Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training

The study was conducted in one large primary care hospital in southern Finland in autumn 2017. This hospital was chosen because it is located in an area that has a large number of immigrants (1/4 of all immigrants living in Finland). In 2017, 16% of the population in this area were foreign-language speakers (compared with 7% in the total population of Finland). The largest groups were Russian, Estonian and Arabic speakers [17]. An invitation to participate in the training was delivered to healthcare professionals in the hospital by the ward managers. Participants were expected to be physicians, registered nurses or licensed practical nurses with prior experience in taking care of culturally diverse patients. A group of 20 registered nurses (n = 14) and practical nurses (n = 6) from seven different units were enrolled in the training. At the end of the training, an email was sent to all participants with an invitation to participate in small group interviews. Ten (n = 10) participants responded and were willing to participate.

Cultural awareness was chosen as the main construct for the training because self-reflection on one’s own culture can be seen as an important component of cultural competence, and understanding one’s own cultural features and values helps in understanding the beliefs, values and behaviour of others [18]. Cultural awareness is one component of Campinha-Bacote’s (2002) model of cultural competence in healthcare delivery, which explains cultural competence as a process that requires healthcare workers to engage in an active and ongoing effort to achieve the ability to provide culturally responsive healthcare services [18]. Instead of providing culturally specific facts about other cultures—which can increase the use of stereotypes [5]—the training was designed to take a more general approach to cultures, with the main goal being to increase awareness of different cultures by scrutinizing one’s own cultural features. In order to develop training that takes into account the context and involvement of key stakeholders, we utilised a wide range of sources in the development. The content of the training was based on (a) the theoretical literature about the different cultural dimensions (e.g. differences in cultural values, such as individualism vs. collectivism, power distance or orientation in time) [19, 20]; (b) several research articles regarding cultural pain, differences in personal space, and the importance of considering the spiritual needs of foreign patients [21‐23]; (c) knowledge obtained from different cultural experts such as a priest and personnel from the Centre for Torture Survivors in Finland; and (d) knowledge obtained from our previous interview study. Interviews with 25 Finnish healthcare professionals were conducted in order to examine the main challenges that such healthcare professionals (nurses, doctors and dentists) face when taking care of culturally diverse patients [24]. Additionally, these interviews assessed perceived educational needs. The interviews revealed that the challenges are mainly related to communication between the patients and healthcare professionals, including language barriers, problems with visitors, gender issues and differences in pain interpretation. Perceived educational needs related to gaining an understanding of patients experiences with the Finnish healthcare system, the need to share experiences with colleagues about cross-cultural care, and learning some culture-specific facts or guidelines that could help in everyday nursing practice.

Constructivism learning theory was chosen as the pedagogical approach because it highlights the activity and engagement of the learner in using one’s own prior experiences in constructing new knowledge, developing an understanding, and making meanings [25]. The participants were encouraged to reflect about their prior experiences and encounters with culturally diverse patients and discuss in groups in order to inspire further thinking. The training included 16 h of face-to-face teaching, which was divided into four 4-h sessions and arranged for 4 weeks. The sessions were arranged once a week to give participants an opportunity to ponder and assimilate the learned content in their daily work before the next session. Participants attended the sessions during their working hours, so afternoon times were chosen. It was believed that afternoon times would improve participants’ opportunities to attend the sessions because more staff was present in the wards then.

The sessions were designed to move from the theoretical level to the practical level, and each session built upon the previous one. The main teaching method was adapted from ‘storytelling’, wherein the educator—an experienced teacher from a multicultural centre—used real-life examples, stories and pictures to demonstrate different cultural aspects. Storytelling was used because of its strength in promoting the adoption of multiple viewpoints and making sense of unknown theoretical situations, norms and values by using real-life experiences [26]. For example, the teacher described situations where differences in the way of communication (regardless of the language) have created unexpected misunderstandings. Furthermore, the teacher showed pictures that demonstrated how differently people with different cultural backgrounds can perceive the same images. Each session also included group discussions and learning tasks such as construing personal factors behind one’s own cultural features in order to become aware of the cultural diversity and to understand why culture-specific ‘facts’ cannot be used in patient care. Web-based learning platforms such as Padlet (an on-line post-it board) were also utilised, as they allowed the participants to share their thoughts anonymously with others. A description of the contents of the sessions is presented in Table 1.

After the final training session, three semi-structured small group interviews (n = 4 + 2 + 3) and one single interview (n = 1) were conducted in the hospital to explore the perceptions of the participants about training. Five (n = 5) of the interviewees had attended all of the training sessions, three (n = 3) had attended three sessions, and two (n = 2) had attended two sessions.

Two researchers with a background in nursing and prior experience with interview studies conducted the interviews. The interviewers were familiar with the content of the training, as they had been present at each training session. The participants were asked questions such as how they perceived the content of the training, what they found useful or not useful in the training and why, whether something was missing from the training, and how they perceived the overall implementation of the training including the learning methods and the timing and length of the sessions. The interviews lasted 30–40 min and were audio-recorded and transcribed verbatim for the analysis. Field notes, such as demographics of the participants and the main points from each interview, were also taken during the interviews and used afterwards in the reflective discussion between the two interviewers [27].

Qualitative content analysis with a conventional approach was used to analyse the data. The method is suitable for interview data collected from open-ended questions, and it allows the researcher(s) to explore personal perceptions without resorting to preconceived categories [28]. First, the interview transcripts were read through several times to obtain a picture of the data in its entirety. After familiarising ourselves with the data, the transcripts were read again to code all the expressions from the text that described participants’ perceptions of the training. The length of the codes (the units of analysis) varied between a few words and a few sentences. While coding, notes were also made about first thoughts and impressions. Next, codes with similar content were grouped as subcategories, which were given a descriptive name. Finally, subcategories that had the same perspective were then grouped into five main categories (Table 2). One researcher made the initial categorisation, which was then discussed and verified by another researcher (who was also present during the data collection phase, had the field notes from interviews, and was familiar with the data).

Participants expressed that they were pleased that the cultural competence training had provided them with a more general, rather than entirely a healthcare-orientated, perspective on cultural issues. The fact that the educator in charge was not a healthcare professional was seen as an advantage because she was able to bring new ideas and viewpoints into the hospital environment. Participants also stated that they were pleased that many of the real-life examples presented in the lectures were not from the healthcare environment but dealt with more general incidences from everyday life.

‘Usually we are educated by nurses or some other healthcare professionals. They are so close to us, and the hospital environment, that they can be as blind as we might be in these matters.’ (i1, n4)

The participants saw the training as an important opportunity to start a general and open discussion about cultural issues and, for example, about conviction, which workers typically avoid discussing and which is not part of the general work culture. Having the possibility to share their thoughts with colleagues was highly appreciated, and the small group and engaging lecturing style of the educator seemed to facilitate participants’ involvement in the discussions.

‘The atmosphere was open and, because we were a small group, it was easy to interact. I realised that people rarely dare to speak up and discuss [things] as freely as we did. Usually people just sit quietly in these training [situations].’ (i2, n2)

Participants described the training as an opportunity to develop their current healthcare practices. In order to achieve any general improvements, they thought that the whole healthcare organisation should have the opportunity to attend such trainings. Participants also noted their own responsibility in making improvements, and they stated they were enthusiastic to share the learned knowledge with their co-workers. However, such sharing was noted to be challenging because increasing cultural awareness was primarily seen as an individual process.

‘It was difficult to tell others what was discussed in the lectures. The knowledge didn’t just come from the sentences that we heard. It was also behind the sentences and cannot be explained with words. When I tried to describe these things to others, the message [got] changed along the way.’ (i1, n1)

The training was described as an important opportunity to become aware of one’s own cultural features. The participants realized the extent to which their own cultural ‘cage’ guided their behaviour, and how it also affects the way they interpret the behaviour of others. Subsequently, the participants noted changes in their way of thinking. They felt more open-minded; and they reported that after the training, they had started paying more attention to the way they acted when taking care of culturally diverse patients. Participants felt that the training provided them many new, even surprising, perspectives about their own daily communication patterns. Realising the common features of their communication patterns, and how they might complicate their interactions with patients, allowed them to develop their communication skills.

‘Training really helped me to understand that that’s exactly how we act, and maybe we should try to act a bit differently … pay more attention to how we talk and interact with others.’ (i2, n1)

‘I really wasn’t aware that we often communicate with silence, [our] eyes, etc. … and how much we tend to communicate between the lines. These things had never crossed my mind because they’re so automatic.’ (i1, n2)

Despite the fact that several participants expressed a need to develop current practices and their own way of acting, many participants also perceived the training as a justification for carrying out certain practices that they feel are important with respect to established customs, regardless of the culture of the patient. The participants also reported that their courage to encounter culturally diverse patients increased as a result of the training.

‘Sometimes I feel that female patients’ husbands or relatives speak for the patients. I think that every patient must have a right to speak up, and the training gave me courage to stick with this principle and say, “In here, we would like to hear [from] the patient alone, therefore, could you please give us a minute … ”’ (i3, n1)

The participants reported that the training had utility value for the patients as a result of nurses having a better awareness of and ability to acknowledge the differing cultural backgrounds of particular patients. For example, participants stated that they had started paying more attention to supporting the communality of certain patient groups after the training.

‘Many cultures are so much more communal than we are. People also want to take care of their relatives when they are in the hospital, and I want to support that. We should try to learn from that.’ (i1, n4)

Additionally, participants reported that the training had increased the respect that culturally diverse patients receive when seeking healthcare. The participants emphasised the importance of providing equal treatment and being respectful and non-judgmental of others, especially when the customs of certain cultures differ from one’s own ideology.

‘Even if the patient and his or her relatives, family situations or way of living goes against my cultural beliefs, it doesn’t mean that I have a right to discriminate against them. For example, in some cultures, girls get married young and men have power in decision making. Despite (the fact that) that’s not happening in my life, in my country or in my culture, it doesn’t make it wrong, and I have to respect that. The training gave me the tools to think about these things.’ (i3, n1)

The participants felt that the training was of a high quality, and many stated that the training had exceeded their expectations. They also noted the importance of providing training that serves the needs of the learners and that it is highly important to consider the starting level of the learner when designing the training. Participants were mostly satisfied with the contents of the sessions, but many felt the discussion model in the conviction session was unnecessary or too straightforward. Instead of using any pre-specified phrases, nurses felt that it is better to be sensitive to the situation and use their professional skills as nurses when discovering patient’s spiritual needs.

‘I feel that as a nurse, and after the nursing education [that] I have completed, I must be able to discuss several things with patients, including [their] convictions. If you can’t do it, you’re in the wrong place. The suggestions about how I can start a discussion with patients about [their] convictions didn’t serve me in any way.’ (i1, n1)

Participants stated that they greatly appreciated the expertise of the training provider and that the educator had done the proper background work and knew what she was talking about. They also noted that excellent teaching skills and the educator’s knowledge of complex cultural issues were meaningful. The ‘storytelling’ type of lecturing, and the high number of real-life examples that were presented in the sessions, were perceived as inspiring among the participants.

‘It was so immersive, lively and multidimensional. Even though it was lecturing, it was somehow creative.’ (i3,n1)

Participants brought up a few notable ideas that could make the training better in the future. Some noted that hearing about the lived experiences of persons from different immigrant groups could be added to the content. Some participants also suggested that the training could be slightly condensed. They felt pressure to finish their work on time to make it to the sessions, and many felt that four full afternoon sessions was too long to be outside the ward.

‘It could have been a bit shorter, for instance by putting some material on the Web beforehand that could be used to orientate oneself and then having the face-to-face session where things would be summarised and discussed.’ (i2, n1)

Participants also shared their opinions about the one-week break after each training session. Some participants felt that it allowed them to think about the contents of the sessions; but others felt that it was difficult to remember what had been previously discussed, which complicated the presentation of the big picture. Many participants stated that a shorter time span would have helped them to remember more clearly the content of a previous session and also helped them to assimilate the learned knowledge. They suggested that a summary from each session could have been provided.

The participants mostly felt that after the training, they no longer needed to use checklists or guidelines about how to act with certain patient groups. However, they still felt insecure about different religions and how the rules of different religions should be taken into account in their daily actions.

‘We discussed how we encounter individuals, but not about how we respect different religious customs. For example, sometimes a male or female nurse is not allowed to help the patient with bathing, etc., or there are certain customs when it comes to end-of-life care.’ (i4, n1)

Certain issues place limitations on the credibility and transferability of the results. A single organisation and a small sample size (consisting mainly of nurses working in somatic wards) restrict the generalisation of the results. It is possible that other healthcare professionals (such as physicians, physiotherapists and mental health specialists) can have different perspectives on cultural awareness. Perceptions about the training could also have differed or be more multifaceted if all the nurses could have attended all four training sessions. Additionally, participants who enrolled in the training possibly were highly motivated to learn and had a more positive attitude towards cross-cultural care before attending the training, which might have affected their responses. It must also be considered that all the participants highlighted the teaching skills and experience of the educator; therefore their perceptions of the training could have been different if less competent educators would have been used. We did not ask for feedback from the participants about the data categorisation or interpretation of the results, which would have increased the trustworthiness of the results. However, two researchers were involved in the data collection and analysis, and frequent discussions were held with the research group during different phases of the study.