Cultural Awareness Module

Appreciation and thanks is extended to the Office of the Provincial Chief Nurse, Department of Health and Community Services, Newfoundland and Labrador for permission to adapt content of its Cultural Awareness and Responsiveness Module for Mentors of Internationally Educated Persons and Communication in Nursing Module.

On completion of this module the nurse or patient care worker (PCW) / resident care worker (RCW) orientating the Internationally Educated Health Provider (IEHP) will have awareness of the following:

Some of the challenges the IEHP may have encountered prior to commencing work on Prince Edward Island.
Terms associated with cultural awareness / sensitivity.
Challenges faced by Internationally Educated Persons as they transition into a new culture and work environment.
Differences between nursing work in Canada versus nursing work in other countries as advised by IEHPs.
Different expectations of nurses, PCW / RCWs from patients / residents in Canada versus their home country.
Potential issues with reusable / disposable products.
Communication differences / challenges the IEHP may face, and
What the person orientating the IEHP to unit / facility on Prince Edward Island can do to enhance culturally sensitivity.

Definition:

An IEHP is an internationally educated person that has completed their education outside of Canada.

Challenges the IEHP may have encountered prior to commencing work on Prince Edward Island.

The IEHP may have a first language other than English. Internationally Educated Persons come from a variety of educational backgrounds, as well as diverse health care systems. Basic training for IEHPs can range from two to four years and take place in culturally different learning environments. It is important to realize that IEHPs are not a homogeneous group. IEHPs bring different skill sets and abilities plus individual personal circumstances and experiences as they begin to practice work in Canada.

Prior to starting work on Prince Edward Island, the IEHP has been through a significant process with Immigration Canada to work and live in this country. They have had their credentials from their country of origin assessed. Some will have taken tests to ensure competency in the English language and may have taken additional courses to improve their English language abilities. They may have had to sit exams! “Wow” They must truly want to come live and work on Prince Edward Island in our health care system.

For some IEHPs, the road to successful employment, adjustment and integration into Canada is fairly straightforward and positive. For others, the route is fraught with difficulty and frustration. It is important to note that the IEHP adds richness and positivity to our environments. Many IEHPs are experienced health care providers with diverse backgrounds. Given a supportive integration experience, they are an asset to any organization. It has been demonstrated that the Canadian healthcare system can derive great benefits from IEHPs who bring their experience, education and often specialization into our system.

Cultural Sensitivity is defined as “sensitivity to cultural differences and to the points of view of people” (Burchumas as cited by Peiying et al, 2012, p.61).

The objective of cultural sensitivity refers to the ability to respond to others in a sensitive, responsive and appropriate manner. To be culturally sensitive requires that we have cultural awareness. Awareness is understanding and recognizing how culture shapes our realities and reactions in different ways. To be aware means having insight into the needs and feelings of others. This awareness requires exposure to and knowledge of how culture can affect our behaviour. To develop awareness of the reactions that may be expected of a co-worker from another country and culture requires knowledge of and exposure to the differences or diversity. For example, if you are orientating an IEHP, it is very useful for you to have some knowledge of the country that IEHP comes from and some of the cultural norms of that country.

Cultural sensitivity is further development of awareness to the point where we not only anticipate the perceptions and feelings of others, but we can modify our behaviour and reactions to them so as to make the other person feel comfortable and understood. It requires us not only to be sensitized to our reactions when experiencing cross-cultural differences and sometimes conflict but also learning and adopting new ways of thinking and reacting when in these situations.

How would you rate our degree of exposure in Prince Edward Island to other cultures as compared with a province like Ontario or British Columbia and cities like Toronto or Vancouver?

Do you think our degree of exposure can influence how we will react to an IEHP and in what way?

Reactions to cultural differences in the workplace can be very non-productive. All staff should be aware of their reactions and sensitive to the need to recognize when they are engaged in reactions characterized by such terms as follows:

Ethnocentrism has been most widely defined as the belief that one’s own ethnic group is better than or superior to others” (Bizumic et al, 2008, p 873).Within this is the tendency to view differences in a negative light. Within our own culture, we value goal orientation, assertiveness, speed of completing tasks. These are not the values of other cultures and can lead to misunderstandings and conflict in cross cultural interactions.

Stereotypes are characteristics imposed upon groups of people because of their race, nationality, and sexual orientation. These characteristics tend to be oversimplifications of the groups involved and, even if they seem "positive," stereotypes are harmful. (Nittle, 2021).

A person can make a generalization about an ethnic group that hasn’t been perpetuated in society. For example, someone who meets a few individuals from a particular country and finds them to be quiet and reserved may say that all citizens of the country in question are quiet and reserved. A generalization such as this doesn’t allow for diversity within groups and may result in stigmatization and discrimination of groups if the stereotypes linked to them are largely negative. [ A Canadian example; all Canadians are polite and nice and say “Sorry” a lot]

Prejudice is a baseless and usually negative attitude toward members of a group. Common features of prejudice include negative feelings, stereotyped beliefs, and a tendency to discriminate against members of the group. While specific definitions of prejudice given by social scientists often differ, most agree that it involves prejudgments (usually negative) about members of a group. Some of the most well-known types of prejudice include: Racism, sexism, classicism, homophobia, nationalism, religious prejudice, and ageism, (Cherry, 2012).

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. ~ Centers for Disease Control as cited by Scott 2021.

These terms are defined to give the participant in this learning module a quick refresher. The purpose is to create a renewed sensitivity of the potential for these reactions toward the IEHP in the workplace.

There are four elements that go into developing cultural competency:

Awareness – Of your own view of the cultural world
Attitude – Toward difference between cultures
Knowledge – Of diverse cultural beliefs, views, and practices
Skills – In dealing with the differences between different cultures and with their interrelationships (Scott, 2021)

The process of integration and transition into practice in a new culture can be overwhelming for the IEHP. Examples of challenges they face include:

Understanding and meeting the requirements for registration in a new country;
Differences in the health care system and how it works;
Differences in the role of the nurse in the system;
Adjusting to new technology which may be unfamiliar to the IEHP;
Adjusting to policies, procedures and practices which may be different;
Lack of familiarity with the concept and practice of the interdisciplinary health team;
Cultural differences and understandings;
Language barriers, not just speaking the English language, but also the particular professional terminology, phrases and abbreviations used in the new health care setting
Local colloquialisms;
Some may experience stereotyping, ethnocentrism or racism in the workplace or the community;
Experiencing loneliness, isolation, stress and anxiety as they adjust to the new environment that they live and work; and,
Little time to adjust to new surroundings before they are participating in an orientation to the work setting. This orientation may not be structured to best meet their needs or to give them the time and the support they need to be successful.

The IEHP is not only entering a new work setting, but also a new country and culture. They will have completed and passed assessments in English, if applicable. However, their particular accent or dialect may make them difficult to understand. To add to this, the Prince Edward Island dialect and colloquialism can affect understanding and interactions.

Tregunno et al (2009) provides a very good overview of the experiences of IEHPs migrating to Ontario. Most of these could be easily experienced by IEHPs coming to any province in Canada and the voices of the IEHPs “say it all” very clearly. The experiences (or comparisons) are captured in the below themes. They are presented with recorded quotes from IEHPs that underscore the reality of the challenges to the IEHP.

Research studies by Nicholson as cited by Rosser and King, 2003, Sherman & Eggenberger, 2008, and Jose, 2010 demonstrate a difference in nursing practice in North America versus the IEHPs home country.

The IEHPs reported that Canadian nurses were:

more involved in decision making and more assertive with co-workers;
assumed more responsibility for patient care;
were more respected by co-workers;
had more equal relations with physicians; and
either had more or less workload than the IEHP was used to.

Recorded Quotes from IEHPs:

The autonomy of the nurse and the level of collaboration between nurses and physicians are different across cultures.
Nurses from India reported that in the United States nurses had so much power.
English, Scottish, Filipino and Indian nurses described the physician as being “more hands on at home”. They voiced difficulty in understanding the chain of command and which physicians to contact for patients needs and how.
Instead of telling you what you’re doing wrong, [say] “let’s do it this way”, therefore correcting the person but not damaging their image.
“It’s all confidence really….and just suddenly realizing that you can do it”.
“I had to learn to say things in a way they will understand” (how a Nigerian nurse overcame the language barrier).
When starting a new job, newcomers may experience skill degeneration and associated negative emotions similar to those expressed by new graduate nurses.

The IEHPs reported that compared to their home countries, in Canada:

Patients are more knowledgeable.
Patients have more rights.
The requirements for consent for treatment differ, there is greater Cultural diversity.

Being the Outsider
IEHPs reported feeling treated as an outsider by co-workers, patients and families; and also experienced:

racism from patients and co-workers;
aggression from other staff;
lack of trust from co-workers;
resentment from other staff; and,
unequal work assignment.

The orientation process is a very effective strategy to support and strengthen the integration and experience of the IEHP. Orientating an IEHP is a challenging responsibility for those who chose and/or are asked to participate in the process. Educating, supporting and teaching others are an inherent part of nursing. More and more, employers and decision makers are recognizing that those who actively engage in this professional responsibility with the IEHP need support and education to equip them to experience success and reward for their efforts.

The IEHPs reported that compared to their home country, in Canada:

Disposable products were used more.
Product waste was greater.
There was more advanced technology.
Religious beliefs and treating decisions were different.
The role of the family in elder care is different.

Therefore, the IEHP may require more instruction around, single use items, reusable products, function of Sterile Processing Department, IV pumps, PCA pumps, TPN solutions, services the pastoral care team offers, valuable function of allied health workers within Health PEI facilities such as physiotherapists, occupational therapists, respiratory therapists, housekeeping, portering services and discharge co-coordinator to name a few. They will need instruction and support on how to complete electronic documentation, where to locate medication orders (where applicable), locate laboratory test results, etc. They may require information on do not resuscitate orders (DNR), advanced care directives, medical assistance in dying, elder care outside of the hospital in Prince Edward Island, etc.

The experience of the IEHPs underscored that issues of language are more complex than proficiency in English and the importance of both verbal and non-verbal cues in communicating effectively. The IEHPs were challenged by the following:

not being understood by others;
not understanding others;
stress related to language with constant vigilance to language;
having to repeat things several times;
working slower; and,
sometimes using humour to deflect attention

While travelling off Prince Edward Island you may have experienced being misunderstood by people from different provinces, countries. IEHPs are living in a new country, may have an accent and are experiencing the colloquialisms on Prince Edward Island. There will be some misinterpretation. Help them with meanings of local language. Please also remember that there are also professional language differences. Medications and equipment are called different names. Introduce the IEHP to the Compendium of Pharmaceuticals and Specialties (CPS): the Canadian drug reference for health professionals, the King Guide and the Vancouver Island Health Authority Monographs and Best Possible Medication History (dependent on being employed as a nurse). Laugh together when appropriate as you both work through the process of speaking the same language yet using different terminology.

Nurses need to use precise language, be aware of language differences, and avoid slang and clichés when communicating to members of the healthcare team who are from another country and where English is a second language. Watching word variations, clearly stating questions, providing verbal cues and allowing more time for answering, conveys respect and reduces anxiety for others. The same rules apply when communicating through documentation. Conversely, Internationally Educated Health Care Providers must clarify any communication uncertainties by asking questions, summarizing, and paraphrasing.

The following are examples of the challenges within colleague-to-colleague communication (Arnold & Boggs, 2007):

An IEHP said she was thoroughly confused by the slang expression, “I want to touch base with you.” The IEHP did not know how to respond because her literal translation of the sentence did not express its meaning to her. Had the nurse orientating her said, “I would like to talk with you”, the IEHP would have known how to respond.
An IEHP stated she was frustrated when assisting the doctor with a procedure. The doctor had asked the nurse to bring him supplies to “deaden” the area. The nurse explained that she did not understand what the doctor was asking. The doctor should have stated that he needed supplies to administer a local anaesthetic.
An IEHP reviews the charts on her clients and is confused by several of her colleagues’ notations, such as:

Client using attends;
Client has NKA; and
Client is PWB.

All health care providers must be familiar with approved abbreviations within their facilities. In this situation, the use of unfamiliar terms and abbreviations has resulted in a lack of communication. The IEHP will seek clarification of abbreviations from the nurse facilitating their orientation. Please note that common abbreviations used in practice on Prince Edward Island may mean nothing, or something completely different to an Internationally Educated Person.

What the person orientating the IEHP can do to enhance cultural sensitivity?

The major challenge with the IEHP may be related to not only the educational and experiential differences but also the cultural differences and how they influence cross-cultural communication and integration. What is required of the nurse orientating the IEHP is the ability and the opportunity to self reflects on one’s own value and belief systems.

Taylor (1998) gives the following advice on how to be more culturally aware and sensitive, advice which is still very relevant today.

Seek information to gain knowledge of the culture of the IEHP:

Complete a Google search on the internet about country of origin, different cultural beliefs, etc. However, do not make assumptions that this is completely accurate (remember all Canadians or Islanders are not the same).
Include topic in health care provider orientation and the initial interaction between the IEHP and nurse facilitating the orientation.
Ensure the IEHP is invited to social events, facility events like nurse's week celebrations, holiday get togethers, unit / household get togethers, etc.

Gain insight into your own cultural beliefs:

This can best be accomplished when you are feeling tension in an interaction with someone from another culture, a sign that your own values and beliefs are being challenged.
Take time to understand the reasons for this.

Confront prejudices when you encounter them:

When you encounter prejudice, acknowledge it in yourself and / or others and discuss it openly or bring it to the attention of your manager for further discussion.
Where possible get out of your comfort zone and expose yourself to different cultures. The Immigrant and Refugee Services Association of Prince Edward Island, (irsapei.ca), may be able to help. They require volunteers, and may have information on different events taking place on Prince Edward Island you may be able to attend.

Resist negative, judgmental reactions to situations:

Different does not mean inferior or worse.
Do not allow stereotypes to mask your reactions to situations.

Concentrate on effective communication and improving communication skills:

This involves effective listening, coaching giving effective feedback.
Conflict resolution knowledge and skill is a key to resolving misunderstandings and improving interactions.

Determine how effective you are at listening by accessing:
Listening: Are you a good listener?

After completing the Cultural Awareness Module, reflect on the following questions.

For the person orientating the IEHP:

In what way will you prepare yourself to orientate an IEHP?
In what way will you create a supportive learning environment for an IEHP?

Developing a culturally competent attitude is an ongoing process. It is important to view all people as unique individuals and realize that their experiences, beliefs, values and language affect their ways of interacting with others and the larger community. Also, be aware that differences also exist within cultures. It is best not to assume that a common culture is shared by all members of a racial, linguistic or religious group.

Please complete the below evaluation. Your evaluations will assist with future revisions and updates to this module.

To obtain your Certificate of completion, please complete the Certificate Request Form, so an e-certificate can be sent to you.

Bizumic, B., Duckitt, J., Popadic, D., Dru, V & Krauss, S. (2008). A cross-cultural investigation into a reconceptualization of ethnocentrism. European Journal of Social Psychology. 39, 871–899. doi: 10.1002/ejsp.589
Cherry, K. (2012). What is Prejudice? Retrieved March 13th 2012, from About.com Psychology website: http://psychology.about.com/od/pindex/g/prejudice.htm
Jose, M.M. (2010). Lived experiences of internationally educated nurses in hospitals in the United States of America. International Nursing Review, 58, 123-129. doi.org/10.1111/j.1466-7657.2010.00838.x
Nittle, Nadra Kareem. "What Is a Stereotype?" ThoughtCo, Feb. 7, 2021, thoughtco.com/what-is-the-meaning-of-stereotype-2834956.
Office of the Provincial Chief Nurse, Department of Health and Community Services, (2011). Cultural Awareness and Responsiveness for Mentors for Internationally Educated Nurses (IENs). Retrieved from https://www.med.mun.ca/nursingportal/default.asp
Office of the Provincial Chief Nurse, Department of Health and Community Services, (2011). Communication in Nursing Module. Retrieved from https://www.med.mun.ca/nursingportal/default.asp
PEI Association of Newcomers to Canada, (2012). Cultural Sensitivity. Unpublished PowerPoint Slides.
Peiying, N., Goddard, T., Gribble, N. & Picard, C.(2012).International Placements Increase the Cultural Sensitivity and Competency of Professional Health Students: A Quantitative and Qualitative Study. Journal of Physical Therapy Education, 26 (1) 61-68. URL: www.cinahl.com/cgi-bin/refsvc?jid=540&accno=2011431645
Rosser, M. (2003). Transition experiences of qualified nurses moving into hospice nursing. Journal of Advanced Nursing, 43 (2), 206-215. doi.org/10.1046/j.1365-2648.2003.02695.x
Sherman, R.O, & Eggenberger, T. (2008). Transitioning internationally recruited nurses into clinical settings. The Journal of Continuing Education in Nursing, 39(12) 535-544. doi.org/10.3928/00220124-20081201-03
Taylor, R. (1998). Check your cultural competence. Nursing Management. 5(6), 30-32. doi.org/10.1097/00006247-199808000-00010
Wilson, S. (2021). Understanding Cultural Competency. Retrieved from https://www.humanservicesedu.org/cultural-competency

Disclaimer: Web links provided in this guide were current at time of development.

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Challenges the IEHP may have encountered prior to commencing work on Prince Edward Island.