Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/locate/nedt Hofstede's cultural dimensions as the explanatory framework for performance issues during clinical placement: A mixed methods study Jacqueline Rojo a, ⁎ , Bronwyn Everett a , Lucie M. Ramjan a , Leanne Hunt b , Yenna Salamonson a a Western Sydney University, School of Nursing and Midwifery, Centre for Oral Health Outcomes & Research Translation (COHORT), Ingham Institute for Applied Medical Research, Locked Bag 1797, Penrith, NSW 2751, Australia b Western Sydney University, School of Nursing and Midwifery, Centre for Applied Nursing Research (CANR), Ingham Institute for Applied Medical Research, Locked Bag 1797, Penrith, NSW 2751, Australia ARTICLE INFO Keywords: Education Clinical learning environment Culture Hofstede Students Nursing Retention ABSTRACT Aims and objectives: The objectives of this study were to examine a) if those with reported clinical perfor- mance issues were more likely to experience course progression issues or withdrew from the program; b) the relationship between clinical and academic performance; c) the relationship between students social- demographic characteristics and clinical performance issues; and d) the utility of Hofstede's cultural dimensions theory in explaining the clinical performance issues students may experience during clinical placement. Method: Retrospective textual reports of clinical issues from 2014 to 2018 were collected. A mixed methods design, particularly Embedded Design, was used. The qualitative data was analysed using Directed Content Analysis using Hofstede's six dimensions as the coding categories, which were further broken down into high and low poles, making a total of 12 subcategories. Univariate and multivariate logistic regression was utilised to analyse the quantitative data. Results: Using Hofstede's framework, it was determined that nursing students 21 years and younger were more likely to have issues related to low long-term orientation. Male students were more likely to have issues related to low uncertainty avoidance and also displayed masculinity related issues. Overseas-born students were less likely to experience issues related to low power distance and students that had not failed a unit of study were less likely to have issues related to low long-term orientation. The study also found that students experienced issues related to poor psychomotor skills and language barriers. Furthermore, the study identified that students who experienced clinical placement issues were three times more likely to leave the course. Conclusion: Hofstede's cultural dimensions framework can be used to explain clinical performance issues among undergraduate nursing students. Early identification of the students likely to experience these issues can lead to targeted and preventative interventions. 1. Introduction Clinical placement experience is central to nursing education, fa- cilitating the integration of theoretical concepts with nursing practice (Atakro et al., 2019; Bisholt et al., 2014) and exposing students to the reality of clinical nursing (Henderson et al., 2012). For most students, this is an exciting learning activity, as they have an opportunity to develop the knowledge and skills required of a registered nurse in an authentic context (Levett-Jones et al., 2015) and become socialised into the profession (Buhat-Mendoza et al., 2014). However, for some, their lack of confidence (Al-Sagarat et al., 2015; Shoqirat and Abu-Qamar, 2013), language and communication difficulties (Mikkonen et al., 2016), inadequate theoretical knowledge and skill incompetence (Buhat-Mendoza et al., 2014; Killam et al., 2011), inappropriate atti- tudes and behaviour, and lack of accountability (Killam et al., 2011) can impact on the students' ability to provide safe care, resulting in a failing grade. Despite the understanding of factors that contribute to nursing students' poor clinical performance, few studies have examined the possible role of culture and how this might impact on clinical perfor- mance. Broadly defined as “the collective programming of the mind that distinguishes the members of one group or category of people from https://doi.org/10.1016/j.nedt.2020.104581 Received 10 September 2019; Received in revised form 29 July 2020; Accepted 8 August 2020 ⁎ Corresponding author. E-mail addresses: j.rojo@westernsydney.edu.au (J. Rojo), b.everett@westernsydney.edu.au (B. Everett), l.ramjan@westernsydney.edu.au (L.M. Ramjan), l.hunt@westernsydney.edu.au (L. Hunt), y.salamonson@westernsydney.edu.au (Y. Salamonson). Nurse Education Today 94 (2020) 104581 0260-6917/ © 2020 Elsevier Ltd. All rights reserved. T