Teaching and Learning Forum 96 [ Contents ]

Cross cultural clinical supervision/education: The SE Asian experience

Rick Ladyshewsky
School of Physiotherapy
Curtin University of Technology

Framing the Action Research Question

With 'internationalisation' becoming ever popular among Australian universities a whole variety of educational challenges are emerging for Academics. These challenges of internationalisation centre around how one can create a cross-cultural environment as part of the learning process, ensure cultural sensitivity and maintain academic standards. For some programs, the challenge of cross culturalism extends beyond the classroom. Health Science programs typically have a 'fieldwork' component to their program of study. This fieldwork typically occurs in health agencies and hospitals which have a unique culture of their own. International students in the Health Sciences may suddenly find themselves quite unprepared for this fieldwork experience as it requires a high degree of cultural awareness and language skill.

The students that were interviewed and observed as part of this action research project were all of a SE Asian background. All of them were of Chinese distraction. A total of 9 students were involved in this project. Interviews were in the form of focus groups. All of them spoke English but their proficiency varied. Clinical educators and university supervisors who had undertaken supervision of a student from a SE Asian NESB were also interviewed. Again, a focus group strategy for their perspectives on cross cultural supervision was part of this action research project.

From the action research cycles undertaken in this particular project, several themes emerged regarding cross cultural supervision. One important consideration is that this information is specific to the group involved in this project. Its applicability to other situations and other SE Asian students must be based upon the reality that there will always be variation and extremes.

Cultural Influence

The fact that a person comes from a NESB does not explain many of the issues faced in a supervisory and learning relationship. The cultural background must also be considered as these influence the communication behaviours of the individual - both from a verbal and non-verbal perspective.

Chang (1995) described the Western model of individuation along 3 parameters which all reinforce the individual's need for 'independence'. This is in contrast to the East Asian model of individuation in which Chang (1995) states, that much of this process is influenced by Confucianism which promotes 'approval' and 'group harmony'.

In terms of cross cultural supervision, this model creates an inherent conflict in the expectations of the Western supervisor and the East Asian Supervisee. First of all, the Western educator/supervisor expects the individual to take responsibility for their own actions, to be an independent learner and to be assertive in the learning experience. In contrast to this expectation is the East Asian's perspective. The supervisee will prefer to do things which gain approval of the supervisor. Actions and behaviours will be undertaken to ensure normative approval and harmony. Behaviours which are seen to be assertive, such as presenting your own ideas and opinions violate the precepts of maintaining harmony.

By being aware of cultural behaviour patterns, supervisors can modify the way in which they interact with their learners.

Cultural Membership

Performance in an outside organisation is quite a different situation and students who have not initiated any strategies to become more familiar with local cultural practice will be at a disadvantage. The following quote from a student illustrates this:
I was doing a placement in psycho-geriatrics. I was supposed to determine the patient's level of orientation by talking about current and past events - eg. Prime Ministers, facts about W.W.II. How am I supposed to know all about Australian culture and history? It puts you at a real disadvantage as you don't know how to communicate around a common issue with your patients because you come from a different culture.
It would seem from the above comment that students of a NESB try to communicate within the appropriate cultural context but miss many of the cues that are culturally bound.

Helping students to become more familiar with cultural membership issues now becomes the big challenge for students, supervisors and teaching institutions alike. For many fieldwork programs, particularly in health, the experience is left towards the end of academic study - after the students have completed all their science and clinical subjects. Immersion into the health care sector, suddenly puts the student into a situation where there is a lot of cultural discrepancy.

The use of mentoring strategies or buddy systems is one potential strategy. By linking students of a different culture and NESB to local students early in their education, opportunities to learn more about local customs and conversational language would become possible.

Authority and Respect - Master vs. Novice

The traditional education system in many Asian countries is quite different from Western models. In most cases, students in Asia 'receive' information from teachers who are considered to be experts in their area. Rote learning and an emphasis on passing examinations is stressed. A teacher holds the same status as one's parents so many of the constructs relating to how one behaves towards parents holds true with teachers. Passivity is emphasised during learning situations. With this culturally ingrained learning behaviour it is not surprising why many supervisors accuse the students of not having any self-evaluation or problem solving behaviours.

This issue of master vs. novice and the cultural factors that influence this relationship are best described by the following contrasting quotations.

Supervisor's comment

The student's problem solving abilities seem very poor, we teach Australian students to be very independent whereas this doesn't appear to be the case with the NESB students.

Student's comment

One's own ideas are not as important as what the actual facts are or what is accurate - rather than take the wrong course of action - it appears more appropriate to hear the information from an expert so that the course of action is correct.
While it is not impossible for students of an East Asian cultural background to develop the skills necessary for success in a Western model of education, being sensitive to the discomfort the learner may be having in confronting the supervisor needs to occur. Explaining the basis for your requests to have the student self-evaluate is a good start. Ensuring that the learning environment is safe and having the student's trust is also imperative.

English and 'English'

What became apparent during the course of this AR project is that individuals have different concepts about what a NESB actually represents. When the SE Asian students in this project were asked whether their first language was actually English several agreed. The following comment was iterated by students in the group.
In Singapore and Malaysia we have better English training and a reasonable command of English. We think in English but our choice of words is the most difficult and the source of most misunderstanding. Peers from Australia have a much wider word choice for each particular situation whereas mine is very limited. Peers have so many words to describe pain, for example... this creates the impression in your Supervisors that you are not very good. If I spoke in Mandarin I could describe pain in many more subtle ways.
Among the SE Asian students, the fact that English is something they are taught throughout their formative years of education leads to the assumption that English is one of their first languages. Certainly, the supervisors that were interviewed during the project would question whether English was the first language of these individuals. The following quotation exemplifies this:
I asked the student what his/her first language was and they said English - but this obviously was not the case. A lot of English may be spoken at school but maybe not at home and not the same English.

Wait Time in Communication

Wait time can be defined as the silent time period which occurs between individuals when communicating (Hall, 1992). In a teaching and learning situation, these wait time expectations can be quite important in the development of assumptions of a person's knowledge. This wait time concept has also been articulated by students.
I found I was having difficulty coming up with the correct words during problem solving sessions with my supervisor. This made me quite anxious. The supervisor was stereotyping me as having insufficient knowledge but the real issue was that it took longer for me to process information and come up with the correct words to express the thought.
As supervisors, being sensitive to this wait time issue is critical. By ignoring this feature of communication with a person from a NESB, misunderstandings may develop. What is interpreted as a knowledge gap can in fact be purely a literacy and language issue.

Developing Rapport with Clients

Language and culture issues produce interesting impacts on the student's ability to develop patient rapport through communication. Word selection is one issue that has been raised that interferes or produces challenges in building patient rapport. The following comment exemplifies this issue:
I feel like I am always using the same words to reinforce behaviour. I notice how other Australian students and therapists show their appreciation and motivate patients - it seems so natural and well communicated. I am very conscious of what I am about to say and it sounds like I am saying the same thing over and over again - probably to the point where it sounds insincere. (Student)
A common concern that was expressed by supervisors is that the students communicate in a very brusque manner. This brusqueness, however, likely stems from the concepts of wait time, the difficulties in word selection and sentence construction and the lack of cultural membership. What the brusqueness represents is the awareness of students needing to respond in an appropriate time frame with the patient. Sentence construction and word selection being difficult for students of a NESB means that the conversation must be kept simple. Because of this, sentences may be clipped and very short, staccato type statements may be expressed. With this limit in word choice and time, it is also impossible to 'wrap' the communication into a cultural context as well. As a result, the communication appears cold and clinical even though the student cares deeply about their patient.

This challenge was not unnoticed by some of the supervisors which is evidenced in the following comment.

It takes longer to develop rapport with patients, this relates to the communication difficulties - the students are spending so much time listening, thinking, translating etc..... It becomes difficult for the patients to develop rapport. The student, because they are anxious and busy thinking, often come across as very blunt - this further cuts off rapport.

General Teaching and Learning Strategies for Supervisors

Paraphrasing and Reflecting

During communication sessions, encourage both parties to paraphrase comments and feedback. If the other party cannot reflect back the correct interpretation then the message has been clearly misunderstood. Find a different way of expressing the thought or ask the individual which part of the message they did not understand.

Lose excess language

The local language is often filled with idioms, colloquialisms and slang which are not part of the typical student's vocabulary if they are from a NESB. It is important to be self-aware of the language one is using when constructing messages to students of a NESB to ensure that the communication is direct and to the point.

Translation of 'Technical' Language

In some cases it may be appropriate to have a specific session to go over certain words if they are outside the vocabulary of the individual. This is particularly pertinent in the health care or fieldwork setting where there is a lot of jargon to be mastered.


One of the messages that has come out loud and clear is the importance of time. The challenge of cross cultural supervision does require more time. For the supervisor it means speaking clearly and slowly and thinking about how you construct your communication. For the student it involves the concept of wait time as well as time to think, translate and process information. Use of other communication strategies also take time. In light of this, fieldwork programs need to take this into consideration when structuring learning experiences for students of a NESB.

Communication Style

Every person has a unique communication style. This must be taken into consideration in addition to all the other factors. As a communicator in a learning/supervisory relationship, try to become more aware of your own personal communication style. Are there things that you do which interfere with effective communication. For example:

Task Selection

Another factor to consider in supervision of students is the selection of tasks for them to undertake as part of their fieldwork experience. While challenges are appropriate to push students to higher levels of performance, supervisors must ensure that they are not setting up learners to fail. In the case of health care, patients who pose extreme communication challenges may not be appropriate initially. In some cases racism may appear and supervisors need to be aware of this occurrence between client and student.

Cross Cultural Integration

Rather than immersing students into practical fieldwork placements without any preparation, cross cultural awareness needs to begin from the moment these students enter a program of study. Particularly if the are migrant or International students of a NESB. Early integration into the local culture should increase the student's awareness as well as elevate their language skill if put into opportunities where they must engage in social dialogue.


The challenge of cross cultural supervision will continue to present itself as migration, multi-culturalism and internationalisation of university programming continue to flourish in Australia. Although health care was the area of study in this report, it is highly likely that other fieldwork programs can use the examples here to reason through some of their own dilemmas in cross cultural supervision.

Question for Teaching Dilemma Discussion

What cultural issues create teaching and learning dilemmas between the Clinical supervisor/educator and student and how do we overcome these?


Chang, S. (1995). Seminar presented at School of Psychology, Curtin University of Technology. "Cross Cultural Counselling".

Hall, S. (1992). Discrimination in Government Policies and Practices S.80 Report No. 9. Developing Anti-Discriminatory Teaching Practices in a Primary School. Equal Opportunity Commission. Perth, Australia. p21.

Please cite as: Ladyshewsky, R. (1996). Cross cultural clinical supervision/education: The SE Asian experience. In Abbott, J. and Willcoxson, L. (Eds), Teaching and Learning Within and Across Disciplines, p99-104. Proceedings of the 5th Annual Teaching Learning Forum, Murdoch University, February 1996. Perth: Murdoch University. http://lsn.curtin.edu.au/tlf/tlf1996/ladyshewsky2.html

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