Using critical incident technique to promote students reflections skills in a transatlantic nurse education project Dr. Kim A. Critchley, University of Prince Edward Island Canada Dr. Liisa Koskinen, Savonia University of Applied Sciences Finland

International Project Inequalities in Access to Health Care for Rural Communities – Funded through Canada – EU Program for Cooperation in Higher Education and Training (October 2004 – September 2007)

International Partners Canada Canada Mount Royal College Calgary – Pam Nordstrom and Maureen Mitchell Mount Royal College Calgary – Pam Nordstrom and Maureen Mitchell Universite de Moncton – France Chasse and France Marquis Universite de Moncton – France Chasse and France Marquis University of Prince Edward Island – Kimberley Critchley and Barbara Campbell University of Prince Edward Island – Kimberley Critchley and Barbara Campbell EU EU England, Bournemouth University – Ann Hemingway and Eileen Richardson England, Bournemouth University – Ann Hemingway and Eileen Richardson Sweden, Uppsala University – Clara Aarts and Eva Bergknut Sweden, Uppsala University – Clara Aarts and Eva Bergknut Finland, Savonia University of Applied Sciences – Liisa Koskinnen Finland, Savonia University of Applied Sciences – Liisa Koskinnen Estonia, Tallinn Health College – Tiina Johansoo Estonia, Tallinn Health College – Tiina Johansoo

Project Objectives To foster student exchange in different health care disciplines. To foster student exchange in different health care disciplines. To establish a network of scholars and practicing health care professionals working toward the enhancement of joint curricula. To establish a network of scholars and practicing health care professionals working toward the enhancement of joint curricula. To promote increased cooperation and exchange of ideas among the partner communities. To promote increased cooperation and exchange of ideas among the partner communities.

Academic Opportunities Increase student mobility Increase student mobility -from October 2004 to September 2007, 24 EU and 40 Canadian students would undertake an exchange visit for 12 weeks. Enhancement of joint modules of training in association with the partner institutions and communities. Enhancement of joint modules of training in association with the partner institutions and communities. Observation of all involvement in International work methods and culture. Observation of all involvement in International work methods and culture.

Project Outcomes Seamless credit transfer for students among consortium partner institutions. Seamless credit transfer for students among consortium partner institutions. Faculties working together in the enhancement of new joint curricula. Faculties working together in the enhancement of new joint curricula. Opportunities for students to work toward achieving proficiency in a second language. Opportunities for students to work toward achieving proficiency in a second language. Web-based joint training. Web-based joint training.

Project Outcomes (cont) Development of a model for the professional recognition and certification of programs. Development of a model for the professional recognition and certification of programs. Increased cross-cultural understanding through student mobility and on-line communication. Increased cross-cultural understanding through student mobility and on-line communication. Stimulated interest among health care students in foreign language and cross-cultural study. Stimulated interest among health care students in foreign language and cross-cultural study. Greater understanding of the strengths of each consortium partner and opportunities to share resources. Greater understanding of the strengths of each consortium partner and opportunities to share resources. Opportunities for students and faculty to work and conduct research. Opportunities for students and faculty to work and conduct research.

Opportunity for Research This presentation presents one example of research conducted as a result of the Canada-EU Mobility Project. This presentation presents one example of research conducted as a result of the Canada-EU Mobility Project.

Critical incident technique Originates from the 1950s (John Flanagan) Originates from the 1950s (John Flanagan) Is a learning/teaching method Is a learning/teaching method Is a research data collection method Is a research data collection method

CRITICAL INCIDENT ANALYSIS RECORD SHEET (for EU/Canada exchange students) Sit down at least three times during your exchange trip and choose one critical incident that has taken place recently and explore it in detail. Critical incidents are brief descriptions written by learners about meaningful events in their lives (Brookfeld 1990). Any experience you encounter during your exchange trip may be a critical incident and therefore a situation you can reflect upon. In the other words: incidents happen but a critical incident is produced by the way you look at a situation; a critical incident is your interpretation of the significance of the event. Here are some key steps for organising youre reflecting and writing.

1 Identify the event or occurrence with as much specificity as possible - the problem to be solved, issues involved, etc. You may not have precise ideas on this when you start writing. Just start writing. 2 Describe the relevant details and circumstances surrounding the event so that you and the tutor who reads your entry will understand what happened. What? When? How? Why? Where? 3 List the people involved, describe them and their relationship to you and to each other. 4 Describe your role in the situation - what you did, how you acted. 5 Analyse the incident. How well or badly did you understand the situation? How did you handle it? What would you do differently the next time? Why? 6 Analyse this incident in terms of its impact on you and explain why you view it as critical in relation to rural inequalities in health or a specific area of the Ottawa Charter. How does it relate to your particular objective(s)? What have you learned from the experience? How has your perspective on your own role and that of others been changed and/or reinforced?

Can critical incidents method be used in educating reflective practitioners in nursing? The method The method –Supports learners critical thinking and experiential learning (Niemi 2003, Mikkonen 2005) –Helps learners personal (Silkelä 2001; Merikivi 2003) and professional development (Turunen 2002) –Assists learners integration of nursing theory into practice (Koskinen, Jokinen & Mikkonen 2007) –Improves learners reflection skills (Koskinen et al 2007)

The study Aim: Aim: –To describe students learning from the incidents –To stimulate discussion on the usefulness of the method in intercultural nursing education Data collection Data collection –Critical incidents (n=92) written by 18 Canadian and 13 British, Estonian, Finnish and Swedish students (n=31) Data analysis Data analysis –Stage 1: data reduction in seven research centres. The data were in English, Estonian and Swedish. –Stage 2: data reduction, data display, conclusion and verification (Miles & Huberman 1994). The data were in English.

Results: The chosen incidents were contexts, events, situations or experiences that were unfamiliar in comparing to the familiar that were unfamiliar in comparing to the familiar that either showed examples of lack of cultural awareness in care or demonstration of culturally sensitive care that either showed examples of lack of cultural awareness in care or demonstration of culturally sensitive care that either showed examples of good nursing care or lack of good nursing care that either showed examples of good nursing care or lack of good nursing care that were pivotal both personally and professionally the extreme as life altering occurrences that were pivotal both personally and professionally the extreme as life altering occurrences that were related to cultural differences that interfere with the students moral values, beliefs, communication abilities and the professionalism in giving nursing care that were related to cultural differences that interfere with the students moral values, beliefs, communication abilities and the professionalism in giving nursing care

Importance of cultural awareness of health care professionals Impact of income, social status, and rural issues in inequalities in health and well-being Impact of lifestyle in health and well-being Dilemma of good/bad; right/wrong in health care (ethical issues) Experiencing particular clinic, programme, service system or method Witnessingunacceptable/warm nurse-patient interaction Impressive personal cultural experience Personal confusion in a difficult and unexpected nursing situation Dress code and safety nursing practices Experiencing communication and culture barrier in Estonia, Finland and Sweden Cultural differences in nursing role and nurses awareness and knowledge of health promotion and sickness prevention strategies EU students Both students Canadian students Table 1. Learning areas the chosen incidents were related with.

Results: In their critical incidents the students showed increased awareness about personal and professional self and own emotions about personal and professional self and own emotions about the importance of non-verbal communication in nursing care about the importance of non-verbal communication in nursing care about cultural differences in nursing role and nursing care about cultural differences in nursing role and nursing care about cultural differences in health programmes, services and methods about cultural differences in health programmes, services and methods about societal inequalities about societal inequalities

Implications for intercultural nursing education Critical incident method can be used in fostering nursing student learning and reflection skills in the context of intercultural education Critical incident method can be used in fostering nursing student learning and reflection skills in the context of intercultural education 1.Make sure that the learning objectives are shared between the project partners and students before they leave and throughout the exchange – more discussion and support on what to expect 2.Increase dialogue about each incident either with the home or host instructor 3.Extend the time spent in each clinical and community setting – more time to bridge the cultural and language barrier and move from observer to the actual patient contacts

Implications… 4.Possibly owing to the shortness of the intercultural visits, the students viewed host culture s health service either through rose-tinted spectacles or negative eyes. These can be seen as consistent with the phenomenon of superiority or reversal in Bennetts (1993) study of intercultural sensitivity – instructors might be valuable for recognizing this phenomenon, in order to be able to encourage further cultural self-examination among the students

To Conclude Students were able to participate, enjoy and learn from this cultural exchange including the critical incident writing Students were able to participate, enjoy and learn from this cultural exchange including the critical incident writing