Key themes from interviews and focus groups

Several themes emerged from the interviews that can inform future nursing education. 

Older people

Theme 1. Positivity and wellness

• Participants’ enjoyment of life and appreciation for some of the advantages of ageing traversed all cultural groups. They belonged to community groups like marae and ethnic societies; some took on positions of responsibility and leadership of committees, others did volunteer work such as neighbourhood watch, or supporting kohanga reo. They talked about the importance of activity and engagement and ‘matter-of-fact thinking’

Theme 2. Language

• Language is well-recognised as one of the fundamental elements of culture and people’s identity, and the importance of good communication was mentioned, either directly or tangentially, by every participant in this group of informants. People want to be seen as individuals, called by their name – and they want to know who they are speaking to. Thoughtful, clear communication and the use of simple language is important when a patient is a second-language speaker. For older Māori, recognition and use of te reo is an important aspect of making them feel culturally safe, and ‘seen’ in healthcare settings. 

Theme 3. Whanau/family

• Some of our Māori, Chinese and Indian participants directly attributed their wellbeing to the close connections and care provided by family. They also talked about how caring for elders is seen as a filial responsibility within their cultures. Yet for others, living in New Zealand meant accepting a separation from family, and connections meant visits home, Facebook and video calls. Pakeha New Zealanders also talked about appreciating visits from family living in the same city. Support was appreciated from nurses and the healthcare system included hospital stays made comfortable when nursing staff allowed visitation by family – including critical care.

Theme 4. Tikanga/cultural practices

• Māori contributors talked about kaupapa and tikanga and offered examples of what this looked like for them: use of te reo, respectful relationship building, whanau wards, karakia, serving food. Some also wanted to make us aware of the long-term, even inter-generational fear and distrust of hospitals and white coats many older people still hold as a post-colonial legacy. 

Theme 5. Social justice

• Participants felt strongly about older people’s entitlement to an equitable health experience. Access to government services, including healthcare, must be available to both English and non-English speakers, and providers need to have strategies rather than letting the burden of cross-cultural communication fall to the unwell person. Respect for elders is deserved, and not just an outdated politeness.

Bachelor of Nursing (BN) teachers and academic leads

(Toi Ohomai, Waikato University, Wintec, AUT and Unitec) 

Theme 1. Culture shock

• Educators talked about how students get their ideas of what nursing is from fairly glamorised depictions in the media. In reality, when they encountered older people, they were unprepared for grief, loss and loneliness. In particular, families leaving relatives to be cared for by others was a cultural shock for many students. Too, there was the shock of “old bodies” and also of menial tasks. Most participants in this group agreed that Aged Residential Care (ARC) clinical placements could often be off-putting for students considering older adults’ care as a career, and would like to see a balance with students in the community, seeing older people in other settings, or working with Grey Power, Aged Concern and ethnic societies.

Theme 2. A cultural lens – on students and with clients

• Teachers reported that students were often shocked when they encountered examples of ageism and racism, stereotypes and assumptions being perpetuated by ARC staff, including Registered Nurses (RNs) and Health Care Assistants (HCAs) during their placements. Educators talked about their professional role here, supporting students, noting that they may need to be ‘talked down’ from wanting to intervene, or counter facility protocols. This is where cultural competence and cultural safety teaching and learning needs to prepare student nurses understanding that prejudice is a part of everyday reality for many New Zealanders, and that they will encounter this in their healthcare career – often far sooner than they might expect.
• Nursing educators agreed that it was very hard to change others’ cultural lenses, but that there were two areas of responsibility held towards students. First was the curriculum focus on Te Tiriti, whanaungatanga and cultural sensitivity and ensuring students understood and practised appropriate tikanga. Second was their responsibility as a role model. They emphasised the importance of a strengths-based approach rather than focusing on problems and modelling different approaches: “making overt what we are doing and why”.

Theme 3. Anticipatory classroom preparation

• Many participants from this group alluded to the wealth of cultural capital found in the classroom, with students from diverse backgrounds, ethnicities, ages and previous careers. Educators talked about a range of activities and approaches to preparing students for clinical placements, in readiness for working with both older adults and different cultural groups: role plays, marae time, case studies, simulations and lab exercises.

Preceptors/Student Nurse Educators (SNEs)

Theme 1. Developing a holistic understanding of practice

• SNEs were supportive of a third year ARC placement, commenting that they saw a big difference between first and third year students who had generally moved on from “seeing the entire population as disabled to some degree” to a more personalized understanding and a readiness to form relationships. Other comments related to the importance of language, and the opportunity of working with students towards the end of their education, to influence communication approaches, encourage critical thinking and provide opportunities to gain deeper insights.

Theme 2. Valuing professional standards – the role of Nursing Council Standards of Competencies

• The Nursing Council of New Zealand (2024) has just updated its Registered Nurse Standards of Competencies. SNEs talked about how students were required to show evidence of working within and towards these competencies, and how they felt this contributes value to the placement experience, but that the Competencies (and similar theoretical frameworks) can seem unrelated to how the students initially think of nursing. Therefore, this is the importance of clinical placements: to apply concepts to practice, and see how enactment makes a difference.

Students

Theme 1. A mismatch of expectations and experience

• Overall, students felt they were well-prepared for their placements, but experienced frustrations related to the facilities and staff, with one student saying they felt as if they were considered a “glorified HCA”, another that “staff don’t know what a Year 3 can, and should be doing”, and a third: “The nurses don’t always take us seriously”. Students found that they were not able to distribute blister pack medications, as most facilities used an online system and students were not given a login – despite having trained for this task. There were similar comments about access to health and safety equipment.
• A second area with which students felt that they were not able to engage effectively, and in which observed practice showed considerable variance with what was taught in class was an almost entirely medically and treatment-oriented approach to care, rather than our current, patient-centered and holistic understanding of wellness. Students would have liked more training students in advocacy and conflict de-escalation, given their challenges in forging collegial relationships with some members of staff, which had the potential to limit the Quality Improvement projects with client-participants that they needed to undertake as part of their practicum requirements. 

Theme 2. Ageism is real

• Overlapping with a predominantly bio-medical practice, students commented that they observed attitudes in the ARC facilities they worked in that perpetuated assumptions and stereotypical judgements about older adults that students had been taught in class to question. Other examples given related to communication from facility management that was often via notices posted in communal areas, which would exclude those who were visually impaired, immobile, or socially reclusive. Students also had stories of staff avoiding residents who had a history of aggression or intransigence, but having shown little interest in the individual’s psychosocial backstory, such as earlier trauma. 

Theme 3. Mixed practice in cultural responsiveness

• Perceptions of how well centres catered for cultural inclusivity varied considerably. Some students reported ARC centres with no client diversity; others with “lots” of Māori and Pacific residents. Both positive and challenging examples were offered, including practices students saw as tokenism and ‘virtue-signaling’. Another shared feature of many students’ ARC placement experience was the large number of internationally qualified staff and the impact that this had on ARC facilities’ organisational culture.

Key elements from Quality Improvement (QI) projects analysis

Student nurses in the final year of their undergraduate programmes undertake a self-selected QI project during clinical placement working with older people in care facilities.

From those which focused on supporting older people’s culture and cultural connections three common elements were noted.

Element 1

• Providing culturally responsive care is often described by the interconnected balancing of Durie’s (1998) four cornerstones, or walls, of his Te Whare Tapa Whā model. Wellbeing is defined by the individual, within their own family, culture, socio-political and environmental contexts, meaning people’s mental outlook plays a significant role in maintaining wellbeing (McBride-Henry et al., 2022).
• When students engaged in projects which considered their participant’s needs from a number of perspectives rather than initiating a bio-medical treatment response, they were acknowledging existing cultural and spiritual beliefs and providing resourcing and education to support these. Examples of values which individuals linked to their sense of wellness are easily seen: faith and religiosity; hearing your mother-tongue; community and inclusion; explanations and tools from an indigenous, not westernised perspective.

Element 2

• Communication is more than just semantics. In all but one of the QI projects, understanding the English language was not the issue. Yet outcomes from some of these projects indicate that older adults from non-Pakeha cultures gained a higher level of understanding and appreciation of what nursing staff had been asking and advising, when it was presented in language and frameworks which were culturally familiar. Several student nurses’ reports of these projects described the importance of establishing rapport and building therapeutic relationships as part of supporting wellbeing. Respecting mana was important.

Element 3

• Initiatives introduced clients to new ways of thinking and new access to funding, demonstrated new documents and approaches to cultural inclusiveness to staff, and socialised important tikanga like karakia for other residents. For some participant-clients, deeply-held values which surfaced through multi-dimensional discussions about wellbeing, like a love of music or a deep Christian faith, were brought to the attention of staff and opportunities for engagement were put in place.

Conclusion

Our ageing and increasingly culturally diverse population will be a feature of our social and healthcare landscape for decades to come – as will be our need for skilled practitioners to provide care and services. When we prepare our students for the world of work, we need to balance the contributions of classroom approaches – textbooks, lectures, labs, simulations, avatars, role play – with authentic voices from real life.

It is hoped that the teaching resources from this project will offer one possible tool for educators moving students from personal reflection to application of cultural consciousness with real-life examples.