Teaching and Learning Forum 96 [ Contents ]

To what extent should we assume or interpret for additionally cultured students: Are we the risk takers?

Vickey Brown
Lecturer, School of Nursing
Curtin University of Technology

Multicultural Australia, Yeah - you're standing in it. [Italics added]. Perhaps for many this sentence is not difficult to believe, yet for others, those in tune with the diversity of needs multiculturalism demands, this statement could indeed be unbelievable, that is, Australia is not truly multicultural. To position these thoughts contextually it is necessary to look at "Additionally Cultured English Plus" ("ACE+") nursing students in higher education settings.

Firstly what is an ACE+ student. For a number of years I have heard different acronyms used for students from non-English speaking backgrounds. For example, "NESB", "LOTE" and "FLOTE". It is not difficult to see the negative images built into these acronyms. NESB (Non-English Speaking Background) can perhaps be seen as a "less than" position because a person comes from a culture where English language is not used or does not dominate. LOTE (Language Other Than English) for some, conjures up, the image of "Little Lottie", an American comic strip character who struggles with adolescent obesity. Thirdly, FLOTE (First Language Other Than English) can easily be perceived to align with the media coined phrase, one that I dislike immensely, of "boat people". Consequently I have consciously played with phrases and acronyms and have developed Additionally Cultured English Plus (ACE+). ACE+ is used to denote that the student has additional cultural influences, not an additional language in isolation. English is included in this acronym because additionally cultured university students can, in the main, communicate in English, albeit at varying degrees of accuracy. The plus at the end indicates the students' ability to speak another language in addition to English. In some cases the student may be identified as ACE+2 meaning the student speaks English, and two other languages. The Macquarie dictionary and thesaurus defines ace as " ... a highly skilled person ..." (1991, p.5). Depending upon the value of speaking more than one language and if this quality is valued at all, then ACE+ students are truly, ace! Much has been written about the additionally cultured student studying at university. From a global view these writings have largely focused upon the problems encountered by such student minorities in terms of "big picture" university studies (Ballard and Clanchy, 1991; Burns, 1991). Little focus has been given to minority students studying nursing (Phillips and Hartley, 1990), especially in Australian universities.

Structural supports, Academic Education Departments, Counselling Services and English Language Courses have all been reported to be contributing to the needs of ACE+ students. Universities, Australia wide, are developing or have implemented Cross Cultural policies. However, fewer schools within universities have taken up the challenge of contextually based communication support strategies (Latchem, Parker and Weir, 1995, p.5).

Schools of Nursing have been aware of the needs of ACE+ students for many years (Brown, 1994, p.5). In some respects the work done by nurse academics in preceding years has gone largely unrecognized. Because of the nature of Nursing, ACE+ students require more than traditional English language support services can offer. Nursing is one of, if not the most personal of the health professions. The philosophical foundations upon which nursing practice is based has at its core, communications (Curtin University of Technology, Division of Health Sciences, School of Nursing Curriculum Document, 1994, p. 2). Every conceivable form of connecting with people comes into play in the many roles performed by nurses.

Time is taken here to acknowledge that ACE+ students are not alone in their journey towards becoming competent communicators. English Speaking Background (ESB) students similarly come across detours or barriers on the road to effective communication and professional practice (Rittman and Osburn, 1995). The focus of this paper, however, is the minority group of ACE+ students, studying at Undergraduate level in a School of Nursing.

Assimilationist views are alive and well, in many areas of Nursing. The best explanation that can be constructed goes along the lines of Nursing being in the real world, in other words, removed from the university campus. At some universities student nurses are required to complete a three and a half year (7 semester) undergraduate nursing course before they can apply for nurse registration. (Others require a 6 semester, 3 year course). "Pre-registration nursing courses are designed to prepare a beginning practitioner to provide safe, competent and responsible nursing care in a variety of health care settings" (Australian Nursing Council (ANC), 1993, p. 5). Upon entering the world of the Registered Nurse (RN); graduates are expected to perform or work at a beginning level practitioner, without supervision and assuming responsibility and accountability for their actions (ANC, 1993, p. 5). At this level graduates are given a degree of leeway and are able to consolidate knowledge. Many are fortunate to gain employment in graduate nurse programs. In the main, however, graduates are expected to be effective two way communicators. There are few, if any, provisions made for additionally cultured RNs. This situation ironically exists in a profession where provisions are supposedly made for ACE+ consumers.

Health care settings all fit somewhere on a continuum. To function in these settings, where life dependent decisions are made and confusing drug orders are given, why should there be different levels of expected communication proficiency? Should all nurses have to communicate at the same level as the dominant culture? By not developing culturally sensitive competencies the simple answer rests in the affirmative. Surely this approach equates then to a degree of assimilation and perhaps needs reconsideration.

Reconsideration is required because as the population mix continues to diversify so too does the makeup of the health care consumer group. Nursing can not hope to holistically meet the needs of such communities without producing graduates from these same communities. Nursing will also have problems recruiting from such communities without respectable ACE+ student graduate numbers, who can act as role models to prospective students within their own communities. Nursing does produce ACE+ graduates, however, their progress through the course is all too often punctuated with failures and patterned late withdrawals. It is timely to outline two commonly re-occurring problems.

The first relates to laboratory settings in which students are to learn and practice new skills and become increasingly competent prior to clinical placement. It is my observation that many ACE+ students hesitate in becoming actively involved in such situations. Where possible the polite, ACE+ student allows all her colleagues to practice skills before her turn. (The female gender is used purposefully in this example as the majority of ACE+ students are female). It is easy to imagine how quickly time transpires and the ACE+ student has done little more than observe a skill performed perhaps six times by novice skill executors. ACE+ students reportedly learn much from repetition (Burns, 1991,p.72) - how meaningful is this repetition if it is demonstrated by neophytes? In addition many of these laboratory sessions pay attention to communication skills - before, during and after procedures. Without practicing the skill, sadly the enmeshed communication is not practiced either. It may indeed be the lack of confidence for some ACE+ students that prohibit their participation in skill practice. A somewhat circular notion exists.

On other occasions I have witnessed ESB students answering and asking questions on behalf of their ACE+ colleagues. This has occurred when students were conducting child health assessments/interviews. Parents and young children attended the practice laboratories, on a voluntary basis, so as students could practice their interviewing skills and child assessments skills on real people (for example, milestone accomplishment assessments). One ACE+ student posed the same question five times to a child's mother. Coincidentally, the mother was a specialist Speech and Drama teacher. The mother could not understand the question posed. ESB students working in the same group of three, took over from the ACE+ student and asked the ACE+ student's designated questions. Again the practice component was avoided.

This brings me to real life situations , that is, when nursing students work as health care team members, albeit in a supernumerary capacity. My own experiences have as a primary base, complex care settings. It is from within these environments the following scenarios are drawn.

Scenario 1: This scenario occurred in a medium sized metropolitan hospital, the student to teacher ratio was 7:1. The backgrounds of the student group were all ACE+ as follows; 5 Asian, 1 Russian and 1 Indian. This situation arose as I was observing student interaction with an elderly female client. Two students were instructing the client to enable the positioning of a bedpan. Instruction given was direct and consisted of "lift your bum" [italics added]. This instruction was repeated four times. Upon intervening, the client was assisted to lift her "bottom" [italics added]. Debriefing took place appropriately during which time both students giggled, perhaps to hide their embarrassment of using the slang word "bum". Curiosity of the origin of the students' knowledge of the word bum for "bottom", revealed they had learnt the word from their ESB friends.

Scenario 2: From a clinical debriefing session with an ACE+ student this scenario arose. "I would say to the patient I am going to put this catheter into your bottom, but other students would say I am going to put this tube into your bladder." As an experienced nurse teacher I am aware that the student is referring to the procedure of urinary catheterization. However, the message sent to the catheter recipient (client/patient) is incorrect. Urinary catheters drain urine from the urinary bladder and are inserted by nurses via the urethral meatus using aseptic techniques. The urinary meatus is shown in Figure 1. Urinary catheters do not enter patients' "bottoms". Communication in this scenario could easily lead the patient to believe a tube, or something, was going to be placed into their "bottom". To continue along this line, imagine the patient's response when the catheter was passed into the urethral meatus. Some patients could think the student placed the tube incorrectly.

Figure 1

Figure 1. Diagrams showing position of bladder and urethra with urinary catheter in place,
female figure followed by male figure. (Modified from Smith and Duell, 1992, p.492).

This particular student owned prohibitive cultural barriers when dealing with male genitals. As the skill of catheterization is one that nurses perform frequently this student required one to one counselling with the initial aim of desensitization. Here again the assimilationist argument surfaces. Should this ACE+ student be expected to handle male genitals when clearly her cultural background is not in favour of such practices. In the "real world" of Nursing RNs are expected to be able to catheterize clients irrespective of the individual nurses beliefs. When placed in a clinical setting and when aware of the holistic philosophical approach to nursing care, then it can be argued that this expectation is not unrealistic, but does it reveal, to a degree, assimilation with the dominant culture?

There are many other varied clinical scenarios that can and do arise for ACE+ students, not to mention the more traditional problems that are documented in the literature (Ballard and Clanchy, 1991; Burns, 1991). The nurse academic working with ACE+ students is placed in a difficult situation and perhaps one that s/he has not experienced previously. Needless to say that as each student, irrespective of cultural background, being an individual as is the nurse academic, that each situation is handled differently. There, however, are common themes that become evident when discussing ACE+ student education. A degree of interpretation or assumption often occurs. This is done by the nurse academic. We often listen to what is said, listen to the cues preceding and during conversation and observe concurrent body language. As well, nurse academics construct diagnostic situations by observation, assessment, intuition and knowing.

Knowing comes about by clinical expertise and teaching experience. The difficulty exists because the nurse academic often interprets the sent message to what s/he believes it should be. The outcome depends on the next step, that is, clarification. It is important that the nurse academic seeks clarification of meaning prior to acting on the received informatics. When this step occurs the ACE+ student also has an opportunity to learn. Unfortunately this step is too often negated. Registered nurses, other health care workers, ESB students and nurse academics too often take the risk and work on, or from, assumption. This type of risk taking occurs for various reasons, for example, time prohibits clarification, expectation exists of same meaning. Due to cultural dictum, for example, that the teacher is superior, students should not be assertive, do not challenge the teacher (Burns, 1991, p. 74) or other culturally bound beliefs such as students should not question, contradict or argue with teachers (Ballard and Clanchy, 1991, p. 30), ACE+ students are less likely to correct nurse academics if miscommunication or incorrect assumption or interpretation has occurred. This is said to be risk taking in nursing because of the possible consequences of miscommunication (see Scenarios 1 and 2).

Further cases of assumption occur when ACE+ students submit written work. The academic reads a piece of work and receives many messages. One such message simplistically is that the academic believes s/he knows what the student meant but what is written is not the same as the interpreted or assumed meaning. This equates to the assumptive role.

Academics do interpret for ACE+ students, some more often than others. In doing so risks may or may not be taken. Examples of such risks are:

Many ACE+ students fail and repeat units. They are often counselled at school level and directed to broad brush type support structures elsewhere in the university. The student completes the extracurricular demands and eventually returns or simultaneously continues to study nursing all too often to face similar barriers or detours in reaching their goal, that is, graduating as an RN. Because universities continue to enrol ACE+ students it is timely for such institutions to fund contextual support structures aimed not only at ACE+ student groups but also to academics working with these groups.

As this paper has been purposively written for the 1996 Teaching Learning Forum: Teaching and Learning Within and Across Disciplines conducted at Murdoch University, Perth, Western Australia; Teaching Dilemmas the following question is posed : "To what extent should we assume or interpret for ACE+ students: Are we the risk takers?"


Australian Nursing Council Incorporated (1993). National competencies for the Registered and Enrolled nurses in recommended domains. Author.

Ballard, B. & Clanchy, J. (1991). Teaching students from overseas: A brief guide for lecturers and supervisors. Melbourne: Longman Cheshire.

Brown, V. (1994). Evaluation report of the non-English speaking background support program for undergraduate students in the school of Nursing, 1994. Perth: Curtin University of Technology.

Burns, R. B. (1991). Study and stress among first year overseas students in an Australian university. Higher Education Research and Development, 10(1), 61-74.

Curtin University of Technology (1994). Division of Health Sciences, School of Nursing curriculum document. Perth: Author.

Latchem, C., Parker, L. & Weir, J. (1995). Communication in context: A report on communication skills development for the Teaching and Learning Advisory committee. Perth: Curtin University of Technology.

Phillips, S. & Hartley, J. T. (1990). Teaching students for whom English is a second language. Nurse Educator, 15(5), 29-32.

Rittman, M. R. & Osburn, J. (1995). An interpretive analysis of precepting an unsafe student. Journal of Nursing Education, 34(5), 217-221.

Smith, S. F. & Duell, D. J. (1992). Clinical nursing skills: Nursing process model, basic to advanced skills (3rd ed). Norwalk: Appleton & Lange.

The Macquarie Library. (1991). The Macquarie Dictionary and Thesaurus. West End: Herron.

Please cite as: Brown, V. (1996). To what extent should we assume or interpret for additionally cultured students: Are we the risk takers? In Abbott, J. and Willcoxson, L. (Eds), Teaching and Learning Within and Across Disciplines, p27-31. Proceedings of the 5th Annual Teaching Learning Forum, Murdoch University, February 1996. Perth: Murdoch University. http://lsn.curtin.edu.au/tlf/tlf1996/brown.html

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