qualitative research critique

Clinical mentors’ experiences of their intercultural communication T competence in mentoring culturally and linguistically diverse nursing students: A qualitative studyPia Hagqvista,b, Ashlee Oikarainena, Anna-Maria Tuomikoskia, Jonna Juntunena, Kristina Mikkonena,⁎a Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland b Healthcare Unit, Centria University of Applied Sciences, FinlandARTICLE INFOKeywords:Clinical practiceIntercultural communication CompetenceCultural and linguistic diversity NurseMentorStudentABSTRACTBackground: Intercultural communication has become increasingly important in nursing due to the cross-border mobility of patients, health professionals and students. Development of cultural competence continues to be a challenge, particularly among professionals such as educators or healthcare providers who work in professions requiring communication across cultural boundaries. Despite challenges in nursing education related to cultural diversity, competence in intercultural communication has been proven to empower students and to help them grow professionally.Objectives: The aim of this study was to describe clinical mentors’ experiences of their intercultural commu- nication competence in mentoring culturally and linguistically diverse nursing students during completion of their clinical practice.Design: Qualitative study design.Participants: The participants were 12 nurses who had previously mentored at least two culturally and lin- guistically diverse nursing students.Methods: Data were collected during spring 2016 using semi-structured interviews of 12 mentors working in specialized nursing care at one hospital located in central Finland. Data were analyzed using deductive-inductive content analysis. The main concepts of the Integrated Model of Intercultural Communication Competence were used during the semi-structured theme interviews and during analysis. These concepts include empathy, moti- vation, global attitude, intercultural experience and interaction involvement.Results: Mentors stated that empathy motivates them in the development of intercultural communication. Mentors experienced a lack of resources and support from their superiors, which caused psychological and ethical strain and reduced mentors’ motivation. Mentors openly admitted that they had experienced fear towards unknown cultures, but that this fear was reduced through positive mentoring experiences and cultural en- counters.Conclusions: Continuous education on intercultural communication competence could succeed to further de- velop clinical mentors’ mentoring expertise, which could have the potential to greatly benefit students, patients and staff. Such education could be designed, implemented and measured for its effect in collaboration between health care organizations and higher educational institutions.1. IntroductionThere is an increased demand for cultural competence in nursing care due to current trends in globalization. Internationally, the expan- sion of nursing education to international students has become a common trend (Mikkonen et al., 2016). The strategic framework forEuropean cooperation in education and training (2009) states that education should promote cultural competencies, democratic values, respect for fundamental rights, as well as work against all forms of discrimination and to teach young people to interact positively with their peers from diverse backgrounds. In the United States, the National Standards for Culturally and Linguistically Appropriate Services call for⁎ Corresponding author at: Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, P.O. Box 5000, FI-90014, Finland. E-mail address: [email protected] (K. Mikkonen).https://doi.org/10.1016/j.nedt.2020.104348Received 14 April 2019; Received in revised form 3 December 2019; Accepted 20 January 20200260-6917/ © 2020 Elsevier Ltd. All rights reserved.P. Hagqvist, et al.Nurse Education Today 87 (2020) 104348healthcare professionals to provide quality care and services that are responsive to diverse cultural health beliefs and practices (U.S. Department of Health and Human Services, 2013). Accreditation stan- dards for programs including nursing and pharmacy require the in- tegration of cultural competency training in their educational programs (Accreditation Council for Pharmacy Education, 2015; Commission on Collegiate Nursing Education, 2018). The common need of promoting safe and quality patient care for diverse patients by enhancing inter- cultural communication serves as a foundation for interprofessional education development (Liu et al., 2015).Due to high levels of immigration (Bhopal, 2014), cultural compe- tence is seen in many countries to be a major future competence area of society. Cultural diversity offers rich opportunities for creativity and innovation, but also requires new leadership practices, development of new skills in the professional context, and continuous education on cultural knowledge (Mikkonen et al., 2017; Oikarainen et al., 2019). Culturally competent nurses are a necessity in today’s healthcare, they play a critical role in improving health outcomes and decreasing health disparities. Nurses and nursing students need to have a deeper under- standing of how to apply cultural competence while conducting patient assessments and delivering treatment options (Alpers and Hanssen, 2014). The development of cultural competence continues to be a challenge, particularly among professionals such as educators or healthcare providers who work in professions requiring communication across cultural boundaries (Oikarainen et al., 2019). A key assumption of education is that cultural competence contains cognitive, affective and behavioral dimensions, which can be developed through partici- pation in well-designed educational programs (Spitzberg and Changnon, 2009).In today’s cross-cultural world, cross-cultural values are needed to break down international barriers to practice (Collins and Hewer, 2014). Culturally and linguistically diverse (CALD) nursing students have been shown to experience greater challenges in clinical learning environments than in academic settings (Mikkonen et al., 2016). Clin- ical practice is an important part of nursing education through which nursing students are provided with the opportunity to familiarize themselves with common nursing tasks and to apply skills and knowl- edge from theoretical studies into practice (Mikkonen et al., 2017). Successful communication between the mentor and the student has been shown to play an important role in satisfaction, achievement of learning outcomes (Mikkonen et al., 2016), and maintenance of patient safety (Sairanen et al., 2012). Effective communication in nursing re- quires knowledge, a positive attitude, and motivation to develop mu- tual understanding with others. Competence in intercultural commu- nication has been proven to empower students and to help them grow professionally (Pitkäjärvi et al., 2012a). It has been previously re- cognized that mentors have negative attitudes towards CALD students (Pitkäjärvi et al., 2012a; Pitkäjärvi et al., 2012b) and that students experience difficulties in communication with their mentors during clinical practice (Mikkonen et al., 2016; Mikkonen et al., 2017; Oikarainen et al., 2018).Oikarainen et al. (2018) observed that although mentors were po- sitive in their evaluations of their competence in cultural diversity in mentoring, they had a tendency to stereotype CALD nursing students. Mentors reported that language barriers hindered interaction with CALD students (Oikarainen et al., 2018). When examining nursing students’ outcomes in clinical learning environments, language and communication were found to affect students’ experiences of cultural discrimination and limitation of learning opportunities in clinical practices (Mikkonen et al., 2017). Based on previous studies, we found it important to address the current gap in knowledge on intercultural communication by searching to understand mentors’ experiences with CALD nursing students. The aim of this study was to describe clinical mentors’ experience of their intercultural communication competence in mentoring culturally and linguistically diverse nursing students during their clinical practice.2. BackgroundNursing degree programs are commonly provided at the university or university of applied sciences degree level and contain a curriculum that requires a total of three to three and a half years of full-time stu- dies. Following completion of degree programs, students are awarded a bachelor’s degree and are given the right to practice the nursing pro- fession. According to the European Union Council Directive (Directive 2013/55/EU), up to 50% of the duration of nursing education should be conducted as clinical practice. In European Union countries on average, clinical practice is conducted during a period of 4–5 weeks (Pitkänen et al., 2018; Warne et al., 2010). While completing clinical practice in clinical learning environments and being provided with mentoring, nursing students are able to fulfill their learning outcomes and pro- gressively deepen their learning experiences (Pitkänen et al., 2018; Tuomikoski et al., 2019).Nursing students from European Union countries are offered the opportunity to go on exchange for a period of three to six months to a European Union country and/or outside of the European Union. In European countries where the native language is not English, nursing students from diverse backgrounds are provided with the opportunity to complete their nursing degree in English-language-taught degree nursing programs. Finland is one of the few European countries that offers these kinds of programs, which are offered so that both inter- national and national students study together. Although the nursing programs are offered in English, students need to conduct up to half of their education in clinical practice with patients who speak only Finnish and/or Swedish (Mikkonen et al., 2017; Pitkäjärvi et al., 2012a).Nurse educators are on the frontline in educating the next genera- tion of nurses and have an important role in developing nursing cur- ricula to withstand international comparison and in preparing cultu- rally competent nurses of the future (Parcells and Baernholdt, 2014; Tella et al., 2015). Since clinical practice takes up to half of nursing education, mentors have great impact on the experiences of nursing students (Pitkänen et al., 2018). It was shown in a previous study that mentors are registered nurses who commonly have no previous edu- cation in mentoring (Tuomikoski et al., 2019). Good mentorship during clinical practice has a positive effect on promoting students’ learning and on assisting students in building their own professional identity (Jokelainen et al., 2011; McSharry and Lathlean, 2017). Mentors of CALD nursing students need to create positive, culturally appropriate learning environments, a process that requires resources and support also from other nurses who work as mentors on the ward (Mikkonen et al., 2017).Hawala-Druy and Hill (2012) argue that it is imperative for all nurse educators to link and bridge cultural competence and to teach cultu- rally congruent care to future nurses. According to Garneau and Pepin (2015), cultural competence “involves knowledge, skills, and know- how that, when combined properly, lead to a culturally safe, congruent, and effective action” (pg. 12). Cultural competence is a dynamic and developmental process, where the nurse is committed to develop his or her own competence to function better with clients who come from culturally diverse contexts (Giger and Davidhizar, 2008). Within the Cultural Competence and Confidence model by Jeffreys (2010), cultural competence is defined as a multidimensional learning process where cognitive, practical, and affective dimensions of transcultural self-effi- cacy are emphasized, that can change over time as a result of for- malized education and other learning experiences. Cultural competence can also be described as the ability to work and communicate effec- tively and appropriately with people coming from culturally diverse backgrounds (Alizadeh and Chavan, 2016).Intercultural communication is key to cultural understanding and in the ability to value cultural differences (Saint-Jacques, 2011). It in- volves knowledge about other cultures and the application of appro- priate and effective communication behaviors (Neuliep, 2015). As a discipline, intercultural communication seeks to understand how2P. Hagqvist, et al.Nurse Education Today 87 (2020) 104348people from different cultures and social groups interact with equal terms and respect to their cultural identities and how they perceive the world around them. Competence in intercultural communication can support nurses and mentors to understand communication better with CALD patients and students (Hawala-Druy and Hill, 2012).According to Arasaratnam (2012), intercultural communication unfolds in symbolical intercultural spaces. Communication between individuals is affected by cultural differences in a way that would not have been noteworthy in the absence of these differences. Members who belong to the same thought community and share the same kind of values and beliefs communicate relatively seamlessly on the premise of shared understanding. However, when members of different thought communities communicate, the differences in their thinking is a sig- nificant factor that affects communication (Arasaratnam, 2012.)In this study, we have applied the Integrated Model of Intercultural Communication Competence (IMICC) (Arasaratnam et al., 2010). In- tercultural communication competence is defined using the concepts of empathy, motivation, global attitude, intercultural experience and in- teraction involvement within communication. Empathy is defined as the extent to which one can infer the cognitions and motivation of another person. Empathy also includes the ability to accurately sense, perceive and respond to one’s personal, interpersonal and social en- vironment. The concept of motivation includes interest and anticipation of actual engagement in intercultural communication. The global atti- tude dimension describes individuals who are open, positive and have a non-ethnocentric attitude. These individuals show interest in differ- ences with awareness towards diversity. Intercultural experience in- volves the actual study of intercultural communication and studying, working and traveling abroad. Interaction involvement includes an individual’s interest and effort to talk and understand. It involves en- gaging in active listening through paying close attention to the other person’s communication (Arasaratnam et al., 2010).3. Methods3.1. Study designA descriptive qualitative study design using a content analysis ap- proach. The content analysis approach was applied in order to under- stand the deeper meaning of nurses’ experiences and the phenomena of intercultural communication competence in the mentoring of students during clinical practice (Elo and Kyngäs, 2008). The content analysis approach is commonly used in critical realist research designs, where the reality of participants is explained through their own experiences (Tong et al., 2012). Data were collected through interviews of in- dividual participants. During the interviews, participants were provided the opportunity to actively share their own experiences related to the research aim.3.2. Data collectionData were collected in spring 2016 from 12 clinical mentors em- ployed at one hospital located in central Finland. Among the 12 par- ticipants, nine were female and three were male. Clinical mentors who met the inclusion criteria for participation in the study worked in acute nursing care and had previously mentored a minimum of two CALD nursing students (including international students from English-lan- guage-taught degree programs, immigrant students studying in Finnish language degree programs or exchange students). Purposive and snowball sampling were used to enroll the participants in the study (Polit and Beck, 2011). Charge nurses provided information on the study to potential participants. Nurses who agreed to participate in the study were contacted via email by one researcher (P.H.). Participants who were recruited into the study suggested additional potential par- ticipants. Two interviews were pretested before the main data collec- tion. The understandability and clarity of the questions were improvedfollowing feedback received during these interviews. The two inter- views were included in the data because the feedback received was minor.Semi-structured theme interviews were conducted. The main con- cepts of the Integrated Model of Intercultural Communication Competence were used including the themes of empathy, motivation, global attitude, intercultural experience and interaction involvement (Arasaratnam et al., 2010). The themes were used as main topics with open questions provided by the interviewer without controlling parti- cipants in the sharing of their experiences. Interviews were conducted in locations most convenient to the participants. Eight interviews were held at the hospital where the participants were employed and the re- maining four interviews were held at a local café and a public library. The interviews varied from 40 min to 75 min in length. Eleven inter- views were held in Finnish and one in Swedish. Data saturation was reached after twelve interviews were completed. The data were tran- scribed word for word into a document in Microsoft Word.3.3. Data analysisData were analyzed using qualitative content analysis (Elo and Kyngäs, 2008). Three main stages were followed during qualitative content analysis: preparation of the data, organization of the data and reporting of the results. A deductive approach guided the analysis during the preparation stage, and data was transformed into a classi- fication matrix according to the five chosen concepts (empathy, moti- vation, global attitude, intercultural experience and interaction in- volvement) from the IMICC theoretical framework (Arasaratnam et al., 2010). Following this, the analysis continued using an inductive ap- proach within the matrix containing the five main themes from Arasaratnam et al. (2010) theoretical model. The data was then orga- nized into meaning-units, which represented one sentence or one phrase. The meaning-units were combined into 951 codes, 259 sub- categories, 44 generic categories and 14 main categories. The cate- gories were named based on the content of the collected data. The analysis process was conducted by one researcher (PH) and con- tinuously verified with another researcher (KM) to maintain double coding and accuracy, and to increase the trustworthiness of the results.3.4. Ethical considerationsThis study was conducted according to the standards of good and ethical practices in scientific research. Research permission was ob- tained from the participating hospital prior to conducting the inter- views. All participants gave written informed consent to participate in the study at the beginning of the interview. The participants were in- formed about the benefits of the study, guaranteed confidentiality and autonomy to remove themselves from the study at any point in time (Stang, 2015). Data from the interviews were stored as secured com- puter files which were accessible only to one researcher (PH). The re- cords and notes will be permanently deleted after the research project has been completed.4. ResultsThe main themes defining clinical mentors’ intercultural commu- nication competence in mentoring CALD nursing students are described through the main categories presented in Table 1.4.1. EmpathyClinical mentors had a caring and empathic approach towards CALD nursing students during mentoring. Empathy was seen as part of men- tors’ personality, but also as a skill gained through nursing education and work experience. Mentors felt that CALD nursing students need more empathy from mentors than national students. One interviewee3P. Hagqvist, et al. Nurse Education Today 87 (2020) 104348Table 1Main categories of data analysis according to the themes of the Integrated Model of Intercultural Communication Competence (IMICC).Main themes of IMICC modelEmpathyMotivationMain categoriesMentors’ caring and empathic approach towards CALD students strengthens mentors’ mentoring competenceCultural and linguistic diversity influences mentors’ empathy towards CALD studentsMotivation in cultural diversity and students’ active approach in learningMentors’ competence relating to motivation to mentor CALD studentsLack of resources and support influences motivation to mentor Mentors’ experiences of prejudice and racism that CALD students faceMentoring CALD students as a way to enhance cultural knowledge in nursingMentoring CALD students contributes to enhanced competence in intercultural communicationMentors’ intercultural communication competence is supported by continuous education and free time activitiesMentors’ international experiences enhances their mentoring of CALD studentsMentors’ cumulative intercultural communication competence is developed in clinical practice and through the mentoring of CALD studentsMentors work as cultural interpreters for students, patients and for the working communityCultural, linguistic and ethical challenges of communication in the mentoring of CALD studentsCategoriesCharacteristics of personal empathy (Nr 1,2,3,4,5,7,8,9,10,12)Caring and empathic mentoring (Nr 2,3,5,7,8,9,10,12)Gaining skills in empathy during professional growth (Nr 1,2,3,5,7,8,9,10,12) Empathy as a motivating aspect to develop one’s own mentoring (Nr 3,4,5,7,8,10,12)The linguistic challenges of realization of empathy in mentoring (Nr 1,2,3,4,5,6,7,11,12)Cultural diversity causes unempathetic behavior by other colleagues (Nr 1,4,8,10,11,12)Students’ culture and linguistic skills motivates mentors (Nr 1,2,4,5,7,8,9,10,12) Students’ own role in learning motivates mentors (Nr 1,2,4,5,6,7,8,9,10,11) Students’ passiveness and lack of motivation in learning reduces mentors’ motivation (Nr 1,2,3,4,5,6,7,8,9)Positive feedback and success in mentoring (Nr 2,5,7,8,10,11,12)Mentor’s competence (Nr 1,3,7,8,9,12)Mentors’ attitudes towards international degree programs (Nr 1,3,4,6,10,11)Psychological and ethical dilemmas in mentoring due to the lack of support and knowledge (Nr 2,3,4,5,8,9,10,11,12)Uneven distribution of resources for mentoring (Nr 1,2,3,5,6,8,10,11)Fears and attitudes towards unknown cultures (Nr 2,3,4,6,7,8,10,12) Racist attitudes of colleagues towards CALD students (Nr 2,4,6,8,10,12) Social media and press affect attitudes towards CALD students (Nr 1,3,4,5,6,8,9,10,12)Effect of increasing migration on general attitudes towards CALD students (Nr 1,2,3,4,6,7,8,10,11)Mentors’ positive attitude of learning about the students’ culture (Nr 1,3,5,7,8,9,10,11,12)Mentors experience mentoring students from different cultures as enriching (Nr 1,2,3,4,6,7,9,10,12)Mentors’ learning experiences of the nursing cultures of different countries (Nr 1,2,3,4,5,6,7,9)Mentors gain learning experiences in cultural interaction and communication in mentoring (Nr 1,2,3,4,5,6,7,8,9,10,11,12)Mentors recognize the students’ individual cultural communication (Nr 1,3,4,5,6,7,8,10,12)Mentors’ experience of recognizing their own bias towards different cultures (Nr 1,2,3,6,7,8,9,10,12)General nursing education provided mentors’ with only limited knowledge on cultural competence (Nr 2,3,4,5,6,7,8,9,10,11)Cultural competence gained from continuous education (Nr 1,3,4,5,6,7,8,10,12) Cultural experiences gained through traveling and free time activities(Nr 2,3,5,6,9,10,11,12)Mentors’ working and studying experience from abroad (Nr 1,7,8,12)Mentors’ international experience enhances cultural diversity in communication (Nr 1,7,8,12)Increase of cultural diversity in nursing practice (Nr 2,3,5,6,7,10) Increase of cultural diversity in mentoring (Nr 2,3,4,5,6,9,10,11,12)Mentors’ experiences cultural interaction in working life of nursing (Nr 1,2,3,4,5,6,7,12)Mentors’ experiences of intercultural communication issues with students and patients (Nr 1,2,3,4,5,6,7,8,9,10,11,12)Mentors experience linguistic challenges in mentoring and in the evaluation of CALD students learning outcomes (Nr 1,2,3,4,5,6,7,8,9,10,11,12)Mentors experience ethical and cultural challenges in the evaluation process of CALD students (Nr 2,3,4,5,6,8,9,10,11,12)Mentors’ foreign language skills facilitates communication with student (Nr 1,2,3,4,7,8,12)Mentors experience students’ language skills and desire to learn Finnish as a promoting aspect for the good mentorship (Nr 1,2,3,4,5,6,7,8,9,10,11,12)Global attitudeIntercultural experienceInteraction involvement4(continued on next page)P. Hagqvist, et al. Table 1 (continued)Main themes of IMICC modelNurse Education Today 87 (2020) 104348Main categoriesMentors’ receive rich learning experiences that enhance their intercultural communication in mentoringCategories(Nr 8) expressed: “Students are that age where they are like my own children or even younger. Mentoring should include motherly empathy. With international students, you should think that their mother is far away. If I think of myself as a self-taught mentor, it was in the early stages of my nursing career that I thought that these students here are now the ones I should pass the knowledge and skills that I had learned to, but now my mentoring may have become motherly.” Mentors stated that empathy is a motivating factor for them to develop their mentoring competence and improve their intercultural communication. They were aware of their lack in theoretical knowledge of cultural competence in mentoring. The impact of communication and cultural diversity on empathy in men- toring was stated by mentors as a challenge. Mentors also faced chal- lenges related to difficulties in communication, with how time-con- suming and burdening mentoring was, and at times were faced with students who had weak commitment to the clinical practice. Mentors reported that they lacked empathetic support from their colleagues and that they had experienced receiving negative feedback from them about students.4.2. MotivationStudents’ cultural and linguistic background and active approach to learning affected the motivation of mentors. Mentors also stated that their experiences of challenges related to intercultural communication and students’ poor Finnish language skills reduced their motivation to mentor. Mentors’ motivation to mentor CALD students was enhanced when they received feedback and felt that they had good mentoring competence. Additionally, successful mentoring experiences with stu- dents motivated mentors to improve their mentoring competence. According to the results, students’ willingness to learn strongly im- pacted mentors’ motivation. One interviewee (Nr 6) shared: “It motivates me if the student gives me the impression that she wants to learn. That she is genuine, asks questions, and comes with me. But then if the student is passive and just comes along but shows no interest, you really get the feeling that how is this going to work. You just want that practice to be over with.” Mentors felt that incentives for mentoring in the English language would succeed to motivate other nurses to agree to mentor CALD stu- dents. They had experiences of compensation for mentoring being un- evenly distributed which affected their motivation to mentor. Although mentors were motivated to mentor and guide students as they learned about health care, clinical nursing and developed skills in the Finnish language, they felt burdened with issues arising from their leaders. During mentoring, mentors experienced a lack of resources, knowledge and support from superiors, colleagues and nurse educators, which caused a psychological and ethical dilemma for mentors and reduced their motivation. Ethical dilemmas arose from mentors’ experiences that CALD students were not given equal learning opportunities due to language barriers with patients and lack of time and resources for mentoring. Mentors felt that they are not able to resolve this issue, which negatively impacted their motivation.Mentors’ experience that CALD students are active listeners who observe the mentors’ interaction (Nr 1,3,5,7,8,9,10,11,12)Mentors apply their own communication competence to facilitate the understanding of CALD students (Nr 1,2,3,4,5,6,7,8,9,10,11,12)Mentors’ experiences of non-verbal communication as a dominant form of communication in student mentoring (Nr 4,5,6,10,11)Mentors experience that they lack the intercultural communication competence needed to interpret CALD students (Nr 2,4,5,6,9,10,11)4.3. Global attitudeMentors reported that CALD students experience prejudice and ra- cism during clinical practice. Mentors openly admitted that they themselves had experienced fear towards unknown cultures, but this fear was reduced through positive mentoring experiences, cultural en- counters and cultural knowledge. Mentors were concerned for CALD students when they had to face people on the working units with racist attitudes, especially when they faced nurses who refused to mentor these students. Mentors recognized the impact of the economic situa- tion and the rise in immigration on the attitudes of staff towards mentoring. They also discussed the effects of certain debates in the press and on social media. Mentors expressed a positive attitude to- wards learning and felt that the mentoring of CALD students was a resource through which they could learn more about cultures. The opportunity to experience different nursing cultures during mentoring was seen as an enriching factor. Interviewee (Nr 6.) replied: “When we had these exchange students on the ward, it was such a rich learning ex- perience to be able to compare their way of doing things, how things are done in their countries and how we do them here in Finland. I remember when we were reflecting together on how different our worlds are.” According to the results, the mentoring of CALD students shaped mentors’ attitudes and contributed to their skill development in intercultural communication. Mentors were able to receive various learning experiences related to intercultural communication during mentoring.4.4. Intercultural experienceMentors stated that their intercultural communication skills devel- oped through continuous education and their personal free time ac- tivities. Mentors felt that nursing education had limited contribution on their development of cultural competence. Interviewee (Nr 10) replied: “There was nothing about different cultures in my education. I graduated in the beginning of the 1980s. There was not a single foreigner, not a nurse, a student, or a patient from another culture. Then later on there were refugees or immigrants as patients. There was one nurse visiting us from the Arab Emirates and he had some experience from working there. These things were nice to listen to, but that was the only time.” Mentors with international and intercultural experience stated that this experience had a positive impact on their intercultural communication skills with CALD students. Mentors with experience working and studying abroad replied that this intercultural experience had given them the courage to communicate effectively in mentoring and the ability to understand cultural diversity in communication. Due to an increase in cultural diversity in nursing, mentors stated that they had cumulatively gained intercultural com- munication skills through mentoring CALD students during clinical practice. Mentors’ working experience increased their intercultural skills and motivated them to develop their cultural competence.4.5. Interaction involvementAccording to the results, mentors acted as cultural interpreters for CALD nursing students, patients and for the working community.5P. Hagqvist, et al.Nurse Education Today 87 (2020) 104348Mentors reported that they teach students about issues related to nur- sing culture and cultural interaction in working life. Mentors reported experiencing issues between students and patients related to inter- cultural communication, for example, the need to provide details on the students’ cultural and linguistic backgrounds to elderly patients who were not accustomed to cultural diversity at the hospital. The results indicated that the mentoring of CALD students increased mentors’ in- tercultural communication skills because mentors received enriching learning experiences in intercultural communication during mentoring and they learned to recognize students’ cultural backgrounds and in- dividuality in cultural interactions. Mentors described that during mentoring they processed their own personal stereotypic attitudes and fears, and also those of other people on the working unit. Mentors ac- knowledged cultural, linguistic and ethical challenges of communica- tion during the mentoring and evaluation of CALD students. Mentors experienced linguistic challenges when communicating in a foreign language and trying to ensure common understanding during men- toring and the evaluation process. Mentors also experienced ethical and cultural challenges during the evaluation process because they lacked clear instructions on how to apply evaluation criteria to the evaluation of students’ learning. Interviewee (Nr 6) replied: “If I have an interna- tional student, or at least I feel so, that there is this assumption, that I need to handle these students more tenderly and not be so strict with them like with Finnish students. But I try to mentor all of my students with the same criteria and with the same demands for basic things, same rules for everyone.”Mentors’ good foreign language skills facilitated communication between CALD students and mentors. Students’ language skills and their desire to learn Finnish was seen to promote a successful student-mentor relationship in mentorship. Mentors had experiences of CALD students being active listeners and observers of the mentors’ interaction during the clinical practice. Mentors stated that they adapt their own com- munication style during mentoring in order to facilitate common un- derstanding between the student and the mentor by avoiding the use of dialects and by speaking slowly and clearly. They learned that non- verbal communication becomes the dominant form of communication in the mentoring of students in situations where the common language is missing. However, mentors experienced a lack in their intercultural communication skills to interpret CALD students’ nonverbal commu- nication in mentoring.5. DiscussionThis study applied the integrated model of intercultural commu- nication competence by Arasaratnam et al. (2010) to the context of the mentoring of CALD nursing students during their clinical practice. This study aimed to describe clinical mentors’ experiences of their inter- cultural communication competence in mentoring. It has been pre- viously shown that there is a need for more research regarding the mentoring of CALD nursing students in nursing education (Mikkonen et al., 2017; Pitkäjärvi et al., 2012a) to create culturally safe learning environments for students by avoiding misunderstandings caused by poor intercultural communication (Sairanen et al., 2012) and to im- prove the quality of mentoring (Jokelainen et al., 2011).Mentors with international experience were more empathetic to- wards the CALD students and had a wider understanding of the cultural effects of communication. These findings are consistent with Arasaratnam et al. (2010) regarding a positive significant correlation between empathy and intercultural communication competence. Ability to empathize is shown to be important in mentoring because it promotes motivation to communicate and engage in active listening, which in turn results in perception of intercultural communication competence (Arasaratnam et al., 2010). Clinical mentors are seen as role models for CALD students and known to be supportive, having the ability to be empathetic and hold nursing in high regard (Montenery et al., 2013).Mentors experienced higher motivation when students took anactive approach to learning and showed courage in communicating with staff and patients despite the existence of a certain level of lan- guage barriers. In previous studies, it was observed that there is con- tradiction between mentors’ evaluation of their competence in men- toring nursing students (Tuomikoski et al., 2019) and students’ experiences of clinical learning environment and mentoring (Pitkänen et al., 2018). Mentors evaluated their competence highly, whereas students evaluated their clinical learning environment and mentoring at the satisfactory but not at the excellent level. (Izadinia, 2016; Moked and Drach-Zahavy, 2016). The role of students is highly emphasized in clinical learning, especially their language competence and ability to speak the language of the country they study in Mikkonen et al. (2016a). However, students are in a vulnerable position when they come to learn in clinical learning environments and highly depend on their mentors, and are significantly impacted by how mentors approach them. Pitkäjärvi et al. (2012a, 2012b) recognized that nurses’ attitudes had positive influence upon students’ motivation to overcome barriers in language and in their learning.In this study, lack of resources and support influenced mentors’ motivation to mentor. In a previous study by Jeong et al. (2011), it was shown that mentors were not provided with resources to take care of mentoring duties in clinical learning environments by the hospital and/ or leadership, but rather had a full workload having to take care for their patients and mentor students at the same time. Carlson (2013) stated that it is difficult to reduce the workload of mentors meaning that they often have to balance patient care with the demands of mentor- ship, leading to feelings of stress and inadequacy. Such pressures create ethical dilemma for mentors. In our study, mentors experienced psy- chological and emotional pressure from colleagues and organizations such as the hospital and higher education institution. Cassidy et al. (2017) emphasize that leaders and educators take team responsibility for the clinical practice of nursing students. According to the results of our study, mentors also experienced pressure related to their mentoring competence and experienced ethical challenges to pass a student with less-demanding evaluation criteria and would have liked to receive more support of their team. Cultural diversity encompasses ethical ac- ceptance and respect, which means understanding and recognizing each individual’s uniqueness with individual differences. The Code of Ethics for Nurses set by the International Council of Nursing (ICN, 2012, 2013) states that inherent in all nursing is a respect for human rights, in- cluding cultural rights, to dignity and to be treated with respect. This can be applied to the mentoring of CALD students. According to our findings, mentors had the competence to identify the need to promote a more culture sensitive evaluation process during clinical practices, but they lacked sufficient resources.In this study, mentors shared their fears related to CALD students experiencing discrimination on the ward and of them not feeling ac- cepted by staff in the learning environment. Pitkäjärvi et al. (2012a, 2012b) and Mikkonen et al. (2017) had similar findings indicating that language barriers and staff attitudes towards students played a major role in whether the clinical practice experience would be positive or negative. However, mentors in this study recognized the changing so- ciety and international mobility, especially visible among patients and the global demand for nurses. The global demand for nurses is fueled by an aging population and nursing workforce, a shrinking applicant pool, unfavorable work environments, the increasing complexity of health care delivery, and international nurse migration (Ford and Stephenson, 2014; Nichols et al., 2010). The increasing number of immigrants in the European Union has the potential to become a future asset that can be used to address the shortage of social- and health professionals (Bhopal, 2014). The World Health Organization recommends preparing for the growing number of aging population by ensuring that the future nurses have the competencies needed to provide high-quality and effective care to older patients (Buchan et al., 2017). Nursing curriculums need to include competencies related to healthy aging in the curriculum of all health professions students. This includes also competencies around6P. Hagqvist, et al.Nurse Education Today 87 (2020) 104348communication and empowerment, interprofessional practice and cul- tural competence (Buchan et al., 2017).In our study, mentors with intercultural experience had an in- creased level of cultural competence and cultural knowledge. They also acknowledged the need to update their cultural competence through continuous education. Alpers and Hanssen (2014) emphasize that nurses are not able to develop sufficient cultural competence solely through working experience, but that there is a need to provide nurses with continuous cultural competence education. However, mentors with intercultural experience had linguistic boldness to communicate and to clarify unclear issues with CALD nursing students. Moulder (2011) stated that development of cultural competence is linked to the amount of cultural encounters a person has experienced and the length of their clinical experience. Shen (2014) reported similar findings based on their study, and they recognized that cultural encounters are an important domain of cultural competence along with cultural sensi- tivity, awareness, skill, communication and knowledge.Mentors who participated in this study experienced challenges re- lated to intercultural communication in mentoring and in under- standing CALD students’ nonverbal communication. However, mentors also received rich learning experiences that enhanced their intercultural communication in mentoring. Mentors observed and recognized dif- ferences in the communication of CALD students compared to native nursing students. Mentors were able to develop their intercultural communication skills during the mentoring of students. Mentors de- scribed their own personal biases and stereotypes related to different ethnic groups or cultural backgrounds during mentoring. This kind of stereotyping was also reported in Oikarainen et al. (2018) where mentors reported having a tendency to stereotype CALD students during their clinical practice. ICN (2013) strongly emphasizes the de- velopment of nurses’ cultural and linguistic competence by under- standing and responding effectively to linguistic needs faced in health care encounters. When interacting with clients and students from cul- turally or linguistically diverse groups, mentors need to be able to re- cognize the extra steps that may need to be taken to ensure interven- tions are sensitive to the client’s cultural and linguistic needs. Employers should provide all mentors with an appropriate orientation to ensure they have the competence to address the cultural and lin- guistic needs of their client and student groups (ICN, 2013).6. ConclusionIt is evident that there is a need to educate clinical mentors in order to increase their competence in intercultural communication in men- toring. Continuous education could succeed to further develop clinical mentors’ mentoring expertise, which could greatly benefit students, patients and staff from cultural and linguistic diversity backgrounds. Such education could be designed, implemented and measured for its effect in collaboration between health care organizations and higher educational institutions. Providing intercultural experiences for nurses could be beneficial in the process of building their intercultural com- munication competence, a process that requires face-to-face encounters with other cultures. Providing mentors with further education on the evaluation and reflection of CALD and national nursing students can provide structure and tools for mentors to use in daily mentoring practice. 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