Diversity & Equality in Health and Care Open Access

Key words

healthcare professionals, intercultural education, train the trainers programmes, transfer of innovation

Introduction

This paper reports on a Transfer of Innovation (TOI) project, funded by the EU through the Leonardo da Vinci scheme; the innovation is a conceptual model for the development of cultural competence that was the outcome of a previous EU-funded project (Intercultural Education of Nurses (IENE1) 2008–2010). The Intercultural Education of Nurses and healthcare professionals in Europe 2 (IENE2) (2010–2012) project continues the work that was started during the IENE1 project (Taylor et al, 2011).

The IENE1 project investigated the perceived learning and teaching needs of healthcare students and practitioners in five European countries in relation to developing cultural competence. In order to provide structure to the investigation, students were presented with the Papadopoulos, Tilki and Taylor (PTT) model for the development of cultural competence (Papadopoulos et al, 1998; Papadopoulos, 2006). This model has been used extensively in education and research with nurses (e.g. Papadopoulos et al, 2004). The learning and teaching needs identified by students and healthcare practitioners during the IENE1 project were used to adapt this PTT model for use in curricula in the participating institutions in order to structure learning and teaching activities. The adapted model is known as the PTT/IENE model (see Figure 1). While the results from IENE1 identified that practical experiences form a crucial element of preparation for professional practice in a multicultural environment, practitioners value the opportunity to learn about culture, to explore values and beliefs, and to practise intercultural skills within the safe environment of an educational establishment, facilitated and supported by skilled teachers (Taylor et al, 2011).

The IENE2 project builds on this work by preparing teachers of healthcare professionals to meet the learning and teaching needs of students and practitioners identified during IENE1, and to integrate the PTT/ IENE model into their curricula. Participating institutions for IENE2 are KATHO, Belgium, SOFOE, France, AWO, Germany, EDUNET, Romania and Middlesex University in the UK. The project members work for a range of institutions. These include, for example, public-sector universities (Belgium and the UK), private non-profit educational organisations (Germany and Romania), and a private for-profit educational organisation (France). Thus the project itself was an exercise in working with people from different cultures to foster collaboration, exchange ideas and share good practice. The work of the project entailed the implementation of EU policy concerning intercultural dialogue and the training of teachers. Most of the work was conducted via email, but there were face-to-face meetings in each of the five countries.

Aims of IENE2

The IENE2 project aimed to contribute to vocational education and training of nurses and other healthcare professionals in Europe by enhancing the capacity of teachers to promote intercultural dialogue and the development of culturally competent care. The specific objectives of the project were as follows:

• to identify the training needs of teachers and trainers from the partner countries and determine the competences necessary to provide intercultural education for nurses and other healthcare professionals.

• to create the methodology and content of a Training of Trainers (ToT) package in order to prepare teachers and trainers to teach transversal competences and to implement the PTT/IENE model for the development of cultural competence in their curricula (see Box 1)

• to implement and evaluate the ToT package following training workshops with teachers and trainers in Belgium, France, Germany and Romania.

This paper reports on the initial needs analysis of the perceived educational and training needs of a sample of teachers of nurses and other healthcare professionals in participating organisations in Belgium, France, Germany and Romania. This stage of the investigation was led by the UK partner.

Policy context for the project

Policy relating to vocational education and training within the EU has a basis within the Treaty of Rome. The Lisbon Strategy (Commission of the European Communities, 2005) emphasised the importance of European education and training systems. The exchange of ideas is facilitated by the Leonardo da Vinci Programme, which supports enhancement of vocational education and training (VET) systems through a range of projects that promote collaboration and the transfer of innovation. The Lisbon Strategy’s call for European education and training systems to become worldwide quality reference points is taken forward by the Education and Training 2020 (ET 2020) work programme (European Commission, 2009). This reflects a commitment to lifelong learning through the further development of education and training systems intended to ensure both the personal, social and professional fulfilment of all citizens, and sustainable economic prosperity and employability whilst promoting democratic values, social cohesion, active citizenship and intercultural dialogue.Afurther document, entitled A New Impetus for European Cooperation in Vocational Education and Training to Support the Europe 2020 Strategy (European Commission, 2010a), emphasises the importance of goodquality education and training, and promoting mobility.

The Copenhagen Process, established in 2002, set out the basis for cooperation in VET and is reviewed every 2 years.More recently, the Bruges Communique´ (European Commission, 2010b) maintained the emphasis on the quality of teachers and trainers, and called for dissemination of best practice through transnational cooperation in VET, mobility of learners, teachers and trainers, and language training. This document notes the value of knowledge, skills and competences acquired abroad, stating that ‘The diversity of European vocational education and training systems is an asset for mutual learning’ (European Commission, 2010b, p. 3). Improving the quality and efficiency of education and training is central to current EU policy, which also recognises that the quality of vocational education and training is related to that of the teachers and trainers and their own initial education and continuing professional development (European Commission, 2010b).

Intercultural dialogue

The Council of Europe (2010), in its White Paper on intercultural dialogue, presents a compelling case for managing Europe’s increasing cultural diversity through the adoption of intercultural dialogue as a conceptual framework and a guide for policy makers and practitioners. Intercultural dialogue is understood as:

an open and respectful exchange of views between individuals, groups with different ethnic, cultural, religious and linguistic backgrounds, and heritage on the basis of mutual understanding and respect. It operates at all levels – within societies, between the societies of Europe, and between Europe and the wider world.

(Council of Europe, 2010, p. 4)

While the promotion and development of intercultural dialogue requires leadership at governmental level, the White Paper argues that intercultural competences should be taught and learned, and spaces for intercultural dialogue should be created and widened (Council of Europe, 2010). The IENE2 project helps teachers and trainers to create such spaces in their curricula and learning and teaching activities.

Cultural competence and education

Although the Council of Europe (2010) brings some clarity to the nature of intercultural dialogue, cultural competence is not so clear. Jeffreys (2006, p. 25) defines cultural competence as:

a multidimensional learning process that integrates transcultural skills in all three dimensions (cognitive, practical, and affective) ... [and] aims to achieve culturally congruent care.

What is important in this definition is the suggestion that cultural competence entails a process, not an end point.

The migration of both populations and healthcare professionals in Europe poses a challenge to the delivery of culturally competent care. Healthcare professionals are required to care for diverse client groups, but are also required to function in multicultural healthcare teams (Pahor and Rasmussen, 2009). In addition, there is continuing concern within the EU about disparities in health, both within and between member states, across the entire social gradient (Peiro and Benedict, 2010), which arise as a consequence of the impact of unequal distribution of health determinants (Commission on Social Determinants of Health, 2008). Migrants may be particularly vulnerable to health problems as a consequence of conditions in their countries of origin, living conditions in their host countries, and difficulties with obtaining access to healthcare systems (Peiro and Benedict, 2010). Gijo´n- Sa´nchez et al (2010) thus recommend intercultural competence training for all health professionals in the EU, accompanied by opportunities for student and staff exchanges between relevant institutions in member states.

There is acceptance of the need to include cultural aspects of caring in the curricula of healthcare professionals (Brathwaite and Majumdar, 2006; Dyson, 2007; Leininger, 1991; Papadopoulos, 2006; Papadopoulos et al, 1998; Purnell and Paulanka, 2003). However, an evidence base to guide the selection of appropriate learning and teaching strategies to facilitate the development of cultural competence is lacking (Koskinen et al, 2012; Long, 2012). The overview by Long (2012) of teaching strategies used in relation to cultural competence in nurse education in the USA identified a range of strategies, including lectures, group discussions, self-directed learning, clinical experiences, simulation, guest lectures, men toring and consultation, education partnerships with community members and study abroad. Although there were suggestions for improvements in knowledge and awareness with regard to working with people from different cultures, as a consequence of using these strategies, there is a lack of conclusive evidence about outcomes and cultural competence (Long, 2012).

Elements of intercultural education can be delivered in stand-alone modules, integrated into educational programmes, or delivered using a mixture of both. The assertion by Gomes and Holmberg (2010, p. 412) that diversity should be presented as normal and natural within educational practice, requiring ‘constant re-assessment of taken-for granted realities’, suggests that integration into all aspects of the curriculum would be the most appropriate approach. UNESCO (2006) emphasises that culture and education are intertwined, that is, that intercultural education cannot be merely an addition to the curriculum, but requires the inclusion of multiple perspectives and voices.

Cultural competence requires first a willingness to approach patients with openness and respect, openmindedness and awillingness to learn about difference (O’Hagan, 2001; Jenks, 2011). Secondly, practitioners need to acquire some specific knowledge and understanding of the cultures of their patients (Papadopoulos et al, 2004). However, contemporary cultural competence education has rejected the list of traits approaches in favour of the development of skills required to negotiate culturally sensitive care (Lipson and DeSantis, 2007).

The IENE2 project aimed to assist teachers to prepare their students, through initial and continuing education and training, to practise in multicultural environments. The train the trainer method has been found to be effective in disseminating knowledge to healthcare professionals (Assemi et al, 2007; Corelli et al, 2007; Rubak et al, 2008). It has proved to be an appropriate strategy for supporting changes in curricula, provided that participants are given teaching materials (Assemi et al, 2007). Corelli et al (2007) further claim that train the trainer models appear to provide an effective strategy for promoting the adoption of shared curricular innovation on a national scale.

Material and Methods

The study reported in this paper aimed to identify the perceived education and training needs of a sample of teachers, from the partner and associated institutions, concerning the provision of intercultural education for nurses and other healthcare professionals.

Methodology

A triangulated approach was adopted and two methods were employed. A questionnaire was used to identify the training needs of teachers of healthcare professionals, in Belgium, France, Germany and Romania, who engage in preparing their students to work in multicultural environments and/or for labour mobility within Europe. This was based on the learning and teaching needs of students and practitioners that had been identified during IENE 1.

Individual interviews were conducted with managers or employers of healthcare professionals in each of the four countries. These interviews aimed to gain some understanding of their expectations of their employees, their potential to influence healthcare practitioner curricula, and their knowledge of institutional contexts. They also explored their thoughts on the preparation of healthcare professionals to work in multicultural environments and for labour mobility within Europe. The research was conducted by the partners in the UK.

Ethics

The investigation was granted ethical approval by the Health Studies Ethics Sub-Committee at Middlesex University. Access to participants was sought from the relevant institution in each participating country. The project leaders in each of the participating countries conducted the interviews with their chosen managers or employers. The interviews were conducted in the local language and translated into English for the purposes of data analysis. The informants were assured both of the confidentiality of the data they supplied, and that it would not be possible for the information they supplied to be attributed to any one of them.

As the researcher is the instrument of data collection in qualitative research (Patton, 2002), they have to be sensitive to the situation in which the investigation occurs and recognise that they cannot be detached. Rather, they have to seek to understand their role in the research process, as well as the political or cultural perspective that they might bring to the interviews (Hammersley and Atkinson, 1995; Mason, 1996; Patton, 2002). It is possible that the researcher might influence the way in which informants reply to questions. Therefore the researcher should be reflexive.

Sampling and the sample

For the questionnaires, the population of interest was that of teachers and trainers of nurses and other healthcare professionals, who were known to the partners in Belgium, France, Germany and Romania. Members of these populations had to have an interest in preparing their students to work towards cultural competence, and had to be in a position that enabled them to do so.

For the individual interviews, the population of interest was employers and senior managers of nurses and other healthcare professionals whowere known to the partners in Belgium, France, Germany and Romania. In total, 20 employers and senior managers were interviewed, who were in key positions, able to make decisions about employment and promotion, usually had extensive experience of healthcare delivery, and were responsible, within national and local policy guidelines, for the provision of healthcare services that met the needs of their local populations. Purposive sampling was used to identify both samples (see Table 1).

Data collection and analysis

The questionnaires were drawn up in English and translated into the languages of the respective countries. A process of back translation confirmed the accuracy of the translations. A total of 79 questionnaires were completed in the languages of the participating countries; any narrative provided was translated into English and then back into the mother tongue in order to ensure the quality of the translations. The questionnaire responses were analysed using SPSS (Statistical Package for the Social Sciences) to produce descriptive statistics.

Individual interviews were conducted by the project members in each country. The interviews were audiorecorded, transcribed and translated into English. Again, back translation into the original language confirmed the accuracy of the translations. Interview data were analysed by content analysis. First-level analysis addressed the details of each individual interview. Analysis across the interviews revealed themes and interrelationships. The data were reviewed line by line, identifying common words and phrases. Thus emergent categories were grounded in the words of the informants, by working from specific observations to general patterns.

Results

The survey

Characteristics of students taught by the participating teachers

The majority of the respondents taught nurses (87.3%, n = 69), and 78.5% (n = 62) stated that their students came from a wide range of cultures. There were differences between the four countries. Only 40% (n= 8) of the Belgian respondents declared that their students came from a wide range of cultures; the majority of the professionals taught were born in Belgium and spoke Dutch. In contrast, Romanian teachers (76.2%, n = 16) reported multicultural student groups representing Roma, Arab, Bulgarian, Serbian and Macedonian cultures alongside Romanian nationals. In France and Germany,100%of respondents stated that their students came from a wide range of cultures. In France, students originated from African, predominantly North African, and South Asian countries; in Germany, many students originated from Polish, Turkish, Russian and African cultures.

Level of confidence in teaching aspects of culture

Respondents were asked to rate their confidence in teaching aspects of culture on a scale of 1 to 5, where 1 represented ‘very confident’ and 5 represented ‘not at all confident.’ When the percentages of respondents who declared themselves ‘very confident’ and ‘moderately confident’ were added together, the highest overall levels of confidence in teaching aspects of culture were seen in respondents from Romania (90.5%, n = 19) and France (77.8, n = 14). Lower levels of confidence were reported by respondents from Belgium (40%, n = 8) and Germany (35%, n = 7), and 15% (n = 3) of Belgian respondents felt ‘not at all confident’ in teaching aspects of culture.

The constructs of the PTT/IENE model for developing cultural competence

Respondents were asked to rank the topicswithin each construct in order of importance and in terms of the teacher’s own preparedness to teach students about culture and developing cultural competence.

CULTURAL AWARENESS

The topics identified as most important were as follows: own culture, identity, ethnicity, ethnohistory, cultural heritage, beliefs, values, norms, ‘culture – what is it?’, and effects of culture on health beliefs and behaviour.

CULTURAL KNOWLEDGE

Health beliefs and the health-related behaviours of different social and ethnic groups were ranked as most important, followed by the impact of migration on health. Causes and consequences of migration and health inequalities were in joint third place.

CULTURAL SENSITIVITY

Communication skills, interpersonal skills, and issues relating to therapeutic relationships were identified as the most important topics.

CULTURAL COMPETENCE

Respondents ranked non-discriminatory practice as most important, followed by teamwork and then developing trust.

The importance of learning about the content and the teaching methods

Respondents were asked which was most important to them, learning about the content or learning teaching methods. Overall, there was a preference for learning teaching methods (53.2%, n = 42). However, there were differences among the countries, with 65% (n = 13) of respondents from Belgium expressing a preference for learning about the content. Some respondents claimed that they felt confident about their teaching skills, but others stated that they needed to learn more about the content before they could think about teaching it. In the other three countries there was a preference for learning teaching methods, although some responses did indicate that these were inseparable from content, as each was as important as the other.

Teaching methods

It was clear from the responses that teachers were already employing a range of methods to teach aspects of culture. These included articles, books, films, and input from disciplines such as anthropology, sociology and human rights, as well as clinical placements and life stories. Respondents stated that they would like to add case studies, role play, group work, storytelling, situation analysis and project work to their repertoires. Respondents from all four countries commented on the need to use students’ experiences. Respondents from France, Germany and Romania reported some use of community groups in learning activities, such as Me´decins sans Frontie`res, the Red Cross, and representatives from different cultural groups. There was a resounding (83.5%, n = 66) acknowledgement of the importance of reflection as a learning and teaching activity.

Individual interviews

Individual interviews were conducted with 20 employers or managers of nurses and healthcare professionals in Belgium, France, Germany and Romania. The interviewees were asked what knowledge and skills nurses and healthcare professionals needed in order to care competently for patients from different cultural backgrounds, and to enable their mobility and employability in other European countries.

Safety

Employers and managers of nurses expressed the view that, in order to practise safely, professionals should have perfected their nursing skills and be able to practise holistically, involving patients’ families in their care. Nurses should convey ‘human warmth’ towards their patients, and they should be aware that their own frames of reference are not necessarily the same as those of their patients. Nurses should be empathetic in terms of seeing situations from the point of view of others.

Migrant nurses required knowledge about the culture of the country in which they were practising. Echoing the reciprocal approach to cultural understanding and integration that was promoted in the Council of Europe’s White Paper (Council of Europe, 2010), a manager in Belgiumstated that ‘culturesmust understand each other.’ Migrant nurses must be prepared to learn, show initiative and possess an ‘unconditional desire to experience new life circumstances.’

Language and communication skills

Not surprisingly, language featured prominently in all of the responses. Reflecting the need to practise safely, it was felt that in an ideal situation nurses would be able to speak the language spoken by their patients. However, informants acknowledged that realistically it was not always possible for nurses to learn to speak the languages spoken by all of their patients. Thus nurses should learn to work appropriately with interpreters.

Knowledge of the healthcare system

Informants emphasised that migrating nurses should prepare themselves adequately for practice in another country by acquiring knowledge of the healthcare system of the destination country. Nurses should know about the laws of that country, including those governing nursing and delivery of healthcare: ‘Know the history and culture of that country to better understand the patient ...’ (manager, Romania).

While acknowledging that the ‘core business of the nurse is generally the same’ (manager, France), it was also important to learn about relationships within the healthcare system, the role of the nurse, the boundaries of practice, and the expectations of patients in the destination country.

Keeping an open mind

Informants acknowledged that it was not possible to become familiar with all of the cultures that nurses might encounter, but pointed out that by keeping an ‘open mind’ they could remain alert to different beliefs about health and healthcare. Keeping such an ‘open mind’ should also enable them to be non-judgemental, to set aside prejudices and to foster nondiscriminatory practice by developing the ability to suspend their own reference points and recognising that they do ‘not have a monopoly on ‘‘truth’’ ’ (manager, France).

Similarities and differences

Certain factors were common to all patients, for example, in relation to respect and dignity, but differences should be acknowledged. Echoing the acknowledgement that it is not possible to know everything about all cultures, one manager believed that it was important to develop ‘certain knowledge of a few differences’ (manager, Belgium), for example, in relation to palliative care and terminal illness. There was an emphasis on acquiring knowledge about religion, customs and food, and an expressed need to know the ‘biography’ of patients (manager, Germany).

Discussion

Although percentage values are presented in the findings from the questionnaires, the actual numbers of respondents were small, and therefore no claims can be made about generalisation of the findings to wider populations. Furthermore, the partner organisations were situated in a particular region of each country, and thus cannot be assumed to be representative of that country as a whole.

Healthcare teams and patient/client groups are becoming increasingly multicultural. Therefore teachers need to rise to the challenge of ‘preparing culturally diverse nursing students to care competently for culturally diverse clients’ (Jeffreys, 2006, p. 24). The diverse nature of the student groups provided a wealth of experience that teachers could draw upon. However, confidence in teaching aspects of culture varied, and to some extent reflected the extent to which respondents were exposed to contact with people from different cultures. With regard to the teachers’ priorities for training, an understanding of the nature of culture and its influence on health beliefs and behaviour represented the building blocks of cultural awareness. Teachers then wanted to use these topics to help students to acquire specific knowledge about patients’ health beliefs, and develop their understanding of the effects of migration on health and the nature of health inequalities. Teachers further wanted to help their students to develop the communication and interpersonal skills that are essential for therapeutic relationships. Teachers prioritised non-discriminatory practice, teamwork and forging trusting relationships in relation to coaching students towards cultural competence. The need for specific knowledge and general skills was apparent.

For their part, the managers and employers expressed an overriding concern to have a safe workforce. They wanted individual practitioners to be secure in their professional practice and to be able to take account of and respond appropriately to cultural difference. Practitioners needed to guard against ethnocentricity, to retain an open mind and to seek to see situations through the lens of others. It was the individual’s responsibility to prepare adequately for work in another European country. However, hosts shared some of the responsibility. Courses designed to enhance cultural competence were a vital part of induction programmes, as they facilitated the integration of migrant nurses into multicultural healthcare teams (Cowan and Norman, 2006).

It is clear, then, that education and training in relation to developing cultural competence are essential in healthcare curricula in order to prepare practitioners to work in multicultural environments, in multicultural healthcare teams, or in preparation for labour mobility within Europe. The next task in this project was to use these findings to inform the development of a core training package that teachers could then adapt to the specific needs of their students, patients/clients, organisations and healthcare systems. This training package would also address the EU policies of promoting intercultural dialogue, and training of teachers.

Developing the Train the Trainer package

The training package was based on the principles of respect for trainees’ knowledge and experience, reflection on existing knowledge and experience, and peer exchange of knowledge and experience. The package consisted of the following elements.

Pre-course work

This required prospective participants to familiarise themselves with the PTT/IENE model and to prepare a brief presentation on one of the constructs of the model. Local project leaders in each country ensured that all constructs were addressed. Participants were directed to the project website (https://ieneproject.eu) and relevant literature. Participants were also asked to consider the courses they were delivering, and to identify when and where aspects of culture were taught.

Activity-based workshops (see Box 2)

A series of workshops, one in each country, was led by the UK partner. Teaching strategies included selfguided study, e-learning, problem-based learning, reflective learning, brief trainer presentations, group discussion and peer learning communities.

The workshops started with cultural introductions, during which trainees introduced themselves, giving as much information about their own cultural background and related beliefs and values as they felt comfortable with. This activity provided an example of how teachers could act on the advice of Gomes and Holmberg (2010) that diversity should be presented as

normal and natural within educational practice, by embedding aspects of culture into already crowded curricula by adapting existing lessons and modules to accommodate diversity. By negotiating ground rules for the activity, trainees could ensure that the ensuing discussion took place within a safe environment.

During group work, teachers shared their achievements in helping students towards cultural competence and discussed how their curricula could be adapted to integrate the four constructs of the PTT/ IENE model to improve learning and teaching. This included an exchange of ideas about how to develop lessons, modules and curricula to include further learning and teaching activities relating to cultural competence. Teachers drew up action plans to take these ideas forward.

As the teachers were already using a range of strategies to teach aspects of culture, a decision was made to use patient narratives for the trainer presentations during the workshops. Elliott (2005, pp. 12– 13) has defined first-order narratives as ‘stories that individuals tell about themselves and their own experiences.’ Scho¨n (1991) has noted that professionals work in a complex and changing environment, and argues that the knowledge acquired during their education/ training does not always equip them to deal with the unique and uncertain situations that they encounter in practice. Scenarios can be used that derive from real-life situations and thus occupy what Scho¨n (1987) refers to as the ‘swampy lowland’ of professional practice that is characterised by ‘messy, confusing problems.’ The use of such scenarios allows students to develop their problem-solving skills in a safe environment, namely the classroom. Scenarios facilitate individual and group reflection on the experiences and relevant theories as a basis for decision making. Presentations by the trainers demonstrated that the selection of suitable narratives could incorporate many important aspects of culture. For example, a detailed story could address culture, identity, ethnicity, beliefs and values, and illustrate the influence of culture on health beliefs and behaviour: ‘the illness narrative of a patient tells at least two stories: the highly personal experience of the illness itself, embedded within a deeper narrative of social networks, folk models, mythology and cultural history’ (Skultans, 1998, p. 226).

Building activities around the story could help students to think about their communication and interpersonal skills in relation to building a therapeutic relationship with the patient in the story. As students engage in greater depth with the story, they can relate to aspects of anti-discriminatory practice. One aim of using narratives as a teaching strategy was to ‘replace fear of the unknown with curiosity’ (Dyson, 2012), and prompt cultural desire (Campinha-Bacote, 2003) to learn more about different cultures and gain insight into lifestyles and situations that students themselves have not personally experienced (Garro and Mattingly, 2000, p. 1).

Post-course support

It was acknowledged that a one-day course on developing cultural competence does not necessarily transform trainees into culturally competent teachers. Developing cultural competence is a process, not an end point, whether applied to practitioners or teachers. Thus it was important to encourage the development of peer learning communities in each participating country, so that learning could continue. This process is supported by the project leaders in each country.

An initial external evaluation of the training workshops indicated that the participants felt better prepared for intercultural education. However, they emphasised the need for ongoing support. This is currently provided through access to the IENE website, a dedicated Internet discussion group where teachers can engage with their counterparts in other participating countries, and by the project leaders in the respective countries.

Conclusion

Drawing on students’ expressed learning needs with regard to developing cultural competence, this project identified the learning needs of the teachers who would in turn be meeting these students’ needs. Workshops were held in participating institutions that aimed to build on the existing knowledge and skills of teachers and trainers in order to enhance their ability to prepare their students for practice in multicultural environments. This project has gone some way towards meeting the requirement of the Council of Europe (2010) for spaces to be created and widened to allow learning and teaching about intercultural dialogue. It has also addressed the suggestion by UNESCO(2006) that teacher training for intercultural education should include familiarising teachers with practical, participatory and contextualised teaching methods, and imparting the ability to adapt educational content, methods and materials to the needs of different cultures.

ACKNOWLEDGEMENTS

We wish to thank Ellen Dierynck and Marie D’hulst, nurse teachers at KATHO, Belgium, for their contribution to the IENE2 project.

The project was funded with support from the European Commission. This paper reflects the views of the authors alone, and the Commission cannot be held responsible for any use that may be made of the information contained therein.

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