Nurse Education Today 34 (2014) 1417–1419
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Contemporary Issues
East meets West in reflective practice Keywords: Reflective practice Nursing Education Cultural Eastern Western
Introduction Reflective Practice Reflective practice is a well-established concept in the education of professionals (Boud, 2010). The ability to reflect in and on practice is recognized as a crucial professional skill (Schön, 1987). Reflective practice is identified as assisting bridge the theory-practice gap by connecting what is taught about a theory and what is delivered in practice (Asselin, 2011) enabling the linking and reinforcement of theoretical and practical knowledge (Hatlevik, 2012). Reflective practitioners make this possible by utilizing a cyclical learning process; reflecting on past experiences in order to gain new knowledge about their practice and themselves as nurses (Johns and Watson, 2000). Learning from experience using reflective practice has benefits for nurses when applied in clinical practice and education settings. Reflection is used as a means of promoting the professional development of both student and practice nurses (Paget, 2001). Reflection assists student nurses to: develop skills in dealing with personal emotions that occur during clinical practice (O'sullivan et al., 2012), better understand and increase their ability to solve problems in the clinical setting (Lie et al., 2010), and develop critical thinking analysis skills (Asselin, 2011). Reflective practice also provides a framework for designing graduate nursing curricula (Horton-Deutsch et al., 2012). This paper uses four dimensions of Hofstede (2011) framework to explore the influence of culture on reflective practice in Western and Eastern nursing education and the implications this has for the future implementation of reflective practice in eastern nursing education. The Influence of Culture in Reflective Practice Reflective practice has its origins and is predominantly used in Western countries (Reynolds, 2011) due to certain cultural characteristics often being present and contributing to reflective practice, for example, individualism and objectivity (Hofstede, 2011). Nevertheless, the use of reflective practice in non-Western countries is growing in prominence among scholars (Stockhausen, 2007). A discussion is needed on whether it is important to consider a country's cultural characteristics prior to the implementation of reflective practice into nursing education and practice. Kawashima and
http://dx.doi.org/10.1016/j.nedt.2014.08.007 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Petrini (2004) claim that differences in Western and Eastern cultures may create conflict that impact nursing education, particularly an individual's way of thinking. Western knowledge which has been used in Japan is not sensitive to Japanese language, culture, and population characteristics (Stockhausen and Kawashima, 2002). While Hancock (1999) identifies that students who come from countries unaccustomed to reflective practice may face a personal conflict due to the dissonance caused by these requirements and their country's culture dimensions. Culture is defined as distinctive attributes shared by a society (Oxford University Press, 2000), which differentiate people who live in different places. The differentiation involves conventional beliefs related to racial, religious, or social group. For the purpose of this paper, culture will be defined as Western and Eastern cultures. Hofstede (2011) identified six dimensions of the culture differences between Western and Eastern countries. The first four have relevance for this paper: power distance; uncertainty avoidance; individualism/ collectivism; and masculinity/femininity. The final two dimensions will not be used due to their lack of significance to reflective practice: long/short-term orientation; and indulgence/restraint. Culture Dimensions and Reflective Practice Power Distance Power distance describes how society handles inequalities among its citizens. According to Hofstede (2011), power distance is the degree to which societies expect and accept unequal distribution of power. A large degree of power distance is experienced by people living in a hierarchical society (Minnis, 1999) where everyone accepts they have a place within the society and this is not challenged. For example Thai society uses big person/little person to describe large power distance (Burnard and Naiyapatana, 2004). Teachers are considered to have a higher-level position, therefore they are highly respected (Kim and Cha, 2013) and are unlikely to challenge what is being taught. The teacher usually takes all the initiatives within the learning process. Consequently, the quality of learning depends on the teacher's ability and expertise (Burnard, 2005), and creates a dominant teacher–student relationship which may hinder the development of students' critical thinking abilities (Kawashima and Petrini, 2004). From the first author's experiences, such situations lead to phenomena where students are not highly motivated to think independently, they rely on the teacher to provide them with the knowledge. In contrast, there is an expectation of minimal inequality among people who live in small power distance countries, resulting in them having interdependent relationships (Hofstede, 2011). Students often treat their teacher as a friend and an equal. Students are expected to demonstrate initiative in the class, therefore the quality of learning depends on both the students and the teacher.
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Contemporary Issues
Power distance may influence the implementation of reflective practice, particularly in Eastern countries. In Chinese educational settings, the teacher is in a more power distance position than a student (Chiang et al., 2010). This hierarchy also occurs in Thai (Burnard, 2006) and Japanese education systems (Stockhausen and Serizawa, 2008). Students' enthusiasm in improving themselves using reflection may be impeded in Eastern countries due to their belief that it is the teachers' responsibility to ensure student learning (Stockhausen, 2007). If a student thinks the learning process is the teacher's responsibility, reflective practice has limited chance of being accepted as an appropriate practice. Uncertainty Avoidance Uncertainty avoidance is the degree to which a society feels uncomfortable with insecure situations (Hofstede, 2011). A society is considered as having weak uncertainty avoidance when they are being positively challenged in various situations and they become use to uncertainty. Societies with weak uncertainty avoidance have openended learning situations, and encourage a robust student discussion between peers in educational settings (Hofstede, 2011). Strong uncertainty avoidance societies have feelings of insecurity if they encounter ambiguous situations (Hofstede, 2011). In the education setting, students prefer to have a structured learning program that includes knowing what to do and when to do it. Students are also concerned with obtaining the right answers from their teachers. They expect their teacher to provide correct answers in response to their questions. From the first author's experiences, students always ask for clear answers if they ask something in the classroom. Hancock (1999) states that some students give what they perceive is the required answer in order to avoid any unnecessary anxiety. “Being different” creates uncomfortable feeling for people who have strong uncertainty avoidance (Hofstede, 2011). Strong uncertainty avoidance may result in a barrier occurring in the application of reflective practice. Thai nurses tend to have avoidance behavior in uncertain clinical situations (Ekintumas, 1999). If reflection is conducted without clear guidelines, it will lead to increasing negative feelings. In a study about reflective practice, Joyce-McCoach et al. (2013) found providing clear expectation about reflective discussions assisted Chinese students in their ability to use reflective practice. Conducting an information session prior to the introduction of reflective practice may enable realistic expectations to be formed. While the strategies used to facilitate reflection need to ensure that students are able to maintain “face”. Individualist Versus Collectivist Individualism and collectivism refers to the power of a group in a specific society (Hofstede, 2011). Individualist and collectivist dimensions can be differentiated based on how they positioned themselves in a group. Individualist is when people act independently or are not influenced by any societal group. People who are strongly influenced and depend on a group are called collectivist. The collectivist will put forward the group's interest rather than their individual interest since group loyalty is important. Students from individualist societies are encouraged to speak on behalf of themselves, while in collectivist societies, students speak on behalf of the group or because they are authorized by the group (Hofstede, 2011). In China, students are likely to avoid offering opinions in class because of two elements of Chinese culture: the belief that they may be “losing face” and shyness (Chiang et al., 2010). The concept of “losing face” can also be found in Thai culture, where students are encouraged not to challenge the teacher in order to avoid a situation where both the teacher and students may lose (Burnard and Naiyapatana, 2004). In regard to reflective practice, this characteristic may become an advantage as well as a disadvantage. If a student participates in
reflection and is able to share the positive aspects of the reflection, other students may also be encouraged to participate in reflective practice. Moreover, Burnard and Naiyapatana (2004) claim a common Thai characteristic is to avoid expressing personal feelings. Another characteristic distinguishing the individualist and collectivist relates to the purpose of education. Individualist societies focus on learning how to learn, whereas collectivist societies prefer learning how to do (Hofstede, 2011), leading to different student and teacher behavior. Teacher-centeredness is commonly found in the collectivist society because the teacher decides what should be taught. Chiang et al. (2010) identified that most of the teaching process in Taiwan is teacher-centered. In this study, some teachers were not prepared to adopt a new paradigm that focused on learner-centeredness. Importantly, a teacher-centered approach has the potential to hinder a student's reflective abilities during the learning process; since the students are not used to think about their individual need (Chiang et al., 2010). They may not use their experiences in reflection due to the belief it will compromise their loyalty to the group. Asian students have been identified as preferring to maintain group harmony rather than to express their own ideas (Wurzel, 1984). Masculinity Versus Femininity The most common characteristics of people who live in countries where femininity is an accepted norms is being responsible for themselves, decisive, ambitious, caring and gentle (Hofstede, 2011). In countries where masculinity is dominant, there are differences in women's and men's characteristics. A man is someone who is responsible for their family and the group, a man is to be decisive and ambitious; while a woman is required to be gentle and caring (Hofstede, 2011). The majority of nurses are women (Ekintumas, 1999), and due to adherence to the masculinity concept, nurses in some countries are not ambitious and are supervised by medical doctors (often men) (Stockhausen, 2007). Therefore, nurses and student nurses are not familiar with clinical practice being guided by reflective practice, as it requires taking responsibilities for their own knowledge and skills development. Burnard (2005) identifies that the issue of “losing face” due to doing something wrong, is commonly found in masculine dominant countries. Femininity and masculinity potentially influence the implementation of reflective practice in terms of the opportunity of students to offer opinions about patient care or nursing practice. Richardson (2004) supports this notion that female Arab students, living in male-dominated society are not permitting to think for themselves. Points to Consider When developing nursing practice approaches or nursing education programs in Eastern countries, four aspects require consideration regarding reflective practice: high power distance, collectivist, stronger uncertainty avoidance, and masculinity. High power distance may create people's unwillingness to confront issues openly (Minnis, 1999). Bakioǵlu and Dalgi (2013) claim that in a homogenous culture, people tend to avoid conflict. Reflective practice is considered as creating inner-self conflict since reflection requires individuals to use past experiences to explore and challenge their attitudes, knowledge and skills (Johns and Watson, 2000). To ensure the successfulness of reflective practice in Eastern countries, clinical teachers need to create a learning environment that encourages and supports a learner-centered approach to assist in decreasing the feeling and reality of a power imbalance between students and clinical teachers. As a result, students will increasingly be motivated to identify their own learning needs. Regular reflective discussions with students have the potential to increase the professional and collegial relationship with their teacher.
Contemporary Issues
The concern of “losing face” during reflective activities might hinder the ability to reflect on past experiences. Conducting individual reflective discussions rather than group discussions may assist students to minimize the risk of these feelings of “losing face” and reinforce the student's efforts. Other strategies using indirect communication with students, such as written feedback, may also reduce risk and enable participation since the students do not have to be face-to-face with the teacher or be exposed to other students' comments (Burnard, 2005). The third dimension to be considered is strong uncertainty avoidance. To avoid this, educators are encouraged to provide students with clear guidance about reflection principles and value, and the reflective practice process (Glynn, 2012). This guidance may also include providing reflective writing examples to assist students understand and develop their reflective skills and capacity. The final issue relates to masculinity dominant norms in a country, where women are not encouraged to think critically or to focus on their experience and learning outcomes. Student must be encouraged and supported to accept that they must take responsibility for developing their professional knowledge and skills, and ensuring safe and competent nursing practice, regardless of their gender. Concluding Thoughts Successful implementation of reflective practice in nursing education and clinical practice requires consideration of the dominant cultural characteristics. Eastern characteristics that potentially impact on students' learning have been identified as high power distance, collectivist, stronger uncertainty avoidance, and masculinity. Such characteristics may become barriers to reflective practice implementation and future development as professionals. To deal with these cultural barriers, teacher may use strategies including providing clear guidance about the importance and use of reflective practice, conducting regular meetings, using indirect reflective activities, providing written feedback, and reflecting on and accepting differences between cultures. Such strategies may assist in dealing with the culture-related inhibitors to implementing reflective practice within nurse education programs. Finally, it is crucial that teachers reflect on their nursing and teaching practice and have knowledge about their own and their students' cultural background (Santoro, 2009). By accepting students' cultural characteristics, teachers increase their ability to facilitate learning through reflective practice. Acknowledgment The first author is a PhD student at University of Technology, Sydney, whom is funded by Directorate of Higher Education, Ministry of Education and Culture, Republic of Indonesia (206/E4.4/K/2012). References Asselin, M.E., 2011. Using reflection strategies to link course knowledge to clinical practice: the RN-to-BSN student experience. J. Nurs. Educ. 50 (3), 125–133. Bakioǵlu, A., Dalgi , G., 2013. The possible barriers behind reflective thinking and practice: experiences of school principals from Turkey and Denmark. Educ. Sci. Theory Pract. 13 (2), 832–838. Boud, D., 2010. Relocating Reflection in the Context of Practice. (URI: http://hdl.handle. net/10453/14325). Burnard, P., 2005. Issues in helping students from other cultures. Nurse Educ. Today 25 (3), 176–180. Burnard, P., 2006. Some attitudes towards teaching and learning in Thai nursing education. Nurse Educ. Today 26 (3), 253–257. Burnard, P., Naiyapatana, W., 2004. Culture and communication in Thai nursing: a report of an ethnographic study. Int. J. Nurs. Stud. 41 (7), 755–765.
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Chiang, C.-K., Chapman, H., Elder, R., 2010. Changing to learner-centred education: challenges experienced by nurse educators in Taiwan. Nurse Educ. Today 30 (8), 816–820. Ekintumas, D., 1999. Nursing in Thailand: Western concepts vs Thai tradition. Int. Nurs. Rev. 46 (2), 55–57. Glynn, D.M.P.R.N.A.N.P.B.C., 2012. Clinical judgment development using structured classroom reflective practice: a qualitative study. J. Nurs. Educ. 51 (3), 134–139. Hancock, P., 1999. Reflective practice—using a learning journal. Nurs. Stand. 13 (17), 37–40. Hatlevik, I.K.R., 2012. The theory‐practice relationship: reflective skills and theoretical knowledge as key factors in bridging the gap between theory and practice in initial nursing education. J. Adv. Nurs. 68 (4), 868–877. Hofstede, G., 2011. Dimensionalizing cultures: the Hofstede model in context. Online Read. Psychol. Cult. 2 (1), 8. Horton-Deutsch, S., McNelis, A.M., Day, P.O.H., 2012. Developing a reflection-centered curriculum for graduate psychiatric nursing education. Arch. Psychiatr. Nurs. 26 (5), 341–349. Johns, C., Watson, J., 2000. Becoming a Reflective Practitioner: A Reflective and Holistic Approach to Clinical Nursing, Practice Development and Clinical Supervision. Blackwell Science Oxford. Joyce-McCoach, J.T., Parrish, D.R., Andersen, P.R., Wall, N., 2013. Unlocking reflective practice for nurses: innovations in working with master of nursing students in Hong Kong. Nurse Educ. Pract. 13 (5), 388–392. Kawashima, A., Petrini, M.A., 2004. Study of critical thinking skills in nursing students and nurses in Japan. Nurse Educ. Today 24 (4), 286–292. Kim, M., Cha, C., 2013. Cultural meaning of course evaluation among nursing students and faculties in Korea. Nurse Educ. Today 33 (6), 639–643. Lie, D., Shapiro, J., Cohn, F., Najm, W., 2010. Reflective practice enriches clerkship students' cross-cultural experiences. J. Gen. Intern. Med. 25 (Suppl. 2), S119–S125. Minnis, J.R., 1999. Is reflective practice compatible with Malay–Islamic values? Some thoughts on teacher education in Brunei Darussalam. Aust. J. Educ. 43 (2), 172–185. O'sullivan, A.J., Howe, A.C., Miles, S., Harris, P., Hughes, C.S., Jones, P., Scicluna, H., Leinster, S.J., 2012. Does a summative portfolio foster the development of capabilities such as reflective practice and understanding ethics? An evaluation from two medical schools. Med. Teach. 34 (1), e21–e28. Oxford University Press, 2000. The Oxford English Dictionary Online. Oxford University Press, Oxford. Paget, T., 2001. Reflective practice and clinical outcomes: practitioners' views on how reflective practice has influenced their clinical practice. J. Clin. Nurs. 10 (2), 204–214. Reynolds, M., 2011. Reflective practice: origins and interpretations. Action Learn. Res. Pract. 8 (1), 5–13. Richardson, P.M., 2004. Possible influences of Arabic–Islamic culture on the reflective practices proposed for an education degree at the Higher College of Technology in the United Arab Emirates. Int. J. Educ. Dev. 24, 429–436. Santoro, N., 2009. Teaching in culturally diverse contexts: what knowledge about ‘self’ and ‘others’ do teachers need? J. Educ. Teach. 35 (1), 33–45. Schön, D.A., 1987. Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions. Jossey-Bass, San Francisco, CA. Stockhausen, L.J., 2007. Developing culturally competent reflective practitioners. Part 1. Cultural reflections. Asian J. Nurs. 10 (4), 212–217. Stockhausen, L., Kawashima, A., 2002. The introduction of reflective practice to Japanese nurses. Reflect. Pract. Int. Multidiscip. Perspect. 3 (1), 117–129. Stockhausen, L.J., Serizawa, A., 2008. Developing culturally competent reflective practitioners. Part 2. The culturally responsive reflective practice model. Asian J. Nurs. 11, 8–12. Wurzel, J.S., 1984. Teaching reflective thinking, cultural constraints and cross cultural responses. (http://eric.ed.gov/?id=ED262019).
Dessie Wanda Faculty of Health, University of Technology, Sydney, Australia Faculty of Nursing, Universitas Indonesia, Indonesia Corresponding author at: Level 7, 235 Jones St, Ultimo NSW 2007 (PO Box 123). Tel.: +61 410 411 973. E-mail address: [email protected]. Valerie Wilson1 Cathrine Fowler1 Faculty of Health, University of Technology, Sydney, Australia E-mail addresses: [email protected] (V. Wilson), [email protected] (C. Fowler).
1
Tel.: +61 2 9845 3093.
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Contemporary Issues
East meets West in reflective practice Keywords: Reflective practice Nursing Education Cultural Eastern Western
Introduction Reflective Practice Reflective practice is a well-established concept in the education of professionals (Boud, 2010). The ability to reflect in and on practice is recognized as a crucial professional skill (Schön, 1987). Reflective practice is identified as assisting bridge the theory-practice gap by connecting what is taught about a theory and what is delivered in practice (Asselin, 2011) enabling the linking and reinforcement of theoretical and practical knowledge (Hatlevik, 2012). Reflective practitioners make this possible by utilizing a cyclical learning process; reflecting on past experiences in order to gain new knowledge about their practice and themselves as nurses (Johns and Watson, 2000). Learning from experience using reflective practice has benefits for nurses when applied in clinical practice and education settings. Reflection is used as a means of promoting the professional development of both student and practice nurses (Paget, 2001). Reflection assists student nurses to: develop skills in dealing with personal emotions that occur during clinical practice (O'sullivan et al., 2012), better understand and increase their ability to solve problems in the clinical setting (Lie et al., 2010), and develop critical thinking analysis skills (Asselin, 2011). Reflective practice also provides a framework for designing graduate nursing curricula (Horton-Deutsch et al., 2012). This paper uses four dimensions of Hofstede (2011) framework to explore the influence of culture on reflective practice in Western and Eastern nursing education and the implications this has for the future implementation of reflective practice in eastern nursing education. The Influence of Culture in Reflective Practice Reflective practice has its origins and is predominantly used in Western countries (Reynolds, 2011) due to certain cultural characteristics often being present and contributing to reflective practice, for example, individualism and objectivity (Hofstede, 2011). Nevertheless, the use of reflective practice in non-Western countries is growing in prominence among scholars (Stockhausen, 2007). A discussion is needed on whether it is important to consider a country's cultural characteristics prior to the implementation of reflective practice into nursing education and practice. Kawashima and
http://dx.doi.org/10.1016/j.nedt.2014.08.007 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Petrini (2004) claim that differences in Western and Eastern cultures may create conflict that impact nursing education, particularly an individual's way of thinking. Western knowledge which has been used in Japan is not sensitive to Japanese language, culture, and population characteristics (Stockhausen and Kawashima, 2002). While Hancock (1999) identifies that students who come from countries unaccustomed to reflective practice may face a personal conflict due to the dissonance caused by these requirements and their country's culture dimensions. Culture is defined as distinctive attributes shared by a society (Oxford University Press, 2000), which differentiate people who live in different places. The differentiation involves conventional beliefs related to racial, religious, or social group. For the purpose of this paper, culture will be defined as Western and Eastern cultures. Hofstede (2011) identified six dimensions of the culture differences between Western and Eastern countries. The first four have relevance for this paper: power distance; uncertainty avoidance; individualism/ collectivism; and masculinity/femininity. The final two dimensions will not be used due to their lack of significance to reflective practice: long/short-term orientation; and indulgence/restraint. Culture Dimensions and Reflective Practice Power Distance Power distance describes how society handles inequalities among its citizens. According to Hofstede (2011), power distance is the degree to which societies expect and accept unequal distribution of power. A large degree of power distance is experienced by people living in a hierarchical society (Minnis, 1999) where everyone accepts they have a place within the society and this is not challenged. For example Thai society uses big person/little person to describe large power distance (Burnard and Naiyapatana, 2004). Teachers are considered to have a higher-level position, therefore they are highly respected (Kim and Cha, 2013) and are unlikely to challenge what is being taught. The teacher usually takes all the initiatives within the learning process. Consequently, the quality of learning depends on the teacher's ability and expertise (Burnard, 2005), and creates a dominant teacher–student relationship which may hinder the development of students' critical thinking abilities (Kawashima and Petrini, 2004). From the first author's experiences, such situations lead to phenomena where students are not highly motivated to think independently, they rely on the teacher to provide them with the knowledge. In contrast, there is an expectation of minimal inequality among people who live in small power distance countries, resulting in them having interdependent relationships (Hofstede, 2011). Students often treat their teacher as a friend and an equal. Students are expected to demonstrate initiative in the class, therefore the quality of learning depends on both the students and the teacher.
1418
Contemporary Issues
Power distance may influence the implementation of reflective practice, particularly in Eastern countries. In Chinese educational settings, the teacher is in a more power distance position than a student (Chiang et al., 2010). This hierarchy also occurs in Thai (Burnard, 2006) and Japanese education systems (Stockhausen and Serizawa, 2008). Students' enthusiasm in improving themselves using reflection may be impeded in Eastern countries due to their belief that it is the teachers' responsibility to ensure student learning (Stockhausen, 2007). If a student thinks the learning process is the teacher's responsibility, reflective practice has limited chance of being accepted as an appropriate practice. Uncertainty Avoidance Uncertainty avoidance is the degree to which a society feels uncomfortable with insecure situations (Hofstede, 2011). A society is considered as having weak uncertainty avoidance when they are being positively challenged in various situations and they become use to uncertainty. Societies with weak uncertainty avoidance have openended learning situations, and encourage a robust student discussion between peers in educational settings (Hofstede, 2011). Strong uncertainty avoidance societies have feelings of insecurity if they encounter ambiguous situations (Hofstede, 2011). In the education setting, students prefer to have a structured learning program that includes knowing what to do and when to do it. Students are also concerned with obtaining the right answers from their teachers. They expect their teacher to provide correct answers in response to their questions. From the first author's experiences, students always ask for clear answers if they ask something in the classroom. Hancock (1999) states that some students give what they perceive is the required answer in order to avoid any unnecessary anxiety. “Being different” creates uncomfortable feeling for people who have strong uncertainty avoidance (Hofstede, 2011). Strong uncertainty avoidance may result in a barrier occurring in the application of reflective practice. Thai nurses tend to have avoidance behavior in uncertain clinical situations (Ekintumas, 1999). If reflection is conducted without clear guidelines, it will lead to increasing negative feelings. In a study about reflective practice, Joyce-McCoach et al. (2013) found providing clear expectation about reflective discussions assisted Chinese students in their ability to use reflective practice. Conducting an information session prior to the introduction of reflective practice may enable realistic expectations to be formed. While the strategies used to facilitate reflection need to ensure that students are able to maintain “face”. Individualist Versus Collectivist Individualism and collectivism refers to the power of a group in a specific society (Hofstede, 2011). Individualist and collectivist dimensions can be differentiated based on how they positioned themselves in a group. Individualist is when people act independently or are not influenced by any societal group. People who are strongly influenced and depend on a group are called collectivist. The collectivist will put forward the group's interest rather than their individual interest since group loyalty is important. Students from individualist societies are encouraged to speak on behalf of themselves, while in collectivist societies, students speak on behalf of the group or because they are authorized by the group (Hofstede, 2011). In China, students are likely to avoid offering opinions in class because of two elements of Chinese culture: the belief that they may be “losing face” and shyness (Chiang et al., 2010). The concept of “losing face” can also be found in Thai culture, where students are encouraged not to challenge the teacher in order to avoid a situation where both the teacher and students may lose (Burnard and Naiyapatana, 2004). In regard to reflective practice, this characteristic may become an advantage as well as a disadvantage. If a student participates in
reflection and is able to share the positive aspects of the reflection, other students may also be encouraged to participate in reflective practice. Moreover, Burnard and Naiyapatana (2004) claim a common Thai characteristic is to avoid expressing personal feelings. Another characteristic distinguishing the individualist and collectivist relates to the purpose of education. Individualist societies focus on learning how to learn, whereas collectivist societies prefer learning how to do (Hofstede, 2011), leading to different student and teacher behavior. Teacher-centeredness is commonly found in the collectivist society because the teacher decides what should be taught. Chiang et al. (2010) identified that most of the teaching process in Taiwan is teacher-centered. In this study, some teachers were not prepared to adopt a new paradigm that focused on learner-centeredness. Importantly, a teacher-centered approach has the potential to hinder a student's reflective abilities during the learning process; since the students are not used to think about their individual need (Chiang et al., 2010). They may not use their experiences in reflection due to the belief it will compromise their loyalty to the group. Asian students have been identified as preferring to maintain group harmony rather than to express their own ideas (Wurzel, 1984). Masculinity Versus Femininity The most common characteristics of people who live in countries where femininity is an accepted norms is being responsible for themselves, decisive, ambitious, caring and gentle (Hofstede, 2011). In countries where masculinity is dominant, there are differences in women's and men's characteristics. A man is someone who is responsible for their family and the group, a man is to be decisive and ambitious; while a woman is required to be gentle and caring (Hofstede, 2011). The majority of nurses are women (Ekintumas, 1999), and due to adherence to the masculinity concept, nurses in some countries are not ambitious and are supervised by medical doctors (often men) (Stockhausen, 2007). Therefore, nurses and student nurses are not familiar with clinical practice being guided by reflective practice, as it requires taking responsibilities for their own knowledge and skills development. Burnard (2005) identifies that the issue of “losing face” due to doing something wrong, is commonly found in masculine dominant countries. Femininity and masculinity potentially influence the implementation of reflective practice in terms of the opportunity of students to offer opinions about patient care or nursing practice. Richardson (2004) supports this notion that female Arab students, living in male-dominated society are not permitting to think for themselves. Points to Consider When developing nursing practice approaches or nursing education programs in Eastern countries, four aspects require consideration regarding reflective practice: high power distance, collectivist, stronger uncertainty avoidance, and masculinity. High power distance may create people's unwillingness to confront issues openly (Minnis, 1999). Bakioǵlu and Dalgi (2013) claim that in a homogenous culture, people tend to avoid conflict. Reflective practice is considered as creating inner-self conflict since reflection requires individuals to use past experiences to explore and challenge their attitudes, knowledge and skills (Johns and Watson, 2000). To ensure the successfulness of reflective practice in Eastern countries, clinical teachers need to create a learning environment that encourages and supports a learner-centered approach to assist in decreasing the feeling and reality of a power imbalance between students and clinical teachers. As a result, students will increasingly be motivated to identify their own learning needs. Regular reflective discussions with students have the potential to increase the professional and collegial relationship with their teacher.
Contemporary Issues
The concern of “losing face” during reflective activities might hinder the ability to reflect on past experiences. Conducting individual reflective discussions rather than group discussions may assist students to minimize the risk of these feelings of “losing face” and reinforce the student's efforts. Other strategies using indirect communication with students, such as written feedback, may also reduce risk and enable participation since the students do not have to be face-to-face with the teacher or be exposed to other students' comments (Burnard, 2005). The third dimension to be considered is strong uncertainty avoidance. To avoid this, educators are encouraged to provide students with clear guidance about reflection principles and value, and the reflective practice process (Glynn, 2012). This guidance may also include providing reflective writing examples to assist students understand and develop their reflective skills and capacity. The final issue relates to masculinity dominant norms in a country, where women are not encouraged to think critically or to focus on their experience and learning outcomes. Student must be encouraged and supported to accept that they must take responsibility for developing their professional knowledge and skills, and ensuring safe and competent nursing practice, regardless of their gender. Concluding Thoughts Successful implementation of reflective practice in nursing education and clinical practice requires consideration of the dominant cultural characteristics. Eastern characteristics that potentially impact on students' learning have been identified as high power distance, collectivist, stronger uncertainty avoidance, and masculinity. Such characteristics may become barriers to reflective practice implementation and future development as professionals. To deal with these cultural barriers, teacher may use strategies including providing clear guidance about the importance and use of reflective practice, conducting regular meetings, using indirect reflective activities, providing written feedback, and reflecting on and accepting differences between cultures. Such strategies may assist in dealing with the culture-related inhibitors to implementing reflective practice within nurse education programs. Finally, it is crucial that teachers reflect on their nursing and teaching practice and have knowledge about their own and their students' cultural background (Santoro, 2009). By accepting students' cultural characteristics, teachers increase their ability to facilitate learning through reflective practice. Acknowledgment The first author is a PhD student at University of Technology, Sydney, whom is funded by Directorate of Higher Education, Ministry of Education and Culture, Republic of Indonesia (206/E4.4/K/2012). References Asselin, M.E., 2011. Using reflection strategies to link course knowledge to clinical practice: the RN-to-BSN student experience. J. Nurs. Educ. 50 (3), 125–133. Bakioǵlu, A., Dalgi , G., 2013. The possible barriers behind reflective thinking and practice: experiences of school principals from Turkey and Denmark. Educ. Sci. Theory Pract. 13 (2), 832–838. Boud, D., 2010. Relocating Reflection in the Context of Practice. (URI: http://hdl.handle. net/10453/14325). Burnard, P., 2005. Issues in helping students from other cultures. Nurse Educ. Today 25 (3), 176–180. Burnard, P., 2006. Some attitudes towards teaching and learning in Thai nursing education. Nurse Educ. Today 26 (3), 253–257. Burnard, P., Naiyapatana, W., 2004. Culture and communication in Thai nursing: a report of an ethnographic study. Int. J. Nurs. Stud. 41 (7), 755–765.
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Dessie Wanda Faculty of Health, University of Technology, Sydney, Australia Faculty of Nursing, Universitas Indonesia, Indonesia Corresponding author at: Level 7, 235 Jones St, Ultimo NSW 2007 (PO Box 123). Tel.: +61 410 411 973. E-mail address: [email protected]. Valerie Wilson1 Cathrine Fowler1 Faculty of Health, University of Technology, Sydney, Australia E-mail addresses: [email protected] (V. Wilson), [email protected] (C. Fowler).
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Tel.: +61 2 9845 3093.
