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Complexity or mutual learning: reframing the narrative of health professional placements for international students
- 1. Complexity or mutual learning: reframing the narrative of health professional placements for international students Dr. Stacie Attrill Senior Lecturer, College of Nursing and Health Sciences Teaching Program Director (Health Professions) @SAttspeech
- 2. Who are culturally & linguistically diverse (CALD) students? •International and domestic students who: •Speak another language at home + English •Include: Migrants, +1st, 2nd gen (?3rd) •Broad acculturative experiences •Influence of culture and language on learning experiences •Differing experiences of education and health professional practice in Australia
- 3. Health services for CALD communities in Australia •Our CALD communities are growing and diversifying. •Globalisation, international mobility, and prominence of 2nd and 3rd generation Australians from migrant backgrounds (Schwartz, et al 2010). •Health access and outcomes for CALD communities in Australia (and globally) are comparatively poorer than for dominant communities (Anderson, et al. 2003; Berger, 2008). •Varied acculturation leading to differing understanding of and engagement with health services •CALD communities perceive that health services do not meet their health needs. •May prefer to access healthcare from culturally concordant clinicians, even when their language differs •People from CALD backgrounds are grossly under-represented among health care professions (Betancourt et al., 2003; Lattanzi & Pechak, 2012). •Structural, procedural, systemic and cultural reforms required to improve health access and outcomes for CALD communities (Betancourt, et al. 2003; Napier et al., 2014)
- 4. Health Services for CALD communities • CALD students, including international students, bring cultural capital to education environments and health workplaces (Nápoles-Springer et al., 2005; Nash, 2011) • CALD health professionals and students: • Facilitate culturally responsive services and practice (Betancourt, et al. 2003). • Model intercultural knowledge and skills for majority culture clinicians and students (Nápoles-Springer et al., 2005).
- 5. Academic barriers for CALD students... •Being CALD, including being an international student is a known predictor of poor academic performance in medicine and other health professions (Haq etal, 2005; Lumb etal. 2004; Woolf etal. 2011). •Being a non-native English speaker also predicts poor academic outcomes (Green, 2015; Woolf etal, 2013). •Students who speak English as a first language, but a Language Other than English at Home (LOTEH) may also have poor academic outcomes (Schwartz etal, 2010).
- 6. Health Professional placements •Completed by all health professional students, as part of their competency development. •Clinical Educators/Facilitators supervise and support students’ learning on placement. •Situated in workplace settings. •the complex and changing needs of patients often have primacy over student learning (Rodger, et al. 2008) Placements are likely to be challenging learning environments for international students (Nash et al, 2011)
- 7. Placement research: International students •Communication load • intelligibility, vocabularly; understanding instructions; • confidence; burden of translation; speed of processing • Adjustment load • Influence of Cultural background on expectations of learning & interactions w patients and health practitioners. • Limited knowledge about Aust health culture & need more individual supervision and time compared with other students. •Strategies suggested increase time and expense of student supervision : •providing earlier introduction to placements, •more 1:1 support with the clinical educator, •conducting role plays to support verbal communication.
- 8. International students as a (wicked) problem • Presented as lacking knowledge and skills for Western educational experiences and as being problematic to teach (Madge et al. 2014). • Deficit approach focusses on the short comings of international students • Insufficient English • Difficulties participating in class/placement • What if international students are conceptualised as assets to practice? • Intercultural skills • Different 'ways' to enact practice that may be more appropriate for CALD communities? • Opportunities for shared learning w practitioners & other students?
- 9. Program of research 1.Who are international students and CALD students in Australia? 2. Does cultural background, being an international student, or language background predict placement outcome? 3. Explore the nature of international students’ competency development and professional placement experiences, and placement outcomes. 4.Identify strategies to assist international students in placements. 5.Do opportunities exist for clinical educators/facilitators to learn from international students?
- 10. Does being an international student predict placement outcome? 1. Scoping Survey of university based, clinical education coordinators in Australia. • Descriptive information about background, number of international students in 10/12 Australian Speech Pathology programs. • Retrospective cohort: included 3,455 student placements. • Ratings and qualitative competency perceptions of placement performance of international students. 2. Prospective regression analysis to model whether being an international student, being a CALD student, or factors related to English language predict poor placement outcome • 852 students from 3 universities, who contributed 2747 placements between 2011-2013. • At risk = student had required additional university supports during the placement but had subsequently passed; • Required supplementary placement or extension of time on placement and subsequently passed; • OR failed the placement.
- 11. Risk of poor placement outcome • 12.4% international students. • From South-eastern and Eastern Asia. • 41.5% speak English as an Additional Language. • Compared with International students, domestic students: • lower rate of placement failure (x2=4.62, p = .032) • and supplementary placements (x2=26.98, p = 0.000) • and additional placement support (x2=21.021, p = 0.0000). • International students were 1.83 times more likely to have an ‘at risk’ placement outcome than domestic students (p = .01). • English as an Additional Language students were 2.38 times more likely than students with English as a first language (p < 0.001). • “Perceived CALD” did not predict ‘at risk’ placement outcome. • LOTEH did not predict ‘at risk’ placement outcome. Study 1 Study 2
- 12. So, we could blame it on language.... • International students compared with “Perceived CALD” students: • No significant differences in the proportion of EAL students in the two groups→ suggests that factors other than language important for placement outcome. • Acculturative factors like prior education experiences, cultural similarity and fluency in the language of the host country may impact International Students differently to domestic CALD students. • International students may need to undertake greater acculturative adjustment cf domestic CALD students for placements
- 13. Perceptions of international students' placement experience and competency development • Separate focus group interviews of international and domestic students; and clinical educators in Adelaide and Sydney. • 14 FGs in total. • Explored placement experiences, competency and strategies for success
- 14. Themes identified from synthesizing FG studies • Communication skills • Adjustment • Complexity • Positive placement experiences
- 15. Learning theories used to interpret the data • Cognitive Load Theory (Sweller, 1998) • Legitimate Peripheral Participation (Lave & Wenger, 1991) • Workplace Learning (Billett, 2002, 2006, 2014)
- 16. Synthesised findings • International students experience and competency development in placements is complex. • Linked with acculturative adjustments for culture, learning and communication. • Impact students’ ability to manage usual learning expected of all students in placements. • ??? linked to the greater likelihood for international students to have an ‘at risk’ placement outcome. • Supervisors perceived international students’ adjustments and behaviours to increase the complexity of facilitating learning. • Strategies and training opportunities identified to assist international students to adjust for culture and learning in their placements, and to help supervisors to manage this.
- 17. • International students undertake acculturative adjustments to approximate the learning behaviours that they perceive will help them to succeed. • Clinical Educators shape learning and behaviours according to their expectations – grounded in Western learning principles. • •Clinical Educators perceive students who demonstrate Western learning and professional behaviours to be more successful. • When students enact expected behaviours, they are given access to more learning activities in the placement, and provided with greater autonomy. • Students’ acculturative adjustments add to their cognitive load. • Clinical Educators also experience more cognitive load, as they manage and support the acculturative adjustments. • Students’ prior learning, and intercultural knowledge present opportunities for mutual learning for the clinical educator. • Facilitator: CE perception of a positive placement experience • Barrier: CE perceives the placement as challenging – increased cognitive load.
- 18. Hypothesis Students who are undertaking more acculturative adjustments for communication, culture and learning experience more cognitive load for competency development in placements. Adjustments are directed according to the nature of the placement, supervisor style, expectations, learning opportunities afforded. Supervisors experience more cognitive load in facilitating learning for international students who are undertaking more acculturative adjustments. This may impact perceptions of a positive placement, reducing the receptiveness of Supervisors for mutual learning of intercultural skills and knowledge.
- 19. Current research Clinical educators' learning during culturally and linguistically diverse students' health professional placements • Preliminary findings: CEs conceptualise learning from CALD students as transferrable to future students. • No evidence of transfer to CALD populations. • Research that seeks to facilitate health outcomes for CALD communities through facilitating successful CALD student training experiences and opportunities for shared intercultural learning with health practitioners.
- 20. References • Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fielding, J. E., & Normand, J. (2003). Culturally competent healthcare systems: A systematic review. American Journal of Preventive Medicine, 24(3, Supplement), 68-79. doi:http://dx.doi.org/10.1016/S0749-3797(02)00657-8 • Attrill, S., et al. (2012). "Student diversity and implications for clinical competency development amongst domestic and international speech-language pathology students." International Journal of Speech-Language Pathology 14(3): 260-270. • Attrill, S.L., Lincoln, M. and McAllister, S. (2015). International students in speech-language pathology clinical education placements: Perceptions of experience and competency development. International Journal of Speech-Language Pathology, 17(3) pp. 314-324. • Attrill, S., et al. (2016). "Supervising international students in clinical placements: perceptions of experiences and factors influencing competency development." BMC Medical Education 16: 180. • Attrill, S., et al. (2017). "Culturally and linguistically diverse students in speech–language pathology courses: A platform for culturally responsive services." International Journal of Speech- Language Pathology: 1-13. • Bandura, A. (1986). Social foundations of thought and action: a social cognitive theory. USA, Prentice-Hall. • Berger, J. T. (2008). Academic Medicine, 83(null), 100. • Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O. (2003). Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118(4), 293-302. • Billett, S. (2006). "Relational interdependence between social and individual agency in work and working life." Mind, Culture, and Activity 13(1): 53-69. • Durning, S. J., et al. (2012). "The impact of selected contextual factors on experts' clinical reasoning performance (does context impact clinical reasoning performance in experts?)." Advances in Health Science Education 17: 65-79. • Kilminster, S. (2009). Recognising and bridging gaps: theory, research and practice in clinical education. Clinical education in the health professions. C. Delaney and E. Molloy. Australia, Elsevier: 38-49. • Lave, J. and E. Wenger (1991). Situated learning: legitimate peripheral participation. Cambridge, Cambridge University Press. • Mann, K. V. (2011). "Theoretical perspectives in medical education: past experience and future possibilities." Medical Education 45(1): 60-68. • Napier, A. D., Ancarno, C., Butler, B., Calabrese, J., Chater, A., Chatterjee, H., & Woolf, K. (2014). The Lancet, 384(null), 1607. • Nápoles-Springer, A. M., Santoyo, J., Houston, K., Pérez-Stable, E. J., & Stewart, A. L. (2005). Patients’ perceptions of cultural factors affecting the quality of their medical encounters. Health Expectations, 8(1), 4-17. doi:10.1111/j.1369-7625.2004.00298.x • Patton, N., et al. (2013). "Using theories of learning in workplaces to enhance physiotherapy clinical education." Physiotherapy Theory and Practice 29(7): 493-503. • Sweller, J. (2011). Cognitive load theory. Psychology of learning and motivation: cognition in education. J. P. Mestre and B. H. Ross. USA, Elsevier Inc. 55: 37-76. • van Merrienboer, J. J. and J. Sweller (2010). "Cognitive load theory in health professional education: design principles and strategies." Medical Education 44(1): 85-93.
- 21. Questions For further information contact: Dr. Stacie Attrill Flinders University E: Stacie.Attrill@flinders.edu.au P: (08) 72218811 @SAttspeech
Editor's Notes
- I’m going to talk with you today about my research program that is really seeking to make connections between a culturally diverse health workforce and better health outcomes for culturally diverse communities. Specifically, my research is about teaching and learning outcomes for international students and particularly those who are culturally and linguistically diverse, or CALD in clinical placements. My team includes Professor Michelle Lincoln from University of Canberra and Professor Sue McAllister from University of Sydney.
- Firstly who are we talking about when we are talking about CALD students? In our student bodies, we are talking about international and domestic students, who either speak English as an Additional Language or a language other than English at home; For this research we are looking at international students, a group with broad acculturative experiences, who are making many active adjustments for culture and language , and importantly, have different experiences and expectations of health and education practices here in Australia. They’re also a group who can contribute to how we understand health practice and how this might be applied with CALD communities who live here.
- We know that the proportion and diversity of CALD communities here in Australia are growing – at about 50% of the overall population right now, and will probably grow steeply in the next century. Our CALD communities, including second and third generation CALD Australians are experiencing worse health outcomes than those from the majority white, Anglo culture, and we know that this results from differences in their access to healthcare, but also differences in the ways they’re treated by majority culture health professionals. We also know that CALD people often prefer services from CALD health professionals, even when they don’t share a first language. But, people from CALD backgrounds are grossly under-represented in the healthcare professions, and are virtually absent from management or policy making discussions, meaning that their perspectives and needs are poorly represented. So there needs to be change at multiple levels if outcomes are going to change.
- That brings me to my research: We are responding to two assumptions in the literature about how to address these disparities: 1) That increasing the proportion of CALD health professionals will facilitate more access, choice and availability of culturally responsive services. And 2) That CALD professionals and students bring cultural capital to health and education environments; and that opportunities must exist for these CALD clinicians to model intercultural knowledge and skills for all clinicians. Both of these strategies are assumed to increase the availability of culturally responsive services.
- However, there are barriers for CALD students in health professional qualifying programs. They’re noted to experience academic challenges, and it’s likely that these issues are magnified for international students who are often making adjustments for both culture and language. Much of this research focusses on how English proficiency contributes to their academic difficulties, but that there is probably more to it than this. But international students are key to increasing the prominence of CALD clinicians in our communities – about 40% stay following qualification, as well as through opportunities during their training to share their intercultural skills and knowledge.
- However, the less overt finding of research about international students’ academic performance is that their difficulties are often associated with clinical placements. All our health professions have clinical placements as critical for students' competency development. In these placements, students are supervised by clinical supervisors, also known as clinical educators who are also managing complex patient and workplace needs. We know that placements present specific challenges for international students, but the factors underpinning this aren’t known, and workable supports are few and far between.
- What previous research about international students in placements collectively suggests is that they carry a communication load if they are non-native English speakers, and an adjustment load from transitioning from their understanding of culture and learning in their previous health and education experiences at home. Their supervisors, meanwhile, may experience more burden if they need more time to understand the Australian health culture, help with communication skills for practice, or more individualised supervision than other students. Given the number of IS enrolled in health professional programs, and the prominence of clinical placements as part of curricula, research that looks at the learning needs of this group is surprisingly limited, and the strategies are largely impractical.
- And all of this is lensed by the general narrative about international students- they’re a 'problem‘; they need 'remediation' in order to be successful in practice. That they must adjust so that their skills match ours. That the skills they come with – whether these be communication, cultural, approaches to learning and teaching or 'ways to enact practice' are not sufficient and must be fixed. All of this rests the blame with the student, and ignores what they could be positively contributing to our knowledge and practice. Yet, when we look at the ongoing, and recursive health disparities of our CALD communities, perhaps we need to reflect about the insufficiencies of our own ways of enacting practice. In this light, what if international and other CALD students could be reconstructed as the assets that we need to identify different and better ways to enact culturally responsive practice?
- And so it was with this in mind that I embarked on a program of research about international students in health placements, and I’ve largely used speech pathology students as a case study. To date, six studies have comprised this research, including my PhD and two post-doctoral studies. Overall, we’ve aimed to determine whether acculturative factors predict placement performance, and to explore features of international students' learning and experiences in their placements, what responsive supports and scaffolds might work, and what are enablers for placement supervisors to learn from their students’ intercultural skills. I’m not going to go into much detail about each study – rather, will provide you with an overview of the findings and how they relate to each other.
- So we needed to preface our understanding of what happens for international students in placement by first understanding if indeed they had more risk of failing or needing more support. To do this, we did a retrospective scoping study of University clinical placement coordinators in Australia using data from 3,455 placements, and a prospective regression analysis of data from 2747 placements from three universities to model the acculturative factors that predict poor placement outcome.
- And the short answer is yes, being an international student did predict poor placement outcome. Our international students were largely from East and South-Eastern Asia, and almost half spoke English as an Additional language, and they were more likely to fail a placement and more likely to need additional support to complete their placement successfully. In line with research about academic performance, those who spoke English as an Additional Language were most at risk of poor placement outcome. But, students who perceived themselves to be CALD or who spoke English as a first language with another language at home did not have more risk.
- So we could blame everything on English proficiency, except that when we compared the international student group who did predict poor placement outcome with the 'perceived CALD' group who did not, we found that the proportion of English as Additional Language speakers in the two groups were the same. This suggests that other acculturative factors like adjusting for culture and learning differences are likely to affect international students more than local CALD students. But why are these factors impacting?
- To answer this, our third and fourth research questions were about the nature of placement experiences and competency development for international students, and strategies to support this. We conducted 9 focus groups with students and 5 with supervisors so that we could explore both perspectives.
- When we synthesised categories from the student and supervisor focus groups, we identified four overarching themes: communication skills, adjustment, complexity and positive placement experiences.
- In interpreting the focus group data, we used three learning theories to provide different lenses on the international students’ placement experiences and learning. The first was Cognitive load theory which explains how WM processes information, and what happens when too much load is placed on our processing system. It helps to identify what features of the learner or a learning environment might increase cognitive load, and suggests ways to reduce this. Secondly, Lave and Wenger’s theory of Legitimate Peripheral Participation, which talks about how novices develop sociocultural skills and knowledge about a practice community, and how prior skills and knowledge of a learner might impact or shape or change the community that they enter. To participate and progress in a placement, a student starts at the periphery of the community, and must be seen as being a legitimate member of that community to progress. And finally, Billett’s workplace learning theory – which explains how a student’s prior knowledge and learning experiences, and their goals and aspirations, all influence their engagement with learning in a placement.
- So, to summarise the findings, IS’ experience and competency development in placements is complex, and this complexity is linked with the acculturative adjustments they are making for culture, learning and communication, which they are actively enacting to help them succeed in the placement. These extra adjustments may impact their ability to manage the usual learning expected of all students, which may increase their likelihood for an ‘at risk’ placement outcome. Supervisors, meanwhile, also felt the cultural, communication and learning behaviours that many international students demonstrate make it more complex to facilitate their learning. We identified strategies that supervisors can responsively and flexibly implement to help IS to adjust for their placements, and to help supervisors to manage this. But, developing IS’ communication skills for practice was actually perceived as too challenging to manage within the practical and temporal constraints of the placement, and we’ve got some recommendations for universities about this. We also found that IS and supervisors were positive about their experiences, and did identify mutual intercultural skills that developed from interacting and learning together that particularly related to how they might work with CALD students and patients in the future.
- So to add a theoretical take on our findings: International students undertake acculturative adjustments according to what they perceive they need to change to succeed in the placement. When supervisors see students enacting professional or learning behaviours that they expect, they give students more access to learning activities and more autonomy which helps them to demonstrate the complex skills needed to pass the placement. Conversely, when students enact behaviours they don’t anticipate, or that seem unusual, they supervise students more closely, and give them less access to learning activities, which reduces their capacity to demonstrate the skills and autonomy to pass. For international students, the adjustments that they undertake add cognitive load to the already loaded task of competency development that all students must undertake in their placements. Similarly, supervisors experience more cognitive load, as they support international students to enact these adjustments whilst also managing their usual competency development, and all this in the context of managing complex patients and workplace activities. Prior learning experiences and cultural skills and knowledge that international students bring to their placements can present opportunities for mutual learning with supervisors, but only if the placement is perceived as positive. The greater the supervisors’ cognitive load, especially where learning challenges exist, the more barriers for them to undertake new learning, and the less receptive they may be to intercultural learning where this is the case.
- So, we’ve hypothesised that students undertaking more acculturative adjustments to participate in their placements experience greater cognitive load for competency development than students undertaking less, and this places them at risk of poor placement outcomes. Conversely, if their supervisors are also experiencing more cognitive load, they may be less receptive to shared opportunities for learning intercultural skills and knowledge.
- So now, to close the loop, my current research is looking at opportunities for mutual learning of intercultural skills between students and supervisors, and how these skills might transfer to practice with CALD communities. We are interested in the moments of learning for supervisors, and how they perceive they might apply this in the future. Our preliminary findings suggest that supervisors conceptualise this learning can be transferred to other CALD students, but not to work with CALD populations – so there is still much to be done in this space, and much more to be done to reverse the health disparities of our CALD communities.