Utilising the hand model to promote a culturally safe environment for international nursing students.
Abstract: The rising number of international students studying outside their own country poses challenges for nursing education. Numbers are predicted to grow and economic factors are placing increasing pressure on tertiary institutions to accept these students. In adapting to a foreign learning environment international students must not only adapt to the academic culture but also to the socio-cultural context. The most significant acculturation issues for students are English as a second language, differences in education pedagogy and social integration and connectedness. Students studying in New Zealand need to work with Maori, the indigenous people, and assimilate and practice the unique aspects of cultural safety, which has evolved in nursing as part of the response to the principles underpinning the Treaty of Waitangi. The Hand Model offers the potential to support international students in a culturally safe manner across all aspects of acculturation including those aspects of cultural safety unique to New Zealand. The model was originally developed by Lou Jurlina, a nursing teacher, to assist her to teach cultural safety and support her students in practising cultural safety in nursing. The thumb, represents 'awareness', with the other four digits signifying 'connection', 'communication', 'negotiation' and 'advocacy' respectively. Each digit is connected to the palm where the ultimate evaluation of the Hand Model in promoting cultural safety culminates in the clasping and shaking of hands: the moment of shared meaning. It promotes a sense of self worth and identity in students and a safe environment in which they can learn.

Key Words: Cultural safety, nursing, education, international students, hand model.
Article Type: Report
Subject: Nursing students (Social aspects)
Teachers (Services)
Authors: Mackay, Bev
Harding, Thomas
Jurlina, Lou
Scobie, Norma
Khan, Ruelle
Pub Date: 04/01/2011
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2011 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: April, 2011 Source Volume: 27 Source Issue: 1
Topic: Event Code: 290 Public affairs; 360 Services information
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Legal: Statute: Treaty of Waitangi, 1840
Accession Number: 276900995
Full Text: Introduction

A new challenge for nursing education is the globalisation of the nursing workforce and the concurrent internationalisation of higher education (Allen & Ogilvie, 2004). According to the New Zealand Ministry of Education (NZMoE, 2001), international experience for tertiary students in formal education outside their own country is now common with worldwide figures possibly reaching 5 million over the next 20 years.

An international student is a foreign student who does not meet domestic student requirements of residency, New Zealand citizenship or exemption criteria (Education Act of 1989). They do not affect the Government cap on student numbers at each institution and must usually pay full fees. The recruitment of such students has become an important component of the strategic planning of many tertiary institutions. International students already contribute significantly to the New Zealand economy (NZMoE, 2008) and in Australia the reduction of government funding for tertiary education institutions has prompted Australian nursing schools to actively recruit international students (Kilstoff & Baker, 2006). In light of the possible decrease in funding signalled by the Tertiary Education Commission, there is every likelihood that there will be pressure on Schools of Nursing to increase the numbers of international students.

If international students are to succeed then the learning environment must facilitate their acculturation into both the New Zealand academic and social cultural milieu. A "Hand Model" of cultural safety was developed by a nurse teacher to assist her in teaching cultural safety and her students to practice cultural safety in nursing (Jurlina, 1995). In this paper we explore the potential of this model in providing a framework for creating a culturally safe environment for international students. The most significant issues for international nursing students studying in a foreign culture are briefly outlined, cultural safety in the New Zealand nursing context is explored and linked to its relevance for international students. Following discussion of the application of the Hand Model, implications for education and practice are considered.

The literature for this paper was generated from a variety of electronic databases including CINAHL and EBSCO and an internet search using Google Scholar. A variety of related search terms were used: 'nurse education', 'international students', 'cultural safety', 'acculturation' and the concepts associated with the Hand Model (awareness, connection, communication, negotiation and advocacy). The papers retrieved were scrutinised for recurring themes.

International Nursing Student Experience

Although, to date, there has been little research conducted in New Zealand into the experience of international nursing students, there is a wealth of international literature describing the challenges for students studying in a foreign culture. Three significant themes that emerge are: difficulties with English language for non-English speaking background (NESB) students; differences in education style; and social integration and connectedness.

For NESB students the most salient challenge is English fluency. Poor fluency creates problems academically with a direct link between poor English acculturation and poor academic performance (Salamonson, Everett, Koch, Andrew, & Davidson, 2008). In the social context, poor fluency creates communication difficulties (Seibold, Rolls, & Campbell, 2007; Xu & Davidhizar, 2005) and feelings of social isolation (Sanner, Wilson, & Samson, 2002). It impacts on the student nurse's clinical experience (Rogan, San Miguel, Brown, & Kilstoff, 2006) and accented English creates communication problems between students and Registered Nurses (Shakya & Horsfall, 2000).

There are significant cultural differences in Eastern and Western pedagogy. For students acculturated in Confucian philosophy, the Western education system can negatively influence student engagement (Seibold et al, 2007; Wang, Singh, Bird, & Ives, 2008; Xu, Davidhizar, & Giger, 2005). Confucian pedagogy values a strong work ethic, respect for the teacher and a practical focus in learning. Western pedagogy, on the other hand, promotes a climate of inquiry in the attainment of new knowledge and ways of thinking (Tweed & Lehman, 2002). Although there are differences between Asian groups there are shared characteristics which can facilitate Western teachers' understanding from a cultural context (Xu & Davidhizar, 2005). Xu and Davidhizar reviewed the research literature on cultural variability and intercultural communication in nursing education finding that personal and cultural factors influenced communication between Asian students and American teachers. Communication was hindered by the need to 'save face', indirect communication styles and wanting to avoid conflict, with some teacher bias against Asian students also being an issue. For Asian students personal factors such as poor English ability are exacerbated by anxiety brought on by lack of confidence (Xu & Davidhizar; Yeh & Inose, 2003). Study pressure, a drive for perfection and highly developed self-consciousness and sensitivity were also issues influencing effective communication with teachers (Xu & Davidhizar).

Social integration and connectedness are also significant problems for international students. Relocation to a foreign environment requires learning about the local culture(s) and functioning within that society. Alongside understanding the cultural norms, expectations, beliefs and communication styles, the hitherto taken-for-granted everyday aspects of life such as food, shopping and transport may be considerably different. Thus, the international student has to develop competency in everyday living requirements (Poyrazli & Grahame, 2007).

The ability to develop social connectedness within the dominant culture was an issue that appeared in many studies about international students (Evans & Stevenson, 2006; Poyrazli & Grahame, 2007; Sanner et al. 2002). Yeh and Inose (2003) examined predictors of stress in acculturation, including social support satisfaction and social connectedness. Both were found to be significant in predicting acculturation distress, especially for Asian students who have a highly developed need for interdependence and close connections, as the emphasis on independence in the majority of Western cultures was a foreign concept to them.

Cultural Safety in New Zealand Nursing Education

In New Zealand there is a strong focus on cultural safety in education and practice. It is required as a Registered Nurse competency and in the nursing education curriculum (Nursing Council of New Zealand, [NCNZ] 2009). In the early stages of theory development (1988-1991), cultural safety had a strong bicultural focus. This arose from the view that student nurses needed to recognise the importance of Te Tiriti o Waitangi/the Treaty of Waitangi, and the impact of colonisation on Maori to be able to practise in a culturally safe manner with Maori. The Treaty was signed between the Crown and Maori, the Indigenous people of New Zealand, in 1840.

In the decade following its initial development the concept of cultural safety was further refined and subjected to political and public scrutiny as it became embedded in education and practice (Ramsden, 2002). Following on from the seminal work of Irihapiti Ramsden, the concept has evolved from its initial bicultural focus (Maori and Non-Maori) to incorporate a wider multicultural focus (Richardson & Carryer, 2005), which is reflected in the current Nursing Council of New Zealand definition:

The effective nursing practice of a person or family from another culture, and is determined by that person or family. Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socio-economic status; ethnic origin or migrant experience; religious or spiritual belief; and disability (NCNZ, 2009, p. 4).

The outcome of cultural safety is to enable "safe service to be defined by those who receive the service" (NCNZ, 2009, p. 5); however, it is the nurse who has become the focus of cultural safety, not the client (Ramsden, 2002). According to the Nursing Council of New Zealand (2009) the achievement of being culturally safe first requires movement through the steps of cultural awareness and cultural sensitivity. A significant part of this process is self-awareness, understanding one's own culture and acceptance of differences between that and other cultures, including the political status and historical circumstances of different groups in society, and recognising and minimizing power imbalances between service providers and service recipients.

It is arguable that nursing education, even given its commitment to the principles of the Treaty of Waitangi and to the teaching of cultural safety, has been able to create an environment that supports Maori students adequately. Maori students with poor cultural identity struggle to succeed in tertiary education (Bennett, 2002) and many are disadvantaged if the education system is not congruent with Maori cultural values (Simon, 2006). Therefore the question arises whether international students, especially those from non-European backgrounds, are placed at cultural risk in New Zealand nursing programmes. There is not the same historical imperative to address this issue as with Maori nursing students. However, notwithstanding moral considerations, there is a mandated duty as outlined in the Code of Practice for the pastoral care of international students to provide "assistance to students facing difficulties adapting to a new cultural environment" (NZMoE, 2003, p. 7).

It is timely to consider how international students can be better supported; the international literature reflects our concern and a range of approaches are suggested. A major focus is on improving English language skills, for example, through the use of language programmes to enhance oral clinical communication (Rogan et al., 2006) or to develop competence in colloquial English and pronunciation (Seibold et al, 2007). The need for academic and cultural support is also widely acknowledged with a range of strategies outlined, including the use of student support systems (Ryan, Markowski, Ura, & Chong-Yeu, 1998; Seibold et al; Shakya & Horsfall, 2000), a dialogic tutor-student relationship (Koskinen & Tossavainen, 2002), academic staff developing awareness of cultural differences and adapting teaching strategies (Amaro, Abriam-Yago, & Yoder, 2006; Gardner, 2005; Xu et al. 2005; Ryan et al.), and supporting students to maintain their cultural identity (Xu et al.).

The strategies described in the international literature to support international students offer a valuable perspective. Incorporating these strategies within the context of an indigenous model has the potential to enhance acculturation and safety in the setting of Aotearoa New Zealand. We suggest that the Hand Model currently used to teach cultural safety in an undergraduate nursing programme may provide a tool to promote this, given that the desired outcome is shared meaning regardless of the culture of the people engaged with the model or existing power imbalances. According to Ramsden (2000) the essence of cultural safety is the trust moment and the shared meaning of power and vulnerability through which differences can be explored, negotiated and legitimised.

The Hand Model

In 1995 there was great demand for Maori nurse educators who were well-grounded in their kaupapa and tikanga (Ramsden, 2002). However cultural safety teachers often felt unprepared to teach the concept and nursing students can struggle with it (Wepa, 2005). The Hand Model was developed by Lou Jurlina, a nursing teacher, to support the teaching of cultural safety from the perspective of the educator and the student. As a new teacher, she felt unprepared to teach cultural safety. She had also been involved with other Maori nurses, including Irihapeti Ramsden, in preparatory work for the initial development of Nursing Council guidelines for cultural safety nursing in New Zealand. These experiences influenced her personal journey towards development of the Hand Model. Other authors have also explored the hand as an approach to articulating a Maori cultural context in nursing practice (Barton & Wilson, 2008). The key element in the Hand Model is that 'cultural safety in nursing is in your hands' and the symbolism of the outstretched hand is presented with each digit being associated with a key word that conveys the essential elements of the model (Figure 1.). Jurlina, the author of the Hand Model, describes her initial experience:

I woke suddenly one night with an idea of how I could teach cultural safety using a simple hand model. This highlighted my own personal awakening to who I was as a Maori woman. I traced my hand on paper thinking "cultural safety is in your hands". Nurses care for people using their hands so it seemed obvious that I could use this model. The hand is also an important symbol for me as Maori, I began to write what each digit represented (Jurlina, L. personal communication, February 2, 2009).

The thumb represents 'awareness', with the other four digits signifying 'connection', 'communication', 'negotiation' and 'advocacy' respectively. Each digit is connected to the palm where the ultimate evaluation of the Hand Model in promoting cultural safety culminates in the clasping and shaking of hands: the moment of shared meaning. When using this model, teacher and students can physically draw around their own hand to embrace the ownership of the process, thereby highlighting the importance of their sense of self worth and identity as expressed in the uniqueness of their hand print (Jurlina, 1995).

The following discussion explores the model in more detail and describes how it can be utilised in promoting a culturally safe environment for international nursing students. It is important to understand the concepts in the model not as separate elements. As Angers can intertwine so do the concepts interweave with one another.

Awareness.

Cultural awareness is the first step towards cultural safety (NCNZ, 2009) and this is reflected in the model by its allocation to the thumb: the dominant digit. It encompasses awareness of one's own culture, self identity, and the recognition, acceptance and respect of all other cultures. It also incorporates prior awareness of a Maori world view of health, including the principles of Te Tiriti o Waitangi, biculturalism and partnership.

Awareness is a complex and dynamic concept and, according to Sayers and de Vries (2008), it encompasses being alert, perceptive and intuitive; recognising the impact you have on other people and "how your judgements can influence your conduct" (p. 294). For the international student, 'awareness' involves not only learning about the Treaty of Waitangi and the bicultural socio-political context in Aotearoa, but also encompasses the student's recognition of their own culture and the impact this has on their nursing practice. Most nursing programmes incorporate self awareness and cultural identification into curricula, it is vital that international students doing shortened programmes do not miss this.

For many nursing students understanding the Treaty of Waitangi and its relevance to health care in Aotearoa New Zealand is difficult. Further difficulties are faced by students who come from a largely monocultural environment or one where the critical dialogue on the impact of hegemonic processes are not occurring or are actively repressed. To initiate the first steps in awareness of the socio-political context of Aotearoa New Zealand it is essential they are engaged in appropriate learning opportunities, such as Treaty of Waitangi workshops.

The need for awareness is not solely the responsibility of the student. As Burnard (2005) notes, "what is logical and important in a particular culture may seem irrational and unimportant to an outsider" (p. 177). Thus, teachers must also be aware of teaching and communication styles as the language used, both spoken and unspoken, may be interpreted differently by people from other cultures. Time and attention needs to be given to understanding the international student's own cultural background, their worldview, learning needs and any factors that may impact on their ability to engage with living, learning and nursing in Aotearoa New Zealand.

It is beholden on academic staff to ensure that they are not attempting to homogenise international students. Cross (2008) argues the importance of seeking out the differences before regarding the similarities, as a focus on the similarities risks not attending to the differences. Students need to be seen and valued as individuals through awareness of their differences (Shakya & Horsfall, 2000). For example, the use of the word 'Asian' may provide a general sense of location in the world as does describing oneself as 'European' but it does little to signify cultural difference. There are over 30 diverse Asian cultures and there is diversity within and between cultural groups. Also it must not be assumed, for example, that a group of students from India necessarily share the same mother tongue, religion or cultural understandings. Therefore, it is important to guard against stereotyping and categorising perspectives.

Connection.

A sense of connection with the teacher and other students will not only assist with personal adaptation but will ultimately facilitate the development of sociocultural awareness and communication skills that will allow connection with the patient and significant others. The next digit (refer Figure. 1) represents the determination of a culturally appropriate connection with other people from different cultures to ensure cultural safety in nursing. According to Xu et al. (2005) international students must be able to function within the dominant culture, while at the same time valuing and maintaining their own cultural identity. It must not be forgotten, as Burnard (2005) reminds us, that these students are likely to be apprehensive, tired from having to constantly adapt, dealing with loss, loneliness and a lack of confidence.

As discussed under 'awareness' teachers need to attend to international students' cultural differences. Teachers then enter the relationship with understanding of cultural differences and are more able to support connection. It is proposed by Gillespie (2005) that student-teacher connection "creates a transformative space in which students are affirmed, gain insight into the potential, and grow toward fulfilling personal and professional capacities: student-teacher connection emerges as a place of possibility" (p. 211). Possibility as transformative space may well be a significant concept when interacting with international students, as these individuals are often in search of the personal and professional opportunities that arise from gaining a nursing degree in an English-speaking country.

To counteract the loss of connection experienced by international students moving to a foreign country, alternative social networks, such as online support groups, can promote interdependency and the sense of connection normally experienced within their own cultural group (Yeh & Inose, 2003; Ye, 2006). Another strategy is to work collaboratively with the agents and international office to enrol students from only a small number of cultures. So, for example, ensuring that students from India come only from one state.

This assists students to retain a sense of connectivity with their own culture through social networking with fellow students who speak the same language and understand one another's cultural perspective. It also facilitates the ability of teachers to develop awareness and connectivity as they can develop a deeper knowledge of this particular culture rather than trying to develop understanding over a wide spectrum.

Communication.

Communication is a subjective experience and cannot be isolated from the other concepts in this model as it interweaves throughout (refer Figure. 1). Language has a constitutive role in social and psychological life and shapes our understanding of the world (Burr, 1995; Davis & Gergen, 1997). It is the key to connecting with other people and is closely intertwined with culture, as communication is essential to convey and protect culture (Xu et al. 2005). This process can be fraught because language is constructed (Phillips, 2000) and neither the structure nor the meanings of language are viewed as fixed; they are contingent on context, history, and the sender and receiver. Thus, the meaning of language is contestible with different languages and different discourses within languages constructing meaning variously, so it cannot be perceived as stable or able to be known essentially (Weedon, 1987).

Communication is enacted in verbal or written language and nonverbal means, which means that the participants must go beyond a mere focus on words. Wittgenstein (1994) describes the concept of the language game. Language games, he proposed, "are the forms of language with which a child begins to make use of words" (p. 47). In the same manner in which they learn game playing, children learn language. As they play games they discover the rules governing the players and the unwritten rules, which regulate conduct during play; for example, cheating is not acceptable: "it's just not cricket." Wittgenstein's premise was that words acquire meaning in a similar manner. Harding (2005) described his experience:

With international students, apart from the differences related to verbal communication, there are also non-verbal communication differences. A nonverbal trait of South Indian students, from our experience, is the lateral nodding of the head while engaged in conversation, which can have a multiplicity of meanings, from a sign of friendship, to agreement or understanding (Cook, 2009). Supervising these students in mental health practice required assisting them to understand that patients may receive this gesture negatively. Differences in verbal and non verbal communication styles, therefore, need to be explored and addressed through discussion of possible clinical scenarios and how these might be managed in the student's own culture and what is expected here in New Zealand.

An issue for international students is often not so much about learning English as a second language but developing an understanding of the clinical jargon, New Zealand (Kiwi) slang and norms. Not understanding may cause confusion, personal distress and possibly unsafe care. It can be as simple as the expectation that students will inform someone if they are leaving the workplace, no matter how briefly. An authentic connection is essential to uncover some of these differences in cultural norms. Students' ability to communicate and collaborate with others within clinical placements is assessed in undergraduate nursing programmes in New Zealand. It is essential that it is not evaluated from the dominant ethnocentric framework without the international student having the opportunity to learn and practice the norms within the new culture: both the culture of New Zealand and the culture of New Zealand nursing.

Negotiation.

Negotiation is represented by the fourth digit (refer Figure. 1). It is associated with the presentation and opening out of the hand directed toward mutual understanding and agreement. Negotiation may be more problematic for international students owing to previously assimilated understandings of student-teacher roles and workplace hierarchies. Those students acculturated in the Confucian paradigm may be less capable of asking questions and challenging those they see as an authority figure (Tweed & Lehman, 2002). A fundamental component of Confucian thinking is the concept of li, which is essential in forming harmonious relationships with others (Bockover, 2003; Chen, 2000). Caldwell, Lu and Harding (2010) noted that aspects of li can be taught and learned, such as bowing down, hugging, shaking hands and even smiling; however, another aspect of li is expressed in the notions of 'respect' and 'authority'. Thus, the teacher is not challenged but is respected, trusted and imbued with parental authority. It is expected that the teacher will approach students individually to ascertain their understanding (Xu et al. 2005). Thus, teachers from New Zealand need to be patient with international students who may not engage in class discussion. They should seek opportunities to talk with them in a 'safe' environment and help them develop the strategies to move toward confident participation in a new learning culture.

Negotiation is not only between the teacher and the student, it must also occur between the education provider and the clinical placement. It is not enough to merely 'negotiate' a clinical placement, there must be preparation beforehand to ensure a successful engagement between the student and the clinical staff. For example, accented English creates communication problems between students and registered nurses, requiring additional support from clinical tutors to assist the student in making sense of the clinical environment (Shakya & Horsfall, 2000) and to negotiate problematic situations. Thought must be given to developing the clinical staff's awareness so they can comfortably work with the international student, to better understand their learning needs and communication styles. The education provider must give consideration to what extra support needs to be provided to both the student and the staff in the clinical area. If the international student is a source of revenue generation for the educational institution then there must be some consideration and negotiation with respect to the resources needed to support both the student and the clinical organisations. Especially when staffing resources are stretched.

Advocacy.

The last digit denotes 'advocacy' and according to Mallik (1997) "the core condition that is most frequently cited as demanding an advocacy action is patient/client vulnerability" (p. 130). Within the framework of cultural safety, safety and risk are defined by the client/ family receiving the service or care, not by those delivering it. When working with the international nursing student, the concept of "client" can be understood from two perspectives. First, is the definition of client, which is analogous with the patient. Second, is the understanding of the client as a customer, in this case the student who is paying the international student fee for their education. The use of the Hand Model, as a framework in developing strategies to support the student's interaction with the client (patient/family) perspective (incorporating the commitment to a Maori perspective mandated by the Treaty of Waitangi), also supports the international student.

When first considering advocacy on behalf of the patient/family perspective the international student must be able to function within the dominant culture (Xu et al. 2005); however more is required to operate safely in the context of contemporary Aotearoa New Zealand. Recognition of the Treaty of Waitangi by the Government in 1988 has led to ongoing critical deconstruction of the dominant culture. As a result nursing has used this understanding of treaty issues to also develop the notion of partnership (Richardson & Carryer, 2005). Partnership is one of the three key principles in the Treaty of Waitangi (NCNZ, 2009). Thus, there is a requirement that nurses work not only in partnership with the patient but also with the Tangata Whenua (the indigenous people of New Zealand). It is not compatible with the concept of cultural partnership if international students are acculturated only to work within a Pakeha framework. It beholds teachers to ensure students can work safely within both a Pakeha and Maori cultural framework in the delivery of nursing care.

It can be argued that to be a true advocate the nurse must work in partnership with the client and in New Zealand our understanding of what this means in nursing has been influenced by the work of Judith Christensen (1990) and the ideal of the nursing partnership. For some international students this may well be a foreign concept, especially those who come from nations in which the 'medical model' of healthcare still predominates, or where gender, intergenerational and professional hierarchies locate power with a person perceived as 'superior' in the relationship. True partnership is negotiated between individuals/ groups with mutual respect for their autonomy; however, autonomy in New Zealand is encouraged and expressed predominantly at a personal or an individual level through autonomy of self. In contrast the 'self' in Chinese culture is subordinate to relationship with others (Bockover, 2003). For these students the notion of working in partnership may also threaten their sense of self within society.

When considering the other perspective of the international student as client, there may be expectations that the teacher acts as their support and advocate. The teacher may need to advocate on their behalf with other students, the institution and the clinical providers to mediate when their international status or cultural differences have the potential to limit their ability to succeed in the programme. Advocacy in this sense is not to be seen as lowering the standards required for success, no matter the compassion that might be felt for the student; rather it is analogous to Roy's theory of nursing in which the student is in interaction with a changing environment and attempting to adapt. According to Roy and Roberts (1981) "one's self-concept is defined by interaction with others. One to one interactions between individuals are characterised by the use of verbal and nonverbal symbolic communication" (as cited in Meleis, 1997, p. 205).

The teacher advocates or negotiates for the international student until they have the confidence and ability to do this. The international student may be isolated, confused and struggling to interact successfully with others. An individual's life as a good human being is dependent on how he or she relates to others (Bockover, 2003); thus, there should be understanding, not criticism, when international students from a particular country group together. Through relationship with others with the same cultural attributes an individual feels more in touch with her or himself: one exists because one relates to others.

Conclusion

When New Zealand is chosen as the place to study both student and teacher enter into tacit accord that the education and lifestyle will be contextualised with New Zealand culture(s). While strategies developed elsewhere may prove useful to help the student acculturate these need to be made relevant to the local context.

The Hand Model of Cultural Safety provides a useful framework for the teacher to underpin the creation of a safe environment for the international student, while at the same time serving as a reminder of the need to incorporate awareness and the development of cultural competence for the student who would participate in the health care environment in this country. The model provides a tool also for the student as they interact with others, using the hand they can 'work through the digits', finishing at the palm of the hand, to come to the moment of 'shared meaning': the metaphorical clasping of hands.

Acknowledgement

The authors would like to acknowledge Dr Stephen Neville from Massey University and Dr Denise Wilson from Auckland University of Technology for their assistance with this project.

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Bev Mackay, RN, DN, Principal Lecturer, Department of Nursing and Health, NorthTec, Whangarei

Thomas Harding, RN, PhD, Associate Professor, Deputy Head, School of Nursing (NSW & ACT) Faculty of Health Sciences, Australian Catholic University, North Sydney Campus (MacKillop), Australia

Lou Jurlina, RN, Advanced Diploma in Child and Family Health, Nurse Consultant

Norma Scobie, RN, MN, Principal Lecturer, Department of Nursing and Health, NorthTec, Whangarei

Ruelle Khan, RN, BHSc, Principal Lecturer, Department of Nursing and Health, NorthTec, Whangarei

Mackay, B., Harding, T., Jurlina, L., Scobie, N., & Khan, R. (2011). Utilising the hand model to promote a culturally safe environment for international nursing students. Nursing Praxis in New Zealand, 27(1), 13-24.
In my role as a clinical nursing tutor I was working
   alongside a group of Chinese students undertaking
   nursing education in Auckland in 2002 who
   were experiencing difficulty in establishing an
   effective mode of communication with a number
   of their elderly Pakeha (New Zealanders of
   European descent) patients. They were at a loss to
   understand the problem; they knew the words and
   thought they used them appropriately. They were
   not, however, using them in the mutual exchange
   (or game) required by their patients in the New
   Zealand context. They had to learn and practice
   such rules as smiling when they said "hello", and
   that it also needed to be accompanied by "How
   are you?" The next move would then be a similar
   question from the other player that required a
   response before moving to the next level of the
   game. Such responses are legitimate in the word
   game of greeting, but the response "We shower
   now" to a greeting from the patient placed them
   outside of the game. (p. 30)


Figure 1. The Hand Model: Cultural safety in nursing is in your hands.

CULTURAL SAFETY IN NURSING

SHARED MEANING

AWARENESS        How? Recognition of own Culture Recognition,
                 Acceptance, Respect of all other cultures. Prior
                 Learning of Maori Culture/Health, Treaty of Waitangi,
                 Biculturalism Partnership

CONNECTION       How? Culturally Appropriate Connection with Client/
                 Family to ensure Cultural Safety in Nursing

COUMMUNICATION   Cultural Safety in Nursing is a subjective
                 Experience

NEGOTIATION      How? Extend this hand of yours.
                 Mutual understanding mutual agreement

PARTNERSHIP

ADVOCACY         Safety and risk are defined by the Client/Family
                 Receiving the service not by those delivering it
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