Midwifery 29 (2013) 559–565
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Commentary
Becoming culturally sensitive: A painful process? Lesley Briscoe, MPhil, MSc, PGCE, RM (Senior Lecturer in Midwifery Education) Midwifery Department, Faculty of Health, Edge Hill University, St Helens Road, Ormskirk, Lancashire L39 4QP, United Kingdom
a r t i c l e i n f o
abstract
Article history: Received 18 May 2011 Received in revised form 28 July 2011 Accepted 28 August 2011
Objective: to discuss how midwifery students develop cultural sensitivity. Design: students carried out international observational elective placements and 13 matched selfassessments from before and after a Global Midwifery Module were compared. The module is based around a model of immersion and permitted measured responses and qualitative evaluation to be explored. Settings: observational placements occurred in the UK, America, Canada, and Gutamala. Participants: seventeen year 3 midwifery students. Findings: raised awareness about international midwifery was identified; the module contributed to enhancement of practice, confidence about caring for those from a different culture varied, the process of critical reflection was uncomfortable for some. Key conclusions: critical reflection facilitated in a safe place may support individuals to transform their way of thinking. Implications for practice: responsibility for developing cultural sensitivity should lie with the individual. However, leaders need to facilitate space for critical reflection. Critical self-assessment and reflection about cultural sensitivity should be part of a life long learning approach. & 2011 Elsevier Ltd. All rights reserved.
Keywords: Student midwife Cultural sensitivity International Critical reflection
Introduction Respect for cultures and traditions remains a fundamental requirement for midwifery (NMC, 2009; WHO, 2009) stipulating that midwives should not discriminate (NMC, 2008). However, evidence suggests that discrimination does exist during episodes of midwifery care (Harper-Bulman and McCourt, 2002; Ali and Burchett, 2004; Pollock, 2005), and highlights that partnership with women from multiethnic cultures may be more difficult to develop. Partnership development may be hindered by a lack of confidence when managing complex issues (Drennan and Joseph, 2005) and disparity may grow further when there is miscommunication, potentially affecting maternal and neonatal outcome directly (Doorenbos et al., 2005; Lewis, 2007; CMACE, 2010). Communicating, when individuals are from different cultures can become complex and the ideal that both parties reach full understanding may never be achieved (Habermas, 1984). One explanation of why complete understanding remains difficult to achieve may be related to how language barriers encourage subtle interaction that permits individual assumptions to be made (Briscoe and Lavender, 2009; Briscoe, 2009). Professionals who speak the same language as their clients provide an important service; however, Kim-Godwin et al. (2006) identified that a caring attitude was more important to clients than language.
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This small Delphi study (n ¼93 round 1; n ¼142 round 2) (Kim-Godwin et al., 2006) involved a convenience sample and was set in Mexico and it would be interesting to explore how transferable the findings are in the UK. Culturally sensitive health care occurs when client expectations are aligned with health-care provider’s knowledge, attitude, and behaviour (Doorenbos et al., 2005). For organisations, aligning knowledge, attitude, and behaviour about culturally sensitive concepts remains difficult (Weiss, 1996; Cummings and Worley, 2009). Additionally, in service training about minority ethnic groups may rely on generalised concepts that are difficult to apply to individual people and may contribute to stereotype (Schim et al., 2007). Individuals who have experienced being with and supporting clients from different cultures may have greater sensitivity because exposure helps individuals to internalise awareness of how other people live (Hogg cited in Burke, 2006, p. 111). However, working in a multiethnic environment does not mean that the carer has implicit cultural sensitivity and competence (Pope-Davis et al., 1994), and it is important to consider how individuals and not systems create the caring environment. Individuals hold the power to influence the client experience, as Reimer-Kirkham (2000, p. 352) comments: It is not the culture that shapes the health care experiences of individuals. It is the extent to which they are stereotyped, rendered voiceless, silenced, not taken seriously, peripheralised, homogenised, ignored, dehumanised, and ordered around.
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For individuals, there is a suggestion that the process of developing cultural sensitivity needs to be pre-empted by a desire within professionals to become culturally sensitive (CampinahBacote, 1999, 2003). However, the provision of culturally sensitive care is a professional standard (NMC, 2004, 2009) that should not depend on whether individuals choose to become culturally sensitive. Constructive development theory (Comings et al., 2004) helps to identify that knowledge is constructed within the individual and holds individual meaning, and therefore, providing and engaging in care for individuals from other cultures will hold a different meaning for each professional. Developing self-awareness becomes the first step (CampinahBacote, 1999; Krainovich-Miller et al., 2008) for professionals who desire to become culturally sensitive and Midwives may have learnt how raised self-awareness assists communication (Hunter, 2005). Critical reflection provides a framework to support learners to become self-aware (Schon, 1983, 1987; Boud et al., 1985; Gibbs, 1988; Quinn, 2000; Johns, 2004). However, critical reflection is not simply assessment and reassessment of assumptions (Williams, 2001). After reviewing theories of reflective process (Mezirow, 1990; 1998 cited in Williams, 2001, p. 30; Brookfield, 1987 cited in Williams, 2001, p. 30; Schon, 1995 cited in Williams, 2001, p. 30), Williams (2001, p. 30) states, ‘critical reflection occurs whenever underlying premises are being questioned’ and Brookfield (2000) relates how ideology critique that promises social transformation helps people to lean to recognise how dominant ideologies pervade everyday events and practices (Brookfield, cited in Mezirow and Associates, 2000, p. 128). The process of becoming self-aware can be allied to theory associated with transformational learning, when a real life dilemma is followed by a self-examination based around critical reflection that aims to explore new roles, negotiate relationships, build confidence, and develop a more inclusive and discriminating perspective (Mezirow, 1990; Mezirow cited in Taylor, 1997, p. 3; Mezirow et al., 2000). Importantly, development linked to cultural sensitivity may become uncomfortable because critical reflection that recognises personal limitation can be a surprising and uncomfortable journey, which is best facilitated in a safe space (Lyons,1999; Iedema et al., 2006). Opportunity for student midwives to develop cultural sensitivity has been provided using the vehicle of a Global Midwifery Module within a 3 year BSc Midwifery programme, in North West England. A safe environment in a university setting was provided, where exploration was underpinned by a transformative philosophical base (Mezirow, 1990; Taylor, 1997; Mezirow et al., 2000; JohnsonBailey and Alfred, 2006). However, in order for a transformation to be visible it was important that level of change was assessed and the findings from evaluations are presented in this paper.
Methods Opportunity to observe midwifery practice in any part of the world is presented at the beginning of the midwifery programme and students plan their elective placement from the beginning of year 2 onwards. The rationale for the module aims to develop cultural awareness and sensitivity and encourage students to gain transferable skills associated with planning and organising their work load. The students are advised to develop a broad aim, which is later honed once the placement has been confirmed by the host. The elective placement is purely observational and there is recognition that the placement is self-funded. However, students are supported and encouraged to apply for funding and in 2006 student midwives achieved a Student Vision Award (RCM, 2006). Later, in 2011 students were awarded the prestigious Iolanthe Student Award (2011) and The Royal College of
Obstetricians Wellbeing of Women Student Bursary (2011). Additionally, students are supported to disseminate their work in local, national, and international settings (Bond, 2008; Briscoe and Cohort-32 Student Midwives, 2008; McEvilly et al., 2008; Partridge et al., 2008; Squires et al., 2008; Dee, 2009). Students search for their elective placement by contacting professional midwifery colleges within individual countries and permission is sought to observe practice. Usually hosts welcome students and plan time when student midwives are able to observe midwives working. However, some applications are declined because host placement areas are oversubscribed. Prior to travel, risk assessment will be carried out and approval for travel is ratified by the Head of Midwifery, Dean of Faculty and university compliance department. To date, students have been facilitated to visit placements in Africa, America, North America, South America, Asia, Australia, Europe, Middle East, and Oceania. Prior to the visit, a literature search aims to develop awareness about the new culture and the topic of interest. During elective placements students’ communicated with the module leader by telephone, e-mail and an eblogger. On return, students were supported to critically analyse and reflect upon their experience by linking theory to their observations within summative assessments of a poster and supportive paper. Prior to and after attending elective placements students are invited to complete a specifically designed self-assessment questionnaire. Additionally, the module is evaluated as part of the university evaluation process. Furthermore, students are provided with the opportunity to reflect in a group or a one tutorial.
Findings Ethical approval was sort from Edge Hill University’s Ethics Committee, which concurred that because this discussion paper involved service evaluation, formal approval was not required. Therefore, out of courtesy, permission was sought from September 2008 cohort who experienced their elective placement in 2011. Eighteen students began the module, however, one student needed to step off the programme during the module leaving the maximum number of matched responses associated with before and after the module of 17. There were 13 matched responses where attrition lost 4 student responses. Comments collected from eblogger reflection and module evaluations help to contextualise student self-assessment. The idea for using an ‘eblogger’ in a virtual learning environment for group communication rests with one innovative student and provided a real time online discussion secured by the University’s Technology Department. Students were asked to identify if they were aware of international issues related to midwifery. Ten of the matched paired students identified an increase in their awareness after the module, 2 responses remained the same and one student (Student 11) identified less knowledge in the after questionnaire (Fig. 1). Concepts such as post partum haemorrhage, infection control, maternal and infant mortality, and Female Genital Mutilation were evident. Individual students mentioned skilled trained attendants, HIV, wearing veils, sickle cell, and Thalassaemia after the experience. Comments from self-assessment supported an increased awareness: International issues in midwifery are vast. This module has enhanced my understanding of global issues related to midwifery and allowed me to develop my awareness of this. Key international issues I am aware of are FGM, inequalities in care provided, reasons for global maternal death (e.g. PPH) (Student 15: Self-Assessment: After). Anonymous module evaluations were submitted by 9 students, eight of whom identified that the module had contributed to
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1=No issues; 2=Some; 3=Most; 4=All n=13 matched pairs
Student midwives Fig. 1. The figure demonstrates the relationship between matched responses of student midwives, before and after the elective placement and asked, the question related to ‘Do you understand about international issues related to midwifery’?
enhancement of their practice, and one student left the area blank. One student expressed a deeper understanding related to high risk care: I have a better understanding of postnatal complications, the management of them and the extent of them worldwide. I valued the experience of observing practice in another country very much. It highlighted many issues and questions for me andy in practice I have become much more aware of high risk complications and the need for a multidisciplinary team (Anonymous evaluation). When asked if there was an appreciation of how the culture of individual clients differed from their own, there was an indication that 2 (Students 1 and 8) understood less but 7 understood more after the module (Fig. 2). Four students distinguished that they held the same opinion after the module a lot of the time (3) and some of the time (1). Virtual learning captured interpretation about how culture differed:
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n=13 matched pairs 1=Not at all 2=Some 3=A lot 4= All of the time
Student Midwives Fig. 2. Excell: culture: The figure demonstrates the relationship between matched responses of student midwives, before and after the elective placement and asked, ‘Do you understand how the culture of individual clients differ from your own’? Understand how the culture of individual clients differ from your own?
When asked if students understood the needs of clients who were not from the student’s own culture 6 students recorded the same score before and after, a lot of the time (4) and some of the time (2) (Fig. 3). Five students were more able to understand the needs of clients and one student (Student 8) was less able to understand the needs of clients after. However, the virtual learning environment portrayed a deeper appreciation of client need: What has struck me this time around is the individual situations of the teenagers and the implications of their pregnancy; separation from their partners, isolation from friends and family to name but a few. With many, their inexperience and lack of support has led to depression. Difficulty with housing issues and the benefits system means that, even on our doorsteps, children are being born into poverty in our ‘developed country’. The stories of abuse, substance addiction and violence are so sad and, as a mother of teenagers myself, at times heart-breaking (Student 5: Eblogger: Unmatched).
Additionally, how culture influenced the way midwives worked and variation in practice was evident:
Five students felt that they responded appropriately to the needs of clients who were not from their own culture more after the module. However, 8 declared no change in their opinion either totally (2) or a lot of the time (6) (Fig. 4). Student number 4 specified that there was an increased ability after the module ‘Clinically, but not culturally’ (Self-Assessment Questionnaire). Confidence about caring for clients whose culture differed from their own identified that 5 students felt more confident after the module and 8 students felt the same before and after, totally (2) a lot (4) or some of the time (2) (Fig. 5). A comment from the self-assessment form identified increased confidence was related to raised awareness of global aspects of care:
Apparently they circumcise newborn boys here usually and there’s no (apparent) advice to avoidyeating liver and they give eye prophylaxis to babies from GBS (Group B Streptococcus) mothers (eblogger: Student 18: Unmatched).
I expected to gain a more in-depth awareness of global aspects of midwifery. I feel this was achieved. Furthermore, I gained a deeper understanding of global midwifery in this country by my elective placement. I was able to relate global aspects to
Today and yesterday during clinic I became more culturally aware yet again. Never before had I met a Mennonite. So what did I do? You know don’t you? Yep! I googled it. Apparently, Mennonites first came to Canada from Pennsylvania during the late 18th century and settled mostly in Ontario. Pennsylvania Mennonites were of German-Swiss and South German origin and the dialect spoken among them was basically high German, mixed with a considerable amount of English (eblogger: Student 18: Unmatched).
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1= Not at all 2= Some of the time 3= A lot of the time 4= Totally
1=Not at all 2=Some of the time 3=A lot of the time 4=Totally
n=13 matched pairs
n=13 matched pairs
Student Midwives
Student Midwives
Fig. 3. Excell: needs: The figure demonstrates the relationship between matched responses of student midwives, before and after the elective placement and asked, ‘Do you understand about the needs of clients who were not from your own culture’? Understand the needs of clients who were not from your own culture?
1=Not at all 2=Some of the time 3=A lot of the time 4=Totally n=13 matched pairs
Fig. 5. Excell: feel confident: The figure demonstrates the relationship between matched responses of student midwives, before and after the elective placement and asked, ‘Do you feel confident when caring for clients whose culture differs from your own’? Feel confident when caring for clients whose culture differs from your own?
Level of confidence had increased for 6 students. However, equally, 6 students felt the same level of confidence before and after the module, completely (1) very (4) or a little of the time (1). One student (Student number 13) felt less confident after the module (Fig. 6). Negative emotion became evident during the module when one student explained that the process of developing cultural sensitivity was troubling: I had an emotional rollercoaster of a night last night yI have to say though that it is a lot harder than I imagined and even though I understood the culture before, to actually live here in it is something else! (Student 10: Eblogger: Unmatched). Furthermore, students suggested that the process of critical reflection may prove disconcerting at times because preconceived ideas become challenged:
Student Midwives Fig. 4. Excell: respond: The figure demonstrates the relationship between matched responses of student midwives, before and after the elective placement and asked, ‘Do you respond appropriately to the needs of clients who are not from your own cultural background’? Respond appropriately to the needs of clients who are not from your own cultural background?
care provided in this country. I feel more confident in caring for clients from different countries, including those that differ from my own (Student 15: Self-Assessment: Matched).
I began this module with the belief that it was every woman’s right to breastfeed, regardless of HIV statusyit is the policy of the UK that all HIV women should be discouraged from breastfeeding, especially where replacement feeds are ‘acceptable, feasible, affordable, sustainable and safe’ (AFASS). Many of the text books also mentioned the results of a study that suggested exclusive breastfeeding was deemed to be safe for the first six months, and the transmission of HIV was very low. I had strong feelings about this and wanted to discover why we discouraged it still in this country after the findings of the research. Attending my elective opened my eyes and I attended clinics that I had never been exposed to before. I have read the research and whilst attending my elective I also had opportunities to ask questions to some of the top leading specialists in HIV, hoping it would give me a better understanding of some of our policies here in the UK. My experience changed the way I look at HIV and breastfeeding, my understanding of why here in
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1=Not at all 2=A little 3=Very 4=Completely n=13 matched pairs
Student Midwives Fig. 6. Excell: how confident: The figure demonstrates the relationship between matched responses of student midwives, before and after the elective placement and asked, ‘How confident do you feel when caring for clients who are from cultures that differ from yours’?
the UK we implement a policy of breastfeeding discouragement is better thought of (Student 13: Self-assessment: Matched).
Discussion Student midwives in a University in North West England engaged in a global midwifery module with the aim of developing cultural sensitivity and gaining a deeper understanding of how international issues influence midwifery practice. A model of immersion (Campinah-Bacote, 1999, 2003; Wood and Atkins, 2006) underpins a belief that individuals become more aware of cultural issues when exposed to alternative cultures or events. However, opportunity for individuals to engage remains pivotal. The three year BSc Pre Registration Midwifery Programme encourages students in their final year to draw on new experiences related to international midwifery for a 3 week observational elective. The experience is situated within a module that considers global perspectives of midwifery care. Additionally, the rationale for the module recognises that adult learning involves four stages of experiencing (activist) reviewing (reflector) concluding (theorist) and planning (pragmatist) (Honey and Mumford, 1992) that supports movement of thought (Mezirow, 1990; Mezirow et al., 2000). Rawls (1981) suggests that individuals need to understand the conditions of others by imagining how their lives would be without the privileges and advantages they, as an individual, experience. By embracing this perspective, a ‘veil of ignorance’ (Rawls, 1981, p. 19) may be lifted, when realisation of what life is like for others becomes clear. Adopting the others perspective helps to realise Aristotle’s premise that individuals should treat others as they would like to be treated (Aristotle cited in Korsgaard, 1992, p. 307). Ethically sound beliefs are to be commended and strived for, however, transferring ideals into society and work places remains a challenge where prejudice exists (Macpherson, 1999; Harper-Bulman and McCourt, 2002; Ali and Burchett, 2004).
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Responses remained the same before and after exposure for some students. One explanation may be that the student had experienced familiar scenarios and adjusted their behaviour based on previous experiences (Blumer, 1969). However, for the students, sensitivity about how others lived, developed and was evident in evaluations. For example, students commented about ‘What struck me this time around’ or events appearing, ‘a lot harder than imagined’ indicating that the existence of the other person had been seen from a different stance and the imperceptible veil of ignorance had been lifted. Moving from one way of thinking to be situated in another provides a challenge and the critical process should never be underestimated. Mezirow et al. (2000) relate the cognitive process to transformation, a word that suggests a radical change from one idea to another. Critical reflection creates a vehicle that is able to transport the learner from embedded ideas to a more considered opinion, but this may be uncomfortable and even painful at times (Atkins and Murphy, 1993; Lyons, 1999). Structuring critical reflection around established reflective frameworks helps to create enlightenment especially around emotive concepts such as seeking asylum, being a refugee, teenage pregnancy, how other cultures practice midwifery or the practice of traditional birth attendants, for example. Emotive topics attract strong opinion best voiced in an environment where there is a climate of trust, respect, openness and safety (Lyons, 1999; Iedema et al., 2006). Previously held beliefs may then be challenged in a structured and supportive environment to reach the point of ethically sound transformation. The process of transformation was demonstrated when one student expressed how strongly she felt about recommended advice against exclusive breast feeding for women who experience HIV (WHO, 2010). Observing women with positive HIV in the clinical setting, discussing the embedded concepts around breast feeding with experts in the field and deepening a knowledge base based around best evidence, contributed to a cognitive movement and transformed how the concept was perceived. The reflective process was uncomfortable, however, the student came to a different opinion, highlighting that cultural and psychological assumptions should be critically analysed (Mezirow, 1984) to help explain why and how beliefs constrain our understanding (Mezirow, 1990). Increased awareness about cultural issues was identified in the responses related to self-assessment. However, for some, scores remained the same or they felt less aware or confident after the module. It is important to understand that the women’s opinions were not part of the evaluation. Therefore, measuring if students demonstrated increased awareness and sensitivity around cultural need may be different if seen from the women’s perspective. Feeling less confident after exposure to a structured model of education is not unusual and relates to a process of reassessment (Fadlon et al., 2004). Or the response may be linked to a transitional stage of knowing where learners display partial certainty and partial uncertainty (Baxter and Magolda cited in Moon, 2005, p. 8). Interestingly, different individuals at different times felt completely confident about cultural issues, responding to cultural needs and having total confidence in their ability. Feeling confident is to be applauded and helps to reassure educators that final year students are at an appropriate level to register as a midwife (NMC, 2004, 2009) and the recording may present actual standard. Even so, mentor perception was not part of this evaluation; therefore, it would be wrong to presume that students were not at the level they record. However, Goldfinch and Hughes (2007) found overconfidence, when confidence is recorded but a student does not achieve, in first year students, which presented a barrier to success in higher education. It may be that those who were less confident before and recorded a higher score after, developed more than those who recorded the same. Additionally,
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recording confidence may reflect a taken for granted opinion that one should have skill because of predisposition or personality (Fadlon et al., 2004). Alternatively, confidence may reflect that exposure to similar situations occurred in the past and the student felt able to cope or refer on. Informing students about perceived confidence should be considered for midwifery programme development. Additionally, measuring if confidence is a predictor for success in the final year may be a concept developed for future research. Fundamentally, the individual experiences care and individuals, who may or may not, work in teams, provide care. Additionally, professional standards require the individual to demonstrate competencies based on appropriate ethical, moral, and legal requirements (NMC, 2004, 2008). Therefore, the individual becomes pivotal to the question about how cultural sensitivity should be developed. Developing cultural awareness, sensitivity, and competence is an important consideration for organisations when the aim is to embrace diversity (Cummings and Worley, 2009) but is difficult to achieve (Schim et al., 2007). Leaders who envision changing environments where health professionals work need to place more importance upon how powerful the individual can be in creating the caring environment. Responsibility for developing cultural sensitivity should rest with the individual but the process of critical reflection should be facilitated by good leadership. Self-assessment about cultural sensitivity and competence should be part of the life long learning approach required for midwives after qualification. Non-judgemental approaches to care may be enhanced if midwives are facilitated to reflect upon how they feel about caring for women from a variety of cultures.
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