Developing Personal Competence in Nursing Students through International Clinical Practice:

Abstract

The purpose of this article is to demonstrate and discuss how personal competence, with emphasis on communication and empathy, can be developed by nursing students through international clinical practice. In order to develop personal competence and establish relationships with patients, the ability to communicate and to empathize is central. The basis for this article is data obtained from logs kept by ten third-year nursing students during their eight-week clinical practice programme at a nursing home and a rehabilitation unit in the Balkans. The logs were analysed by hermeneutic method, where the objective is to create meaning and understanding. The findings are discussed in relation to the importance of non-verbal communication when words are in short supply, the significance of being emotionally touched - empathy as a bodily response, empathy: neutral versus non-neutral, feeling versus emotion, empathy dependent upon similar experiences versus empathy as an affective response to the situation and the significance of critical reflection upon experience.

Keywords: personal competence, communication, empathy, log-based supervision, international studies, critical reflection.

The purpose of the present article is to demonstrate and discuss how personal competence, with an emphasis on communication and empathy, can be developed by nursing students through international clinical practice. Based upon my experience (as a teacher for Norwegian students in international clinical practice) and the study findings, I would suggest that international clinical practice is highly suitable as an arena for the development of personal competence.

Personal competence constitutes part of a person’s total professional competence together with theoretical knowledge and vocationally specific skills (Skau 2005). It is not easy to define personal competence precisely, because it is experience-based and unique. It is by working with patients in the practical setting that one becomes emotionally touched, thus developing as both a professional and as a human being. This involves being challenged with respect to values, attitudes, mindset and behaviour (ibid.). To develop personal competence and establish relationships requires the ability to communicate and to empathize. Since empathy is an essential component in developing personal competence, this concept will be further explained.

The concept empathy has, to a great extent, been a matter for research in moral philosophy, psychology and nursing. In moral philosophy, the impact of empathy on moral practice is highlighted. Psychological aspects, such as how empathy develops in humans and the object relation-theory, through the mother-child dyad, have received a great deal of focus. Nursing research emphasises the significance of empathy in patient relationships. Common to these approaches is a focus on how empathy can be defined and described, the conditions that must be present in order to develop the capability to empathize, whether empathy can be learned and if so, how.

Empathy can be described as the ability to put oneself in someone else’s place and share his world of experience (Nortvedt 2001, Nerdrum 2000, Vetlesen 1996). According to Travelbee (1971, 1999) empathy involves the ability to exist in, or to participate in and understand the other person’s mental state at a particular moment in time. She describes empathy as an intellectual and neutral process. Other researchers evaluate this differently by pointing out that empathy is not morally neutral, because empathy means that one cares about and becomes involved with the other person (Vetlesen and Henriksen 2006, Vetlesen 1996).

Empathic response is an interaction between emotional and cognitive abilities (Vetlesen 1996). Morse et al. (2006/1992) explain this interaction by describing the emotional component of empathy as a focused response and the cognitive as a pseudo-focused and professional response. An initial stimulus creates an empathic response, which gives the nurse an intellectual understanding of the patient’s experience, and what anxiety and insecurity mean to the patient. The nurse’s emotional and intellectual understanding then combines to implement measures that satisfy the patient’s needs. Vetlesen (1996) agrees with this and states that empathic responses include an interplay between emotional and cognitive abilities, where cognitive ability includes the ability to interpret and to imagine.

Travelbee (1971, 1999) argues that empathy can be learned by reflecting one’s own life experiences. To empathize with a patient requires a willingness to understand others, and also that the nurse and patient have a common background or have experienced a similar situation. Since empathy can only function on a basis of equality, it is unrealistic to expect that a nurse would be able to empathize with all patients. This means that nursing students with little practical experience may find it difficult to empathize based upon such a small amount of life experience.

Other researchers maintain that empathy cannot be learned merely intellectually; one must also have experienced empathy through the influence of others, such as in the mother-child dyad, in order to empathize with others. It is argued that empathy is not mainly a skill that can be learned as a technique or procedure, as empathy is an affective and spontaneous response to the moral implications of a situation, caused by the patient’s pain (Henriksen and Vetlesen 2006, Nortvedt and Grimen 2004, Vetlesen 1996). The affective side of empathy is emphasized in recent moral-philosophical research. Fundamental to the affective dimension of empathy is the experience of discomfort caused by the discomfort of others, thus being influenced by their pain. Vetlesen (1996) suggests that there are differences between affect and feeling. Affect is described as being so absorbed by the situation and feeling so closely involved that one becomes one with the other person. The result is lack of distance and over- involvement. Feelings are different, because they contain elements of reflection. Feelings are also cognitive in the sense that they produce a certain understanding of reality (ibid.). So, learning empathic communication requires a balance between closeness and distance.

As a conclusion one can argue that empathy is a concept consisting of various dimensions. To develop empathy is a central component in the development of personal competence, and it involves some challenges.

To develop personal competence creates a number of challenges. Carper emphasizes that "Personal knowledge in nursing is the most problematic, the most difficult to master and to teach. At the same time, it is perhaps the pattern most essential to understanding the meaning of health in terms of well being." (Carpter 1978:18). Skau (2005) states that personal competence is difficult to conceptualise because it is about our personal behaviour. Furthermore, Nerdrum emphasizes challenge related to teaching students about empathic communication: "The results indicate that the process of changing into a genuinely higher level of empathic communication is a more demanding process than reported in several other studies" (Nerdrum 2000:48).

In addition, evidence based medicine traditionally implies that clinical practice is based upon knowledge generated through systematic studies. According to this understanding universal knowledge exists, so that research results can be used in a non-contextual manner, independent of person and situation (Heggen 2004). This approach to interpretation of evidence-based knowledge has influenced nursing education to a large extent. However, Martinsen challenges this understanding of evidence based nursing by arguing that evidence is not a clearly defined term. Within life philosophy, for example, narratives are used to develop clear insight (Martinsen 2005). Narratives, viewed in relation to situated learning, indicate that learning takes place in a specific situation and in a special context (Lave and Wenger 1991, 2003). This poses a challenge to students in international clinical practice; they must constructively use themselves and their knowledge in a new and unfamiliar setting.

Based upon this, I suggest that the development of personal competence in international clinical practice is challenging. At the same time, I also wish to assert that international clinical practice may be particularly well suited to develop personal competence, as students have been forced to substantiate and reconsider their own points of view and ways of thinking in a new and foreign context.

In the spring of 2004, ten third-year nursing students from Lovisenberg Deaconal University College carried out an eight-week clinical practice at a rehabilitation unit and a nursing home in the Balkans. This was a pilot project and we were two teachers who accompanied the students to supervise and guide them throughout the duration of the project. The objective of the pilot project was to:

1. Organise clinical practice for the students at the nursing home and rehabilitation unit and provide clinical practise follow-up.
2. Contribute to raising nursing competence.
3. Test various teaching methods related to clinical practice in another cultural context.

Our experiences as teachers, as well as studies conducted by Bøckmann (2002) and Mittet (2000), suggested that preparations are important to the learning process in international studies. Cultural understanding and cultural sensitivity are vital factors (Hillestad and Sørensen 2007). Cultural sensitivity can be defined as: "(…) to understand other people by accepting their premises without feeling provoked or threatened by their perception of reality" (Magelssen 2002:22). To develop cultural sensitivity is significant for how one views the patient and one’s local colleagues, and this has consequences for the care one provides. Knowledge about intercultural communication is important.

We as teachers were responsible for planning and implementing the students’ preparations. This involved clarification of expectations and planning the clinical practice period with emphasis on practical conditions, working conditions and reflection on these, as well as different views of knowledge and cultural codes. Furthermore, the students also had to prepare by attending a 20-hour course in the local language.

In this project, the supervision of students was as far as theory based upon a combination of a socio-cultural view of learning (Dysthe 2001, Säljö 2001, Vygotsky 1978) and confluent pedagogy (Tveiten 2002, Braute 1993, Grenstad 1990). A socio-cultural view of learning means that learning occurs as a process of interaction between people and participation. The ability to look upon oneself as a part of the community, to communicate and to co-operate are all necessary in order to be able to contribute to this interaction. Dysthe (2001) points out that learning is situated, fundamentally social, distributed and mediated. Language plays a key role in active learning, and learning is a result of practical participation. One criticism of the socio-cultural view of learning is that it does not pay sufficient attention to each individual student. Learning also takes place on an individual level, and each single participant plays a unique role in the community. The combination of a team and teambuilding is therefore influenced by individual courage, motivation, willingness and ability to contribute actively. Confluent pedagogy strongly emphasizes creativity and imagination, in addition to the individual’s development as a competent professional individual (Tveiten 2002, Braute 1993, Grenstad 1990).

Furthermore, in order to learn from experience, critical reflection is essential. Critical reflection can be defined as a cognitive, emotional and experience related process where assumptions from actions or experiences are investigated (Fook, White and Gardner 2006). Student supervision included the following learning tools: logs, reflection notes, guidance, peer response, assessments and evaluation. This article focuses on the students` clinical practice logs.

Data material used in this article is based on the students’ practice logs. The students wrote daily logs throughout the duration of their clinical practice programme. The purpose of log-writing was to give the students the opportunity to describe practical situations and experiences based upon events, thoughts and feelings in their practice period. According to Martinsen (2005) and (Lave and Wenger 1991, 2003) logs may then be defined as narratives, as description based experiences in a specific situation and in a special context. This makes log-writing a highly suitable tool for developing personal competence.

To learn from experience requires critical reflection. The student logs forms a basis for the reflection process. The reflection process involves dealing with feelings by emphasizing positive elements and dealing with the negative in order to be able to evaluate experiences through association, integration, validation and internalisation. The last phase in the reflection process involves making a summary of what one has learned. Learning represents a new perspective of experience. One is prepared for application, and new knowledge requires action (Fook, White and Gardner 2006, Bjørk 2003, Bjerknes and Bjørk 1994, Boud, Keogh and Walker 1985).

Having read the logs, the assessment is that the students’ logs were characterised by openness, honesty, commitment and personal involvement. This personal involvement is particularly apparent in descriptions of communication situations and situations that affect them emotionally through vulnerability and sensitivity.

The student logs were analysed by using hermeneutic method where the objective is to create meaning and understanding (Gadamer 1989). Based on Gadamer, Flemming (2003) has described hermeneutic research in nursing in five steps: (1) Deciding upon a question, (2) identification of pre-understanding, (3) gaining understanding through dialogue with participants, (4) gaining understanding through dialogue with the text and (5) establishing trustworthiness.

The question is set by the focus for this article: How do the students develop personal competence through international clinical practice. My personal pre-understanding was based on my personal preparations prior departure together with my colleague, the other teacher in this project, including studying the local language, culture, history and literature. The purpose of our preparations was to understand local context as well as we could. We also prepared by working at the nursing home and rehabilitation centre. In addition, we had meetings with local leaders and staff for planning and getting to know each other and to express expectations so as to create mutual trust and understanding. In this situation it was very useful to be two teachers, so that we could discuss challenges related to differences in views of knowledge, nursing approach, organisational structures and lack of modern equipment. Furthermore we worked together with our students in local clinical settings. We as teachers gained understanding through dialogue with the students through guiding them in clinical practical settings, reading their logs once a week and giving them feedback by reflecting together with them and by carrying out evaluations in the middle and at the end of the period. In addition, we also had four whole days during the practice period in a neutral place, in which we used the time for critical reflection according to personal, practical and professional challenges. In the analysis phase, in order to gain understanding through dialogue with the text, we reviewed the text several times, with an emphasis on the total, the parts and also on significant themes. The logs where characterized by a combination of reporting actions and continually reflecting over the events. Furthermore, they showed signs of association, as thoughts and feelings were described successively as they occurred in the students’ minds. This article is primarily based upon the significant themes: communication, empathy and being emotionally touched. The empirical basis for the analysis is in one way rather narrow consisting of only ten student nurses' reflections during eight weeks of practice abroad. This limits the scope of the conclusions.

Qualitative research claims trustworthiness and in this project it has been established through triangulation of methods. To participate together with the students in practical settings made it possible to be part of the same situations, so we had a common experience as basis for critical reflection. I also wrote my own logs and field-notes during the period. In addition, my colleague and I discussed our personal understanding of the clinical reality on a daily basis according to our professional knowledge and local context in relation to our own pre-understanding.

In this section our findings will be discussed in relation to the importance of non-verbal communication when words are in short supply, the significance of being emotionally touched - empathy as a bodily response, empathy: neutral versus non-neutral, feeling versus emotion, empathy dependent upon similar experiences versus empathy as an affective response to the situation and the significance of critical reflection upon experience.

Communication between people together with empathy, are important factors in establishing a human-to-human relationship. Pre-departure preparations including courses in language and culture contributed to the students’ knowledge about codes for politeness and showing respect. This helped the students to make contact. Based upon their understanding of the significance of verbal language, the students expected that they would experience a language barrier in establishing relationships with the patients. Initially they experienced moderate frustration in relation to this, but the main impressions from the logs was that the initial encounters went better than they anticipated, and that they were met with kindness. As one student wrote: "With good will, we are able to understand each other".

After initial meetings where the students established contact, they experienced that they could understand more than expected, and that verbal language isn’t as important and decisive as they initially predicted and believed. They manage to get their message across non-verbally through facial expressions and gesticulation. One student wrote: "We communicate using pointing, nodding, smiling, thumbs up, laughter, a bit of English and a bit of local language." One student described this as: "This is communication, actually good communication, stripped of paraphrasing and open-closed questions. I believe that being there as we are, with body contact and continuity, at the same time as we catch one thing or another he (the patient) says, and getting things translated works well. At the same time, it is also about doing well for the patient and for him to feel safe and secure". Being together with the patients was characterised by the fact that they became familiar with each other and recognised each other as human beings. Like one student pointed out: "A number of communication situations are also going better now, because I have learned quite a few words and because I am beginning to get to know the patients. I know a bit more about how they want things to be, about their routines and about the prerequisites we have to consider in order to meet their needs. In the beginning I didn’t really know what kind of equipment they had or what the differences were in relation to Norway. Many things are quite similar…"

The students also developed skills in understanding non-verbal communication in relation to the therapeutic use of vocal pitch in order to calm the patient, and how physical touch and continuity contributed to creating mutual trust in the relationship. One student explained this as: "We have heard that T (student) speaks Norwegian to the patients as a reassurance technique, in order not to seem unsure and "dumb" when we only speak one syllable words and also in broken speech. We tried it today with several patients and it actually went rather well. Just to hear someone speak calmly to them and knowing that we are present can work extremely well on the patient’s perception of the situation. Then, it isn’t so important that they don’t understand what we say. Vocal pitch and body language can say more than words." This shows how the students became more aware of the importance of active listening in relation to non-verbal communication as an empathic response and open- minded attitude.

The students worked hard to learn more of the local language. In this way, they cooperated constructively with the patients and staff, but it also caused some misunderstandings. Illustrative excerpts from logs: "D (patient) corrected our language a bit. T (student), for example, has gone around saying «Ne pala» instead of «Ne hvala». «Ne pala» means « she did not fall out of bed» but he wanted to say «no, thank you»". In this situation the patient was the one that corrected the student. This shows the patients’ involvement and may suggest that the relationship between them was based on cooperation: the student assisted the patient according to basic needs, and the patient helped the student to learn more language. In this way they established a relationship based on trust and mutual understanding. One other example shows cooperation with the staff in spite of language barriers: "Something funny happened today. The list we made on Friday, about O (patient) sitting up, was the topic of discussion amongst the staff. «Stolice» means chair, but it is also slang for bowel movement. The staff discussed whether O (patient) should sit on the toilet and have a bowel movement 2 x 30 minutes per day or sit in a chair for 2 x 30 minutes per day. Luckily, they went for the second option". These two examples indicate that humour can be of great importance. There will always be some misunderstandings. To share and understand local humour and irony indicates communication at a high level in relation to understand local context.

After the initial phase and positive experiences, the students portrayed a more varied picture of the situation. Frustration occurred in relation to several factors. First, the students experienced frustration about wanting to be able, but not being able, to understand completely what the patients were trying to get across verbally. They also experienced frustration in relation to their desire to communicate better in order to appear as the person they really are. Excerpts from logs can illustrate this frustration: "I feel that frustration about the communication problems we have is growing. We have now been here for a while and I believe that more of the patients are tired of not being understood. It is difficult to know whether we understand them correctly. I feel that I am interpreting and assuming all the time, but I still don’t know if I have understood it correctly. It isn’t a good feeling. I so want to talk more and get more of myself across to the patients and my understanding of the situation, but then it all just comes to a complete halt. I am able to ask some questions in between, but what good does it do when the patient doesn’t answer? I can very well understand that the patients feel abandoned; I would also have felt the same! To not be truly understood isn’t very easy for someone to come to terms with." This indicates that the students must find new ways to establish a deeper relationship when words are in short supply. Crucial to this is that they dare to participate in this unfamiliar setting, dare to involve themselves as persons in all their vulnerability. Vulnerability can be expressed emotionally as a bodily response.

The logs indicated that empathy may manifest itself as a bodily response to the other’s situation. The students described experiences resulting from taking the patients’ suffering upon themselves, where their entire person was affected. Their bodily response of being emotionally touched was described as a "knot in their stomach and a lump in their throat", "being angry inside" and feeling "disgust welling up inside". The students sensed the patient’s pain and they felt physical discomfort themselves, which the students describe as having stomach pains, nausea and discomfort. Illustrative excerpts from logs showed that the students experienced these bodily reactions as overwhelming: "In particular the matter was raised about the feeling of not knowing / having an overview combined with language and communication problems (…). We have long been prepared for the conditions down here being completely different from those at home. However, I don’t believe that any of us, at least not me, could have imagined how the patients’ problems would actually affect our bodies. These statements can be connected to the body’s phenomenology. Merleau-Ponty argues that the body is the personality’s subject as a sensing, perspiring, acting, feeling and speaking phenomenon. It is through the body that consciousness takes shape, as it is through the body that one is present in the world through embodied consciousness and recognition (Merleau-Ponty 1994). Therefore, one cannot differentiate between body and feelings. Experiences make lasting impressions as the body remembers. In this way, one can say that the body is both perception and experience.

Students may use various strategies to overcome personal vulnerability and reactions by being bodily touched. To create distance is one strategy, and as one student describes it: "I have thought that we actually have to block out many of the impressions we have. If we don’t, it can be rather tough!" When empathy is described as a bodily response it indicates that empathy is not neutral. On the other hand: when students use distance as a strategy to not be overwhelmed, can this be regarded as a neutral response?

Travelbee (1971, 1999) describes empathy as an intellectual and neutral process. This is in contrast to Vetlesen (1996), who maintains that empathy isn’t morally neutral and that an empathic response is an interaction between emotional abilities on the one side and cognitive abilities on the other. Morse et al. (2006/1992) share this point of view. The students’ logs indicated that empathy is not neutral but manifests itself through emotional involvement. This experience is contextually situated in a foreign setting. From their studies in Norway, they bring knowledge about ethics, through which they have learned about the undisputed value of human life and that every patient is a unique individual. In this foreign culture and in the actual clinical practice setting, it appears different because the society is both patriarchic and hierarchic. It is the family’s, that is to say, the women’s task to care for the aged and infirm. Thus, being a patient at a nursing home is viewed as a shameful thing and the patients appear as a stigmatised group. Therefore, how the students treat and care for these patients is highly significant. By acting openly and respectfully, as well as showing interest and acknowledgment, the students make initial contact and receive very positive responses from the patients. This becomes a good situation for both the patients and the students through establishing human-to-human relationships based on mutual understanding.

However, the students’ ethical knowledge and emotional involvement in the patients’ situation contributed to make them particularly vulnerable. Their limited language skills created a lack of ability to gain a total overview of the situation and to explain their point of view. The logs reflected this, through emotional and normative descriptions. The students had a clear perception of what was right and wrong based on knowledge of humanism. In this case, developing personal competence by exploring their individual limits became a challenge. Equally important was to be aware of exceeding the boundaries for over-involvement through "sentimental feelings" (Martinsen 2006). This does not create a therapeutic relationship. In some situations, creating distance is a prerequisite for being able to carry out professional measures in order to help the sick. To distance oneself may occasionally be appropriate if it prevents generation of chaotic feelings that paralyses one’s actions. This doesn’t mean that one doesn’t become used to see daily suffering (Hillestad 2007). It involves exploring one’s own boundaries through awareness of oneself as a vulnerable person in relation to patients who are also vulnerable. The students develop their personal competence by daring to challenge their own boundaries.

Based on these arguments, the claim is that empathy is not neutral, but based on emotional and cognitive abilities. The next question is: how can this emotional ability be explained?

Vetlesen (1996) maintains that there is a difference between emotion and feeling. Emotion involves being engrossed by a lack of distance. Feelings differ from emotion as they contain an element of reflection. To learn empathetic communication requires a balance between closeness and distance. The question is how it is possible for students to learn this? However, if students never overstep their personal boundaries for commitment and involvement, they will never be able to find out where their personal boundaries lie in relation to closeness, over-involvement and "sentimental feeling". Therefore, this is about having the courage and the ability to cross one’s own boundaries and face one’s own vulnerability as a person. In this manner, the student may learn through experience what the ability to show empathy means to them as a unique human being.

Nortvedt and Grimen (2004) state that sensitivity and reflection are two completely central characteristics in the implementation of knowledge in health studies. Sensitivity is a central term involving susceptibility and responsiveness; it augments one’s focus and makes one more receptive to the patient. Equally important, it also refers to the interpretation and meaning of the situation. Martinsen describes the professional nurse as a person with emotions, and she makes a distinction between emotions and emotionality. She states: "Whereas emotion for the other is a seeing emotion. It is an emotion for which perception opens, and it is exactly perception which opens the world to me and lets created life come to me. Perception opens the seeing emotions and the access granting emotions. They grant us access to the world and our existence. The horizon of meaning is opened by the seeing emotions" (Martinsen 2006:74). According to Martinsen and her concept of "seeing emotions", excerpts from the student logs show how the students use themselves in order to understand and make themselves understood. This is described as "using the senses". As one student wrote: "I very much wanted to understand and tried to concentrate to listen for meaning." This student describes her wish to understand, but is situational understanding possible in a foreign context?

Travelbee (1971, 1999) maintains that common experience is a precondition for empathy. This can be interpreted as recognising the patient’s suffering based upon something a person has experienced himself. In this way, one can identify with the patient. To have the same experience can cause a person to become focused on how one solved a similar

problem oneself. This may affect the way one listens to the patient. If this view forms the basis, the students in this study would have limited opportunity to empathize with the patients for several reasons. First, the patients in the nursing home were significantly older than them, up to 75 years older. Other elements that differed were language, culture, financial situation, and perhaps religion, education level and the fact that the patients were stigmatised because they live in an institution. The student logs did not show that this contributed negatively in relation to experiencing the other person’s suffering. The patients’ suffering affected the students strongly. Vetlesen maintains that one can understand the other’s pain. He states, "(..) physical pain understood as subjection to pain has something universally human about it, something we can collectively share our experiences of. However, as soon we begin dwelling upon what such pain does to me, a strong individualised element becomes apparent" (Vetlesen 2004:34). The pain phenomenon generates a universal human appeal, through being subjected to pain both as an opportunity to exercise compassion and as an experience of reality. Vulnerability is something we all have in common as persons. Do we need to have experienced empathy in order to develop the ability to empathize? It was not easy to find an answer to this in the student logs. Many logs contained descriptions of the local carers’ actions that contributed to dehumanisation of the patients, but for that reason one cannot assert that these carers lack empathy. In this context, reflection is an important factor in the ability to analyse and learn from actions. The students have raised their awareness through cultural sensitivity and as the logs showed, reflection involved insight according to: "we can’t do something about everything" and "Rome wasn’t built in a day". Through critical reflection, the students became conscious of what they could do instead of allowing their frustrations to overpower them into a state of decision paralysis.

The logs showed how being emotionally touched affected the students through landmark experiences. If these situations are not analysed and processed by the individual, this may result in negative feelings and frustration, as they become attached to the body as raw and painful experiences. One student stated, "I feel it is perfect planning that we have one day for reflection- day the first three weeks we are here. It is a big help, actually, to be able to talk about experiences, any dilemmas or troubles with all of the others. Reflection is extremely important and I feel that reflection is absolutely necessary to integrate so that the quality of care we provide will be good. Speaking for myself, I feel that it becomes a natural part of me to assess, consider for and against and if necessary, re-evaluate implemented measures and it is good to note that it is me, with professional knowledge, experience based knowledge and personality, who forms the basis for the reflection." The intention of reflection is to turn reflection into learning. Critical reflection is important in order for new knowledge to create meaning for the individual student and contribute to the formative process as a professional. Events are situational, everything that is different and thus perceived as meaningless or negative can contribute to frustration and decision paralysis.

In learning and reflection frustration is a common reaction. In international practical studies students also experienced frustration as a part of a "U-curve" (Oberg 1960 in Dahl 2001). After an initial positive phase in which everything seems nice, it is common to experience a phase of "culture chock". Preparations prior to departure may prevent a lasting and overwhelming frustration. To have knowledge about what to expect according to the Oberg "U-curve", each student can formulate a strategy for how to overcome this phase. This strategy should be made both individually and in co-operation with the other participants.

To have qualified instructors and reflection partners creates greater understanding. This may be obtained by being able to vary the situations, something that contributes to one’s social learning process. Listening to the experiences and understanding of the situation which others have had, may contribute to broadening of one’s own action repertoire. To be able to understand local practices and create meaning from experiences, it is of great importance to have an instructor who knows both cultures (in this case Norwegian culture and local culture in the Balkans). Through guidance and reflection, the students created a new understanding, based on cultural sensitivity.

Conclusion

The purpose of this article is to demonstrate and discuss how personal competence, with emphasis on communication and empathy, can be developed by nursing students through international clinical practice. In this type of practice, students can find it particularly meaningful to work in an unknown context where many things are new and different. They have the opportunity to be challenged as far as what they have taken for granted in Norwegian culture and customs, that "this is just the way things are" can also be different. However, a new cultural setting makes them more vulnerable to the suffering of others. To be committed and to participate causes a strong emotional involvement that challenges students to find a balance between emotional closeness and distance. To be touched and to empathize create new dimensions. Through critical reflection students adapt their impressions and develop personal competence by raising awareness of how their bodies are affected by the suffering of others. This indicates development of personal competence as a process of learning by changing into a genuinely higher level of empathic understanding. Guidance from instructors who are familiar with both cultures is important in order to prevent frustration and decision paralysis.

Student logs illustrate how students develop as professionals and human beings by becoming emotionally engaged and touched by their patients. They learn to communicate and establish relationships when language is limited, and they widen their repertoire as far as creating relationships. This is important knowledge for them to take home, thus increasing their competence in dealing with Norwegian patients suffering from communication problems, such as those related to aphasia and dementia.

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RN 1985, Post-bachelor speciality in Geriatric Nursing, Post-bachelor speciality in Workplace Management and Leadership, Master of Nursing Science.
Assistant Professor at Lovisenberg Deaconal University College, Oslo, since 2001. 
Courses at the University of Oslo in the history, language, culture, and literature of the Balkan region.
Supervision of Norwegian nursing students in their international praxis at a nursing home and rehabilitation centre in the Balkan region.  
Nursing Development Consultant in both an advisory and a 'hands-on' capacity at a nursing home in the Balkan region since 2002
Lecturer and supervisor for Montenegrin nursing students in Montenegro since 2002, as 30% job in the Bachelor Program there 2005-2007.
Equal co-authorship together with Adelheid H. Hillestad of a student handbook for Bachelor health care students in international praxis:
Hillestad, A.H and Sørensen, A.L (2007): "BARE REIS!" Oslo: Cappelen 

Anne Lene Sørensen
Lovisenberg diakonale høgskole
Lovisenberggata 15
0487 Oslo
e-mail: anne.sorensen@ldh.no

Journal of Intercultural Communication, ISSN 1404-1634, issue 19, Januari 2009.
URL: http://www.immi.se/intercultural/.