Table 2.

Summary of themes and subthemes and example quotes from the personal interviews.

Theme	Sub-Themes	Selected Quotes
Concept of culture	Meaning of culture	I understand culture as a space, right? Like a moment in which there are various ways to understand the same concept, in this case health. (…) Like having different points of view depending on where and how we have been raised (L5).
		It is where you come from, no? People that come from a different country, also have a different culture; there are differences even within the same country, no? We have students who come from different regions, or who are from the same country but they ethnicity is different, like being a gypsy; their culture is different, religion is another aspect (L6).
	Cultural diversity in the classroom	What do you mean? Like having students from different places? (L1).
		There are people from different age groups, there are people…, this is an intuition, okay? From different educational levels, people who have other diplomas or degrees. I don’t remember having students from a different race, or culture. I do believe we once had a female student who was gypsy Roma (L2).
Impact of own culture on teaching practice	Training, personal and clinical experience	Yeah, I don’t have any, um, I haven’t had any lessons about that. Just from my own experience. Both in the care sector and in the educational setting... (L9).
		No, none. With that name and all that…, I am too old! Perhaps life, yes (L1).
		I had no formal training, and this fact highlights the need for structured programs of multicultural training in nursing (L19).
	Perception of own culture	I’ve never thought about that before., I was raised a Catholic, but I don’t believe anything myself, so gosh, I don’t know if that really affects my lessons. I don’t think so because of the fact that I don’t believe in anything specific. And if for example you see culture as a vision on clothing, on tattoos, on.... I think that’s pretty broad out there, too, I think (laughs) (L8).
		Yes, I guess one is influenced by his or her own culture and belief’s consciously or sub-consciously. I try to utilize the positive aspects of my culture and family tradition in my professional life for e.g., having empathy towards others, showing tolerance to other beliefs and cultures, impartiality in teaching as well as clinical practice and likewise (L15).
	Culture as a source of misunderstanding	Yes, they had for example a very different style of life, those typical things. They are less alert than the local students in class and that is certainly not the case with all of them. But that is very typical for the group where there are a lot of students of foreign origin, that my lessons there are a bit more difficult... (L10).
		Since my classroom has mostly Muslim students, if I had to speak on a topic that is against the norms of the religion and culture, I would find that somewhat difficult. Discussing sexuality and sex related topics are difficult for me (L11).
Teaching and learning cultural competency	Content	I talk a lot about what I call negotiation, that is, to abandon the idea that this is mine and it is all that matters, and the rest doesn’t count, no? That is not possible, and it is a lie. I think life is pure interpretation; (…) you have to negotiate and agree with whoever is in front of you. You are nobody to discard their opinions or preferences (L2).
		Yes, I do. In the context of a multicultural approach to paediatric patients. I emphasize the preparation that nurses should have, be attentive when receiving and providing nursing care, particularly with regard to specific aspects such as religion, ethnicity, beliefs, and nutrition (L19).
	Teaching methods	I think these gender issues could lead to…, don’t you think? I mean, they could be controversial. For example, once, in clinical simulation, we gave one of the patients a more blasé attitude, a more…, you know, and one of the students actually defied him. Well, I think that these students in the end…, they have much to learn (L5).
		So, I discuss these topics in class presenting case studies. I also present these topics for open discussion in my class (L15).
		I insert that content as I go. Often, it isn’t planned; it just happens. Circumstances, examples that kind of sneak in. I don’t plan for these things, but they happen, and quite frequently too! (L1).
Integrating cultural competence in the nursing curricula	Values	You know, we try in class, we all say it…, respect. Not only towards other cultures, but also towards different political or religious opinions, or whatever (L4).
		I think empathy as a tool for interacting with people based on universal values such as respect, dignity, justice and equality (L22).
		They should not judge individuals coming from other cultures, by their own thinking and beliefs. Good communication and empathy is very important for patient satisfaction—it also plays a role in their recuperation. These aspects of nursing care should be taught to students (L13).
	Knowledge	To give a simple example; for a patient diagnosed with Cancer, how should the news be shared to the patient or his family—this would differ in every culture. So, the nursing students must be aware of the patient’s background and culture and behave accordingly (L13).
		What I was telling you about before, the more theoretical aspects, knowing the needs of people from different cultures maybe, the more basic aspects, perhaps? (L6).
	Skills	They should be good listeners, minute observers and excellent communicators. They should learn to accept differences in opinion and try to ease out some of their concerns of patients through proper communication and help with hospital staff (L16).
		I think that, when you relate to other cultures, ages, blah, blah, blah it’s complicated; you have to work with language issues and many other things that, in truth, I do not address; only as case studies, or factors to consider (L2).
Barriers to teaching and learning cultural competence	Educational (lecturers)	As a teacher..., (pause) I don’t have enough time to teach them everything; I don’t have time to think about what else I should add, you know (L4).
		I mean, I think I have acquired the (cultural) competences through my clinical experience in the hospital, but I may not be able to pass them on to my students (L6).
	Educational (students)	Somehow, we are not able to get to some of the students... I wonder if it is something that is deeply rooted within them; I don’t know if we would capable, no matter how much effort we put in, of changing certain things that they have acquired from their family perhaps, and that they accept as an absolute and immovable truth. I don’t know (L4).
		People tend to hold on to their preconceptions. (…) Then..., it’s like something visceral. But visceralism is encouraged nowadays. Visceralism is promoted so that people are less rational..., less reflexive. So, voilá, the mess is served. I say to them: “if you are visceral, they’ll do anything with you. You have to be reflexive. You have to have inner life”. Then, okay, I can be tiresome. Some people accept it very well, and some people don’t understand or don’t care (L1).
	Social	It always happens. When you try to explain that..., that we have to adapt to the patient and the students think that it should be the opposite, that they are here and should therefore do things as they are done here. This is way of thinking should be banished if you ask me, but I am not sure that I convince them because, to do that, you need to know the reality in such a way that I don’t know if it can be explained theoretically (L2).
		We have had some uncomfortable debates about..., in public health we talk about healthcare systems, and the never-ending debate about which healthcare service model is more appropriate and who should be covered by our public healthcare service. And there is always debate, like: “immigrants cannot have the same healthcare coverage as us”. But, relatively, that is also a reflection of the society we live in and, well, perhaps they say things that are politically incorrect in the classroom, but they are out there too, you know (L3).
Facilitators to teaching and learning cultural competence	Lecturers	Bringing someone who represents a culture, that’s what works. It would be amazing to bring a nurse who was Gypsy Roma, for example (L4).
		While discussing the case studies, the students know that there is not “one right approach”. Everybody feels free to share their ideas or practices in their community regarding that issue. There is no bias or prejudice to any idea. This definitely creates a positive impact on students learning process (L15).
		Whenever necessary, I mobilize another language such as English, I try to identify the students’ learning needs, taking into account their experiences and trying to articulate everything with the subject’s program. In this way I try to comply with it, meeting the diversity presented by the students themselves (L22).
	Students	We were taking about brain death and ictus and I remember that there was a Muslim student in the classroom; the other students kind of wanted to ask him, but they did not want to say something that could offend him, and they wanted to ask him how best to approach someone who was a Muslim and who was in that same situation (L5).
		I think that was especially surprising. Uh yes, I think they can learn from each other, from each other’s culture and sometimes students don’t even think about it, because we see a lot of different cultures in our society and we are so used to that that that sometimes we don’t think about them enough, because we are different, you know what I mean? (L8).
	System	Gee, I think the fact that they are already in a program where that already has a more diverse audience, that that already helps. You create a certain context within a university of applied sciences in which the multicultural aspects are already interwoven, so I think that they will be able to take that into account more, even unconsciously, than perhaps 20 years ago. What else can we do ourselves? Um... yes, the fixed framework of traditional nursing, or what should I call that, which we sometimes give, is kind of limiting (L10).