Supporting culturally and linguistically diverse students during clinical placement: strategies from both sides of the table

Participants

Thirteen students participated in the CALD student focus groups, 12 females and one
male. The country of permanent residence profile for participants was 92 % Asian (Chinese,
Chinese Malaysian, Chinese Singaporean, Japanese, Malaysian and Singaporean) and 8 %
European (Norwegian). This is relatively reflective of figures given for overseas
students in Australian health programs, 59 and 10 % respectively 16]. The mean student age was 29 (±5.6) years. Most students were in their 3rd year (n?=?7) and 4th year being the next most common (n?=?3), there were single student’s representing 1st and 2nd year plus one recent graduate.

Twelve supervisors participated in the clinical supervisor focus groups, all were
female. The majority of supervisors (n?=?10) were involved in dietetic supervision within their third and fourth years of
training. The remaining two supervisors taught into the nursing course year’s one
through three. Most supervisors identified with being between 30 and 40 years old
(n?=?8) with those in the 20–30 and 40–50 years groups having two supervisors each.

Themes and sub-themes

Table 1 summarises the main challenges and the associated strategies identified by supervisors
and students to increase CALD student success on placement. Illustrative quotes of
the themes and sub-themes from the two participant groups are contained within Tables 2, 3 and 4.

Table 1. Summary of main themes resulting from CALD student and clinical placement supervisor
focus groups

Table 2. Verbatim statements for the theme “Placement planning and preparation”

Table 3. Verbatim statements for the theme “Teaching, assessment and feedback”

Table 4. Verbatim statements for the theme “Cultural and language issues”

Theme 1: placement planning and preparation

There were three sub-themes within this theme: provision of supervisor training around
specific CALD student issues; undertaking student orientation and preparation in a
timely manner; and CALD student placements requiring more time allocation on a regular
supportive basis.

The workload of supervisors demands that they manage their own caseloads and provide
high-level student support. However, the level of supervisory training appears to
be inadequate when the topic of CALD supervision was discussed. Whilst training is
provided by university staff, the overall level of supervisor awareness about the
training was low with only one group mentioned it with a varying levels satisfaction
on its relevancy to their needs. Other supervisors remarked on a lack of resources
available to help them manage issues relating to CALD students. The lack of consistency
in supervisor CALD training awareness and their training experience is a potential
concern.

Student placement preparation is essential for the smooth transition from classroom
to workplace. Whilst all courses have a placement preparation plan and orientation
processes, there was an inconsistent level of experience reported. Within the student
preparation process, it appears that the timing of learning activities within degree
programs is critical—too early and it is undervalued, too late and the opportunity
is missed.

Students as well as supervisors discussed the influence of time constraints on placement
organisation, structure and duration, pace, rotations and capacity. Both groups wanted
more time allocated to placement planning and the importance of time management on
placement was repeatedly stated. Supervisors reported being conflicted on the notion
of a ‘level playing field’ put forward by universities to ensure student equity during
learning experiences. While they supported the notion in principle, they weighing
up the needs of CALD students on placement and found it difficult to implement in
practice. Supervisors also felt it was a university responsibility to ensure all CALD
students were adequately prepared before going on placement.

The strategies proposed for this theme to improve outcomes were: appropriate student
placement preparation; pre-placement identification of higher risk CALD students;
and supervisory training focused on CALD students.

Preparation was universally held as being important and both groups stressed the need
for it to be specific, focused and well timed within degree programs to increase its
effectiveness and maximised student engagement. A wide variety of formats were proposed
(lectures, tutorials, workshops, clinical lab session, role plays, practical applications)
as well as integrating an extra stream of support tutorials solely for CALD students
throughout a teaching semester. The conclusion was a need for more time, resources
and specific support services to be put into placement preparation.

Early identification of at-risk CALD students by university coordinators was a commonly
identified strategy by supervisors. In several degree programs formal peer-to-peer
learning occurs on placement; supervisors suggested more feedback and information
pre-placement on the suitability of potential student pairings to create better matches
would increase student learning rather than detract from it.

The final strategy was the need for specific and skilled training to give appropriate
support to CALD students. Supervisors noted the need for teaching time to be allocated
in order for the training to occur and linking into existing “in-house” training about
cultural awareness for common client populations would help reduce any overlap within
placement organisations.

Theme 2: teaching, assessment and feedback

The sub-themes were: the difference in approach to learning and teaching styles within
placements, and double-edged sword of regular assessment and feedback.

CALD students and their supervisors reported experiencing a learning environment that
the students may not be prepared for. Students may have well-developed rote learning
strategies and the expectation of ‘learning on the run’ can be fundamentally challenging.
Both participant groups commented on the impact of culture on learning/teaching styles
with specific difficulties noted asking questions, giving peer feedback, undertaking
self-directed learning and reflective practice. Differences in prior learning and
teaching experiences, time constraints and language barriers seem to play a role and
were mentioned on both sides. Certain styles of placement supervision appear to be
more problematic for CALD students, specifically when they were in a two student to
one supervisor ratio.

Students valued the opportunity to demonstrate competency once they acquired a skill
and use regular feedback as a mechanism to improve their learning. Some CALD students
reported feeling like they were constantly being assessed with little opportunity
to practice skills before assessment and supervisory engagement in the process and
providing feedback was varied. The process of formative assessment requires dialogue
to occur between students and supervisors. Supervisors commonly reported low levels
of CALD student engagement in the process yet at the same time they reported the same
students regularly asked for feedback. More informal supervisor-student relationships
presented other challenges where students saw supervisors more as friends leading
to feedback not being accepted.

The strategies proposed for this theme to improve outcomes were: adapting student
caseloads; regular casual supervisor-student conversations; supportive placement delivery
modes and structures; early expectation setting and modelling of constructive feedback
process; visual aids and tailoring the learning environment.

Supervisor judgement or ‘screening’ of patient types was put forward to ensure CALD
students are not given overly complex cases too early in their placement. While this
process is considered part of normal placement supervision, supervisors felt it was
especially important for at-risk CALD students where complexity might not be simply
their clinical condition but potentially those with complex social situations, low
levels of English language skills and/or strong accents. Allocating time to have regular
informal conversations and clarifying early on with CALD students that those conversations
are not assessed was also proposed.

Creating a peer-support network and allocating supervisor time to engaging with the
network to model good communication skills and increasing student confidence was identified
by supervisors. Another strategy identified on several occasions was ensuring CALD
students had longer placements blocks at a single location. This strategy helped to
reduce student anxiety and the stress of adapting to different environments on a repeated
basis.

Other practical suggestions around how supervisors support CALD students in their
learning were clarifying expectations early on for tasks in different settings and
modelling of constructive peer feedback conversation. Some supervisors took time to
personalise teaching experiences—diagrams and illustrations were mentioned—for CALD
students to meet their learning needs.

Theme 3: cultural and language issues

The sub-themes were: interpersonal placement relationships; using English as a primary
communication tool; insight needed into the healthcare system, professional roles
and society generally; and self-care pressures in a culturally foreign setting.

Learning and working in a different cultural and linguistic setting presents a host
of challenges. Both groups reported the social nature of healthcare work and the pressures
that it creates for CALD students being an issue. Specific aspects identified were:
student understanding and undertaking of professional interactions, differences in
personal space interpretation, difficulty in being assertive or interacting in groups,
CALD discrimination and display of emotions. The concept of personal space and the
process of establishing rapport were culturally variable; both aspects were recounted
as impacting patient interactions. Language issues and established local social networks
affected interpersonal relationships between CALD students and their peers. One supervisor
reported this behaviour as being such that it could be described as discriminatory
within their workplace.

English language skills to gain entry into a university course does not equate directly
to an ability to converse casually or communicate complex health messages in simple
language. The more nuanced practice of communicating within a healthcare setting means
that CALD students and their supervisors identified several aspects that need to be
considered: gaining sufficient exposure and practice opportunities; adapting language
to suit different contexts; supervisor bias of perceiving CALD student communication
issues; and the extent of language skills impacting student assessment and progress.
Just as language skill is crucial, understanding the complexity of the healthcare
system is equally fundamental. Both groups discussed this aspect at length and how
it will impact patient care, student functioning on placement and academic assessment.
Supervisors noted that CALD students might lack social support to help with daily
living issues and pastoral care. These issues extended to practical components of
placement like transport to placement site resulting in exhaustion from the stress
of relying on public transport to get to their final destination.

The strategies proposed for this theme to improve outcomes were: building language
and practical approaches for communication; raising awareness of the healthcare system
(how it interacts with healthcare professions and how patients access it); and mentoring
programs.

CALD students put forward practical suggestions on addressing their issues communicating
with peers, for example, doing voluntary work and being pro-active when engaging with
non-CALD students. Supervisors favoured students having a more formal University-based
integration of peer interactions, for example University workshop or events such Australian
culture evenings. A practical communication strategy identified by both groups was
getting students to ask their patients to speak a bit more slowly and to speak slowly
to them to ensure the patient understood them. Another strategy mentioned by a student
was to speak quietly when they were unable to hear the patient so the patient would
raise their voice. Practical supervisor communication strategies included showing
interest in the student’s background by asking questions and encouraging students
to paraphrase/reflect back on what they understood the supervisor was explaining.

Pre-placement preparation was a key strategy to tackle CALD student awareness and
understanding of the healthcare system; both groups identified it. Supervisor’s comments
came from wanting to ensure time on placement was not wasted and needing students
to be ready to learn during the valuable placement blocks. CALD students proposed
any university preparation be very practical and include hands-on learning. Both supervisors
and CALD students mentioned mentoring as a way of improving social interaction skills.
CALD students supported a formal mentoring scheme where more senior CALD students
supported more junior ones.