Healthcare organisations across the globe are seeing a widening sociocultural diversification of patients and staff, as a result of expanding global migration patterns. Culley (2014) defined this widening diversification as ‘super diversity’, highlighting the challenges nurses experience in adapting their behaviours during cross-cultural encounters with patients and staff. Evidence on declining standards of care for culturally diverse patients is mounting (Kovner et al, 2018; Markey et al, 2019a). The multifaceted challenges of working in intercultural healthcare teams are also widely reported (Andonian and Rossenblum, 2017). The role of nurse education in preparing graduates to work in culturally diverse contexts and to engage effectively with culturally diverse patients and staff is becoming increasingly important. It is vital to ensure that intercultural competence is explicitly developed in nurse education programmes and becomes the responsibility of all practising nurses. Deardorff (2006) defined intercultural competence as the ability to behave and communicate appropriately in intercultural situations and this requires understanding and respecting cultural difference.
There is growing evidence on the value of focused educational interventions on intercultural competence to prepare nurses to work in culturally diverse healthcare settings (Sjögren Forss et al, 2019). Despite the many reported benefits of such initiatives, nurses continue to report feeling ill-prepared during cross-cultural encounters (Almutairi et al, 2017; Markey et al, 2018), raising questions about the effectiveness of the educational preparation received. Nurse educators need to re-examine ways of creating educational interventions and learning activities that support nurses' understanding of intercultural competence and requirements for working in a globalised healthcare environment.
The widening landscape of cultural diversity in the nursing classroom, as a result of expanding international education initiatives and global migration patterns, can provide a vehicle for intercultural learning and a catalyst for intercultural competence development. Drawing on experiences of international students studying on postgraduate nursing programmes, this article highlights some practical suggestions for capitalising on intercultural learning in culturally diverse classrooms. It calls on all students to embrace culturally diverse learning environments and highlights the importance of maximising opportunities to learn with, from and about students from different cultural backgrounds.
Valuing intercultural learning opportunities
Students need to appreciate the importance of intercultural competence development as a means of developing the knowledge, skills and attitudes to work in culturally diverse healthcare settings. Choi and Kim (2018) and Markey and Okantey (2019) called for more non-traditional ways of developing intercultural competence, highlighting the importance of encouraging intercultural engagement during all learning opportunities. The culturally diverse classroom provides a rich intercultural learning environment to learn with, from and about students from diverse cultural, linguistic and ethnic backgrounds. However, unless students have the courage, curiosity and commitment to maximise formal and informal intercultural learning opportunities, intercultural competence development will become tokenistic and meaningless. Intercultural learning provides opportunities for students to learn about and understand one's own and other cultures, while providing opportunities for intercultural interaction (Hollinderbäumer et al, 2013; Chan et al, 2017). It provides opportunities for students from culturally diverse backgrounds to share and learn about different cultural norms and experiences of health care and can help reduce some of the uncertainties nurses experience during cross-cultural encounters. In this way, intercultural learning supports the development of intercultural competence as it encourages acknowledgement and respect for cultural difference and supports the preparation for communicating cross-culturally (Malau-Aduli et al, 2019).
The benefits of engaging with intercultural learning opportunities are well recognised (Garone and Van De Craen, 2017; Chan et al, 2017). Intercultural learning environments enrich intercultural dialogue and learning, valuing different perspectives on health care and nurturing confidence in cross-cultural interactions (Prieto-Flores et al, 2016). Intercultural learning does not occur spontaneously and requires commitment from both students and educators. Opportunities to explore and appreciate one's own and different perspectives on healthcare experiences, while understanding how to explore cultural similarities, respect differences and integrate learning, are core. However, engaging and navigating intercultural learning is not without its challenges (Day and Beard, 2019; Markey et al, 2019b; O'Brien et al, 2019). Developing culturally responsive capabilities to meaningfully and sensitively engage in intercultural learning is essential and will help surmount the reported challenges.
The importance of culturally responsive teaching as advocated for by many authors is indisputable (Killick, 2018; Day and Beard, 2019). However, students also need to understand the important role they play in culturally responsive learning, for it to have meaning and utility. Students have responsibilities to meaningfully and proactively engage in intercultural learning opportunities, which is an area that receives limited attention in the literature. Day and Beard (2019) drew attention to the importance of developing the confidence and skills in respectfully exploring different perspectives and experiences in valuing diversity and meaningful inclusion. However, this requires courage, commitment and curiosity when learning with, from and about students from different cultures. The following outlines some suggestions of how this can be achieved.
Learning with culturally diverse students
Developing skills in independent learning, collaborative working, critical thinking and information technology are core requirements for higher education in the 21st century. However, transitioning into higher education can be challenging for all students where there are differing teaching pedagogies and academic expectations to navigate (Graue et al, 2015; Clark et al, 2015). These difficulties can be exacerbated for international students when trying to acclimatise to new cultures (Markey et al, 2019b), new pedagogies (Yang et al, 2019) and learning in a different language (Garone and Van De Craen, 2017). Culture influences learning behaviours (Hudiburg et al, 2015). Therefore, it is inevitable that there will be wide-ranging learning styles, cultural norms, clinical experiences and linguistic styles in culturally diverse classrooms. Students need to appreciate the benefits of learning in such fertile environments and develop proactive culturally responsive approaches to intercultural engagement in the classroom. Culturally responsive learning environments empower students to listen with intent, to share their perspectives, experiences and cultural knowledge, and to reflect on experiences, beliefs and values as a means of improving understanding. However, cultural differences in learning behaviours can present as a challenge in intercultural learning environments (Chan et al, 2017). Students need to understand and respect diversity in learning behaviours, while acknowledging differences in prior educational experiences. This requires developing the capacity to see oneself and others in more inclusive ways (Killick, 2018) and fostering commitment to intercultural inclusiveness (Malau-Aduli et al, 2019), where cultural diversity is valued and respected.
It is inevitable that all students will feel uncertain when engaging in culturally diverse classrooms. Recognising the importance of developing resilience in learning environments that are perceived to be threatening can help students navigate such uncertainties. Benson (2019) highlighted the necessity of resilience for intercultural learning. However, students also need to be proactive and committed to learning about one's own and other cultures. This requires developing the confidence and commitment to actively engage in intercultural activities. Developing a sense of ‘belonging’ to the learning environment (Malau-Aduli et al, 2019) and focusing on ‘forming connections’ with other learners (Carlson et al, 2017; Gillespie et al, 2017) is essential for developing the confidence and courage to integrate. Being supportive, valuing relationships, and acknowledging and respecting difference can support growth in confidence and comfort in expressing and sharing personal views. Students need to be open, non-judgemental and learn to respect and accept collective perspectives and different ways of interacting across cultures in the classroom. However, this requires the development of courage to meaningfully engage in intercultural learning and teaching activities.
Learning from culturally diverse students
Learning to work with colleagues from different cultural and ethnic backgrounds is important as the nursing workforce is becoming increasingly diverse (Kovner et al, 2018). The intercultural classroom has the potential to provide a rich intercultural dimension to learning that can help to prepare nurses to communicate effectively and sensitively during cross-cultural encounters with staff and patients. However, the differences in clinical exposure and different perspectives of healthcare systems, nursing environments and nursing practice can impact on student integration (Higginbottom, 2011). Students need to learn to be open and non-judgemental when hearing different perspectives and experiences of healthcare practice. This requires reviewing how we conceptualise cultural differences. Conceptualisation of cultural difference impacts on stereotype formation and can negatively affect perceptions of cultural difference (Almutairi et al, 2017). Students need to appreciate cultural similarities, while respecting differences in cultural norms, healthcare structures, clinical experiences, and learning styles. This requires becoming aware of ethnocentric ideologies regarding cultural norms, learning behaviours and clinical competence. Eriksson et al (2018) and O'Brien et al (2019) have drawn attention to feelings of inferiority and notions of superiority in intercultural learning environments and the negative impact that this can have on perceptions of cultural difference and inclusiveness. Students need to examine the way in which they judge others through the lens of their own perceptions of ‘normality’. Appreciation of cultural difference can be enhanced through listening to and sharing cultural values and beliefs, creating a greater awareness of the need to acknowledge and respect cultural difference.
The intercultural classroom provides a useful platform where culturally diverse students can learn to collaborate together on learning activities. Carlson et al (2017) reported how teamwork and intercultural communication skills improved when students from different cultural backgrounds collaborated on learning activities. Although cross-cultural group work is effective in developing intercultural competence as it can bring greater diversity of experiences and perspectives (Killick, 2018), it is not without its challenges. Students have a tendency to engage and work with students who are perceived to have similar backgrounds, which has been described by some as a ‘comfort zone’ (Tilki et al, 2007) and ‘sticking together’ (Markey et al, 2019a). This provides comfort and familiarity for students but ultimately limits cross-cultural engagement, integration and effective intercultural learning. Benson (2019) argued that repeated intercultural learning encounters are effective and they can occur in multiple contexts through formal and informal classroom interactions. However, Byrne et al (2019) identified the fears students have with mixing in culturally diverse classrooms and drew attention to the difficulties in forming cross-cultural relationships. Developing the confidence and courage to feel comfortable when engaging with students from different cultural backgrounds is paramount. This takes time, commitment and an appreciation of the value of the philosophies underpinning intercultural learning.
Learning about culturally diverse students
Engaging in opportunities that consider cultural knowledge and different norms, values and beliefs can help nurses consider how culture influences care needs and preferences. However, the growing evidence highlighting nurses' cultural knowledge deficits requires attention (Hart and Mareno, 2016; Markey et al, 2018). The intercultural classroom provides opportunities for students to develop cultural awareness, knowledge and sensitivity, which can help prevent cultural misunderstandings. Developing cultural knowledge is important but this requires recognising and respecting diversity among and within different cultural groupings. Hearing students from diverse cultural and ethnic backgrounds share health beliefs can assist with understanding individual choice and preferences and, more importantly, can enable cultural similarities to be explored while respecting differences. Having opportunities to hear real practice stories from nurses who have worked in different countries can assist in the exploration of broad and specific issues that need consideration when planning care for culturally diverse patients. However, it is important to explore commonalities of cultural norms and beliefs, rather than solely focusing on differences.
The intercultural classroom provides opportunities for nurses to challenge stereotypes and dismantle the myths and labels attached to cultural groupings. However, this requires developing the courage to question others in respectful and sensitive ways, while critically reviewing one's own beliefs and values that inform behaviours. Students need to appreciate the value of engaging with learning activities that encourage intercultural dialogue, while appreciating that meaningful intercultural learning is about accepting and respecting cultural differences. Opportunities to act out different cross-cultural encounters, in a safe environment, can create greater understanding of one's own and other cultures (Ndiwane et al, 2017). Additionally, Chan and Nyback (2015) highlighted how students eventually felt comfortable when sharing cultural values, beliefs and behaviours, resulting in enhanced intercultural engagement and learning.
Conclusion
Intercultural learning environments offer opportunities for intercultural interaction within a safe environment, where students learn to understand the importance of acknowledging cultural similarities, while respecting cultural differences. The value of maximising intercultural learning opportunities in the classroom can support students' personal, professional and collaborative learning, which can help prepare nurses to work in culturally diverse healthcare settings. Although much has been written about the role educators have in navigating culturally diverse classrooms, students also have a responsibility for proactively and meaningfully engaging in culturally responsive learning opportunities. Capitalising on opportunities to learn with, from and about students from difference cultures is essential. However, students need to nurture commitment to maximising intercultural learning opportunities, the curiosity to develop cultural awareness and knowledge and the courage to question self and others in the spirit of intercultural inclusiveness and integration.