Fostering a Culture Shift Assessment of Competence

Cynthia Johnston

a,b,*

,E.Ann Mohide

b,1

a City of Hamilton Public Health Services,1Hughson Street,N.,Hamilton Ontario,Canada L8R 3L5b

McMaster University,School of Nursing,Hamilton,Ontario,Canada L8N 3Z5

Accepted 13August 2008

KEYWORDS

Clinical education;Preceptorship;Diversity;

Role modelling

Summary

Nursing preceptors are challenged by a broad set of teaching–learning

diversity issues that are related to their role as clinical teachers of senior nursing students in clinical settings.A lack of awareness and understanding of these diver-sity issues may contribute to preceptor-student miscommunication and conflict.Ultimately,these factors can impact on the extent to which the educational objec-tives are achieved.Most of the health sciences literature focuses on diversity and patient care,and unfortunately,the literature that does address diversity and learning primarily examines the influence of culture and language in classroom edu-cation.Few resources are available to guide preceptors as they engage in ‘‘real life’’real-time clinical learning encounters.To assist preceptors with their teaching strategies and skills,a diversity and learning workshop was developed to support preceptors in their critical role as both clinical teachers and role models.A diversity and learning framework is suggested and applied to the set of teaching–learning diversity issues.

c 2008Elsevier Ltd.All rights reserved.

Introduction

As preceptors,direct care nurses play a critical role in the education of senior professional nursing stu-

dents.In this capacity,as both clinical teachers and role models,preceptors need to recognize educational diversity issues that can impact on teaching–learning encounters.While preceptors can access considerable literature addressing diversity within learning,usually the foci are eth-nicity (Amaro et al.,2006;Gardner,2005;Villarr-uel et al.,2001;Yoder,2001)and language (Abriam-Yago and Kataoka-Yahiro,1999;Malu and Figlear,2001;Xu et al.,2004).Furthermore,the literature is directed mainly at classroom learning

1471-5953/$-see front matter

c 2008Elsevier Ltd.All rights reserved.doi:10.1016/j.nepr.2008.08.005

Corresponding author.Address:City of Hamilton Public Health Services,1Hughson Street,N.,Hamilton Ontario,Canada L8R 3L5.Tel.:+19055462424x3029;fax:+19055461019.E-mail address:Cyndy.Johnston@hamilton.ca 1

Tel.:+19055259140x22267;fax:+19055700667.

Nurse Education in Practice (2009)9,

340–347

www.elsevier.com/nepr

Nurse

Education in Practice

Preceptors require awareness of diversity issues in teaching–learning encounters,as well as the educa-tional content to address educationally-related diversity.Just as clinicians use diversity models and frameworks to guide patient management,pre-ceptors would benefit from the use of a diversity and learning framework in clinical education encounters. This paper describes a preceptor workshop address-ing diversity as it relates to the clinical education of senior undergraduate nursing students.A diversity and learning framework that supports preceptors in their role as clinical teachers is introduced.

The BScN Preceptorship Program

In2005,McMaster University School of Nursing developed a BScN Preceptorship Program in collab-oration with a BScN Program partner,Mohawk Col-lege School of Nursing,to ensure high quality preceptorship experiences for their senior level nursing students.The important contribution of preceptorship as an educational model for profes-sional practice development and the need to sup-port the members of the preceptorship triad (student,preceptor and nursing faculty member) provided the rationale for the Program’s creation. Specifically,the Program’s mission is to strengthen senior undergraduate clinical nursing education, foster the professional development of the triad members,and enhance senior student preparation for professional practice.

The Preceptorship Program’s framework utilizes Bandura’s(1977)social learning theory as a basis for the two major preceptor roles,one as active clinical teachers and the other(often unrecog-nized,but critical)as role models.Social learning theory posits that learning occurs by observing and imitating the behaviours of another.However, before staff nurses act as models,they need to be aware of the behaviours that will bring about posi-tive change and also be able to articulate values, attitudes,and ways of thinking and behaving.Role modelling also involves encouraging learners to re-flect upon what they have observed and assisting them to refine their behaviours through feedback and discussion(Bandura,1977).

One activity mandated by the Preceptorship Program is the annual offering of a set of preceptor workshops,including an introductory workshop and seven advanced workshops.The advanced work-shop addressing diversity and learning was devel-oped in response to preceptors’perceived diversity-related education issues,such as inter-generational learning encounters and student abil-ities.The Program viewed this topic as a priority because a lack of awareness and understanding about differences between individuals can result in miscommunication and conflict(Abrums and Leppa,2001).In fact,Myrick et al’s(2006)study examining conflict within preceptored education highlighted the perceived impact that clinical teachers’or supervisors’actions can have on the professional identities and practices of future health professionals.Certainly there are many fac-tors leading to conflict in a preceptored relation-ship;however,the preceptor workshop sought to focus on education-related differences that can re-sult in conflict and overwhelm the goal of a teach-ing–learning encounter.

Diversity framework

In searching for an appropriate framework to examine and respond to diversity and learning is-sues,a number of selection criteria were identi-fied.The framework or model needed to be:(i) compatible with the experiential learning nature of preceptorship,(ii)easily applied by preceptors with different levels of teaching experience,(iii) related to diversity issues encountered in the nurs-ing care of diverse populations,but applicable to examination of educational issues,such as,ability and learning,(iv)oriented towards action and(v) amenable to the use of reflection by learners and teachers engaged in experiential learning.The Inequalities Imagination Model(Hart et al.,2003) met these criteria.

While the model required adaptation to address the specificity of teaching–learning diversity is-sues,a number of Hart et al’s(2003)assumptions underlying the model were relevant to the adapta-tion:that a willingness to learn about diversity is required to become responsive;that individuals can use the model whether they are highly skilled or novice in dealing with diversity issues;and that becoming responsive to diversity is an ongoing and continuous process.

Adaptations in Hart et al’s model(2003)resulted in the Diversity and Learning Framework(Fig.1). The framework is centred on the situation in which it would be applied,the RN-nursing student’s learning encounter in the clinical setting.This

Addressing diversity in clinical nursing education:Support for preceptors341encounter recognizes the unique aspects that each individual brings to the situation and the opportu-nity for reciprocal learning.Surrounding the frame-work are typical teaching–learning diversity issues connected to other components of the model by a circle that is dashed to represent the notion of one’s willingness to address teaching–learning diversity or openness to diversity.

As Hart et al.(2003)commented,without being open and receptive to issues of difference,it would not be useful to initiate the activities within the framework.Assuming that a preceptor possesses openness to diversity,specific activities can be carried out sequentially,moving clockwise from awareness to reflection.A preceptor’s awareness of an issue requires the examination of personal values and beliefs and appreciating those of others. This is important as one may be unaware of the val-ues and beliefs that may be embedded in actions and language.A preceptor can develop awareness by being open to learning about teaching–learning differences and role model this important profes-sional attribute.Being aware of possible differ-ences includes recognizing uniqueness,developing an understanding and respect for others,valuing multiple ways of knowing and creating inclusive learning environments(Decker-Lardner,2003; Gardner,2005;Omeri et al.,2003).A foundational activity involves the development of a knowledge base about teaching–learning diversity issues by identifying learning gaps,acquiring information, either formally or informally,and seeking re-sources that can inform and expand one’s world view(Hart et al.,2003).In order to anticipate learning encounters with a student,a s kill set is re-quired that will assist a preceptor to become responsive and create an inclusive learning envi-ronment.Examples include getting to know the preceptee and using the preceptee’s experience as background to personalize teaching,consis-tently providing feedback on performance and helping the student to acquire resources,in associ-ation with the nursing faculty member(Williams and Calvillo,2002).

The framework’s action activity involves taking opportunities to challenge and act on potential inequalities for a given teaching–learning issue (Hart et al.,2003),but also might include engaging in a teaching–learning encounter differently or using a different teaching strategy.Reflection on practice is required to re-visit beliefs,thoughts, and feelings.Reflection also increases one’s expe-riential teaching knowledge,expands one’s world view,and serves to facilitate self-evaluation of one’s skills and actions taken,which can maximize the transferability of the preceptor’s learning to

342 C.Johnston,E.A.Mohidenew situations.Opportunities to reflect with stu-dents and peers provide‘‘teachable moments’’to learn more about one’s patterned responses,so that the next encounter can be approached with greater awareness and appropriate actions.

The Diversity and Learning Workshop

In developing the workshop,the concept of diver-sity within the teaching–learning encounter was recognized to encompass much more than ethnicity and language,also covering ways of being,know-ing,and doing that contribute to individual unique-ness.As a result,a broad definition of diversity was used to guide the workshop development,whereby important facets that define each person as being different from one another,and therefore unique, were considered(e.g.,age,gender,spiritual be-liefs,socio-economic status,and sexual orienta-tion)(Canadian Nurses Association,2004).

The workshop objectives were to:(i)explore the nature of diversity as it relates to the undergradu-ate professional practice education of senior stu-dents,(ii)examine some key diversity issues related to modern learners and teachers,(iii)de-velop an inventory of strategies for examining and becoming responsive to issues of diversity, and(iv)identify a variety of resources to help pre-ceptors optimize the educational experience of students.(It was an expectation that preceptors participating in the workshop would understand their own learning styles and preferences,as this fundamental knowledge is required in teaching–learning encounters involving others.)

A variety of teaching strategies were used to en-hance the preceptors’ability to respond to educa-tional diversity issues.Because awareness is the first step to becoming responsive,we encouraged preceptors’to reflect on their values,beliefs and assumptions through the use of a buzz group exer-cise,where preceptors discussed positive or nega-tive teaching–learning encounters,either as former students or as teachers.This created an environment that engaged preceptors in subjective knowing,where they shared their lived experiences and listened to others’perspectives,and con-nected knowing,where they explored different perspectives and their educational implications (Stanton,1996).Using discussion and analysis of problem-based scenarios,preceptors applied and critiqued the framework.Throughout the work-shop,preceptors were encouraged to share their stories about teaching–learning diversity encoun-ters;pose questions to the group about how to ap-ply ideas and problem solve issues;and to explore how their assumptions might influence the execu-tion of the clinical teacher/role modelling roles. Role playing was used to enhance skill develop-ment,to the extent that classroom education can achieve skill development.Preceptors were encouraged to develop their responsiveness by using the framework as a guide to identify their learning gaps.Further to this,the concept of becoming responsive to diversity was highlighted. Teaching–learning diversity issues

The workshop addressed diversity issues with impli-cations for education and learning(see Fig.1)rang-ing from bio-psycho-social factors to broader issues,including demographic and socio-economic trends.

Abilities

Differences in ability between a preceptor and stu-dent may involve the cognitive,emotional,devel-opmental or physical domains.For example,in the cognitive or intellectual domain,differences may relate to the way in which individuals learn. In the emotional domain,differences may involve individual psychological responses to stress or reac-tions to new situations.Varying educational back-grounds and life experiences may contribute to developmental differences,while deficits in motor or sensory abilities may contribute to differences in the physical domain.All of these may affect how learning situations should be approached,planned, and enacted.

A preceptor can respond to differences in an individual’s abilities using the process of accommo-dation;where a student is provided with opportuni-ties to be successful,while recognizing and responding to the individual’s needs(Sowers and Smith,2002).For example,a student with an iden-tified learning impairment,such as dyslexia,may experience difficulties with short term memory, motor skills or visual processing which can be exac-erbated by task demand and stress level(Roberts and Mitchell,2005).In this situation,a preceptor can respond by presenting an overview of the stu-dent’s tasks and activities before discussing de-tails,reviewing protocols and procedures,and helping students to prioritize the work at hand (Sanderson-Mann and McCandless,2006).In other situations,a preceptor can address differences in ability by providing learning opportunities that are consistent with the student’s learning style and developmental level.This may require that

Addressing diversity in clinical nursing education:Support for preceptors343the preceptor alter a preferred personal teaching style.

Some situations will require consultation with the nursing faculty member to provide access to re-sources and services that will assist students to achieve course and specific learner objectives. One example is the process of accommodation; however,this process does not reduce the level of expectations of the educational program and the student needs to have the ability to achieve the educational outcomes(Sowers and Smith, 2002).In Ontario,Canada,the Accessibility for Ontarians with Disabilities Act(AODA)requires employers to provide access,through measures that remove or prevent barriers,to all individuals with disabilities,defined as any degree of physical, mental(including emotional),or learning impair-ment(Government of Ontario,2005).

Age and age cohort

Differences in age and age cohort can create edu-cational diversity issues between a preceptor and preceptee.With respect to age,it is important to note that ageism can work both ways.On the one hand,an older nurse may be labelled as‘‘over the hill’’or‘‘outdated’’.On the other hand,a young nurse may be labelled as‘‘green’’or‘‘na-ı¨ve’’.Either of these stereotypic portrayals can serve to diminish the unique contributions that an individual brings to the learning encounter.

While it is important not to make generaliza-tions,individuals from a particular age cohort may share similar beliefs,values,abilities,and skill sets that are shaped by experience and the pre-dominant social and political influences of their youth.These differences may be unappreciated or overlooked by individuals from different age cohorts.

The youngest of recent students,often referred to as‘Gen Y’,are optimistic and assertive,investi-gative by nature,technologically proficient,and accustomed to collaboration and networking. Although‘Gen Y s’mayfind it tedious to focus on one task,preferring to‘multi-task’,they under-stand the need for career related skills and train-ing.However,they do not expect employment to be the sole source of meaning in their lives(John-son and Romanello,2005;Stewart,2006).Con-versely,the cohort nearing retirement,often referred to as the‘Baby Boomers’,are driven and dedicated and loyal to their employers.They work relentlessly to pursue their goals and want their work to be recognized and valued.‘Baby Boomers’equate work with self worth(Johnson and Roma-nello,2005;Stewart,2006).While one might auto-matically presume that a‘Gen Y’would be the student,and the‘Baby Boomer’would be the pre-ceptor,more and more,the reverse also may be true.

At a recent Diversity and Learning Workshop, one‘Boomer’preceptor expressed concern that her‘Gen Y’preceptee questioned the value of pol-icies and procedures and was not willing to stay overtime to complete her work.The preceptor felt that these behaviours were unprofessional and dis-respectful.Another preceptor at the session com-mented that her‘Gen Y’student had taught her how to search electronic databases tofind the best evidence about a clinical topic.Through encoun-ters that involve inter-generational differences, preceptors can create opportunities to discuss the unique abilities and skills that each contributes to learning.A‘Boomer’preceptor can validate the technological abilities of the‘Gen Y’student and encourage the‘Gen Y s’collaborative nature by providing opportunities to share expertise with team members and contribute to team meetings (Stewart,2006).Likewise,a‘Boomer’preceptor can share important professional values,model important behaviours and be open to learn new ways of approaching work(Stewart,2006). Language

Language has been identified as the primary barrier to learning in ethnically diverse students.Students whosefirst language is not English have perceived faculty and peers as interpreting their language dif-ficulties as negative reflections of their intelligence (Villarruel et al.,2001).Furthermore,English as a second language(ESL)students have experienced difficulties in clinical settings related to the use of professional terminology,introducing them-selves,understanding patient requests and provid-ing explanations,(San Miguel et al.,2006).These issues can become pronounced when a student experiences the pressures of a fast paced environment.

A preceptor may require the assistance of a nursing faculty member when working with an ESL student,but prior to enlisting assistance,a precep-tor can employ some strategies to create respon-sive and supportive learning environments.For example,a preceptor can role play different ways that an ESL student can initiate therapeutic discus-sions with clients(Abriam-Yago and Kataoka-Ya-hiro,1999;San Miguel et al.,2006).Additionally, preceptors can avoid the use of colloquialisms, speak at a reasonable pace and ask students to

344 C.Johnston,E.A.Mohiderecount information for comprehension(Omeri et al.,2003;San Miguel et al.,2006).

Culture

Cultural differences can have a significant impact on the teaching–learning encounter.In North America and other westernized countries,the cul-ture is considered low-context,meaning that indi-viduals are motivated by their own preferences and communication is explicit.Conversely,Asian and Hispanic cultures are considered high-context, where individuals are motivated by strongly reinforced societal duties and communication is implicit(Xu et al.,2001).Students from non-west-ernized societies who are unfamiliar with a low-context culture have been reported to experience isolation and stress related to differences in cul-tural practices and gender roles,perceptions of authorityfigures and the need for constant adapta-tion(Burnard,2005;Xu and Davidhizar,2005).

Another preceptor at a workshop provided an example of an Asian preceptee’s belief in deferral to authorityfigures.Even though the preceptee knew that a particular policy did not reflect current evidence,the student deferred to a senior nurse’s support of the outmoded policy.To respond to cul-turally diverse student’s needs,a preceptor can take opportunities to learn about and be sensitive to different world views,provide opportunities for the student to share experiences,beliefs and values in a safe learning environment,clarify the expectations of the dominant culture,and identify a role model from a similar background who can articulate how to bridge the cultural gap in the work place(Yoder,2001).

Gender

In2004,male nurses representedfive percent of all nurses in Canada(Canadian Nurses Association, 2005).Although men are increasingly choosing pro-fessional nursing as a career and are advancing fas-ter and attaining higher positions than their female counterparts(International Council of Nurses, 2004),barriers for male nursing students cannot be overlooked.Perceived barriers have been iden-tified,such as the lack of role models and lack of curricular content addressing communication style differences between men and women(O’Lynn, 2004).

Many preceptors at the workshop identified clin-ical challenges experienced by male nursing stu-dents,such as,refusal of care by the elderly, being treated differentially by staff(sometimes more positively)than female students,and being mistaken for medical students or residents.A pre-ceptor can create an inclusive environment for a male nursing student by providing opportunities to debrief about gender-related nursing experi-ences with clients and other team members,create learning opportunities that will assist the student to manage situations as described above(e.g.,role playing scenarios with the student),and identify male role models among the staff and faculty who can provide job shadowing opportunities and guidance.

Sexual orientation

Failure to recognize factors that contribute to indi-vidual uniqueness can result in discrimination and lack of opportunity.A recent study exploring the experiences of gay students and faculty in their daily campus lives found that the incidence of homophobia was relatively rare,but that the inci-dence of heterosexism,or the social structures and cultural attitudes that systematically privilege heterosexuals,was pervasive(McMaster University, 2001).A preceptor can model responsiveness to is-sues of sexual orientation of the student by being aware of and challenging discriminatory com-ments,identifying the sources of bias(for exam-ple,a lack of knowledge,conflict of personal values,or previous experiences),and by using gen-der-neutral language to create an inclusive learn-ing environment.(Long and Lindsey,2004).A preceptor also can seek guidance from a nursing faculty member to provide supports to a student through resources,such as campus student centres.

Socio-economic status

The high costs of education and a variety of com-peting demands can create barriers to student learning.Students depending on scholarships or bursaries need to maintain grade averages to as-surefinancial assistance in the future.Other stu-dents may need to maintain jobs while attending school or may be required to care for young,ill or elder family members due tofinancial constraints. These factors can contribute to enhanced stress, making it difficult for a student to focus on clinical learning.If a preceptor detects that the student is unfocused,inconsistent in performance,or unduly stressed,it may be helpful to create opportunities to discuss the described behaviours.This may open up a dialogue that can lead to problem-solving.A nursing faculty member,in collaboration with a

Addressing diversity in clinical nursing education:Support for preceptors345

preceptor,can help a student to accessfinancial information and provide referral to counselling ser-vices for time and stress management. Spirituality

Not infrequently,students in clinical practice may experience conflicts between spiritual values or religious practices and obligations of professional duty that can impede learning.For example,a stu-dent who is a Jehovah’s Witness may feel con-flicted if required to initiate or monitor a blood transfusion.As another example,a student cele-brating Ramadan cannot eat or drink anything dur-ing daylight hours,which may lead to fatigue during the workday.Understanding a student’s spiritual and religious beliefs can help a preceptor to work with the student to explore personal values and beliefs in relation to client care.In addition, the preceptor can play an instrumental role in clar-ifying professional responsibilities and assisting the student to meet professional standards by linking the individual to staff of similar backgrounds who can articulate how the staff members have bridged their differences in personal and professional val-ues(Yoder,2001).

Conclusion

No one questions whether nurses working in multi-cultural contexts require specialized knowledge and skill sets to provide culturally competent and responsive care to their clients.Likewise,in an analogous situation,direct care nurses who pre-cept senior nursing students require specialized knowledge and a set of skills related to diversity and learning in order to be competent and respon-sive clinical teachers and role models.Nursing fac-ulty and clinical educators working with preceptors should view this topic as a priority for preceptor education.

Preceptors need to understand their own beliefs and values about educationally-related diversity is-sues.By developing awareness,knowledge,and skills,preceptors can identify educationally diverse student issues and respond to the issues in a posi-tive manner to create positive and inclusive teach-ing–learning encounters.Effectively applying the Diversity and Learning Framework can influence the process of the teaching–learning encounter, and ultimately,the learning outcomes.Further-more,the role modelling opportunities created through sensitive and responsive teaching by pre-ceptors may positively influence diversity behav-iours of neophyte nurses making the transition from the role of student to professional. References

Abriam-Yago,K.,Kataoka-Yahiro,M.,1999.The Cummins model:a framework for teaching nursing students for whom English is a second language.Journal of Transcultural Nursing 10(2),143–149.

Abrums,M.,Leppa, C.,2001.Beyond cultural competence: teaching about race,gender,class and sexual orientation.

Journal of Nursing Education40,270–275.

Amaro,D.,Abriam-Yago,K.,Yoder,M.,2006.Perceived barriers for ethnically diverse students in nursing programs.Journal of Nursing Education45(7),247–254.

Bandura,A.,1977.Social Learning Theory.Prentice Hall,NJ. Burnard,P.,2005.Issues in helping students from other cultures.Nurse Education Today25,176–180.

Canadian Nurses Association,2005.2004Workforce Profile of Registered Nurses in Canada.Ottawa,Author.

Canadian Nurses Association,2004.Promoting Culturally Com-petent Care.Ottawa,Author.

Decker-Lardner,E.,2003.Approaching diversity through learn-ing communities.Washington Center Occasional Paper, Winter No.2,pp.1–12.

Gardner,J.,2005.Barriers influencing the success of racial and ethnic minority students in nursing programs.Journal of Transcultural Nursing16(2),155–162.

Government of Ontario,2005.The Accessibility for Ontarians with Disabilities Act.(retrieved

07.12.07).

Hart,A.,Hall,V.,Henwood,F.,2003.Helping health and social care professionals to develop an inequalities imagination:a model for use in education and practice.Journal of Advanced Nursing41(5),480–4.

International Council of Nurses,2004.Minutes of the Workforce Forum(September).Wellington,New Zealand.

Johnson,S.,Romanello,M.,2005.Generational diversity.Nurse Educator30(5),212–216.

Long,J.K.,Lindsey,E.,2004.The sexual orientation matrix for supervision:a tool for training therapists to work with same sex couples.Journal of Couple and Relationship Therapy3 (2/3),123–135.

Malu,K.,Figlear,M.,2001.Six active learning-based teaching tips:promoting success for ESL nursing students.Nurse Educator26(5),204–208.

McMaster University,2001.Recognizing Sexual Diversity at McMaster University.Hamilton,Ontario,Author.

Myrick, F.,Phelan, A.,Barlow, C.,Sawa,R.,Rogers,G., Hurlock, D.,2006.Conflict in the preceptorship orfield experience:a rippling tide of silence.International Journal of Nursing Education Scholarship3(1).Article6.

O’Lynn,C.E.,2004.Gender-based barriers for male students in nursing education programs:prevalence and perceived importance.Journal of Nursing Education43(5), 229–236.

Omeri, A.,Malcolm,P.,Ahern,M.,Wellington, B.,2003.

Meeting the challenges of cultural diversity in the academic setting.Nurse Education in Practice3,5–22.

Roberts, D.,Mitchell, D.,2005.Problem-based learning in nursing education:an unexpected problem for students with dyslexia.Nurse Education in Practice5,328–332.

346 C.Johnston,E.A.MohideSanderson-Mann,J.,McCandless,F.,2006.Understanding dys-lexia and nurse education in the clinical setting.Nurse Education in Practice6,127–133.

San Miguel, C.,Rogan, F.,Kilstoff,K.,Brown, D.,2006.

Clinically speaking:a communication skills program for students from non-English speaking backgrounds.Nurse Education in Practice6,268–274.

Sowers,J.,Smith,M.,2002.Disability as difference.Journal of Nursing Education41(8),331–332.

Stanton,A.,1996.Reconfiguring teaching and knowing in the college classroom.In:Goldberger,N.R.,Tarule,J.M.,Clin-chy,B.M.,Belenky,M.F.(Eds.),Knowledge Difference and Power:Essays Inspired by Women’s Ways of Knowing.

BasicBooks,NY,pp.25–56.

Stewart,D.,2006.Generational mentoring.Journal of Contin-uing Education in Nursing37(3),113–120.Villarruel, A.,Canales,M.,Torres,S.,2001.Bridges and barriers:educational mobility of Hispanic nurses.Journal of Nursing Education40(6),245–251.

Williams,R.,Calvillo, E.,2002.Maximizing learning among students from culturally diverse backgrounds.Nurse Educa-tor27,222–226.

Xu,Y.,Davidhizar,R.,2005.Intercultural communication in nursing education:when Asian students and American faculty converge.Journal of Nursing Education44(5),209–215. Xu,Y.,Lippold,K.,Gilligan,A.,Posey-Goodwin,P.,Broome,B., 2004.A model for enhancing intercultural communication in nursing education.Home Health Care Management and Practice17(1),28–34.

Yoder,M.Y.,2001.The bridging approach:effective strategies for teaching ethnically diverse nursing students.Journal of Transcultural Nursing12(4),319–325.

Available online at www.sciencedirect.com

Addressing diversity in clinical nursing education:Support for preceptors347