Abstract
This thesis reports on a qualitative study of the role of reflection in the development of second year medical students’ intercultural competence. Reflective capacity is an important professional competency and is crucial for the development of intercultural competence in medicine. Few studies have examined students’ reflective thinking in relation to intercultural competence and no studies have done so in a medical context. This study aimed to evaluate students’ levels of reflection in online discussions and to explore the connection between students’ reflections and intercultural sensitivity—a component of intercultural competence.
The context of the study was two online discussions with 123 students and 12 tutors in a Culture and Health unit in second-year medicine at a New Zealand university. In the first online discussion, students were asked to apply Hofstede’s dimensions of culture to the actions of the doctor, patient, or family depicted in an intercultural clinical case reading and analyse how cultural differences impacted patient outcomes. In the second, students considered a documentary film and discussed how a doctor’s culture and perceptions may impact his or her ability to provide culturally competent care. Each online assignment required students to make at least one post and to reply to a classmate’s post.
In this thesis, I explore 1) students’ levels of reflection in the two online discussions, 2) the quality of intercultural sensitivity observed at each level of reflection, and 3) the factors that fostered or hindered students’ reflection and intercultural learning online. Data included students’ posts in two online discussions and written feedback from students and tutors. In order to assess students’ levels of reflection, I adapted a framework from the literature that identified three levels of reflection: ‘understanding’ (L1), ‘practical reflection’ (L2), and ‘critical reflection’ (L3). At ‘understanding’ (L1), students described cultural concepts but did not relate them to personal experience or practice situations. At ‘practical reflection’ (L2), students applied course content to intercultural clinical cases and related new knowledge to prior experience or practice situations. At ‘critical reflection’ (L3), the student reviewed their assumptions, and showed evidence of the development of a new conceptual framework. The majority of posts were at ‘understanding’ (L1). Only one student demonstrated ‘critical reflection’ (L3).
To evaluate students’ intercultural sensitivity, I used the Intercultural Development Continuum, which indicates their ability to notice cultural differences, analyse their impact, and identify strategies for effective intercultural interaction. The continuum is based on the notion that as a person’s intercultural sensitivity increases they move from an ethnocentric to an ethnorelative mindset. The stages of the continuum range through denial, polarisation (i.e., defence or reversal), minimisation, and acceptance, to adaptation. Only a few students at ‘understanding’ level exhibited ‘defense’, an ethnocentric perspective. These students made simplistic comparisons that portrayed unfamiliar cultural characteristics as ‘wrong’ while representing familiar cultural characteristics as ‘correct’. Most students at all levels of reflection viewed culture from a position of ‘acceptance’, an ethnorelative perspective, in that they recognised how individuals’ behaviour made sense from a particular cultural worldview. What distinguished students at ‘practical reflection’ level was the ability to relate concepts of culture to themselves, their prior experience or their future practice. Two students at ‘practical reflection’ level demonstrated ‘adaptation’ or the ability to shift frames of reference and engage in cultural empathy.
The online discussions successfully encouraged reflective discussion and recognition of multiple perspectives. However, the design of the online assignment, students’ surface approaches to the online task, and the public and obligatory nature of online reflection hindered some students’ reflection and participation. The study revealed how complex it was to evaluate reflection; other limitations of the study were noted.
The study findings add three important insights to existing literature on reflection and intercultural competence in medical education. First, it revealed that even at ‘understanding’ level students recognised multiple perspectives and demonstrated valuable insights into the impact of culture in a medical context. This finding differs from prior research that found that non-reflective students struggled to recognise multiple perspectives. Second, the study confirmed and extended prior research indicating that reflection plays a key role in students recognising their own worldview, and its impact on their beliefs, which may differ from others’. Third, the study findings suggest that online discussion is a useful tool for encouraging students to think more reflectively about the implications of culture in medicine.
Study findings highlighted several implications for those wishing to introduce blended learning approaches in medical education, especially those involving reflection. A key implication is that programme coordinators must ensure the ‘buy in’ of teaching staff, and recognise the time required to monitor and facilitate online reflection. Furthermore, where the learning activity involves reflective tasks, staff and students need to have a shared understanding of what constitutes reflection and be clear about the purpose of any online discussion. Future studies are needed that explore how formative feedback on students’ online reflection can encourage deeper reflection over a longer timeframe. Further research is also needed that explores the impact of staff attitudes on students’ intercultural learning.