics approval had to be obtained from the university at which I am a student. 2. I had telephone conversations as necessary and meetings with the persons responsible for research in the school and the students to explain the study, Concept of Culture 85 the expectation, of participants, and how confidentiality would be ensured. The voluntary nature of participation was emphasised. 3. The written consent for participation explained the purpose of the study, what would be expected of participants, and how confidentiality would be ensured (see Appendix D and E - letter of information about participation in the proposed research project and participant consent form). The voluntary nature of participation was emphasised. 4. Documents, tapes, disks, and transcriptions were coded to remove any identifying characteristics. Tapes were erased as soon as they were transcribed. Reflective journals were returned to the students once copies were obtained, and the copies were returned on completion of the study. Access to the tapes, disks, transcriptions, and journals were limited to the researcher and her thesis committee chairperson and faculty advisor. Documents, tapes, disks, and transcripts were locked in a secure place when not in use. Summary In this chapter, the methodology of critical ethnography has been described and the rationale for using it to study the research questions was clarified. This method was used to explore nursing students' understanding of the concept of culture, how students learn about the concept o f culture, and how they apply what they learn in providing care to a culturally diverse population. Sampling, participant selection, procedures for data collection and Concept of Culture 86 analysis, criteria for evaluation of qualitative research, possible limitations to the research, and ethical considerations were also explained. Concept of Culture 87 CHAPTER 4 Presentation and Discussion of Meaning Reconstruction In Chapter 3,1 described how I searched for meanings, how I learned from nursing students, and how I sought the meanings to be narrated in this study. In this Chapter I w i l l show what I re-constructed. Given that what I re-constructed is "inherently connected" with how I learned (Emerson, Fretz, & Shaw, 1995, p. 11), I w i l l comment on both as I proceed. In profiling the data, I have worked to preserve the students' voices 4 2 by editing their words as little as possible, and by including enough interview data for the reader to be able to get a sense of the nursing students' stories and their contexts. This means that I often return to the same transcript segment for different aspects of the analysis. Moreover, I concurrently present and analyse the re-constructions so that I may foster dialectic between nursing students' voices and relevant empirical and theoretical literature. Consequently, the analysis presented in this Chapter sets the stage for much of what I w i l l narrate and summarise in Chapter 5. Before presenting the reconstructed meanings, I w i l l share some of the socio- demographic information to give the reader a sense of where the participants are coming from and profile the voices of the participants. The participants were within the 2 3 - 4 1 age group and were from diverse ethnic, religious, and philosophical backgrounds with clinical work experiences 4 2 Voice is a metaphor for the tangible expression of a person's thoughts and feelings in the context of interaction with another (Belenky, Clinchy, Goldberger, & Tarule, 1997). Concept of Culture 88 ranging from 40 weeks -16 years in and outside of Canada. Five o f the 8 participants were immigrants who have lived in Canada for varying lengths of time. In addition, it came out in conversation and during the interviews that except for one participant all had travelled internationally. Consequently, on reflecting on how they perceive culture, I believe that the experiences gained from travel may have influenced the way in which they learn about the concept of culture. I knowingly omitted to share the countries of origin and the gender and educational backgrounds of the participants for reasons of ensuring participants' confidentiality: P7 expressed the following point of view in the second interview: I feel that it is important to tell the readers the background of the participants, as their descriptions/ conversations are being quoted; because to say something (what culture means) from a position of power and privilege can carry different meanings than when something is said from a position of being oppressed. I reflect on P7's comment about the importance of knowing 'where a person comes from', in order that I may have some understanding o f their positionality, because this may have an effect on their representation of cultural meanings. I am aware that not sharing 'where a person comes from' with the reader may be seen as a limitation in how I have reconstructed meanings. A s I have previously mentioned, I am conscious that I must maintain participant confidentiality. I w i l l , share however, enough information to provide some sort of context, while not disclosing the information about 'where a participant is from'. Concept of Culture 89 Though the aforementioned questions guided me in this study, students reflections on how they understand and learn about culture and how they apply what they have learned in providing care could not be neatly teased apart. The students did not treat these questions as discrete. Therefore, I have organised, presented, and discussed the re-constructed meanings to mirror students' conceptualisations of culture. Then, through the isomorphic relations I have tried to examine how what they said link with the questions that guided me in this study. Reflecting on what I learned from the horizon analysis, apart from emerging high level categories to the foreground, I was also able to unearth an analytical structure. The analytical structure set the scene for how I presented and discussed the reconstructed meanings and isomorphic relations (See Figure 3 and Figure 4). I have organised the presentation o f the re-constructed meanings within the three contexts o f personal life experiences, academic experiences, and nursing experiences. However, I do not see the boundaries between these contexts as fixed and see the processes o f learning about culture threaded through each of the three contexts. The Processes of Learning about Culture When I was asked by a participant to describe how I understood the concept of culture, I found myself reiterating what I learned following the literature review for this study. That is mainly to say that culture is a capacious, capricious, and complex concept represented by matrixes of historical, socio-cultural, political, and economic contexts. Concept of Culture 90 The Processes of Learning about Culture Academic Experiences <C^ —^> Nursing Experiences Figure 3 Analytical Structure Concept of Culture 91 Personal Life Experiences Seeing the world Tension between what is shared and what is different • Falling in common with others • Understanding others • Culture is shared and individualistic The quagmire of understanding culture • Cultural grouping and social division • Qiltnrp of oppression and exploitation _ Academic Experiences Importance of learning about culture What to learn about culture Ways of learning about cultun Politics of learning about culture. A time to learn. PROCESSES OF LEARNING ABOUT CULTURE Nursing Experiences Confronting values, beliefs, assumptions & bias • Witnessing in-equitable access to health care Managing moments of cultural differences Power of language Language barriers Process Figure 4: The Processes of Learning about Culture Concept of Culture 92 On reflection, in saying this, I noted that I was aware of whom I was speaking to and conscious that my thoughts and views were filtered due to my extensive reading of materials on 'culture' and my cultural lens. In addition, I found myself asking a rhetorical question: Given the complexity of the concept can I really articulate what I understand by the concept of culture? In the context of learning about culture, P7 expresses the following point of view: .. .1 don't see that we can learn about culture, because as cultural beings we are participating in the making and re-making of culture, and as students not only do we participate, but I think that we should keep, we should keep thinking about it, we should keep problematising it, and we should not forget that it is a process of evolution What I learned from the nursing students through this study does not contradict my initial conceptualisation, but provides enrichment, in that, in understanding culture, I do not need to arrive at a place where I feel obliged to say, 'I know what culture means', as understanding culture is an evolving process that requires continuous problematising. The following participants articulate the amoebic nature of the concept and the need for on-going discourse: P5: . . .when I think about what culture is, I think culture can be, we can perceive it, it is not a fixed thing, this is culture, when I think of culture, I think of very global and abstract sense of what culture i s . . . Similarly, in reflecting on the concept of culture, P6 expresses the view that, P6: .. .it's hard to.. .it just seems so complex because there is so many different shades on it. . .on the idea of culture.. .what (does) culture mean to me.. .1 don't have a solid definition, it's still in flux in my brain In the transcript segment below, P8 echoes P5 and P6's thoughts on culture. In that, the concept of culture is complex, and dynamic. Participant 8 also Concept of Culture 93 resonates P7 in the belief that as students we need to keep thinking and entertaining discourses on culture because culture is in the process of "evolution".. .and "our notions change over time." P8:1 think culture is a very complex concept. I think it changes. I think it's boundaries shift, and that is why I believe that being involved with this type of research, and having these sort of discussions at student level and practice level once students have qualified is especially important, because I think that our notions change over time. Certainly what we consider to be culture now is very different to what perhaps our grandparents considered culture to be fifty years ago... In accordance, with the above participants, Anderson, Blue, and Lau (1991) theorise that culture is not static but involves processes by which beliefs are constructed (Allen, 1990) and maintained. Participant 5 illustrates the point that culture is dynamic and involves processes, (and says) it's interesting because social fabric 4 3 , culture, they don't exist. It is not something that is tangible, it is something that is dynamic and felt, so.. .you can't grasp it, it is not a graspable thing to say, this is social fabric, this is culture, we can't.. .feel i t 4 4 . 1 do not think we necessarily feel it directly, it is something that we create person to person, within groups within dyads and within small groups that make up large groups. So within families, within communities, within regions, within a nation, and that relationship, that dynamic to me is what is cultural, what is a social fabric is to a certain extent, the dynamics of what is going on there, that is society.. .(that is cultural). What I learned from the students supports the perspective that the concept of culture is complex. A s Al l en (1990) suggests, culture is created and recreated (my emphasis, because to say that culture is created implies that 4 3 In clarifying what is meant by social fabric, Participant 5 articulates: what I mean by social fabric is the norms, the established norms, whether it is spoken or unspoken, the rituals, the relationships and ties that are established within a society that make up the social fabric of a society Concept of Culture 94 culture is a fixed product) through discursive 4 : > acts and arises from different perspectives, each of which serves a different purpose. From a critical standpoint, these perspectives represent different values related to power relations and oppression. Consequently, the representation o f culture varies depending on the perspective assumed. In the following sections I present and discuss my interpretations of the data gathered thorough interviews with the students about how they understand the concept of culture, how they learn about the concept of culture, and how they apply what they learn in providing culturally competent care. The processes of learning about culture emerged as the hinge which holds together learning about culture from three sources: personal life experiences, nursing experiences, and academic experiences. Personal Life Experiences Personal life experiences emerged from the horizon in students' discourse on 'culture'. Three major themes emerged: seeing the world, tensions between what is shared and what is different, and the quagmire o f culture. Students talked about the ways in which they perceive the world and the interpretation of what they see, and argued that there are multiple ways of seeing and interpreting the world. The need to entertain discourse about what is shared and what is different emerged as an important theme because 4 4 When sharing the reconstructed meanings with Participant 5, she commented that 'we can't.. .feel it'.. ."is something confusing. It seems that we can feel it, but perhaps only indirectly." 4 5 By "discursive" .. .Allen (1990) means "a series of conversations or texts that are organised around a similar topic or discursive object" (p. 96). Concept of Culture 95 dialogue on tensions between what is shared and different brings to the foreground meanings of cultural experiences. Reflecting on the tension between what is shared and what is different, students described values and behaviours that they may share with others and how these values and behaviours shape the way they are in the world. I have labelled the third theme that emerged "the quagmire of understanding culture." This theme emerged as students eloquently described the matrixes of historical, socio-political, and economic contexts, and everyday life experiences that shape their understanding of culture. Students' reflections on personal life experiences and the socio-cultural, and political contexts in which these experiences occur suggest that learning about culture cannot be thought of in the isolation of personal life experiences. The following sections outline my interpretation of the students' discussions of their personal life experiences of learning about culture. Seeing the World Nursing students talked about how "where they are from" correlates with how they "see the world." This perspective is echoed in the following statement from participants, P3, culture organises our lives in a very deep way.. .(and an) individual's experiences, their growing up experiences of mother, father, or mother alone, dictate what kind of culture you have, your religion, your ethnic experience. Everything comes together to make this person and culture, certain things may be shared in common with other people or believed to be shared in common. P5: How we see the world, how we interact in the world, all of that which makes us who we are, come from the milieu in which we came Concept of Culture 96 from whether that's the country that we came from, the social class that we came from, whether or not we were brought (up) by women, men or combination P6: culture has a lot to do with. . .where you grow up, who you are genetically. The process of understanding culture involves reflecting on life experiences. When talking about where they are from students include the diverse set of factors: the place (the geographical area) of birth, where they grew up, their genetic 4 6 background, educational background, values and beliefs, and life events. In emphasising the importance of the geographical place of origin, P5 makes the following comment, .. .there must be some awareness of how we see the world, and how we interpret the world through our own perspective through our own lens. A n d that is determined so much by the place in which we grew up in. The educational background, our values and beliefs, past experiences and then, that is in of itself a perspective. So to foster that notion that there are multiple ways of seeing the world, and interpreting the world, and that we need to really acknowledge that and some how create a forum for people to share those things that (we), not only share but learn how to work through areas in which we did not know there were differences. These comments from P3, P5, and P6 demonstrate that students believe that the ways in which they see the world are interpretations based in experience. These interpretations are a part of culture. Students believe that their life experiences influence how they interpret the world and that those interpretations affect how they "interact with people." A s P5 illustrates, The kind of experiences that we have.. .even when we get into more abstract things, .. .whether or not we feel secure in who we are.. .how that affects how we see the world, how we are in the world, and By "genetic" participant, six is talking about her parents and family. Concept of Culture 97 interprets in many ways our ability to interact with people who have similar ways of being in the world Similarly, P7 articulates that, Sometimes, what I see, what I have experienced w i l l influence what I think, (and) what I believe in. What I believe in and what I see might influence how I see culture, and how I represent myself as a cultural being. A n d how I present myself as a cultural being could influence my interaction and my experience with other people... In addition, P5 suggests that there are multiple ways of seeing the world. L ike P7, P5 identifies the need to create "a forum for people to share" those multiple realities. These perspectives on "seeing the world" underlie the next theme "tensions between what is shared and what is different."Because the ways in which persons interpret what they see effects representations of multiple realities, it is important to entertain discourse about what is shared and what is different or perceived to be different. Jordon and Weedon (1995) write that culture is a fundamental aspect of the fabric o f everyday life and helps to give us our sense of identity, telling us whom we are, where we are from, and where we are going. In reflecting on P3, P5, P6 and P7's explications, I learned that when thinking about the concept of culture students thought of the ways in which they see the world and interpret what they see. In addition, they identify the need for discourse on multiple realities 4 7. 4 7 At this juncture, I will not what Guba (1990) writes about constructivism as I believe it links in with P5's belief that there are multiple ways of seeing the world, and interpreting the world, and the need.. .to create a forum for people to share those things.. .Guba, theorises that constructivism is founded on a relativist ontology (realities exist in the form of multiple mental constructions), a subjectivist epistemology (inquirer and inquired are fused into a single entity), and a hermeneutic (interpretive), dialectic methodology (individual constructions are elicited and refined hermeneutically, and compared and contrasted dialectically, with the aim of generating one, or a few, constructions on which there is substantial consensus (pp. 25-27). I feel I must critically reflect on the notion put forward by Concept of Culture 98 Tension Between what is Shared and what is Different When reflecting on the concept of culture students entertained the notion that discourses on culture enumerate differences. Dialogue on tensions between what is shared and different comes to the foreground in the exploration of learning about culture. P5: there is that tension between what is different and unique, between people, groups of people to some extent, and culture often comes in exploration of that.. .culture is a way of probably connecting with both those things (what is different and what is shared) and appreciating both of them. When focusing on the differences, the 'others' point of view is obscured. In reference to differences P5 articulates: .. .when we say someone is, it's a cultural issue, it's because it's different, we are not seeing what we share, we are seeing what we don't share, so therefore one decides what is cultural.. .you can't see their point of view, don't understand why they behave in that way or I can't understand the rationale or the motivation for what they are doing, or what they are thinking or how they think.. .because they are from a different culture than I am.. .so often we talk about culture.. does seem to me that.. .it points out the differences.. .it also shows what we share In the transcript segment below, when talking about similarities, P5 reflects that,. .. .the way in which I seem to be defining culture really has to do more with what defines us as human beings, so what is it that defines you that I can understand, what I can understand and feel that I share on some level, I would say in that sense we have shared culture. What it is about you that I simply can't understand or that I, not only that I can't Guba (1990) that interpretations must be compared and contrasted dialectically" with the aim of generating one or few constructions on which there is substantial consensus. I take issue with this view, because my interpretations or what I feel Guba suggests leads me to believe that by aiming to arrive at a consensus, in discourses about culture, I may risk essentialising (Allen, 1990) and reducing culture to a residual category, and making generalisations that are then used to create stereotypes which in turn are used to justify prejudice. Concept of Culture 99 understand, where I feel there is a lot of difference, where I feel the difference is then I w i l l label that, this is a cultural difference.... Why recognise differences? P5 suggests that it is important to grapple with questions of the sources of perception of difference and the purpose of the distinctions. I think recognising differences is part of the ability to discriminate, and discriminating awareness, now I do not mean discriminating in the sense of oppressing one group over another. I think to look at something and be able to see the similarities, see the differences. The important thing I suppose is to look at why does one want to see similarities, why does (one) want to point out the differences, to what end, for what purpose, why is it helpful? I think that is where it gets difficult, it is to know the motivations and the reasons for finding differences, and what use that information w i l l be put to.. . In unpacking P5's colloquy on 'difference' I draw upon theoretical positions posited by Stewart Ha l l (1997). In addressing the question, "why recognise difference?" Hal l advances that 'difference' matters because "it is essential to meaning; without it meaning could not exist.. .meaning depends on the difference between opposites" (p. 234-235). Comparing and contrasting differences and similarities derives meaning about a 'cultural experience.' To illustrate, P5 talks about culture in relation to an experience she had in Bangladesh, P5: .. . in Bangladesh when I worked in the clinic, there was a woman there who was a biologist, and I felt a lot of connection with her. I think it was because we were women. The fact that we were women, and we could sit and talk about things, so we shared the future of women within this very male dominated society. On the other hand, on another level, we shared very little, in terms of a life experience, and the directions in which our lives would take us. Concept of Culture 100 What I heard in P5's description of this experience was that in order to discern what is culturally different one must also look at similarities (what is shared). I postulate that because P5 and the biologist were both women within a "very male dominated society" they had some similarities. However, on another level they shared very little because their life experiences and the directions in which their lives would take them were very different. The above excerpt from the transcript of P5 is an illustration of Hall's (1997) point that we learn about 'difference' and shared experiences by constructing meaning through dialogue with the 'other'. Jordon and Weedon (1995) share this perspective that discourses are more than ways of giving meaning to the world, they are forms of social organisation and social practices which constitute individuals as thinking, feeling and acting subjects (p. 14). A s P5 indicates in the above transcript, segment "we could sit and talk about things, so we shared the future of women within this "very male dominated society." Three sub-themes were apparent in the participants' discussion of the tensions between what is shared and what is different: (a) falling in common with others, (b) understanding others, and (c) culture is individual and shared. Each of these sub-themes raises particular foci of tension that influence understanding of culture. Falling in common with others. Culture has a lot to do with values, beliefs, and behaviours that may be shared with others and what is shared and/or not shared shapes an individual's way of being in the world. This perspective which came through in several of the transcripts points to a static Concept of Culture 101 rather than a dynamic understanding of the concept of culture. This emphasis on culture as a shared rather than a static entity comes through in the following excerpt from the transcript of P6. .. .when I think of culture, my own culture, I think about those values and belief, norms.. .that I fall in common with others.. .that shape then the way that I live my life in many ways that I may not even be aware of... When talking about fitting in P5 says that: .. .every situation is fluid and dynamic, and the way in which we learn to value fitting in, to what degree or not, is very individual. For example, P5 illustrates by referring to her experience in Bangladesh, .. .it was a Mus l im country. I didn't know what are the parameters of acceptable behaviour for a single woman.. .so I would ask and read, I watched, I saw what people did, and I imitated to the best of my ability. Yet in that situation, I wasn't just any single woman, I happen to be a .. .white woman.. .there were very few of us around, and so I was already in (a) different category, so the expectations and demands about what is acceptable behaviour for me also isn't exactly the same as it is for Indigenous Bangladeshi women, so trying to figure out .. .where I fit, and not wanting to, and be offensive, but also to connect with people, and the way to do that I felt was to find what we do share. To increase awareness, to be able to connect and not offend people or groups of people, P5 expresses the need to look at what is different and what is shared through discourse, watching, seeing, and understanding expectations and demands about what is "acceptable behaviour." In understanding demands and expectations about what is acceptable behaviour and the need to 'fit in' P5 also talks about "imitating to the best of my ability." Participant 8 concurs with P5 that, .. .you do sometimes have to make perhaps modulations in your way of being in order to perhaps (be accepted), then you w i l l be better Concept of Culture 102 understood and through in doing, .. .come to understand the other person's culture.. .one then is able to make those adaptation... A view of the tension between what is shared and what is different, when examined through the lens of falling in common with others, leads to a static and conventional understanding of culture. It is interesting that another tension begins to emerge, the multiple and conflicting perspectives on culture -the quagmire of understanding culture, I w i l l come back to this theme later. Understanding others. In discussing culture, students talk about whether there is a way of understanding others. In the process of seeking this understanding, P I grapples with the notion that you can never truly understand another person: I guess in a way you can't really totally understand.. .1 guess I mean I am uncomfortable with that word understand.. . Y o u can hope to understand, but I really think you can never really truly understand unless you are in i t . . . . i f I have a certain experience, how can someone truly understand because everyone's experience is different... P2 echoes P I in saying that we can never really understand each other because we are all different. Y o u can understand the words that are applied to what the meaning of what culture is but unless you are really, we can never really understand each other, because we all look, we are all different Exploring the tension between what is shared and what is different involves focusing, P5 . . .again on the fact that there w i l l always be things we share, things that we don't share, that there w i l l always be diversity. To illustrate, I reflect on P5's experience in a "Musl im country"; P5 implies that by virtue of the fact that she was racially different, "...I wasn't just any Concept of Culture 103 single woman, I happen to be a single white woman..." the expectations and demands about what was acceptable behaviour although she was a woman, were not the same as they were for an indigenous Bangladeshi woman. Culture is shared and individualistic. When thinking about culture, participants think of culture as "circles that inter-link", or as an "umbrella" or as a "pyramid", and within those circles, the umbrella or the pyramid is the individual. P3 expresses: Culture is sort of like a pyramid or umbrella. Can take a pyramid at its smallest it's the individual and then it sort of spans out taking in other people in common, probably a better idea about it would be sort of like circles that inter-link, concepts that inter-link. In other words, an individual shares a piece of that person's culture and a piece of another culture and that then sort of makes up their own, you know, but no two people are identical. Culture is like circles that inter-link and individuals share pieces of the different circles to make up their own culture. However, no two people are the same. P8 echoes a similar thought in reflecting on culture, .. .If I had to nail down what my culture was, it would be like series of overlapping circles.. .the core of which is me. The overlapping circles represent different groups that I might share values with, my family, nursing colleagues, neighbours, and close friends, there is all this different groups of people that influence who I am. P5 foregrounds the view that: .. .there is not one main culture, within cultures we have many cultures and resonates the thoughts of P3, and P8 in that there are many cultures. However, P3 acknowledges that, .. .each person or corporation represents a unique culture. A s finger prints no two cultures are the same. This is a fact as no two people are Concept of Culture 104 the same and by extension, no two corporations are the same given that each corporation is made up of different people. In the context of thinking about culture as shared and constructed, P6 believes that, P6: .. .a huge part of me is constructed from my participation in these various groups. But there is still something else as a person that exists outside of that, and that works, that exists dynamically within those groups. When talking about culture being constructed P6 suggests that, .. .there has to be something like more than just being, like it seems to me.. .the total social construction means that I am just going to be a product o f the intermingling of the various groups which I find my-self, or put my self. In contrast to thinking that culture involves circles that inter-link and is individualistic, some participant's thoughts on culture resonate what I found following the literature review for this study - that culture is determined mainly by ethnicity and race. P I : I originally thought of culture as sort of ethnicity.. .within a certain geographical area. P4: .. .1 used to think it (culture) was a .. .affiliation to a religious body, or colour of your skin, but now I know different. In talking about culture, P3 talks about concepts that inform people's perspectives: .. .when I think of culture.. .1 do think of ethnicity the concept of ethnicity, I don't think you can isolate that, I think of concepts such as sexual orientation immediately, gender. I think of the concepts of oppression, another big buzz word with me. I think of the concept of.. .all the isms.. .the racism's the ageism's the heterosexism's that comes in to it, because I think these concepts inform people's perspectives. Concept of Culture 105 The literature I reviewed for this study does not explicitly state that culture is related to ethnicity, but in writing about cultural issues many implicitly rely heavily on an understanding of culture as ethnicity (Leininger, 1994; Leininger, 1996; Lipson & Steiger, 1996; Lock, 1993; Murphy & Clark, 1993; Spector, 1991; Waxier-Morrison et al., 1990). What I learned from the participants and is reflected in the literature is that culture is like "over-lapping circles." Culture includes metaphoric circles of the interrelationship of beliefs, values and language, modes of dress, social relationships, rules or norms of behaviour, economics, politics, law and social control, artefacts, technology, dietary practices and health care (Burtonwood, 1988; Herman, 1990; Leininger, 1998; Spector, 1991). Some of the participants take the notion of culture as shared a step further, and suggest that within these circles, exists a person with their own culture. For example, P2 illustrates, .. .the whole country is affected by political decisions that affect the predominant culture here, which is western and white, and you know people have, we still have Sunday off, it is not a workday cause it's Christian philosophy. On reflecting on the participants' perspectives on culture, it became apparent to me that in thinking of culture, participants believe in valuing and respecting the individual and believe that within the circles that inter-link the individual exists as a distinct entity. P7 reflects, I have a critical notion about culture, but I would not give up the idea that I do have a culture, so again it depends on how I interpret it, how I want to represent... how I want to present to other people. However, there are ways that I live my life. There are things that I do on a regular Concept of Culture 106 basis, there are things that I enjoy, there are things that I see as appropriate or in-appropriate. I think that I can include those as part of my cultural being. The Quagmire of Understanding Culture Understanding the concept of culture is a theoretical and political quagmire. This subtheme is evident in all the transcripts. Culture is theory laden and contextual. A l l en (1990) says that the concept of "culture" is not a theory neutral descriptor, but a theory-laden construct inseparable from systems of injustice (p. 95). Participant 3 explicates, How one talks about culture is in a state of constant flux given that it is always changing. Further, culture is more than ethnicity even though it is talked about in relation to ethnicity.. .how we talk about culture certainly depends on ones cultural perspective.... Given that culture depends on a unique perspective, it seems to be a given that i f we make assumptions we can easily misunderstand a situation. Culture seems never to be able to be talked about in neutral terms as it involves in some way the social processes on which the issues related to culture are based. What I learn from P3 is that culture is in constant flux and how we talk about culture depends on our cultural perspective. Moreover, because we talk about culture from the way we see the world, we may create injustice, as P I suggests: .. .Discovering the very nuances that surround us all for the purpose of creating separation, segregation, inferiority, and superiority P3 states that, .. . in examining culture, it is always important to examine racialisation given that it implies the reality that whole groups can be disadvantaged when we think of culture and others. Concept of Culture 107 The discourse with participants revealed that in reflecting on the concept of culture students thought about what A l l en (1990) refers to as systems of injustice. Cultural grouping and social divisions. In the context of talking about culture participants talked about the fact that societies contain divisions of age, gender, ethnicity, and social class. P I suggests that people are grouped according to their economic status, .. .depending on .. .how much resources you have as income.. .you are grouped... you don't have equal access to a lot of things that, say someone of a higher economic status would. . . . I see the poor and needy as being individuals who don't have resources.. .it is difficult for them to meet their basic needs.. . in this culture anyway.. .they are taken advantage of.. .not considered worthy.. . in comparison to someone who is not poor and needy... Jordon and Weedon (1995) suggest that "divisions are marked by differences in appearances, behaviour and speech and.. .their reproduction is secured through belief systems, social rituals, ideologies and other modes of inter-subjective thinking and acting" (p. 4). P5 illuminates this point: .. .depending on one's proclivity .. .depending on how we want to group them (people) according to geographic area, we w i l l call that something else, we w i l l group them according to skin colour, or race, or whatever that is, whatever that word means now.. .that's coming from the mind that wants to group,.. ..because sometimes I think it is helpful, sometimes it's not... P2 describe an example of grouping leading to a negative backlash, I was just astounded by the negative backlash as towards trying to make it possible for Sikh men to become a member of the R C M P (Royal Canadian Mountain Police). Because you can't put a cap on top of a turban.. .we are not multicultural at all we are little groups that are constantly.. .conflicting with each other.. .hence you have little areas that pop up that are little communities.. .that you can identify.. .that's Concept of Culture 108 little.. .India, and little China town.. .and then there w i l l be the Caribbean area that everyone is just sort of little pockets spring.. .and to me that is not conducive to what we have been considering multiculturalism . P7 emphasises how grouping leads to racism. .. .we cannot talk about culture without talking about race and racism. In the context of talking about being in a particular community in Australia, P2 discloses how she experienced "culturally indoctrinated racism." Culturally indoctrinated racism, I mean I was in the Northern territory (in Australia) and I was just absolutely astounded by being at a table and with .. .a family and them just going "aah.. .we w i l l take you over to where all those Abo's (aboriginal people) are and (we) w i l l show you, you are too left, we gotta straighten you up and show you what happens, we spend our tax payers dollars and they just rip-up the floors and have fires that's what they are bush people However, in talking about grouping, P5 stresses, I don't think it's the grouping (that is) the problem, it's the why we are doing it, because grouping w i l l happen all the time. I think that's again that is some kind of to me a natural process, 'people' we are social animals, social beings, where we do get together based on certain things, common sharing interests, values, beliefs, and then in other situations we w i l l leave that group and go to another group, based on other reasons, and so, the grouping isn't the problem, it is more why we are grouping based on what is the criteria in order to be a member of this group or not be a member of this group, and what is the purpose of all this... Societies contain divisions, and people are grouped according to various characteristics (as mentioned above). Grouping people has negative and positive consequences. The importance of motivation and purpose for the 48lMulticulturalism' speaks to... "a multicultural society, which is a product of the diverse heritage of Aboriginal people, generations of immigrants and their descendants.... People are diverse in terms of race, cultural heritage, religion, ethnicity, ancestry, and place of origin.... Thus, multicultural refers not to any particular ethno-cultural communities, but to the diverse Concept of Culture 109 grouping o f people came through in the interview as a very important factor in the determination of the consequences of a particular grouping. Culture of oppression and exploitation. In the context of discussing culture, students talked about the culture of oppression and exploitation. There was a shared perspective that a culture of oppression stems historically, is real, and needs to be addressed. P 3 4 9 suggests that, We are so shaped by this oppression it's of such a force o f it's own. .. .ethnicity it's certainly recognised as a culture, but the culture o f oppression, I don't think people (realise that it exists).. .that the culture of oppression stemming historically you know to which it exists, and is real, and needs to be addressed. For example, P2 suggests that people adopt rituals for a reason, and they go back hundreds and thousands of years. P7 echoes P2, and says that, .. .what we see as something that is, you know part of life, actually might be a result of something very critical and political in the past.... I am thinking about historical happenings in a particular time, which shape the evolution of culture in two different places. P3 tells a story o f how the culture o f oppression historically evolved, Cultural oppression is where when.. .the slaves were brought over.. .there was a systematic means by which tribal groups were separated, because for reasons of security they didn't want.. .groups of people speaking the same tribal language to band together, because they could easily form resistance groups, sabotage groups, slave rebellions. So, the English.. .divided up people, mixed people.. .different tribes, so that they didn't, they couldn't communicate in their native tongues. They had to therefore learn a form of bastardised English, which then the English overlords could hear. B y nature of society as a whole" (Discussion Paper on a Multicultural Health Policy Framework. Policy Branch. 1995). 4 9 Speaking from the position of a person who has immigrated from a previously Colonised Nation that has experienced oppression. Concept of Culture 110 doing this they broke down the customs the ways of each tribe, the family unit of each tribe, because their culture in a broad sense was taken away from them and they had to sort of adapt to this sort of new culture, and again the culture o f oppression went on to state that they weren't, the idea of family for instance was not fostered. M e n were awarded for having as many children, with various women as possible because the child of a slave was a slave, and that was like a free slave that the master didn't have to pay for. He had to pay for new slaves coming form Africa from the slave traders, but children born were his. So the whole culture of 'go out there and have as many kids as you want, sow your seed' was planted in these men, and this is happening over three four hundred years of history. What has happened now, we look back at the emancipated slave and you say, oh why are they just having all these children and, and they get, you have to understand it from, "they are now free," where is this idea coming from for them to have ten children, can't they see they can't support them, and then although they have been many years when slavery has been abolished. It has this culture of oppression, that they had for three hundred years prior to that has created a culture of this is why we.. .and how we live and people have not recognised that this cultural oppression, has caused, you know the problems. I relate it to the aboriginal population, who again stripped of, moved to residential schools, stripped of their family unit, and now you wonder why don't they move to the suburbs and have nice little single family units, which you know, all comes to the whole culture o f oppression, that they fall into, no the thing about it is what spawns the culture, another asset to the culture of oppression is also the fact that the oppressed begin to feel, this is what we sow... Wi th regard to the latter point, (the culture of oppression has historically evolved) and P3's narration, I was interested to note that, In 1859, Dr. James McCune Smith, the first university trained professor in the United States, challenged the prevailing view - one upheld most strenuously by supporters of slavery-that the poorer health status among blacks reflected their innate inferiority.... Smith argued that apparently intrinsic traits could be the consequence not of innate factors but of environments that were socially created and inherited from one generation to the next. To prove his point, he compared the prevalence of bone deformities from rickets.. .among children in both black families and poor white families. Finding the rates to be nearly equal, Smith concluded that rickets was more prevalent among black families not because they were biologically "black" but because they were poor and they were poor because they lived in a society that either condemned blacks to slavery in the South or to a marginal Concept of Culture 111 existence as the most poorly paid workers in the North (Krieger, et al., 1993, pp, 84-85). Reflecting on Smith's work as cited by Kriger et al., (1993), I take particular note o f the notion that "intrinsic traits could be the consequence not of innate factors but of environments that were socially created and inherited from one generation to the next." This notion links in with P3's explication that the culture of oppression has evolved historically. In continuing the discourse on the culture of oppression, P3 talks about a cycle o f oppression. To explicate, .. .you say wel l this isn't healthy for you to have ten kids because it keeps you in a cycle of poverty, you could explain to the .. .lady, but as far as she is concerned this is what she does, and that feeds into the oppressor saying well , they are really irresponsible people they just, and so it continues.. ..they are oppressed being irresponsible, they feel that they are irresponsible, they therefore do the irresponsible thing and that further oppressors them as being irresponsible, and so this culture of oppression continues by the oppressor and the oppressed. Reflecting on P3's narration on the culture of oppression, reference is made to colonialism. In continued discourse, P3 talks about collective responsibility, and reveals that, Collective responsibility spins off from the whole idea o f oppression, in that.. .from a very religious perspective, the sins of one generation follow each other, and that is tied in with oppression, because this cycle o f oppression continues and you develop a pattern that feeds itself. To break such a pattern for instance of oppression, you certainly need the oppressor who is having the better of both, of all worlds of course to admit at some point that they were oppressors and walk with the oppressed together to try and break this cycle, but again what I, what sort of responsibilities that people don't want to claim the responsibility of being the oppressor, such as well slavery happens. Concept of Culture 112 To break such a pattern of oppression requires that the oppressor admit at some point that they are the oppressors and walk with the oppressed to break the cycle. However, P3 expresses that, A s with most things no one wishes to think that their possible acts of mercy are perpetuating or at the very lest contributing to the status quo o f western oppression that has been inflicted on the rest of the world since the days of Christopher Columbus. In those days rather than saying that the west came to oppress, they said they came to spread the gospel and save the souls of the infidels. O f course, that meant slavery, changing one's diet, dress, to conform to the European concepts and standards. Naturally, also there was the blatant exploitation of land and resources to Europe as payment in exchange for this great gift o f religion and so called civilisation. The only difference with what was done before and now.. .is that the rationales for the interference has changed but the effect is still the same. Instead of saying that, the west is bringing religion or civilisation to justify oppression, now they bring technology or medicines to improve the lot of disadvantaged. The question is what happens as a result of this new form o f justification, oppression. In short, western, technology/medication so changes the lives and systems of the less developed countries that they become dependent on technology and expertise that their developing economies cannot afford. This leads to a form of indenture to the west once again as valuable natural resources are bartered away for a little or nothing in exchange for the trinkets of medicine and computers that are offered. In talking about oppression and "exploitation", P2 resonates P3 and talks about the power of the western culture, P2: any part of the developing world that is getting paid twenty cents a day to manufacture running shoes that we sell here for a hundred and fifty dollars.... I could go on. . . . I . . . feel that sometimes I've been saddened where I've gone to places where I felt that spirituality and family and all those things are really important, and notice the power of western culture and certain parts of the world. . . . Y o u know when you are in a rural village and you see like billboards of coca-cola everywhere it is like, Oh my god, it's encroaching even here. Y o u know what I mean, like, and seeing, when you go to places like B a l i that are totally destroyed now, there like, it's like going to Fort Lauderdale, and it's like all of a sudden you see how, there is some sort of pull . A n d I don't know whether it's just the way we are as human Concept of Culture 113 beings, I am not really sure. But, there is some real need, it makes me sad, when I see people on the street that are willing to give away, give me their child so that they have the Birkenstocks (sandals) that I had on my feet. Through my cultural lens and through the voices of the participants, I have painted the theoretical and political nature of the construct of culture inseparable from systems of injustice. In the context of the discourse on culture, students talked about oppression. I extrapolated that the 'culture of oppression' evolved historically with simultaneous intrinsic traits -consequences resulting from the environment (supported by difference within political and social systems) that were socially constructed, and passed on from one generation to another. When thinking about oppression, students indicated a circular relationship between the oppressed and oppressor, as seen for example in P3's narration of poverty. To interpret the conglomerate of the culture of oppression, P3 suggests that, as we collide with others.. .as rationale beings and for the best we need to negotiate a modus operandi... Nursing Experiences The participants' experiences as nurses were another place where they learned about the concept of culture. In the reconstructing of meanings in the horizon analysis, two major themes came to the foreground: confronting values, beliefs, assumptions, bias, and the power of language. Students believed that conceptualisations of culture influence their values and beliefs, and their values and beliefs in turn shape how they see culture. They also argued that individuals' experiences are shaped by the institutions within Concept of Culture 114 which they function and identified some of the injustices that can and do occur within the health care context. In the context of talking about the concept of culture students reflected on their experiences in nursing. P2 expressed that, When you are in that position as a nurse, what you do for them (patients), they are entirely, pretty much at your mercy... . Y o u have to be sensitive and you have to be aware of what is going on around you. . . P I echoes P2 in saying that it is, Important to be aware of yourself and the people around you and what is going on.. .(with regards to).. .pre-conceived ideas, notions, interpretations, traditions, and beliefs. Confronting Values. Beliefs, Assumptions and Bias When talking about being aware of "what is going on" and conversing about culture, P6 suggests that, my (understanding of the) concept of culture influences my values and beliefs, other things shape my values and beliefs.. ..and leads to particular ways of interacting with .. .clients. P6 also suggests that, Ideas around values and beliefs are important to understanding the concept of culture.... (it is) . . . important.. ..(for me) to remain aware o f my beliefs, value and assumptions.. .so that I don't impose those on someone who may have different values and beliefs... P5 echoes P6, .. .my values and beliefs influence my perception and the way in which I . . . conceptualise culture... P7 expresses, .. .the way I see culture influences my values and beliefs.. .1 think they influence each other.. values and beliefs are very much rooted in my experience.. .(and) I see culture as rooted in my experience... Concept of Culture 115 What I interpret from these excerpts from the transcripts of P5, P6, and P7 is that our conceptualisation of culture influences our values and beliefs, and our values and beliefs in turn shape how we see culture. This is true of both health care providers and recipients (Nardi & Rooda, 1996; Rooda & Gay, 1993; Wright, 1997). On a different note, P6 suggests that, Values come to you as a result of being part of a cultural group.. .you are stuck with those until you look at, until you can see them, and then you may be able to remove, maybe able to use them or not use them or shift or change them P6's thoughts resonates with that of Lynam (1992) who suggests that people's views are shaped in part by the groups of people with whom they interact. P4's narration suggests that individuals' experiences are also shaped by the institutions within which they function. In the context of reflecting on nursing experiences within an I C U , P4 talked about the contrasting views between nurses and patients relating to health care practices. P4 recounts, We have a really big Chinese Canadian population .. .things come to mind, such as different ways of healing.. .acupuncture, and a lot of the herbal medicines. They use in a very different way to the westernised approach that is generally acceptable to our hospitals, so they stand out for that reason. I can think of a young woman who had severe encephalitis. (She).. .had acupuncture performed on her while she was ventilated and.. .was anticipated to have a poor prognosis. She stands out in my mind because she did well . The family was very rigid in their practices and one of the reasons that I remember that case is because people did not laugh in an unkind way but she was certainly visible. In reflecting on the nurses' attitudes at the time P4 comments that some of her, colleagues felt very strongly that it was a total waste of time, some of them more than that.. .just felt it was ridiculous to think that anything Concept of Culture 116 could be superior to what we (were) doing for her, which ironically was very little.. . . Certainly, in I C U . . .a lot of people have a fairly superior attitude when different types of approaches are brought in. In relation to seeing or confronting one's bias, P2 argues that, .. .it's really a big task.. .confronting your own biases, your own culture.. .like i f you have been raised to believe that certain groups of people are this or that, I mean that's a quite a painful experience to look at your self in the mirror and go.. .1 am racist, and this is affecting the way I care for people.... Nobody likes to look at their.. .emotional baggage or biases unless they are forced to do so.. .because it is not an easy thing to do In relation to providing care, PI claims that, .. .quality of care can be, sacrificed immensely i f you let certain ideas or preconceived notions get in the way of caring.... (Therefore you).. .need to .. .delve into the things that you are finding uncomfortable Reflecting on the theoretical literature, Campinha-Bacote (1995), Ginger and Davidzar (1991), Leininger (1988), Lynam (1992) and exhort nurses to recognise their own cultural biases, seek out their clients' cultural perspectives and provide culturally congruent care. Anderson (1990) offers a negotiation model by which nurses can determine different cultural perspectives on health and illness held by clients and adjust the care so that it is culturally acceptable to the patients and their families. Continuing the discourse on culture, in relation to talking about interactions with people, this might reflect how the concept is drawn upon in providing care to patients. P6 expressed the view that, Understanding of culture doesn't necessarily help me, like thinking in terms of culture doesn't help me in particular interactions with people.. .1 am going to respect each individual person for who they (are).. ..respecting individuality I think is . . .important.. .respecting Concept of Culture 117 values and beliefs that arise from a particular culture that are different than mine. P4 echoes P6, I think to believe that you could truly understand a lot of other cultures is not necessarily possible, I am not even sure that it needs to be, but I think i f you can have respect for somebody else's belief system whether or not you share it or understand it, basically professionally guides your conduct. I learn from P I , P2, P4, and P6 that confronting bias, and respecting individuals and their values, beliefs, and practices is important for providing "quality care." Witnessing inequitable access to health care. Reflecting on the concept of culture students talked about equal access to the health care system. P3 says that, The health system involves the oppression of women, the aged, homosexuals, people of colour, the poor, the less educated, the less influential, and even the patient who it's (the health care system) meant to serve. In relation to talking about access to health care, PI expresses the view that, everyone who enters the health care system has an equal right to receive quality care.. .it just doesn't seem fair to me to have a middle class, English speaking Canadian, having excellent care and maybe immigrants or refugees coming in and either not receiving any care or receiving poor care... P3 echoes the perspective that access to health care is inequitable, Although systems may espouse equality, true equality is not achieved. A n example of this is the way the health system treats doctors and nurses differently when they are patients than it treats everyone else. The reality is that although health is supposed to be equal for all , the realities of health professionals having more knowledge creates (for) them a benefit as such (that) gives them an advantage, which no longer makes equality a reality. In conclusion, therefore although equality is a Concept of Culture 118 value that we all espouse, equity is the means by which this fairness can be achieved based on need and individual cultural experience. What I extrapolate from the students is that increasing costs, economic pressures, sexism, and racism deprive a large number of people from accessing health care, particularly those who represent a minority group. Managing moments of cultural differences. During the discourse on culture, students reflected on managing moments of cultural differences in interactions with people and interpretation of those differences. In relation to talking about difference, the following participants reflect on their nursing experiences. P6 articulates how a family's cultural background influenced their values and beliefs and affected their interaction with nurses: .. .their cultural background.. .lot of this w i l l just be my assumptions about them.. .that they were people who grew up in rural [name of city omitted], were a bit odd I think to start with, and became part o f a religious group that was very strict and dogmatic about little truth's of the bible. I mean they went so far as to name their kids, things l ike. . .actually this little girl's name was 'God's loving kindness'.. .the other children were named in equally what was, what seems to be absurd ways and then this girl was gravely i l l , she was with us, with a serious head injury and .. .the father would just, he would try to convert us as opposed to maybe really focussed on (the i l l child). A n d here is this girl who was.. .almost as i f they (were focussed) on whatever is out there and they couldn't even see what is happening in front of their own faces. On reflection, P6 comments that the other part that.. ."is important in this excerpt is the distress that this difference creates." Reflecting on an experience of managing difference, Participant 5 foregrounds her experience with an older gentleman, Here was an older gentleman who simply wanted to go home, and that's what he said to me, "I want to go home." Why I say he is an experience of someone who is from a different culture was that to me Concept of Culture 119 he was coming from a different place that I knew nothing about. I could not get a sense of who he was as a person, what he valued. He was from a different age; he is in a different age group than I am, so he comes with a whole history of experience and life that are different from mine. P I and P8 comment on the affect of their having a different skin colour, P I reflects on an experience: How threatening the simple pigment of the skin can be.. .someone does not connect with me as their child's nurse and I let myself assume, is it the colour of my skin P8: .. .1 know a lot of people would argue that I couldn't call myself an African for instance because I am Caucasian (white) and that you could only regard yourself as African i f you were native to the continent and had a black skin.-, .where as I would argue that anyone born and raised in Africa could consider themselves an African regardless of skin colour, beliefs, and religion.. . In reflecting on P I and P8's explication, I recall an excerpt from a book, Africana Womanism: Reclaiming Ourselves by Hudson-Weems, that eloquently describes the effect of a woman's experience of being different, Consider the experience of a woman who said that from so many feet away, her race was noticed; as she got into closer proximity, her class was detected; but that it was not until she got in the door that her sex was known (cited in Talor, 1998, p. 53) In terms o f providing care, P3 suggests that, .. . i f you wanted to for instance care for H I V infected people as a group in the downtown east side, you can't take just information about all H I V infected people, you have to take certain givens which certainly they share.... (for example), everybody has to go through the trauma of hearing about their infection. So how each individual related to that (news) is going to be different. But that experience is common to a l l . . . , so that defines their culture. Then when you want to look at it in that particular population, you need to start going, what does it mean that when you hear that news in the Lower East Side? (How does) it effects you? Some people it would effect them in terms o f . . .it is an automatic death sentence kind of thing. A n d you run away and hide - shame and Concept of Culture 120 whatever. Somebody on the lower east side w i l l say, wel l that's just the risk of l iving in this.. .you know needle, I V drug culture that I live in, and it's just one of the things we take and we live with it until it kil ls us... In terms of providing care I discern from P3's explication that although at the outset, the experiences of a group of people may appear similar, it is important to consider all experiences. Moreover, in considering those different experiences it is important to consider the interpretation of those experiences. Considering differences, however is not an easy task as P4 expressively portrays through the following narration of reflecting on a "difficult social situation" she was grappling with in her area of work at the time of this interview, .. .there is a little Native Indian boy, he is 20 months old. He was left unsupervised in his back garden.... (He) crawled into the next door garden and got mauled by a husky dog. He was eaten for about five minutes.. .the dog ate half his pancreas, part of his intestines, mauled his neck. A n d by the time the ambulance got there he was unconscious so he was resuscitated and had a series of strokes following that because o f damage to his carotids. (He) had a lot of abdominal surgery, horrific abdominal wounds. His parents have been previously flagged on their health chart because they have not been bringing him in for immunisations and follow-ups, and appeared to lack parenting skills in terms of understanding that at twenty months he didn't understand cause or effect. Once a week we have social rounds - a lot of the RN's on my unit feel very strongly that.. .him going back to his parents.. .to go back to the Native Indian community w i l l be a total disaster for him, because he's now got a left sided weakness, he's even less able than he ever was to look after himself. A n d the parents never demonstrated.. .from our perspective that they care or that their parenting skills are geared towards safety for a toddler. So, that's a struggle for us, and .. .yet when we discuss him in social rounds, the social work care said to us that we have to understand that "we can't find foster homes for all these children, especially in this area.. .you have to understand it is a different culture, it is a different life style." I remember being really upset about that, because although it's imposing my values, I wonder why (in this) health care system.. .we accept Concept of Culture 121 lower standards for some children than we do for others. Because I know i f that had been a Vancouver family that child would have been fostered, the parents would have had to probably get some counselling and, and some education in terms of how to look after their child, and yet for this family because of his culture, or perceived culture, and the community that he came from it is ok to send him back to his parents.. .and so culture aside that to me is offering a different standard of care to that child, and one that I don't find acceptable. A n d it's interesting because I consider myself to be a very open minded person, and respectful of other people's cultures. But this is the odd situation where I would probably say, I am sorry, cultures doesn't come in to it. This is a safety issue and this child deserves the same.. .degree of safety as other children. I know it is not that simple, but that's sort of been a.. .cultural conflict for me and one that I've given great deal of thought to. Because I also know the damage that can arise from being in a foster family .. .some foster families - foster for an income, versus a real love for children, and certainly some of the foster homes are terrible. Some have been sexually abused or physically abused in foster homes, or just ignored or neglected It's like a zoo out there, you have to be very careful, and there is a real attempt to foster children into a culturally similar home. So we wouldn't take that little boy and put him in a Mexican home for instance.. .we would always try to find a native family for him. The community they (the family) live in is a very poor community, and there is a definite lack of ideal foster parents, so it's riddled with problems, and yet for me I wonder, and I struggle with whether or not the benefit o f maintaining someone's cultural identity outweighs the benefit o f bringing them up in a safe environment.. .it's difficult. In the process of deconstructing P4's narration above and P6's story of the child named "God's loving kindness" the implicit principle of cultural relativism comes to mind. Cultural relativism "refers to the perspective that the behaviours of individuals should be judged only in the context o f their own cultural system. Its proponents argue that it buffers against parochialism, encourages openness to others, and results in flexibility when cultural differences occur" (Baker, 1997, p. 3). In relation to P4's and P6's stories, it could be argued that a relativist approach might cause more harm than good, Concept of Culture 122 because such an approach would undermine issues related to the safety, for example, of the little boy in P4's narration. Critics have called, and I concur that cultural relativism is a "nihilistic doctrine that undermines any condemnation for the violation of human rights or of repression in culture's other than one's own" (Baker, p. 3). The Power of Language Reflecting on the dialogue on culture, students talked about the power of language and communication. I reflect on P5's explication, .. .language is very powerful, in contributing and creating the culture, which is why here in Canada, the French Canadians.. .would very much like to protect their language, because without their language the culture is at risk, .. .and I suppose it makes sense because the way in which we articulate something through language does in many ways direct our experience of the world. P5's reflection mirrors Ha l l (1997) who wrote that "language is one of the vehicles through which thoughts, ideas and feelings are represented in a culture (p. 1).... Languages carry meaning because they operate as symbols, which stand for or represent the meanings we wish to communicate" (p. 5). P5 continues her dialogue, .. .the whole question of globalisation, where the threat to various languages is very real, and now i f the information highway and people on the internet, in villages like in M a l i , Western Africa, you can go to this land locked dessert country, and find e-mail cafe's.. ..and most of this is happening in English. What w i l l that do to our notion o f what is culture? When languages become very threatened or the dominance or particular imagery and symbols become very prominent.... So, when you go anywhere in the world almost, you w i l l find people w i l l recognise what a coca-cola sign is, what does that symbol mean? What is the impact on the experience of culture for people? I fear that a lot of the uniqueness of a group or culture may be lost with the dominance... Concept of Culture 123 In the context of nursing and the provision of care, P3 expresses the view that, The power of language is important and as such nurses should be instructed to choose words with care.... Nurses need to appreciate that with the right phrase or word one can either engage a patient or shut them down completely. The trick o f course to find that right phrase given the fact that different words carry different meanings for different people based on their own experiences. Language barriers. P4 articulates, .. .when people say culture to me, and I link it to work, one of the first things that come to mind is language barrier.. ..and I don't mean verbal language, every language, the body language, which I think.. .often western nurses interpret.. .(and) misread. Because of language barriers, students expressed an inability to assess patients' level of understanding, although at times interpreters were used (not professional interpreters, but family and friends) P I : I never really knew how she was feeling, or how she was doing, or i f she was comfortable, or i f there was more we could do.. .because interpretation was through the daughter.... P2:1 was really worried as to what their level of understanding was, because I felt that in order to make things easier, they would go ok, when maybe they didn't really understand. P7: .. .a terminally i l l gentleman, who wasn't that old . . .he was from one of the Eastern European countries, and he was an immigrant to Canada. He didn't speak very much English, and every time when we went i n . . . i f we had to ask him (a) question, and really try to understand something, we had to ask one of his friends to come and interpret for us... P I provides a powerful narration of a woman's childbearing experience, incorporating some of the issues this woman faced because she did not speak "English." Concept of Culture 124 .. .In a maternity cl inic . . .1 had the opportunity to be a "hand, arm, and shoulder grip" of a 29 year old Vietnamese woman. She spoke very little English. .. .Despite our language barrier she would grab my hand and reach for me in her pain, fear, and frustration o f labour. I tried to picture myself in Vietnam with my husband - having my first child, surrounded by Vietnamese women and possibly men unable to speak or understand the language. The young woman began to push, guided by grunts and encouragement's from the obstetrician and the nurses on duty. She followed their English commands superbly. She was progressing with each push. Despite this progression, the obstetrician became impatient. He groped her protruding belly; he placed his fingers and hands painfully inside the woman for what reason I can still not determine. He ordered delivery by vacuum. When there seemed to be no stress for mom or baby, he performed an episiotomy when the woman's perineum had barely begun to stretch. Finally a beautiful baby was born. The physician, two minutes later began a manual removal of the placenta. The woman was squeezing my hand so hard she could have left permanent fingerprints. The physician continued, and piece by piece brought out torn placental tissue. Finally in five - ten minutes all was over. The placenta was extracted (and) examined carefully. I left this woman extremely exhausted and extremely angered. When I questioned the R N she explained to me that this is quite common for this physician. Especially when the patient is not English speaking and when there is a medical student who needs to see and perform procedures.... I f English is spoken (and the woman is able to understand,) to empower the woman with information, (she w i l l be able to) re-enforce her right to care as she sees fit. The non-English speaking woman patient however remains vulnerable and subject to poor quality treatment. Deconstructing P i ' s narration brings many issues resulting from the Vietnamese woman's inability to speak English to the foreground. For example, on a positive note, P I was able to provide some support. However, the woman's inability to speak English caused powerlessness, exploitation and put her at the receiving end of poor quality care. What I extrapolate from P i ' s narration leads me to reflect on the culture of silence among nurses when confronted with seeming injustices and inequality of care. Concept of Culture 125 From the transcripts of P I , P2, P4, P5, and P7 it can be argued that language has the power to organise, and regulate practices, influence our conduct and consequently have real, practical effects (Hall , 1997). Academic Experiences So how do formal academic experiences influence students' understanding of the concept of culture? The participant's had varying perspectives on this topic. Five themes emerged: the importance of learning about culture, what to learn about culture, ways of learning about culture, politics of learning about culture, and a time to learn. The Importance of Learning about Culture P I thinks that, .. .the whole idea of teaching 'culture' to nursing students is very important. A s P4 reflects, .. . i f you think (of) what is happening in Canada, there are an increasing amount of immigrants.. .a lot of mix marriages happening.. .more than ever you just cant' put people in a box, you cannot make assumptions based on what people look like or the language they use.... There is so much misunderstanding out there, we are all brought up with our own prejudices and I think it's a wonderful opportunity to .. .get people reflecting on their practice and why they think the way they do. In addition, it is a wonderful opportunity for people to have open discussion.. .about their cultural experiences.. .and learn from them. Similarly, P6 articulates that it is, .. .important to learn about challenging ones assumptions about learning to learn from other people, and to be able to really come to an appreciation that there are many points of view.. .and to look at the consequences of how they are associated with various points o f view. Concept of Culture 126 Lynam (1992) advocates that nurses be aware of their own culture and belief system. Likewise, Meleis (1996) remarks that in providing care for people with a range of needs and expectations, it is important for health professionals to acknowledge and value diversity. I learn from P4, in the context o f her experience, that because students may have limited experiences talking and interacting with individuals from different ethnic and racial groups a lack of knowledge about any experience other than their own may become evident as dialogue takes place. Baldwin and Nelms (1993) posit that when students are introduced to different perspectives, as can happen in formal learning contexts, they begin to question old assumptions and ideologies. Consider P4's narration about the benefit o f attending a course on culture, .. .1 thought I used to do a good job (caring for people from a diverse culture), until I did a couple o f courses on culture, and went on to a conference on culture. I learned so much.. .it changed my approach (to care). I stopped putting people in boxes, which is what I did before, with the best intentions in the world. (Before the courses and conference) I literally went away and I read up on Chinese people,.. .Buddhism, S ikh . . . What We Need to Consider in Learning about Culture In the course of learning about culture, students expressed the need to be self aware and aware of the politics of culture. P7 expresses, .. .1 think culture itself is poli t ical . . . . Concepts like race and racism are embedded within this whole complex of culture. A t this juncture, when I introduce the term the politics of culture, I am thinking of the concepts of race, racism, in-equality, power, oppression, and Concept of Culture 127 exploitation, to name a few, as identified above and below by P I , P7 and P8 in the transcript segments. P I : .. .being aware of your own self and being aware o f what else exists as far as culture.. .power, and oppression.. .you know struggles that we all go through being from different culture.. .needs to be looked at... In addition, P7 says that, North American culture has a history.. .a history of exploitation. A n d the history is not only in the past but also in the present.. .1 think I would like students to see that they have a culture, but see how this culture (has) come about.... P6 brings a piquant perspective on what to consider when learning about culture. .. .1 believe there are many in-equalities in the world, and gender being a major one, but not the only one, and that there are structures in place that keep those in-equalities as they are, and that action is needed to change that.... So, certain concepts of culture can be very oppressive to a particular people, i f in this society a person who, who is poorly dressed and lives down in a particular area o f town, I mean that, there is a cultural group there that is just devalued.. .so that person has a right to have a voice as we l l . . . . (P6 speaks from her philosophical orientation).... Given a feminist worldview and a post structulist , perspective on reality, in interaction with any individual. . . . I am called onto .. .issues of power, of individuality, of diversity.... (for example), .. .a student who might be silenced or other'd because o f being put into a category such as... it is easy to use (an) ethnic example, I am trying to think of other ones, .. .such as particular religious groups l ike. . .she is a Jehovah's witness or what ever or they wouldn't be nurses.. .by putting them into the category you are not really saying anything about them as a person, but you are taking away from them opportunity and 5 0 P 6 explicates that.. ."when I talk about voice I mean.. .the person's voice opportunity or ability to act on their own behalf.. .1 do believe that feminism has a lot to do with.. .for instance women's voices, of a group of women, of women being oppressed and helping them to or from and creating conditions under which they can be heard and speak and change things on their behalf Concept of Culture 128 Deconstructing P6's explication, I learn that it is important to listen and hear each person's voice, as all the voices represent different perspectives. P8 notes that, because we need to be able to provide culturally appropriate care to clients whether the client is an individual, family, community, or nation.. .1 think .. .(we need to) talk about it and have discussion about it. . .provoke in students some consideration of the concept.. .1 don't think (however, that) we can teach every aspect of every culture but we can certainly (raise) awareness. P3 resonates with P8 in saying that, you are not going to be able to touch all aspects of culture.. . in terms of nursing.. .you would .. .highlight.. .those areas of culture.. .that appear to impact most on nursing practice, such as ethnicity.. .because we live in a multicultural (society). I f we lived in part of the world, and we are learning nursing.. .and there was no minority population.. .everyone is homogenous in terms of ethnicity, and then I wouldn't necessarily raise the ethnicity component. Y o u raise those areas that are going to impact people.... (For example)...ethnicity, sexism, gender; because.. .everywhere is going to (have) women and men issues.. .You need to bring in the whole concept of religion.. .1 am saying the elements.. .(you include in a course) are dependant on where you are and the nature o f nursing in that culture. Alternately, P3 suggests, .. .learning about culture by bringing home.. .the laws of culture: Culture is individualistic, it is never static, and you can never understand another person's culture.... I think that when (you) meet somebody (you need to understand) our worlds are coll iding. . .(you) need to negotiate.... Y o u spark somebody to engage in this analytical process, (and) you then taught them, what they need to know about culture.. .1 think the need for culture, in terms of teaching culture is just to expose, engage (people) in discussion, .. .(and) go through learning the art of negotiation In the context of learning about culture, I learned from the participants that it is important to self reflect and be aware of the 'political nature of the concept.' Ethnicity appears to continue to play a huge role in the implicit Concept of Culture 129 definition of culture. Participant six and I concur that "this speaks to the personal struggle the participants face, and the complexity of the concept of culture...." In addition, I acknowledge and re-affirm my notion that it is not possible to 'learn all there is to know.' I ascertain, however, that it is important to participate in discourses on culture to raise awareness of related issues and/or concepts. Ways of Learning about Culture Students talked about the ways of learning about culture. Because of the way in which P5 conceptualises culture, she says, I would want to do it through experiential learning and through reflection.. .have pre-readings that would relate to what the literature says about culture. Have a diversity of literature from various cultural backgrounds and /or, various writings from different parts of the world, and from different world-views and from (different) perspectives i f possible. A n d then so people w i l l come with some kind of understanding of the concepts of culture that have been put forth, and then in the actual class.. .reflect on them. The following student reflects P5's thoughts. Concerning reading, discussions and journalling as an exercise, P2 articulates, Y o u can learn.. .1 mean we can only look at text right.. .most o f us do not have the opportunity to live the experience.... Discussion is important.... Journaling as an exercise, I think is a wonderful thing to do.. .you can learn a lot that way, because all o f a sudden once the stuff is down on paper, "do I actually think that", it seems real.. .whereas i f it is in your head, and not transmitted into text it doesn't seem real P6 and P3 talk about another dimension to learning about culture. P6 suggests that, .. .there is opportunity for those discussions (discussion related to culture) in every interaction.. .particularly in clinical settings. Because (clinical settings are) so rich with interactions with actual people, are rich with differences. I guess that kind of thing you could never make Concept of Culture 13 0 up in a class-room setting that comes to life in a clinical setting and also the kinds of discussions you could have with particular students at particular times. In the course of learning P3 says that she, .. .1 think it would help by having.. .other people in from the profession that are working in various areas.. .various different cultures.. .(to) come in and relate their experiences. (For example), people working in rural lower economic status areas In a course targeted at developing cultural awareness and cultural sensitivity in students related to the values, beliefs and behaviours of others, Lockhart and Resick (1997) allude to the fact that they build in learning opportunities for students within the local community. In addition, they invited guest speakers in health-related activities to share their perceptions and experiences. On reflection, there seems to be a tension sustained in the words of the students. On the one hand, there is an acknowledgement that each person has a culture (or more than one culture) and there is great value in exploring that and other values and beliefs related to culture. On the other hand, the tendency to speak in terms of the 'other' is rather consistent when the students talk about how they learn about culture. I came to understand, however, from the students that there are different ways of learning about culture. I ascertained that active student involvement in the learning process would help students adapt and react to similar experiences they w i l l encounter outside the classroom. Concept of Culture 131 Politics of Learning about Culture In discussing learning about culture, the politics of learning about culture came to the foreground. Within the horizon, students expressed the following concerns relating to saying what would be considered 'politically correct.' The conception of'political correctness' comes into effect in discussing sensitive issues and relationships with faculty and fellow students. P3: .. .1 feel due to political correctness no one wants to voice or take a position that may offend. Hence the lack of engagement. This facet of class dynamics I feel is very instructive to the issue of culture. Often issues are not raised (because of) an inherent oppression/power dynamic and the fact that no one wishes to either offend or upset the status quo.... (For example, in relation to talking about upsetting the status quo).. ..raw data would indicate that there are people.. .who are homophobic, yet in all the times gender issues and sexual orientation issues (are raised), no body says anything.. .nobody comes out because it is not politically correct.. .we all have to seem to be liberal and accepting and but deep inside it doesn't go anywhere, it is all veneer... P2 resonates with P3 and says that, people are afraid of backlash, i f you discuss culturally sensitive issues.. .because any time there is a power imbalance between students and faculty... For instance, P3: .. .when I open my mouth and put forward my views and that hits somebody else it, it impacts the relationship.. .cultures start to collide, because me the individual begins to collide with that faculty member or student and it creates a result.. .the faculty member either looks at you less favourably more favourably.. .and their response affects me. I realise that the moment that you open your mouth and begin to interact, collide, you are going to affect things P5 expresses that, .. .we can somehow be aware of why we do what we do, and to see on a systemic level, why we do what we do, which is so easy to say, and very difficult to do, and also very difficult when one is not in that Concept of Culture 132 dominant group. In addition, to be able to do anything about it, but also when one is in that dominant group to appreciate what one is doing is very difficult. A n d to be able to actually relinquish that position of power, (and) privilege is also perhaps extremely naive to think that anyone w i l l do it without it being necessary. De-constructing P2, P3, and P5's explications I refer to Friere (1997) who suggests that learning begins with resolution of the teacher-student (and student-student - my emphasis) contradiction. This involves "really talking" to each other (Belenky, Clinchy, Goldberger, & Tarule, 1997). Real talk reaches deep into the experience of each person; it also draws on the analytical abilities of each. Real talk involves discourse and exploration, talking and careful listening, questions, argument, speculation and sharing. It involves creating an optimum setting so that emergent ideas can grow (Baldwin & Nelms, 1993). P I stresses the need for, Discussing about it (sensitive issues), and just providing a safe place for students to be able to say what they are really thinking, and what they (are) really sort of feeling about issues, even i f it is not politically correct To illustrate "real talking" I quote P3 hypothesising that, A s an instructor doing the course.. .(and discussing) sensitive issues.. .1 would state my opinion on like, I am racist, and explain what I mean.. .that we are all in some form or respect racist, we have prejudices and biases.. .so that people may feel that (it is) ok.. . i f I say something that may shock somebody. Y o u develop.. .an atmosphere where people feel a little bit more comfortable. They don't feel that i f they say something that isn't square on the points, .. .everybody w i l l agree with or not, or (consider) politically correct, they wouldn't be frowned on, and sometimes (wil l feel encouraged to) push the end a little bit . . . Concept of Culture 133 Reflecting on the politics of learning about culture, I extrapolate that students are conscious of saying what is considered politically correct, and the implications of refuting the need to be 'politically correct' and airing their view. In addition, I argue that, for discourse, students need a "safe environment." A Time to Learn I return to P7's explication that, .. .as cultural beings, we are participating in the making and re-making of culture, and as students.. .we should keep problematising it . . .we should not forget that it (culture) is in the process o f evolution.... She adds, I think that this is not about nursing. It is about the whole society, so people should not only learn about culture when they come into a nursing program, (but).. .start grappling with it as soon as they come into school. For nursing education P6 and P8 echo similar thoughts, P6: I'd say ideas related to culture need to be woven throughout the curriculum.. .1 think that looking at issues about culture provides a way for students to examine their own perspective, world views. P8:1 do not think you can take culture and isolate it into a single course and hope that students w i l l carry that through to practice. I think that this is a thread that needs to run throughout a curriculum and one needs to have re-occurring conversations. I learn from the students that learning about culture is a continuous and evolutionary process. Isomorphic Relations Searching for isomorphic relations is a process of finding relationships among the themes, of generating understanding at a higher level of Concept of Culture 134 abstraction. In order to create these isomorphic relations, I began by reflecting on the research questions of this study. To recapitulate, I sought to explore: nursing students understanding of the concept of culture, how they learn about the concept of culture, and how they apply what they have learned in providing care to a culturally diverse population. The isomorphic relations that emerge from this research project are built within three broad categories: understanding culture, learning about the concept of culture, and applying what is learned in providing care. Understanding Culture Two significant isomorphic relations emerge within my interpretation of the students understanding of the concept of culture. The first has to do with the complexity of the concept of culture. Students' understanding of the concept resonates with that of Al l en (1990), when he says that, "culture is not a theory neutral descriptor, but a theory laden construct inseparable from social injustice" (p. 95). The second isomorphic relationship has to do with the fluid and dynamic nature of these students' understanding of culture. The paradigms of culture held by the students are amoebic in nature and continuously evolving. For example, as expressed by P3: Today I am here discussing culture, going through my ideas having this interview with you. In that way I rather refine, I think, I am building on my own concepts. I may get a new idea, and therefore, when I leave this room, my concept of culture w i l l not be the.. .same, or even i f I hold the same.. .1 think maybe more firmly entrenched. In other words, nothing stays the same. Concept of Culture 13 5 It became clear to me that learning about culture does not occur in isolation (for example, at any one particular moment or period o f time), but is a process that is threaded and evolves through personal life experiences, nursing experiences, and academic experiences (see Figure 4). Learning occurs, as P7 expresses, through continuous "problematising," and as A l l en (1990) articulates through "discursive acts" that arise from different perspectives influenced by matrixes of historical, political, socio-cultural and economic contexts. Students believed that their life experiences influence how they interpret the world and those interpretations affect how they interact with people. In addition, given that each person's experiences are different the need to create a forum to entertain discourse about the multiple representations of realities was recognised as being important because discourse gives meaning to the interpretations. In understanding culture, students mirrored what I learned from the literature review for this study, that culture includes metaphoric circles of interrelationship of beliefs, values, behaviours and social contexts. Students believe that while there is a sense of a shared culture, culture is also individualistic. Furthermore, they argued that to think of culture only in terms of 'shared' would result in loosing the individual in the maze of 'culture' (my words). On reflection on what I learned from the students I posit the following rhetorical questions for contemplation. Why is culture discussed in the literature primarily in terms of shared values and beliefs, or essentialised Concept of Culture 136 according to, for example, an individual or groups' ethnic background? Is this the hegemonic dimension to thinking about culture? In talking about culture as shared, are we underscoring the value of the individual? Are we denying or marginalising cultures other than those of the dominant group and thus affecting their subjectivity and identity? Students' understanding of the concept was not isolated from political and social injustices that have occurred historically and continue today. When talking about culture students portrayed their awareness of cultural groupings and social divisions, and injustices resulting from these groupings and divisions. Students expressed that at times groupings or social divisions are helpful. However, it is important that we examine the motivations and purpose behind those groupings, and for what purpose, as in "who benefits?" In the context of talking about the political side of culture, students entertained discourses on oppression and exploitation, specifically the historical evolution of oppression and the cycle of oppression between the oppressor and the oppressed. I learned from the students that what is required of the oppressor and the oppressed is for them to negotiate a "modus operandi" and walk together to break the cycle. Learning About the Concept of Culture I extrapolated from the reconstructed meanings that students learned about culture through reflecting on their personal life experiences, academic experiences and nursing experiences. What students learn is not isolated from Concept of Culture 137 their way of being in the world, where they are from, the experiences they have encountered and the interpretation of those experiences. Reflecting on learning, especially through their academic experiences, students contemplated, as I have mentioned, the why, what, how and when of learning about culture. What I learn from the students is that we need to "participate" in the "making and re-making" of culture, and it is a process of evolution. In learning about culture, apart from discourses involving all voices on the political nature of culture, the students fore-grounded the politics of learning about culture. They talked about the power hierarchy and relationships between faculty and students and between student and student when discussing what may and/or may not be considered politically correct, and the repercussions of not tempering a point of view. I w i l l discuss the implications for nursing education in Chapter 5. How Students Apply What is Learned in Providing Care Given that learning about culture is an evolving process how students react or provide care to a culturally diverse population also evolves. Reflecting on P4's learning about culture, before taking a course or attending a conference, "with the best of intentions" she read about different ethnic and religious groups and used to "box people." However, in the process of learning about culture, she has now learned the in-appropriateness of putting people into boxes. Students revealed that their understanding of culture influences their values and beliefs which are rooted in their experiences, and in turn the Concept of Culture 138 experiences influence their values and beliefs, which in turn then influences their understanding of culture. In this process of understanding culture, students also identified the importance of reflecting and recognising their bias and negotiating to understand the clients' perspective. Moreover, they reflected on the distress and injustice that can result from not examining ones bias and cultural perspective and/or that of the patients' cultural perspective and the inequity caused by inaccessibility to a vehicle for communication. In reflecting on P4's and P6's stories of their experiences o f providing care for children, it could be argued that the values, beliefs and behaviours o f the parents of these children are oppressive and violate their children's rights. However, on reflection, by laying weight in my interpretations am I oppressing the parents' rights by imposing my values and beliefs about what is right or wrong? Reflecting on P4 and P6's narratives, I posit the following rhetorical questions: Should nurses put aside their values, avoid cultural imposition and provide culturally congruent responses in all situations or only in some? If only in some, how w i l l nurses decide? From the students I came to understand the complexity of grappling with cultural differences, managing moments of difference and the interpretation of those differences and the need to go beyond 'culture' and consider, for example, ethical or human rights issues. Summary In this chapter themes and sub-themes that emerged from analysis of the data have been presented and discussed in ways that reflected students' Concept of Culture 13 9 conceptualisations of culture. Although I presented the reconstructed meanings within the three contexts o f personal life experiences, academic experiences, and nursing experiences, the boundaries between these contexts are not fixed and the processes of learning about culture are threaded through each of the three contexts. Isomorphic relations created to present the reconstructed meanings at a greater level of abstraction are presented. The implications for of the reconstructed meanings for nursing are discussed in the following chapter, following a summary of the study and its conclusions. Concept of Culture 140 CHAPTER 5 Summary, Conclusions, and Implications for Nursing Summary of the Study How nurses think about culture has profound implications for the care that they provide to clients. Canada's current demographic profile indicates a society that is ethnically and culturally plural. Therefore, nurses are continually confronted with issues related to culture. In reviewing the literature for this study, it became evident that culture plays a role in how individuals define and seek to attain health. It is argued that health care that is not culturally responsive is likely to be ineffective, and that nurses who are not sensitive to cultural issues provide less than optimal care. Numerous authors have developed models and frameworks to enable health care professionals to meet the range of needs and expectations of a diverse population. On the one hand, some models and frameworks (Campinna-Bacote, 1995; Chrisman, 1991; Leininger, 1988) are incongruent with a non-essentialised, pluralistic perspective on culture. On the other hand, from a critical perspective, other theorists and researchers (Allen, 1990; Anderson, 1990; Anderson, Blue, & Lau, 1991; Kleinman, 1978) advocate the provision of culturally competent care through a process of discourse and negotiation that takes into account the wider socio-cultural, political, and economic contexts in which nurse-client interactions take place. Rather than focusing on the socio-cultural, political, and economic contexts in which nurse-client interactions take place, most theoretical and Concept of Culture 141 empirical knowledge related to culture and health has tended to focus on the difficulty nurses' experience in providing care or the clients' perspective of health and illness. I submit that many authors, when discussing 'cultural groups or cultural differences,' refer primarily to race, nationality, or ethnicity, and omit discussion on age, gender, class, and religion. From the literature review conducted for this study, it is evident that nurses are encouraged to incorporate a balance between ethno-specific knowledge, and general cultural concepts into their practice. However, literature that identified nurses' awareness of that knowledge and how understanding culture might occur could not be located. From a critical perspective, culture is a theory-laden construct inseparable from social injustice (Allen, 1990) and, as such, culture cannot be examined, explored, or understood outside historical, socio-cultural, political, and economic contexts, or extricated from power structures and discourse. Thus, structures and discourse affect conceptualisations of culture and become interwoven and embedded in the responses of individuals to their experiences of health and illness. This critical perspective informed the formulation of my research questions and the processes of my data collection, analysis, and interpretation. The purpose of this study was to explore nursing students' understanding of the concept of culture. The following research questions were raised as a result of the literature review and guided me in this study: (a) how do nursing students understand the concept of culture, (b) how do nursing Concept of Culture 142 students learn about the concept of culture, and (c) how do nursing students apply what they learn in providing care to a culturally diverse population. B y eliciting the experiences of students, I obtained a comprehensive and valid account of students' understanding of the concept of culture and their perceptions of learning about the concept of culture. A s a neophyte researcher, I referred to critical ethnography as used by Carspecken (1996), and narrative analytical techniques as used by Lincoln and Guba (1985), to guide me in reconstructing meanings. In this study, critical ethnography guided me to assist the participants to uncover and reflect upon their conceptualisation of culture and to examine the consequences of their relationships with clients, to learn about the context in which their ideas about culture are formed and challenged, and to bring that interpretation to the practice of nursing education. Eight nursing students within the 2 3 - 4 1 age group, from diverse cultural and educational backgrounds and with clinical experiences o f varying length, participated in this study. A l l were students in the undergraduate and graduate nursing programs of a School of Nursing at a major Canadian university. The voluntary nature of participation was emphasised. Over a one-month period data was collected by reviewing reflective journals kept by two nursing students, and conducting in-depth interviews, for approximately one-and-a-half hours using open-ended questions, which were audio-taped and transcribed verbatim. Five participants were interviewed twice, and three participants were interviewed once due to the students' busy schedules and the Concept of Culture 143 time constraints of the study. The interviews were conducted in a comfortable place and at a time mutually agreeable to the participants and myself. In addition, socio-demographic data was gathered from all participants. Data collection and analyses were done concurrently. Narrative analytical techniques were employed in the analysis of the data (Carspecken, 1996; Lincoln & Guba, 1985). A s I analysed the data, I attended to issues of credibility, fittingness, auditability, and confirmability as recommended by Carspecken and Sandelowski (1986, 1993). Although the aforementioned research questions guided this study, the reconstructed meanings suggested that participants did not treat these questions as discrete. Because of how they conceptualised culture, these three questions could not be neatly teased apart. Students spoke about 'culture' in terms of evolving processes of learning. The Processes of Learning about Culture The processes of learning about culture emerged as the hinge that holds together learning about culture from three contexts: personal life experiences, nursing experiences, and academic experience. Although organised and presented within three contexts, the boundaries within the three contexts are not fixed and the processes of learning about culture are evolving and threaded through each of the three contexts. Personal Life Experiences Three major themes that emerged from the students' discourse on learning about culture from their personal life experiences were: seeing the Concept of Culture 144 world, tensions between what is shared and what is different, and the quagmire of understanding culture. Students talked about the ways in which they perceive the world and their interpretation of what they see, and argued that there are multiple ways of seeing and interpreting the world. The need to undertake discourse about what is shared and what is different emerged as an important theme because dialogue on tensions between what is shared and different brings to the foreground meanings of cultural experiences. Reflecting on tensions between what is shared and what is different, students talked about falling in common with others. They described values and beliefs that they may share with others and how these values and behaviours shaped the way they are in the world. In addition to 'falling in common with others', 'understanding others' emerged as another sub-theme and students wondered about whether there was a way of understanding others i f everyone is different. The notion that culture is shared and individualistic emerged as the final sub-theme when students reflected on and discussed the tensions between what is shared and what is different. Students talked about the quagmire of understanding culture, which I argue is valuable to note as it suggests that students believed that understanding of culture cannot be thought of in isolation from socio-political contexts. Culture was viewed by students as theory laden and contextually inseparable from systems of injustice. Two sub-themes came forth during the discourse on the quagmire of understanding culture: cultural grouping and social division, and the culture of Concept of Culture 145 oppression and exploitation. Students argued that societies contain divisions, that people are grouped according to various characteristics, and that such groupings have negative and positive consequences. They submitted that what was important was to determine the consequences of particular groupings. Students presented the view that the 'culture of oppression' has historically evolved with simultaneous intrinsic traits. These traits are viewed as consequences resulting from the cultural environment (supported by differences within political and social systems) that were socially constructed and passed on from one generation to another. When speaking of oppression, students indicated a circular relationship between the oppressed and oppressor and advocated the need to negotiate to break the cycle of oppression. Nursing Experiences The participants' experiences as nursing students and nurses were another way in which they learned about the concept of culture. Two major themes came to the foreground: confronting values, beliefs, assumptions, and bias and the power of language. Students believed that conceptualisations of culture influence their values and beliefs, and that, in turn, their beliefs and values shape how they see culture. They also argued that individuals' experiences are shaped by the institutions within which they function and identified some of the injustices that can and do occur within the health care context. Witnessing inequitable access to health care and managing moments of cultural difference emerged as the sub-themes of confronting values, beliefs, Concept of Culture 146 assumptions and bias. The participants in this study recognised that there is inequitable access to health care for under-privileged populations, with many of these populations representing 'different' cultural groups. Increasing costs, economic pressures, sexism, and racism were also seen as shaping accessibility to health care. During discourse on culture, students reflected on managing moments of cultural difference in interactions with people, the interpretation of those differences, and the distress those differences may cause. Students talked about the power of language and communication. Language barriers emerged as a sub-theme of the theme 'power of language'. Students talked about the inability to assess patients' level of understanding, although at times, interpreters were used, and the injustices and inequality of care received by patients who are unable to communicate in the dominant language. Academic Experiences Reflecting on their academic experiences participants had varying perspectives on the topic. Five themes emerged: the importance o f learning about culture, what to learn about culture, ways of learning about culture, politics of learning about culture, and a time to learn. Students presented the view that it was important to learn about culture because it was important to challenge assumptions, appreciate many points of view, and understand the consequences for the various points of view. Concept of Culture 147 Students' reflections on personal life experiences and the socio-cultural and political contexts in which these experiences occur suggested that learning about culture cannot be thought of in isolation from personal life experiences. Students stressed the need for a forum to be created to facilitate discourse on the multiple ways of seeing the world. Reflection on personal experience, the context in which this experience occurred, and exploring the assumptions underlying their beliefs about culture are steps in this discourse. Exposure to multiple perspectives on culture and the implications of assuming particular perspectives was considered essential to the development of an understanding of culture that is complex, multifaceted, and dynamic. Students expressed the view that not all aspects of culture can be touched upon, but that it is important to have awareness o f the different issues. They talked about learning about culture by bringing home "the laws of culture." According to one student, culture is individualistic, is never static, and one can never understand another person's culture. This seemed to be the quagmire of understanding culture. While many of these ideas seem contradictory and irreconcilable, they illustrate the point that we must not reduce culture to an essentialised, mechanical understanding. In reflecting on the processes of learning, students talked about the politics of learning about culture. They expressed the need to be self aware and aware of the politics of culture. In talking about the politics of culture, students included the concepts of race, racism, inequality, power, oppression and exploitation. In this context, students expressed concerns about speaking Concept of Culture 148 of culture in a 'politically correct' manner. Students suggested that the concept of 'political correctness' came into effect in discussing sensitive issues including relationships with faculty and fellow students. The students who participated in the study had been introduced to the concept of culture and related concepts and issues in a particular class or in their experience as students. When discussing ways of learning about culture students suggested experiential learning, reflection, reading materials, clinical and community experiences, and guest lecturers. Most students believed that learning about culture is an evolving process and should be threaded throughout the curriculum; and not isolated into a single course. This integration would need to be addressed by faculty at a curriculum level. Conclusions This study examined nursing students' conceptualisations of culture, the ways in which they learned about culture and their experiences of culture in nursing practice. Four conclusions can be drawn from this study: 1. The first is that students' hold diverse perspectives on the concept of culture. A t the same time, it is also crucial to value and respect the perspectives o f others and recognise the implications of particular ideological stances toward the concept of culture. 2. The second is that the process of learning and understanding about culture involves giving voice to multiple representations of realities, and Concept of Culture 149 cannot be isolated from socio-cultural, historical, economic, and political contexts. 3. The third is that inequalities and oppression that result from particular perspectives on culture can only be overcome when nursing students and nurses engage in a continuous discourse and problematise culture and bring critical perspectives to the processes of learning about culture. In addition, learning about culture must be ongoing and must be drawn from academic, personal and nursing experiences. 4. The fourth and final conclusion is that there is a dialectic relationship between culture and life experiences. This research indicates that the perception of culture influences values and beliefs, and these values and beliefs are rooted in life experiences, whether they be of a personal, academic, or nursing nature. Implications for Nursing Culture viewed as a complex, multifaceted, and dynamic concept has implications for nursing practice, education and research. Nursing Practice: There are implications of the results of this research for nursing practice on two levels: within particular nurse-client relationships and in the social and political structuring of health care. Within particular nurse-client relationships, nurses' and clients' understanding about culture, whether examined or unexamined, shape and constrain the interaction. The implications for nursing practice are for nurses Concept of Culture 150 and/or nursing students to be self-reflexive and confront their values, beliefs, assumptions, and bias in order that they may provide culturally competent care. Given that each person's experience and perspective is different, the implications for nursing practice is that nurses must endeavour to negotiate and re-negotiate culturally appropriate caring practice by engaging in discourse and reflexivity. From this stance, a new question arises: H o w do we create the conditions in which nurses can engage in this kind of activity, where discourse and reflexivity are valued? Nurses must critically examine the diversity in experiences o f clients in the health care system in terms of structural, political, and social differences and the ways in which embedded cultural values and beliefs shape those experiences of health and illness. For example, educated middle-class women and uneducated low-income women within the same country may confront substantively different issues in spite of sharing a similar culture (Anderson, Blue & Lau, 1991). A fundamental problem to consider is how certain populations become disenfranchised and marginalised through stereotyping, which may lead to decreasing a client's chances of obtaining equitable care. In providing culturally competent care, nurses must take into account the historical, socio-cultural, political, and economic contexts of the nurse-client interaction. Concept of Culture 151 Nursing Education: The findings of this research project have implications for the process of nursing education. The findings suggest that consideration for teaching and learning about culture must be woven through all layers of the curriculum. This has implications for all venues in which formal nursing education takes place. This study raises two crucial considerations for the delivery o f nursing education. First, a critical examination of the concept of culture must occur. This must begin as teachers explore their own beliefs about culture and the ways that these beliefs translate into the curriculum philosophy. This exploration is essential in determining whether critical exploration of the concept of culture is valued in the nursing program. The second crucial consideration related to nursing education is the importance o f providing opportunities for students to engage in discourse and a process that synthesises academic, nursing, and life experiences. Exposure to multiple perspectives on culture and the implications of assuming particular perspectives is essential to the development of an understanding of culture that is complex, multifaceted, and dynamic. The implications for nursing education, as Friere (1997) suggests, begin with strengthening of the teacher-student and/or student-student relationship through discourse, exploration, sharing of views, and the creation of an optimal setting conducive to the growth of emergent ideas. Teaching and learning about culture involves providing a forum for discourse threaded Concept of Culture 152 through the curriculum at undergraduate and graduate levels, as the concept of culture requires continuous problematising. This research does not suggest a mechanistic approach to teaching and learning about culture, but has implications for nursing education as it, (a) illuminates the complexity of the notion of culture, and the importance of including it as a major concept in all forms of nursing education, and (b) suggests some approaches that may be useful in structuring a course related to culture (experiential learning, reflective journals, reading material on culture, related concepts, and issues with discussions to follow, clinical and community experiences, and invitations to guest speakers). Nursing Research There have been no research studies in nursing that have explored how nursing students or nurses understand the concept of culture, or how they learn about the concept of culture and how they apply what they learn in providing care for a culturally diverse population. The findings of this study suggest that this topic may be worthy of further research. In considering the findings of this study I wondered whether students who have had a course or been introduced to the concept o f culture may have different perspectives from students who have not had a course in culture. It would be interesting to conduct a comparative study to explore the possibility of differing perspectives, and to determine students' learning from academic experiences. Concept of Culture 153 Moreover, non-white and non-majority students' perspectives on culture may differ from that of majority students. In a similar vein, Paterson et al. (1996) reported a phenomenological study they conducted that looked at the lived experience of male nursing students as they learned to care. K e l l y et al. (1996) described a study conducted to identify male students' perceptions of the motivational factors, barriers, and frustrations encountered in becoming a nurse. Further research of non-white and other minority students' perspectives on culture could be useful to consider whether their positions as minority students have an affect on how they perceive culture. Another related area of research is the exploration of the relationship between nurses' concepts of culture and their nursing practice. Analysis of discourse with nurses in clinical practice could elucidate how nurses learn about the concept of culture and bring this learning to their practice. Furthermore, when patients are unable to communicate in the dominant language injustices and inequality of care may result. A question arises that could be considered for future research: How often do nurses keep silent when confronted with injustice and inequalities in care? Additionally premises underlying certain social values such as ageism, sexism, racism, and how these impact on students' and or nurses' perceptions of culture, learning about the concept of culture, and provision of care are also possible topics for nursing research. In conclusion, I have ended this chapter with the implications for nursing, education, and research in the anticipation that the reader w i l l take Concept of Culture 154 away the understanding that what I have discussed and presented in this thesis is evolving and requires ongoing problematising. Therefore, the findings of this research have not provided a mechanistic approach to teaching and learning but have illuminated the complexity of the notion of culture and the importance of including it as a major concept in all forms of nursing education. Concept of Culture 155 REFERENCES Aune, J. A . (1994). Rhetoric and marxism. Boulder: Oxford. Ahmad, W. I .U . (1993). 'Race' and health in contemporary Britain. 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Journal o f Advanced Nursing. 25, 199-203. James, B . , & Saville-Smith, K . (1994). Critical issues in New Zealand society: Gender, culture and power. (2 n ed.). Oxford: Oxford University Press. Jeffreys, M . R . , & O'Donnell , M . (1997). Cultural discovery: A n innovative philosophy for creative learning activities. Journal of Transcultural Nursing. 8(2). 17-22. Concept of Culture 160 Jordan, G . , & Weedon, C. (1995). Cultural politics: Class, gender, race and the postmodern world. Oxford: Blackwell . Ke l ly , N . R . , Shoemaker, M . , & Steele, T. (1996). The experience of being a male student nurse. Journal o f Nursing Education. 35(4). 170-174. Kleinman, A . (1978). International health care planning from an ethnomedical perspective: Critique and recommendations for change. Medical Anthropology. 2(4). 71-76. Kleinman, A . , Eisenberg, L . , & Good, B . (1978). Culture, illness, and care: Clinical lessons from anthropological and crosscultural research. Annals of Internal Medicine. 88. 251-258. Koggel, C M . (1998). Perspectives on equality: Constructing a relational theory. Lanham: Rowman & Littlefield Publishers, I N C . Krieger, N . , Rowley, D . L . , & Herman, A . A . (1993). Racism, Sexism, and Social Class: Implications for studies of health, disease and well-being. American Journal of Preventative Medicine. Supplement to 9(6). 82-122. Lea, A . (1994). Nursing in today's multicultural society: A transcultural perspective. Journal of Advanced Nursing. 6. 27-39. Leininger, M . (1978). Transcultural nursing. New York: Masson International Publishing. Leininger, L . (1988). Leininger's theory of nursing: Cultural care diversity and universality. Nursing Science Quarterly. 152-160. Leininger, M . (1991). Leininger's theory of nursing: Cultural care, diversity and universality. Nursing Science Quarterly. 1(4). 152-160. Leininger, M . (1994). 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Thousand Oaks, California: Sage. Shapiro, J.P., Sewell, T., & DuCette, J.P. (1995). Refraining diversity in education. Lancaster: Technomic. Shareski, D . (1992). Beyond boundaries: cross-cultural care. Nursing B C . 25. 10-12. Smith, J. (1989). The nature of social and educational inquiry: Empiricism versus interpretation. New Jersey: Ablex. Smith, B . , Coll ing, K . Elander, E . , and Latham, C. (1993). A model for multicultural curriculum development in baccalaureate nursing education. Journal of Nursing Education. 32(5). 205-208. Smith, S.E. (1997). Increasing transcultural awarenss: The McMaster-A g a K h a n - C I D A project workshop Model . Journal of Transcultural Nursing, 8(2), 23-31. Spector, R. (1991). Cultural diversity in health and illness. (3 r d ed). New York: Appleton-Century-Crofts. Spitzer, A . , Kesselring, A . , Ravid, C , Tamir, B . , Granot, M . , Noam, R. (1996). Learning about another culture: Project and curricular reflections. 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Cross-cultural caring: A handbook for health professionals in western Canada. Vancouver: U B C Press. Warren, K . , & Rheingold, A . (1993). Feminist pedagogy and experiential education: A critical look. The Journal of Experiential Education. 16(3), 25-31. Wilkins, H . (1993). Transcultural nursing: a selective review o f the literature, 1985-1991. Journal of Advanced Nursing. 18. 602-612. Wilson-Thomas, L . (1995). Applying critical theory in nursing education to bridge the gap between theory, research and practice. Journal of Advanced Nursing. 21. 568-575. Wright, J. (1991). Counselling at the cultural interface: is getting back to roots enough? Journal of Advanced Nursing. 16. 92-100. Concept of Culture 165 APPENDICES Appendix A Tentative Interview Guidelines I w i l l precede the interview with an introduction... Upon reflecting and reviewing a copious amount of literature relating to the concept culture, I have realised the complexity of the concept. I have also found from the literature that an individual's culture influences how illness events are perceived; and there is a need for nurses' to provide culturally sensitive care. In preparing nurses to provide culturally sensitive care, a range of approaches is addressed in the literature. However, a gap exists in the literature that is important to address. The gap relates first, to nursing students understanding of the concept of culture. Second, how they learn about the concept of culture. Third, how they apply what they have learned in working with clients. Because of my reading, I had a number of questions about nursing students understanding of the concept of culture of culture. I think the information that you share with me w i l l provide insight into how students' perceive their understanding of the concept of culture w i l l influence their values, beliefs and behaviours in providing nursing care for a culturally diverse population. Furthermore, provide direction for those planning, developing and revising nursing curricular in schools of nursing. I will begin the interview with the question51: I am interested in looking at how nursing students' understand the concept of culture. Can you think of a time that you cared for a person from a different culture.. .tell me about some of your clinical experiences...? I have prepared the following trigger questions, to which I will be able to refer if there is a need for a specific direction from me to facilitate the participant in providing information. Culture What do you understand about the concept of culture? What are some of the other concepts that inform your notion of culture? Carspecken, (1996) suggest that the "most effective way to use qualitative interviews with subjects is to get them to describe events they remember taking part in: to begin at a concrete level where a specific action situation is recalled and then to work toward articulations of interpretive schema that the subjects applies in many diverse situations" (p. 39). Concept of Culture 166 Why do you feel these concepts inform your understanding of the concept of culture? Does your understanding of the concept of culture influence your values and beliefs? How would you suggest that the concept of culture is generally viewed.. .is it the same or is it different from the way in which you understand the concept of culture? Nursing Practice If your understanding of the concept influences your values and beliefs, how do you perceive this w i l l influence your behaviour in providing care? In what way do you feel your values and beliefs w i l l influence how you may provide care.. .you may give me an example i f you wish? On reflection, what issues relating to culture do you perceive you may face in the clinical area? Nursing Education Do you think it is important to learn about the concept of culture.. .why do you think you need to learn about the concept of culture? I would like to know why you think it is important to include a course relating to the concept of culture in the nursing curricula. Given the complexity of the concept of culture, do you think it is possible to learn about the concept of culture? How would you suggest learning about the concept of culture? Would you feel comfortable in discussing sensitive issues related to culture with fellow students and faculty.. .what problems do you see arising? Concept of Culture 167 Appendix B Socio-Demographic Information (Confidential) Name Code . . . . Age Sex Ethnicity Cultural Identity Religious, Spiritual or Philosophical Orientation Education before Entering the Current Nursing Program Length of Clinical Experience Concept of Culture 169 Appendix D T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A School of Nursing T201-2211 Wesbrook Mall Vancouver, B.C. Canada V6T 2B5 Tel: (604) 822-7417 Fax: (604) 822-7466 L E T T E R OF I N F O R M A T I O N A B O U T P A R T I C I P A T I O N I N T H E R E S E A R C H P R O J E C T " N U R S I N G S T U D E N T S U N D E R S T A N D I N G OF T H E C O N C E P T OF C U L T U R E . " Dear Student I am a registered nurse and a student in the Master of Science in Nursing program at the University of British Columbia. In partial fulfilment o f the requirements of my graduate education, I am conducting a research study to explore nursing students' understanding o f the concept of culture. I hope the results of my research w i l l provide insight into how students' learn about the concept o f culture, and how they apply what they have learned in working with clients, and also provide direction for those planning, developing and revising nursing curricula in schools of nursing. Y o u are being asked to participate in this study because you have had the opportunity to reflect on the concept of culture. Your participation in this study is voluntary. Y o u may choose not to participate in this study without penalty or risk to you or to your continued education. I f you choose to participate, you can expect that: Interviews & Reflective Journals • Y o u w i l l be interviewed one or two times by the researcher. • The first interview w i l l be approximately one to one-and -a-half hours long. • Y o u may be asked to do a one-hour follow up interview to verify the accuracy and meaning of what you said. • Y o u may refuse to answer any question during an interview. • Y o u may stop the interview at any time. • The interviews w i l l be audiotaped and transcribed, and then the tapes w i l l be erased. • Y o u may have any portion of my interviews erased from the tape or - deleted from the disk or transcript. Concept of Culture 172 Page 2 of3 I am being asked to participate in this study because I am an undergraduate student nurse. I have been introduced to the concept of culture, have some clinical learning experiences, and kept a reflective journal. I have had the study explained to me and I understand that: • I w i l l be interviewed one or two times by the researcher; • The first interview w i l l be approximately one to one-and-a-half hours long. • I may be asked to do a one-hour follow-up interview to verify the accuracy and meaning of what I said in the interview. • I may refuse to answer any question during the interview. • I may stop the interview at any time. • The interviews w i l l be audiotaped and transcribed, and then the tapes w i l l be erased; • I may have any portion of my interviews erased from the tape or deleted from the disk or transcript; • I w i l l be identified by a code number on the documents, tapes, disks, and transcripts to ensure privacy; • M y reflective journal w i l l be required as part of the data (for undergraduate students) • With my permission the researcher w i l l obtain a photocopy of the reflective journal, and return the original to me once a copy is obtained. • On completion of the study, the photocopy of the journal w i l l also be returned to me. • Socio-demographic data (age, gender, ethnicity, cultural identity, religious, spiritual or philosophical orientation) w i l l be required as part of the data. • Only the researcher and the chairperson of her thesis committee and faculty advisor, Prof. Joan Anderson, who is supervising her work, w i l l have access to the documents, reflective journals, tapes, disks, and transcripts. • The documents, journals, tapes, disks, and transcripts w i l l be kept in a secure locked place when not in use. • Documents, photocopies of reflective journals and transcripts w i l l be destroyed and data w i l l be deleted from disks and hard drive within three years after the study is finished. • The researcher and the chairperson o f the thesis committee w i l l hold all information and discussion with me in the strictest confidence. • I f I wish, I w i l l be given a copy of the findings of the study. The findings of this study w i l l be shared and used in future professional presentations or publications. There would be no information that could identify me in these situations. 


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