Assessing outcomes of a study abroad course for.ABSTRACT There is little debate about the importance of preparing nursing graduates to provide culturally sensitive care to an increasingly diverse society. However, it is difficult for nurse educators to fit learning experiences that help students develop cultural competence into already full programs and create mechanisms to evaluate the results. This article describes a study to assess the impact of a study abroad program on developing cultural competence, including cultural awareness, sensitivity, knowledge, and skills. Results from the Cultural Awareness Survey, reflective journals, and interviews illustrate how the study abroad experience influenced the development of components of cultural competence and might influence clinical practice. Results suggest effective teaching strategies to assist students in becoming culturally competent are experiential in nature and include role modeling, reflective activities, and group discussion.
Key Words Cultural Competence--Study Abroad--Learning Outcomes--International Programs--Nursing Students
AS HIGHER EDUCATION INSTITUTIONS SEEK WAYS TO PREPARE GRADUATES TO LIVE IN AND CONTRIBUTE TO AN INCREASINGLY GLOBAL SOCIETY, GROWING NUMBERS OF COLLEGE STUDENTS LEAVE CAMPUS EACH YEAR TO STUDY ABROAD (Belyavina & Bhandar, 2012). However, there is little research that explores the link between nursing students' experiences in international programs and changes in their cultural competence (Evanson & Zust, 2006).
A course titled Spanish for Healthcare Professionals, described by Bloom, Timmerman, and Sands (2006), was adapted into a study abroad experience in Guadalajara, Mexico, for a baccalaureate nursing program at the University of Texas at Austin. This article reports on findings from a descriptive study conducted to assess outcomes of the experience. Two research questions were asked:
* How has the study abroad experience influenced the participants' awareness, sensitivity, knowledge, and skills related to culture of the people in Guadalajara?
* How has the study abroad experience influenced participants' clinical practice as nurses?
Background and Significance To meet the health care needs of individuals from diverse cultural and ethnic backgrounds and deliver appropriate care, nurses must be aware of, and sensitive to, cultural issues and differences among various groups of patients. This study was guided by the conceptualization of cultural competence as having four components: cultural awareness (affective dimension), cultural sensitivity (attitudinal dimension), cultural knowledge (cognitive dimension), and cultural skills (behavioral dimension) (Rew, Becker, Cookston, Khosropour, & Martinez, 2003).
In choosing strategies for developing cultural competence that fit into otherwise full nursing programs and creating mechanisms to evaluate the results, nurse educators have been guided by the document "Cultural Competency in Baccalaureate Nursing Education" (American Academy of Colleges of Nurses [AACN], 2008a) and its accompanying toolkit of resources (AACN, 2008b). The toolkit offers an extensive list of integrative classroom and clinical learning strategies, references, and web resources to foster cultural competency. The National League for Nursing toolkit on innovations in curriculum design (2011) also offers suggested strategies to enhance development of cultural competence. The Guadalajara experience described in this article illustrates the use of some of the suggestions found in these toolkits, for example, offering an immersion experience, participating in community activities, arranging field trips, and encouraging students to keep a journal.
Study abroad is one way to broaden American college students' worldview, but nursing curricula are sequential and crowded with essential content and practice competencies; thus, nursing students rarely have the luxury of spending a semester abroad to experience another culture. Depending on the location of the nursing program and available clinical experiences, students may be exposed to patients from diverse cultures, but such experiences are random. Although a recent search cited the existence of more than 220 study abroad programs for nursing students (Nursing Study Abroad, 2012), many nursing students are unaware of opportunities outside the prescribed curriculum.
Previous studies support the value of international experiences for preparing nursing students to incorporate cultural competence into clinical practice (Evanson & Zust, 2006; Wood & Atkins, 2006). Studies have demonstrated positive short-term outcomes, including gains in substantive knowledge, changes in values, improved communication skills, and the development of culturally focused practice (Caffrey, Neander, Markle, & Stewart, 2005; Evanson & Zust; Ryan, Twibell, Bighman, & Bennett, 2000; Wood & Atkins). In Evanson and Zust's study, nursing students showed long-term benefits in the form of increased understanding as well as uncomfortable, lingering, unsettled feelings resulting from the awareness of inequities in resources. The current study combines data from the Cultural Awareness Survey collected prior to the immersion experience, with qualitative data from interviews, surveys, and reflective journals to illustrate strategies to assess how learning experiences influence the development of cultural competence.
Development of the Study Abroad Course The Spanish for Health Care Professionals course, a requirement in this university's baccalaureate program, was designed to make the nursing curriculum more responsive to changing United States demographics and to help nurses communicate with Spanish-speaking clients (Bloom et al., 2006). The course was designed to teach nurses to do specific things in Spanish, including, but not limited to, taking a health history, doing an analysis of symptoms, and scheduling an appointment.
The school transformed the course for an alternative option from a traditional classroom course to a cultural immersion experience in another country to allow for a life-changing study abroad experience without adding coursework to the undergraduate degree plan. To that end, the nursing faculty collaborated with the university's Study Abroad Office and with professional colleagues at the medical, nursing, and language schools at the University of Guadalajara in Mexico. Since the initial four-week immersion experience, the course has been expanded to a six-week, six-credit experience. The program includes living with a Mexican family, studying at the language school, and collaborating on projects with public health nurses and nursing students from the University of Guadalajara. Students pay for the study abroad program as summer tuition; many students obtain scholarships to offset the costs.
Over the five years the course has been offered, 12 faculty members (all with Spanish language skills) and 85 students have participated. The nursing faculty's primary responsibilities are to help the students navigate the logistics of traveling from their neighborhoods to the language school and to various clinical experiences, and to help students understand the cultural dynamics and differences in health care beliefs and practices in Mexico.
Research Methods The descriptive study used quantitative (survey) and qualitative (interviews, journals, and written responses to open-ended questions) methods to assess the influence of the Spanish for Health Professionals course on students' development of cultural competence. Approval to conduct the study was obtained by the university's institutional review board. Students were invited to participate in the research and were assured of confidentiality in all phases of the study. Students signed informed consent agreements.
Prior to departure, participants completed a modified version of the Cultural Awareness Survey (CAS) (Rew et al., 2003). The original CAS consisted of 37 items rated on a seven-point Likert scale (1 = strongly disagree, 7 = strongly agree). Rew et al.'s factor analysis accounted for 51 percent of the variance in responses and showed items grouped into subscales pertaining to general educational experience, cognitive awareness, research issues, students' behaviors and comfort with people from different cultural backgrounds, and patient care and clinical issues. Rew et al. reported good estimates of internal consistency for the total scale (alpha = .82) and for the subscales (alphas ranged from .91 to .94) when tested with 190 baccalaureate nursing students. Krainovich-Miller et al. (2008) reported a slightly higher reliability coefficient on the CAS (alpha = .86) with 472 undergraduate and graduate nursing students.
For the current study, all items except those pertaining to research were administered; students did not conduct research during the program. At the end of the course, students were asked to complete five additional survey questions (Post-Study Abroad Perspective) developed by the principal investigator using components identified by Rew et al. (2003). The questions addressed how the course affected awareness, knowledge, attitudes, and skills related to culture and how it might influence students' clinical practice.
Survey data were entered into SPSS version 15.0. After data were checked for accuracy, descriptive statistics (means, standard deviations, frequencies) were calculated, reliabilities of the total items and subscales were estimated, and t-tests and chi-squares were used to compare students by year of attendance. The qualitative data consisted of weekly reflective journal entries submitted as course assignments; written responses to open-ended survey questions completed at the end of the program; and extensive notes taken during five focus groups and three individual interviews one to three months after the program.
The two research questions helped focus the data collection and guide the development of a set of target questions that were asked during the interviews and on the open-ended survey questions. Text from the journals, open-ended questions, and field notes of the focus group and individual interviews were subjected to content analysis (Miles & Huberman, 1994) and organized according to cultural competence concepts and research questions. Summary sheets similar to those suggested by Miles and Huberman were used to sort the data from the field notes and guide planning for subsequent contacts with participants. Themes were identified from reoccurring phrases in the field notes and reflective journals and written answers to open-ended questions. Quotations selected for this article illustrate the themes.
Quantitative Findings SAMPLE Thirty-five students participated in the evaluation of the study abroad course. Most were female (85.7 percent), white (63 percent) undergraduate nursing students (age range 19 to 35 years). At the beginning of the course, 75 percent tested into the beginner levels of Spanish ability. There were no significant differences between the two cohorts studied (2007 and 2008) except in gender; more male students participated in 2008 than in 2007 (chi-square = 7.78, df = 1, p = .005). (See Table 1 for demographic characteristics of the sample.)
FINDINGS FROM THE CAS The survey consisted of 32 items. After reverse coding, responses to seven negatively worded items were not conceptually consistent with other items in the subscales and were not included in these analyses. The remaining 25 items were internally consistent (alpha = .81) and were analyzed for this study.
The General Learning Experiences subscale included 12 items focused on students' perceptions of their learning experiences at this school of nursing (alpha = .86). The item with the highest mean (5.8 [+ or -] 1.0) indicates students believed instructors were comfortable interacting with people from different cultures. Asked if classroom experiences helped students become more comfortable interacting with people from different cultures, students responded less positively. The mean score for this question, 4.7 [+ or -] 1.5, was well above the midpoint of response options, but was the lowest mean score for this subscale.
The Awareness and Attitudes Subscale included seven items about cultural beliefs and attitudes and how they influence behaviors (alpha = .66). The item with the highest mean (5.7 [+ or -] 1.2) indicated students thought their beliefs and attitudes were influenced by their culture.
Behaviors and Comfort with Interaction was represented by a single item (the others in the subscale were negatively worded): "I feel comfortable working with patients of all ethnic groups" (5.5 [+ or -] 1.6). The large variation in responses (range 1.0 to 7.0) likely illustrates the wide range of experiences and educational maturity among participants in the course.
The Clinical Practice subscale included five items focused on how cultural issues influence working with people from different cultures (alpha = .71). The item with the highest mean level of agreement (6.1 [+ or -] 0.8) reflected the deep respect students have for decisions patients make that are influenced by culture, even if students disagree with the decision.
The Post-Study Abroad Perspective subscale (added to the original questionnaire) included five items (alpha = .79) and had the highest scores overall. (See Table 2.) The first four items were written to reflect the components of cultural competence as conceptualized by Rew et al. (2003). Two items had identical means (6.3 [+ or -] 0.9): showing enhanced awareness of culture and gaining skills to work with people from a different culture. The item on how clinical practice might be influenced following the study abroad experience had the highest mean (6.4 [+ or -] 0.9).
Qualitative Findings Data from students' reflective journals, written answers to open-ended questions, and field notes from group and individual interviews were categorized based on the four components of cultural competence (awareness, sensitivity, knowledge, and skills) plus the influence of the experience on clinical practice. Students were required to write some journal entries in Spanish; those with stronger Spanish skills tended to write more in Spanish. Although several entries in the reflective logs were personal (for example, about fun on the beach or feeling tired after classes), students offered thoughts and reactions reflecting their passion and desire to improve strategies for care through an understanding of the Mexican people. These comments, offered without prompting, are important to the overall analysis.
Interviews and open-ended written survey questions further clarified how experiences in Mexico influenced students' thinking. Examples of responses are arranged into the five categories and offered here.
CULTURAL AWARENESS Several students indicated they had experienced a change in cultural awareness. One student explained: "I feel that I have gleaned more of a cultural understanding than an understanding of the language this past week." Another wrote, "I think it is true that Americans in general don't understand Mexican culture correctly. However, from my interactions with the locals, Mexicans seem to have a true understanding of the American culture." One student explained: "My [homestay] family taught me about the Mexican culture and allowed me to be a part of it. The experience I took from the house will stay with me forever." A student wrote in Spanish (translated): "Prejudices that I have had in the past have disappeared ... I feel like my whole attitude towards caring for others of different cultures is so much more positive."
CULTURAL SENSITIVITY Several students indicated that their respect for cultural differences grew, as did their appreciation for the uniqueness of the Mexican people. One student said: "I have grown to respect the differences in other cultures more than I did [previously] and become aware of my own biases." Another stated: "It has been fun to embrace and love the way the Mexicans live differently than me and grow and be changed by their culture."
CULTURAL KNOWLEDGE Most students noted that it was important to learn about the Mexican health care system and how it differed from, and resembled, the system in the United States. Several noted how much Mexicans trust their health care providers. One student wrote: "Spanish clients always have open ears to take advice and they really value what health professionals say." Another said: "I feel like this will affect my nurse-patient relationships a lot."
Although students developed cultural knowledge during the study abroad immersion, several felt they were already familiar with Mexican customs before the course. "I grew up close to Mexico but actually living in the country allowed me to learn more and be a part of the culture."
CULTURAL SKILLS Most students, even those who entered the course with high levels of proficiency, indicated significant improvement in their Spanish language skills. A student wrote: "I have noticed tremendous improvement in both my understanding and ability to speak this language." However, another stated: "I'm getting frustrated with my Spanish skills, which is making class muy dificil ... I understand that this is the process that you have to go through when learning a new language."
The immersion component helped advance language skills quickly. A student wrote that his "host Mom finally 'banned' us from speaking English in the house which severely limits the amount I can actually talk about. She says we need to practice our Spanish."
EFFECTS OF THE EXPERIENCE ON NURSING PRACTICE
One student wrote in Spanish (translated): "I have learned that patients in Mexico are very trusting of their health care providers. I hope that I can uphold that belief with my patient care." Another student said: "I did not think culture affected medical decisions. Now I am aware of this aspect and plan on practicing with these ideas in mind." Students in the group agreed with a graduate student who said that he will be more sympathetic to people who have a language barrier."
Observing and providing health promotion projects in community settings in Mexico were life-changing experiences. Students wrote: "I left [the clinical site] with new thoughts about life and how I am living it. I have to change my way of thinking" (translated from Spanish), and "[The community experiences] reemphasized why I want to be a nurse."
Responses related to this behavioral dimension, how the study abroad experience might influence patient care, drew issues and examples from the other components of cultural competence. Students believed that language skills and knowledge about Mexican culture would help them deliver better patient care. Experiences in community settings sensitized students to basic needs and cultural aspects of health care delivery that contrasted starkly with American health care. Learning of the respect and trust Mexicans have for health care providers was a powerful lesson for all students; several said such awareness heightened their consciousness of the influence and responsibility they have as nurses.
Discussion The study's limitations are understood. A small convenience sample from a single school was used, and there were small variations in the learning experiences from one year to the next that could not be controlled. The study allowed for an exploration of the short-term effects of the study abroad experience on students' cultural competence and clinical practice. A longitudinal study would be needed to evaluate long-term effects. While these limitations prevent generalization of the findings to other programs and schools, nurse educators may find the results helpful as they plan learning opportunities for nursing students.
The key findings from the CAS suggest that students did not think that classroom experiences were sufficiently effective in helping them become more comfortable interacting with people from different cultures. They agreed generally that instructors modeled sensitivity to multicultural issues, appeared comfortable interacting with people from different cultures, and respected differences. The results suggest that experiential teaching strategies, such as field trips, postconferences, and reflective journaling, as recommended by the AACN toolkit (2008b), may be more effective than merely presenting content in a classroom.
Students began the study abroad experience with wide variation in their experience and understanding of nursing care strategies necessary for providing culturally competent care. The voluntary nature of the Guadalajara course, and the extra expense involved, suggests that students wanted to become more comfortable interacting with patients of different ethnic groups. According to Campiuha-Bacote (2003), desire is foundational to the process of cultural competence in the delivery of health care services.
Responses to the Post-Study Abroad Perspective items suggest that students' beliefs and attitudes about culture before they went to Mexico were not dramatically changed by the experience. They do reinforce the idea participants were notably interested in cultures other than their own. They also indicate that the Spanish for Health Care Professionals course in Guadalajara will influence students' clinical practice as nurses.
The main goal in developing and requiring this course (Bloom et al., 2006), and then making the intensive immersion experience in Mexico available, was to help graduates communicate better with Spanish-speaking patients and enhance their understanding of cultural and social factors that influence communication with Spanishspeaking patients in a health care setting. The scores on the items in the post-study abroad perspective suggest these goals were achieved.
The qualitative data reflect that students perceived gains in their awareness, sensitivity, and knowledge of Mexican culture and skills for working with Mexican-origin and Spanish-speaking patients. As they immersed themselves in Spanish language practice, they were simultaneously able to develop their understanding of Mexican culture and their ability to function effectively.
Conclusions and Implications Campinha-Bacote reminds us that effectively teaching cultural competence in nursing education "is a journey that reflects an ongoing transformational process" (2006, p. 244). We must keep working to address perceived barriers for ethnically diverse students; the challenges faced by students and faculty of color; gender and disability issues among nursing students; and cultural and linguistic issues in caring for culturally and ethnically diverse patients (Campinha-Bacote, 2003). This study showed that a study abroad experience provided deeply personal learning opportunities resulting in enhanced awareness, sensitivity, knowledge, and skills important for addressing cultural differences in nursing practice. Study abroad embraces the notion of experiential learning leading to meaningful outcomes for all who participate. We must continue to develop and study innovative learning experiences throughout our nursing programs to ensure and enhance the development of cultural competence to provide better care to a diverse society.
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About the Authors Linda J. Carpenter, PhD, RN, CNE, is associate professor of clinical nursing, and Alexandra A. Garcia, PhD, RN, is associate professor, University of Texas at Austin School of Nursing. For more information contact Dr. Carpenter at email@example.com.
Table I. Demographic Characteristics of Sample 2007 COHORT 2008 COHORT (N = 20) (N = 15) Age 22.2 [+ or -] 2.6 23.67 [+ or -] 4.9 Female 20(100%) 10(66.7%) Race/Ethnicity * Non-Hispanic: African American 2(10.0%) 0 Asian American 1 (5.0%) 2 (13.3%) White 15(75%) 7 (46.7%) * Hispanic 2(10.0%) 6(40.0%) Student Class Non- or Pre-Nursing 3 (15.0%) 4(26.7%) Junior 1st semester 2(10.0%) 1 (6.7%) Junior 2nd semester 5 (25.0%) 5 (33.3%) Senior 1st semester 8(40.0%) 0 Senior 2nd semester 0 1 (6.7%) MS or PhD student 2(10.0%) 4(26.6%) TOTAL (N = 35) Age 22.9 [+ or -] 3.8 Female 30(85.7% Race/Ethnicity * Non-Hispanic: African American 2 (5.7%) Asian American 3 (8.6%) White 22 (62.9%) * Hispanic 8 (22.9%) Student Class Non- or Pre-Nursing 7 (20.0%) Junior 1st semester 3 (8.6%) Junior 2nd semester 10 (28.6) Senior 1st semester 8 (22.9%) Senior 2nd semester 1 (2.9%) MS or PhD student 6 (16.2%) Table 2. Scores on Cultural Awareness Survey Subscales SUBSCALE NUMBER RANGE MEAN STAND. ALPHA OF ITEMS DEV General Educational Experiences 12 3.5-6.5 5.3 0.7 0.86 Cognitive Awareness 7 3.7-6.7 5.4 0.8 0.66 Behaviors/Comfort with Interaction 1 1.0-7.0 5.5 1.6 N/A Patient Care/ Clinical Issues 5 4.8-7.0 5.8 0.7 0.71 Post-Study Abroad Perspective 6 3.8-7.0 5.9 0.9 0.79 N/A = Not Applicable