Nurse educators have long recognized the need for a transcultural component in undergraduate and graduate nursing curricula, a component which emphasizes ethnic and cultural differences as they relate to nursing practice (Branch & Paxton, 1976; Fong, 1985; Gosnell, 1985; Meleis, 1985). Some nursing programs, in an attempt to expand students' awareness of different cultures, have begun to include international and transcultural experiences (Cotroneo, Grunzweig, & Hollingsworth, 1986; Levinson, 1979; MacAvoy, 1988; Macey & Morgan, 1988). For the most part, these programs have been highly successful if only because they have allowed students to overcome their own tendencies toward ethnocentrism; the exposure to a variety of ethnic and cultural attitudes, beliefs, and values has enhanced the nursing students' perspective; and, ultimately, improved the quality of their practice.
Nursing students who participate in a transcultural program not only acquire first-hand knowledge of another health care system, but are also able to observe the process of nursing education in another country. Through such an experience, nursing students perceive that, for the most part, nursing education in the United States differs in significant ways from nursing education elsewhere. In most countries, nursing students receive their education and training in the hospital setting. Within the last 3 decades, the educational focus in the United States has changed, with a far greater emphasis on the 4-year baccalaureate and 2-year associate programs and a pulling away from the traditional 3-year hospital-based diploma program. As a consequence, many 20-year-olds enrolled in baccalaureate programs of nursing have not yet had the opportunity to interact or work with diploma students and diploma nurses. Nursing education and nursing practice are among the factors which help define the field of nursing in all cultures - a greater understanding of what constitutes nursing in another culture can often expand one's perception and acceptance of oneself as a nurse. Thus, when planning a transcultural or international program, nurse educators should provide an opportunity for students to participate in nursing care and nursing education in another culture. In addition, students should be exposed to a variety of nursing experiences within the host country. This exposure provides a broad spectrum for comparison between cultures and among nurses within those cultures.
In January 1989, the College of Nursing at the University of Delaware offered 18 undergraduate nursing students a 4-week course in England in an attempt to emphasize a transcultural perspective in nursing. The faculty believed it would be an important and exciting course for a number of reasons. First, nursing students at the University of Delaware have a full curricular schedule and have only limited opportunity to either participate in a semester abroad plan (which traditionally has afforded University liberal arts students exposure to other cultures) or to continue with a foreign language (most of these courses meet on a regular schedule that is not always compatible with nursing's clinical focus). Students at Delaware are able, however, to take a nursing elective during the January winter session. While it is generally acknowledged that a year or even a semester in another country would provide students with a more complete and satisfactory exposure to another culture, the 4-week winter session course offered students a beginning transcultural opportunity. Second, in Delaware, a small state with a fairly homogeneous population, nursing students, in general, tend to care for hospital clients who are very much like themselves, socioeconomically middle-class, with the same attitudes, beliefs, and value systems. In planning the course, then, faculty sought to arrange an experience which allowed a view of a different culture or cultures and a different health care system but which did not require students to be proficient in a foreign language in order to interact with hospital clients.
Finally, because most students today must be concerned about costs, participating faculty hoped to provide an international and multicultural experience that was not so exotic as to be unaffordable. For these reasons, England seemed ideal. Fortunately, nursing colleagues in England were receptive to plans for the course and extremely helpful in suggesting and arranging possible clinical and educational opportunities.
The goal of the course was two-fold: that students would be able to recognize differences in nursing education in the two countries and, through clinical practice, would expand their understanding of nursing's role within the health care system. To achieve this goal, the following objectives for students in the course were established:
* To explore sociocultural beliefs, values, and practices relevant to health and health-seeking behavior.
* To analyze the influence of one's own beliefs and values on perceptions of health and health care.
* To examine health care practices among persons of different religious, ethnic, or cultural backgrounds.
* To assess, through weekly logs, cultural influences on the implementation of health care.
* In collaboration with other professionals, to plan health care appropriate to a clients cultural belief system.
In order to meet these objectives, arrangements were made for students to live and work with British nursing students in both Sheffield and on the Isle of Wight. Not only were these two communities at different "ends" of England - Sheffield, inland, is in the north of England and the Isle of Wight lies off the southern coast - but nursing education and the delivery of health care in these two areas are also considerably different.
In Sheffield, an industrial town of 565,000 set in a basin of hills at the edge of the moor in South Yorkshire, University of Delaware students were paired for clinical experiences with English nursing students from Sheffield City Polytechnic, a 4-year program awarding a Bachelor of Arts in Nursing Studies (degree with honors). At this time there are still relatively few 4-year baccalaureate programs in England. For logistical reasons, however, Delaware students lived with 3-year hospital nursing students in the nurses' residence of a large hospital. Through the kindness ofthat institution's nursing faculty, the students were able to procure the student rate for governmentsubsidized rooms and meals. The advantages of this arrangement extended beyond room and board as the students met and socialized with hospital students and were thus able to interact with nursing students in two different types of educational programs.
Clinical experiences in Sheffield included a day at a hospice and a number of days on a hospital floor paired with a Polytechnic student. Students were assigned to a variety of floors, including medical-surgical, maternity, and pediatrics, and had the opportunity to meet and observe many members of the health care team.
Both University of Delaware and Polytechnic students spent a day in a seminar exchanging information about their respective educational programs, their country's health care policy and health care delivery systems, and nursing's position and role within the larger community of health care providers. This exchange of information was important to a greater understanding of what was expected of nurses within each country and helped many students to recognize different nursing practices among baccalaureate or 4-year students. In addition to direct student interaction or client care, the Delaware students in Sheffield also participated in field trips to a coal mine and a steel plant. The Polytechnic faculty arranged this experience in an attempt to illustrate the working conditions of most residents as well as the subsequent health care concerns of this population. As many Delaware students discovered, the bottom of a coal mine, especially when one follows the 2-feet high face of the mine for several hundred meters on hands and knees, is a dark, isolated, and none-too-clean setting in which many underappreciated individuals work very hard.
Students were quick to note the parallels between nursing and mining. For example, both "industries" have similar organizational structures, employing both supervisors and staff, as well as the use of shift work, and, inevitably, the need for double shifts.
These unique experiences enabled the Americans to empathize with miners and steel workers and, subsequently, to follow more closely discussion in the media about industrial unions and strikes. Conversations with their student hosts began to include questions and comments about the government's role and influence in the workplace and the Americans became more aware of the structure and balance between government and the health care system.
The alternate site we visited, the Isle of Wight, was strikingly different. In contrast to Sheffield, the Isle of Wight is essentially rural. Its population swells considerably in the summer months, with an influx of yachtsmen and other people on holiday. It was for many years the summer home of Queen Victoria. The population is older and many of the residents have never been off the island, although ferries, Hovercraft, and catamarans run daily. Most of the young people now leave the island after leaving school at age 16.
There are numerous hospitals on the island. Some are cottage hospitals, used for less serious illnesses and as "recuperating" hospitals. The island's largest hospital, in Newport, will, when work is completed, be the most energy-efficient in all of England. The island also boasts a dedicated and active St. John's Ambulance crew, which provides health-related transportation between localities throughout the island.
Again, students were housed in the hospital's nurses' residence with students on placement from the Queen Alexandra Hospital School of Nursing in Portsmouth. This 3-year program has recently affiliated with hospitals on the Isle of Wight and was able to offer its students a change of pace and placement on the Isle for at least one clinical rotation. At that time of year many of the nursing students were on night duty. (University of Delaware students were able to interact during the day with medical and physical therapy students at the nurses' residence and with staff nurses during their clinical experiences.)
On the Isle of Wight, students spent a day with the ambulance crew, transporting clients and answering calls in the community as well as spending time on various units at the hospital. Some students were able to go out with a district nurse, some went to a burn unit on the mainland, and everyone visited the Royal Naval Hospital in Gosport. Students presented their seminar on American health education and policies to 3-yeaT students and staff nurses.
In addition to clinical and nursing experiences in Sheffield and the Isle of Wight, the group also spent some time in London. Students were encouraged to explore the city, to take advantage of cultural offerings, and to compare and contrast Londoners and their lifestyles with people from the other two locations.
In their daily logs, the Delaware students noted both differences and similarities between the English and Americans as well as among the English themselves. They observed and participated in different health care settings and had the opportunity to interact with many health care providers. Taken as a whole, this experience greatly heightened the American students' awareness of both the distinctiveness of and the differences in nursing's role and function in Great Britain and the United States.
Comparing and Contrasting Nursing
First and foremost in this experience was the need for all of the students and faculty who participated to grasp the differences in the educational systems of both countries.
While in England, Delaware students had clinical experiences in a variety of settings and came in contact with nurses and health care providers with varying levels of education. They learned that in the hospital there were auxiliary nurses, or care assistants, comparable to our nursing assistants or aides. These individuals had completed a short training course and performed "housekeeping" or maintenance tasks. The state enrolled nurse had 2 years of training and functioned bike a licensed practical or vocational nurse. In England, as in the United States, these nurses do not have educational responsibilities. The Registered General Nurse (RGN) functions as a staff nurse in the hospital setting and had either a 3-year hospitalbased education or a 4-year degree and RGN qualifications from an institution of higher learning. Like registered nurses in the United States, the RGN may or may not have a baccalaureate degree. Most RGNs in Great Britain have attended a 3-year program. There did not seem to be a category of nursing degrees in England equivalent to the 2-year, community college-based associate degree.
In the hospital settings, English nursing students give patient care. Their responsibilities vary with their level: first-, second-, or third-year. (Most baccalaureate, or degree, courses still grade students at three levels, but stretch the levels over 4 years). In Sheffield, both types of students work together in the hospital wards in a complementary schedule devised by the heads of nursing of both the hospital and the Polytechnic programs. On the Isle of Wight, the English nursing students were from a hospital-based program. All students, from both 3-year hospital programs and 4-year baccalaureate programs, are precepted by hospital staff Nursing faculty from the Polytechnic program do not go onto the hospital floors.
The 4-year degree students have clinical placements similar to the rotations of nursing students in the United States. Hospital-based nursing students function as hospital staff their education includes work in the hospital. The University of Delaware students were familiar with the use of students as staff but were surprised at the amount of nursing care and responsibility expected of the English students - many actually worked the night shift and could very possibly be put in charge. At the same time, Delaware students felt that nursing students in England had fewer pressures and time constraints placed upon them and that this was probably a reflection of the work ethic of the larger society. Tb the Americans, life in England seemed much slower paced and consequently, much less stressful. To the English, the American students seemed more "intense" and "worried" about their nursing care during this particular course.
Of ,particular interest to the American students were the different uniforms worn by the nurses in England. At the University of Delaware, nursing students do not wear a nursing uniform; this often results in their being taken for a staff nurse by hospital clients, visitors, and even doctors. Most Delaware students prefer this policy, however, because they feel more "professional" in their regulation white uniforms. Yet in England, the Americans were continually confused by the different types of nurses and found it easy to identify the nurse's status by the uniform she wore - colors, cuffs, and belts differed depending upon level and position. One pediatric ward that the students visited had dolls for the children dressed in the different nursing uniforms; the Delaware students spent a great deal of time with those dolls, brushing up on their own identification skills.
Daily care on the hospital floor, as delivered by nursing students in England, was essentially the same as that given by the Americans. The skills used by both groups of students in bed-baths, bed-making, and bed-pans were interchangeable. The Delaware students initially believed that, because of the nature of their baccalaureate education, they had fewer clinical nursing skills than their English counterparts. This belief was reinforced by the English students' reaction to information about the amount of time in clinical practice that the Delaware students spent in their baccalaureate program. When compared to clinical time spent by the English students, in particular the hospital-based students, the Americans spent far fewer days on the hospital floor. However, the Americans discovered that the Delaware faculty had different, more autonomous, expectations of them when delivering client care. One example was in health assessment, including the use of auscultation in assessing client's health status.
English nursing students use stethoscopes, of course, but primarily for blood pressure readings. They were quite surprised to hear that the Americans were expected to assess heart and lungs sounds for each client they cared for. On a tour of a coronary care unit, the Americans were told by the head nurse that in that unit, "English nurses do not have the authority or the knowledge to assess the patients." Furthermore, she told the Delaware students that she did not think they should be allowed to do so because "it was not within nursing's scope to perform a doctor's task." She was very surprised to hear that nursing students at Delaware were actually taught to perform this skill.
The students then began to take notice of the skills employed by their English hosts, students and staff alike, and discovered that, in fact, nurses in England had fewer opportunities to act independently in the hospital setting than nurses in the United States. While they were given the responsibility of patient care, they had almost no authority to make decisions about that care. The Delaware students and faculty conjectured that part of the explanation for this lay in the fact that, given the economic differences of their national health care system, there is currently less use of technology in most English hospitals; thus, in the latter half of the 20th century, the scope of nursing care has probably not changed as dramatically in England as it has in the United States. The Delaware nursing students came to recognize that while they possessed similar basic nursing skills to their English counterparts, the technological advances in their American educational health care settings afforded them the opportunity to expand and enhance their practice of nursing.
The Delaware students identified another factor as important in the differences between nursing, and nursing care, in the two cultures. This was the role of nursing education in shaping their identities as health care professionals.
At the University of Delaware, students are socialized to believe that their baccalaureate education prepares them for their professional role and professional obligations. While in England, the students met and worked with nurses from all educational backgrounds and were challenged to reexamine their preconceived notions of what makes a professional nurse.
Most of the Delaware students believed that a baccalaureate education is a requisite for professional standing. A nurse with a baccalaureate degree, stated one student, was "better able to integrate knowledge into the vastly complex health care system." "As a baccalaureate nurse," wrote one student, "I bring something different to nursing than just how to do things." "Professionalism is an attitude," declared one student, "exhibited through behaviors. . .[which] baccalaureate programs emphasize, [therefore] it is a 4-year program which enhances professional identity."
The Delaware students did not believe that education was the only factor in the English nurses' perceptions of themselves as professionals. Rather than differentiate between student attitudes in 3- and 4-year educational programs, the Delaware students mentioned time and again how little autonomy their hosts, no matter what level of education they had, seemed to have while delivering nursing care to clients in the hospital. English students, according to the Americans, see themselves as "subservient" and "handmaidens to physicians;" they must "defer to the doctor for care which American nurses (and nursing students) do routinely, such as assessing breath sounds." One Delaware student noted that for English nursing students "the most independent part of their job is making care plans, but even then they used medical rather than nursing diagnoses."
When exploring the differences in professional identity and professional standing among nurses in the two countries, the students initially focused on the surge, which began in the 1960s, of feminism in the United States and its effect on nursing, an essentially "female" profession. Discussions with their English hosts revealed to the American students that the rise of feminism in Great Britain, and its influence not only on the members of the culture but also in the workplace, has been a slow process. The students felt that this might have some bearing on the issue of professional identity, but this belief was complicated by the fact that in both Sheffield and the Isle of Wight, there were many males in nursing - students, staff, and educators.
The Delaware students who spent time with district nurses, health visitors, and midwives - all specialties requiring postgraduate, but not necessarily baccalaureate, education - found those nurses to be "more self reliant and more self-confident than staff nurses." They worked in clinic settings and in the community and were free to practice more independently and make their own decisions about clients. Some American students expressed the belief that this type of nurse had "more of a professional demeanor."
In discussions with English nursing students, it became clear that for the Delaware students, the issue of professional identity and its relationship to the level of nursing education is complex with no clear-cut boundaries. The literature reports similar confusion among registered nurses in the United States as they struggle with the entry into practice resolutions (Bullough, 1979; Muzio & Ohashi, 1979; Schoen, 1982; Uphold, 1983). The students decided that perhaps the differences they observed in professional identity between nurses from the two countries is in part due to the fact that generally, in the United States, the nursing profession is more rapidly moving away from a hospital diploma education and toward a baccalaureate degree.
The students in Great Britain believe they may possibly face a heightened awareness of professional identity and professional standing as they move toward the implementation of Project 2000, a new educational plan for nurses in Great Britain. Project 2000 calls for a more academically based common educational foundation for nursing students and a move away from training programs directed by nursing service. Nurse educators in Great Britain hope that, through this educational revision, nursing students will be better qualified to meet the more complex demands of health care in the 21st century (Frost & Nunkoosing, 1988).
The opportunity to take part in health care delivery and nursing education in another country gave baccalaureate nursing students at the University of Delaware a wealth of knowledge and experience. With this newfound awareness, they were better able to evaluate not only their perceptions of nursing but also nursing's role. Although faculty have suggested some changes for the future to strengthen this program, including more clinical and more "hands-on" care, those of us who directed the course and accompanied the students believe that it was highly successful; student evaluations supported this view.
What was especially valuable for students was living with the English nursing students. The gap between the two cultures seemed less imposing when the English and American students discovered so many similarities in their basic nursing education. They had common complaints, such as care plans, and common concerns, such as AIDS precautions. They were all aware of the current nursing shortage and the role that they might play in meeting the world's future health care needs.
They realized, despite some difficulty in understanding one another's accents and use of the vernacular, that they were, on occasion, talking about the same subject but in different terms. This prompted one group to keep a running tally of American and British words meaning the same thing. Needless to say, not all of these words were relevant to nursing, but they made the reading of student logs more tolerable (and often highly amusing).
The Delaware students also learned what individuals from another country thought about Americans. They sometimes found themselves on the defensive with the English nursing students about the "American" way of life and especially about health care in America. Much of the English students' perceptions were based on television's portrayal of life in America. Our students were frequently asked if it was true that people in the United States were left to die on the street if they did not have health insurance. In answering this question, the Delaware students were forced to look more closely at the obvious inequities in health care delivery in the United States and to examine nursing's role and obligation in the delivery of safe and competent health care for everyone.
The students returned to the United States to take their final course which focused on professional issues in nursing. Because of this transcultural experience, they returned with a far greater understanding of the role of nursing in another culture and a far greater appreciation for the differences which exist among people in England and in the United States.
In a speech before American nurses in Washington, D. C, Trevor Clay, General Secretary of the United Kingdom Royal College of Nursing, spoke about nursing as a universal profession. He also spoke about the necessity of creating links among nursing communities, in particular, Clay stated, "I would like to see more opportunity for student nurses to travel as part of their education" (Clay, 1987). We at the University of Delaware, students and faculty alike, are pleased that we could enjoy that opportunity.
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