Examining nursing students’ learning through reflective analysis using Ray’s Transcultural Caring Dynamics in Nursing and Health Care Theory

Abstract

Background

Critical reflection empowers nursing students understanding as they become caring health professionals. Clinical nursing staff must have cultural sensitivity and empathy to provide culturally relevant care that meets the needs of patients from diverse cultures and ethnicities. Currently, the nursing profession is facing a shortage of nurses, which challenges the quality of care in Taiwan and the global community. An important mission of education is to cultivate nursing students with the professional competence to provide appropriate care to patients and families. This study explored nursing students’ reflections on the meaning of caring in professional nursing.

Method

Data were collected from the written reflections of 32 who completed their basic professional nursing courses at a Taiwanese university. A reflective thematic analysis guided by Ray’s theory of Transcultural Caring Dynamics in Nursing and Health Care, highlighting the dimensions of caring, transcultural ethics, transcultural context, and universal sources (spirituality), was used to provide an understanding of how students viewed integrative patient-centred caring, and how they gained self-awareness and insights into their family relationships.

Findings

Four themes were derived from students’ reflective documents. The identified themes included building a caring experience to meet individuals’ physical and psychological needs; learning caring ethics by respecting individual’s integrity and rights; family, school peers, and communities affecting the caring experience, and exploring teaching and learning approaches to enhance the caring experience.

Conclusions

Findings from students’ reflections indicate that individual patient needs should be considered when providing appropriate nursing care. Additionally, multiple teaching–learning strategies demonstrated their effectiveness in enabling nursing students to develop self-awareness in seeking an understanding of culturally appropriate care decisions.

Background

Critical reflection is an in-depth, creative, dynamic, and transformative learning process that enhances practice [1]. This process enables learners to identify what has gone well and recognise areas for improvement, ultimately enhancing their professional practice. During this critical reflection process, students are taught how to care for others across their lifespan, focusing on physical comfort and psychological safety, problem identification, assessment data, and proposed solutions. Thus, learners become self-aware, improve their problem-solving skills, and develop their critical thinking skills [2]. Critical reflection is essential for students to learn and understand caring, their formation as human beings, and their ability to interact with patients in an empathic caring manner [3]. Consequently, to facilitate nursing students’ development as professionals, learning support is needed with a focus on understanding care and ways of becoming caring nurses [3].

Caring is defined as an active relationship between charity and right action, grounded in love as compassion for suffering and need, and justice or fairness in determining what ought to be done, all within the context of cultural and organisational dynamics [4]. It transcends beyond technical proficiency, emphasising meaningful connections with patients while addressing their physical, emotional, and psychosocial needs. In nursing, caring is not just a professional expectation but a fundamental ethical commitment to upholding human dignity and promoting justice in healthcare [5, 6]. Caring is a core competency of nursing graduates [7]. In the process of interacting with patients, empathy plays a crucial role in establishing nurse-patient relationships and engaging patients in a deeper way [8]. Nursing staff can use empathy, keen observation, and listening skills to discover the needs of patients and their families and provide support and assistance [9].

Transcultural caring emphasises empathy and responsiveness to the suffering and needs of others [10]. Ray’s Transcultural Caring Dynamics in Nursing and Health Care Theory with its dimensions, provides a holistic perspective for nurses and patients. This model supports the value of gaining a cultural perspective through all dimensions: the nature of care/caring, transcultural caring ethics, transcultural contexts, and universal sources, with central themes of transcultural care awareness, seeking understanding, and choice (decision-making) for all populations. A scoping review explored best practices for increasing cultural competency [11]. The findings showed that multiple educational strategies, such as lectures, discussion groups, simulations, reflections, immersion experiences, and case-based learning, could be used to develop knowledge, awareness, attitudes, and skills.

With the advancement of technology, medical internationalisation and global nursing are topics that nursing staff must understand. Therefore, clinical nursing staff must have cultural sensitivity and the capability to provide culturally appropriate care to meet the needs of patients from different ethnicities [12]. Cultural competence is the capacity to respond to the unique needs of a population from a different socioculturale background [13]. For example, culturally competent providers need to have knowledge and awareness of health-related beliefs, practices, and cultural values of diverse populations, or illness and diagnostic incidence and prevalence among culturally and ethnically diverse populations. Cultural humility comprehensively focuses on self-evaluation and critique, enhancing interpersonal sensitivity and openness, addressing power imbalances, patients’ lay expertise, sharing power with patients, and continuing to learn from one’ s patients [12, 14]. A provider operating with cultural humility must listen with interest and curiosity, have an awareness of their own possible biases and attempt a non-judgemental stance about what they hear, recognise their inherent status of privilege as a provider, and be willing to be taught by their patients. A caring with cultural approach shifts the focus from simply acquiring knowledge about other cultures to fostering authentic, respectful, and collaborative relationships with patients and colleagues from diverse backgrounds [12, 15].

To provide personalised, patient-centred care, healthcare providers must consider the diversity of patients’ lifestyles, cultures, ages, experiences, and perspectives to collaborate in shared decision-making. Patient-centred care can potentially enhance equity in healthcare delivery, and cultural sensitivity can improve patient-centred care [12]. Cultural comprehension, which includes the recognition of cultural differences in models of health and disease, cultural values, and cultural differences in patients’ preferences for the health professor-student/patient relationship, including race and potential cognitive biases, and language (barriers) is imperative. Otherwise, incomprehension will lead to inequitable healthcare delivery in medical/nursing care [16]. Thus, healthcare providers must openly reflect on and discuss patients’ cultural issues, including ethnicity and race, gender, age, class, education, religion, sexual orientation and identity, physical abilities/disabilities, as well as inequalities, such as generational differences, and problems with the distribution of power [12]. All cultural phenomena need to be addressed and require processes of cultural humility, ensuring cultural competence for health care professionals to interact effectively with culturally diverse patients [17]. Given the shortage of nursing staff, improving nursing students’ capacities to provide appropriate care to patients is crucial [18].

Aims

This study explored nursing students’ critical reflections on the meaning of caring for student nurses from the perspective of providing culturally appropriate and intergenerational care.

Methods

Research design

This research employed critical reflection, as guided by Ray’s Transcultural Caring Dynamics in Nursing and Health Care Theory [10], to analyse data from students’ reflective documents, which included students’ translation of the knowledge they had learned into person-centered care. The Ray’s theory is the most appropriate theory as it focuses on culturally sensitivity, which integrates being present, thinking and doing, transcultural caring ethics, transcultural context (social-cultural phenomena), and universal sources (religion or spirituality). The theory has been applied in previous studies to mitigate transcultural clinical barriers in providing health and wellness services [22] and home health nurses’ culture-sensitive care in assessing and planning care [23].

Settings and sample

This study was conducted at a University in Southern Taiwan. The inclusion criterion was university nursing students in the participating university. First-year nursing students were studied on-campus and were not required to undertake clinical practicums. The exclusion criterion was the participation of nursing students in another study.

Data collection

Data were collected from students’ open-ended reflective documents about their experiences during their first year of learning. Critical reflection is the process of analysing, questioning, and evaluating experiences, beliefs, and assumptions to gain a deeper understanding and improve future actions. It involves thinking critically about one’s own thoughts, decisions, and practices to identify biases, uncover new perspectives, and foster personal or professional. Prompt questions such as gains from courses, including thoughts and suggestions about the courses that related to individual learning gains, differences between learning contents and past learning, and how to apply the learningas content to the care and reflection of practitioners, were provided [19]. The ‘What?’, ‘So what?’, and ‘Now what?’ formats were used for journal entries [20], whereby students were invited to describe an experience of related nursing care (What?), critically analysing the lessons learned (So what?) and implications for future nursing practice (Now what?).

Data analysis

The de-identified reflective documents were managed using NVivo V12 [21], which included a description of the experience, the person’s feelings and thoughts, an evaluation of the experience, the analysis of the situation and the conclusion what they have learned and what they could have done differently, and making an action plan. The data were analysed using qualitative coding methods, identifying themes guided by Ray’s theory [10]. Data analysis was conducted by two bilingual researchers (T-JT and C-JW). Participants statements (quotes) were translated from Chinese into English. The first author carefully read all documents to understand the content, thereafter noting the underlying meanings were assigned topic names, and similar topics were clustered into different columns. Subsequently, codes were written and organised into different categories. Descriptive words were assigned to each topic, and all similar data were grouped into their corresponding categories. Another author repeated the same coding process, whereafter the two authors discussed and further discussed with the author of Ray’s theory to reach a consensus on the final themes.

Ethical considerations

Ethical approval was obtained from the Human Research Ethics Committee (IRB No. 202200129 A3), and written informed consent was obtained from participants who volunteered and had the right to withdraw from the study at any time without penalty. All the data used a code to replace individual identities when they were analysed and stored.

Results

A total of 36 students participated at the beginning of the semester. During the study, four students withdrew from this study due to their ‘previously engaged’ school schedules, ultimately 32 students completed the data collection. The study included 11 men (34.4%) and 21 women (65.5%). The results revealed four themes: building a caring experience to meet individual physical and psychological needs; learning caring ethics by respecting an individual’s integrity, rights, family, school peers, and communities that affect the caring experience; and exploring teaching and learning approaches to enhance the caring experience (Fig. 1).

Fig. 1

An example of reflective analysis using Ray’s Transcultural Caring Dynamic in Nursing and Health Care Theory (adapted from Ray, 2016)

Building a caring experience to meet individual physical and psychological needs

Students expressed that a caring experience ensured that the essential physical and physiological aspects of an individual’s health needs were met; the experience fostered active listening, love, and open communication to help individuals feel supported.

‘… We [nursing students] found that understanding an individual’s physical, psychological, and social behaviours at different stages helps us to recognise an individual’s needs. For example, infants priorities their oral needs.. …However, we are progressing differently…. Some people may physically deteriorate, and require special attentions to nutrition and physical functions…’ (P11).

‘ From the discussion, we understand that some patients [suffering from cognitive disabilities/dementia] may be unable to recognise the people around them, get frustrated, or upset with familiar surrounding …., or have difficulties in managing their daily routines; we now know how important it is to consider the needs of elderly patients … observing their reactions and providing appropriate care, such as love, warmth, and sincere care.’ (P21)

‘Caregivers also bear a heavy burden, special elder couplese. I believe that this is a challenge. When caring for elderly patients, I need to have more patience and compassion, using simple and easy-to-understand language, while listening to and providing companionship at the right time.’ (P31)

‘Caring for elderly patients [patients who are aging] requires patience and love. Therefore, we [the students] should use simple vocabulary, listen attentively, and remain accessible to those we care for. For example, when I visited my family over the weekend and met my grandmother, who had auditory issues and was forgetful, I became more patient with her.’ (P29)

Learning ethics of caring by respecting individuals’ integrity and rights

Students discussed care ethics by interacting with others. The ethics of caring were recognised, and upheld an individual’s integrity and rights that ensured that they were treated with dignity.

‘I believe it is ‘s important not to define them by their illness but to see them as individuals, and unique persons. How an issue is addressed in the previous stage is impactful... You [the student] should offer kind, supportive care and respect the privacy and dignity of the elderly in the family.’ (P10)

‘Some patients got angry because they were not sent to home care centre facilities without any prior discussion,it is just because they have complex conditions; all people say the same things to tell patients what they need to do. … they should be treated as unique individuals with distinct personalities, feelings, and values. These aspects should be considered.’ (P26)

Family, school peers, and communities affecting caring experience

Students learn about caring experiences that can be affected by the family, school peers, and community. Each of these factors plays a vital role in shaping students’ understanding of individual diversity. Students shared their own experience, for example:

‘I used to feel that my younger sister was too spoilt and stubborn, At that time, I would only blame her and did not understand why mom was so tolerant and patient. Now, looking back, It realise that she (her young sister) is very sick needs a lot of attention. I hope that in the future, I will have a better understanding of why families or schoolteachers was behave in such way and,.. the people I interact with, while recognise the phases they are going through, so I can find the most suitable care to help them’. (P11)

‘…We discussed how about students behave differently when at school. School students from different family backgrounds may differ because of their lifestype at home and the environment in which they grow up, leading to different personalities. Work to learn about tolerance and care: Through human development, your family or background shapes your learning personality, so you must be tolerant and caring.’ (P32)

Exploring teaching and learning approaches to enhance the caring experience

Students stated that the group discussion stratagies after viewing case scenarios that focused on promoting individual cultural diversity helped with their learning experience.

‘The videos were of the corresponding age groups. The characters will have very typical behaviours that age groups will develop, and we will then use discussion methods to deepen our impressions and discover the different opinions observed by other students. We find this helpful to see other students’ thoughts in learning to care for patients in different stages of life…. ‘ (P16)

‘….Many examples of practical experiences in the videos have improved my understanding. In each period, people attempt to integrate their thoughts and consider problems. I now understand how cultural diversity affects patients’ (P13)

‘…related topics showeed in the videos impart theoretical knowledge, and group discussions allow us to think and share with each other. I believe this process is effective, asut help students’ thinkabout cultural diversity and their needs ….. ‘ (P24)

‘ …The course includes many real-life examples, that help me better understand people at different stages of life. This allowed me to put myself in their shoes, integrate their perspectives, and consider the challenges they faced. ……During group discussions, I realised how different my thoughts were from those of others. In the future, when caring for patients, I will first listen to the patient before thinking about how to provide care.’ (P29).

Discussion

This study explored how first-year nursing students shared the nursing knowledge they acquired during their studies through reflective journals after studying nursing courses. The main themes included: building a caring experience to meet individual physical and psychological needs; learning ethics of caring by respecting individuals’ integrity and rights; family, school peers, and communities affecting caring experience, and exploring teaching and learning approaches to enhance the caring experience.

People have different physical, psychological, and social priorities throughout their lifetime. Nursing students believed that it was necessary to provide age-appropriate nursing care, including understanding individual needs and care and maintaining the patient’s self-esteem. By delivering age-appropriate care based on empathy, nurses ensure that every patient receives the support they need, with respect and compassion. Nursing students reflected on the fact that ageing is inevitable, and they understand the emotional changes caused by the physical and mental health problems of older adults. This finding is consistent with a previous study [24] that focuses on understanding individual patients’ needs to adjust nursing plans based on priorities to provide compassionate, patient-centred care and promote well-being. The study explored the health professional perceptions of communicating with adolescents, and found the importance of specialist technical competence in building trusting patient-professional relationships and recognising aged-friendly healthcare [24]. Similarly, patient-centred care considers patients’ perspectives and psychological and interpersonal effects on caring that promotes the well-being of patients [25].

Furthermore, nursing students understand the impact of early childhood development on later development during the human growth process and within other environments that may affect individual growth factors, including innate physical health, family environment at birth, school education, and social environment [26]. Although caring is a human trait, not every individual possesses the same caring abilities. Care experiences affects caregivers’ caring abilities, and professional knowledge plays a vital role in executing these caring abilities [6]. Professional knowledge includes not neglecting patients’ self-care needs and acting in their best interest [27]. Therefore, nursing staff with caring qualities can alleviate patients’ pain or suffering when interacting with patients [6].

Caring can reflect attentions to the feelings and needs of others through the caregiver’s touch and emotional expressions. This can bring about physical and psychological harmony and engender physical and emotional comfort. Caring involves “feeling” the physical and psychological feelings of the patient [empathy] at that moment of interaction and then becoming more aware of the situation and thus providing appropriate interventions [6]. Therefore, the nursing staff should exhibit caring qualities and empathises with others. The interpersonal interactions can easily help build trusting relationships and promote patient adherence to disease management [11].

Our findings showed that students learn about care by reflecting on their families, school peers, and communities. Various environmental factors, such as innate physical health, family conditions at birth, school education, and social support systems, play a significant role in shaping individual development. Previous research supports that a cultural sentive clinical environment as well as a friendly campus environment are essential for cultivating care [28], Teachers should provide warmth and affirmation and engage in sincere interactions with students. Schools should provide a stable and effective environment to help students learn and allow them to feel that their privacy is respected [29,30,31]. From the cultural perspective of scholar Ray [6], ethical care emphasises respect for human rights, which includes respect for individual differences. Living in the campus help nursing students understand the diversity of people, respect individual independence and singularity in the cross-cultural care process and provide individualised strategies for future care planning.

Our findings indicated that using teaching strategies with critical reflections empower students to develop caring experience. Teachers use multiple teaching strategies, such as face-to-face and group discussions, case studies, and video tapes, to attract students’ attention and promote learning. These methods promote active learning and help students become emotionally involved with one another [31, 32]. Open-minded discussions enhance students’ understanding of strengthening students’ abilities to understand and relate to others on a deeper level. During group discussions, students engaged in active listening, which helped them comprehend emotions and thoughts they might not have considered before. This emotional connection and sharing of experiences foster a sense of empathy [33]. These teaching methods not only provide an opportunity for students to share their learning environment in the classroom, but also apply to families and communities [30, 34, 35]. Therefore, the care and cultivation of nursing students are not only visibly shown but also, invisibly accumulated.

Limitations

Participants were first-year nursing students who did not have practical experience in hospitals, which might limit the results, particularly in the terms of how they engaged with and benefited from their own critical reflection ability, as they might not have fully grasped the complexities of patient care, including emotional, ethical, and interpersonal challenges. Another limitation of only the written reflections that are used in the study suggests that future research could include reflective dialogue which can further provide insights into enhancing the caring experience to improve healthcare provision [36, 37]. A critical reflection is context-bound in school learning, further investigation is needed to explore how reflective education empowers caring in other settings and contexts, such as indigenous communities.

Conclusion

Students’ critical reflections indicated that they learned about caring and that attention to individual needs increased their knowledge of cultural diversity and intergenerational empathy for persons, an issue that must be considered when providing comprehensive nursing care. We also found that students’ caring abilities developed though their daily routines. Students appreciated multiple engaging teaching–learning strategies. Nursing students should be encouraged to use self reflections raise awareness, think about events and experiences, express feelings and emotions, exchange experiences, and gain greater insight into their caring behaviours to improve the health and well-being of themselves and others.