CHAPTER I

THE PROBLEM AND ITS BACKGROUND

INTRODUCTION

The influx of international student nurses here in the Philippines is to no surprise for us at these days.

The struggle on cultural differences fosters a lot of factors, like language barriers and contrasting beliefs, which

may affect the working relationship between them and their patients. Each of the students has their own way of

coping with this situation; and the question is, are patients satisfied with the kind of care that they receive from a

non-Filipino nurse? Rendering quality nursing care is the main goal of nursing. Subsequently, patients’

satisfaction is the main determinant of the quality of care provided.

The patient's perception of care is an important indicator of health care quality. Valid and reliable

measures of patients’ perceptions of patient-centered care are vital to investigations that relate the quality of care

to patient outcomes, health care system characteristics, and patient characteristics (Radwin, 2006).

Satisfaction can be defined as the extent of an individual's experience compared with his or her

expectations. Patients' satisfaction is related to the extent to which general health care needs and condition-

specific needs are met. Evaluating to what extent patients are satisfied with health services is clinically relevant,

as satisfied patients are more likely to comply with treatment, take an active role in their own care, to continue

using medical care services and stay within a health provider (where there are some choices) and maintain with

a specific system. In addition, health professionals may benefit from satisfaction surveys that identify potential

areas for service improvement and health expenditure may be optimized through patient-guided planning and

evaluation (Guldvog B., 2006)

It is indeed a fact that the PERPETUAL HELP COLLEGE OF MANILA, NURSING DEPARTMENT

class from NCM 203 comprises the highest number of students which includes foreign nursing students. We

can’t deny the fact that as the demand for nurses’ increase; the more that the course is being chosen by students

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that even foreign students go here at our country to study nursing which has been a challenge to the Nursing

industry. Foreign student nurses caring for Filipino patients have been intriguing because the question would

always be: Are the patients satisfied with the care rendered by foreign nurses / student nurses? Would they be

able to render quality care to patients? These issues triggered the interests of the researchers to find out whether

international students’ in the college of nursing are rendering the quality nursing care needed by the patients

despite of the difference in culture, language and beliefs.

In this study, the researchers aim to find the relationship between the quality of care rendered by

international students and patients’ satisfaction because they believe that this study would help improve the

quality of health care provided to patients. It would also give an idea about how to reach maximum patients

satisfaction in terms of care. It can also help in developing more ways to render quality care because we would

let the patient talk about what they think on the care rendered to them. Here, quality of care would be measured

through self assessment and patients’ evaluation.

Hence, doing this study would help us gain more knowledge about our profession. Since the primary

goal of nursing is to render quality health care to attain patients’ satisfaction. This study focused merely on

patient and the care delivered to them by foreign student nurses.

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THEORETICAL FRAMEWORK

This study is guided by the following theories: Madeleine Leininger’s Culture Care Theory, Hildegard

Peplau’s Interpersonal Relations Theory, and Bonnie. W. Battey’s Humanizing Nursing Communication

Theory.

In her Culture Care Theory, Leininger states that caring is the essence of nursing and unique to nursing.

(Leininger 2007, Reynolds 2005.) Care always occurs in a cultural context. Culture is viewed as a framework

people use to solve human problems. (Orque et al. 2008, Leininger 2007) It is also diverse, as Leininger (2007)

refers culture to the specific pattern of behaviour which distinguishes any society from others. Leininger (2007,

38) states that culture refers to “the lifeways of an individual or a group with reference to values, beliefs, norms,

patterns, and practices” and agrees that culture is learnt by group members and transmitted to other group

members or intergenerationally. Leininger (2007) actually criticizes the four nursing metaparadigm concepts of

person, environment, health and nursing (Fawcett 2009.) First, Leininger considers nursing a discipline and a

profession, and the term ‘nursing’ thus cannot explain the phenomenon of nursing. Instead, care has the greatest

epistemic and ontologic explanatory power to explain nursing. Leininger (2007) views ‘caring’ as the verb

counterpart to the noun ‘care’ and refers it to a feeling of compassion, interest and concern for people (Leininger

2007). Second, the term ‘person’ is too limited and culture-bound to explain nursing, as the concept of ‘person’

does not exist in every culture. Leininger (2007) argues that nurses sometimes use ‘person’ to refer to families,

groups, communities and collectivities, although each of the concepts is different in meaning from the term

‘person’. Third, the concept of ‘health’ is not distinct to nursing as many disciplines use the term. (Leininger

2007.) Fourth, instead of ‘environment’ Leininger uses the concept ‘environmental context’, which includes

events with meanings and interpretations, given to them in particular physical, ecological, sociopolitical and/or

cultural settings. (Leininger 2007)

The orientation component of the experience can be influenced by factors associated with both the nurse

and patient, such as personal values, culture, beliefs, expectations, and past related incidents.

The Interpersonal Relations in Nursing theory stressed the importance of the nurse’s ability to

understand his or her own behavior to help others identify their own perceived difficulties (Tomey, 2005).

Peplau (2008) describes nursing as: “a significant, therapeutic, interpersonal process. It functions co-operatively

with other human processes that make health possible for individuals in communities. In specific situations in

which a professional health team offers health services, nurses participate in the organization of conditions that

facilitate natural ongoing tendencies in human organisms.

Humanizing Nursing Communication Theory and its companion theory, Ethics of Humanizing Nursing

Communication, by B. W. Battey (aka B. W. Duldt) were developed to bring into nursing the knowledge base of

the Communication and Human Relations discipline. The theories are believed to be consistent with holistic and

humanistic theoretical paradigms. They are designed to be used in conjunction with other theories to not only

facilitate compassionate care, but also support an awareness of the range of patterns and attitudes one may

choose to use in positive as well as unpleasant relationships. These theories emphasize the interpersonal

relationships between the nurse, patient, peers and colleagues.

We formulated a framework in this study to depict on how the cultural differences affect the quality of

nursing care rendered by international student nurses. Moreover, the aim of this demonstration is to show how

the different factors brought about by those differences in culture influence the patient’s satisfaction on the care

that they receive

THEORETICAL FRAMEWORK

TABLE 1

STATEMENT OF THE PROBLEM

This study sought to determine the relationship between quality of patient care given by international

students and patient satisfaction. Specifically, it aimed to answer the following questions:

1. What is the socio-demographic profile of international students pursuing a nursing career in terms of:

Age

Sex

Religion

Country of origin

Residency

2. What is quality of patient care delivered by international student nurses?

3. What is the level of patient satisfaction on the care given by international student nurses?

Cultural differences

Patient’s satisfactionQuality of patient care

Country of origin

Religion, values, beliefs

Sex

Age

4. What is the difference in the level of patient satisfaction contributed by their socio-demographic

characteristics?

5. Is there a significant relationship between the quality of patient care given by international student nurses and

patient’s level of satisfaction?

RESEARCH HYPOTHESIS

Differences exists in the patient satisfaction rating as influenced by the in socio-demographic

characteristics

The study tries to prove that patient satisfaction is associated with the quality of patient care delivered by

international students.

SIGNIFICANCE OF THE STUDY

The study is believed to be relevant in nursing profession and for the community in establishing a link

between an international student nurses and caring for a global patient. That the result of the research will be

useful for both the non and international nursing students to help provide a tender loving and efficient care to

their patients. And also to determine or to discover other barriers that may affect quality nursing care by

international nursing students in satisfying patients, thus it will be useful to develop or improve the ways on

how these students will deliver care. Findings of this study were deemed significant to the following:

Nursing Administration. The study may provide effective guidelines in the administration and supervision of

instructions in all levels of nursing education. Furthermore, the outcome of the study may serve as the basis for

the formulation of a rigid program that will put emphasis on the quality of nursing care rendered by the

international student nurse so as to satisfy patients in different institutions.

Nursing practice. Through this study the international student nurses were made aware of their nursing care

rendered to different patients in different institutions by means of nursing interventions to help in patient’s

recovery.

Nursing Education. In clinical education, assessment of student nurse especially the international nursing

students is very important to guarantee that Bachelor of Science in Nursing graduates are competent. The study

may contribute to the improvement of nursing care rendered by the international nursing students that can also

contribute in nursing education and nursing research to improved quality of life.

Nursing Research. The findings of this study could be used as an allied study and baseline data for future

research.

Patient. Given that the researchers valued patient’s satisfaction, this study was focused on the ways to promote

good health service given by international student nurse to satisfy patients.

Student Nurse. Determining the patients’ satisfaction on the care rendered by international student nurse could

push students to strive harder in rendering quality care to patients. And also this will be significant by knowing

their weakness and strengths so that they could work or change it in order to provide much effective nursing

care.

SCOPE AND LIMITATIONS OF THE STUDY

The study is set at the Institute of Nursing- PERPETUAL HELP COLLEGE (Manila) and

different affiliated clinical institutions wherein the foreign students/students acquired residencies in the other

country had their clinical exposure or RLE (Related Learning Experience). The inclusion criteria for the student

respondents to be included were: (1) enrolled in the PHCM BSN program; (2) 3 rd yr and 4th yr international

student nurses who are having their clinical exposure at different affiliated hospitals; (3) 26 years old and below;

(4) had their clinical duties at the time of the research was conducted; (5) willing to participate in the study

The characteristics of the participants that are not taken as subject of the study includes: (1) not enrolled

in the PHCM BSN program; (2) 1st yr, 2nd yr, 3rd yr and 4th local student nurses; (3) 1st yr non-resident Filipino

student nurses; (4) 25 years and above; (5) 1st yr and 2nd yr PHCM international student nurses who were not yet

able to have their clinical duties; (6) not willing to participate in the study.

The inclusion criteria for patient are: (1) either male or female; (2) has been in the care of an PHCM

international/residency acquired in other country student nurse; (3) 16 years old and above; (4) able to read and

write; (5) not suffering from any cognitive or mental disorders; (6) willing to participate in the study.

The exclusion criteria that deterred the patient respondents from participating (1) has not been in the care of

an PHCM international student nurse; (2) 15 years old and below; (3) not able to read and write (4) under the

care of foreign student nurses from 6 A.M. to 10 P.M.;(5) refusal to participate in the study.

The researcher selects the respondent from both sexes to avoid bias. Age is important because it will

determine the patient ability to answer questions competently and independently. Superfluous variables like: (1)

patient receives care from the staff nurses not solely from the foreign student nurses were illicit so they will not

affect the relationship of patient satisfaction and the performances of the foreign student nurses in the clinical

field.

The evaluation time of the nursing care rendered by foreign students included was restricted to those with

shifts from 6 in the morning until 10 in the evening given that beyond the required shift, patients were asleep;

thus may thwart the evaluation of satisfaction on the part of the patient.

The study is exclusively for foreign nursing student of PHCM who are rendering care for their clients

because the utilized tool is rigorously for use of this institution and its foreign nursing students, to evaluate their

effectiveness in rendering nursing care for their client in the Philippines. Measuring the effectiveness of care by

the foreign students is depends on the patient satisfaction in services given by the foreign nursing students

DEFINITION OF TERMS

Quality of Patient Care

- involves assessing the appropriateness of medical tests and treatments and measures to continually

improve personal health care in all fields of medicine(Source: http://www.kaiseredu.org)

- In this study, quality of care is the ability of the student nurse to deliver effective nursing care based on

individual needs wherein patient’s can experience satisfaction. This is measured using Nursing Quality

Scale Tool with the following scores: 5-point Likert scale (5-strongly agree, 4-agree, 3-Neutral, 2-

disagree and 1-strongly disagree) .

Patient’s Satisfaction

- is the degree of congruency between a patient’s expectations of ideal nursing care and his perception of

the real nursing care that he receives (SOURCE: www.hrsdc.gc.ca).

- In this study, patient satisfaction is measured using the following domains:

(i) Responsiveness is conceptually defined as the degree to which the nurse demonstrates that she or he is able

to meet patient needs in caring and attentive manner.

(ii) Individualization is the degree to which the nurse personalizes care according to the patient's feelings,

preferences, and desired level of involvement in care.

(iii) Coordination is the degree of communication among other nurses and the patient.

(iv) Proficiency is the degree to which the nurse provides knowledgeable, skillful nursing care.

The mean of the satisfaction rating were assigned according to the four domains. The total mean for each

domain of patient satisfaction was used to derive the general average of patient satisfaction. Mean was used to

identify the average of the patient satisfaction from the respondents.

International Student Nurses

- Refers to students with foreign nationalities who studied nursing course in foreign (Philippines)

educational institutions. In addition, the term also suggest non-resident Filipinos or those who have

Filipino lineage but either live permanently or was raised in another country however decided to pursue

nursing in the Philippines, to be considered as international student nurse. (Source:

http://www.icn.ch/ns/ns_home.htm)

- International students, under the nursing curriculum are exposed with the clinical situations in their

related learning experiences. That encompasses autonomous and collaborative care of individuals of all

ages, families, groups and communities, in hospital settings.

CHAPTER II

REVIEW OF RELATED LITERATURE

This Chapter presents the reviewed literature and studies that are related to the present study.

The Provider Culture

Providers of health care are often faced with challenges. One of those is the culture differences which

exposes them to a set of different values, beliefs, and practices. With the nature of our profession, it is one of

our responsibilities to understand, learn, and eventually accept that even though our patient’s culture is

different from us, we should serve them without prejudice. Our approach must correspond to the needs of the

patient, regardless of the gap between his and the providers culture. Care means that the patient should be

treated as a human being, with a life beyond the hospital and a meaning beyond the medical world. Nursing

care is hands on, a face – to – face encounter with the patient.  It is entirely appropriate to explore alternative

ideas regarding health and illness and adjust our approach to coincide with the needs of the specific patient 

Galanti (2007) makes two important points regarding disease etiology.  First, the treatment must be

appropriate to the cause.  If the germs cause disease, kill the germs.  If the body is out of balance, restore

balance.  If the soul is gone, retrieve it. If a spirit has taken over the body, exorcise it.   If a rule has been

broken, do penance.  If an object has entered the body, remove it.  All these remedies are perfectly logical.

Whether these etiologies are the true causes of the disease is irrelevant.  A patient who believes he or she is ill

because of soul loss will not be cured by any amount of antibiotics.  The mind is very powerful, as the placebo

effect demonstrates.  The patient’s beliefs, as well as body, must be treated.

Second, we must not let our ethnocentrism blind us to the merits in the beliefs of other cultures. They

may be right. It is easy to look down on other systems, citing science to support Western medical beliefs. But

all medical systems are based on observed cause – and – effect relationships. The major difference with the

scientific approach is that science is falsifiable. A scientific hypothesis can be proven wrong. The beliefs of

other systems cannot.

Communication Barriers

Communication is one of the most important factors in our profession. However, effective

communication may be hard to achieve because of some factors such as cultural differences. Communication

specialist Stella Ting-Toomey has identified three cultural barriers that impede effective communication.

Knowing these barriers can help you avoid or at least do something about them. These include cognitive

constraints, behavior constraints, and emotional constraints.

Cognitive constraints are the way people view the world based on their culture. Basically, these are

created by the way people give meaning to the world around them based on the knowledge and perceptions they

have obtained. It varies from culture to culture. Behavior constraints are the ways people behave from different

cultures. This can be as simple as eye contact or how close you should be to somebody. The third cultural

barrier that blocks effective communication is emotional constraints. Each culture has rules that tell us how

emotional we can be in a situation.

Quality is seen as an experiential judgment emerging from the nurse patient interaction (Gunther, 2001;

Fedorawicz, 2009) as advocated in the King’s model. It requires the nurse’s understanding, self-awareness and

perceptual accuracy to guide communication effectively during the nurse-patient interaction.

It is further assumed that nurses who are intuitive and empathic provide high quality nursing care

(Reynolds, 2006). Dungan model of dynamic integration (DMDI) views humans as possessing synergistic

dimensions of body, mind, and spirit. Therapeutic relationships are accomplished through the provision of

presence, listening, and communication through “mutuality of concern” which is a construct believed

synonymous with empathy.

Research findings of Brown (2005) indicated that nurse empathy positively influences patient

satisfaction with care. Nurses and patients agreed that the relationship developed between the nurse and patient

is very important. Patients identified the most important nursing action as “being there”, and “taking time to sit

down and listen”

According to a study conducted by Yow (2007), nurse-patient interactions are important in the delivery

of effective nursing care. The combined effects of role and personal relationships influence the working

relationships that develop between nurses and patients. Categories of role relationships are direction and

information exchange. The category that describes relationships, on the other hand, is rapport.

Moreover, nurses are expected to develop some of the features of what Morse (2005) described as a

“connected care relationship”. Person-centered care relies on effective nurse-patient communication. The

central tenet of person-centered care is that nurse practitioners work closely with the patients’ perspectives and

needs (Clarke et al 2008). Through effective communication skills, nurses need to know how to “say the

words” that give shared meaning and respect for dignity to physical care.

Communication failure may occur due to the high stress inherent in the medical situation and the

hospital setting or due to the time constraints placed on health care providers. The nurse especially should be

aware of culturally appropriate ways to intervene in stressful situations. Maintaining a neutral space with a deaf

patient to limit misinterpretation of confrontation or authority is crucial to de-escalating a tense situation.

Interpreters also should be aware of de-escalating techniques. When interpreters facilitate the communication

between the nurse and deaf patient, the angry patient may feel more isolated; conversely, the interpreting lag

may allow the patient the time needed to regain composure (Jeffrey & Austen, 2005).

Non-aggressive, socially ap propriate eye contact should be maintained, as discontinuous eye contact is

perceived as impolite within the Deaf community (Jeffrey & Austen, 2005). If the deaf patient seems to respond

solely to the interpreter and to disregard the health care providers, the nurse should be aware that this could be a

sign of hostility toward the provider. Even greater sensitivity is needed in this situation as the nurse looks for

signs or gently asks the patient for information that will allow confirmation of a possible explanation of the pa

tient's behavior (Jeffrey & Austen, 2005).

Socio-demographic factors and self-reported functional status: the significance of social support

These results suggest that socio-demographic factors are as important as physical health variables in

affecting a person's ability to function normally in their everyday life. Social support appears to play a

significant role in explaining differences in subjective functioning: people living alone or only with the spouse,

particularly the elderly, seem to be in greater risk for disability problems and should be targeted by preventive

programs in the community. Additionally, even in a medium size semi-rural community as this one, where

social ties remain still strong among its members, the 'live alone' or the 'live only with the spouse' patterns of

living arrangements were identified as high-risk groups for disability. In Greece, a country with a fast growing

elderly population, more consistent and coordinated measures of community care should be considered in the

future in order to meet effectively the needs of those groups. (© 2008 Koukouli et al)

Cultural Competence

To be culturally competent the nurse needs to understand his/her own world views and those of the

patient, while avoiding stereotyping and misapplication of scientific knowledge. Cultural competence is

obtaining cultural information and then applying that knowledge. This cultural awareness allows you to see

the entire picture and improves the quality of care and health outcomes.

Since the perception of illness and disease and their causes varies by culture, these individual

preferences affect the approaches to health care. Culture also influences how people seek health care and how

they behave toward health care providers. How we care for patients and how patients respond to this care is

greatly influenced by culture. Health care providers must possess the ability and knowledge to communicate

and  to understand health behaviors influenced by culture. Having this ability and knowledge can eliminate

barriers to the delivery of health care.  These issues show the need for health care organizations to develop

policies, practices and procedures to deliver culturally competent care.

Cross, T., Bazron, B., Dennis, K., and Isaacs, M. (2009)  list five essential elements that contribute to

an institution’s or agency’s ability to become more culturally competent. These elements are valuing

diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when

cultures interact, having institutionalized cultural knowledge, and having developed adaptations of service

delivery reflecting an understanding of cultural diversity. 

Meyer CR.(2009) describes four major challenges for providers and cultural competency in healthcare.

The first is the straightforward challenge of recognizing clinical differences among people of different ethnic

and racial groups (e.g., higher risk of hypertension in African Americans and of diabetes in certain Native

American groups). The second, and far more complicated, challenge is communication. This deals with

everything from the need for interpreters to nuances of words in various languages. Many patients, even in

Western cultures, are reluctant to talk about personal matters such as sexual activity or chemical use. How do

we overcome this challenge among more restricted cultures (as compared to ours)? Some patients may not

have or are reluctant to use telephones. We need to plan for these types of obstacles. The third challenge is

ethics. While Western medicine is among the best in the world, we do not have all the answers. Respect for

the belief systems of others and the effects of those beliefs on well-being are critically important to competent

care. The final challenge involves trust. For some patients, authority figures are immediately mistrusted,

sometimes for good reason. Having seen or been victims of atrocities at the hands of authorities in their

homelands, many people are as wary of caregivers themselves as they are of the care.

Cultural differences and workplace values are important factors to consider when recruiting a foreign-

educated nurse. Flynn and Aiken (2010) reported American-born nurses were concerned that a large influx of

foreign-educated nurses might not share their culture, workplace values, and goals and might undermine efforts

to improve hospital working conditions and standards of nursing practice.

Flynn and Aiken (2010) conducted a secondary analysis of prior research that examined professional

values related to nursing practice environment. The analysis investigated nurse autonomy, control over practice

environment, and relationships with physicians. Flynn and Aiken's (2010) findings suggested that nurses

worldwide shared core professional values that led to a positive workplace environment, improved job

satisfaction, and patient outcomes; however, American nurses placed a higher value on autonomy than foreign-

educated nurses. Carney (2005) recommended a strong mentor and orientation program to facilitate the

development of autonomous and competent foreign-educated nurses. Cultural competency training is

recommended for both the foreign nurses as well as the institutions' staff to ensure effective communication

between colleagues and patients (Carney, 2005).

Differences in culture affect the way student nurses provide care for their patients. Such differences must

not be a barrier for the patients not to receive the quality of care that their condition requires. In these cases,

student nurses should exert an effort and their patients must cooperate for them to establish a healthy working

relationship in order to produce positive outcomes.

The Role of Culturally Competent Communication in Reducing Ethnic and Racial Healthcare Disparities

Promoting culturally competent communication at the provider, care institution, health plan, and national

levels is likely to contribute to success in reducing racial and ethnic disparities in the receipt of high quality

care. Although some health plans recently have shown interest in addressing racial and ethnic disparities in care,

very few have addressed how health plans can improve their cultural competency to reduce disparities. This

commentary summarizes the importance of culturally competent communication across several levels of the

healthcare system and details concrete steps that managed care organizations can take to maximize their ability

to provide culturally competent communication and care. (Am J Manag Care. 2005;10:SP1-SP4)

The importance of effective patient-provider communication in delivering high-quality care is well

accepted. Good patient-provider communication is associated with better patient satisfaction, better adherence to

treatment recommendations, and improved health outcomes. It is assumed, but not proven, that the components

of communication that acknowledge and take into account differences between providers and patients—

particularly with regard to culture, ethnicity, and beliefs—play an important role in efforts to reduce racial and

ethnic disparities in the quality of care. Culturally competent communication refers to communicating with

awareness and knowledge of healthcare disparities and understanding that sociocultural factors have important

effects on health beliefs and behaviors, as well as having the skills to manage these factors appropriately. This

issue is so important that the Institute of Medicine, in its seminal report Unequal Treatment, identified cross-

cultural training as a key recommendation for reducing healthcare disparities. Numerous other organizations

have addressed the need to incorporate culture in the training of health professionals. (S.Taylor, N.Laurie,

2008)\

The Cultural Lens of Genomics

It is essential that healthcare professionals provide genomic-focused care in a culturally sensitive

manner, recognizing and respecting the cultural values and beliefs of each and every patient.

Knowledge of the basic ethno-cultural values of patients and their families can guide the healthcare

provider in delivering ethno-culturally competent, genomic healthcare that meets the needs of a rapidly

growing, diverse population. A growing understanding of the importance of unique, ethno-cultural values will

equip the healthcare provider to deliver culturally sensitive, genomic care to individuals from any culture, race,

or ethnicity.

Failure to consider ethno-cultural health practices and beliefs, including those related to causes of disease and

birth defects, may decrease the effectiveness of genomic care, as ethno-cultural beliefs directly influence how

the genomic information related to counseling is received by the client (Weil, 2008). Additionally, the absence

of patients' basic knowledge concerning body structure and function, the relative importance attributed to

physical as compared to cognitive limitations or disability, the use of lay and/or community health practices and

healers, and expectations concerning medical treatment and practitioners, also influence the effectiveness of

genomic services. Understanding the association between racial/ethnic ancestry, culture, healthcare values, and

behaviors is of major importance when conveying genomic information.

The Danger of Stereotyping

A stereotype is an ending point, and no effort is then made to ascertain whether it is appropriate to apply

it to the person in question. A generalization, on the other hand, serves as a starting point. Knowledge of cultural

customs can help avoid misunderstanding and enable practitioners to provide better care. A generalization is a

statement about common trends within a group, but with the recognition that further information is needed to

ascertain whether the generalization applies to a particular person. Therefore, it is just a beginning. Because

differences always exist between individuals, stemming from a variety of factors, such as, in the case of

immigrants, the length of time they have spent in the United States and their degree of assimilation, even

generalizations may be inaccurate when applied to specific persons.

Lack of eye contact in American culture may indicate many things, most of which are negative. A

physician may interpret a patient’s refusal to make eye contact as a lack of interest, embarrassment, or even

depression. However, a Chinese patient may be showing the physician respect. If the patient is female and from

a Muslim country, and the physician is male, she may be trying to avoid sexual impropriety. A Navaho patient

may be trying to avoid soul loss or theft. Knowing the meaning of eye contact, or lack thereof, may help avoid

misinterpreting a patient’s behavior. Many health professionals think that if they just treat each patient with

respect, they will avert most cultural problems. Nurses are generally taught the importance of touch. Yet, if they

are caring for a patient of the opposite sex and that patient is an Orthodox Jew, for example, it is important to

know that, for that religion, contact outside of hands-on care is prohibited.

Cultural generalizations will not fit every patient whom physicians see, but knowledge of broad

patterns of behavior and belief can give physicians and other health professionals a starting point from which

to provide the most appropriate care possible. In the coming months, we hope this series will provide insights

that can help in the treatment of patients from a variety of ethnic and cultural backgrounds with greater

awareness and competence.

Synthesis:

Foreign students should be culturally competent in order to give the best nursing care for patients.

Studying in foreign country is never easy. And these foreign students are equipped with new perspective to the

differences of both cultures. It’s an important lesson for nursing students to learn as the world becomes a

smaller place. Not only are students taking advantage of opportunities to travel abroad, but also becoming more

diverse and bringing their cultures and beliefs with them.

Communication is the most important way to stay ahead in the world. However, communication can be

difficult sometimes. There are many reasons for this, one of which is cultural differences.—E.J. Benac

Stella Ting-Toomey, a communication specialist, describes three ways in which cultures interferes with

effective cross-cultural understanding. First is what she calls cognitive constraints. It is created by the way

people’s mind give meaning to the world around them based on the knowledge and perception they have

obtained. Second is behavioral constraint. Each culture has its own rules about proper behavior which affects

verbal and non verbal communication. Third factor is emotion constraint. It is how different cultures display

their emotions.

GA. Galanti (May 2008) point out examples of the danger of stereotyping and role of generalizations.

According to Galanti, the most profound difference is may be cultural. Knowledge of cultural customs can help

avoid misunderstanding and enable practitioner to provide better care.

Promoting culturally competent communication at the provider, care institution, health plan and national

levels is likely to contribute to success in reducing racial and ethnic disparities in the receipt of high quality

care. Good patient-provider communication is associated with better patient satisfaction, better adherence to

treatment recommendation and improved health outcomes—S.Taylor, N.Laurie(2008).

Considering the ethno-cultural health practice helped increase healthcare providers' awareness of basic

cultural values that can influence the decisions made by members of diverse patient populations. (Paniagua,

2008).

Quality nursing care and patient’s satisfaction must always be the priority despite the presence of

cultural differences.

CHAPTER III

RESEARCH METHODOLOGY

This Chapter discussess the method of research used, the population and sample data gathering

instrument, procedure in gathering the data and statistical treatment of the data.

RESEARCH METHOD USED

The study used a qualitative research design; particularly the Descriptive- Correlational Design because

it’s the best tool used to describe a statistical association between two or more variables and as it involves

observing and describing the behavior of a subject without influencing it in any way. The study describes

relationship between patient’s satisfaction and quality of nursing care rendered by international student nurses.

The researcher observed the phenomena as they occur naturally and does not intervene in any way but

difference in the level of patient satisfaction influenced by the international student nurse’s socio-demographic

characteristics was established. Subsequently, Grouping and Ranking Patient’s satisfaction and quality of

nursing care will be possible made through data gathering and using spearman’s rho which is a non-parametric

measure of correlational as it illustrated the relationship of two variables.

POPULATION AND SAMPLE

The inclusion criteria for the student respondents to be included were: (1) enrolled in the PHCM BSN

program; (2) 3rd yr and 4th yr international student nurses; (3) 24 years old and below; (4) had their clinical duties

at the time of the research was conducted; (5) willing to participate in the study

The exclusion criteria that deterred the student respondents from participating were: (1) not enrolled in

the PHCM BSN program; (2) 1st yr, 2nd yr, 3rd yr and 4th local student nurses; (3) 1st yr non-resident Filipino

student nurses; (4) 25 years and above; (5) 1st yr and 2nd yr PHCM international student nurses who were not yet

able to have their clinical duties; (6) not willing to participate in the study.

The inclusion criteria for the patient respondents to be included were: (1) either male or female; (2) has

been in the care of an PHCM international student nurse; (3) 16 years old and above; (4) able to read and write;

(5) not suffering from any cognitive or mental disorders; (6) willing to participate in the study.

The exclusion criteria that deterred the patient respondents from participating (1) has not been in the care of

an PHCM international student nurse; (2) 15 years old and below; (3) not able to read and write; (4) refusal to

participate in the study

The student respondents were 24 years old and below, 2nd yr, 3rd yr and 4th yr foreign and non-resident

Filipino student nurses enrolled in the PHCM BSN program that had their clinical duties at the time of the

research period and were willing to participate. These criterions were applied for the reason that the researchers

wanted to make a study about their clinical performance in rendering care to patients while being in a different

country and caring for patients who had a different culture form their own.

The patient respondents were 16 year old and above male or female patients who were under the care of an

PHCM international student nurse, able to read and write, not suffering from any cognitive or mental disorders

and were willing to participate. These criterions were applied for the reason that the researchers wanted the

patients to evaluate the care rendered to them by someone who had a different nationality or culture from theirs.

The researchers used non-probability purposive sampling design in sample selection wherein the sample

were handpicked because the researchers knew who among the population could meet the criterion and also this

type of sampling design was the most applicable to the study.

RESEARCH LOCALE

The research study was conducted at different hospitals but no exact location due to different places of

duty that was assigned to international student nurses. The questionnaires were given to international student

nurses and for the patients who will evaluate the efficacy of nursing care delivered by international student

nurse. It was chosen because of its accessibility for the researchers and the qualified samples needed for the

study were situated at the locale. The researchers selected different affiliating hospitals as locale for the

following reasons: (1) PHCM international students were having their clinical exposure in the affiliating

hospitals (2) researchers were permitted to conduct study to the patient involve before or after the duty of the

student subjects (3) researcher’s communication letter was approved and evaluation of foreign student nurses in

a certain hospital were they render care to patient was easily done.

RESEARCH INSTRUMENT

The instrument that was used by the researchers to measure the self assessment of the foreign

nursing students on their effectivity as care providers was Nursing Quality Scale (NQS) developed by Mamauag

and Magno (2005) composed of 120 items with 30 items for each factor, using a 5-point Likert scale (5-strongly

agree, 4-agree, 3-neutral, 2-disagree, 1-strongly disagree). The domains used to measures effective nursing

quality traits: caring, commitment, compassion, and connectedness. The focus of the questions is to

Assess/Evaluate the perception of the foreign nursing students on their effectiveness. After revising the tool,

some questions were removed and it was reduced to 40: henceforth it was easier for the respondents to answer it

and understanding of each queries was guaranteed due to lessen number of questions. The original score of the

test is Cronbach’s alpha value of .95. High scores indicate possession of strong characteristics of the domains

measured thus ensuring the effectivity of the nursing student as care provider. The participants chose the most

appropriate rating for each question asked to indicate their assessment of their nursing care. Demographic data

such as name (optional), age, sex, residency were asked in the instrument.

In terms of measuring the level of patient satisfaction with the care rendered by the foreign nursing

students, the researcher used a checklist to gather data on patient satisfaction. The tool developed by Suhonen,

Schmidt, & Radwin(2006) was originally devised to measure oncology patients’ perceptions of patient-centered

care. The scale was subsequently reviewed in a sample of hospitalized medical-surgical patients in Finland and

found to be psychometrically sound (Suhonen, Schmidt, & Radwin, 2007), providing assurances that the

OPPQNCS can be used with non-cancer patient populations. The scale developed Suhonen, Schmidt, & Radwin

consisted of 40-item statement comprising of four domains used to evaluate patient level of satisfaction:

responsiveness, individualization, coordination, and proficiency. Always, almost always, often, sometimes

almost never and never was the original scale used to attest the four domains.

The original Internal consistency reliability of the OPPQNCS© was assessed using coefficient alpha.

Coefficient alpha of the total 40-item scale was .99; .99 for the Responsiveness subscale, .97 for the

Individualization subscale; .87 for the Coordination subscale, and .95 for the Proficiency subscale.

The instrument was modified by the researchers: it was changed into 5-point Likert scale (5-strongly agree,

4-agree, 3-neutral, 2-disagree and 1-strongly disagree) in order to measure patient satisfaction and term nurses

was changed into singular form to satisfy the what the researchers are looking for. In the direction, international

student nurses were added and phrase last hospitalization was removed. The study participants checked the

rating which corresponds to the degree of satisfaction they had received from the care delivered by the foreign

nursing students.

Prior to the dispersion, the questions were translated to Filipino language in order to assure better

understanding of the study participants. Demographic data liked name, age and gender were asked.

Clarifications regarding the Likert scale was done, so as the participants understood well how to rate each

questions.

DATA COLLECTION PROCEDURE

Before the actual survey dissemination the researcher’s also sought for the help of RLE coordinators from

Level III - Level IV for the rotation plan of the foreign student nurse and the clinical instructors assigned. A

request to conduct research on different affiliating hospitals were foreign students were having their duty was

also asked to the professor in charged and it was made to the hospital administrator through the help of training

officer to be able to conduct study. The purpose of the study was discussed to assure the hospital administrators

the validity and confidentiality of the data that will be gathered and that it will only be used for research

purposes, thus ensuring the understanding of both the researchers and the hospital management. The researchers

also coordinated with the international student nurses for their schedule of activities and informed them about

the study before visiting them in their duty.

Purposive non-probability sampling design was used in sample selection. The respondents were

handpicked because of their representation on a certain population of interest which is international student

nurses. Informed consent was given to international student nurse to be able to conduct primary data gathering.

The Nursing Quality Scale checklist was given to second year to fourth year international student nurses to

gather data about their self-assessment as care providers. The purpose of the study was also introduced to the

study participants. Student nurses were not forced to answer the self-assessment test because they are asked to

signed the inform consent given prior to dissemination of the checklist. The researchers ensured that the

standard procedures of test administration were followed. Instructions were explained thoroughly and

confidentiality of the results was assured to the participants. After the administration of the Nursing Quality

Scale Test, the students were debriefed about the purpose of the study and their permission was asked to include

their test scores as part of the processing and analysis of the study.

In relation to data about patient satisfaction, the researchers coordinated with the clinical instructors to

be able to satisfy what had been asked in the inclusion criteria. Specific targets that are qualified in the inclusion

criteria were the only one asked to conduct study with. Explanation about the purpose of the study was done to

the participating patients and assurance of confidentially was also made. The researcher conducted the study

guided by checklist wherein it was given to evaluate their nursing care experience from the international student

nurses. The instruction in answering the checklist was also explained, proper terms were used to ensure better

understanding of the respondents. Before the end of communication, confidentially of the results was again

guaranteed to the participants.

STATISTICAL TREATMENT

The researchers used statistical procedures that summarized, organized, evaluated, interpreted and

communicated numeric information that gathered in this study.

This study will determine the patient’s satisfaction and quality of nursing care rendered by the

international student nurses.

1. The socio demographic profile variable of the patient respondents name (optional), residency, age and

sex. The sex was grouped into Male and Female. The mean score of the patient satisfaction was grouped

according to profile variables.

FREQUENCY: It is counted number times that each age and gender appeared in the survey. It is also

counted the number of respondents who answered a certain scale.

PERCENTAGE: This was employed to determine the proportion of respondents who are involved in the

study. The formula is:

P=f/N x 100

Where: P = percentage

F = number of scores

N = total number of respondents

WEIGHTED MEAN: Is used to aggregate the importance of the respected subjects being studied. The

formula is:

W1 (scale) + w2 (scale) + w3 (scale) + w4 (scale)c/ N

Where: W = scale

N = total respondents

2. The quality of care rendered by the international student nurses was evaluated through a Nursing

Quality tool. It was measured in the tool using a 5-point Likert scale (5-strongly agree, 4-agree, 3-neutral, 2-

disagree, 1-strongly disagree). The total mean of each was used to derive the general average of the quality of

care.

3. The satisfaction ratings of patient respondents were grouped into four domains (Responsiveness,

individualization, coordination, and proficiency). The mean of the satisfaction rating were assigned according to

the four domains. The total mean for each domain of patient satisfaction was used to derive the general average

of patient satisfaction. Mean was used to identify the average of the patient satisfaction from the respondents.

4. The relation between the general average of quality of nursing care delivered by international student

nurses and the general average of patient satisfaction were treated using Spearman’s Rho to identify the degree

of the relationship between patient satisfaction and quality of nursing care. Spearman’s rho is a non-parametric

test that was used because ordinal and nominal numbers were employed in the study.

5. The relation between the general average of quality of nursing care delivered by international nursing

students and the general average of patient satisfaction was treated using t-test to determine the level of

significance between the two variables. In addition, as it is a parametric procedure for testing differences in

group means and it can be use when there are two independent groups & when the sample is paired or

dependents.