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An interpretive description of the influence of cultural differences and social context upon the learning… Helewka, Anna Maria 2003

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A N INTERPRETIVE DESCRIPTION OF THE INFLUENCE OF C U L T U R A L DIFFERENCES A N D SOCIAL CONTEXT UPON THE L E A R N I N G ENVIRONMENT AS PERCEIVED B Y B A C C A L A U R E A T E NURSING STUDENTS by A N N A M A R I A H E L E W K A Diploma in Psychiatric Nursing, The British Columbia Institute of Technology, 1975 Diploma in General Nursing, The British Columbia Institute of Technology, 1976 B.S.N. The University of British Columbia, 1986 A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF M A S T E R OF SCIENCE IN NURSING in THE F A C U L T Y OF G R A D U A T E STUDIES (Faculty of Applied Science, School of Nursing, Master of Science in Nursing Program) We accept this thesis as conforming toJ^e required standard THE UNIVERSITY OF BRITISH C O L U M B I A August 2003 © Anna Maria Helewka, 2003 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 <_^M*#-<. The University of British Columbia Vancouver, Canada Date DE-6 (2788) Cultural Differences ii Abstract We could learn a lotfrom crayons: some are sharp, some are pretty, some are dull, some have weird names, and all are different colours... but they all exist very nicely in the same box. The cultural landscape of nursing education is shifting as individuals from various social and ethnic backgrounds aspire to enter the nursing profession. Despite curricular innovations, nursing programs continue to have difficulty retaining culturally diverse nursing students (CDNS). The majority of nursing education literature is concerned with ethnically diverse students, not reflecting expanded definitions of diversity evident in the general culture literature. Therefore, my intent was to add to an understanding of the CDNS in nursing programs of today, exarnining how CDNS construct cultural differences within their learning environments and how they perceive these differences to influence the learning experience. Also, I hoped to discover how CDNS relate social context to learning success by exarnining how they describe and explain feelings of social comfort and discomfort. I chose the qualitative research approach, interpretive description, as my design (Thorne, Reimer Kirkham & MacDonald-Emes, 1997), the purpose being to describe the lived experience of CDNS as interpreted by the participants of this study in order to understand the meaning of this experience. In-depth interviews were conducted with five baccalaureate nursing students who self-identified as being culturally diverse. The analytical process began with a preliminary organizational framework, which oriented the study to the existing literature and was the basis of the inductive analysis that occurred throughout the study, Morming the data collection and analysis of data in subsequent interviews. The interviews were tape recorded and transcribed verbatim. The findings of the study represent the culmination of this inductive analysis and can Cultural Differences iii be considered an interpretive description of the lived experiences of these CDNS. The participants of this study characterize a different aspect of diversity from that which is contained in the literature—they considered themselves diverse due to various socio-economic and lifestyle choices rather than ethnicity. The findings that emerged revealed three common themes — being culturally diverse, experiencing cultural diversity and managing cultural diversity. These themes represent a process describing how each participant conceptualized the meaning of diversity, experienced the impact of their diversity, and made decisions as to how to manage their diversity within their learning environment. The findings support discussions in the literature that focus on the importance of the personal and social contexts to the learning environment of CDNS (social comfort). Also, the findings reflect general discourses on cultural diversity that suggest that the increase in cross cultural encounters and exposure to diversity experienced by individuals in today's world make it imperative that an expanded and dynamic perspective of cultural diversity be considered. Cultural Differences T A B L E OF CONTENTS Abstract ii Table of Contents iv Acknowledgements vii CHAPTER I Introduction 1 1.1 Background of the Study 1 1.2 Purpose of Study 12 1.3 Research Questions 12 1.4 Assumptions 13 1.5 Definitions 13 1.6 Research Design 14 1.7 Limitations and Significance of Study 16 1.8 Organization of the Thesis 17 CHAPTER II Review of the Literature 18 2.1 Introduction 18 2.2 Definitions Related to Cultural Diversity/Cultural Differences 18 2.3 Cultural Difference in Nursing Education 21 2.3.1 Education of Culturally Diverse Nursing Students 22 2.3.2 Lived Experience of Culturally Diverse Students 30 2.4 Conclusion 34 2.5 Preliminary Organizational Framework 38 CHAPTER III Research Design 40 3.1 Introduction 40 3.2 Recruitment, Sampling and Informants 42 3.3 Characteristics of Participants 44 3.4 Ethics 44 3.5 Data Collection 46 3.6 Analysis and Interpretation of Data 47 3.7 Rigor 48 3.8 Summary 49 CHAPTER IV Findings 50 4.1 Introduction 50 Cultural Differences v 4.2 Being Culturally Diverse 51 4.2.1 Defining Cultural Diversity 51 4.2.2 Perceiving Cultural Diversity 54 4.3 Experiencing Diversity 59 4.3.1 Feeling Culturally Diverse 59 Not Fitting In 61 Being Judged 65 4.3.2 Confirming Cultural Diversity 69 4.4 Managing Cultural Diversity 73 4.4.1 Coping With Diversity 74 Communicating Diversity 75 o Concealing 77 o Context of Individual Diversity 79 o Context of Learning Environment 82 Getting Support 84 4.4.2 Outcomes of Managing Diversity 91 The Facade 91 Self-Exclusion 93 Learning Environment 94 Positive Aspects 96 4.5 Conclusion 99 4.5.1 Thematic Structure of Findings 105 CHAPTER V Discussion of Findings 106 5.1 Introduction 106 5.2 Constructing Cultural Differences 106 5.2.1 Exposure to Diversity 107 5.2.2 Appraising and Rearranging 109 5.3 Social Context and the Learning Experience of CDNS 110 5.3.1 Student-Faculty Relationships I l l 5.3.2 Social Comfort 113 5.4 Conclusion 116 CHAPTER VI Summary, Conclusions and Implications 117 6.1 Summary of Study 117 6.2 Conclusions of Study 121 6.3 Implications 122 Implications for Nursing Education 122 Implications for Nursing Practice 124 Implications for Nursing Research 124 References 127 Cultural Differences vi Appendix I Participant Recruitment Flyer/Memo 135 Appendix II Letter of Initial Contact 137 Appendix III Behavioural Research Ethics Approval, UBC 139 Appendix IV Participant Consent and Information Form 140 Appendix V Participant Demographic Questionnaire 144 Appendix VI Sample Questions for Initial Participant Interviews 146 Cultural Differences vii ACKNOWLEDGMENTS My sincere appreciation is extended to all of the nursing students who volunteered to participate in this study. They gave so generously of their time and energy so that others may benefit from the sharing of their experiences. The knowledge and insights I gained from you will never be forgotten. I would like to extend my heartfelt thanks to my wonderful thesis committee. To my chairperson, Dr. Sally Thorne, thank you for your wisdom, your scholarship, your expertise, but most of all for your caring and support. I don't have the words to express how much it meant to me to know that you believed in me every step of the way along this path to enlightenment. Your strength and humour carried me through some very difficult times in this thesis 'adventure'. I have learned so much from you in this process, your talents as a teacher are unsurpassed. Under your guidance, qualitative research came alive for me so that I fully appreciate the richness of such research in all human health care and educational contexts. To Dr. Marg Osborne, thank you so much for your expert counsel in relation to diversity and thank you for your willingness to be a member of my committee in the last stages of the process. I appreciate your kind, open nature as a teacher. To Dr. Carol Jillings, thank you for your patience and for being there in support of this endeavour throughout all the time constraints and pressures I put you through. To my friends and colleagues at Douglas College, Faculty of Health Sciences, Department of Psychiatric Nursing, I would like to express my appreciation for all the support, understanding and laughter. A special thanks to my treasured friend Kathy Liebelt, my ex-officio committee member, for listening to my ramblings about cultural differences and for the valuable insights you provided when I needed another perspective. To, my dear friend Lori Townsend, thank you for you support and understanding not only as my buddy but also as the coordinator of our program for encouraging me in my studies—but most of all thanks for the humour you always see in situations. To Mike Tarko and John Crawford, valued friends and special cheering section—thanks for the comfort, warmth and caring you provided during some very crazy times. To, Laura McDonald, thank you for your excellent transcribing capabilities, I appreciate your time and attention to detail—it made this whole process so much easier. Also, a special thanks to Joy Holmwood, Dean of the Faculty of Health Sciences at Douglas College, for her constant understanding and support in my educational endeavours. I would also like to extend a special appreciation to Lois Bowman of Nimpo Lake, your kindness meant a lot to me when I was feeling stressed out and needed to get away but still had to have access to a computer—I will always be grateful to you for opening your house to me. I would like to thank my family for their patience in this whole thesis process. I would like to thank my parents Pasqualina and Michele for mstilling in me a love of education and the courage to pursue dreams. To Nick, Wendy, Alison, Dave, Jordan, Adam and Sam, thanks for listening. Finally, I would like to thank my partner in life, my husband A l , for his love and understanding that sustained me during some very crazy times—thank you for all your efforts in supporting me as I finished this thesis. Cultural Differences 1 CHAPTER ONE: INTRODUCTION Background Canadian society is a dynamic multicultural mosaic comprised of individuals from a variety of diverse backgrounds and groups (Garcia, 1999; Jairrels, 1999; Kalbach & Kalbach, 1999; Kim, Clarke-Ekong & Ashmore, 1999; Kulig & Thorpe, 1996; Lea, 1994; Pizanias, 1992). Demographic trends in North America suggest this mosaic wall become even more complex and intricate as our society continues to evolve into the new millennium (Barnes, Craig & Chambers, 2000; Lea, 1994; Poss, 1999; Rew, 1996). The Canadian Nurses Association's (CNA) policy paper on cultural diversity discusses 1996 statistics which indicate migration to Canada increased by fifteen percent in the five years leading up to the census; a significant trend considering this number is three times higher than the growth of the Canadian born population (CNA, 2000). Groups that used to be considered 'minorities' are, and will increasingly be, considered national 'majorities' (Barnes et al.). Whilst the term cultural diversity automatically paints a mental portrait of peoples of various ethnic and racial origins, the cultural differences evident in individuals and/or groups within our society are also influenced by a myriad of biological, sociological and environmental factors such as: age, gender, life experiences, sexual orientation, language, family, ethnicity, religion, race, lifestyle choices, socio-economic status, education, country of origin, and disabilities (Levin & Riffel, 1994). Utilizing a broad t perspective to understand cultural differences illustrates that individuals in our society have at least one thing in common—their diversity. Societies all over the world have been and continue to be influenced by globalization. Increased migration and immigration rates among the nations of the world, ease of travel to all Cultural Differences 2 points of the world combined with the ever advancing electronic communication technology has resulted in what is loosely termed by Spence (2001a) as 'cultural confusion'. Groups that were once viewed as 'minorities' in some societies are now evolving into 'majorities' (Yoder, 1996; 2001). In addition, traditional cultural categories are considered by some to be ineffective in describing an individual's background—culture is no longer seen as being linked solely to nationhood or ethnicity (Baker, 1997; Canales & Bowers, 2001; Kalbach & Kalbach, 1999; Samantrai, 1995). Globalization has caused the distinctions between cultures to blur wherein the national character of nations is becoming increasingly difficult to define. Samantrai describes cultures as 'interpenetrating' meaning they are not separate entities but rather involved in the mutual creation of each other. The traditional concept of distinct separate societies and cultures appears to be difficult to rationalize in today's world; an example of this thinking is the idea that cross cultural encounters should be viewed as an evolving interpretation of historical and current events towards new shared meanings (Baker; Kalbach & Kalbach; Samantrai). Globalization of today's world has added intricacy to the understanding of cultural differences, an intricacy that points to a constantly changing process or drama involving interactions between and among various historical and current elements (Baker; Lea, 1994; Pizanias, 1992; Samantrai). North American society is an excellent example of the influences of globalization. Population statistics, migration and immigration rates indicate that the structure and visage of North American society continues to change at an ever-increasing rate, resulting in a transformation from the traditional homogeneity of North American population to a multicultural pluralistic mosaic (Lea, 1994; Dowell, 1996; Kalbach & Kalbach, 1999; Pizanias, 1992; Yoder, 1996; 2001). Cultural difference appears to be an integral component of our Cultural Differences 3 society influencing many facets of life: education, professions, occupations, consumer spending, communication, trends in food and dress, health care services, religion, family life, social rituals etc. Mosaic is an apt term to describe cultural differences in today's society in that it brings to mind a rich tapestry of separate entities brought together by various forces and events. Canadian society has historically been defined as cultural mosaic (Kalbach & Kalbach; Kuehn, 1992). Conversely, the United States has traditionally given credence to a 'melting pot' perspective and has only recently adopted the cultural mosaic or 'salad bowl' viewpoint (Kuehn; Heuberger et al., 1999; MaCavoy & Lippman, 2001). A 'mosaic of cultures' does not have the same connotations as 'melting pot'; a mosaic indicates diverse cultures can remain distinct within the mainstream society whereas 'melting pot' suggests a blurring or dilution of cultures into a homogeneous entity (Kuehn). The 'melting pot' analogy is no longer appropriate in today's world for it suggests individuals from diverse backgrounds must strive to 'fit in ' , 'acculturate' or 'assimilate' into mainstream society and thereby lose or alter their cultural identity (Merrill, 1998). The idea of assimilation into mainstream society has its roots in ethnocentric perspectives, which assume that mainstream society is superior and therefore desired. In today's world, individuals from diverse backgrounds no longer have the need to 'fit in' . Conversely, it is now considered an individual's right to have his/her diverse needs met, especially in the professional, educational and industrial arenas (Garcia, 1999). Professions, occupations, workplaces and educational institutions are expected to be aware of diversity issues as well as provide services to, and employ individuals from diverse backgrounds (Midobuche, 1999). Therefore, educational institutions are in the unique position of being able to play a major role in 'opening the gates' of the various professions and occupations to individuals from diverse Cultural Differences 4 backgrounds by implementing culturally sensitive educational policies and practices. Educational institutions at all levels are aware that they must embrace diversity by demonstrating an awareness of cultural differences, but more importantly, this awareness must result in the ability to develop programs that will attract, retain and graduate individuals from diverse backgrounds as well as prepare individuals to function in a diverse world (Heuberger et al., 1999; Levin & Riffel, 1994). The general education literature describes the current trend of incorporating multicultural and cross-cultural concepts into the programs of colleges, universities and K-12 programs. Teachers and educational administrators at all levels are becoming increasingly aware of the need to develop educational policies and strategies to assist students from culturally diverse backgrounds (Garcia, 1999; Kim, Clarke-Ekong & Ashmore, 1999; Gorski, 2000; Levin & Riffel). Diversity is also a common subject in the collective nursing literature. As a concept in nursing, diversity originated from Madeline Leininger's cultural care and universality theory development work of the 1950's. Leininger's research resulted in the emergence of transcultural nursing as a substantive field of nursing practice in response to the changing demographics and globalization of society (DeSantis, 1994; Lea, 1994; Leininger, 1995,1996; Poss, 1999). Many nurse scholars believe transcultural nursing must continue to expand as a distinct specialized field of practice in order to meets the needs of a diverse society (Bucher, Klemm, & Adepoju, 1996; Leininger; Rajan, 1995; Zorn, Ponick & Peck, 1995). Conversely, other authors suggest transcultural nursing should not exist as a separate field of practice, as transcultural concepts and issues are important to nurses in all practice arenas (Andrews & Boyle, 1999; Barnes et al., 2000; DeSantis; Kirkham, 1998; Mulholland, 1995; Jeffreys & Smodlaka, 1999). In addition, Cultural Differences 5 many nurses report feelings of frustration and anxiety in caring for clients from diverse backgrounds (Davidhizar & Giger, 1995); they often feel that cultural differences jeopardize their ability to provide high standards of care and impede their communication with clients (Abbot, Short, Dodson, Garcia, Perkins & Wyant, 2002; Baj, 1997; Lea, 1994; Kirkham; Murphy & Mcleod Clarke, 1993; Spence, 2001a). An examination of the literature from these perspectives reveals agreement on one point—many of the issues that arise in nursing practice related to cultural differences can and must be addressed by nursing education. Nursing education is in the choice position of being able to resolve some of the diversity issues that exist in practice by preparing nurses to care for culturally diverse clients (Barnes et al., 2000; DeSantis, 1994; Kirkham, 1998; Poss, 1999). In recent years, nursing programs have been attempting to meet the challenge of globalization by developing and implementing curricula based on multicultural concepts and knowledge (Kirkham; Yoder, 2001). However, much of the nursing literature suggests nurses are not adequately addressing the needs of clients from diverse cultural backgrounds (Baj, 1997, Barnes et al.; Campinha-Bacote, 1999; Jeffreys & Smodlaka, 1999; Murphy & Macleod Clark, 1993; Yoder). An explanation for this phenomenon may be that nurses are graduating from programs grounded in the traditional perspectives of the nursing profession, namely, non-minority, Caucasian, Protestant and female (Kulig & Thorpe, 1996; Ryan, Twibell, Miller & Brigham, 1996). These traditional perspectives, along with a lack of diversity among nurse educators, fail to provide graduates with the required knowledge, skills and attitudes to practice in a culturally competent manner (Davidhizar, Dowd, & Giger, 1998; DeSantis; Leininger, 1995; Murphy & Clark, 1993; Poss; Ryan et al.; Yoder). Therefore, it seems the development of curricula based on multicultural theory is insufficient to successfully Cultural Differences 6 prepare nursing graduates to practice in a global world; a major paradigm shift must occur from traditional perspectives to those which reflect current demographic trends and the cultural diversity evident in today's society. Nursing programs are credited with making legitimate attempts to address issues related to diversity in nursing practice, as is evident from the amount of literature available which discusses curricular revisions for nursing programs. Multicultural concepts and knowledge are now considered important horizontal streams in many nursing curricula. These curricular modifications have been developed as a way of exposing all students and faculty to cultural differences, with the aim being to encourage a deeper awareness and understanding of diversity. As crucial as this curricular innovation is to the preparation of culturally competent nurses, nursing programs must also demonstrate a commitment to meeting the needs of culturally diverse nursing students (Yoder 1996; 2001). Meeting the needs of culturally diverse students entails applying the multicultural concepts embedded within a curriculum to the educational policies and practices of a nursing program (Yoder, 2001). In this way, nursing programs may be able to meet the needs of culturally diverse students, and at the same time provide educational environments respectful of cultural differences, resulting in nursing graduates that are better prepared to care for culturally diverse clients (Jeffreys & Smodlaka, 1999; Yoder). Increasing the numbers of nursing graduates who have culturally diverse backgrounds will result in improved care to culturally diverse clients as well as positively alter the homogenous 'face' of a profession which has traditionally been female, Caucasian, Protestant and Anglo-Saxon (Yoder). Unfortunately, much of the nursing education literature suggests culturally diverse nursing students continue to encounter many barriers to success (Condon, 1996; Yoder, 2001). If nursing Cultural Differences 7 programs wish to be successful in recruiting, retaining and graduating students from culturally diverse backgrounds, a concentrated effort must be made to examine and resolve any barriers to success that may exist to these students (Condon, Yoder). The nursing education research literature is rife with studies which have investigated the barriers to academic success as experienced by culturally diverse students; most of these studies are consistent in recommending the need to develop culturally sensitive educational policies and curricula as strategies to decrease the barriers to culturally diverse nursing students (CDNS). Results from research in this area have encouraged nursing programs to develop academic and administrative policies to meet the needs of CDNS. Philosophy and mission statements of programs have also been revised to reflect the diversity issues occurring in nursing education and practice. Nursing programs currently provide various forms of financial and educational resources in an attempt to attract and retain CDNS. However, the innovative changes occurring in educational curricula and policies do not seem to be having the desired effect; nursing programs continue to struggle with the recruitment and retainment of culturally diverse students—a curious phenomenon and one which needs further exploration. Innovations that reflect our diverse society are desperately needed in traditional nursing programs but, as with any change, innovations often result in controversy and challenges. An example of such as a controversy stems from recommendations from the nursing research literature, which direct nursing programs to develop flexible academic policies to meet the needs of CDNS. While it is inarguable that academic polices must be evaluated to ensure they are current and relevant for nursing practice in today's society, increased flexibility in academic policies raises concerns among educators. Nurse educators may interpret flexible academic Cultural Differences 8 policies to mean a relaxation of admission, progress and graduation standards within programs, with the end result being inadequate preparation of graduates for practice, as well as subsequent detrimental effects on the health care needs of society (Culley, 1996; Duffy, 2001). Another controversial suggestion arising from research done in this area is that nursing programs need to increase the diversity among nursing faculty, thereby providing CDNS with role models who will respect and understand their diversity (Kulig & Thorpe, 1996; Yoder, 1996; 2001). Again this seems like a good idea, albeit a challenging one, raising the following questions: • Does this mean CDNS can only receive support and understanding from faculty that are also from diverse backgrounds? and • How does one increase the numbers of culturally diverse faculty if barriers continue to exist preventing CDNS from graduating from nursing programs? Another challenge, interestingly enough, arises from the commitment of nursing education programs to providing supplementary educational resource programs (often termed remedial learning) to assist CDNS with learning, reading and writing skills. Some examples of supplementary educational programs are: special tutoring for language deficits, reading and writing courses as preparatory courses before entering a nursing program, teaching of exam taking, note taking and study skills. Many nursing programs have developed and implemented such resource programs based on recommendations contained within the nursing and education literature. Many of these programs are not meant solely for CDNS, as they address specific learning deficits, and are therefore meant for all students. Condon (1996) suggests that the factors, which influence student success, are similar for all students but in varying degrees; it would follow then, that supplementary programs would be attractive and beneficial to all Cultural Differences 9 students. Therefore it is difficult to interpret the statistics from the literature that indicate educational resource programs are underutilized by all students (including CDNS) and even more puzzling are the findings suggesting that when these programs are used by CDNS there is little or no significant difference in academic success rates. Two possible explanations for the under utilization and/or lack of success of educational resource programs for all students (including CDNS) may be: the perceived stigma of being in a remedial learning program resulting in feelings of inadequacy, and limited study time available resulting in the majority of time being spent on remedial learning with less time being spent on nursing courses. It is apparent, then, that the changes in curricula and academic policies occurring in nursing programs are important and needed, but these changes do not seem to be enough to successfully meet the unique challenges of educating CDNS. A logical 'next step' in exploring the issues surrounding the success of CDNS, is to examine the teaching strategies utilized in nursing programs for their role in enhancing or inhibiting learning experiences. The increased amount of research examining diversity in the nursing education, nursing practice and general education literature has led to an increased awareness of cultural differences by nurse educators, resulting in the development of culturally sensitive teaching strategies. Some of the strategies discussed in the literature are: student or faculty mentorship programs, learning activities and assignments that do not require written work, faculty and student workshops on diversity, familiarity with cultural orientation of CDNS, cross cultural courses, culturally diverse speakers, various clinical teaching strategies and practice settings to meet the specific needs of CDNS, diversity assignments, student exchanges, individualized teaching strategies based on the learners needs and style (Kirkham, 1998; Ross, 2000; Kulig & Cultural Differences 10 Thorpe, 1994; Yoder, 2001). It is evident that nurse educators are making the effort to develop and implement teaching strategies that decrease the barriers to success for CDNS. The above-mentioned strategies (and others not mentioned here) are significant as methods which increase awareness and respect of cultural differences among faculty and students, but unfortunately these strategies are not always feasible given the financial, personnel and time constraints most nursing programs operate under in today's economic world. Nursing programs have responded to increasing cultural diversity in today's world with innovative changes in program curricula, policies and teaching strategies, but CDNS continue to encounter barriers in nursing programs. Results from research in this area indicate that these barriers are related to issues such as; overwork, inflexible policies, insufficient study time, lack of academic, emotional and financial support/resources, and lack of personal motivation/commitment. Condon's (1996) research also concludes with the identification of a number of crucial elements required for success and persistence of all students in a nursing program. An interesting and novel element that surfaced from Condon's study is the idea of social comfort. Condon illustrates the concept of social comfort by discussing statistics that indicate African American nursing students (with the same background and abilities) do much better in colleges considered 'all black' rather than in 'mainstream' colleges. Condon uses this example to suggest individuals may be more successful in learning situations when a sense of belonging, 'fit' or 'social comfort' is experienced. The concept of social comfort is intriguing; a sense of belonging or fit is important for the successful navigation of many situations individuals encounter throughout life, learning may be one such situation. The idea, that learning may be influenced by how similar the individual is to the mainstream student population and/or how Cultural Differences 11 familiar the individual is with the accepted customs, beliefs and values of the learning environment is an interesting one to ponder. Additionally, social comfort may determine how safe one feels in a situation, affecting variables such as: communication style, motivation, persistence, help seeking behaviours, self esteem, self respect and self confidence—all of which have been identified as issues in successful learning. Social comfort, then, may be one of the missing links involved in solving the dilemma of cultural diversity in nursing programs— suggesting students may need to feel they 'fit' into an educational environment in order to be successful. The idea of social comfort may have a special significance for the education of nursing students with diverse backgrounds. A consideration of its implications raises the following questions: is it possible for CDNS to experience a sense of fit or social comfort in nursing programs? and how would nurse educators address this issue? CDNS may differ from the mainstream student population in various ways (racial, ethnic, economic, language, sexual preferences, social group, class, educational experiences, life experiences, disabilities, life style choices etc.) and some students who may appear 'different' are actually more similar to the mainstream student body than they are different. The confusion surrounding 'who' the CDNS is requires an investigation into the lived experience of the nursing student to provide some contextual meaning to the term 'culturally diverse'. Examining the lived experience of nursing students may provide some insights as to how cultural differences are perceived and/or constructed by nursing students as well as how such differences may influence the experience of t social comfort or fit. Finally, an understanding of the issues related to cultural differences and social comfort as perceived by nursing students may assist educators in solving some of the Cultural Differences 12 recruitment and retention concerns evident in nursing programs. Purpose of the Study Nursing students can be assisted in their studies by many methods, strategies and tools. As valuable as many of these strategies are for improving academic performance, there seems to be a gap in the effectiveness of these strategies for CDNS. No matter what strategies, resources and/or policies are in place in nursing programs, CDNS continue to have difficulty with success. An enhanced understanding of cultural differences and the influence of social context to the learning experience may provide some insights into why this gap exists. Therefore, the purpose of this study has been to learn how baccalaureate nursing students perceive cultural differences and how they understand these differences to influence the learning environment. A secondary aim of the study was to develop an understanding of how baccalaureate nursing students relate their social context to learning success by investigating how students describe and explain their feeling of social comfort and discomfort. Research Questions The questions addressed in this study were: 1. How do baccalaureate nursing students describe and explain cultural differences between and among them? 2. How do baccalaureate nursing students understand cultural differences to influence the quality of their educational experiences? 3. How do baccalaureate nursing students relate their social context to their learning success? 4. How do baccalaureate nursing students describe feelings of social comfort or discomfort within their learning environment? Cultural Differences 13 Assumptions • Nursing students are the best sources of information related to the lived experience of being a student nurse. • The culture of a population of nursing students is best described by members of that group. Similarly, cultural differences among nursing students are best described by members of the student group. • Nursing students have the best understanding of the social context that exists within a nursing program and therefore can relate the influence of social context to the learning experience. • Feelings of social comfort or discomfort are best described by individual(s) experiencing these feelings. Definitions Cultural differences and cultural diversity may seem to be interchangeable terms and both terms are used in this study. However, the literature seems to primarily use cultural diversity to refer to individuals who are ethnically or racially diverse. I wish to focus on a broader definition of cultural diversity; therefore I will use cultural differences/cultural diversity to depict those individuals who may have different life experiences from the majority population (in this case the student nursing body), such as socio-economic and socio-cultural variations, as well as those individuals who differ because of racial and/or ethnic backgrounds. In this way, individuals from mainstream society who may be 'different' but not visibly or traditionally so, can also be included in the group. Similarly those individuals who are from a minority group but who may actually be more similar than different from the mainstream population will not be Cultural Differences 14 singled out and stereotyped. The second term, which needs some definition, is that of social comfort. Social comfort is only alluded to in the literature and has not been researched in any depth. Condon's (1996) findings suggest social comfort is a possible factor influencing the success of nursing students. Social comfort was used in Condon's study to describe students' comments on questionnaires related to feelings of 'belonging' or feelings of 'fitting in'. I will explore the utility of the idea of social comfort to depict the social context of the learning experience for nursing students, thereby referring to a phenomenon that may influence communication styles, behaviour, self-confidence, self-esteem and motivation. Research Design The research design chosen for this study was noncategorical interpretive description (Thorne, Reimer Kirkham & MacDonald-Emes, 1997). Utilizing this type of design meant that the philosophical and theoretical foundations of nursing and nursing education were used to guide the study. Historically much of the research related to cultural differences in education and nursing education has been quantitative in nature wherein studies report and attempt to generalize causal, correlational or comparative findings. The quest to move from generalizations to more in-depth understandings of the lived experience of the individual and the meaning individuals give to these experiences has resulted in an increase in qualitative research methodology in both the nursing and education fields, giving rise to paradigms such as naturalistic, grounded theory, phenomenological, ethnography, hermeneutic or participatory theory (Mertens, 1998). The interpretive descriptive approach is one such paradigm but one which has the principles of the nursing profession as its philosophical underpinnings. Cultural Differences 15 Using an interpretive descriptive approach to conduct this study meant that I was able to use perspectives from the discipline of nursing to access knowledge about cultural differences and the social context of the learning environment as constructed by nursing students. Whilst various conceptual frameworks related to nursing education and cultural differences have evolved from both quantitative and qualitative research, many of these frameworks are the result of research methods arising from the disciplines of anthropology, sociology, philosophy or natural science, disciplines which have quite different perspectives and visions than nursing. Since it is a given that the education of nursing students involves upholding the aims of the nursing profession, nursing education research methods of inquiry must also uphold the same values of the discipline. As obvious as the last two statements seem, the fact that nursing education encompasses the disciplines of education and nursing has resulted in a medley of various of research methods being used to examine and develop knowledge about the field. Similarly, cultural differences in nursing practice and education have been researched from the perspectives of various disciplines such as anthropology, sociology and philosophy. Therefore, was interesting, in this study, to examine cultural differences within the context of nursing education from the unique aims of the nursing profession. Utilizing interpretive description meant that a formal descriptive framework was not part of the design for this study; rather an organizational framework was formulated from the existing knowledge available in the field. In this case, literature related to cultural differences (both research and anecdotal) from the fields of nursing, nursing education and general education was critically analyzed and used to develop a preliminary organizational framework which provided direction for the processes of data collection, analysis and interpretation. A key Cultural Differences 16 element of this type of design is that preliminary organizational framework was not static, its parameters shifted as the study progressed and the inductive process revealed insights not included in the preliminary framework (Thome et al, 1997). In this way I maintained the exploratory and discovery nature of the study whilst still adhering to the principles of qualitative inquiry for nursing science. Limitations and Significance of Study The qualitative and exploratory nature of this inquiry limits the generalizability of the findings. Findings are also limited by the size of the sample and the characteristics of the participants. The five participants of this study were individuals who self-identified as feeling culturally diverse or different from their peers. None differed because of ethnic difference; rather they stated their differences as being related to various socio-economic backgrounds and lifestyle choices. Thus the findings do not reflect the perceptions of those who are ethnically diverse. In addition, all the participants were female students between 20 and 28 years of age, thereby the findings are not representative of other potential diversities, such as the experience of male nursing students or those students considered 'mature'. However, the findings have some significance for nurse educators. This study has described the influence of cultural differences upon the learning experiences from the perspective of baccalaureate nursing students. In describing this phenomenon, it has provided some insights into how baccalaureate nursing students construct cultural differences and the social context of their learning experiences. The idea of social comfort as it relates to the cultural differences in learning experience surfaced in this small study, and holds promise for further exploration to discover the extent of its role in explaining the 'gap' that exists in nursing Cultural Differences 17 programs for CDNS. The findings of this exploratory study give some preliminary direction to nurse educators as they develop programs that respect and support cultural differences among nursing students. In this way, the study has provided some beginning ideas to those engaged in the larger challenge of providing excellent nursing education for culturally diverse nursing students. Organization of the Thesis The thesis is organized into six chapters. In Chapter One, I have described the background to the research problem, delineated the research questions, provide a definition of key terms, and discuss the assumptions, research design and significance of the study. Chapter Two represents a literature review encompassing literature from the general education, nursing, nursing education fields. In Chapter Three I describe the use of interpretive description as a research design as well as the preliminary organizational framework formulated from the literature review, which was used to direct the study. In Chapter Four I report the research findings. Chapter Five contains a discussion of the research findings from the study. Chapter Six is a summary and conclusion of the study, including implications and recommendations of the study findings for nursing education, practice and further research. Cultural Differences 18 CHAPTER TWO: REVIEW OF THE LITERATURE Introduction The following chapter provides a review of the available literature related to nursing education and cultural diversity. The purpose of this literature review is to situate the proposed study within the available knowledge from nursing education and its related fields. As a way of providing a 'setting' for this study the literature review will begin with a brief discussion of how the terms cultural diversity and cultural differences are defined for this study. The literature review will then provide a discussion of the available knowledge related to the education of culturally diverse nursing students and their lived experience within nursing programs. Definitions Related to Cultural Diversity/Cultural Differences Cultural Diversity is a common term in today's world. The term is referred to in many arenas and is used to describe a variety of phenomena. In order to provide a clear understanding of how cultural diversity will be used in this thesis the words 'culture' and 'diversity' are examined separately, thereby providing a basis for defining the notion of cultural diversity. Merriam Webster's (2002) dictionary has numerous definitions for the word 'culture', ranging from the art or practice of cultivating, to the cultivation of living material (as in bacteria or tissues) in prepared nutrient media. The definitions most relevant to this study are: ... .a: the total pattern of human behavior (sic) and its products embodied in thought, speech, action, and artefacts and dependent upon man's capacity for learning and transmitting knowledge to succeeding generations through the use of tools, language, and systems of abstract thought b: the body of customary beliefs, social forms, and material traits constituting a distinct complex of tradition of a racial, religious, or social group... Cultural Differences 19 that complex whole that includes knowledge, belief, morals, law, customs, opinions, religion, superstition and art...c: a complex of typical behavior(sic) or standardized social characteristics peculiar to a specific group, occupation of profession, sex, age grade, or social class... .(on line reference). Similarly, Leininger (in Lea, 1994), gives a broad definition of culture when she states it is, "...the learned, shared and transmitted values, beliefs, norms and life practices of a particular group that guides thinking, decisions and actions in patterned ways" (p. 307). Historically, Leininger and many others have defined culture to mean race and/or ethnicity but it is evident that contemporary definitions of culture have evolved to mean any number of biological, sociological or environmental contexts (Barnes et al., 2000). Additionally, most definitions allude to communication, in all its varied forms, as being key to the transmission and understanding of all cultural knowledge (Donnelly, 2000; Lea, 1994). Conversely, the word diversity has a much more abbreviated definition in the literature, it is considered "... the condition of being different or having differences; variety" (Merriam Webster, 2002) and stems from the word diverse meaning "differing from one another., .having various forms or qualities" (on line reference). Levin and Riffel (1994) indicate that individuals can differ in many ways from each other and that they do not always differ in the same way in all contexts; they also suggest that some differences are more predominant in social and academic discussions than other (i.e. race, religion, language are more intensely debated than differences such as class, lifestyle, sexual orientation, disability). Therefore, the term cultural diversity in its broadest sense appears to reflect the biological, sociological and internal/external environmental differences among and between Cultural Differences 20 individuals (age, gender, lifestyle choices and experience, sexual orientation, language, family, social groups, occupational groups, genetics, religion, socio-economic status, education, life experiences, country of origin and disabilities). The myriad of factors that contribute to the differences among and between individuals, impart a certain complexity to the term cultural diversity—it is evident then that race and ethnicity are only two 'pieces' of the cultural diversity puzzle. As complex as the term cultural diversity appears to be, it is curious to note that population statistics and a great deal of the literature appears to interpret the term to mean racial or ethnic differences (Barnes et al., 2000; Canales & Bowers, 2001; Spence, 2001). For the purpose of this study, the term cultural diversity will be used to portray a rich phenomenon that refers to the many differences that exist between and among individuals, incorporating a multitude of interpersonal and intrapersonal factors. Cultural difference, a term used in the literature as a synonym of cultural diversity, is also used to describe the variations among and between individuals and/or groups. Cultural difference seems to be a more current term than cultural diversity and appears to be used in contexts that do not refer solely to racial/ethnic differences (Levin & Riffel, 1994). An examination of both terms reveals that it is the word 'culture' which is most problematic to define because of its complex, evolving nature and so it seems that the word differences (or diversity) is crucial to the understanding of the concept of culture (Spence 2001). In summary, the terms cultural differences and cultural diversity, when defined generically, both conjure up a broad perspective of the differences among and between individuals. These terms will be used interchangeably in this paper. Cultural Differences 21 Cultural Difference in Nursing Education Nursing education programs have been identified in the literature as being critical to the goal of increasing the numbers of culturally diverse practicing nurses (Abdullah, 1995; Barnes et al., 2000; DeSantis, 1994; Murphy & Macleod Clarke, 1993; Reeves, 2001; Rossiter, Bidwell, & Chan, 1998). Nurse educators have become acutely aware of the importance of the expanding the numbers of culturally diverse nursing practitioners; the philosophy underlying this belief is that culturally diverse nurses will be better able to provide culturally competent care to clients from diverse backgrounds (Abdullah; Abriam-Yago, Yoder & Kataoka-Yahiro, 1999; Barnes et al.; Canales & Bowers, 2001; DeSantis; Dowell, 1996; Kirkham, 1998; Murphy & Macleod Clarke; Rossiter et al.). However, it has been argued by some theorists that nursing programs will have to undergo a paradigm shift and critically evaluate policies related to attracting, retaining and graduating culturally diverse individuals in order to meet this goal (Dowell; Kevern, Ricketts, & Webb, 1999; Merrill, 1998; Yoder, 1996,2001). The field of nursing education has as its roots the philosophical ideals of the nursing profession wherein schools of nursing have always mirrored the traditional and historical perspectives of the profession (white, female, middle class and Anglo Saxon). As has been pointed out by some authors, many nursing education programs in North American colleges and universities continue to have an inherent lack of diversity, evidenced by faculty and student populations that do not proportionately represent the diversity of populations of the patients they serve (Campbell & Davis, 1996; Dowell; Wilson & Mitchell, 1999; Yoder, 2001). These authors indicate that this lack of diversity influences learning environments, curriculum, policy development, student services/resources, as well as the recruitment and retention of CDNS. Cultural Differences 22 In perusing the nursing education literature, two themes arise that are related to CDNS; the following discussion will be organized according to the themes: teaching culturally diverse nursing students and the lived experience of CDNS within nursing programs. These topics have been examined using quantitative and qualitative methods in an attempt to develop knowledge and theory in these areas. In addition, numerous discussion papers and anecdotal presentations related to these topics also appear in this literature. Education of Culturally Diverse Nursing Students This literature revolves around the following themes: organizational characteristics of nursing programs which may create barriers to success for CDNS, the development of knowledge, strategies and theory related to teaching CDNS, and the need for resources aimed at ensuring academic success for CDNS. A large portion of this literature discusses the organizational characteristics that influence the recruitment, retention and attrition rates of CDNS (Dowell, 1996; Kevern et al, 1999; Merrill, 1998). Institutions and programs that are rigid, inflexible and steeped in traditional perspectives in their administrative, recruitment and evaluative policies seem to have less success with attracting and retaining CDNS (Dowell). Condon's (1996) large quantitative study (N=500) examines the self reported similarities and differences between CDNS and mainstream students in relation to the factors that increase and decrease their chances of academic success. In addition to these issues she also examines individual background, environmental, social integration and academic integration as factors related to academic success. Condon concluded from her findings, that although the academic needs of CDNS were similar to those of mainstream students, their needs were often more intense and especially Cultural Differences 23 influenced by social, environmental and background factors. Another example of such a study is Kevern et al.'s quantitative study of entry characteristics and course outcomes in which they examined the organizational characteristics that influence the recruitment of CDNS. The findings from this study suggested that many entry requirements and evaluative processes create barriers for CDNS within nursing programs. Findings from studies such as the two discussed above present conclusions that direct educational institutions to revise policies and philosophies to reflect an inclusive paradigm rather than an exclusive one. Interestingly, there seems to exist numerous discussion papers that caution against any proposed changes to traditional educational polices—it seems these changes pose a threat for some educators. Some educators believe that changing administrative and educational policies to meet the needs of non-traditional students by permitting increased flexibility within programs will result in a lowering of standards for the nursing profession (Dowell, 1996; Yoder, 2001). Other studies employ qualitative methods for the purpose of developing theory and knowledge about the teaching of CDNS. Findings from this research have resulted in various theoretical frameworks that educators can utilize in their teaching of CDNS. Much of this literature is presented from the perspective of nurse educators wherein the struggles and strategies associated with the teaching of culturally diverse students are documented and analyzed (Abriam-Yago et al., 1999; Kevern et al, 1999; Rew, 1996; Yoder, 1996; 2001). An example of such a study is Yoder's (1996) large grounded theory study in which she investigates the processes nurse educators' experience when teaching students of diverse backgrounds. Yoder describes the beginning of a substantive theory or model wherein she examines the interactive Cultural Differences 24 process (sending cues, interpreting cues, acting and interacting) that occurs between CDNS and faculty. Yoder's findings suggest that CDNS benefit when faculty respond to students in culturally sensitive ways and that faculty responses' to CDNS are dependent on an the individual faculty's background, life experiences, education and commitment to diversity. Yoder describes culturally sensitive interactions as those that demonstrate awareness and valuing of cultural differences. A key concept to Yoder's theory is the need for faculty to be able to distinguish differences between the needs and responses of CDNS and those of students in general. Yoder believes the ability to distinguish differences leads to an understanding of the barriers that face CDNS, which in turn positively contributes to the development of teaching strategies designed to meet the needs of CDNS. Yoder proposes the idea that it is the interactive processes that occur between nurse educators and students that are crucial to the success of the CDNS. In order to employ culturally sensitive teaching approaches, nurse educators must have the ability to examine their own background, values and biases and be aware of how these may affect their interactions with students. Yoder discovered that faculty responses to CDNS are directly related to the level of cultural awareness they possess and demonstrate. The range of faculty responses and level of cultural awareness along with their consequences are described by Yoder as: - generic (low level of cultural awareness; see no differences) - mainstreaming (high level of cultural awareness but requiring students to learn and adapt to mainstream values and beliefs) - culturally non tolerant (those who create barriers by being unwilling to tolerate cultural differences) - struggling (moving from low awareness to high causing anxiety) Cultural Differences 25 - bridging (high cultural awareness and use culturally sensitive teaching strategies— see diversity as positive and fulfilling) The various types of responding have differing consequences for both instructor and student but the study indicated that the bridging approach was the one most useful for successful interactions in the teaching of diverse nursing students. Yoder suggests meaningful learning must be grounded in a philosophy of difference rather than consensus. Yoder (2001) further interprets the findings from her research to indicate that the predominant model in nursing education focuses on how to best assimilate diverse students into the mainstream—this strategy often creates tensions for CDNS, as it requires that individuals adopt the values and beliefs of the dominant culture. An explanation for this model of assimilation is that nurse educators, charged with the responsibility of maintaining the standards of the nursing profession, interpret the notion of meeting the educational needs of CDNS as somehow interfering with this responsibility (Yoder). In keeping with the theme of attending to the interactions that occur between CDNS and nursing faculty, Abriam-Yago et al. (1999) discuss the implementation of the Cummins Model of language acquisition for teaching of ESL nursing students (ESL students are considered a major sub-group of CDNS within the nursing education literature). This model discusses the influence of context to the learning environment. This model is based on a conceptualization of high context and low context culture to explain communication difficulties encountered between and among individuals (Hall, 1976 in Abriam-Yago et al.). The premise of this framework is that all cultures have low and high context features but that some cultures are predominantly high context and others are predominantly low context. Context is defined as: the cognitive, Cultural Differences 26 structural, symbolic and environmental elements pertinent to any situation. In addition, it is the behaviour patterns of individuals that reveal low or high context orientation. High context cultures use covert communication cues which depend upon nonverbal communication, relationship between individuals and situation specific features to communicate; whereas in low context cultures (such as the dominant Anglo Saxon culture), change occurs quickly and depends less upon sharing within interpersonal relationships—communication styles in these cultures are much more complex. The findings from this research are used to explain the difficulties encountered by ESL students in nursing programs. Cummin's theoretical model indicates ESL students may have difficulty with interpersonal relationships and cognitive academic language acquisition because of the difference in contextual communication and learning styles. Academic activities (lectures, textbooks, classroom discussion) considered cognitively demanding but low context, present difficulties for students accustomed to high context communication styles. This model suggests that faculty can meet and support the learning needs of CDNS (in this case ESL) students by devising teaching strategies that provide high context learning activities (Abriam-Yago et al). Another interesting model associated with teaching CDNS is the Pathways model (Rew, 1998). Intrinsic to this model is a process approach for affirming cultural diversity among nursing students, a process wherein a travel metaphor is applied to describe CDNS. The underlying assumption to this model is that CDNS have travelled 'different' roads on their way to nursing education—these different paths are reflected in the diverse knowledge, skills and attitudes that these students may have obtained through their travels. Interaction with the environment is crucial to this model, for it is assumed that as one travels the different roads one Cultural Differences 27 will interact with different environments thereby gaining valuable experiences and knowledge. This model directs nurse educators to develop a 'learning landscape" and pathway to success for CDNS which permits the sharing of resources and knowledge within the learner-educator relationship. A similar framework described in the literature discusses curricular transformation in nursing education (Saylor & Taylor, 1993; Sturch, 1994). Discussions within this literature, centre around the idea that nursing education approaches need to be transformed to make the learning experience relevant to the CDNS, suggesting that this is best done by drawing on the students' own life experiences. This framework asserts that there is often incongruence between Western theory and the CDNS's own cultural perception of reality. Authors who promote this curricular transformation convey the notions that students and faculty must share worldviews within the student/faculty relationship, thereby ensuring that the CDNS own culture is not eroded (Crow, 1993; Gay-Templeton, Edgil & Stullenberger, 1993; Snead, 1982). The curricular transformation framework and the Pathways model both seem to present arguments against the assimilation model of nursing education. Various other frameworks for teaching CDNS are borrowed from existing nursing practice models that have been adapted for nursing education. An example of this notion is the suggestion from Abriam-Yago et al., (1999) that Leininger's Sunrise model could be used to direct the teaching of CDNS. The utility of the Sunrise model to nursing education appears to be related to the importance this model assigns to the influence of language and environment as it pertains to an individual's perceptions and interactions; it is suggested that these interpersonal and intrapersonal elements are crucial to the teaching of CDNS. Similarly, Rossiter et al. (1998), Cultural Differences 28 in a quest to gain knowledge related to how nursing programs could successfully develop and implement strategies to recruit and retain culturally diverse individuals, conducted a quantitative study using Leininger's cultural care diversity and universality theory as a way of examining the career preferences of culturally diverse high school students. Another body of literature within the nursing education literature explores the various supports and resources available to CDNS. Many studies within this literature, examine the recruitment and support strategies of various nursing programs, with many of these authors suggesting nursing programs must devise and implement policies to ensure adequate educational support services are in place to enhance the success of CDNS (Condon, 1996; Dowell, 1996; Kevern et al., 1999; Merrill, 1998). The findings from Condon's study add complexity to this issue for she concludes that even when support service are available, they are underutilized by CDNS as well as, by 'traditional students'; she suggests that fear of being stigmatized and lack of available time to devote to remediation programs are two possible reasons for this occurrence. Furthermore, Condon reports from her findings that even when the educational support programs were utilized, students did not necessarily do any better in their nursing studies suggesting that CDNS may end up spending more time on remediation work than nursing studies. Additionally, some authors believe there is a lack of long-term commitment to specific comprehensive programs aimed at retaining CDNS; also it seems that when these programs exist, they are of a low institutional priority and therefore poorly funded (Campbell & Davis, 1996; Merrill). As an interesting aside to this particular topic, the general education (K-12; generic post secondary education) literature appears to convey a greater awareness of the need to be aware of and appreciate the cultural differences among individuals. The general education system has had Cultural Differences 29 to keep up with the changes in society for virtually all individuals will in some way go through this system. This may explain the many studies contained within the general education literature that are devoted to examining the concept of cultural diversity in relation to the development of teaching polices aimed at meeting the needs of culturally diverse students within this system. Reasons for this extensive research may be the fact that the general education system is under a great deal of public and political scrutiny; the general education system has as its mandate the responsibility of ensuring public education meets the needs of society. Much of this literature seems to give credence to the empowerment model wherein diverse students are encouraged to maintain and express their cultural backgrounds. This ideology appears appropriate and reasonable when one considers that in K-12 programs, students are not selected but rather they are a cross section of individuals in the current society. Therefore, the general education field appears to have experienced an educational multicultural reform movement as a way of ensuring that all students have equal opportunities to learn (Garcia, 1999; Kim, Clarke-Ekong & Ashmore, 1999; Levin & Riffel, 1994; Yoder, 2001). In summary, a review of this body of literature indicates that although great strides have been made in revising nursing program curricula, philosophies and policies, CDNS continue to experience difficulty learning within nursing education programs (Abriam-Yago et al.; Campbell & Davis; Merrill, 1998; Yoder, 1996). In spite of the fact that nursing programs have been attempting to resolve many of the issues surrounding the recruitment and retention of CDNS, the numbers of culturally diverse individuals within nursing programs remains proportionally low in comparison to the numbers of culturally diverse individuals in society. Cultural Differences 30 Lived Experience of Culturally Diverse Nursing Students A segment of the nursing education literature focuses on the lived experience of CDNS and examines the many personal and contextual issues related to this experience. Within this literature, these issues are often discussed under categories such as: cultural isolation, alienation, lack of support, cultural conflicts, communication difficulties, and lack of role models (Abriam-Yago et al., 1999; Campbell & Davis, 1996; Condon, 1996; Dowell, 1996; Kevern et al, 1999; Kirkland, 1996; Kosowski, Grams, Taylor, & Wilson, 2001; Yoder, 1996). Although many of these issues are considered to be associated with various individual, social and environmental factors, much of the literature indicates these issues are a direct result of the lack of diversity that continues to exist within nursing programs (Abriam-Yago et al.; Campbell & Davis; Dowell; Shakya, & Horsfall, 2000; Yoder, 2001). Many studies in this body of literature report findings that suggest CDNS often feel a lack of support within their nursing programs, resulting in feelings of alienation and isolation. Many of these studies suggest that a supportive student-faculty relationship is essential in creating a positive and accepting learning environment which will subsequently contribute to the success of CDNS in nursing programs; it is evident from this literature that this type of supporting relationship allows the student to feel comfortable, share perceptions, clarify learning and be able to ask for help (Campbell & Davis, 1996; Josipovic, 2000; Kevern et al, 1999; Randle, 2001; Yoder, 1996; 2001). These authors suggest that faculty commitment to nurturing CDNS is more important to academic success than organized academic remediation programs. For this reason, many authors within this body of literature promote faculty professional development related to cultural diversity; the goal of this faculty development is to ensure Cultural Differences 31 educators become more cognizant of cultural differences through strategies such as developing an awareness of their own cultural beliefs and values, with an understanding of how these may influence their relationships with CDNS—the premise being that this knowledge will enable them to provide CDNS with the support they need within their learning experience (Campbell & Davis; Leininger, 1989; Yoder). Many of these authors also suggest 'majority' faculty must develop sensitivity and awareness to the issues faced by CDNS, but it is unclear from their discussion how this is to be achieved. In addition, Kevern et al., suggest that nurse educators must become aware of and develop their mentoring supportive role in order to adequately support CDNS in their learning endeavours. Unfortunately, many of the studies in this area also conclude with the caveat that all too often nurse educators with their various teaching, research and administrative commitments do not have the time or resources to foster supportive nurturing relationships with students (Kevern et al; Campbell & Davis). As a final point in this area, Kevern et al., propose that further qualitative research needs to be done to assist nurse educators in understanding the social experience of CDNS, suggesting that this knowledge will assist nursing programs in developing adequate support systems for them. In conjunction with a lack of support, some studies present findings wherein CDNS have reported that there is a paucity of available role models for them in most nursing programs—a fact that is considered by some authors to be a direct result of the cultural homogeneity among nurse educators (Campbell & Davis, 1996; Yoder, 2001). The assumption by many authors seems to be that role models are crucial for the success of all students but especially CDNS— these authors suggest that it would be beneficial for nursing programs to recruit faculty that have had multicultural preparation and/or have diverse backgrounds as a means of providing role Cultural Differences 32 models for CDNS. In addition, findings from some studies report that CDNS believe faculty with diverse backgrounds are more supportive in their learning endeavours (Campbell & Davis; Canales & Bowers, 2001; Yoder, 1996; 2001). Kosowski et al., (2001) present similar findings from their critical phenomenology study involving 10 African American students within a predominantly 'white' nursing program. The authors discovered that the students from this study felt they needed to bond with faculty or peers in order to feel a sense of being connected or belonging, and that this feeling of being connected was crucial to their success. What seemed to surface from this particular study as a key factor to feeling connected was not only the notion that students need to receive support through the process of faculty mentoring, but that it was critical that this mentoring was with a faculty who was from a culture similar to that of the student. Some authors report that CDNS often experience communication difficulties and barriers within their learning environment (Randle, 2001; Shakya & Horsfall, 2000; Villafuerte, 1996). These communication difficulties are often related to language differences but may also be associated with differences in social customs and values thereby influencing many interaction and relationship protocols. In addition, communication difficulties can negatively influence help seeking behaviours resulting in academic difficulties for these students. These authors believe communication is critical to the learning processes of all students and especially CDNS, such that communication difficulties can contribute to feelings of isolation and decreased self-esteem often resulting in tensions or conflicts within student-faculty and/or student-student relationships thus affecting the learning and social environments of CDNS. Yoder (1996, 2001) believes cultural conflict and cultural isolation are intrinsic to the Cultural Differences 33 lived experience of many CDNS. She reports from her studies that CDNS often experience cultural conflict as they struggle to adjust or adapt to the traditional perspectives of their nursing programs—often this struggle culminates with a loss of individual values. In addition, CDNS experience feelings of frustration as they attempt to make their cultural values known and respected by faculty and peers (Yoder). Along these lines, some authors present the argument that when cultural diversity is not understood, valued or acknowledged, students will experience feelings of alienation, invisibility, low self esteem, anxiety, pressures to conform and cultural isolation—all things which will negatively impact the learning environment (Campbell & Davis, 1996; Yoder). Adding credibility to these ideas, Kevern et al. (1999) suggest from their findings that although the statistics on student success and attrition are important, more attention needs to be paid to the processes and transitions CDNS experience as they negotiate their learning environments. According to Kevern et al., focussing on the experience of CDNS will not only inform educators on how to meet the challenge of teaching CDNS but will also demonstrate a respect for cultural differences, a notion that also has the potential of enriching the learning experiences of all students in relation to cultural diversity. As is evident from the literature associated with student success, one of the biggest barriers for CDNS seems to be a feeling of alienation with its resultant lack of self-esteem and self respect; it seems students must be able to identify with their learning environment and feel accepted to be successful (Campbell & Davis, 1996; Condon, 1996; Dowell, 1996). Condon, in her large quantitative research study, tentatively coined the intriguing term 'social comfort' to represent the feeling of 'fit' or 'belonging' as verbalized by some nursing students in her study. She found that nursing students who were enrolled in programs with peers who had similar Cultural Differences 34 backgrounds and educational experience were much more successful than those students who were in programs in which they were considered 'different'; students in Condon's study repeatedly described the need to feel like they 'belonged' or 'fit in' . The idea of social comfort is echoed in various conceptualizations within the cultural diversity and nursing education literature. For example, Yoder (1996; 2001) identifies that a comfortable supportive environment is crucial to the 'bridging' approach to teaching CDNS—wherein teachers create a comfortable learning environment for students by correctly interpreting and acting on cues sent by students; in this way students feel their cultural differences are acknowledged, welcomed and taken into consideration within the teaching/learning process. Similarly, Campbell and Davis discuss the need for faculty to be committed to student success by having the knowledge and abilities with which to provide competent didactic instruction in conjunction with the capability to understand the students' background thereby being able to provide comfort and support to students during the learning experience. An interesting parallel conceptualization comes from Kevern et al.'s (1999) study in which they suggest that nurse educators must develop their 'pastoral' role in order to adequately support the non-traditional student. Kevern et al. do not define this term but the use of the word in their findings conjures up the idea of a supportive educator that provides solace and comfort within the learning experience. Conclusion The concept of cultural differences in today's world is multidimensional in nature reflecting the biological, sociological, contextual, and environmental differences that exist between and among individuals. Globalization of our world seems to suggest that an expanded definition of cultural diversity is essential to understanding the CDNS. Considering the Cultural Differences 35 complexity of the notion of cultural diversity in today's society, it seems imperative that the profession of nursing also reflect a broad perspective of cultural diversity in all of its substantive fields. Therefore, it is interesting to note that the nursing and nursing education literature predominantly contain limited depictions of cultural diversity—the term is used most often to refer to individuals who are members of visible or traditional minority groups, meaning those who differ because of racial or ethnic backgrounds. However, it is apparent from various definitions of cultural diversity within the general culture literature, race and ethnic origin are only two examples of the differences among individuals; consequently it seems logical that the diverse or non-traditional nursing students must also refer to those individuals who differ from their peers due to a variety of factors such as age, life experiences, disabilities, gender, class (as well as ethnic differences). From what has been written in this area, it seems nursing education programs must ensure their organizational structure, academic policies, philosophy and curriculum are grounded in a wide-ranging multicultural ideology so as to graduate increased numbers of culturally diverse nurses and/or more nurses who are able to provide culturally appropriate care to increasingly diverse client populations. Nursing programs have been evolving to mirror the multicultural trends of society and have established curricula aimed at meeting the needs of diverse populations, but it seems they are still have difficulty attracting, retaining and graduating CDNS—suggesting that the historical perspectives of the nursing profession (white, female, middle class and Anglo Saxon) continue to influence nursing education. In addition, many authors suggest the origin of many of the struggles in nursing education associated with diversity are related to the cultural homogeneity evident among faculty and student populations within many nursing programs. Cultural Differences 36 A great deal of the nursing education literature is devoted to issues associated with the teaching of CDNS, and from studies done in this area it seems many nursing programs have instituted organizational and curricular revisions aimed at attracting and retaining CDNS. Various frameworks for teaching CDNS are discussed within the literature and many of these frameworks support the notion that student-faculty relationships and interactions are crucial to a successful and positive learning experience. Supportive student-faculty relationships that reflect awareness and acceptance of differences are seen as contributing to a feeling of belonging or 'fit' for CDNS thereby alluding to the importance of social context and communication to the learning processes of CDNS. Additionally, a smaller portion of the nursing education literature reports findings related to the lived experience of CDNS in an attempt to discover the personal and contextual concerns of CDNS within nursing programs. Qualitative and quantitative research methods have been employed to examine issues related to the teaching of CDNS and to their lived experiences; in addition anecdotal discussion papers abound in the literature wherein the authors (as nurse educators) present their perspectives related to teaching CDNS. A predominant theme in this literature is the academic deficiencies and abilities of CDNS, with the focus being on how to develop academic programs to resolve these deficiencies thereby assisting students to be successful. Many nursing education programs have been focussing on ways to assist CDNS with issues related to academic success—articles abound which present teaching strategies that take into account language, academic preparation and learning styles of CDNS. Also, it is interesting to note that many frameworks developed for teaching culturally diverse students have been adapted from nursing practice frameworks suggesting that nurse educators need to engage in a process of assessment, planning and intervening when teaching CDNS. Cultural Differences 37 An important caveat to any discussion of cultural diversity in nursing education is the awareness that not all CDNS need recognition of their cultural diversity to be successful in their nursing programs, many are able to maintain their cultural identities and still accommodate to the values and beliefs of nursing programs (Yoder, 1996). The literature clearly states that while it is unacceptable to minimize cultural differences, it is also erroneous to assume differences are always a disadvantage (Lea, 1994). The crucial idea these authors propose is that nurse educators need to be able to identify or assess circumstances in which cultural differences may result in barriers to success for the students—meaning educators must be able to identify cultural differences within nursing student populations and be able to devise supportive teaching strategies to assist CDNS in their learning processes. As I perused this body of literature, I found it was interesting to note that much of what is written has been written from the perspective of nurse educators as they endeavour to meet the challenge of teaching CDNS, or from the viewpoint of culturally diverse nurses who have already graduated and are commenting on their experiences as CDNS. In addition many studies utilize existing educational data (i.e. attrition and success rates) suggesting a retrospective examination of the subject. There appears to be limited qualitative research that examines the influence of social context to the learning experience of CDNS from the perspectives of those individuals who are still students within nursing programs. Finally, the studies that have investigated the lived experience of CDNS have done so using traditional definitions of diversity and therefore the majority of the literature is associated with nursing students who differ because of ethnic or racial backgrounds. Very little nursing education research employs an expanded definition of cultural diversity that reflects society's trends in this area—its seems crucial to Cultural Differences 38 discover 'who' is culturally diverse in the nursing programs of today. Preliminary Organizational Framework for Study Using the perspectives of the nursing profession in conjunction with the insights derived from the review of the literature the following conceptualizations formed a preliminary organizational framework for the study: • Social context may be an important element in the learning environment of CDNS. This idea would signify the need to experience a sense of belonging or fit within the learning process; this may also entail an understanding of the values and beliefs of the mainstream student population. Students need to feel comfortable asking for assistance and sharing their perceptions within any learning environment. The idea of considering the role of social context to the lived experience of CDNS would correspond with the current nursing paradigm in which a holistic perspective is used to view clients. Utilizing a holistic perspective to understand the clients' lived experience results in an awareness and acknowledgment of the clients' diverse background and needs. The assumption is that CDNS must feel valued and must be able to feel safe within their learning environment. • A crucial element in any study on diversity is the acknowledgement of similarities. Not all CDNS are dissimilar to the mainstream student population and therefore it is crucial to also be aware of any similarities between CDNS and the mainstream student populations. This must be done to avoid making assumptions about groups and individuals. This is true within the nursing practice field as well—much of the literature Cultural Differences 39 indicates that while a need exists to be aware of and acknowledge the differences among various individuals, it is also imperative to be aware of the similarities among individuals and groups. Positive supportive relationships and interactions may also be key in the development of a positive learning environment for CDNS. This would mirror the caring and respect involved in the nurse-client relationship that is the foundation of nursing practice. Caring and respect seem to be crucial elements in the relationships and interactions that occur between CDNS and faculty, CDNS and other students, CDNS and nurses. Positive supportive relationships and interactions require open and direct communication styles as is true for any nurse/client or professional relationship. The literature points to self-esteem and a positive self-regard as being crucial to the learning process. Interactions within the teaching/learning relationships must focus on maintaining the self-esteem of the learner. The learning process is interwoven with self-esteem and self-respect. Students must be able to identify with the learning environments and must feel accepted to learn. These ideas reflect the teaching/learning process utilized with clients in which nurses strive to make the environment conducive to client learning. Globalization has produced a world in which traditional cultural categories no longer are adequate in defining who is culturally diverse—many cultural groups that were considered a minority in the past are now considered a majority. This is true for the client populations that nurses care for and therefore it must follow that this be true for nursing student populations—there seems to be a gap in the identifying 'who' the CDNS is. It seems apparent then that nursing educators must be able to distinguish differences and similarities among nursing students. Cultural Differences 40 CHAPTER THREE: RESEARCH DESIGN Introduction This exploratory qualitative study has attempted to elicit the perspectives of baccalaureate nursing students in relation to the influence of cultural diversity and social context upon their learning experiences. The current thinking in cultural diversity research directs an interpretive approach for this study. For many years the anthropology and nursing disciplines used quantitative research methods to study and describe different cultures. It was soon discovered that such studies, although statistically descriptive, were somewhat hollow in their ability to describe the richness of cultural information such as beliefs, values and ways of life; qualitative research methods began to be used with much better success to examine cultural differences among and between people (Leininger, 2001). Interpretive descriptive methods possess many possibilities as qualitative designs which researchers can utilize to discover, explore and interpret covert truths associated with various cultural groups and the myriad of cross cultural interactions that occur in today's world (Spence, 2001). For this reason, the research design chosen for this study is noncategorical interpretive description (Thorne et al., 1997). Employing this type of design meant that the philosophical and theoretical foundations of nursing and nursing education were used as a guide to understand how the CDNS of this study described and perceived cultural differences, and how they understood these differences to influence the learning environment. Also, this design seemed appropriate to exploring how these students described and interpreted feelings of social comfort and discomfort within their learning milieu. Nursing and nursing education are considered dynamic interpersonal practice disciplines Cultural Differences 41 wherein the intrinsic interactions involve emotional and cognitive factors as well as a multitude of cultural, historical and political contexts (Spence, 2001). The complexities involved in examining and understanding the lived experience of CDNS within nursing programs are suited to the use of interpretive description as a method for this study. The philosophical basis of this type of design is that 'understanding' is both a process and a mode of being whereby traditions and meanings are inherited through language and the non conscious process of socialization (Spence). Interpretive description as design provides for in-depth understandings of the lived experience of individuals and the meanings individuals assign to these experiences (Mertens, 1998; Spence). In the past, much of the research devoted to cultural differences has been qualitative in nature wherein the findings reported were causal, correlational or comparative and often considered to be generalizable to other contexts and/or populations. The findings from many qualitative methods differ in that generalizations to other populations cannot be easily assumed, as many qualitative studies seek to discover underlying and often covert phenomena, resulting in studies that are by necessity small scale in size. Historically cultural differences in nursing and nursing education have been researched from the perspectives of various disciplines such as anthropology, sociology, education and philosophy. It follows then that the development of conceptual and descriptive frameworks related to nursing education and cultural differences that originated from these methods of inquiry may not necessarily correspond with the unique perspectives and visions of the discipline of nursing. Therefore, a formal descriptive or conceptual framework is not part of an interpretive descriptive research design rather a preliminary organizational framework is developed from an analysis of the existing available knowledge. The preliminary organizational framework for this Cultural Differences 42 study was formulated from the literature related to cultural differences within the nursing and nursing education disciplines and provided direction for the processes of data collection, analysis and interpretation. A crucial component to this type of design is the notion that the analytical framework is not static, therefore, the parameters of the preliminary organizational framework shifted as the study proceeded and as the inductive process revealed insights not included in the preliminary framework (Thorne et al, 1997). Utilizing this design ensured the study adhered to the principles of qualitative inquiry for nursing science but at the same time permitted an exploratory and discovery approach to the topic. The education of nursing students involves a faithfulness to the values, beliefs and assumptions of the nursing profession, therefore having used an interpretative descriptive approach in this study to access knowledge about cultural differences and the social context of the learning environment as constructed by these nursing students, meant that the concept of cultural differences was examined from the unique perspectives of the nursing profession. Recruitment, Sampling and Informants I utilized theoretical purposive sampling for this study. Participants were recruited through the use of third person recruitment strategies (recruitment posters and letters of contact to faculty and staff; posters—See Appendices I and II). In addition I went to various classes to hand out recruitment flyers and give a short (5-10 minute) presentation introducing and explaining the study. The participants for this study were recruited from a variety of schools of nursing. In recruiting for volunteers it was made explicit that anyone who felt they were culturally diverse or had an interest in cultural diversity were welcomed to be part of the study. In presentations to the classes of students and in recruitment flyers, those individuals with visible diverse ethnic or Cultural Differences 43 racial backgrounds were invited to participate as well as those that felt their difference(s) to be invisible one(s). An expanded definition of cultural diversity was provided to all potential participants through email memos, recruitment flyers and from my personal presentations to each class. I structured the recruitment process so as to have participants self select for the study based on their perception of being culturally diverse in relation to their peers; in addition the process also invited those interested in cultural diversity with goal being to obtain data on how nursing students define and perceive cultural diversity/differences. Traditionally, cultural diversity refers to individuals who are ethnically or racially diverse. Based on current culture literature that gives credence to broad definition of diversity, I hoped to attract those individuals who had different life experiences from the majority population (in this case the nursing body), such as socio-economic and socio-cultural variations, as well as those individuals who differed because of racial or ethnic backgrounds. In this way, individuals from the majority student population who were 'diverse' but in a non traditional sense could be included in this group. Similarly, those who were from a minority group but who may actually be more similar than different from the majority population would not be singled out and stereotyped. Participants were recruited from the third and fourth year of various baccalaureate nursing programs. Inclusion criteria included: (1) any student who was currently enrolled in a program of nursing studies leading to a baccalaureate degree and (2) any student who was interested and willing to share their experiences and perceptions related to cultural diversity and the social context of learning. Exclusion criteria included any individual who were known to me personally or professionally. First and second year nursing students were also excluded from the Cultural Differences 44 study, as they were involved in general studies and did not as yet have any experience with nursing education or practice. Characteristics of the Participants A total of five participants volunteered for the study (others expressed an interest but were unable to commit due to time and school pressures). A l l participants were female between the ages of twenty and twenty-eight years old. A l l participants were in either third or fourth year of a baccalaureate nursing program. Each participant identified herself as being either culturally diverse or culturally different from her particular nursing group. Three out of the five participants expressed that they were diverse on multiple fronts but none of the participants indicated they were diverse because of racial or ethnic backgrounds. The specific cultural differences expressed were socio-economic and lifestyle related: "street involved" and a "recovering addict" background; "strict religious" background; small town upbringing; lower socio-economic class; sexual orientation, and being a young unwed mother. A l l participants stated they were interested in cultural diversity, and often a cultural diversity class or some other sociological or anthropology class they had taken as part of their education had triggered this interest. In addition, all participants at the beginning of each interview expressed a seemingly altruistic reason for volunteering, they indicated that wanted to be of assistance to the researcher in conducting this study because they felt that they may one day be conducting their own research and be needing participants (one participant identified this as "karma"). Ethics Application for ethical approval was obtained from the University of British Columbia Behavioural Research Board (see Appendix LTJ). Research protocols were in place and adhered Cultural Differences 45 to as a way of ensuring confidentiality, anonymity and privacy of the participants. Participants were assigned a participant number to ensure confidentiality any demographic data used has been presented in such a manner as to protect the identity of the individual participants. In addition, any data collected has been kept secure and confidential—participant responses have been kept confidential and used for analysis and interpretation of data only. Verbatim transcripts in written form are secured in a locked filing cabinet at my place of residence. Computer based data (transcripts and analysis of transcripts) are kept on a password secured file on my home computer. Back up computer files are on disc and are also secured in a locked filing cabinet at my place of residence. I directed the hired transcriptionist to delete any related files from her home computer. I will retain the documentation of data analysis and findings for a period of five years from the date of formal approval of the completed thesis by the Faculty of Graduate Studies (UBC). After the five-year period has elapsed I will destroy all verbatim transcripts and computer files. I reviewed the consent form (see Appendix IV) with each participant before beginning any interviews, ensuring that the participant was fully cognizant of the parameters of the study. The purpose of the study was fully disclosed to the participants and any questions were answered. Participants agreeing to participate were asked to voluntary sign the consent form. If any participant did not feel comfortable with any part of the consent form or the study, the session would have been terminated and the participant would have been unconditionally released from any obligation to participate. If the participant agreed he/she was provided with a copy of the signed consent form. In addition after signing the consent form, as a way of tracking the characteristics of the participants, each participant was asked to fill out an anonymous Cultural Differences 46 demographic questionnaire (see Appendix V). Participants were free to unconditionally withdraw at any time during the course of the study without impact on their status in their program of studies. Participants also knew they had the right to decline to answer any question at any time during the study and/or request to have any section(s) of the audiotapes and/or transcripts be erased/deleted. Upon completion of the study, participants will receive a written summary of the study findings and will be informed as to where the completed thesis will available for their perusal. Participants may or may not have benefited from being involved with this study. At the very least it is hoped that the participants will have reflected on the meaning of cultural diversity and its influence on their learning and clinical practice as nursing students. Another potential benefit for the participants is their knowledge that they may have contributed to an enhanced understanding of how nursing programs can meet the needs of culturally diverse nursing students. This understanding may provide direction to nursing programs on how to attract, retain and graduate students from diverse cultural backgrounds, thereby increasing the diversity among the members of the nursing profession the participants are soon to enter. Data Collection Initial contact occurred when the participants contacted me via phone or email indicating their interest in being involved in the study. At this point, I explained the study further i f necessary and provide answers to any questions the potential participants may have had. An appointment for an interview session was made for a mutually agreed upon time and place. The interviews lasted approximately 1-1.5 hours and were organized as a semi-structured interview in which I posed some open-ended initial questions as a means of collecting data (See Appendix Cultural Differences 47 VI). Each interview was audio taped and I took some very brief notes during the interviews if necessary. The audiotape did not function well for one interview, following the interview I formulated extensive notes on what I could recall from the interview. The participant agreed to a second interview during which I clarified and confirmed my notes with the participant and invited her to elaborate further on some topics. Following each interview, I made note of any insights and ideas that surfaced from the interview and I used these notes to track my inductive processes. A transcriptionist transcribed each audiotape verbatim. I reviewed each tape and transcript making further notes in my study journal. At the completion of the study, each participant received a written summary of the study and information as to where and how to access the completed thesis. Analysis and Interpretation of Data I recorded any emerging insights, ideas and conceptualizations in a study journal hoping to ensure a dynamic inductive analysis. Following each interview I documented any insights or ideas that arose from the interview. I listened to each audiotape, read the written transcripts and make further entries into the study journal. Analysis began after the first interview so that any new ideas and concepts, which surfaced, could direct subsequent interviews. This method allowed adjustments to the preliminary analytical framework so that subsequent data collected was interpreted utilizing the concepts that related to the participants experience. Expert informants (faculty, thesis committee members) were asked to review conceptualizations and provide input to the analytical framework as it developed. In addition, I continued to peruse any pertinent literature related to cultural differences and nursing education. Cultural Differences 48 Rigor Rigor in research refers to the ability to ensure validity and reliability of the findings (Morse & Field, 1995). The traditional criteria for rigor as stated by Lincoln and Guba (1985) refer to truth value (credibility), applicability, consistency and neutrality. These criteria are well suited to empirical research but are sometimes difficult to meet in qualitative research (Morse & Field). It is difficult to find one truth in qualitative research for often the data points to multiple truths, therefore the researcher must report the informants' perceptions and viewpoints accurately. Consistency is also a difficult criterion to meet in qualitative research. What is crucial is the personal experience of the participant and therefore variations are expected; the variations often provide additional insights to the phenomenon. The qualitative and exploratory nature of this type of inquiry limits the applicability and generalizability of the findings. Although these findings present in-depth descriptions and interpretations specific to the lived experience of the study participants, they may yield valuable insights that may lead to greater understanding within a larger context of the experience. Ensuring rigor or trustworthiness in qualitative research requires that the researcher spend long periods of time immersed in the data. In this study, maintaining an audit trail of the interpretive logic and consultation with other researchers served as additional strategies to enhance the rigor of the research. Qualitative researchers must also be aware of and document personal contexts and biases throughout the study in order to understand how these may influence the analytical process and to ensure some measure of neutrality. Although an interpretive description design acknowledges the researcher's background and experience as being an integral part of the inductive analytical process, care must be taken to ensure that the findings are derived from the participants' Cultural Differences 49 description and perception of the phenomenon being explored, rather than the study being a vehicle with which to present the researcher's biases and beliefs related to the topic under study. Ensuring rigor for this study meant that I needed to be constantly aware of my role as a practicing psychiatric and general nurse, as a nurse educator, and most importantly my own history as a non-traditional CDNS. I was aware of the presence of these personal contexts throughout the study and realized the potential for bias within the data collection, analysis, and interpretation processes. For this reason I felt it crucial to document my thinking, decisions, choices, and insights throughout the entire research process. I compiled dated field notes and kept a study journal that I reviewed periodically attending to any potential areas of bias or personal slant. Further to this I discussed emerging ideas and insights with my thesis committee members remaining open to any feedback regarding the emergence of personal biases in the study processes. Summary In this chapter, I have presented an overview of the research approach of interpretive description and how this approach was implemented in the design of this study. I also included a brief description of the characteristics of the participants of this study as a way of situating the findings that emerged from the data collection process. The findings of the study will be presented in chapter four. Cultural Differences 50 CHAPTER FOUR: FINDINGS Introduction My aim in conducting this study was to develop an understanding of cultural differences and how these differences may relate to the social context of the learning environment as constructed by nursing students. The path to this understanding is portrayed in this chapter in which I present the findings which emerged as I analyzed the data from in-depth interviews with five baccalaureate nursing students who had self identified as being culturally diverse or different from their peers. As each participant conveyed her unique narrative, it became apparent to me that there were certain common themes to all these stories, themes which revealed the participants' experiences with being culturally diverse and how these experiences influenced their social and learning environments. The findings presented within the first theme of "being culturally diverse' describe how the participants conceptualized and defined cultural diversity. Secondly, the findings related to "experiencing cultural diversity' provide a glimpse into the lived experience of being a culturally diverse individual within a nursing program. Lastly, the findings associated with the third theme, "managing diversity' describe the processes utilized by the participants to cope with their perceived diversity. These themes illustrate the commonalities in experiences related to being culturally diverse among this group of students who are so different from each other. In addition, any variation among the students' narratives that seems significant to the conceptualization of the lived experience of culturally diverse students will also be presented. An understanding of these common themes, how they are interconnected, how they vary and how they may be linked to social context/environment will serve to illuminate what it means to feel different or diverse from one's peers in a nursing program. The findings of Cultural Differences 51 this study appear to highlight some slightly different issues from that which might be expected from a review of the literature in this field, therefore the discussion chapter that follows will present additional analysis of these issues. Being Culturally Diverse In analyzing the themes that surfaced from the interview data this particular theme seemed to be the basis or the 'jumping off point' in the process of understanding how the participants of this study constructed cultural diversity in relation to the social context of their learning environment. I have provided descriptions of how the participants self-identified as being culturally diverse to have some comprehension of their conceptual thinking in relation to cultural diversity. Adding layers to these conceptualizations, findings associated with how the participants intellectually defined cultural diversity as well as some notion of how (and why) they perceived others to be diverse are also presented. Inherent within their description of how they came to consider themselves culturally diverse, participants also provided information on their background, life experiences and current life transitions, information which I incorporated into the findings if they appeared to be relevant to how the participants self-identified as being culturally diverse. Defining Cultural Diversity Each participant identified herself as being either culturally diverse or culturally different from her particular student nursing group. A l l five participants also expressed that they were diverse on multiple fronts and some commonalties were evident among them in relation to their various differences. The differences cited by these students for being culturally diverse from their peers are as follows: sexual orientation, small town/rural upbringing, lower socio-economic Cultural Differences 52 class, strict religious upbringing, history of substance abuse/street involved, young unmarried mother, sheltered upbringing. What struck me as an interesting was that each participant was unique in how she perceived herself to be different—as each differed from the others in what she described as the primary reason for feeling different from her peers. Another interesting aspect of how each participant self-described herself is that each one considered herself a minority among her peers in relation to her cultural diversity. In addition, all the participants differed somewhat in the comfort level they demonstrated when they conveyed their diversity during the interviews—their disclosures ranged from being 'open and matter of fact', 'reserved and covert' 'to 'tentative and somewhat flippant', and unexpectedly one participant became visibly distraught when disclosing her 'difference' to me. Finally, contrary to the literature reviewed for this study, none of the participants were of a visible ethnic or racial group. Some of the participants indicated that they were of various ethnic backgrounds but none identified this as a primary source of feeling culturally diverse. A remarkable finding connected with this theme is that each participant self-identified as being different based on something other than the usual racial or ethnic grounds that are commonly ascribed to as cultural diversity. It seemed obvious to me at first that the way in which these participants self defined as being culturally diverse must mean that they were operating from a much broader definition of cultural diversity than is evident in the literature—each one of them seemed to have an awareness or understanding that being diverse meant much more than having a visible/invisible racial or ethnic background—in fact each of them defined diversity as being associated with an individual's life experiences, life style choices and background. An interesting perspective from one participant that illustrates an expanded view of cultural Cultural Differences 53 diversity as well as presents the notion that culture is how one's life experiences influences current contexts, is her comment that culture can be described as: ... people's life experiences, their background, and how they look at things differently ...I think culture is a lens with which to view your life experiences that you are having now so I mean anything that you've done in the past or seen in the past whether that is the country you came from or whatever, its going to affect the way you see things now. Most of the other participants' verbalized similar comprehensive definitions of cultural diversity such as the one presented by this student which portrays diversity as a unique personal narrative, .. .1 think everybody is diverse... to me everyone has a story to tell and everyone comes from a different background, different relationships, different religions, different everything... my big thing is everybody has a story... or as another student indicated in describing culturally diverse groups, ... a group ofpeople with different belief systems... different way of acting. It could be just any group of differences... racial, gender... anything... basically every person is different but like there is homogeneity in some groups, but interestingly this same student did not consider herself culturally diverse, for she stated, "cultural diversity is not something I'd associate to myself I'm more unique or different", a comment that may reflect the entrenched connotation of the term culture in our society (especially considering that I had specifically indicated to all participants that I was using the term cultural diversity broadly to mean differences of any sort). In addition, it was interesting that the latter two quotes incorporate the concept of uniqueness into the definition of diversity— an interesting idea to ponder for it suggests differences is the key to understanding diversity Cultural Differences 54 rather than similarities. As I thought about the data and wondered how each of these individuals had come to conclude they were diverse, I found that all the students except one referred to some event or situation they had experienced in their nursing program as the trigger that led them to deduce that they were diverse. This is not to say that these students were completely unaware that they might be different from their peers before entering their programs, but only that this awareness seemed to become more acute through actual exposure to the culture of their nursing program. One student commented that once you are in nursing " you run into a lot of ethical belief systems ... and you realize that where you are standing is different than a lot ofpeople " and she suggests that this exposure causes "you to see a difference in your belief system because get some interesting comments about your beliefs". The one student who did not fall into this category was the one that was the most 'extreme' (self defined) in her diversity. This student was also the most articulate in her definition of diversity and demonstrated the most comfort in disclosing her diversity. This student had entered her program with a preconceived notion that she would be different from her peers—a notion that alludes to how society views nursing education. Perceiving Cultural Diversity At this point a certain irony surfaced into my consciousness. In the process of verbalizing insights associated with the concept of cultural diversity, the participants offered their perceptions of who they thought was culturally diverse in their class. Therein, surfaced the puzzle for me—most of the participants seemed to initially focus on those individuals that were of an obvious racial or ethnic background followed by examples of those who were different because of various backgrounds and life experiences (such as divorce, choice of life-style, Cultural Differences 55 mature students, mothers, etc). Pondering this surprising and unexpected paradoxical finding associated with the inconsistency in perceptions of diversity, a simple explanation seemed to be that physical attributes are noticed first when one is not personally involved with another individual (explaining why the visible minority groups within their classes came to mind first for most of these participants when thinking about diversity). In addition, I suspected that there might be some other shared feature among the participants influencing their notions of cultural diversity. I noted that a commonality among them was that all the participants had taken or were taking various 'culture classes' in their current education. Therefore, I surmised that there might be some connection between how the participants felt they should define cultural diversity and the fact that they had all been exposed to diversity concepts through these 'culture classes'. In fact some of the participants indicated they "would not have included life experiences'" in their definitions of diversity prior to having taken these classes. As I thought about this data I tentatively deduced that exposure to these diversity classes may have been the beginning of a process I have labelled 'rearranging'. This 'rearranging' meant that these participants, at the time of the interviews, may have been involved in the mental rearranging of their existing conceptualizations of cultural diversity as a result of having been exposed to various diversity concepts within their 'culture' classes. I have chosen to label this process as a 'rearranging' because all except one participant (an exception which I will discuss below) seemed to struggle somewhat when expressing their ideas of the meaning cultural diversity often referring to what had been said in class or what they "shouldknow" having taken such a class. I noted two interesting variations to these findings—variations that at first seem to be contradictory but on reflection are related and add some depth to my notion of a 'rearranging' Cultural Differences 56 process. The first variation lies with the one student who was very articulate and comfortable in defining cultural diversity; further analysis of the data from this interview revealed that this student had had a great deal more exposure to diversity^ in her life than the other participants of the study. The second variation, was with the participant who indicated she felt different because she was from a rural background and was of a lower socio-economic class. This participant became visibly distressed when discussing her diversity and it would have been easy to make the assumption that this young woman had led a sheltered life with little or no exposure to diversity. However, it was fascinating to discover that in fact she had spent almost a year doing volunteer work in a third world country and in a small town in Europe. From this information I expected that she would be aware of and comfortable with individuals from diverse backgrounds—but surprisingly, not only did she have difficulty defining diversity and subsequently have difficulty with the perception of her own diversity—she also admitted to being uncomfortable when faced with individuals of diverse ethnic background, whether she encountered them socially or in her practice as a student nurse. This unease with diverse individuals was very apparent in her comment, So here[in Vancouver] it was an adjustment, getting used to the fact that English isn 't the only primary language and it seems to me that Cantonese is also widely spoken if they speak English to me I don't have a problem, but if there is a language thing then I tend to shy away, or certain cultures ... now with the war and everything, people from the Middle East when I see them I know there's nothing wrong but it still makes me nervous. She explained her discomfort with diverse individuals by stating that she felt this way "because everyone where I grew up with was white and everyone was made fun of if you weren't" Cultural Differences 57 At first these two variations appeared to have no connection to each other, as I thought it possible that they were a result of circumstance, personality or maturity, but on closer inspection these variations seem to give credence to the idea that exposure to diversity forces individuals to readjust (and possibly expand) their conceptualization and understanding of cultural differences. Specifically, the participant who was articulate and comfortable with her diversity had been exposed to many different types of diversities and also had been in the position of living a diverse lifestyle for an extended period of time. In contrast the second participant had indeed led a life with no exposure no diversity followed by a relatively short exposure to diversity that was of no personal relevance—whereas she was now feeling that she herself was diverse in the nursing program and was not comfortable with this awareness. What these variations may indicate is that temporal and personal dimensions are elements of the process of 'rearranging' one's conceptualization of cultural diversity for the participants of this study. In addition, determinants of how cultural diversity was defined or perceived by these students may have been influenced by where they were situated in the process of 'rearranging' and by how personally relevant they perceived any exposure to diversity to be. If this idea holds true, the individual who was articulate with her definition of diversity, describing it as a "culmination of individual life experiences", may actually differ in another way from the remainder of the participants—her definition may not come from what she thinks she should be saying based on current classroom learning but rather from her own personal 'rearrangement' of the meaning of cultural diversity. An interesting digression associated with the above discussions is that all the participants acknowledged that although the male students in their group were a minority they were not perceived as being culturally diverse. In fact male students were considered an elite group, Cultural Differences 58 evidenced by comments such as, ... they are almost in a position of power. Like they seem to have better relationships with teachers and people are naturally excited to have them there [in nursing programs]... .1 think they almost get preferential treatment.... I found this to be an interesting commentary on the culture of nursing programs. Also, this perception seems to suggest that having a presence that conveys power means one is not considered diverse—a notion which implies cultural diversity continues to associated with 'marginalized' constructs. In summary then, all the participants of this study defined themselves as being a minority among their peers and as being culturally diverse; they utilized a broad definition of diversity to self-identify as diverse but continued to demonstrate vestiges of traditional paradigms of diversity when it came to defining others as culturally diverse. An understanding of the processes individuals engage in when conceptualizing cultural diversity may help to explain how these individuals define and perceive cultural differences in themselves and in others. In view of the fact that each participant was diverse for a different reason, and that life experiences, background and exposure to diversity influenced how each participant conceptualized the meaning of 'being culturally diverse', I suggest that defining cultural diversity for the participants of this study, may in some way be contingent on the historical and current contexts available to them. In addition, these contexts may be a result of an ongoing process of 'rearranging' in which the students redefined their ideological stance in relation to the meaning of cultural difference; this rearranging may be an outcome of exposure to diversity in others or of personally relevant experiences with diversity which increased awareness of their own Cultural Differences 59 differences. Finally, understanding where these students were located in this process of 'rearranging' may help explain their awareness of and comfort with differences in others as well as themselves. Experiencing Diversity Within this theme, I have presented findings related to the participants' lived experience of being culturally diverse within their educational contexts—this encompasses any personal, environmental, interpersonal and/or situational events that may have led them to feel that they were diverse. What I have tried to convey is the common elements associated with experiencing diversity among this group of participants who have self-identified as being diverse. Whilst there are many commonalities among the participants in this area there are also some interesting disparities that add intricacy to understanding their lived experience of cultural diversity. The findings that I present within this theme have emerged from the participants' personal experiences related to cultural diversity, as well as from the participants' perceptions of the lived experience of other diverse students in their classes. Although, it is difficult to draw precise distinctions amongst the themes of being culturally diverse, experiencing cultural diversity and managing cultural diversity as it is evident they are intimately intertwined, I believe the elements contained within the theme of 'experiencing diversity' link the themes of 'being diverse' and 'managing diversity' in the overall understanding of how the participants of this study construct the meaning of cultural diversity in relation to the social context of their learning environment. Feeling Culturally Diverse In the initial stages of my analysis this sub-theme 'feeling culturally diverse' seemed to be the one that would be the easiest to describe and interpret, for all of the participants were Cultural Differences 60 willing to share their feelings and emotions related to being culturally diverse; but in fact this analysis proved to be more difficult than I expected. Listing the range of feelings and emotions as experienced by the participants was in itself an easy task but discovering the linkages amongst the feelings so that I could logically describe the lived experience of these five participants proved to be much more challenging. The myriad of feelings and emotions disclosed by the participants was one reason this process was so challenging; another reason and perhaps the more significant one was that the feelings and emotions originated from a multitude of sources. The description of these emotions was made even more complicated by the fact that at times the participants either contradicted themselves in describing their feelings or were nebulous in their descriptions, stating that feeling diverse was "difficult to pinpoint"; as I delved deeper into the meaning of this phenomenon, it became apparent that these contradictions and ambiguities may have been associated with the participants' level of comfort with what they were disclosing (in addition to the fact that I was an 'unknown' to them). As complex as the elements of this sub-theme seem to be, what I found noteworthy was that these feelings and emotions were central to the experience of being culturally diverse for these participants. The feelings and emotions as described and perceived by the participants emerged from sources such as: how people in their learning environment (peers, faculty, clients and nurses) responded to the participants' diversity (if known); how people in their learning environment responded to diversity of others (clients, other students); various interpersonal interactions or encounters with peers, faculty and/or nurses in learning or social situations and of course, the intrapersonal or psychological make-up of each participant. In addition, considering that the environment is always a critical aspect within any description of feelings and emotions—all the Cultural Differences 61 situations described by the participants occurred either in a classroom setting, a clinical practice setting or in a social situation (related to their learning milieu). Finally, after having taken all the above factors into account, I surmised that the many feelings and emotions described by the participants were associated with two states of being—that of 'not fitting in ' and of 'being judged'; two states which I have presented as separate entities but which are closely linked in the construction of the lived experience of being culturally diverse for these participants. Not Fitting In. Many of the feelings and emotions described by the participants associated with experiencing diversity seemed to materialize from a sense of "not fitting in' with their peer group. This sense of not 'fitting in' materialized in many forms within the narratives and seemed to originate from various sources; however some participants in describing their feelings of not fitting were unable to articulate the origin of these feelings, as on student said, ... and then I came here and everything was going on, people were doing this and that and it was very busy and I just felt like I didn't really fit in sort of... I don't know I can't pinpoint it really... " A l l the participants indicated that the feelings related to 'not fitting in' were a result of their diverse backgrounds and/or diverse lifestyle choices. I found the language used by the participants to describe their feelings of 'not fitting in' particularly revealing—it seemed that they were all situated in somewhat of an indeterminate state. Some of the phrases used by the participants to describe this state are: ... not in the inner circle" "...fragile relationships with the group", "... its like where you are standing is different", " I don't have the 'click' with my peers ", "• feels like I am Cultural Differences 62 in an opposite place " and "between two worlds ". As the participants discussed 'fitting in' they all indicated that although they may "look" (outwardly) like they fit in with their peers, their differences meant that they could not. An interesting similarity among the participants is that they all expressed in some way that they would like to fit in but could not because they were uncomfortable in social situations with their peers; one participant described this dilemma as such, ... when I go to some of these events, I feel uncomfortable, so I usually don't go but like I do want to be social with these people but its not very easy ...I mean I'd like to fit in. I mean they are my peers for the next two years... .its like I'm here so I want to be a part of it but it doesn't' come naturally... It was also interesting to note that when the participants identified their peer group, they referred to those that were of the same age and appearance; this did not seem unusual except for the fact that they all expressed that their past or current life experiences probably meant that they fit in better with the 'older or mature entry students' in their class, but they perceived that they could not be a part of this group either because of the differences in age and interests. The participants also perceived that the 'older group' would not accept them because they (the participants) looked young and "like any other university student with no responsibilities". In addition all the participants commented on the various informal groups that had formed in their class such as the "fun " or "popular" group, or the "close knit" groups that the 'traditionally culturally diverse' students belonged to—the consensus among the participants was that these groups had formed because of common interests and needs. I surmised from their stories that this particular group of individuals did not fit in easily Cultural Differences 63 with any of the established informal groups within their educational setting. What varied among the participants were the reasons they gave for not fitting in—feeling they would not be accepted, choosing not to fit in, and feeling uncomfortable within the groups. Although the predominant reason given for not being part of any of these groups seemed to be associated with sentiments such as "I choose not to belong to any of these groups ...I have my own friends that I have more in common with and that way I'm not the subject of any curiosity", it was clear from their stories that choosing not to fit in, may have been a way of self-excluding to avoid feeling uncomfortable and /or encountering judgmental attitudes. The only groups which the participants seemed to be members of, were the 'formal' groups such as clinical or laboratory groups—groups in which the students feel they are "thrown together" and in which the "walls are broken down" or as one participant stated "the people that are the easiest to get to know are the people that are placed within clinical with you " Adding further intricacy to the sense of 'not fitting in' is the notion of being an 'impostor' that seemed to surface from the narratives of some of the participants. The students did not overtly articulate this feeling but rather it seemed to be an underlying tone to comments such as, "you feel like you have to prove that you are good enough to be here" or "they might think that you should have stayed where you come from because people from small towns are not as smart as city people". From comments such as these, I surmised that the some of the participants felt that they did not deserve to be in their various nursing programs because of their self-defined diversity. I found this to be a curious phenomena as it seemed to indicate that the students had some predetermined belief of who was deserving of an education in nursing and had somehow come to the conclusion that they, by virtue of their diversity they did not fit into Cultural Differences 64 this image. The origins of these perceptions may be rooted in historical and current experiences wherein the participants were made to feel by others that they 'didn't belong' because of their diversity—a perception that they had internalized and subsequently transferred to their current learning milieu. It seemed to me that the participants arrived at these conclusions by engaging in process in which they appraised their learning environments against the backdrop of their diversity and came to the realization that they did not belong or that they were 'impostors'. As I thought about these ideas further and analyzed related statements from the students such as, We were told that we are the cream of the crop, that we are hand picked and better than the rest. I think the culture of the school is somewhat elitist, like everyone knows how difficult it is to get into this program... or I think most of the people in our program are good at learning in this sort of setting because of the selection process and the fact that you have to have a certain GPA. Like everybody here is able to do well, if they choose to work I became aware that there may be one more element involved in the students' perception of 'not belonging' or of 'being undeserving' and that this element may be related to how the 'culture' of the nursing program is communicated to prospective and current students. As I examined the idea of 'not fitting in' , the complexity of this notion continued to emerge. At first glance it seemed that the participants' stories pointed to external cues as being responsible for the perception that they did not fit in with their peers. Through observation of how others in their educational environment responded to diversity, be it their own diversity or that of others', the participants seemed to go through a process in which they internalized and Cultural Differences 65 personalized these responses resulting in a feeling of not 'fitting in' . Whilst there seems to be a great deal of validity to this idea, another process also seemed to be inherent to the participants' perception of not 'fitting in'; it seemed that each participant arrived to the nursing program with a preconceived notion of her particular place in the educational milieu—in effect possibly a product of her own self-esteem, self-confidence and personal historical contexts. Being Judged Another set of feelings and emotions expressed by the participants seemed to be associated with the idea that they felt they were 'being judged' or would be judged by individuals within their educational environment. In discussing various experiences and observations related to being diverse, the participants shared a vast array of feelings—some examples of the feelings expressed were: sadness, frustration, appalled, shocked, overwhelmed, stressed, shame, alone, isolated, resentful, bitter, misunderstood, powerless and ostracized. The context of the these feelings may differ in that they may have arisen from the participants' personal interactions, from content presented within the classroom setting, or from the participants' observations of how 'other' diverse individuals were treated, but what was common to all the emotions expressed is that they were directly associated with what the participants perceived as judgmental attitudes towards those that are culturally diverse by individuals within their educational environments. An interesting aspect to the participants' narratives is that they were similar in their how they explained the existence of this judgmental attitude within certain elements of their nursing program—an analysis that may be intriguing to ponder. The foremost premise for the presence of judgmental attitudes within their learning environments as presented by the participants was that Cultural Differences 66 'ignorance' or a lack of knowledge/awareness of diverse lifestyles led to many of these judgmental attitudes, as one participant commented, "you always get the same tree of questions... they just don't know a lot about it" or from another participant who described why she felt others in her learning environment would judge her if they knew about her diversity, ... I think the group would be judgmental, mainly caused by lack of knowledge. And I don't think that nurses are educated adequately about these [diversity issues] I don't think the education is accurate or adequate so people are going to have these opinions and I just wouldn't wanted to be labelled with that brush. Another powerful example of this belief is contained within one student's description of a situation she had observed in which members of her class and a faculty member were commenting on a specific lifestyle (which was similar to hers), ... [the discussion] was so far beyond naive that I couldn't believe that these were my peers, yeah it was like a total and complete ignorance. In the true sense of the word. Like no knowledge, especially because they 're going to be caring for patients with some of these situations, probably already have and they 're not prepared at all to care for these diverse clients... resulting in judgmental attitudes and erroneous assumptions about diverse lifestyles... As the participants told their stories and expressed their feelings related to being judged, they shared experiences that described how some individuals within their educational environment responded to cultural diversity-responses such as fear, disgust, impatience, negativity, arrogance, curiosity, non-accepting, narrow-mindedness and a lack of understanding. An interesting and compelling comment from one student regarding the origin of many judgmental Cultural Differences 67 responses also suggests how these attitudes may persist and/or are communicated, ...she talked in disgust about this patient and how he was like this because people like him did these disgusting thing. I was sickened as I realized how wrong her assumptions were. Also the fact that she would say this to a group of students, assuming that they all had similar backgrounds, especially because, as a faculty member talking to six young students, she is in a position of power where like people will generally take what she says at face value and just believe it, its kind of dangerous how someone in that position, puts ideas across as if they are fact, for if a student has like no experience with that group of people... they might say 'oh that must be the case cause I learned it in school... A similar comment from another student regarding a situation that she observed in a classroom setting adds to this notion, .. .this one student was educating the other students about the 'disgusting' things that [specific diverse lifestyle related to participant's self-identified diversity] do saying can you believe this and that, it wasn't that what she was saying could never have happened. It probably has happened. But these are really really extreme things... its just not the norm at all...And I was like ... she probably heard something once and she was telling it to everyone as if this is what happens always which I don't think is accurate... the other students were sitting there and going oh really... and I'm like they are going to think this forever... cause they thought she knew what she was talking about.... Finally, all the participants verbalized that many classroom discussions and presentations portrayed judgmental attitudes towards diversity; as I analyzed this finding it became clear that this may one of the factors that influenced the students' perceptions on how their diversity would Cultural Differences 68 be accepted or judged within their educational environment. A comment from one student that portrayed this clearly, ... I took the culture course and in it we talked a lot about diversity and I just thought it was a very biased the way it was presented and very judgmental and narrow ...they were really focusing on certain populations that were outwardly diverse and using very stereotypical things about the certain population... people really focus on just kind of conglomerating everybody into ...oh you 're Christian, you 're homosexual, you 're whatever... people just get slotted into these categories... What I found fascinating about these comments is not only did they provide some insights to the existence of judgmental attitudes; they also suggest how such attitudes persist and are transferred within the context of a learning environment. It is also interesting to note the reference to faculty being in position of power—a notion that I will discuss further within the theme of managing diversity. Initially, I found it easy to arrive at the conclusion that judgmental attitudes and responses portrayed by the participants may have been products of uncaring insensitive attitudes or of ethnocentric philosophies within the learning environment. But an incongruence in the participants' stories between their feelings of being judged and their reports of how others responded to diversity led me to believe there may be some other dimension to the judgmental attitudes they perceived within their learning milieu. The inconsistency that I noted within all the narratives was that contrary to what each participant stated about having experienced 'judgmental attitudes' within her nursing program, each participant also indicated that, generally, her classmates and most faculty were "caring and accepting people"; in addition all the Cultural Differences 69 participants expressed the belief that as nursing students they were expected to accept differences in others and teaching strategies were aimed at this goal. I believe that this apparent discrepancy within the students' stories may add credibility to the their conceptualizations that a 'lack of knowledge' is the foundation of many judgmental attitudes and responses. The participants' perceptions of their peers and faculty seemed at odds with their narratives and the depth of emotions expressed related to feeling judged. As I have alluded to in the above paragraph, one of the reasons for this inconsistency in the narratives may be the 'lack of knowledge' argument. It is also possible that this incongruence is based in the participants' expectations of the nursing profession—in that anyone involved in the field of nursing will be caring, knowledgeable and accepting of cultural diversity. Therein may lie another plausible reason for the above noted inconsistency—it may be that the participants' perceptions of the acceptance of diversity by those in their educational environment are based on the 'traditional' view of cultural diversity, wherein the participants may have observed accepting attitudes to the more commonly known cultural diverse groups, given that there is a great deal of emphasis in the nursing education on the importance of meeting the needs of culturally nursing students (meaning the traditional culturally diverse—racial or ethnic). The fact that the participants of this study are diverse in a 'non-traditional' way may be the clue to why they felt judged within a 'caring and accepting' milieu—little is known about the 'non-traditional' student. Confirming Cultural Diversity I have chosen 'confirming cultural diversity' as a sub-theme of 'experiencing diversity' for it seems that all the participants experienced an episode within their educational milieu that strengthened their belief that they were diverse from their peers. It became clear to me as the Cultural Differences 70 interviews progressed and as I reviewed the data, that this episode or 'critical event' as I shall call it, connected the two themes, 'being culturally diverse' and 'experiencing cultural diversity' and led to 'managing diversity'. I believe this event, not only confirmed for all the participants that they differed from their peers, but also seemed to serve as a paradigm with which to interpret past and present experiences in their educational environment. An unexpected finding for me related to the lived experience of cultural diversity is that each participant volunteered this 'critical event' as one of the reasons for deciding to become involved with this study. At first there seemed to be no logic to this occurrence, but on further analysis I inferred that it was possible that these 'critical events' may have become points at which the participants began to shift their perceptions of cultural diversity (rearranging). The participants sometimes had a variety of situations to share but all had the one primary event, which they considered to be the main impetus to becoming involved in the study. Surprisingly, the participants were not always personally involved in the event(s) but they interpreted the meaning of the event and applied it to their own personal situation. The events described by the participants were of the following nature: • Issues related to the presentation of classroom topics related to diversity, • Clinical practice situations related to diverse clients, or to being diverse as a student • Personal experiences and/or interactions with peers or faculty related to the participants' self identified differences or those of others • Observations of actions and interactions between peers and faculty related to cultural diversity. What was intriguing for me as I analyzed the meaning of these events was that it did not Cultural Differences 71 matter whether the participants were personally involved in the event or whether they merely observed the event, the participants all revealed that the events had caused them feelings of discomfort or distress related to their diversity. In addition, all participants indicated they were unprepared for and completely surprised at their emotional reaction to the event. A comment from one participant's narrative revealing this sentiment states she "found it so disturbing" she had to "leave the class". This student indicated she had no idea she was going to react so strongly to this situation which involved a classroom discussion of her particular diversity, she goes on to say that "if I knew I as going to react like that I would have left. Like at the beginning of the class. I stayed and felt out of control... cause I was definitely embarrassed [at her reaction]... I would rather just like quietly left the room before the class" .These events all seemed to cause dramatic reactions and emotions in the participants as is evident with this comment from one student in relation to having to participate in a classroom activity which she stated offended her belief system, I found it [classroom activity] to be highly shocking... it wasn't done in a neutral sense so that I felt comfortable in the class... we had to participate and they were activities that I did not want to participate in. I thought the whole class context was completely inappropriate and against my beliefs. I did not feel like I was able to say I don't want to participate without making a huge deal... and I was so frustrated already that I didn't think I would be able to express myself... in addition , I was absolutely shocked that I had that reaction... I felt like throwing up... this whole emotional thing happened... I just wanted to get out of there... I was just sick and tired... it was weird.... The above comments illustrate the range of the participants' feelings of discomfort and distress Cultural Differences 72 related to these events. However, what I found to be the most intriguing commonality among all the narratives of these of these 'critical events' is that all the participants interpreted the event as an indication that cultural diversity was not accepted among certain elements of their educational environment (this could be peers, faculty and/or nurses), a perception which they then seemed to personalize as meaning their own diversity would also not be accepted. The participants all labelled the situations as examples of "judgmental attitudes" based on biased perceptions, stereotyping and/or ignorance related to diverse lifestyles. The lived experience of cultural diversity, as described by the participants of this study, seems to be a multifaceted and dynamic process. I found it notable that although the participants differed in their diversity and in the nature of the experiences or events they described, all the participants expressed similar feelings of 'not fitting in' and of 'being judged'. Experiencing diversity for each of these participants seems to be a result of past life experiences and background tempered by personality and current situations, resulting in a ongoing readjustment of their perception of what it means to be culturally diverse. An interesting finding within this theme was the participants' belief that the judgemental attitudes they encountered may be caused by a lack of knowledge of diverse lifestyles instead of the more common assumption that people are merely insensitive and uncaring. Additionally, the participants' stories portrayed possibilities of how these 'judgemental attitudes' persist within learning environments. Another remarkable finding related to the lived experience of diversity for these students was their apparent preconceived ideas that only a certain type of individual had the 'right' to enrol in their various nursing programs and that they concluded that because of their diversity they were not worthy of being there—perceptions that may have arisen from how the 'culture' of the nursing program is Cultural Differences 73 presented. The participants of this study may or may not have thought of themselves as diverse when entering their nursing education, depending upon their definition of diversity at their time of entry to the program. Subsequent to entering their programs, they seemed to encounter situations that may have altered their perceptions of their own diversity. The notion of this 'rearranging' of perceptions related to their own diversity may help to explain some of the students' feelings of surprise when reflecting upon their reaction to the various situations they encountered. In addition, the participants may also have been experiencing a concurrent process in which the participants are in the midst of altering their perceptions of how others in the nursing profession respond to diversity. These processes may provide some clue to the range of feelings and emotions described by the participants of this study as well as further elaborate on their connotation of cultural diversity. Managing Cultural Diversity Within the theme of 'managing diversity' I present the findings related to how the participants of this study coped with their perceived diversity. The elements of this theme originate from those contained within the themes of 'being diverse' and 'experiencing diversity' wherein the individuals have gone through various processes to arrive at the awareness that they are diverse and are now faced with the task of 'managing their diversity'. I have incorporated the findings which informed me about the participants' decision making processes associated with managing diversity into a sub-theme entitled, 'coping with diversity' to reflect the notion that the individuals have devised and implemented various coping strategies in order to live comfortably with their perceived diversity in their learning environments. In addition, within the sub-theme entitled 'outcomes' I have presented findings related to significant consequences that Cultural Differences 74 emerged from the decision-making processes associated with 'managing diversity'. As I examined these consequences, I began to more fully understand the impact 'managing diversity' has had on the day-to-day personal and academic life of the participants of this study. Coping With Diversity Based on the literature related to culturally diverse nursing students, I expected the participants' narratives associated with the theme of 'managing diversity' to inform me about coping strategies aimed at ensuring academic success. A surprising discovery for me was that academic performance was not an issue for any of these participants—all of them stated they were doing well in their programs. I inferred from this data that these students must have well-developed strategies with which to achieve their academic goals and that being culturally diverse was not interfering with the academic performance of these participants. What seemed to be more of an issue for these students was how others in their learning environment might perceive their diversity. This concern seems to have surfaced from the participants' lived experiences related to being culturally diverse, in which the occurrence of various processes resulted in a review and subsequent 'rearranging' of their ideas associated with cultural differences, with the final outcome being an increased awareness that they were culturally diverse from their peers. In response to this concern and as a way of successfully living with their diversity within their educational environment, all the participants seem to have developed various coping strategies. The participants' descriptions of how they were coping with their diversity increased my understanding of the impact of cultural differences on the learning context of these particular students but what I found most enlightening was the decision making processes involved in formulating their various coping strategies. The decision-making processes associated with the Cultural Differences 75 coping methods employed by these students appear to be linked with two notions which I have entitled "communicating diversity' and 'getting support'. These two sub-themes are clearly intertwined and dependent on each other but for clarity I have presented the findings separately. Communicating Diversity As the participants described issues related to coping with diversity, it became apparent to me that most of their decisions in this area were linked with the communication of their diversity to peers and/or faculty. A l l the participants expressed the belief that communicating or sharing their diversity with individuals in their learning environment meant that they would have to "expose " themselves, thereby placing them in a "uncomfortable " and "vulnerable position"— a situation that they believed would invite judgmental attitudes from others. Not only were the participants concerned that others would judge them, they were also equally apprehensive about their own emotional responses to any judgmental responses they might encounter, it seemed they did not want others to see them "getting upset" as they perceived this would "display weakness". Furthermore, the participants expressed that communicating their diversity to others in their learning environment would " not serve any useful purpose" in the pursuit of their academic goals. In fact some participants were of the opinion that sharing their diversity might actually interfere with their progress in the nursing program because it would "create more problems " and cause them "more grief" in their learning environment. One student had an interesting slant to this dilemma as she stated that she would like to be able to share her diversity so that others in her learning environment would become more knowledgeable about her type of difference but she made the decision not to reveal her diversity because she believed "the only thing I will change is their perception of me ". Cultural Differences 76 I was intrigued as I contemplated these revelations and wondered how the participants had reached the conclusion that sharing their diversity with others would place them in precarious positions as students. Upon further analysis, I determined that the participants had arrived at these conclusions through various complex processes involving historical and current circumstances. As each participant told her story, it became clear to me that each individual had conducted an appraisal of her learning environment and personal situation in relation to how her cultural diversity would be accepted. These appraisals seemed to involve an assimilation of personal, environmental and historical factors. It seemed that most of the participants entered their nursing programs with preconceived ideas of how cultural diversity was tolerated in their program. One participant described her perceptions as such, ... nursing is very traditional Ifind. It attracts a very traditional person... In history it's been a traditional profession ...so sometimes I feel uncomfortable... Yeah I definitely noticed getting here, coming into it. It's just been like wow. Cause my friends are out of school and are all very I guess what I'd say diverse...like here its more narrow... Subsequent to entering their programs, the students then observed or experienced situations that further informed them about the acceptance of cultural diversity in their particular program, an example of such a story is, / know a couple ofpeople that don't speak English well... and I think some of them have been ridiculed for it... for being stupid or not speaking out... instead they should be helping them work it out since the selection process allowed them in... some faculty just don't have time for that in their life... These two factors, in conjunction with each individuals' unique personal background or Cultural Differences 77 experience with diversity in various contexts culminated with the participants concluding that sharing their diversity would be a risky endeavour and one which could potentially be the source of personal discomfort and unease in their learning milieu. Concealing diversity. Understanding how the participants had arrived at the conclusion that it was disadvantageous for them to share their diversity with others in their learning environment, made it easier for me to comprehend their choice of coping strategies. As a result of perceptions formed during the processes of appraising their learning environment, most of the participants had devised coping strategies that would enable them to 'hide' or conceal their differences in some way because as one participant indicated "7 don't think it is a safe enough environment ...I would feel over-exposed". Remaining 'safe' seemed to be a recurrent theme in their narratives with some of the participants actually commenting that they needed to protect themselves from "attack". The participants differed in the degree or extent of concealment of their diversity, which in turn influenced their choice of coping strategies. From the narratives I noted that the level of concealment ranged from absolute secrecy such as "no one knows" to that of partial secrecy so that "only selected people know... and only a few in school and my friends know and I've chosen these people " with these 'selected people' being those individuals whom the participants had appraised as being trustworthy, accepting and non-judgmental. I listened with fascination to the participants' stories associated with making decisions as to whether to conceal or disclose their diversity, but what struck me as being significant was the relationship between the level of concealment and the choice of strategies wherein the more 'secret' the diversity the more intricate the choice of coping strategies. As I attempted to unravel the mystery surrounding the participants' decision making Cultural Differences 78 processes related to 'hiding' their diversity, I noted another small but noteworthy piece to this puzzle. Whilst it is true that most of the participants' narratives indicated they were reluctant to be open about their diversity for fear that others in their environment would be judgmental or non-accepting, they seemed to be equally concerned that revealing their diversity meant they were making an 'issue' of their diversity—something which they were all loathe to do. It seemed to me that "not wanting to make an issue " of their diversity was critical to the participants' overall goal of maintaining a comfortable learning environment for themselves especially in relation to developing and maintaining the relationships that are inherent within these environments. One participant expressed this clearly when she said that she wanted to: keep my personal world and educational world separate... I know I am different but they don't know I am different... because otherwise people will always have that perception [of her diversity] clouding everything and its just like I'd like it to be a small part, like yeah its diverse and its going to change the way that I view things on a daily basis, but I don't want that to be the first thing people think of when they see me. One participant conveyed an interesting perspective to this issue when she indicated that her diversity just seems so normal [to her]... / mean maybe that's part of being who I am it just seems normal... that's just one piece of me... there is so much more to me than that part... I think people get slotted into these categories by others but they may not think of them as their diversity ...I want it to be a non-issue, or as another student commented "ifyou bring something like that up its kind of like dropping something on a table and its saying like look at this ". These participants seemed to be inferring Cultural Differences 79 that sharing their diversity would mean making an issue of it and possibly categorize it as 'abnormal'. I found it interesting that the notion of 'not making an issue of diversity' was often covert within the narratives and it was only after much analysis did I understand the meaning of some of these statements. For example, one individual indicated that if she were to be more open with her diversity would be like announcing it and saying "look at me " or believing that her peers would then consider her a "curiosity". I inferred from such comments that the participants may have been struggling with 'normalizing' their differences in an effort to 'fit in ' with their peers. In addition, it was interesting to note that while the participants felt their differences to be 'normal', they feared others would make it abnormal, suggesting subtle undertones of the processes of marginalization and 'othering'. Context of individual diversity. Within this theme of communicating diversity I noted that one participant told a somewhat different story from the rest of the participants. This participant differed from the rest of the participants in that she stated she had no difficulty sharing her diversity of being an "unwed mother with small child" with individuals in her learning environment. On initial examination, I thought this variation was the result of an appraisal the student had made of her situation, in which she decided that it was 'safe' to disclose her difference. I also surmised that this participant might not have had much choice in sharing her diversity because it is difficult to 'bide' the fact that one has child. Both of my assumptions may very well be correct, but as I continued to ponder the meaning of this variation, it seemed plausible that the significance of this disparity might also be associated with another dimension embedded within the decision making processes related to coping with diversity. This other dimension became apparent to me when I thought about certain sentiments expressed Cultural Differences 80 by the some participants such as the student that stated " I am so diverse from them that I couldn't possibly fit in. " or conversely the student who indicated she didn't feel, like way out in the periphery of diversity but I feel like even though it's [her specific diversity] accepted it's still questionable and people are wondering about it so it makes it more unaccepted... having people still wondering about it makes it out there... like out on a limb instead of sort of contained with all the normal things in society... Initially, I thought these comments and others like them represented an element of the individuals' personal definition of cultural diversity but upon further examination, I recognized that there was also a relationship between these statements and the participants' choice of coping strategies. From comments such as those described above in which the students made some reference to how diverse they were, I inferred that these students seemed to conceptualize cultural differences as being on a continuum with the 'mainstream' being the centre point or norm thereby indicating that the further one was situated from the norm the more 'extreme' one's diversity would appear to be. As I thought about this idea, it seemed reasonable to assume that as each participant appraised their learning environment in relation to their diversity, they would have come to some conclusions as to what was considered the 'norm' or centre point of the continuum as well as where on the continuum their diversity was situated. Therefore, for the participants of this study, there may be some relationship between how far removed from mainstream they considered their particular diversity to be (i.e. how extreme) and their comfort in disclosing their diversity to others. This notion may partially explain why the individual who self-identified as being 'unwed with a young child" had no qualms about sharing her difference with others in her environment—a situation which is not all that uncommon in our current Cultural Differences 81 society and which she may have initially assessed as not being that far removed from the 'mainstream' or from the 'centre point' of such a continuum. However, what is significant about this individual's narrative is that although she differed from the rest of the participants in that she was open about her diversity, she was similar in that she still expressed feelings of being judged and not fitting in within her learning environment as was evident by her comments I guess just the questions about it or, you just sort offeel like people maybe judge you a bit more, you fell a little bit uncomfortable when you talk about it. When we go out and you wonder if people think well she's a mother what is she doing going out... I don't know what it is... yeah you feel just a bit of a judgment... and I feel like a little bit of an outsider, I have good relationships with different groups... but J feel like they will always be closer than I will cause of my child... I have fragile connections to different groups but no real best friend like some of them have... In addition, like the other participants, this student indicated that even though she had shared her situation, she found herself making a "conscious effort" not to bring attention to it with those in her learning environment. She stated she had made this decision after experiencing (and being surprised at) the various judgmental attitudes she encountered from peers and faculty in relation to her specific difference or as she expressed, like I got the big talk about responsibility and how I chose to come into the class ... and you know with a young child and that it was my problem kind of thing and that I shouldn't be making excuses... .and it was very bizarre because I hadn't even used my son at all as an excuse. Like I purposely avoid doing this... a bizarre experience. And she Cultural Differences 82 made some hurtful comments... like your son is holding you back or something like that ... and that he is not a joy to me or something. As I pondered on the complexity of the meaning of this variation I came to the conclusion that this young woman may not have considered her situation diverse until she encountered the 'culture' of her particular nursing program—exposure to this culture may have caused her to 'readjust' her perception of her own diversity and where she is situated on the 'continuum' of diversity as defined by her particular nursing program. Context of learning environment. One final aspect of the decision making process related to communicating diversity that surfaced for me was that all the participants seemed to be of the opinion that the sharing of differences was not encouraged nor invited within their educational environments. The participants expressed this sentiment in relation to various facets of their learning environments—classroom settings, peer group interactions and faculty-student interactions. In discussing the classroom settings, the students all indicated that they found it uncomfortable to share in these large groups and that diversity issues were usually discussed in general terms leaving little opportunity for personal disclosure. As far as any peer group interactions, the participants simply indicated that diversity issues seldom came up as a discussion topic-they felt peer interactions were mainly focused on academic issues (such as assignments, clinical concerns etc). The faculty-student relationship seemed to be the element that had the most impact on the decision-making processes of these participants in relation to disclosing or sharing their diversity. The explanation of this phenomenon seems to be rooted in a belief held by all the participants that most faculty-student relationships are "hierarchal" in nature wherein the Cultural Differences 83 "power" rests with the faculty member. This perception is illustrated by comments such as, "there is a lot of hierarchy... where students fall at the bottom of the ladder". The belief in the existence of this hierarchal structure combined with a perception that most faculty have "no time for" or are "wary " of diverse students, resulted in the participants thinking that it was easier not to "rock the boat' or "ruffle any feathers" by disclosing their diversity. Another example of this perception is from a student who perceived she was being judged based on her difference and that she had been the target of some hurtful remarks—her response to this situation was to "just nod and smile kind of and say thanks for the input... so I just had to bow to her more powerful position ". One individual, in explaining the reasoning behind her decision not to share her diversity, exemplified the sentiments of the other participants in relation to the this 'power' structure in her remark " it doesn't matter who you are as long as you do what you were supposed to do ", similarly another student commented that when she alluded to her diversity with a faculty member, s/ie[faculty member] is so focused on herself and her opinions ...my best way to deal with this was to just do whatever makes her happy in some sense... I would never bring up anything personal with her again because she is very judgmental and I could tell that right away by her response to my input...so I said to myself okay shut your mouth ... she forgot how to be culturally appropriate to others like even with religion... Finally, a very poignant and disturbing comment from one participant, which further illustrates the belief of these participants that a hierarchy exists between students and faculty, is that "when you are at the very bottom of the food chain you don't do anything to expose weaknesses " It is significant to note that the students' referred to their diversity as a weakness which i f revealed Cultural Differences 84 would place them in a vulnerable position within the student-faculty relationship—a relationship that is usually considered central to the experience of most student nurses. I also discerned from the above comments that a sense of powerlessness was a component of the lived experience of these participants. From the above findings, I arrived at the tentative conclusion that this perception of being powerless within the student-faculty relationship in conjunction with the notion of diversity being a weakness may have been influential in the participants' decision to conceal their diversity. I also wondered if concealing their diversity from others in their environment allows them some way of exerting control over their learning environment. Once again, there appears to be a strong relationship between what the participants observed or experienced in their educational environment as part of their appraisal process and their choice of coping strategies; in this case the belief that sharing diversity was not encouraged in addition to the perception that sharing their differences might adversely affect the perceived hierarchal student-faculty relationship may have strengthened the students' decision to take control of their environment and somehow 'hide' their diversity and pretend to fit in, or at the very least, not draw attention to their differences. Getting Support As I perused the nursing education literature I came to the conclusion that having a good support system was crucial to the academic success of nursing students and this appeared to be especially true for culturally diverse nursing students. Therefore, it seems that all nursing students must have access to a variety of resources to assist them in getting support for all aspects of their educational endeavours—it seems that CDNS often require support in areas such Cultural Differences 85 as study skills, time management, academic writing, financial needs and various personal issues. As I reviewed the data from the interviews with this particular group of students, it quickly became evident that none of these particular students required academic or learning supports, as all of them indicated their progress in the program was "fine" with their marks ranging from above average to excellent. However, the participants all expressed in some way, that they were in need of personal and emotional supports to manage various aspects of being different from their peers. Surprisingly, not one of the students indicated that they had incorporated any institutional resources into their support system. The participants varied in their reasons for not utilizing supports within their educational institutions, with the one of the reasons being that the resources available did not adequately meet their needs as exemplified by statements such as "its difficult to talk about this to someone you don't know personally " or "/ don't need to get help from someone that is helping from a book". Some of the students had investigated the resources available and found them lacking, but most of the students indicated that although they knew about various resources (such as peer support, counselling, speak-easy, specific diversity groups etc) they had made a decision not to use them. As one participant commented in explaining why she didn't accept support for a specific situation related to her diversity when it was offered to her, .. .she was being really supportive and saying do you need anything, is there any way we can support you, like do you need someone to talk to a... And I was like no, like I already have all of that set up outside of school but they were nice... I felt their concern and support... like everyone in our program is compassionate, caring people or else they Cultural Differences 86 wouldn't be here otherwise. It's just my personal choice. Like I have family and friends and everybody to share with outside of school and I just want to be here for my education. I'm not here for peer counselling As I listened to the participants' stories I was puzzled to note this apparent lack of interest towards the idea of using any institutional support—the overriding tone seemed to be even i f the resources were available or adequate they would never use them. It was also curious to note that most of the participant had conveyed the importance of resources being provided for other diverse students having difficulties within their programs, as one student expressed, I'm very sad for her, that she didn't receive the support that we felt that she needed and deserved given that she was accepted into this very competitive program and that they were well aware of her English skills in the interview... .so she needed support... and I don't think she got it. Initially, an obvious explanation of this phenomenon is that it seemed that most of the participants had established a support system outside of the educational setting to facilitate coping with their differences within their programs. Depending on the individual, these support systems consisted of a variety of individuals such as significant others, family, friends and those with similar backgrounds or lifestyles. A l l the participants had expressed that the most important factor in getting support was that the 'supporting' individual(s) must be "compassionate... open minded and non-judgmental" and be able to "understand and accept" their diversity but what seemed most crucial is that the supporting individual must " have had the same background or at least have known someone who may have had the same background". In addition, most of the participants felt it was to difficult to explain the issues related to their diversity to an individual Cultural Differences 87 who did not have a similar background, with one participant indicating that the best support for her would be a "role model" or someone who had gone through the same thing. It is apparent that none of the participants felt they could get the support they needed from any of the available institutional resources, including faculty or others within their own nursing program. In fact one individual stated that it would be difficult to go to anyone associated with her program for support because, its like letting everybody know that things aren't working out that well... they will always be going ...well can they handle it they have so much going on ... it might also might impact letters of reference in the future or clinical placements and then they might caretake you when you don't need it, suggesting that this would impact her learning experience. Therefore, it seemed reasonable to me that most of these participants had not accessed institutional resources for support but instead had set up their own support systems outside of their programs. Whilst the above arguments seemed valid as an explanation for not utilizing certain institutional resources, I was puzzled as to why not one of these participants expressed interest in becoming members of the specific formal groups on campus that were associated with their own diversity. I found that the participants' rationale for not joining these groups to be somewhat vague as seen in the following comment by one student who considered joining a group but in the end decided not to: .. .1 mean, its not like I look down upon them but for my own purposes, I don't really feel like I want to be a part of that. I thought about it [joining a group], but then I was just wavering... I was surprised at the students' lack of interest in joining these groups especially considering that Cultural Differences 88 as members of these groups, they might be able to access support related to their struggles with diversity from individuals who by virtue of having had similar had backgrounds and experiences, would be understanding and accepting of their particular diversity. As I thought about this issue, I sensed there was some element missing in the description of the processes employed by these participants in making their decisions related to getting support. Upon further review of the data, I realized that one possible clue to how these participants had made their decisions related to getting support may be embedded within the one issue that I had initially thought to be merely endemic to any situation in which one accesses support—the issue of anonymity. Most of the participants had indicated that if they were to access resources within their educational institution they would have to be assured confidentiality as one participant clearly stated, that it would have to be totally anonymous, 1 think. But personally I wouldn't go anyways. But if they were going to have something it would have to be something that my peers wouldn't know about and that the faculty in general wouldn't know about.... As I thought about this piece of data, I realized that I might have underestimated the importance of this issue to these participants. It became clear to me that there was a relationship between the choices made by these students to conceal their diversity and the decisions associated with getting support—once having made the decision to somehow conceal their differences and/or not make an issue of their diversity within their educational milieu, accessing institutional resources for support would be antithetical to this decision. In other words, it is possible that for these participants getting support from resources within their educational environment would be another way of 'exposing' themselves and placing them in a vulnerable position. Therefore, Cultural Differences 89 having a support system outside the educational arena would seem to be a 'safer' option for these students as well as allow them to 'normalize' their diversity within their educational milieu.. As I examined how the participants of this study obtained support to help them cope with their diversity in their educational environment, I noted that the stories of two participants differed from the rest in their description of getting support. Like the other participants, both of these students had come to the conclusion that they did not want to access institutional resources for support but they differed in that neither one of them seemed to have a well established support system outside of the educational environment, a fact which is not unexpected considering that both of these students were new to the Vancouver area. What seemed significant to me about this variation is that both of these student presented narratives indicating that they were having a more difficult time than the other participants coping with their diversity within their educational environments, suggesting that they were in need of some support but for some reason were reluctant to access any institutional resources for this. In addition, both of these students became visibly distressed as they told their stories with comments such as "you end up feeling alienated" or "no one understands " with one student who had chosen to segregate herself rather than seek support stating, a numbness occurs because... when your views are pushed down... you then hide them... its brutal ...the core of my being was shaken... and there is no support system or no role models... I had to segregate myself... that's my safety ...to keep myself safe and build myself up again... getting support meant I would have to explain [her diversity] to someone and that can be so frustrating.... Cultural Differences 90 Adding further intrigue to their stories is the fact that neither student has a diverse background or lifestyle that is traditionally considered 'extreme', but both students operated from the perception that sharing their diversity might place them in a vulnerable position and therefore made the decision to conceal their differences from others in their educational environment. As I pondered these findings, I wondered i f there was some relationship between how comfortable the participants were with their own diversity with the decision-making processes associated with getting support—suggesting that self-esteem and self-confidence may play a role in these decisions. Nevertheless, I concluded from this particular variation in the findings that an adequate support system is indeed crucial to a positive learning experience for diverse nursing students, but that it is even more important with students who have chosen not to share their diversity with individuals in their learning environment. As a final comment associated with getting support and the decisions involved in this process, I noted that each one of these students expressed the belief that one has to be in nursing to understand the issues and worries of a being a student nurse. In fact, the participants indicated that the learning environment is such that, students share many powerful and paradigm experiences within the process of becoming a nurse, which results in a sort of "bonding" occurring among students whether they desire it or not—this appears to be especially true with clinical practice situations. This is clearly illustrated within this fascinating comment by one of the participants, I think nursing has a kind of uniqueness in the sense that you all bond not matter what you are, what you believe, because you are in nursing and nobody outside of nursing really understands what it is about and you can't really explain it to anyone... how it can Cultural Differences 91 emotionally drain you... .it creates a sense of community in itself... In addition, an observation which at first seemed merely interesting to me but may actually be relevant to the issue of getting support is the fact that all of the participants expressed the notion that they were changing as a result of being in nursing education and that this may be influencing their relationships outside of their learning environment, as one student stated, "its hard cause then you start to feel like you don't really fit in where you came from either" or as another student shared, "even going back wasn't the same. Like I felt like everything sort of changed. Even going back to where I was familiar it was still different". Therefore, I wonder if some of the external support systems established in the early stages of their education experience, will continue to be a source of effective support for these participants as they go through the transitions involved in becoming a nurse and they encounter the various situations wherein their diversity influences various elements of their nursing practice. Outcomes of Managing Diversity As participants described the decision-making processes related to managing their differences, it became clear to me that the consequences of these decisions exerted a potent influence on the learning and social environments of these participant. In most cases these decisions allowed the students to feel more comfortable within their environments but it seemed that in some situations the decisions created more distress for them as they struggled to adhere to their decisions. The Facade I inferred from that data, that in order to be successful in concealing their diversity most of the participants had constructed a facade or 'pretend' world that they presented to individuals Cultural Differences 92 in their learning environments. Additionally, I surmised that in presenting such a facade the participants exerted some control over their learning environment with the result that they protected themselves from being judged, as well as, allowed them to present a semblance of 'fitting in' with their peers. An intriguing comment by one of the participants associated with this issue and one which further illuminates how this student conceptualized diversity, Its like the student who is East Indian... because she fits in and you know talks English and all that... they think she's exactly the same and after when they get to know her diverse home life that she lives with her grandparents and all that, well you know they '11 accept that... but its like a white person putting some black things in instead of seeing her as she is from the start... kind of it's the majority pushing and..., conveying the idea that a diverse person has to 'fit in' first by appearing to have the same values and beliefs as the mainstream which increases the likelihood that their diversity will be accepted—suggesting another dimension to the decisions surrounding the construction of a facade to manage diversity for some of the students in this study. Whilst the construction of this facade was meant to manage the negative aspects of being culturally diverse (as perceived by the participants), it seemed to me that maintaining this 'pretend' world caused some of the participants further stress. An example of this stress is evident in the participants' narratives wherein they describe the need to be vigilant so as to not give themselves away, meaning that they needed to constantly scan their environment and decide how to respond to various situations. A l l the participants expressed that maintaining this 'pretend' world was often "frustrating" and "confusing". In addition, the struggle to maintain such a facade may have been the source of many of the upsetting emotions expressed by the Cultural Differences 93 participants as they shared their lived experience of being culturally diverse with me during the interviews. One participant expressed the effect of having to maintain a facade when she said ... it was more than the setting, it was the comments but also just feeling like I had to hide, it was hard to sit there quietly and then listen to comments. I just didn't want to be there at all... in relation to a classroom discussion focused on her particular diverse lifestyle. Therefore, even though constructing a facade may be a successful coping strategy for these participants in managing their diversity, further analysis indicates that the strategy also seemed to result in some undesirable outcomes in relation to their social and learning environments. It is also interesting to note that the construction of a facade parallels the strategies used by many marginalized people as the live a world of secrecy and reflectiveness in order to survive. Self Exclusion As I thought about the idea of the participants having constructed a facade of some sort to manage their diversity, I noted that this notion might be linked to another coping strategy described by the students—that of voluntary 'self-exclusion' from any social situations or informal groupings with their peers. Most of the students described this 'self-exclusion' as a personal choice with statements such as: "I want to be different, I have no need to fit in " or " / don't want to be part of the in-group, I have no desire to" and "its just easier not to fit in " Initially, I inferred that this strategy of 'self-exclusion' was either a form of rationalization used by the participants to protect themselves from situations in which they might be subjected to judgmental attitudes or else a defensive response to having been excluded by others in certain situations. In either case, the participants' decision to self-exclude could be perceived as taking Cultural Differences 94 some control over a potentially damaging situation. As I thought about this scenario I wondered if the decision by the participants to 'self-exclude' may also have been a result of the tensions they may have experienced in having to develop and maintain social relationships with their peers within a facade—the difficulties inherent in 'pretending' renders the idea of self-exclusion a much easier and therefore desirable solution for these students. One student suggested that she had to be constantly vigilant about her environment. She stated that she was stating she was, "constantly observing who is there and what sort of reactions I'm getting ". She also found herself to be acutely aware of non-verbal nuances among her classmates, "that glance of the corner of everybody's eye " and because of these things she felt most social situations with her peers were "not relaxed" so she found it "easier to not go ". It seems this dilemma is made even more difficult because all the participants "look' like their peers and appear to 'fit in' , therefore they will get invitations to social events at which they feel uncomfortable because of their diversity. As one student indicated in relation to her participation in various social functions, I'm more similar than different which allows me to be accepted into the group so I get invited but I usually give some excuse or if I do go to stuff I have a time limit so that I can get away. Whilst this self exclusion may serve to relieve of the stress of maintaining a facade for the participants, I believe it also negatively affects the participants in that they will not be able to avail themselves of the support, sharing and camaraderie that are intrinsic to the informal social groupings of a nursing program—thereby resulting in feelings of isolation and alienation. Learning Environment As the participants described their struggles at managing their diversity, I noted that Cultural Differences 95 maintaining a facade seemed to influence certain aspects of the students' learning processes as well as the above-mentioned social relationships. I surmised from listening to the stories of the participants that operating from within the perspective of a 'pretend' world prevents the students from fully participating in some of the learning activities available to them in classroom or practice settings often resulting in feelings of frustration. Many of the 'critical events' as well as other learning situations described by the participants as part of their lived experience were situations in which the participants found themselves unable to advocate for themselves or for others; they often felt torn between the desire to speak up for those with a diverse background and the desire to keep their diversity a secret. Examples of this predicament are contained in the following quotes from various students' narratives, ... its hard because I will want to make a point but I feel like I can't back it up without saying to much so then I just can't make the point. So then I just have to not say things or else if I say things then it comes across really weak because I don't have anything to back it up with, like I will say I think this happens, or you know I heard this is what happens, even if its like I know for a fact that this is what happens and I've seen it a hundred times but I can't really say that... and, Like if you say something you may have said too much and if you don't say anything maybe you should have said something. So no matter what it's kind of wrong. Yeah and I couldn't really bring up my point and so I think it was frustration ...I don't think I would have been able to change anything but I felt useless and hopeless. Cultural Differences 96 In addition, maintaining their facade meant that in many learning situations the participants were unable to express their opinions related to their personal experiences with diversity resulting in feelings of disillusionment regarding the learning situation, such as this student's story, I felt powerless and useless as I know I came across as vague and it's sad too that others couldn't learn from my experiences but that's just how it has to be... .and it's sad you know if other people [students] with diverse backgrounds feel the same way. Like I mean as far as I'm concerned the more differences that we could bring in would be the better it would be for education andfor nursing... because the population is so diverse... but its like not really that easy for someone to do this as an undergrad. This student was suggesting that although she felt she should be advocating for those that were culturally diverse, so that others could learn from her environment she was not prepared to take the risk of jeopardizing her progress as a nursing student by giving input in class which would reveal her diversity to individuals in her learning environment. Positive Aspects As a final point in the discussion of outcomes, I noted that that most of the participants' stories contained elements that could be considered positive consequences of the struggles they encountered while managing their diversity. I considered it exciting to note that these positive consequences seemed to be associated with what the participants had learned from their experience and how this was going to influence not only their personal life but also their future nursing practice. The predominant personal gain expressed by the students seemed to be that the students' experience with being diverse had made them "stronger" and more " self-aw are". From a professional perspective, all the students indicated that the experience of being diverse within a Cultural Differences 97 nursing program helped them in comprehending the impact of being culturally diverse on one's environment, something that they believe they will be able to translate to their nursing practice. In addition, most of the participants expressed the belief that being diverse has enhanced their therapeutic relationships with clients. One individual stated that she could "now relate better to all people especially patients who are diverse " with another stating that she now knew, .. .not to judge a book by its cover but to look at each person individually and to keep my eyes open so as to look at the whole person, holistically as well as understanding that differences could mean a lot of things, suggesting that being culturally diverse has increased these participants' ability to acknowledge and accept others' diversity. Another student indicated that her experience with being culturally diverse has resulted in "a wider lens with which to view clients, I think it's a benefit because I mean I just think I'll be able to understand a lot ofpatients that some of my classmates won't really know what's going on with; the main thing is just how I can relate to people and also I think I know who I am more maybe than somebody who hasn't gone through that much, so I think I can understand the pain which people have when they are sick and the things they have to go through..., a comment that not only alludes to being better able to comprehend clients' diversity but also to her own personal growth. As fascinating as these positive consequences are insofar as the personal and professional gains for the individuals, the disconcerting note for me is that most of these students have partially or totally concealed their differences from others within their educational milieu with the result that no one else will be able to learn from their experiences. Cultural Differences 98 In summary, the findings associated with managing diversity seem to explicate the decision-making processes and related outcomes associated with how the participants coped with their perceived diversity. Once again, it is apparent that these processes and decisions are based on personal and historical events, as well as the various appraisals conducted by the participants within their educational environments in relation to their self-identified diversity. Communicating diversity to others in the learning environment or making an issue of their diversity seemed to be the issues that were central to most of the decision-making processes related to coping with diversity for these participants—the underlying premise to this belief seemed to be that their diversity was a weakness. Therefore, the students perceived that revealing their diversity would place them in precarious situations within their learning environment which could subsequently affect their progress within their nursing programs—the origin of this belief seemed to be the notion that student-faculty relationships are hierarchal with the students having little power. Based on these perceptions and in an effort to normalize their diversity, all the participants decided to conceal their diversity in some way from individuals within their learning environment; with the amount of concealment dependant upon how far from 'norm' they perceived their diversity to be. It is evident that this decision was a coping strategy aimed at keeping the participants 'safe' from judgmental attitudes as well as giving the appearance of fitting in with their peers. In addition, it seems to me that by making the decision to conceal their diversity, the participants were exerting some control over their learning environment to prevent feelings of vulnerability and powerlessness. The decision to conceal their diversity seemed to influence how the participants went about getting support. Although all the participants acknowledged the need for a good support system, none of the participants expressed interest in Cultural Differences 99 any on-campus resources for this support—most of the participants had support systems outside their educational environment. It appears possible that accessing on-campus resources would be perceived by these students as exposing their diversity and therefore defeating any efforts to conceal it. In concealing their diversity, the students took control of their environment by creating a facade to present to their learning environment. As beneficial as this facade is to ensuring a safe, comfortable learning environment, the struggle to maintain it seems to have some undesirable personal, social and academic consequences for the students. Conclusion In this chapter I have presented the findings that emerged from the narratives of five baccalaureate students who self-identified themselves as being culturally diverse. As unique as each participant's story is, certain commonalities among the stories emerged which are represented by the following themes: being culturally diverse, experiencing cultural diversity and managing cultural diversity. In my analysis of the findings I believe these themes symbolize a conceptualization of the participants' lived experiences of being culturally diverse and how these lived experiences impact their social and learning environments. For clarity I presented these themes separately but they are not in any way distinct entities, in fact they are interconnected and interdependent in such a way so as to represent a dynamic process. For the participants of this study, this process involved conceptualizing the meaning of cultural diversity through defining and perceiving diversity based on their ongoing appraisals of personal experiences and environmental situations, which in turn influenced the decision making processes associated with managing cultural diversity within their educational contexts. Cultural Differences 100 I began my discussion of this process with the findings related to being culturally diverse, as I believed an understanding how the participants constructed their meaning of cultural diversity was an appropriate springboard to understanding the lived experience of each individual and of the group as a whole. As background information to this theme, I noted that none of the students were of a visible ethnic or racial group, something that is contrary to what the literature refers to as the culturally diverse student. In addition, the participants were similar in that each participant considered herself to be a minority within her peer group but each student differed in what she considered her primary reason for feeling diverse. It was also evident from the findings that the participants were using a broad definition of cultural diversity when they self-identified themselves as different, as none of them fit into the category of what is traditionally considered to cultural diversity; however they all seemed to operate from a more traditional perspective when defining diversity in others. One of the main ideas that surfaced for me within this theme is that exposure to diversity seemed to be largely responsible for how the individuals defined and perceived cultural diversity. It seemed that any exposure to diversity compelled the individuals to examine their preconceived ideas related to cultural diversity, which was often followed by a 'rearranging' or readjustment of their perceptions. Also, it was evident that there were temporal and personal dimensions involved in how these students perceived diversity, in that the amount of time exposed to diversity along with how personally relevant they perceived the exposure, influenced how comfortable the participants were with their own diversity and with that of others. As I continued my analysis of the data, the findings related to experiencing diversity seemed critical to the understanding of the complex processes, experiences and emotions Cultural Differences 101 associated with the participants' self-defined status as being culturally diverse. The core issues for all the participants associated with experiencing diversity within their educational contexts seemed to be the notion of 'not fitting in ' with their peer group and that of 'being judged" by others in their learning environment, issues which appeared to be the origin of most of the discomfort they experienced in relation to their perceived diversity. The perceptions of 'being judged' and 'not fitting in ' seemed to be based on historical contexts and preconceived ideas as well as the participants' appraisal of various critical events and situations within their learning environments. In addition, it seemed that some of the students had some preconceived ideas of who merited being in the nursing program as they seemed to infer that because of their diversity they did not deserve to be there—perceptions that may have arisen from how the 'culture' of the nursing program is communicated. None of these participants seemed to participate very much in any of the informal social groupings that are inherent within a nursing class—the reasons given for this were varied but most of them expressed concerns related to ideas such as not belonging {impostor), not being accepted, fear of being judged and generally feeling uncomfortable within groups. A n interesting aspect to these findings is that even though all the students expressed fears of being judged or of not being accepted, they also indicated that they believed their peers and most faculty were accepting and understanding of cultural differences— it seemed that this incongruence may be based on the expectation that anyone involved in the field of nursing wi l l be caring and accepting of cultural diversity. As part of the lived experience of diversity, all the participants relayed a discomfiting event that led them to believe their diversity was not accepted and at the same time seemed to confirm their diversity—it appeared Cultural Differences 102 that this event was a paradigm with which they interpreted other experiences related to diversity within their educational environments. Additionally these events may also have been points at which the participants rearranged or redefined their perspectives of the nursing profession as well as their perceptions of the meaning of cultural diversity. Initially, an obvious interpretation of these findings seemed to be that external factors were responsible for the students' perceptions but with further examination I realized that personal qualities such as self esteem and Self-confidence could also contribute to the students' perceptions of not fitting in or of being judged. One other noteworthy idea within this theme is that the various judgmental attitudes experienced by the participant of this study may not be a result of cultural insensitivity but rather they are symptoms of ignorance or a lack of knowledge associated with what are considered non-traditional cultural differences—how these assumptions and attitudes persist in these learning environments may be reflective of the intrinsic culture of nursing education programs. In the final stage of conceptualizing the lived experience of the participants and in understanding the impact of being diverse on their social and learning environments I presented findings related to the decision-making processes associated with how these students managed their diversity. It is evident from these findings that the processes involved in making decisions regarding appropriate coping strategies seem to be influenced by the students' experiences and perceptions as well as their appraisals of various elements within their learning environment in relation to the acceptance of their diversity. The decision-making processes utilized by the participants in choosing coping strategies seem to reflect a desire to exert some control over their learning environment so as to guarantee situations that are comfortable, safe and accepting of diversity. Communicating diversity to peers and faculty seemed to be the critical issue for all of Cultural Differences 103 the students in this study in relation to managing their diversity. The students believed that disclosure of their diversity was risky to their progress in their nursing programs and would adversely affect their relationships with peers and faculty. The element that was of most concern to these students seemed to be the student-faculty relationships which they believed to be hierarchal, therefore precluding any sharing of diversity due to the perception that this would be like exposing a weakness. Based on these perceptions, the participants decided to cope with their diversity by somehow concealing it from others in their learning environment, believing that this would protect them from being judged and permit them to remain 'safe'. The amount or level of concealment seemed to be dependant on how 'extreme' the students perceived their diversity to be in relation to the 'mainstream' culture, suggesting that they conceptualized cultural differences as being on a continuum. It became evident during my analysis that hiding their diversity had some repercussions on the students' decisions related to 'getting support' in coping with their cultural diversity within the educational environment. None of the participants felt comfortable accessing any institutional resources for support but instead relied on outside support systems if they were available. The reluctance to access on-campus resources included established campus groups dedicated to specific cultural differences. The participants provided various reasons for their apparent disinterest in on-campus resources but an underlying tone to these findings seemed to be that accessing resources for support would negate all efforts aimed at concealing their diversity and instead draw attention to it. Additionally, I became aware that the participants' comfort with their own diversity may also play a role in how they went about getting support—in other words self-esteem and self-confidence may be hidden elements to these decisions. However, it was evident that concealing their diversity did not preclude the need Cultural Differences 104 for a support system; in fact it may actually increase this need. An interesting dimension to getting support seemed to be that all the student felt they were going through some transitions as they progressed in their nursing programs, transitions which they felt family and friends could not understand—that only another nursing student could comprehend—on hearing this I wondered if their external supports would continue to be effective as they progressed in their nursing program and encountered diversity issues related to their practice. Finally, as I examined the consequences of the decisions of the decisions made by the students in relation to coping with their diversity, it became clear to me that in their efforts to create safe, comfortable learning environments and somehow normalize their diversity within their educational milieu, they had in effect constructed a facade with which to manage their diversity—a world over which they had the control. Unfortunately, it seems that the struggle to maintain this facade has some negative consequences to their learning processes and personal well being—such as self-exclusion from social situations with peers and limited opportunities to actively participate in some learning activities related to diversity, resulting in feelings of frustration and powerlessness. A positive outcome to the participants' experiences with managing diversity seems to be the perception that they are more knowledgeable and accepting of differences in others, a quality, which they believe, will enhance their future nursing practice. Sadly, by deciding to conceal their differences from individuals within their educational environment, these participants have in effect precluded anyone else from learning from their unique experiences. A thematic structure of the findings is presented on the next page, followed by a discussion of the findings in relation to the available literature in the next chapter of this thesis. Cultural Differences 105 The following is a summary of the thematic structure of the findings as they emerged through the inductive analytical process I engaged in whilst describing and interpreting the influence of cultural differences and social context upon the learning environment of these CDNS. Thematic Structure of Findings Being Culturally Diverse • Defining cultural diversity • Perceiving cultural diversity Experiencing Cultural Diversity • Feeling culturally diverse Not Fitting In Being Judged • Confirming cultural diversity Managing Cultural Diversity • Coping with cultural diversity Communicating Diversity o Concealing o Context of Individual Diversity o Context of Learning Environment Getting Support • Outcomes of Managing Diversity The Facade Self-Exclusion Learning Environment Cultural Differences 106 CHAPTER FIVE: DISCUSSION Introduction The purpose of this discussion is to situate the findings of my study within the current body of knowledge, both empirical and theoretical, related to the lived experience of culturally diverse nursing students and how they conceptualize the meaning of cultural diversity within the social context of their learning environment. In this chapter, I will discuss some of the findings of this study as they correlate to ideas expressed by other authors. Toward this end, I have identified some key ideas from the study that warrant additional consideration in relation to some of the literature in this area. I have organized these key ideas under the two themes: "constructing cultural differences' and "social context and the lived experience of CDNS'. Within the first theme, constructing cultural differences, I will discuss the notion that conceptualizing cultural differences may be viewed as a dynamic and intricate process involving numerous contextual factors; a process that for the participants of this study involved three elements: exposure to diversity, appraisal of personal and environmental experiences associated with diversity, and a rearranging of perceptions relating to understanding the meaning of cultural differences. Secondly, as a way of explicating the lived experience of the CDNS from this study, I will discuss the interaction between social context and the learning environment by presenting two key ideas associated with this - the relationships between students and nursing faculty, and the concept of social comfort. Constructing Cultural Differences The participants of this study represent a slightly different element of cultural diversity than that which is prevalent in much of the nursing education literature. Because none of them Cultural Differences 107 were of a minority ethnic group, they would likely be considered 'non-traditional' according to the traditional definitions of cultural diversity as represented in the dominant literature in this field Indeed, this sample seems to be more reflective of the expanded definitions of diversity that are contained in the more recent general literature associated with cultural diversity. Within this literature, the concept of cultural diversity is considered a product of today's global world— a dynamic and multifaceted phenomenon involving the interplay of factors such as lifestyle choices, age, sexual orientation, religious preferences, social background as well as, race and ethnicity (Baker, 1997; Barnes et al., 2000; Canales & Bowers, 2001; Kalbach & Kalbach 1999; Samantrai, 1995; Levin & Reiffel, 1994). Some authors expand this notion further, describing cultural diversity as a drama involving interactions between a multitude of historical and current events (Baker, Lea, 1994; Pizanis, 1992; Samantrai). The findings of this study suggest that this may be a useful way to understand cultural diversity in the nursing education context in that they orient us toward conceptualization of cultural difference as a complex and ever-evolving process. In order to further examine the implications of this expanded conceptualization, I will discuss two particularly salient ideas emerging from this literature: 'exposure to diversity' and 'appraisal and rearranging'. Exposure to Diversity The participants of this study appeared to be involved in a process of conceptualizing cultural diversity that reflected the amount and type of exposure to diversity they had experienced. According to some authors, increased exposure to a multitude of cultural differences not only amplifies awareness of diversity among individuals but also dramatically alters the conceptualization of cultural diversity. These authors propose that cultures are not Cultural Differences 108 inert but rather constantly evolve through a mutual creation of each other resulting in mutual interpretations of historical and current events towards a goal of shared perceptions (Baker, 19971; Kalbach & Kalbach, 1999; Samantrai, 1995). The findings of this study parallel this literature in that the participants applied insights gained from historical and current experiences with diversity to self-identify themselves and others as diverse, revealing that they had incorporated these experiences into their vision of cultural differences. In addition, the composition of the sample of this study also appears to mirror ideas from the literature that indicates 'exposure to diversity' influences how cultural diversity is constructed in today's world. I noted this in the findings which revealed that although 'traditional' diverse students were apparent as members of the student population, it seemed that the students who 'self-identified as being diverse were those who differed with regards to lifestyle and background issues rather than race or ethnicity, something which the expanded definitions of culture diversity suggest is more appropriate in today's North American society. The plethora of literature that discusses the consequences of globalization is testimony to this notion. The assumptions from this literature is that the increased mobility of the world's population through migration and immigration has resulted in a situation in which traditional cultural categories are no longer adequate in defining who is culturally diverse in today's world (Barnes et al., 2000; Dowell, 1996; Lea, 1994; Poss, 1999; Rew, 1996; Yoder, 1996). Exposure to diversity seems to be a critical factor in how cultural differences are constructed among nursing students in today's nursing education programs. However it is evident that exposure to cultural differences is only one element in this conceptualization, what is also crucial is the apparent consequences of this exposure—appraising cultural difference and rearranging one's Cultural Differences 109 ideas about its meaning. Appraising and Rearranging Further examination of some of the literature reveals exposure to diversity is only the first stage in the constantly evolving drama that is played out within cross cultural encounters and interactions (Baker 1997; Kalbach & Kalbach, 1999; Lea, 1994; Pizanias, 1992; Samantrai, 1995; Spence, 2001). Intrinsic to this literature and adding credibility to the premise that cultural diversity is a fluid and ever-changing concept is the idea that exposure to diversity must be followed by an appraisal of such encounters with the subsequent redefining of one's ideological stance on cultural differences. Such an appraisal is similar to the idea of reflectiveness seen in some of the literature on marginalization, which suggests that diverse peoples lead an examined life in which they must be constantly vigilant for safety (Hall, 1999). Whilst it cannot be surmised that from this study that this small group of participants who are so different from each other are a 'marginalized' group, the findings of this study reflect the occurrence of such an appraisal process, for as the students described their conceptualizations of diversity, they appeared to be engaged in an appraisal of various personal and environmental events against a backdrop of historical and current contexts. These appraisals appeared to have influenced how each student self-defined as diverse, as well as how diversity in others was perceived; these perceptions seemed to reflect a 'rearranging' or redefining of previously held definitions of cultural diversity. This 'rearranging' process appeared to be contingent upon the significance assigned to these experiences as well as how personally relevant the participants interpreted these situations to be. Cultural Differences 110 The findings from this study also seemed to indicate that most of these participants had to encounter and appraise the culture of their nursing program to become aware of their diversity, whilst those students considered diverse according to 'traditional' perspectives seemed to be less aware of or less concerned about their differences, suggesting that the 'norm' or 'mainstream' has the potential to be fluid and context dependant. This may be due to the fact that, in recent years, a great deal of focus in the nursing education literature has been on the needs of 'traditional' CDNS, which may have resulted in a rearranging of what is considered the 'norm' or mainstream. This notion may also reflect assumptions within the general cultural diversity literature that suggests assimilation by an individual into a 'mainstream' culture is no longer desired (Garcia, 1999; Merrill, 1998; Midobuche, 1999); conversely, it seems more advantageous to readjust what is considered the norm, by assimilating differences into mainstream, a concept described by Samantrai as 'interpenetrating' wherein the norm or mainstream remains fluid and responds to cultural contexts. Social Context and the Learning Experience of CDNS As is apparent from the discussion of this study's findings and the perspectives arising from the related literature, the process of constructing diversity appears to illuminate many personal, interpersonal and environmental aspects of the lived experience of CDNS. From this analysis, it appears that social context seems pivotal to the meanings assigned to the concept of cultural differences. Similarly, social context seems to be a critical element in attaining high quality learning experiences for CDNS. Social context is understood to be an important element associated with quality learning experiences. This term conveys the dynamic interplay that exists among the many personal, Cultural Differences 111 interpersonal and contextual factors contained within learning environments. A great deal of literature is available that examines issues related to creating positive learning environments for CDNS. Some of the identified issues are: interpersonal (student-faculty, student-student, student/nurse) relationships, availability of role models, teaching/learning strategies, communication styles, learning styles, curriculum factors, academic and social supports, and organizational policy and structure (Abriam-Yago et al., 1999; Campbell & Davis, 1996; Condon, 1996; Dowell, 1996; Kevern et al., 1999; Kirkland, 1996; Yoder, 1996). The findings from this study indicated that the participants had no concerns with any of the academic dimensions of their learning experience; instead most of their issues were related to social context factors. This is contrary to what is contained in most of the literature, as the majority of the literature focuses on barriers to academic success for CDNS. This difference may be related to the fact that these students are not considered 'traditional' diverse students. In order to more fully consider how these findings related to social context, I will examine two key ideas from the literature - student-faculty relationship and social comfort. Student-Faculty Relationships The findings from this study suggest that the student-faculty relationship and the interactions inherent within this relationship played a key role in the learning environment of these CDNS. This was most evident in the participants' decision-making processes associated with sharing or concealing their diversity from others in their environment. These processes appeared to be related to how the students perceived faculty would view their differences and how this in turn would affect their progress through the program. The findings seem to suggest the student-faculty relationship is so critical to the lived experience of CDNS that the student Cultural Differences 112 must cultivate it in some manner so that the faculty member views the student in a positive light. This idea is echoed in much of the nursing education literature which suggests that the student-faculty relationship is critical to the development and maintenance of positive learning environments for CDNS influencing factors such as: help seeking behaviours, sharing of perceptions and experiences, and comfort within the learning milieu (Campbell & Davis, 1996; Josipovic, 2000; Kevern et al., 1999; Yoder, 1996; 2001). In addition, many authors within this literature discuss various teaching/learning frameworks and approaches aimed at creating a positive, supportive learning environment for CDNS—approaches that are deemed to be culturally sensitive and responsive to cultural differences (Abriam-Yago et al., 1999; Rew, 1998; Saylor & Taylor, 1999; Sturch, 1994; Yoder). It is interesting therefore to consider the findings from this study, in which the participants perceive that the student-faculty relationships are hierarchal in nature with faculty having the power; this perception appeared to influence how the students managed their diversity in that they believed the sharing of their differences would place them in a vulnerable position within this hierarchal structure. What is noteworthy about these findings is that the perceptions of who has the 'power' appear to represent another property of marginalization in relation to the risks associated with sharing diversity versus appearing to conform to the cultural mainstream (Hall, 1999). However, what is illuminating about these findings for the purpose of this study is that they support the literature that indicates the student-faculty relationship is critical to the learning environment of CDNS. Additionally, what seems to be more critical and worthy of further investigation is how CDNS develop their perceptions related to the student-faculty relationship and the manner in which these perceptions persist and are communicated. The student-faculty relationship and the way it is perceived by students leads Cultural Differences 113 to an understanding of contextual influences to the lived experience of CDNS within their learning environments. This learning environment becomes the environment in which social comfort is or is not experienced. Social Comfort An interesting impression I obtained throughout the conduct of this study, and which is emphasized in the study findings is that the notion of comfort was pervasive throughout the narratives and inherent in all aspects of the participants' conceptualization of cultural differences. Based on appraisals of their learning environments and on personal attributes, all the participants described a sense of discomfort with their own diversity as well as within their various learning contexts as evidenced by their comments related to "not fitting in " and of "being judged". Most of the students responded to this discomfort by concealing their diversity from others in their learning environment by creating a facade' based on their understanding of what was considered the 'norm' within their peer group. The findings indicate that this facade served to keep the students 'safe' from being judged, decreased their feelings of vulnerability and allowed them some measure of control over their environment. This facade seemed to allow the students to 'normalize' their diversity within the context of their learning environment. Unfortunately, maintaining this facade appears to be a stressful in itself, with the result that none of the students felt comfortable accessing support within their educational environment for fear of being 'discovered' and most of the participants chose to voluntarily self-exclude themselves from various social and learning situations which they perceived may have caused them discomfort. It seemed apparent from these findings that the idea of comfort was a critical factor associated with the learning environments for the Cultural Differences 114 students of this study. The notion of comfort appears in Condon's (1996) study in which she utilizes the term 'social comfort' to depict how the participants of her study described their feelings related to 'belonging' or 'fitting in'. Based on the findings from her study, Condon suggests that CDNS need to experience a sense of social comfort in order to be successful within nursing programs. The term "social comfort" is not commonly used in the nursing education literature. However, evidence of the importance of the idea can be extrapolated from the works of several authors wherein they present findings related to barriers to success for CDNS, discussing issues such as alienation, cultural isolation, self esteem, self-confidence and support (Campbell & Davis, 1996; Dowell, 1996; Kevern et al., 1999; Yoder, 1996: 2001). These issues all arise from an individual's interaction and experiences with his/her environment and result in feelings of distress or discomfort. They serve to 'marginalize' the student within the sub-culture of the nursing student body or demonstrate (as described ins some diversity literature) the occurrence of 'exclusionary othering'. Marginalization and othering are two terms used commonly in relation to the study of socially vulnerable populations, connotes the complex interplay between social forces used to exclude an individual from the mainstream and the individual's enactment of behaviours that sustain that exclusion. Behaviours such as secrecy and reflectiveness are seen as panaceas to the distress associated with marginalization (Hall, 1999). Exclusionary othering refers to the processes enacted within relationships that utilize power for domination and subordination—to avoid this it seems 'inclusionary othering' must be strived for wherein the power within relationships is used for transformation (Canales, 2000). Although, difficult to apply to this study, these concepts are related to the idea of social comfort as they allude to the Cultural Differences 115 importance of social context in creating positive, supportive and accepting environments for diverse individuals (in this case CDNS). Because it effectively depicts the interactions between an individual and his/her environment, social comfort seems a fitting concept to further our understanding of how the learning environment may influence the experience of CDNS. Adding further credence to this possibility are the findings from Gloria and Ho's (2003) large quantitative study conducted with Asian American undergraduate students representing all fields of study. In this study, comfort was defined as a construct that included students' perceptions related to such factors as: cultural fit within the environment, warmth and receptivity of the university environment and any stress created by the environmental context. These authors examined the idea of comfort along with other 'non-academic' indicators (such as social support and self beliefs) of 'persistence' among undergraduate university students. They concluded that, although comfort was significant as a factor in academic persistence, further study was warranted in this area, particularly because non-academic factors are so difficult to access using self-reporting methods. The concept of social comfort appears to signify the need to experience a sense of belonging or fit within the educational milieu. The underlying assumption from the literature for this premise is that when students feel like they 'fit in' they are more likely to feel comfortable and confident in sharing perceptions and asking for assistance in the learning process. A sense of belonging or fit would seem to require an understanding and internalization of the values and beliefs of the mainstream student population. The CDNS of this study demonstrated that whilst they did not necessarily have the same values and beliefs as the mainstream student population, they were undoubtedly cognizant of what these were so that they could develop strategies Cultural Differences 116 allowing to present the appearance of fitting in resulting in a greater sense of comfort within their learning environments. Therefore the emerging idea of social comfort within the education literature appears to be a notion worthy of further examination as it appears to have inherent possibilities in assisting educators to comprehend the role of the learning environment in relation to factors such as: communication styles, self confidence, help-seeking behaviours, self esteem, persistence and motivation. Conclusion The insights gained from this discussion may assist nurse educators in understanding how nursing students construct cultural diversity. In addition, an appreciation of the evolving nature of culture may help to explicate the 'identity' of the CDNS in the nursing programs of today. Social context appears to be a critical factor within the process of conceptualizing cultural differences as well as to the learning processes of CDNS. An appreciation of the potential contribution of factors such as the student-faculty relationship and social comfort towards the attainment of quality learning experiences and environments for CDNS, may be of considerable benefit to nurse educators as they take on the mission of teaching nursing students in an world in which the concept of cultural diversity is contextually defined and constantly changing. Cultural Differences 117 CHAPTER SIX: SUMMARY, CONCLUSIONS and IMPLICATIONS Summary I designed this study to learn how baccalaureate nursing students perceive cultural differences and how they perceive these differences to influence the learning environment. In addition, I fashioned the study so as to develop an understanding of how students describe and explain feelings of social comfort and discomfort within their learning environments. As I reviewed the literature in preparation for this study, it became evident to me that cultural difference is a notion which is at once fascinating but also complex and multifaceted. The outcome of globalization has been the creation of a world in which the traditional cultural categories have been diluted and are no longer satisfactory in defining who is culturally diverse. This is evident in the client populations that nurses care for and therefore may also ring true for nursing student populations. As a nurse educator, I am aware that the cultural landscape of nursing education has been shifting in recent years in response to the influence of globalization on North American society. Individuals from various social, ethnic and racial backgrounds are arriving at the 'gates of knowledge' aspiring to enter the profession of nursing. According to the literature, despite the many teaching and organizational innovations instituted by nursing programs, aimed at retaining CDNS, many diverse students continue to encounter difficulties within nursing programs-educational support resources are considered ineffective and/or underutilized by CDNS. The education literature cites various reasons for this phenomenon with a key one being, the dearth of cultural diversity within nursing programs resulting in learning environments that are not culturally sensitive; parallel to this idea many authors suggest that nursing programs remain Cultural Differences 118 entrenched in traditional perspectives and philosophies thereby making it difficult for CDNS to identify with the culture of the nursing programs. In addition, the majority of the literature is focused on students who are ethnically diverse, which does not appear to reflect the expanded definition of diversity evident in the general cultural literature. Based on this understanding from the literature, I believed there to be some merit in exploring 'who' the CDNS was in nursing programs of today, examining how such students construct cultural differences within the context of their learning environment and finally, how they understand these differences to influence learning environments. In addition, considering the amount of literature devoted to student success concerns, I felt there was value in understanding how CDNS relate their social context to learning success by examining how they describe and explain feelings of social comfort and discomfort. I reviewed relevant empirical and theoretical literature within the nursing, nursing education, and general education fields in order to situate this study within the existing knowledge related to CDNS. The focus of the literature review was the nursing education literature, wherein I found many anecdotal discussion papers written from the viewpoint of nurse educators engaged in teaching CDNS. Large quantitative studies that employ retrospective data (organizational statistics) or self-reporting methods of data collection are also evident in this literature. Very few studies or discussion papers reflected an enhanced definition of diversity, as most of the research utilizes the traditional paradigms of ethnicity or race. In addition, there seemed to be a scarcity of qualitative research that examined the influence of social context to the learning experiences of CDNS from the viewpoint of students still in their programs—rather the literature is rife with historical inquiries based on insights from culturally diverse graduates. Cultural Differences 119 I chose interpretive description as my research design for this study as I thought it to be suited to the challenge of exploring the complexities associated with cultural differences and the social context of the learning environment as conceptualized by CDNS. This approach follows the principles of qualitative inquiry but allows for a reflective and inductive analytical process of discovery situated within the perspectives of the nursing profession, and for this study, the nursing education field. This design allows for the dynamic interplay between the data and the inductive analytical process, meaning that the preliminary organizational framework is expected to shift as the inductive process reveals new insights. The analytical process for this study began with a preliminary organizational framework that was developed from a perusal of the literature; this framework oriented the study to the existing literature and was used to direct the data collection, analyze the date and develop the findings. Therefore, the purpose of this approach for this study was to describe the lived experience of CDNS as interpreted by the participants of this study in order to understand the meaning of this experience. In-depth interviews were conducted with a total of 5 third or fourth year baccalaureate nursing students who self-identified as being culturally diverse based on parameters presented within recruitment posters and presentations. The interviews were tape recorded and transcribed verbatim by a transcriptionist. Inductive analysis occurred throughout the data collection process, informing the collection and analysis of data in subsequent interviews. The findings of the study represent the culmination of this inductive analysis and can be considered an interpretive description of the lived experience and perceptions of these CDNS. The findings that emerged from this study revealed three common themes. These themes ~ being culturally diverse, experiencing cultural diversity and managing cultural diversity -Cultural Differences 120 seemed to represent a process each of the participants was involved in as they conceptualized the meaning of diversity, experienced the impact of their diversity, and made decisions as to how to manage their diversity within context of their learning environment. As the participants told their stories it seemed evident that they constructed the meaning of diversity through a process which involved defining and perceiving diversity based on their ongoing appraisals of personal experiences and environmental situations; these appraisals also influenced the decision making process associated with managing their diversity within their learning environments. None of these participants differed from their peers because of 'ethnic' differences, suggesting that they employed an enhanced definition of diversity in self-identifying as diverse for this study. Indeed, all of them described cultural diversity as being a related to a multitude of personal and environmental factors. The dominant findings associated with the lived experience of being diverse seemed centred around the perception that diversity would negatively influence progress through the nursing program, with specific concerns being the fear of being 'be judged' and not 'fitting in ' . These concerns influenced the decisions these participants made in relation to managing diversity, in that the participants, with some individual variation, made a decision to conceal their diversity in some way from others in their environment. They all seemed to have constructed a facade that allowed them the semblance of fitting in, giving them some control over their environment, as well as keeping them safe from being judged. The findings of this study were discussed in relation to the existing body of knowledge. The majority of the research and discussion associated with culturally diverse students focuses on those who differ because of race or ethnicity, whereas the participants of this study characterize a different aspect of diversity in that they considered themselves diverse due to Cultural Differences 121 various socio-economic and lifestyle choices. Therefore a great deal of the nursing education literature cannot be applied to this study as many studies discuss ways to overcome barriers such as language, comprehension, and writing difficulties. However, the findings of this study support the discussions in the literature that focus on the importance of the personal and social contexts to the learning environment of CDNS (self-esteem, relationships, accepting environment, fitting in, social comfort). Also, the findings of this study do seem to reflect the general discourses on cultural diversity wherein the notion exists that the increase in cross cultural encounters and exposure to diversity experienced by individuals in today's world make it imperative that an expanded and dynamic perspective of cultural diversity be adopted. Conclusions The following conclusions can be drawn from the findings of this study. • Constructing the meaning of cultural diversity for nursing students may involve the interaction of personal, interpersonal, temporal, environmental and social factors within the context of their educational environments and the meanings assigned to this interplay. • Cultural differences and how they are interpreted may have an impact on the quality of learning/educational environments. • Social context may be critical to the learning experiences and environments of CDNS. Within this social context, the student-faculty relationship plays a critical role in the attainment of positive learning environments for CDNS. • Social comfort may have a special significance for the education of nursing students with diverse backgrounds. The concept of social comfort in the nursing education context Cultural Differences 122 • implies a sense of belonging or fitting in within the educational setting and may influence such factors as communication, self-confidence, help seeking behaviours, persistence and motivation. Implications The findings of this study have implications for nursing education, practice, and research. Although the findings from a small study such as this one cannot be generalized, when considered the context of the existing body of research related to cultural diversity and nursing education, they may provide some insights as nurse educators encounter the critical challenges of teaching in a multicultural world. Implications for Nursing Education Traditional categories of diversity appear to be inadequate in delineating 'who' is diverse within current North American society. The complexity of cultural differences as interpreted from the current literature has the potential to exert a considerable impact on all aspects of nursing education, in that individuals choosing to enter the nursing profession today come from a variety of backgrounds and lifestyles reflecting the composition of the population within our society. As diverse students attempt to negotiate the traditional paradigms and cultures evident in many nursing programs, conflict may arise for both CDNS and nurse educators in areas such as curricula, teaching/learning strategies, communication and teaching/learning environments. Nurse educators will be required to develop an awareness of the dynamic qualities inherent to an expanded definition of cultural differences, so that they may fully appreciate the contextual nature of differences and similarities among nursing student populations, for the trends in current society may mean that some students who may appear 'diverse' are actually more similar Cultural Differences 123 to the mainstream student body than they are different. Also, knowledge of how nursing students conceptualize culturally diversity will add to this appreciation and assist educators in understanding the entity known as the culturally diverse student. In conjunction with this awareness, comprehensive paradigms of cultural diversity may mean that faculty will have to develop a new set of skills with which to identify which students may be significantly diverse from the majority, as it is apparent that differences are not always visible or self-evident. Understanding the identity of the CDNS appears to be only one aspect of the challenge faced by nurse educators in relation to diverse student populations. Social comfort is an emerging concept that may have value as a key factor influencing the quality of learning experiences for CDNS. Attending to the notion of social comfort might mean that nurse educators could develop and support learning environments that are culturally sensitive and accepting in a broad sense. This goal requires an awareness of who is/feels diverse within a student body as well as an understanding of the relationship between social context and quality learning experiences. Whilst nurse educators are only one element within the social context of CDNS, the findings of this study in keeping with current literature, indicate that CDNS perceive the student-faculty relationship as critical to a positive learning experience. Specifically, the student-faculty relationship appears to be vital to CDNS experiencing a sense of comfort and acceptance within his or her educational environment. Considering that there are many elements involved within the social context of CDNS, placing such a responsibility on the student-faculty relationship may seem presumptuous. However, nurse educators create and construct the culture within nursing education programs, and communicate this culture to others within and outside the educational milieu. Program Cultural Differences 124 philosophy, teaching/learning strategies, curricula, recruitment strategies, recruiting and student-faculty relationships could all be examined for culturally exclusionary elements which might contribute to the alienation or marginalization of CDNS, in other words adding to their experience of social discomfort. Implications for Nursing Practice Although, the findings of this study are predominantly relevant to nursing education they also have implications for nursing practice. There is no better evidence of the multicultural world that we live in than the client population nurses care for in practice. A great deal of the nursing practice literature focuses on issues related to caring for culturally diverse clients. Unfortunately, many diverse clients continue to feel their needs are not met by nurses and parallel to this many nurses express frustration and anxiety in caring for such clients. Many of these issues seem to be related to a lack of cultural awareness and knowledge resulting in nursing practice that is considered by some clients as culturally insensitive and disrespectful. Discussions abound in the literature related to providing culturally competent or culturally competent care. Once again much of this literature is focussed on traditional categories of diversity, which as much of the culture literature indicates can be considered stereotyping and only appropriate to a certain segment of the population. The nursing practice world may also benefit from employing an enhanced perspective of cultural diversity and being attuned to differences that may not be considered traditional. Implications for Nursing Research This insights from this study, while interesting, cannot be considered representative of the baccalaureate nursing student because of the limitations of size, gender and level of student. Cultural Differences 125 Any theorizing done in the process of this study can only be applied to this group of students. However linkages with the existing literature indicate that there are some insights within this study that warrant further investigation. Social comfort appears to be a concept that merits further examination in order to fully understand its meaning and its influence on the learning environment of CDNS. It may also be interesting to examine the perceptions of students who are not culturally diverse in relation to social context and their learning environment, potentially accessing further information as to what it means to actually 'fit in' . In addition, further studies involving greater numbers and greater diversity among participants would be invaluable in generating an understanding of the potential and limitations of this concept for enhancing the educational environment. Further research examining influence of social context to the learning experience of CDNS may also be beneficial to nurse educators as they develop culturally sensitive teaching strategies and curricula. An integral piece to this research would be to examine the student-faculty relationship, which seems so critical to the lived experience of CDNS. Examining the student-faculty relationship in more depth may mean applying some of the concepts from the body of literature associated with marginalization and othering. Whilst initially it may seem inappropriate to label the CDNS a vulnerable population, insights might be gained from applying the constructs of these ideologies to understanding the impact of the student-faculty relationship to the learning environments of CDNS. Understanding the parameters of how it feels to be different and comprehending the origins of these feelings both from a personal and social perspective will assist nurse educators in understanding the lived experience of CDNS no matter what form this diversity takes. In addition, understanding how we as nurse educators engage with those that are Cultural Differences 126 different from ourselves (others) may provide us with the knowledge of how to devise teaching strategies and curricula that are respectful of differences but also transformative as educational paradigms. As I perused the literature for this study it became obvious that there was little Canadian literature in this area, with the majority of the literature being American. Canadian society is considered to be unique in its multicultural context and radically different from American culture. This notion may have been one of the issues related to the lack of 'traditional' participants for this study—ethnic diversity may not have the same meaning in Canadian schools of nursing as it has in American culture. For these reasons it seems to be imperative to conduct more research associated with CDNS located within a Canadian context. Despite its limitations, this study has provided some insights to the nursing education field, regarding the lived experience of CDNS, albeit 'non-traditional' diverse students. In addition, it has created an opportunity for some beginning thinking on the concept of social comfort associated with the lived experience of CDNS. These will be promising areas for future investigation and inquiry as we attempt to increase the effectiveness of the nursing education experience for students with increasingly diverse backgrounds. Cultural Differences 127 References Abbott, P. D., Short, E., Dodson, S., Garcia, C , Perkins, J., & Wyant, S. (2002). Improving your cultural awareness with culture clues. Nurse Practitioner, 27(2), p44+. Retrieved October 21,2002 from Academic Search Elite (#6462295; ISSN 0361-1817 Nurse Practitioner) Abdullah, S. N . (1995). Towards individualized client's care: Implication for education. The transcultural approach. Journal of Advanced Nursing, 22, 715-720. 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Issues in recruitment and retention of minority nursing students. Journal of Nursing Education, 55(7), 293-297. Duffy, Mary E. (2001). A critique of cultural education in nursing. Journal of Advanced Nursing 36 (4), 487-495. Available from: http://dx.doi.Org/10.1046/i.1365-2648.2001.02000.x Garcia, E. E. (1999). Reforming education and its cultures. American Behavioral Scientist, 42(6), p.l072+. Retrieved October 11,1999 from EBSCOhost database (#1545198). Gloria, A. M . , & Ho, T.A. (2003). Environmental, social and psychological experiences of Asian American undergraduates: Examining issues of academic persistence. Journal of Counselling and Development, 18(\), 93-116. Gorski, P. (2000). Defining multicultural education. Multicultural Pavilion, (February, 27). Available: http://curry.edschool.virginia.edu/go/multicultural/initial.html.**** Hall, J. M . (1999). Marginalization revisited: Critical, postmodern and liberation perspectives. Advances in Nursing Science, 22(1), 88-102. Heuberger, B., Gerber, D. & Anderson, R. (1999). Strength through diversity. College Teaching, 47(3), pl07+. Retrieved October, 11,1999 from EBSCOhost (Item # 2116067). Cultural Differences 130 Jairrels, V. (1999). Cultural diversity: Implications for collaboration. Intervention in School & Clinic, 34(4), p236+. Retrieved October 11,1999 from EBSCOhost database Jeffreys, M . , & Smodlaka, I. (1999). Construct validation of the transcultural self-efficacy tool. Journal of Nursing Education, 38(5), 222-227. Kalbach, M.A. & Kalbach, W. E. (1999). Becoming Canadian: Problems of an emerging identity. Canadian Ethnic Studies, 31(2) pl+. Retrieved October 13,2000 from Academic Search Elite database (#2668763; ISSN:. 0008-3496). Kevern, J., Ricketts, C , & Webb, C. (1999). Pre-registration diploma students: A quantitative study of entry characteristics and course outcomes. Journal of Advanced Nursing, 30(4), p. 785+. Retrieved December 12, 2002 from EBSCOhost database (# 5866933; ISSN: 0309-2402) Kim, S., Clarke-Ekong, S., & Ashmore, P. (1999). Effects of a hands-on multicultural education program: A model for student learning. Social Studies, 90(5), p. 225+. Retrieved October 11,1999 from EBSCOhost database (#2215245). Kirkham , S. R. (1998). Nurse's descriptions of caring for culturally diverse clients. Clinical Nursing Research, 7(2), p215+. Retrieved January 1, 2001 from Academic Search Elite (AN: 538527; ISSN: 1054-7738). Kirkland, M . L. (1998). Stressors and coping strategies among successful female African American baccalaureate nursing students. Journal of Nursing Education, 37(1), 5-12. Kosowski, M . M . , Grams, K. M . , Taylor, G. J. & Wilson, C. B. (2001). They took the time... .they started to care: Stories of African-American nursing students in intercultural caring groups. Advanced Nursing Science, 23(3), 11-27. Cultural Differences 131 Kulig, J., & Thorpe, K. (1996). Teaching and learning needs of culturally diverse post R.N. students. Canadian Journal of Nursing Research, 28 (2), 119-123. Kuehn, L. (1992). Education: mosaic versus melting pot. Social Policy, 23(1), p65+. Retrieved October 13, 2000 from Academic Search Elite (#9301070056; ISSN: 0037-7783) Lea, A. (1994). Nursing in today's multicultural society: a transcultural perspective. Journal of Advanced Nursing, 20, 307-313. Leininger, M . (1995). Transcultural nursing: concepts, theories, research and practices (2 n d ed.). Detroit, MI: McGraw Hill . Leininger, M . (1996). Culture care theory, research and practice. Nursing Science Quarterly, 9(1), 71-78. Leininger, M . (2001). Founder's focus: Types of science and transcultural nursing knowledge. Journal of Transcultural Nursing, 6(4), p.333+. Retrieved October 21, 2002 from Academic Search Elite database (#5341607; ISSN1043-6596). Levin, B. & Riffel, (1994). Dealing with diversity: some propositions from Canadian education. Education Policy Analysis Archives, 2,(2), 10 pages. Retrieved November 11, 2000 from EPPA listserve database. MaCavoy, S., & Lippman, D. T. (2001). Teaching culturally competent care: Nursing students experience rural Appalachia. Journal of Transcultural Nursing, 72(3), pp221+. Retrieved October 21,2002 from EBSCOhost Academic Search Elite database (#5044153 ISSN: 1043-6596) Merrill, E. B. (1998). Culturally diverse students enrolled in nursing: Barriers influencing success. Journal of Cultural Diversity, 5(2), 58-65. Cultural Differences 132 Merriam Webster Unabridged Dictionary (2002) Online version. Mertens, D. M . (1998). Research methods in education and psychology. Thousand Oaks, CA: Sage. Midobuche, E. (1999). Respect in the classroom. Educational Leadership, 56(7), pp80+. Retrieved October 11,1999 from EBSCOhost database (#1792619). Morse, J. M . & Field, P. A. (1995). Qualitative research methods for health professionals. (2 n d ed.). Thousand Oaks, CA: Sage. Mulholland, J. (1995). Nursing, humanism and transcultural theory: the 'bracketing-out' of reality. Journal of Advanced Nursing, 22, 442-449. Murphy, K. & Macleod Clark, J. (1993). Nurses' experiences of caring for ethnic-minority clients. Journal of Advanced Nursing, 18, 442-450. Pizanias, C. (1992). Centering on changing communities: Mulhculturalism as meaning and message. Canadian Ethnic Studies 24(3), p87+. Retrieved October 13, 2000 from Academic Search Elite database (#9607036698; ISSN: 0008-3496) Poss, J. E. (1999). Providing culturally competent care: Is there a role for health promoters? Nursing Outlook 47(1), 30-35. Rajan, M . J. (1995). Transcultural nursing a perspective derived from Jean-Paul Sartre. Journal of Advanced Nursing, 22, 450-455. Randle, Jacqueline. (2001). The effect of a 3-year pre-registration training course on students" self-esteem. Journal of Clinical Nursing 10 (2), 293-300. Available from: http://dx.doi.Org/10.1046/i.1365-2702.2001.00483.x Cultural Differences 133 Reeves, J. S. (2001). Weaving a transcultural thread. Journal of Transcultural Nursing, 12(2), 140-145 Rew, L. (1996). Mfirming cultural diversity: a pathway model for nursing faculty. Journal of Nursing Education, 35 (7), 310-314. Rossiter, J.C., Bidewell, J., & Chan, P.T. (1998). Non-English speaking background high school students' attitudes towards the nursing profession. Journal of Advanced Nursing 27(3), p.604+. Retrieved December 12,2002 from EBSCOhost #5278020 ISSN: 0309-2402. Ryan, M . , Twibell, R., Miller, A., & Brigham, C. (1996). Cross-cultural nursing: a report of faculty collaboration through regional networking. Nurse Educator, 21(6), 28-32. Samantrai, R. (1995). States of belonging: Pluralism, migrancy, literature. Essays on Canadian Writing, 51,33-51. Retrieved October, 13, 2000 from EBSCOhost. Saylor, C , & Taylor, T. (1993). Transformation: nursing education and cultural diversity. Nurse Educator, 18 (1), 26-28. Shakya, Anita & Horsfall, Jan M . (2000). ESL undergraduate nursing students in Australia: Some experiences. Nursing and Health Sciences 2 (3), 163-171. Available from: http://dx.doi.Org/10.1046/i.1442-2018.2000.00050.x Spence, D. (2001a). Prejudice, paradox and possibility: Nursing people from cultures other than one's own. Journal of Transcultural Nursing, 12(2), 100-106. Spence, D. (2001b). Hermeneutic notions illuminate cross-cultural nursing experiences. Journal of Advanced Nursing, 35(4), 624-630. Retrieved October 21, 2002 from Academic Search Elite (#4989665; ISSN 0309-2402; Journal of Advanced Nursing). Cultural Differences 134 Thorne, S., Reimer Kirkham, S., & MacDonald-Emes, J. (1997). Focus on Qualitative Methods. Interpretive Description: A Noncategorical Qualitative Alternative for Developing Nursing Knowledge. Research in Nursing & Health, 20, 169-177. Villafuerte, A. (1996). Structured clinical preparation time for culturally diverse baccalaureate nursing students. International Journal of Nursing Studies, 13,(2), 161-169 Wilson, C. W., & Mitchell, B. S. (1999). Nursing 2000: A collaboration to promote careers in registered nursing. Nursing Outlook, 47 (2), 56-61. Yoder, M . K. (1996). Instructional responses to ethnically diverse nursing students. Journal of Nursing Education, 35 (7), 315-321. Yoder, M . K. (2001). The bridging approach: effective strategies for teaching ethnically diverse nursing students. Journal of Transcultural Nursing, 12(4), p.319+. Retrieved from EBSCOhost: Academic Search Elite, October 21,2002. #5341595; ISSN 1043-6596. Zorn, C , Ponick, D. & Peck, S. (1995). An analysis of the impact of participation in an international study program on the cognitive development of senior baccalaureate nursing students. Journal of Nursing Education, 34 (2), 67-70. Cultural Differences APPENDIX: I Participant Recruitment Flyer/Memo Cultural Differences APPENDIX II Letter of Initial Contact (Faculty/Staff of Nursing Education Programs) Cultural Differences ATTACHMENT UI Ethics Approval University of British Columbia Behavioural Research Ethics Board Cultural Differences APPENDIX IV Participant Consent and Information Form Cultural Differences 142 that may have different life experiences from that of the majority population (in this case the student nursing body), as well as, those individuals who differ because of racial and/or ethnic backgrounds. In this way, individuals from the majority population who may be 'different' but not visibly or traditionally so, may be included in the group. Similarly those individuals who are from a minority group but who may actually be more similar than different from the majority population will not be singled out and stereotyped. The following assumptions guide the study: • Nursing students are the best sources of information related to the lived experience of being a student nurse. • The culture of a population of nursing students can best be described by members of that group, and therefore cultural differences among nursing students are also best described by members of the student group rather than by an outsider. • Nursing students also have the best understanding of the social context that exists within a nursing program and therefore can best describe the influence of social context to the learning experience. • Feelings of social comfort or discomfort in learning situations are best described by the individual experiencing these feelings. It is hoped that your participation in this study will provide the researcher with some preliminary insights into cultural differences and the social context of learning, which may be used to guide nurse educators as they develop nursing programs which enhance the recruitment, retention and success of culturally diverse individuals into the profession. Study Procedures: I, Anna Helewka, as a graduate student in the School of Nursing at UBC, am conducting this research study for my graduate thesis as partial fulfillment of the requirements for the degree of Master of Science in Nursing. I am currently registered with the Registered Nurses Association of British Columbia (RN) as well as the College of Registered Psychiatric Nurses of British Columbia (RPN). My clinical expertise is adult medical/surgical nursing and adult acute psychiatry. If you agree to participate in the study, I will interview you on at least two occasions for approximately 1-1.5 hours each time, at a time and location mutually agreed to. The interviews will be audio taped and written notes taken by researcher as necessary. A transcriptionist will transcribe the interviews verbatim. During the second interview, you will be presented with interpretations of the data collected during the first interview that will describe emerging concepts, categories and themes associated with cultural differences and the social context of learning; you will be asked to validate, clarify and comment on the accuracy of these accounts. Any concerns you may have regarding the material will be recorded by the researcher and the descriptions will be altered to more accurately reflect your experience as a nursing student. On completion of the study you will be given a written summary of the study findings. In addition, information will be provided to you as to where to access the completed thesis. Confidentiality: At the beginning of the first interview, I will identify you as participant #1, #2, etc., as a means of ensuring confidentiality and privacy. A l l references to you in the study will be made according to your assigned participant number. Demographic data collected will be presented in Cultural Differences 143 such a manner as to protect your identity; it will not be possible to link you to a specific class or faculty member at UBC. Protocols are in place to secure the storage of the research data (audiotapes, transcripts, computer files). At no time will any information, which identifies you, be made available to anyone other than as required by law. I will retain the raw research data collected for a period of five years from the date of completion of this research study, at which time all raw research data will be destroyed. Components of raw data collected during this study may be used by the researcher in order to develop paper presentations for professional / educational purposes. Potential Risks/Benefits for Participants Potential risks for you as a participant include experiencing both positive and negative feelings related to the sharing of your perceptions and experiences regarding the influence of cultural differences and social context to your present and past learning experiences. The researcher will remain cognizant of these possibilities and will provide external resources as needed to manage such situations. As a participant, you may or may not benefit from the being involved with this study. At the very least it is hoped that by sharing your insights and experiences you will increase your understanding of cultural diversity. Another potential benefit is your contribution to an enhanced understanding of how nursing programs can better meet the needs of culturally diverse nursing students. This understanding may provide direction to nursing programs on how to attract, retain and graduate students from diverse cultural backgrounds, thereby increasing the diversity among the members of the nursing profession. Contact for Information About the Study: If you have any questions or desire further information with respect to this study, please feel free to contact my committee chair and principal investigator, Dr. Sally Thorne or myself as the co-investigator. Dr. Sally Thorne is located in the School of Nursing at The University of British Columbia and may be contacted at 604 822 7748 or by e-mail at thorne@nursing.ubc.ca. Please refer to page 1 for my contact information. Contact for Information About the Rights of Research Subjects: If you have any concerns about your treatment or rights as a research participant feel free to contact the Research Subject Information Line in the UBC Office of Research Services at 604 822-8598. Consent: Your participation in the study is entirely voluntary and you may refuse to participate, or withdraw from the study at any time without prejudice or jeopardy to your standing as a nursing student in the School of Nursing at UBC. You may also decline to answer any questions at any time. A l l of your rights remain protected during this research process. Your signature below indicates that you consent to participate in this study. You have received a copy of the consent form for your records. Participant Signature Participant Name (printed) Date Cultural Differences APPENDIX V Participant Demographic Questionnaire Cultural Differences 145 Participant # Demographic Data Date of Birth: Sex Marital Status Place of Birth: Religion Ethnic Background Language First Language Spoken at Home Currently living in (municipality) Length of Time in BC; Canada Formal Education Previous or Current Employment/Volunteer Experience Current Nursing Student Status ( Year/Semester): Children/Depedents Cultural Differences A P P E N D I X V I Sample Questions for Initial Participant Interviews Cultural Differences 147 SAMPLE QUESTIONS FOR INITIAL INDIVIDUAL INTERVIEWS **NB I will use the term cultural diversity and cultural differences interchangeably during this interview but I will explain this to participants. • What do the terms cultural diversity and cultural differences mean to you? How would you define the terms? • How would describe someone who is culturally diverse? • Do you consider yourself culturally diverse from your peers in the nursing program? How would you describe these differences? • If you consider yourself culturally different, describe how you feel others in your learning environment (students, instructors) respond to your difference. What situations have led you to believe this? • How would you describe your similarity to others in your class? • Describe individuals from your class/program that you would consider to be culturally diverse? Explain your reasons for having these perceptions. • Describe your responses towards those you consider culturally diverse. • Reflecting upon your experience as a nursing student what can you tell me about the relationship (if any) of cultural diversity to your learning experiences in your nursing program? • What can you tell me about the learning experiences of others in your program in relation to their cultural differences? • Describe a learning situation in which you felt your cultural difference positively influenced the quality of your learning. What do you feel contributed to the positive tone of this situation? Describe your feelings in this situation. • Describe a learning situation in which you felt your cultural difference negatively influenced the quality of your learning. What do you feel contributed to the negative tone of this situation? Describe your feelings in this situation. How was the situation resolved? What were the outcomes? • Describe a learning situation in which you have felt supported. What can you tell me about the circumstances of this situation that led you to feel this way? Cultural Differences 148 Describe a learning situation in which you have not felt supported. What can you tell me about the circumstances of this situation that led you to feel this way? How was this situation resolved? What strategies have you developed (if any) to help you deal with situations in which you feel your cultural diversity may negatively influence your learning? Describe any strategies you have developed to assist you in being successful in your nursing studies What resources are available to you at the university to assist you in your learning? Describe situations in which you have had to use these resources? Describe your experience with using these resources? What other resources do you feel should be available to you to assist you in being successful in your nursing studies? 

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