Author: Claribel Nkansah (UVA ID: 11729139) MSc. Medical Anthropology and Sociology Thesis Department: Graduate School of Social Sciences Submission: 10/07/2019 (UvA Roeterseiland) Supervisor: Dr. Victor Toom
Second Reader: Dr. Patrick Brown
Word Count: 18282
De-Stabilizing
Instruments on culture
and competence
An Actor-Network Theory inspired approach to culture and competence training for healthcare professionals within the Netherlands
ABSTRACT
Inspired by the sensibilities and methodologies of actor-network theory (ANT), this thesis explores the training of health care professionals on culture and competence through the practices of curriculum-making. This empirical exploration pursues pre-scriptions of curriculum, or scripts, as they enact and are becoming enacted1 in the course development, teaching and assessment of courses at the Vocational
School and Post-School Training Center of The Netherlands. Drawing on work by Madeline Akrich (1997) and the de-scription of technical objects, this summation attempts to de-stabilize instruments, scripts, as they are enrolled in the social-material networks of the Interculturele Diversiteit (Intercultural Diversity) and Cultureel Sensitieve Gezondheidszorg (Culturally Sensitive Healthcare)2 courses. Utilizing the
Vocational School as the main site of research, this thesis aims to shift discussions on cultural competence from epistemologies to ontologies as the differences in curriculums and knowledges produced are explored and not filtered out in the name of standardization.
Keywords: culture, competence, vocational education, standardization, de-scription, actor-network theory, curriculum-making practices
1
This thesis adopts the sensibilities, methodologies and styles of writing that are inspired by ANT. (e.g. ‘enact and are becoming enacted). This type of phrasing highlights the symmetry and relationality of objects and subjects within ANT. 2
Throughout this thesis, I use the Dutch language with the English translation placed in the parenthesis punctuation. (e.g. Dutch word (English translation). Translation occurs once per Dutch word when it is first introduced. Please see the glossary in the annex(s) section for a full summary of translations.
TABLE OF CONTENTS
Introduction
• Shifts: Epistomologies to Ontologies………3
• Central Terms………5
• Formulated Research Questions……….6
Literature Review: Cultural Competence at a Glance.……….8
Actor-Network Theory………..10
• Cultural Competence and Topology………11
Methodology………13
• Methods……….13
• The Field: Health Professions Education……….16
• Emprical Cases: The Vocational School and The Post-School Training Center……….17
• Field Research Plan: Data Collection and Analysis………22
• Ethical Considerations………..24
Data Analysis………26
• Enacting Scripts: Materials, Sources and Software Enrolled in Adaptations………..26
• Preparations and Adlibs………..32
• Images and Spaces of Meeting………39
Inferences (Conclusions)……….43
Acknowlegements………..45
Bibiolography (References)………..46
INTRODUCTION
Shifts: Epistemologies to Ontologies
Hey there again! I thought to myself. I have been following them for a while now, looking through every interview transcript, field note and source of material. I didn’t know what they were at first, what they were doing “here” or how they would “be” there, but I just followed. Sometimes they are visible and other times hidden but every step of the way and in different ways, these scripts were becoming…
What is cultural competence? This question is how I began the journey towards this thesis, so it’s only fitting that this thesis is initiated from this inquiry. When I was in nursing school, only five years ago, we were given a lecture on Cultural Competence. By the end of this lecture, my notes were littered with the
do’s and don’ts3 for the African, Asian and Native American patients; they were, ironically, also
accompanied by a bold lettered phrase: DO NOT STEREOTYPE. Two years after nursing school, during my practice in the emergency and trauma department, I sat at the hospital computer to finish my
continuous learning modules. Continued education was meant to maintain a certain level of knowledge
for a practicing healthcare professional and, to my surprise, I had a module entitled: Culturally Competent Nursing. I then proceeded to take a self-assessment that quantified my level of cultural competence. The results of this self-assessment were irrelevant to me; I was, again, faced with this topic of cultural competence in different settings and through different modes of delivery, but what was I
learning about culture and competence? After five years as a registered nurse and ten years as a
healthcare professional, I chose to engage with this topic, again, in different contexts and with different tools.
So! What, is cultural competence? This question will not be answered during this thesis; I will not explore the right or wrong way to educate healthcare professionals on this topic. I will not develop a new model, conceptualization or theory on the topic of cultural competence. Un/fortunately4, my experiences, knowledge and positionality, have changed through and since my nursing career. This
3
Italics is used to emphasize phrasing, concepts, terms, quotations and thick descriptions that are meant to catch the reader’s attention and highlight arguments.
4
The splitting of words with a slash punctuation (e.g. un/fortunately or inter/cultural) is meant to illustrate the opening up and “un-raveling” of concepts that is inspired by ANT.
thesis, also, doesn’t examine a problem within the social-technical world. The question: What is cultural competence? is relevant for some researchers and sociological explorers, but this thesis will push you, as it has pushed me, to shift your perspective and, consequently, your questions. By moving away from the conceptualization of cultural competence to the materiality of culture and competence, I was
empowered towards a different approach to culture and competence. This shift is not simply for fun (well we might have fun), but aims to take the seemingly static concept of cultural competence and unravel it. The unraveling, within this thesis, is not intended to see what is inside but to see how culture and competence are becoming…This is the shift I was talking about: from a discussion about what an entity is to how it is coming into being. Inspired by the work of Annemarie Mol (2002;2010), John Law (1999;2009) and Bruno Latour (2005), this research grapples with the ever-moving sensibilities and methodologies of actor-network theory (ANT)5 in relation to the concept of cultural competence. Before I unpack the term ANT, my research plan, central terms and research questions, I will begin with the topic of relevance. In preparation for this thesis, I read various articles on the topic of cultural competence: its origins as a concept and the scholars attempting to duct tape it to a model, illustration or guide for success. I read literature on scholars who critique the concept as essentializing culture and masking structural inequalities as well as those who rave about the healing powers of cultural
competence and its influence on the quality of patient care. Relevance is something different to these scholars and, in my opinion, represents an ability to conceptualize or define a concept. This thesis attempts to align with a movement from epistemologies (knowing) to ontologies (being) and this shift isn’t relevant to everyone. This way of asking questions can become important to those engaged with the topics of culture, competence, education research and actor-network theory. Because I identify with these terms, I challenge those who also feels a kinship towards them to keep reading and, hopefully, find their own relevance within this work.
The following chapters will engage with the current literature on the topics of cultural competence and actor-network theory; I will then outline the research methodology, through the methods, research sites and their rationales. After exploring the empirical cases, field work plan and ethical considerations, the data analysis section will highlight three main themes or arguments. To conclude, I will return to the research questions, reflect on the research process, lessons learned and recommend further points of
5
In resistance to the temptations of oversimplification and the decreased tensions that accompany the use of the abbreviation ANT, I utilize the term ‘Actor-Network Theory’ interchangeably.
interest within education research and cultural competence. To begin this thesis, I will describe the central terms and concepts utilized in this work.
Central Terms
As previously stated, this thesis draws inspiration from the sensibilities and methodologies of actor-network theory (ANT). Although the name: Actor-Network-Theory seems to imply a framework that aligns with concrete ways of theorizing, it certainly does not. ANT engages with the ways of asking questions and perceiving the world that take practices as a starting point (Law, 2009; Mol, 2002, 2010; Fenwick & Edwards, 2010;). In the following literature review chapter, I will further justify this way of looking at culture and competence.
This work moves away from the conceptualization of cultural competence as a single subject, object or entity; it moves away from the idea that a certain amount of knowledge can be accumulated about cultural competence that will illuminate its various angles and give light to what it really is. It is the messiness of culture and competence, that I experienced as a nursing student and professional, that propels this shift throughout this work. Drawing on the work of Law & Singleton (2005), these scholars eloquently describe movements from epistemologies to ontologies in relation to objects and subjects: “It is assumed that different diagnostic techniques more or less imperfectly discern an underlying disease object. Seen in this way the issue is to try to sort out what that object really is on a basis of insufficient information. This, we might say, is an
epistemological approach. But Mol argues differently. She follows the relational STS (Science and Technology Studies) line
which argues, as we have seen, that the accounts of realities and the realities that they describe are produced together. Accordingly, she recommends that difference be understood ontologically. This means that difference is no longer a matter of different perspectives on a single object, but the enactment of different objects in the different sets of relations and contexts of practice,” (Law & Singleton, 2005: 8).
Therefore, cultural competence is not seen as a single entity (subject or object) but, in this research, as multiple entities of culture and competence. The terms enactment, curriculum-making practices and
scripts, highlighted in italics, are guided by the research questions and enrolled within the central
makeup on this thesis. The practices of curriculum-making: course development, teaching and
assessment, will be the points of entry into how scripts on culture and competence enact and are
becoming enacted (Edwards, 2011). Although curriculum-making is not limited to these practices, in order to work with the research questions and perspectives, this thesis cuts the network at these points. When we think about scripts, we think about a play or a scenario that is pre-determined, outlined and designed for specific users who may take on a specific role. This thesis takes up the term scripts and the ways of discussing technical objects from Akrich (1997). Within the practices of curriculum-making for
Interculturele Diversiteit (The Vocational School), we see that pre-scripted curriculum, scripts, are
utilized. Similar to a script for a play, they outline pre-determined scenarios in the form of course descriptions, competencies and behaviors. Influenced by these scripts, my research questions were reconfigured for their inclusion. This adjustment enabled me to focus on how scripts on culture and competence were taken up, enacted and translated through curriculum making practices. The term
enactment highlights how entities come into being through practices, shape and are becoming shaped
by their relations to other entities (Law, 2009; Mol, 2002).
In order to answer my research questions and unravel the concept of cultural competence, I mobilize with the acts of de-scription throughout my analysis. This term is outlined by Akrich (1997):
“Thus, if we are interested in technical objects and not in chimerae, we can’t be satisfied methodologically with the designer’s or the user’s point of view alone. Instead we go back and forth continually between the designer and the user, between the designer’s projected user and the real user, between the world inscribed in the object and the world described by its
displacement. For it is in the incessant variation that we gain access to the crucial relationships: the user’s reaction’s that give
body to the designer’s project, and the way in which the user’s real environment is in part specified by the introduction of a new piece of equipment. The notion of de-scription proposed here has to be developed within this framework,” (Akrich, 1997: 208-209)
De-scription aims to de-stabilize the scripts on culture and competence in order to uncover how culture and competence are becoming. It is through these terms, that situate and are becoming situated within this research, that I follow and de-script these instruments on culture and competence. The following section clearly formulates the main research question and sub-questions that will guide this thesis.
Formulated Research Questions
The main site for this research was a Dutch secondary vocational school in a large city of the
Netherlands. This site will be referred to under a pseudo-name: The Vocational School. I was able to participate in the Interculturele Diversiteit course, which relates to the topics of culture and
competence, which trained care and social care students at levels 3 and 4. The pseudo-named: Post-School Training Center was utilized in this research as a small site of contrast to The Vocational Post-School. The course called Cultureel Sensitieve Gezondheidszorg is taught to established healthcare
professionals (general practitioners and practice assistants) who pay for the course and attendance. A full description of these empirical cases, courses and their social-material networks will occur in the methodology chapter.
Furthermore, this thesis examines how culture and competence training is facilitated, in the courses above, through the methods of ethnography: observation and semi-constructed interviews, actor-network theory and printed/online document analysis. For the purposes of this research, I write the concept of cultural competence into terms of culture and competence. This not only illustrates the
de-scription of the concept, but also enables culture and competence to be taken up as terms that are fluid,
ever-changing and situated in their context of use (Law, 1999).
During fieldwork, the focus of my main research question shifted to an understanding that the
Interculturele Diversiteit course was designed with the use of dossiers called: Interculturele bewustzijn Diversiteit (Intercultural Diversity Awareness) for Level 3 students and Interculturele overbruggen Diversiteit (Intercultural Diversity Bridging) for Level 4 students6. These documents were designed and dispersed to educators of The Vocational School as guides to develop, teach and assess their course. In light of these discoveries, my main research question focuses on care and social care students as well as the scripts used in the practices of curriculum-making: course development, teaching and
assessment. I use the term scripts, instead of dossiers, to highlight the end product of a designer’s inscribed thoughts, beliefs, competencies, materials and sources that assume a reality in particular ways (Akrich, 1997). It became apparent that my research questions needed to incorporate the materiality of culture and competence as subjects and objects.
Therefore, main research question and associated sub-questions that guided this research are as follows:
How are scripts of culture and competence becoming enacted and how do they enact within the
curriculum-making practices of the Interculturele Diversiteit course, for care and social care students, at a secondary vocational school in a large city in the Netherlands?
Sub-Questions: What materials or sources do educators draw on in the practices of curriculum-making?
How is culture and competence developed, taught, assessed? (by whom and with which materials?) What versions of culture and competence are built-in to scripts and learning materials? What is left out?
6
This research was initially guided by the following main research question (per the submitted research proposal): How are
culture and competenceenacted in the practice, development and education of cultural competence for care and nursing students at an MBO in The Netherlands?
Further influenced by ANT, the Post-School Training Center is used as a point of contrast, when relevant, to juxtapose the enactments of scripts on culture and competence within The Vocational School. The analysis of clashes and similarities between these contexts, highlights the diversity of enactments. The following research question seeks to guide these points of contrast between the Post-School Training Center and The Vocational School:
How are scripts on culture and competence done differently or similarly between the Vocational School and Post-School Training Center?
The following chapter reviews the past and current literature on the topics of cultural competence and actor-network theory (ANT), its movement to and within the Netherlands and the stance taken by this research.
LITERATURE REVIEW: CULTURAL COMPETENCE AT A GLANCE
In order to explore the research questions and aims previously outlined, I will examine the relevant literature on cultural competence and actor-network theory (ANT), discuss how the naming and portability of cultural competence as a concept enables its movement and translation from the United States (US) to the Netherlands via the term topology, and by engaging with the relevant intersections between cultural competence and ANT, I focus on the topics of stability and standardization in relation to culture and competence. This literature review is intended to summarize past and current knowledge on what cultural competence, presumably, is within the US and the Netherlands as places to work and
converse from throughout this thesis.
Originating from the United States in the early 1990s, the concept cultural competence was first conceptualized as ethnic competence in health services and social work literature (Gallegos, 1982; Green, 1995; Winkelman, 2005).
…"a set of procedures and activities to be used in acquiring culturally-relevant insights into the problems of minority clients and the means of applying such insights to the development of intervention strategies that are culturally appropriate for these clients,” (Gallegos, 1982: 4).
From this point, several models, theories and conceptualizations on cultural competence arose in relation to multiple knowledge systems: Leininger Sunrise Model (transcultural nursing), Cultural
Competence, Practice Stages, Client Intersectional Systems, & Case Studies Model (social work), Multicultural Counseling Competence (psychology) and Purnell Model for Cultural Competence (healthcare: practice, education, research and administration) (Leininger, 1988; Cross et al., 1991; Lum et al., 1999; Purnell & Paulanka, 2003; Sue et al., 1982; Gallegos et al., 2008). Outlining how best to achieve, evaluate, measure and/or assess cultural competence, these models illustrate attempts to
carve out real estate within the epistemology of the concept.
For example, tools like the Purnell Model for Cultural
Competence were developed as a guide for
healthcare professionals to gather “cultural” information in order to give culturally competent care in healthcare settings (Purnell & Paulanka, 2003) Figure 1.
This model describes cultural competence as a process of awareness towards other cultures and cultural information. The four outer circles highlight the process of providing care to an individual by evaluating their position in global society,
community, family and within themselves (person). The twelve pieces of the cultural pie summarize cultural domains that are assessed when evaluating patients, and the dark circle in the middle portrays a black box of what is still unknown about culture (Purnell, 2002). The Purnell model is well-known within
nursing practice and healthcare research, but this research will not focus on affirming or refuting it, models like it or their conceptualizations. Instead, I aim to fore-front the static, definitive and compact nature of knowledge about culture and competence that are engrained into these modes.
As the concept of cultural competence moved to and within the Netherlands, it is translated through the topics of inter/cultural sensitivity, communication and diversity responsiveness (Seeleman, 2009;
Seeleman, 2014; Wieringen et al., 2002). As scholars in the Netherlands grapple with culture in the healthcare setting, the increasingly diverse work force of the Netherlands and how best to educate professionals on the topic of culture (Geerlings et al., 2018; Knipper et al., 2010), they stimulate debates on the relevance of culture within the Netherlands.
When speaking with people native to the Netherlands, there is strong desire to treat everyone equally and this creed seems to stand in opposition to recognizing ethnicity or cultural differences. In the Netherlands, the last census was conducted in 1971 not only because of the belief that the census infringed on the privacy of the population, but also because personal data was used during the Second World War to identify Jewish populations. For this reason, data regarding the Dutch population is collected from the municipal registries and information on race, ethnicity and religion are excluded (Guiraudon et al., 2005). This point is contrasted by scholars who seek ways to bring culture and competence into medical education. A report to the Dutch ministry of Health by Bekker & van Mens-Verhulst (2008), called for research into competency-profiles for cross-cultural practices (as cited in Geerlings, 2018: 88). This enables the gathering of knowledge, abilities and skills in relation to operating across cultural lines, and in work by Knipper et al. (2010), scholars literally plea for standardized training on cultural competence. Based on the key issues of Epidemiology: knowledge of ethnic variations in
disease epidemiology and reactions to therapy; Culture, ethnicity and identity; Social, economic and legal context; Communication (particularly non-verbal), the article petitions for coherence in medical curricula
from a local to global perspective and the standardization of curriculum on cultural competence means to hold the answer.
Even with the diverse, and at times contradictory, views on culture and competence presented within the Netherlands, the naming, framing and packaging of what cultural competence is or is not allows it to move and translate. This interpretation is explored and supported through the following literature on
actor-network theory and the term topology.
ACTOR-NETWORK THEORY
Actor-network theory (ANT) is a branch within Science and Technology Studies (STS) that encompasses material-semiotics tools, sensibilities and methods of analysis that treat everything in the social and natural worlds as continuous, relational and situated networks (Law, 2009). As previously discussed, ANT does not abide by a framework or way of doing ANT, but provides ways of perceiving and thinking about objects and subjects. This is further examined through the terms symmetry and translation. Symmetry highlights how ANT acknowledges human and non-human entities as relational, without pre-determined characteristics and taking shape within networks. It is within these social-material networks that entities
(subjects and objects) are coming into being (Bruno, 2005; Law, 2009). The term sociology of translation or translation is a process described by the work of Michel Callon (1984) through four moments:
problematization, interessement, enrollment, mobilization. The process of translation enables the forming, reforming, maintenance and dissolving of networks that can be explored through curriculum-making practices. (Edwards, 2011):
“In particular, curriculum-making can be traced in the processes of assembling and maintaining these networks, as well as in the negotiations and translations that occur at and within various nodes comprising a network,” (Edwards, 2011:43).
Sparked by the terms, sensibilities, methodologies and ways of asking questions associated with ANT, education studies and scholars strive to unravel the tensions within standardized curriculum (Fenwick & Edwards, 2010; Fenwick, 2010; Edwards, 2011). Edwards (2011) follows the enactments of standardized curriculum within the college and school settings of vocational education. These enactments produced multiple, ontological forms of the prescribed curriculum through translations, and the standardized prescriptions meant to fix curriculums and learning objectives were performed differently:
“Difference and multiplicity in the curriculum are therefore to be expected and described rather than be identified as problematic and explained (away). This raises important educational questions about the status and equivalence of learning
outcomes within a standardized curriculum and the type and amount of work that is necessary to exclude multiplicity in the name of standardization,” (Edwards, 2011: 53).
In an attempt to make curriculums and knowledges seemingly coherent and exclude the differences in curriculum, prescribed standards seek stability and homogeny. ANT affords education research the ability to analyze the clashes between standardization and negotiation by following standards (Fenwick, 2010). Now that we have touched on the literature of cultural competence and actor-network theory (ANT), I will take this next section to look at cultural competence through sensitives of ANT and set my stance for this research.
Cultural Competence and Topology
“For as we practice our trade as intellectuals, the premiums we place on transportability, on naming, on clarity, on
formulating and rendering explicit what it is that we know—this premium, though doubtless often enough appropriate, also
imposes costs. And I am concerned about those costs. I believe that they render complex thinking—thinking that is not strategically ordered, tellable in a simple way, thinking that is lumpy or heterogeneous— difficult or impossible,” (Law, 1999: 9).
In the work After ANT: complexity, naming and topology, John Law (1999) examines how the condensing of actor-network theory into the commonalities of theorization, renders the messiness and tensions within its phrasing to a simplified framework. It’s through this framing, that the sensibilities of ANT are
becoming something concrete, fixed and transportable. The term topology pertains to how relating parts are held in a shape as its characteristics are mapped. It’s through this compact shape that complex ways of thinking and conversing about objects and subjects are becoming harder to accomplish.
For this thesis, I render this way of thinking in the direction of cultural competence. Cultural competence is seen as an instrument in the care of patients who are perceived as other through, but not limited to, the knowledge of ethnic differences, “cultural elements”, ways of doing, thinking, acting and/or
communicating. This tool proclaims to improve patient outcomes, decrease health inequalities, produce culturally competent health care professionals and patient-centered care practices (Betancourt, 2003; Betancourt, 2006; Gallegos et al., 2008). Eager to take part in these promises outlined, healthcare professionals, educators, researchers etc. demand digestible information on culture and competence, and keen to oblige with ideas on how to truly do cultural competence the right way, scholars fix cultural competence in models, assessments, concepts and theories (Papadopoulos et al., 2016; Matsumoto., 2013); stabilized and naturalized cultural competence becomes a whole entity that is easily
transportable, with its topology assumed and complexity diminished.
The instrumentation of cultural competence has stimulated strong opposition as scholars assert that it essentializes culture in the form of stereotypical characteristics and masks structural inequalities within the healthcare system (Kleinman & Benson, 2006; Van Dijk, 1998). In highlighting cultural competence done the wrong way, literature highlights a process of renaming and restructuring it as cultural humility and/or diversity responsiveness (Seeleman, 2014; Trevalon & Murray-Garcia, 1998). With each new model, conceptualization and operationalization attempting to stabilize cultural competence in the right
way, cultural competence becomes a dichotomy of right and wrong ways of doing. What is learned and
practiced about culture and competence is, therefore, inscribed within these objects. It is from this stance that this thesis aims to engage with culture and competence as an object and subject through its
scripts. Instead of taking these scripts as a fixed instrument, I seek to de-script and therefore de-stabilize
them in order to explore how culture and competence are becoming. In order to accomplish this goal, the following section will describe the methodology deployed, its rationale and operationalization.
By providing an outline of the research methods, field of study, fieldwork plan and ethical
considerations, this methodological chapter aims to summarize the actions taken in this research and their rationales. Specifically, this chapter is concerned with how the research was conducted. Data was obtained through a combination of methods: ethnography (observation), semi-structured interviews and analysis of printed/online documents. Each method and its rationale will be operationalized in relation to the research questions, the field of Health Professions’ Education will be described, the cases (The Vocational School and Post School Training Center) and their networks outlined, and I shall
conclude this chapter with a brief explanation of how data was analyzed and the ethical considerations taken.
Methods
The following research methods relate to qualitative research design and were utilized in data collection. These research methods (ethnography: observation, semi-structured interviews and document analysis) are representative of a research strategy, with no explicit hypothesis, that enables pertinent data to be collected, analyzed and discussed in relation to the research questions (Pope et al., 2002). I will describe each method in detail, with the use of supportive literature, the type of data intended for collection via the method and its rationale within this research.
Ethnography
The methods of ethnography are a holistic approach to research which involves observation, interviews and the interpretation of material culture in order to generate data that is representative of their contexts (Green & Thorogood, 2004: 135). In the acts of observing, interviewing and interacting with sources and materials of curriculum-making, I was situated within and became situated by the research sites. The following sections will describe the methods of observation and semi-structured interviews as they were utilized.
Beginning with the concept of observation, Green and Thorogood (2004) utilized the researcher roles, developed by Gold (1958), to highlight the researchers’ positionality in relation to observation. The roles of a participant as an observer and an observer as a participant represent a gradient for observation techniques within ethnographic studies. It is within this range that I found myself as a researcher. I was active in observing educators and students throughout the courses; I asked questions regarding teaching style, materials used and the perceptions of students. As I observed, participated in and interacted within each course, I was observing from a point of reference and a perspective…from somewhere,
rather than nowhere (Harraway, 2007).
“From this perspective, the researcher no longer stands from a safe distance, ‘objectively “doing” research “on” objects’, but is researching from somewhere, including with the human child, teacher, and co-researchers, as well as the nonhuman elements such as the texts on the wall, pencils, paper, or books,” (Harraway, 2007 as cited in Blaise et al., 2013).
My positionality as a researcher was further influenced by my knowledge as a graduate social sciences student, former health care professional (nurse) trained on cultural competence, a native English-speaking person with a West-African (Cameroon and Ghana) background, and an American citizenship who required an interpreter with participants. As I watched and learned from the students and
educators, they also watched and learned from me. Un/fortunately during the practice of observation, I attempted “not to disturb” the learning process of students by sitting in the back of the classroom; this became a learning moment for me. My physical presence in the classroom and my interpretation of the students as they interpreted me, made “objective observation” unrealistic. In this way, observation was not a one-sided act but a mutual and collaborative effort to engage with the socio-material world around me. As I reflected on this, I met these confronting truths with adjustments. For example, during my second observation day, I decided to sit with the students during the lesson. I realized that I could not avoid these confrontations or be prepared for them, but that they were situated within their contexts and I needed to engage with them.
Green and Thorogood (2004) outlined observation as a method to gain an understanding of a
phenomena or behavior. This method generates data related to what people do as well as what they say
they do. For example, I attended three in-class days at the Vocational School were educators guided
students in the discussion of topics like culture, diversity and discrimination. I sat with the students, with the assistance of a native Dutch interpreter, as they discussed personal experiences and clashes in cultural norms. This method enabled me to observe educators and students in what they say they do,
what they actually do and with which materials. These observations gave me a better understanding of
how these scripts were brought into the classroom and what they were doing.
Semi-Structured Interviews
Interviewing is a common method used to gather data from consenting participants. According to Green and Thorogood (2004), interviews are classified in a gradient from informal interviews to structured interviews. Structured interviews abide by a set of questions that are discussed in a specific order. For example, a survey can be used to make a direct comparison between respondents. Informal interviews are described as natural conversation within the field of study where data is spontaneously produced. For this research, I chose to utilize semi-structured interviews when interacting with research
participants.
Pope and Mays (2006), describe semi-structured interviews as a discussion were the researcher determines the topics but the data collected is guided by interviewee’s answers. In practice, I interviewed educators, students, exam developers and volunteers associated with the practices of curriculum-making at each site. In preparation for interviews, I chose 3 topics to discuss with participants and let interviewees’ responses develop my follow up questions. For example, when speaking with educators in the course Interculturele Diversiteit at The Vocational School, I chose the initial topics of: Culture, Competence and Materials because they acted as starting points into how culture and competence are discussed.
Since this research was conducted in the Netherlands where the native language is Dutch, I needed to constantly address language throughout my fieldwork. As a native English speaker with a basic
understanding of the Dutch language, I needed to invest in an interpreter for interviews, observations with participants and the translation of materials. In preparation for interviews, I asked my participants if they would like a native Dutch interpreter present and provided one if requested. They were also given the option to respond to interview questions in Dutch or in English. Even though translation enabled my own understanding, throughout this thesis I kept some words and phrases in the Dutch language. This was done to allow data extracted from the courses, participants, and materials to remain somewhat situated in their contexts.
In this research, printed and online documents on cultural and competence became important materials and sources of data for analysis. By employing the acts of de-scription outlined in Akrich (1997), the analysis of these scripts within The Vocational School enabled me to explore data that gave light to my research questions. For example, scripts were utilized in the curriculum-making practices: course development, teaching and assessment. Specifically, a script called the Interculturele (bewustzijn) Diversiteit is a written document containing learning outcomes, competencies and behavior that the course must enable students to achieve. This script was made available to me in Dutch. I then translated this document from Dutch to English using Google Translate, the English translation was verified by a native Dutch speaker then translated back to Dutch in order to assess for meaning lost.
This process can become time consuming and not all documentation can be accounted for when analyzing these social-material cases, so the scope of document analysis was limited to scripts, literature, course content and software user guides utilized in the curriculum-making practices of the Interculturele Diversiteit and Cultureel Sensitieve Gezondheidszorg. Documents were entered into NVIVO software for thematic coding analysis. This process is discussed further in the data collection section of this methodology chapter.
The Field: Health Professions’ Education
The education and training of health care professionals from school to post-school education is part of the broad field of Medical Education. Within this field, Health Professions’ Education arose from the need to format and structure teaching objectives, strategies and evaluations of healthcare professionals’ education. Ultimately this initiative is meant to drive the quality and efficacy of health professions’ programs and, therefore, impact the quality of patient care and health services (Heflin et al., 2016). I chose to highlight this field because it reflects the Interculturele Diversiteit and Cultureel Sensitieve
Gezondheidszorg courses. Both courses are elective and depend on the choice and interests of the
students and participants, respectively. For example, at The Vocational School students spend a certain percentage of time in practical training, where they interact with patients and other healthcare workers, and another percentage of time within school training. Neither of these courses are fully integrated into medical curricula, but they presented a unique opportunity to study not only the education of students and participants, but also the molding of working professionals.
Health Professions’ Education is changing in the face of research and innovation. From simulation and gamification to blended learning, education research hopes to inform curriculum-making practices as well as shape and be shaped by healthcare professionals, researchers, educators, students and materials (Car et al., 2019). Therefore, I focused this research on vocational school education and continued education of healthcare professionals within the Netherlands. As a hub for tolerant policies, the Dutch population has become increasingly diverse with 23% of the population representing a migration background, CBS (2018). In light of changes in the make-up of the Netherlands, there is a push to arm healthcare professionals with the knowledge, skills and abilities, afforded by cultural competence, in order to combat poor access to health services and quality of care (Knipper et al., 2010; Betancourt, 2006; Seeleman, 2009). With similar goals to impact the quality of care, the field of Health Professions’ Education presents an entry point into culture and competence through curriculum-making practices. The following sections will describe the empirical cases utilized within this study: The Vocational School and Post-School Training Center, the rationale for the chosen sites and their social-material networks.
Empirical Cases
The Vocational School
In the Netherlands, middelbaar beroepsonderwijs (secondary vocational training or MBO) represents an educational pathway for Dutch citizens at the age of 16. The main site of research was conducted at an MBO vocational school in a large city within the Netherlands. This school is one of many regionaal
opleidingscentrum (regional training centers or ROCs) that conduct secondary vocational education in
the area of South-Holland. Several colleges are represented in this school but the scope of this research will remain on the Zorgcollege (Health College). The Zorgcollege is responsible for the education of healthcare students in the care, social care, nursing, doctor and pharmaceutical assistant programs. Before zooming in on the course related to the terms culture and competence, I will give some background information on the vocational education system in the Netherlands.
The education system of the Netherlands was restructured with the 1997 Dutch Act on Adult and Vocational Education. This adjustment was made to improve connections between secondary/tertiary education pathways and the labour market. The Netherlands education system is broken into 3 divisions after the age of 12: VMBO, HAVO, VWO. Each division is further differentiated into specific durations,
education pathways and competencies that are in line with students’ needs and capabilities. Many students with an VMBO (preparatory for secondary vocational education) diploma, attend an MBO secondary vocational training school (Luijkx & Heus, 2008) Figure 2.
Secondary Vocational Education (MBO): Levelling Attendance (Years)
Level 5: Specialty (Post Level 4) Optional Training 1
Level 4: Middle Management Training 4
Level 3: Professional Training 3
Level 2: Basic Vocational Training 2
Level 1: Entry-Level Training 1
Learning TRACKS
BBL: Block or Day Release with practical training more than 60% of courses
BOL: Vocational Training with practical training at 20-60% of courses
**Interculturele Diversiteit is an elective course for care and social cares students at level 3 and level 4 for both BOL and BBL learning tracks.
The Vocational School site was chosen in relation to the course called: Interculturele Diversiteit that is taught to care and social care students who are in training to become care givers and social workers, respectively. Care givers have the responsibility of attending to the daily living activities of patients while social workers enable patients to cope with and achieve daily living activities. In order to address
diversity within the healthcare setting, this course was developed using pre-scripted curriculum or
scripts provided by an association called SBB (SBB, 2019)7.
I was introduced to the Vocational School and this course through their collaboration with the IENE (Intercultural Education of Nurses in Europe) project in 2015. This project aimed to develop culturally
competent compassion, courage and intercultural communication tools for standardized use across
7
I keep this association abbreviated in order to anonymize their involvement within this research. This choice will be further explained in the ethical considerations section of this thesis.
Europe (Papadopoulos et al., 2016; Taylor et al., 2011). It is through investigation into this project, that I came into contact with the educators of Interculturele Diversiteit, Marga and Joyce. After their
experience with the IENE project, Marga and Joyce, alongside a team of educators, sources and materials, developed Interculturele Diversiteit at the Vocational School. Currently in its third year of existence, this course presented an opportunity to study culture and competence in the Netherlands with educators who were familiar with the topic of cultural competence.
The Course: Interculturele Diversiteit
During their last year of study students in care and social care programs (level 3 and 4), are given a
keuzedelen (elective course) as a supplement to their program; one of these electives is called
Interculturele Diversiteit. This course is comprised of blended learning: two modules of online learning (e-learning), that were developed via OneNote software and dispersed via SharePoint, as well as 4 days of in-classroom learning. The in-class portion of the course incorporates e-learning modules, case studies, fieldtrips and final presentations. Students then take a final examination that is designed by the Consortium association (Consortium, 2019). The scripts on culture and competence as well as the
e-learning platform were two materials, main, materials that were analyzed at The Vocational School.
During fieldwork, the focus of my main research question shifted towards the use of scripts called Interculturele (bewustzijn) diversiteit and Interculturele (overbruggen) diversiteit in the development of Interculturele Diversiteit; these scripts were provided to Marga and Joyce via the SBB association. SBB acts as an advisor to the Dutch Ministry of Education, Culture and Science in order to ensure that vocational training (e.g. learning materials, competencies, course descriptions) aligns with Dutch labour market qualifications and ultimately practice, (according to the SBB website). These scripts were enrolled in the curriculum-making practices Interculturele Diversiteit as well as the design of its online learning platform.
Each e-learning module comprised of a Beroepsituatie (professional situation) that outlines a case study or case studies that pertain to an experience of diversity within the Dutch healthcare setting. Students then answer the questions associated with this case study in order to have meaningful discussions during in-class learning; these questions are more easily answered after completion of the Leskaarten
(lesson cards) within each module. The Leskaarten contained five to six activities that the student could
choose from in order to gain more knowledge on the module topic and support their reflections in the
present in this course, the social-material network illustrates the various materials, sources and software enrolled in the designing of this course.
Social-Material Networks
Within the Vocational School context, the sources include the educators, students, students’ employers, specialists, external participants, exam consultants and advisors of SBB and Consortium. The materials include scripts, online applications like OneNote and SharePoint, case studies in group discussion, visual interpretation papers and colored discussion cards. These sources and materials enable the practices of curriculum-making within Interculturele Diversiteit. The methods of ethnography: semi-structured interviews, observation and printed/online document analysis further enable interaction with these entities in order to collect pertinent data related to the research questions.
The Post-School Training Center
The major cities of the Netherlands (e.g. Rotterdam, Groningen, Eindhoven and Amsterdam) reflect an increasingly diverse population of expats, im/migrants and asylum seekers (SGEi, 2017; CBS, 2018). This diversity has spawned several companies within Amsterdam who attempt to train professionals on inter/cultural communication. One such institution, is the Post-School Training Center which is located in Amsterdam. In response to surveys that revealed dissatisfaction with the Dutch healthcare system amongst expats (ICAP, 2017), the course Cultureel Sensitieve Gezondheidszorg was developed to train Dutch general practitioners (GPs) and praktijk (practice) assistants on the topics of inter/cultural sensitivity. The surveys revealed a lack of trust in Dutch GPs and their lack of openness to alternative forms of treatment (ICAP, 2017). The main designers and educators for this training, Bart and Eveline, strived to bring awareness and sensitivity to differing expectations between the Dutch healthcare systems and non-Dutch patients.
The Post-School Training Center and this course represented an opportunity to add a small layer of contrast to The Vocational School. Although both courses were, seemingly, derived from the concept of cultural competence, they represent differences and similarities within the curriculums of culture and competence. During fieldwork, limitations prevented the observation of the Cultureel Sensitieve
Gezondheidszorg course and hindered the direct comparison of the courses. Therefore, the methods of
presentations) were deployed in this site. The findings were explored when relevant to the analysis of
Interculturele Diversiteit.
Field Research Plan: Data Collection and Analysis
As stated above, this research was conducted mainly at a vocational school in a large city in the Netherlands. The Post-School Training Center in Amsterdam was utilized as a small point of contrast to
the main focus of this thesis. The fieldwork period was from mid-February until the beginning of May 2019; even though I was the sole researcher for this research, I utilized three native Dutch speaking interpreters for interviews, transcription, document translation and verification throughout fieldwork. After receiving ethical approval from the Universiteit van Amsterdam, I began my first interviews around February 2019. I observed the Interculturele Diversiteit course at The Vocational School for 3 out 4 in-class days of the course for 3-4 hours. At Post-School Training Center, interviews were conducted sporadically between mid-March and the beginning of May 2019 Figure 3.
The Vocational School The Post-School Training
Interviews Course Educators 4 2 Students 6 ---- Other 3 4 Total 13 6 = 19 Observation Hours 10 ---- Documents 8 5
The above table visually illustrates the methods: semi-structured interviews (research participants), observation hours and number of documents for analysis. The Vocational School represents the main site of research with The Post-School Training Center as a point of contrast when relevant to the research.
**The label “other” pertains to participants that are unique to each site. For example, at the Vocational School: Consortium exam developers and volunteers specific to teaching exercises were interviewed. At the Post-School Training Center expats and general practice (GP) assistants were interviewed in relation to topics of the course.
Data analysis began at the end of April 2019 via NVIVO 12 Plus software. English-translated scripts, documents, literature, interview transcripts and thick descriptions of field observations were imported into NVIVO 12 Plus software and organized per site. NVIVO 12 Plus is a qualitative analysis software used to thematically code, organize and visually depict qualitative data for the purposes research, practice and/or education. I gained experience with this software during a research internship at (KIT) Royal Tropical Institute and as a research assistant in the Graduate School of Social Sciences at the Universiteit
van Amsterdam. Through the open coding method (What is this an instance of?), I used the code function to sort sections of interview transcripts, documents, literature, scripts and observations notes. This approach to analysis is outlined in grounded theory as open, axial and selective coding (Glaser & Strauss, 1967; Strauss, 1987 as cited in Green & Thorogood, 2004). Grounded theory stems from the idea that “theory” could emerge from data through systematic analysis. For example, after openly coding data, axial coding involved looking for relationships between categories and assessing for an overarching theme. This process is highlighted by the grouping and regrouping 28 codes Figure 4.
Assessment (Code) Sub-codes:
• Competency
• Practical Exam (Consortium) • School Exam (Assessment) Culture • Topic Relevance Curriculum-Making • Blended Learning • Cases • Course Feedback • Materials • Script Translation • Teacher’s Education • Teacher’s Experiences Other Disciplines in Zorg College
**The above 28 codes represent the beginning stages of analysis via NVIVO software. Interview, documents and observations from both the Vocational School and Post-School Training center were coded in NVIVO.
Even though this research is inspired by ANT, this data was analyzed by the structure of grounded theory analysis. With this said, the sensibilities of ANT are inscribed into this analysis. For example, data
analysis was conducted and reported with attention to the clashes or conflicts and the effects or Practice • Adjustment • Clash • Exchange • Operationalization
• Student Field Experiences • Students’ Experiences Teaching • Field Trips • In-Class Learning • Online Learning • Students’ Choice
outcomes of those clashes (Law, 1999). The results of these effects are reflected in the data analysis
below. As research was conducted, data collected and analyzed, ethical considerations were taken at each step.
Ethical Considerations
Similar to the format of data analysis for this thesis, ethical considerations emerge from reflections on the conflicts within this research. In Green and Thorogood (2004), the discussion on ethics begins with the researchers’ reflection on their position in relation to the research and society. One of the major ethical considerations of this work was that of language and informed consent. Because Dutch is not my native language and the Netherlands is not my native country, I attempted to stay aware of how my perspective as a non-native expat and student could influence my participants and the materials I came into contact with.
In order to combat these ethical issues, I initiated contact with research sites by using Dutch and English research flyers. This was done to inform participants of my research questions, aims and goals within their site, and as I met with other associations and networks (e.g. LEMAT and the Verhalenhuis), I reiterated purposes to these entities. As I gained access to the Vocational School and Post-School Training Center, I came into contact with their social-material networks. By utilizing interpreters during interviews, class participation and translation of documents from Dutch to English, I was aware of positionality and its possible limitations. Throughout this thesis, I developed ways to work with the Dutch language and participants in order keep them informed and respect the materials utilized in this research.
As a second point of consideration, the use of materials in the form of literature, online learning (e-learning) content and scripts posed ethical dilemmas. For example, Marga and Joyce (education at the Vocational School) granted me access to their e-learning platform for Interculturele Diversiteit. This content afforded me great sources of data and I made sure to ask for consent when analyzing the case studies, lesson cards, activities and competencies it contained. Even though I was granted access to this platform via a password, I kept Marga and Joyce informed of how I was using their creative content because access isn’t a blanket statement and it requires constant monitoring and feedback (Cassell, 1982; Richards & Schwarz, 2002). Another pertinent clash was with the SBB scripts (Interculturele
Marga and Joyce, since they used them in the development of the course, but I was unable to make contact with the original designers of the scripts in order to gain permission for their use in analysis. As I reflected on this dilemma, and with input from my supervisor, I chose to leave the name of the script designers, SBB, abbreviated. I chose to keep the names of the script because of the nuances within the Dutch language that became pertinent to my data analysis. These solutions aimed to protect the
association, who were unable to give consent for participation, and utilize documents that are pertinent to this research.
The final point of consideration was for the students who participated in the course Interculturele
Diversiteit. Even though Marga and Joyce gave me access to the e-learning platform, consent for
interviews and course participation, we discussed how the students’ participation in this research should be guided by the students. Students of any age could be seen as a vulnerable group in the context of classrooms or learning environments (Konza, 2012). Because classrooms are multi-dimensional and, in some ways, represent free spaces for students to express opinions and learning from each other, students were informed of this research in a verbal and written format (Doyle, 1986). In order to protect the schools, participants, materials and sources from the unwanted attention of this research,
participants were given the option to anonymize their names while material remained vague unless pertinent. Although the above ethical considerations were taken into account, this research has the following limitations.
Limitations
A limitation noted within this research was the inability to observe the course at the Post-School Training Center. Because of this limitation, direct comparison between the Vocational School and Post-School Training Center wasn’t substantiated. This course and site are therefore used as points of contrast and highlight how culture and competence are done similarly or differently, when relevant. Some readers might also conceive that my lack of Dutch language skills and/or nationality limits this research and I can’t deny their opinion. In response, I point out the considerations taken at every step to adequately portray and protect the integrity of the research participants, sources and materials within these Dutch contexts. In the following chapter, I describe the major themes and arguments that emerged from data analysis.
DATA ANALYSIS
With the main research questions formulated, current literature reviewed and methodology outlined, this section contains the results of data collected and analyzed during the allotted fieldwork period. Each argument will begin with a small vignette that introduces the tone of the argument and is followed by excerpts from the SBB scripts as well as thin and thick descriptions of supportive data. Thick
description consists of factual details, commentary and interpretation that enable a portrayal of the socio-material networks and practices that are central to the research questions (Geertz, 1994). By going back and forth between the designers and the users of these scripts, “we obtain access to the crucial relationships: the user’s reactions that give body to the designer’s project and the way in which the user’s real environment is in part specified by the introduction of a new piece of equipment,” (Akrich, 1997: 209). Through this dance of de-scription, clashes and alignments are fore-fronted and it is from the effects of these clashes, that my main arguments are formed. The first argument illustrates how the SBB scripts are brought into the networks and practices of curriculum-making and how they shape and are shaped by networks through the term adaptations. Argument two builds on the presence of the SBB scripts, in these networks, to highlight what versions of culture and competence are built into them, the practices of preparations and adlibbing that are enabled through them and the effects of these practices. The third argument seeks to explore images evoked through the effects of practices in the second argument and how these images come into contact through spaces of meeting. These arguments allow me to explore my research questions and add to discussions on culture, competence, standardized curriculum, curriculum-making practices and education research within the Netherlands.
Enacting Scripts: Materials, Sources and Software Enrolled in Adaptations
Day 1 of Interculturele Diversiteit (The Vocational School) was underway for one hour when Marga announced a 15min break; I looked around the room as students threw on their jackets, grabbed their cigarettes and bolted fromthe room. That’s it…, I thought to myself. I reflected on my time in nursing school where we sat in a lecture hall of 119 students, one teacher and lectures for… HOURS. How dull that time was and how stressed we all were. Rianne, an educator who will take over the course from Marga next year, saw my confusion. “Yea, they need a break. They
are doers, these students. They can’t sit for too long. I know it’s different from university level,” she said. Indeed, she read my mind, curriculum-making is not just content but also networks of audience, material and timing.
During my first interviews with Marga and Joyce at the Vocational School, we discussed and I observed their practices of course development, teaching and assessment. They formed networks of materials (e.g. scripts, literature, models, competencies), sources (e.g. educators’ teaching experiences, work experiences, education and collaboration) and software into the design of Interculturele Diversiteit. Pieces of material, I called scripts (Interculturele bewustzijn diversiteit) and (Interculturele overbruggen diversiteit), became the object and subject of this research and as I followed them through various networks of curriculum-making, I noted how they became translated by and through those networks: “For translation is the process or the work of making two things that are not the same, equivalent. But this term translation tells us nothing at all about how it is that links are made. And, in particular, it assumes nothing at all about the similarity of different links,” (Law, 1999:8)
This argument aims to explore the translation of SBB scripts into course content, but also the enactment of these scripts through the use of sources, materials and software. As these scripts on culture and competence left the SBB network and entered the curriculum-making networks of Marga and Joyce, they did not remain static instruments of course design:
Marga: “Looking at the script from the ministry (SBB scripts) and the exams (Consortium) then we (the educators) start discussing. Most of the time it’s a brainstorm session just to start and think of what we would like to do or what would we like to…doelstelling…”
Interpreter: “the goals we are aiming for…target”
Marga: “Yea, what are the goals. So, we look at the paper from the ministry (SBB scripts). There are some goals there. They are very cryptic and blah blah blah. So, we have to make them concrete. So that’s what we are going to do first and then start to do, okay…how can we get to this goal.
Then all the teachers that are here already and give lessons about this subject, because we are free to do so and no one says we can’t… so we do, most of them say, “oh yea! I know something for this goal.” I want to do this and that and now so! the program starts. That’s it! Simple! It’s completely simple… so we have the exam, we have the ministry (SBB scripts) and we do something in between. And we use all the knowledge already present. Poof! Put it together beetje husselen...”
Interpreter: Mix up and together
As Marga, Joyce, my interpreter and I sat discussing the design of Interculturele Diversiteit, I noted how the scripts were taken apart, formed and reformed through their practices. The scripts acted as
stimulators for debate and pushed educators to reflect on their own education, experiences and possible contributions to the subject of inter/cultural diversity; these ideas and experiences, I call them
sources, began to influence how the scripts were interpreted and translated into course content. The
final exam, from Consortium, also acted as scripted material that was brought into this round table discussion. Curriculum-making was becoming a collaboration and negotiation of sources and materials
within this network of actors. As the scripts were translated from vague script competencies into course learning objectives and content, Marga and Joyce employ not only sources and materials but also software.
When Marga and Joyce developed the course further, they utilized One Note software to aggregate course learning objectives, videos, articles, literature, case studies, activities and lesson plans into a free-form Figure 5.
This information becomes accessible to students, educators and students’ employers with Marga and Joyce as the gate keepers. As educators are becoming designers of online curriculum and dispersible information, their deployment of OneNote software enables not only the translation of the SBB scripts but also their adaptation.
In this thesis, I take up the broad language of scripted scenarios within film studies. This allows me to describe data results in a way that is understandable and specific to my inferences. The term
adaptation, situated in the contexts of film studies, is the process of adding to, altering and converting
commonly written work into another mode of media. I render this term in relation to the SBB scripts on culture and competence; as these scripts enter the networks of curriculum-making and are translated
into course content they are further adapted to and adapted by their audiences. This assertion is further explored by the illustration of the CanMEDs model within the online course content.
The CanMEDs competencies, originally formulated for physicians in Canada, display the seven abilities needed to effectively meet the healthcare needs of patients. Together, these abilities form the Medical Expert Figure 6 (CanMEDs, 2019). Illustrated on each Leskaarten of the online course, these competencies are described and explored through associated activities. The healthcare professional is portrayed through these competencies and developed through engagement with
course content. This model is not part of the SBB scripts but represents adaptations to Interculturele
Diversiteit through the use of One Note software. The implications of software in curriculum-making are
further supported by the following quotation:
“… ‘to bring software back into visibility so that we can pay attention to both what it is (ontology), where it has come from (through media archaeology and genealogy), but also what it is doing (through a form of mechanology)’, (Berry, 2011: 4). The latter is particularly important in relation to the work of education. There is a clear need to examine the ways in which software is entangled in curriculum-making practices in relation to forms of representation and the nature of knowledge, and the ways of interacting and knowing that are possible,” (Edwards, 2015: 276).
As the software is taken up into course development, teaching and assessment, it brings in the ability to shape what is learned about culture and competence. The SBB scripts are no longer static instruments but are formed and reformed as they are translated and adapted by materials, sources and software. The diversity of how scripts are enacted, becomes more evident when looking at how literature and survey results are utilized in the training general practitioners and practice assistants.
As previously discussed, Cultureel Sensitieve Gezondheidszorg (Culturally Sensitive Healthcare) is a course taught to practicing general practitioners (GPs) and praktijk assistants at the Post-School Training Center. This course is guided by and in my interpretation, scripted by, survey results that revealed expats’ dissatisfaction with the Dutch healthcare system Figure 7.
As this course was designed by Bart and Eveline, they used survey results and literature Figure 8, via PowerPoint slides, to stimulate attendees with the question: Is
there a problem?
This form of problematization is discussed in a broad sense; this means that in the patient-healthcare provider relationship, there could issues of miscommunication, mismatched expectations, lack of knowledge regarding the Dutch healthcare system and/or a cultural dimension:
“I have a feeling over the past few years this topic (cultural competence) is gaining a bit more attention. It’s not yet widely acknowledged that this should get attention. It’s also sometimes quite funny, mainly my experience is with GPs, you really have
