EMPIRICAL STUDIES
Student nurses’ experiences of communication in cross-cultural
care encounters
Maria Jirwe MSc, RN, PhD (Senior Lecturer)1, Kate Gerrish PhD, RN, RM (Professor of Nursing)2 and Azita Emami
PhD, RNT, RN, MSN (Professor)1
1
Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Huddinge, Sweden and 2Sheffield Hallam
University/Sheffield Teaching Hospitals NHS Foundation Trust, Centre for Health and Social Care Research, Sheffield, UK
Scand J Caring Sci; 2010; 24; 436–444
Student nurses’ experiences of communication in
cross-cultural care encounters
Background: Communication is a fundamental component
of cross-cultural care encounters. Nurses experience com-
munication difficulties in situations where they do not
speak the same language as their patients. Communication
difficulties are a major obstacle for immigrant patients and
can lead to insufficient information and poor quality
nursing care in contrast to the majority population.
Aim: To explore student nurses’ experiences of communi-
cation in cross-cultural care encounters.
Methods: Semi-structured interviews were undertaken a
purposive sample of 10 final year students from one uni-
versity in Sweden: five participants were from a Swedish
background and five from an immigrant background.
Interviews explored participant’s experiences of commu-
nication in cross-cultural care encounters. Interviews were
tape recorded, transcribed and analysed using ‘framework’
approach.
Results: Four themes were identified: conceptualizing
cross-cultural care encounters, difficulties in communica-
tion, communication strategies and factors influencing
communication. ‘Culture’ was equated with country of
origin. Cross-cultural care encounters involved patients
Introduction
Nurses face particular challenges when caring for immi-
grant patients who are from a different cultural back-
ground to themselves. They need to be able to adapt their
caring strategies to respond to the cultural needs of their
Correspondence to:
Maria Jirwe, Department of Neurobiology, Care Sciences and
Society, Division of Nursing, Karolinska Institutet, Alfred Nobels Allé
23, 23 300, SE 141 83 Huddinge, Sweden.
E-mail: maria.jirwe@ki.se
436  2010 The Authors. Journal compilation  2010 Nordic College of Caring Science
doi: 10.1111/j.1471-6712.2009.00733.
from a different immigrant background to the nurse. Stu-
dent nurses experienced particular difficulties communi-
cating with patients with whom they did not share a
common language. This led to care becoming mechanistic
and impersonal. They were fearful of making mistakes and
lacked skills and confidence in questioning patients. Vari-
ous strategies were used to overcome communication
barriers including the use of relatives to interpret, non-
verbal communication, gestures and artefacts. Other
factors which influenced communication included the
student’s attitude, cultural knowledge acquired through
education and life experience.
Conclusion: Although student nurses seek creative ways to
communicate with patients from different cultural back-
grounds they lack skills and confidence in cross-cultural
communication. Nursing programmes need to address this
deficit to ensure that nurses are equipped with the
knowledge and skills to provide quality care to patients
from different cultural backgrounds.
Keywords: student nurses, nurse education, framework
approach, communication, cross-cultural communication,
cross-cultural care encounter, multicultural, cultural
competence.
Submitted 31 August 2008, Accepted 31 May 2009
patients (1–3). Culture in this context, is defined as the
shared beliefs, values, ideas, language, communication and
norms of a group of people (4). Moreover, cultures are
dynamic and undergo constant change so nurses need to
be flexible and responsive (3).
Several studies have identified that migrants often
experience poorer quality of care in contrast to the
majority population (5–8). Nurses, alongside other
healthcare professionals, often lack the necessary knowl-
edge and skills to respond to the needs of people from a
different cultural background to their own (9, 10).
Communication difficulties, in particular, present major
obstacles in cross-cultural care encounters, i.e. an

encounter between a nurse and a patient who are from
different cultural backgrounds (11–15).
Communication is a fundamental part of nursing (16,
17). It involves sharing information, caring conversations
and social interactions (18). Communication is a signifi-
cant factor with regard to patient satisfaction and the
quality nursing care (16, 17, 19). Patients’ emphasize that
nurses should take time to communicate since it is through
communication that nurses get to know patients, identify
their needs and inform them. When communication is
poor patients are dissatisfied with their care (16, 20).
Communication is a complex process comprising much
more than just a linguistic component. It requires the
interpretation of speech, tone, facial expressions, body
language, gestures and assumptions shared between the
communicants about the context and purpose of the
exchange (15). Communicating effectively with patients
presents challenges for nurses. In addition to being skilled
in interpreting the factors identified above, the profes-
sional language nurses use can be difficult for patients to
understand, so nurses need to simplify complex terminol-
ogy and avoid jargon (15). The challenges are even greater
where the patient is from a different cultural back ground
to the nurse and they do not speak the same language
(11, 21).
Immigrant patients who are not fluent in the language
of the host country face particular obstacles. Language
barriers can hinder access to and use of healthcare as it is
difficult for immigrant patients to find out what services
are available, communicate their needs to health profes-
sionals and understand the care or treatment they require
(9). As a result, cross-cultural care encounters between
nurses and patients who do not speak the same language
often lead to insufficient information exchange and poor
quality nursing care (13). The situation is compounded for
patients who may already feel vulnerable and anxious
because of their illness (20).
Nurses employ a range of strategies in cross-cultural care
encounters where they do not speak the same language as
their patients. To bridge the language barrier they often
rely on relatives to interpret, rather than use an accredited
interpreter. This decision is often for pragmatic reasons as
it can take some time to arrange an accredited interpreter,
because of financial constraints on hiring interpreters, or
due to nurses’ lack confidence in the interpretation
process (11–13, 22). When nurses do not have someone
present who speaks the patient’s language they make do
by using nonverbal strategies and aids to facilitate com-
munication, for example picture cards, playing charades
(11, 15, 18). Bi-lingual staff can be extremely useful in
bridging the communication gap (11, 15, 21). However,
in a UK study bi-lingual student nurses, who were
themselves from an immigrant background, were used so
frequently to interpret that it compromised their learning
in clinical practice (9).
 2010 The Authors. Journal compilation  2010 Nordic College of Caring Science
Communication in cross-cultural care encounters 437
Clearly, it is important that nurses develop the skills to
communicate effectively in cross-cultural care encounters.
Much research to date has focused on the experiences of
Registered Nurses from the majority population engaged in
cross-cultural care encounters with patients from an
immigrant background (11–13, 23) rather than student
nurses. One exception to this was a UK study in which
student nurses felt that their education had not equipped
them with the skills to communicate effectively in cross-
cultural care encounters (9). It is not clear whether
Swedish student nurses feel similarly ill-prepared. In North
America, the communication skills required for cross-cul-
tural care encounters have been introduced into some
nursing curricula with good effect (24, 25). But Swedish
nursing programmes do not necessarily enable nurses to
develop knowledge and skills for cross-cultural care
encounters (26). Clearly, there is a need to understand
more about the experiences of student nurses in
cross-cultural care encounters to inform curriculum
development.
Aim
The aim of the study was to explore student nurses’
experiences of communication in cross-cultural care
encounters with patients from different cultural back-
grounds.
Methodology
An exploratory qualitative study was undertaken. Semi-
structured interviews were conducted with a purposive
sample of 10 student nurses: five student nurses were from
a Swedish background and five from an immigrant back-
ground. In addition to ethnic background, students were
selected because they had undertaken a taught course in
transcultural nursing and had experience of working in
multi-cultural care settings which they could draw upon
during the interview. Volunteers, who fulfilled these
criteria, were sought from a cohort of final year students.
All students spoke Swedish and English and students
with an immigrant background spoke some additional
languages. The participants were from one university in
Sweden and had undertaken their clinical education in
healthcare settings serving a multi-cultural population
originating from over 180 different countries (27). The
demographic characteristics of the participants are shown
in Table 1.
Approval was obtained from the Ethics Committee at the
Karolinska Institutet and the study was conducted in
accordance with the University’s requirements. Verbal
informed consent was obtained at the time of the inter-
view. Participants were assured of the confidentiality of the
information they provided and that their anonymity
would be ensured in any reports emanating from the
438 M. Jirwe et al.

Table 1 Demographic characteristics of the participants analysis. To enhance credibility of the analysis, the inter-
views were analysed by the first author and the analysis
Age when Years of was confirmed by the other authors who read through
moving to experiences in the Ethnic transcripts, verified the coding and the organization of data
Participant Age Sweden healthcare sector background into themes. Dependability of the study was enhanced by
following recognized procedures for data collection and
1 40 7 0 Finnish
analysis and by providing a clear account of the decision
2 36 16 1 Kurdish
3 25 – 3 Swedish
trail for each stage of the research (32).
4 21 8 0 Bosnian
5 29 – 0 Swedish
Results
6 34 – 14 Swedish
7 26 – 0 Swedish
Conceptualizing cross-cultural care encounters
8 26 – 5 Swedish
9 21 1 0 Bangladeshi The analysis showed that participants equated ‘culture’
10 23 5 3 Iranian with country of origin rather than taking a broader defi-
nition of culture. All the cross-cultural care encounters
described by participants were with patients or relatives
study. The identity of students who took part was not from an immigrant background. Even participants who
disclosed to other participants or to the wider student were of immigrant origin described encounters with
cohort. It was recognized that students might become patients/relatives from an immigrant background as
distressed during an interview if they recounted incidents opposed to a Swedish one. Although one immigrant
that had proved stressful. Students were offered the participant acknowledged that she frequently encountered
opportunity to talk through any issues with the first author Swedish patients who were from a different culture to her
after the interview should they so wish. In the event, own, she did not consider these to be cross-cultural care
although some students recounted difficult situations, no encounters.
students took up this opportunity. I have immigrant background and live in Sweden so I
Although the first author who undertook the interviews meet patients from other cultures every day. I’m not
was a nurse lecturer she was not involved in teaching any Swedish and we don’t belong to the same culture, but
of the participants. It was hoped, therefore, that students I wouldn’t say that these are cross-cultural care
would feel able to openly discuss both the theoretical and encounters. (Participant 2, Kurdish background)
practical aspects of their education experiences. Effective communication was seen to be fundamental to
The interview guide asked participants to identify two satisfactory cross-cultural care encounters. When partici-
cross-cultural care encounters, one that they considered to pants were able to establish what they considered to be
have been satisfactory and one they considered to have satisfactory communication with the patient or their rela-
been unsatisfactory. Participants received the interview tive through verbal or nonverbal means they felt satisfied
guide in advance to allow them time to identify the cross- with the care they provided and the outcome of the
cultural care encounters that they wanted to share. encounter. By contrast, where communication was
Interviews were undertaken at the preferred location of lacking, participants described the nursing care and the
the participant: at the university, a clinical setting or the outcome of the encounter as unsatisfactory.
participant’s home. Four interviews were undertaken by Three themes were identified in relation to communi-
telephone as this proved most convenient for the partici- cation in cross-cultural care encounters:
pants. All interviews were conducted in Swedish; the (i) difficulties in communication, (ii) communication
interviews lasted between 20 and 45 minutes and were strategies and (iii) factors influencing communication.
tape-recorded and transcribed verbatim.
The interviews were analysed using the ‘framework’
Difficulties in communication
approach (28–30). This involved five stages of (i) famil-
iarization with the data, (ii) identifying a thematic frame- Participants drew attention to the difficulties they experi-
work for coding data from the interview agenda and initial enced when they did not share a common verbal language
scrutiny of the transcripts, (iii) coding individual tran- with the patient. The lack of a shared language created
scripts by applying the thematic framework, (iv) organiz- problems for both the nurse and the patient. Participants
ing the coded data into major themes using a matrix and voiced concern that they were at risk of giving limited
(v) mapping the relationships between different themes by information when they were explaining procedures to
interpreting the data set as a whole (28, 31). Due to patients. Whereas they felt that they generally communi-
practical reasons it was not possible to employ member cated the technical aspects of what the procedure entailed,
checking with the research participants as part of the explanations regarding the reason why the procedure was

 2010 The Authors. Journal compilation  2010 Nordic College of Caring Science

necessary were often omitted. Additionally, the normal
social intercourse that they would engage in during the
procedure where they shared the same language as the
patient was missing. This led to care becoming mechanistic
and impersonal and a concern that the nurse was failing
the patient. One student nurse described the difficulties
she experienced:
We couldn’t communicate, he didn’t understand why
we needed to replace the intravenous line and I didn’t
really manage to explain it either. It was more that I
just did my job and… I just replaced the intravenous
line and that’s it…it didn’t feel right, just going in
there, performing the task and then leaving. (Partici-
pant, 6, Swedish background)
In such situations participants felt that an essential ingre-
dient of the caring relationship was missing:
When I deliver nursing care that’s when I get in
contact with the patient. It’s not so structured…but
more chatting during the caring process. You miss so
much …when you don’t have a way to communi-
cate…communication is prerequisite for good nursing
care. (Participant 7, Swedish background)
Participants also expressed concern when patients were
unable to convey their message to the nurse. One partic-
ipant described an incident when she was replacing an
intravenous line for a patient. She had communicated her
intent through using gestures and felt that the patient had
understood what she was planning to do. However, when
she began the procedure the patient became distressed and
started to cry out. As there was no shared language the
patient was unable to express her concerns to the nurse.
The participant speculated as to the distress the patient was
experiencing: did it hurt, did it hurt more than usual, was
something wrong or was the patient afraid? However, it
was impossible for the participant to understand the
situation and she was, therefore, unable to provide
appropriate support to the patient.
The patient knew that she was going to get a new
intravenous line, we showed her with gestures. But
when I started to put in the intravenous line she just
screamed…It’s hard to say why (she was distressed)
since she couldn’t speak any Swedish, you just didn’t
know. (Participant 4, Bosnian background)
Participants also expressed concern that they were often
fearful of making mistakes when communicating in cross-
cultural care encounters.
There was a patient…from an African country and
hadn’t lived in Sweden for long…somehow I became
afraid of talking to her, afraid of making a mistake.
(Participant 7, Swedish background)
They pointed out that they were often anxious and
sometimes avoided interacting with patients because they
wanted to avoid causing offence. Anxiety was greatest
when they encountered a situation that was unknown, for
example meeting a patient from a country they had not
 2010 The Authors. Journal compilation  2010 Nordic College of Caring Science
Communication in cross-cultural care encounters 439
come across, encountering behaviour they had not
observed before, and they did not know how to respond.
Difficulties also occurred due to different preunder-
standings between the nurse and the patient which could
lead to misunderstandings, for example when assessing the
patient. One participant described an incident where a
note in the patient’s records indicated that the patient ‘ate
everything’ yet the nurse was aware that the patient came
from a country were Islam was the main religion. The
participant decided to check with the patient as to whether
the information was accurate and discovered that the
patient’s interpretation of ‘eating everything’ was different
from that of the nurse who had recorded in the notes.
I asked, ‘do you eat everything?’ And she said ‘yes’.
Then I asked ‘do you eat pork as well?’ ‘No, I don’t’.
So she didn’t even think of this before. (Participant 4,
Bosnian background)
The participant then probed further regarding the patient’s
food preferences to avoid future mishaps in relation to diet.
Both the nurse and the patient were pleased with the
outcome. However, the same participant described a
different situation in which she was responsible for the
care of a man who also came from an Islamic country. She
sought to clarify his food preferences but instead of being
pleased, the man became offended.
Once I asked a patient whether he ate pork and he
took it so personally. ‘I eat everything, I am not a
Muslim’. He was very offended. How do you ask these
questions? If the patient has food prohibitions then
they are not offended. But in this situation he was.
(Participant 4, Bosnian background)
After this incident the participant became wary of asking
patients about food prohibitions as she was concerned
about causing offence. She felt she lacked the skills to ask
such questions in a nonoffensive way but at the same time
she did not want patients to have inappropriate foods
because of her lack of confidence in probing further.
Communication strategies
The participants described a range of strategies that they
used to establish communication with patients in situa-
tions where they did not share a common spoken
language. Most participants drew attention to the benefits
of using an interpreter to facilitate communication.
However, participants had little firsthand experience of
communicating through an accredited interpreter. They
pointed out that in their experience it was the doctors
rather than nurses who used accredited interpreters.
According to some participants, nurses made limited use of
accredited interpreters because of financial constraints
imposed by the hospital in which they worked. Only one
participant had experience of using an accredited inter-
preter. This had involved a telephone interpreting service;
something she had found difficult.
440 M. Jirwe et al.
And it became so complicated with the interpretation
process over the phone instead of having someone
there in the room. You have more of a one-way
conversation even though there are three people.
(Participant, 8, Swedish background)
In the absence of accredited interpreters, participants relied
on patient’s relatives to interpret for them. Participants
generally viewed the relative’s role positively as it enabled
them to overcome the language barriers. By communi-
cating through relatives, they felt better able to identify the
patient’s concerns:
Her daughter told me if her mother was not satisfied.
It was really good that she could tell us… that we got
this information from her. (Participant 1, Finnish
background)
However one participant voiced concern that there was a
risk of selective information exchange in situations where
relatives interpreted as they may not translate verbatim.
Alternatively, in their effort to be helpful, relatives may
take over the situation thus hindering the nurse-patient
relationship from developing.
They (the relatives) came in and said ‘this is our
mother, she can’t speak Swedish but we can interpret’
and then I became a little thoughtful…Often I have
been in the situation where the children take over.
(Participant 3, Swedish background)
Participants had observed that relatives responded differ-
ently to a request to act as an interpreter. Many relatives
viewed this positively.
They were very willing to help. ‘If it is okay for you
one of us can be here most of the time so mum can
understand what is going on’. They made it so much
easier to communicate with the woman. (Participant
3, Swedish background)
However, one participant described a situation where a
relative had been reluctant to fulfil this role.
And then we called the daughter and she felt it was
disturbing to interpret for her mother all the time. She
was really worried and also she had other things to do.
(Participant 8, Swedish background)
Several participants described situations in which they had
made a deliberate effort to facilitate communication. For
example, some participants had learnt a few words in the
patient’s language. All participants spoke Swedish and
English and immigrant nurses spoke some additional lan-
guages. Nurses used their bilingual abilities to communi-
cate with patients who did not speak Swedish and where
the nurse and the patient shared more than one common
language, patients were given the opportunity to choose
their preferred language.
It was a mix of languages but mostly English, he
knew Swedish but maybe he spoke more English
because he was nervous…it could be that he went
back to English since it was more natural for him, he
was able to ask more detailed questions in his own
 2010 The Authors. Journal compilation  2010 Nordic College of Caring Science
language which I also understood. (Participant 5,
Swedish background 5)
Participants also stressed the importance of using body
language as a means of communication when there was no
common spoken language.
You use body language instead and a smile…we have
learnt that 70% of communication is body language so
why not use it; it is a great tool for communication.
(Participant 10, Iranian background)
Interestingly, although all participants mentioned body
language, those who were from an immigrant background
emphasized it more.
Other strategies used included the use of pictures or
artefacts such as showing a patient equipment to try to
convey amessageandencouragingthepatienttodo thesame,
for example to point to a drinking glass if they were thirsty.
You can show the tablets, ‘take this’, ‘do you want
water’ (showing a glass of water), ‘do you want
something to drink’ and then they nodded. They
understood what I wanted to say to them. (Participant
2, Kurdish background)
One participant from an immigrant background suggested
that her own experiences of not being able to communi-
cate when she first arrived in Sweden had increased her
creativity in identifying strategies for overcoming com-
munication barriers.
When I came here I couldn’t speak Swedish. You try
to communicate in any way you can think of. This is
your experience and you use this experience when
you meet a patient that cannot speak Swedish. (Par-
ticipant 2, Kurdish background)
Some participants emphasized other communication
techniques that could be used to facilitate understanding.
For example, mirroring the patients’ emotions and listen-
ing actively.
What I did was that I mirrored her emotions, it was
something we were taught during the first semes-
ter…her facial expressions, when she showed that she
was unsatisfied I showed the same to confirm that I had
understood her right. (Participant 1, Finnish back-
ground)
Participants pointed out that seeking to establish effective
communication when there was no common language was
demanding and it was, therefore, important to set aside
sufficient time. Cross-cultural care encounters that were
rushed were unlikely to lead to a satisfactory outcome.
However, as one participant pointed out:
If you take time and try to analyze the patient, try to see
the whole picture, then you can communicate. You
need to be patient. (Participant 2, Kurdish background)
Factors influencing communication
Whereas participants employed a range of strategies to
overcome the communication difficulties they encountered,

it was apparent that there were other factors which
influenced communication in cross-cultural care encoun-
ters. Participants varied in their attitude towards over-
coming communication difficulties. Participants who were
from an immigrant background generally emphasized the
importance of adopting a positive attitude towards tackling
communication problems. For example, a participant from
a Kurdish background explained:
If you take your time and are interested in the patient
then you can understand them. (Participant 2)
Participants who entered cross-cultural care encounters
with a positive approach usually found it easier to cope
with communication difficulties. However, this approach
was less evident among participants with a Swedish
background. Whereas a shared spoken language between
nurses and patients was important, Swedish participants
stressed this more than those from an immigrant back-
ground.
Since she could not speak any Swedish, an interpreter
was the only way to communicate with her. (Partici-
pant 7, Swedish background)
In contrast, those from an immigrant background
emphasized a range of strategies that could be used to
facilitate communication.
Communication in cross-cultural care encounters was
also influenced by participants’ knowledge of cultural
issues. Knowledge was acquired formally though nurse
education or informally through life experience. However,
although knowledge was beneficial it did not mean that
cross-cultural care encounters would be unproblematic.
Most participants emphasized how an understanding of
different cultural norms and traditions helped them to
appreciate that people behave differently and have differ-
ent world views. Cultural knowledge gave them more
confidence in tackling unfamiliar situations which in turn
led to improved communication.
You have a different attitude, you have learnt how to
handle…different situations. You have learnt how to
think in a different way. (Participant 8, Swedish
background)
Whereas cultural knowledge was important to inform
practice one Swedish participant highlighted the risk of
categorizing patients inappropriately when learning about
cultural differences. She emphasized the needed for a
balance between acknowledging both cultural and indi-
vidual differences.
I think it’s difficult; education must not make the
individual invisible. It shouldn’t be that everybody is
alike within a culture. You have to recognize that
there are differences…education can tend to catego-
rize patients and the individual perspective is lost.
(Participant 7, Swedish background)
Participants stressed that it was inappropriate to assume
that because a patient ‘looked different’ or came from a
‘different country’ that they would behave in a particular
 2010 The Authors. Journal compilation  2010 Nordic College of Caring Science
Communication in cross-cultural care encounters 441
way. Although cultural differences existed it was impor-
tant to recognize that differences occurred between people
from the same immigrant background and respond to
these individual differences.
There are individual differences and cultural differ-
ences but the individual ones are more important.
(Participant 5, Swedish background)
Swedish participants placed most emphasis on knowledge
gained through education, whereas immigrant participants
emphasized how their own experiences of migration and
living in neighbourhoods with immigrant communities
had helped them communicate in cross-cultural care
encounters.
I think it’s due to the multicultural area where I lived
during my youth and where I still live. I speak some
Somali, Arabic and Turkish. And my family are Mus-
lims, I’m not but I’m raised in a Muslim family and
have Muslim relatives so I know how it works. (Par-
ticipant 9, Bangladeshi background)
They suggested that their experience as immigrants had
made them culturally aware and had helped them to see
the individual and not just the cultural group they
belonged to. It also helped them be comfortable with
meeting patients from different cultural backgrounds.
I have so much experience due to my background.
Somehow it comes automatically and then…you cross
a line, in the end you don’t see cultural differences
but individual ones. (Participant 2, Kurdish back-
ground)
Discussion
The findings reported in this article are from an explor-
atory study of student nurses experiences of communica-
tion in cross-cultural care encounters. The small sample,
drawn from one university, means that caution should be
exercised in drawing conclusions from the findings. It is
recognized that the education preparation and clinical
experience of the students who participated in the study
may be different from students at other universities and
this may be reflected in the findings. It is also acknowl-
edged that the experiences of the Swedish and immigrant
student nurses in the current study may not reflect the
experiences of other students of comparable ethnic back-
ground. Nevertheless, many of the findings are supported
by the wider international literature examining cross-
cultural care encounters in nursing. However, this study
contributes two new perspectives. It examines the expe-
riences of student nurses, as opposed to studies that have
focused on Registered Nurses, and, by considering the
experiences of immigrant nurses it draws out some
differences (albeit tentative) between these nurses and
their Swedish counterparts. Further research is needed to
see if the findings are transferable to student nurses in
other settings.
442 M. Jirwe et al.
Student nurses conceptualized a cross-cultural care
encounter as one in which the patient came from a non-
Swedish background. This observation is interesting on
two accounts. First it suggests that student nurses have a
limited interpretation of culture in terms of their inter-
actions with people who they consider to be from a dif-
ferent culture to their own. Consistent with the literature,
culture is conceived within the context of country of origin
rather than a broader interpretation to include, for
example, subgroups such as homeless people (1, 33, 34).
Second, cross-cultural care encounters are viewed as those
which involve interactions with patients from an immi-
grant background. Nurses who were from an immigrant
background themselves all provided examples of cross-
cultural care encounters that involved patients from a
different immigrant background rather than Swedish
patients. This may be due to the emphasis student nurses
placed on the importance of a shared spoken language.
Immigrant student nurses spoke Swedish and therefore did
not appear to view their encounters with Swedish patients
as cross-cultural. It implies that in subscribing to the values
of the Swedish healthcare system immigrant nurses share
similar values and beliefs to their Swedish colleagues and
patients, a view supported by studies of the experiences of
immigrant nurses working in the UK (35, 36).
In agreement with the wider literature on cross-cultural
care encounters (1, 3, 4, 15, 21, 37), student nurses
identified that effective communication was fundamental
to providing quality nursing care. However, they experi-
enced considerable challenges when seeking to commu-
nicate with patients when they did not speak the same
language. Student nurses from a Swedish background
were unsatisfied with the encounter if they did not share a
common language with the patient. Immigrant nurses,
whilst still emphasizing the importance of shared language
appeared more confident in their ability to use other
strategies to address communication difficulties. This may
be because their life experience had helped them over-
come communication barriers in the past when they had
not been fluent in Swedish. Other research indicates that
there may be benefits to having an immigrant background
when caring for other immigrants (38, 39) although the
reasons for this are not clarified. The current study suggests
that immigrant nurses are able to transfer learning from
their life experience to nursing practice.
Other authors have identified the anxiety nurses expe-
rience when they are unable to communicate effectively
with patients (9, 15, 40) and this observation is endorsed
by student nurses in the current study. Kai et al. (40)
identified the professional uncertainty and disempower-
ment that qualified nurses and other healthcare profes-
sionals experience in cross-cultural care encounters due to
a perceived ignorance of cultural differences. Practitioners
are anxious about being culturally inappropriate, causing
affront or appearing discriminatory or racist. Student
 2010 The Authors. Journal compilation  2010 Nordic College of Caring Science
nurses in the current study identified how cultural
knowledge acquired through their nursing programme had
helped to equip them with an understanding of cultural
diversity that could inform their interactions with patients
from different cultural backgrounds. However, they lacked
skills and confidence in applying knowledge to practice
when assessing patients’ needs and were anxious about
causing offence through their line of questioning. Medical
students in the UK report similar challenges in cross-
cultural care encounters (41). The current study points to
the limitations of the students’ training in communication
skills but suggests a willingness to learn more.
Gerrish et al. (9) have identified how nurses can work
towards ensuring effective and sensitive communication in
cross-cultural care encounters. Drawing upon Kim’s (42)
work they propose that there may be generic communi-
cation skills which can be learned and which prepare
individuals to be optimally flexible and adapt at meeting
the challenges of cross-cultural communication, irrespec-
tive of the specific cultures involved in the exchange. They
call this ‘intercultural communicative competence’. They
also emphasize the need to develop ‘cultural communica-
tive competence’ whereby individuals acquire specific
knowledge about the patient’s cultural background that
might have a bearing on nursing care. Nurses should avoid
stereotypes but need sufficient knowledge to know what
might be relevant in the cross-cultural care encounter. The
findings from the current study highlight the need for
student nurses to develop these two dimensions of com-
municative competence.
Student nurses in the current study made limited use of
accredited interpreters to facilitate cross-cultural commu-
nication. Although they recognized the value of trained
interpreters, they perceived that financial constraints pro-
hibited their use. Instead, student nurses relied on relatives
to interpret in situations where there was no shared
language. These observations are consistent with studies
undertaken in Sweden (43) the UK (12) and Australia
(11). Although this approach may be an expedient way of
overcoming communication difficulties it raises several
issues. As one participant pointed out relatives may be
selective in their translation. This may be because they do
not want to cause their relative distress or may find con-
veying the message embarrassing, particularly if it relates
to personal aspects of care (15). Although relatives may be
able to converse in normal social situations, they may not
have sufficient grasp of the second language to translate
complex medical concepts (9). Additionally, the use of
relatives as interpreters can compromise confidentiality as
patients may not wish their relative to know the full details
of their condition and required care (21).
Solving these problems is not easy. Publicly funded
healthcare systems such as that in Sweden inevitably face
financial constraints on budgets. Nurses have contact with
patients 24 hours a day and it would be impractical as well

as financially prohibitive to use accredited interpreters in
all cross-cultural care encounters. Moreover, some patients
may have a preference for family members to interpret in
some situations (13). However, it is important that nurses
are aware of the limitations of using family interpreters
and provide patients with a choice. Moreover, as Gerrish
(12) points out, if nurses continue to make do with family
members rather than advocate on behalf of their patients
for better access to accredited interpreters the situation will
not change.
Conclusion
Although the current study was undertaken in Sweden,
the findings resonate with the international literature
relating to communication in cross-cultural care encoun-
ters. The implications arising from this study, therefore,
extend beyond the country in which the research was
undertaken. Student nurses face many challenges when
communicating in cross-cultural care encounters, espe-
cially when they do not share the same language with
the patient. Although they use a range of strategies to
facilitate communication they find themselves in
situations where they are unable to communicate effec-
tively and this leads to dissatisfaction with the caring
experience. They also lack skills and confidence in cross-
cultural communication. Even in situations where
students felt satisfied that they were able to communicate,
it does not mean that the patient was satisfied with the
interaction. In the light of these findings, is important that
nursing programmes enable student nurses to become
competent in communicating in cross-cultural care
encounters and that the clinical learning environment
provides them with the opportunity to put their learning
into practice.
Acknowledgements
The authors would like to thank AMF Pension, the
Department of Neurobiology, Care Science and Society,
the Division of Nursing at Karolinska Institutet for their
support.
Author contributions
M. Jirwe was involved in the study design, data collection,
data analysis and manuscript preparation. K. Gerrish was
involved in the study design, data analysis, critical revision
of manuscript, linguistic revision. A. Emami was involved
in the study design, data analysis, critical revision of
manuscript.
Funding
This research was supported by AMF pension.
 2010 The Authors. Journal compilation  2010 Nordic College of Caring Science
Communication in cross-cultural care encounters 443
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