TEN Case Exemplar: Linking Strategies—Spotlight on the Cultural Discovery Integrated Approach with contributions from Mary O’Donnell and Judy Xiao Many students described their experience as helping them develop an open mind toward the beliefs and practices of others. SNAPSHOT SCENARIO Professor Strong: Nurses of the future need to have strong foundational knowledge, skills, and professional values in transcultural nursing in order to provide culturally competent care for diverse populations currently and in the future. Professor Weave: Yes, I agree. Transcultural nursing skills must begin in the beginning course and be strategically and visibly woven in throughout all subsequent courses and their components. Professor Clock: There’s so much to cover and not enough time, especially in a 2-year associate degree program. Most students will continue on for their bachelor’s degree so there will be time then for them to include culture. Professor Uno: Well, I teach in an associate degree program and every faculty member gives a 1-hour lecture on transcultural nursing once during each course. It’s usually given during Week 11 during the 15-week semester once the main clinical topics and main nursing concepts are covered. Professor Quick: I teach in two types of accelerated programs. One program is for students who already have a baccalaureate degree in a field other than nursing and are seeking to become registered nurses (RNs). The other program is for RNs with a baccalaureate in a non-nursing field who are seeking to earn a bachelors and master’s degree in nursing. I’m not sure if and how culture can fit in such fast-track curricula. Professor Frank: Faculty need to make transcultural nursing and cultural competence education a priority. It needs to be a collaborative effort, utilizing all available resources from within nursing and beyond. If faculty don’t convey to students that culture matters, students and nurses of the future will not be adequately prepared to provide quality health care to diverse patients. It’s our responsibility as educators and as nurses to design, implement, and evaluate cultural competence education strategies that are connected, multidimensional, and relevant. Professor Ponder: Now I’m wondering how I can provide a substantive foundational beginning for my first semester students so that they will value transcultural nursing, develop beginning skills for providing culturally appropriate care, and have a strong knowledge base fueled with a quest to learn more. What strategies have others used that were successful? How can I adapt them for my students in my course and across the curriculum? This chapter describes an innovative philosophical approach and learning activities for integrating general transcultural nursing concepts and skills within a first semester introductory nursing course. The approach and activity design will assist novice nursing students to achieve the following objectives: (a) systematically conduct a basic general cultural assessment; (b) identify some similarities and differences among individuals within cultural groups; (c) distinguish between varying dimensions of acculturation (nontraditional and traditional values, beliefs, and practices); and (d) discover the importance of culture in nursing care. “Cultural competence in nursing education is receiving renewed emphasis. Cultural competence is linked increasingly to reducing health care disparities among racial, ethnic, uninsured, and underserved U.S. populations” (1, 2). “The immigrant population in the United States is increasing, which suggests that education is needed in transcultural nursing to allow nurses to provide culturally competent care” (3, p. 1). This activity design was developed to assist the beginning student on the journey toward cultural competence (see Figure 10.1). The nurse educators also wanted to enhance a course that would provide meaningful experiences and stimulate critical thinking among nontraditional, culturally diverse students who need to care for many clients of culturally diverse backgrounds. Gilchrist and Rector (4) recognize “the great need for a culturally representative workforce as our population continues to become diverse. In order to serve our diverse population, our RNs should mirror that diverse U.S. population” (p. 277). The philosophy and activity designed in this course are imperative steps in helping the nontraditional student to develop those skills necessary to effectively take his or her place in this workplace. The need to create a learner-centered philosophy and activities to develop critical thinking skills has long been supported in the literature (5–15). In their effort to complement course topics, the nurse educators developed an approach called Cultural Discovery, which focuses on the concepts of culture, aging, and health. These learner-centered activities emphasized learning outcomes in the cognitive, affective, and experiential (practical or psychomotor) domains. The cognitive domain focuses on knowledge outcomes, intellectual abilities, and skills (16) while the affective domain involves attitudes, interests, appreciation, and modes of adjustment (17). Of these two, the affective domain needs the most attention because affective outcomes include students’ professional values, motives, and attitudes (18-21). The experiential approach of learning directly about cultures was also important here. Without challenges such as encountering people with different worldviews and social norms, “Lindgren notes … students often see culture as something out there, irrelevant, and not affecting their practice. They tend to judge their client’s beliefs and practices from their own perception of reality” (1, p. 19S). FIGURE 10.1 Cultural Discovery Overview The learning activities included several components in conjunction with the Leininger Acculturation Health Care Assessment Enabler1 for Cultural Patterns in Traditional and Nontraditional Lifeways (22, 23). The activities were: (a) background reading assignments; (b) classroom activity component; (c) collaborative library introductory program; (d) videotape program; (e) interview; (f) literature review; (g) reflection; and (h) written paper assignment. Basic principles of transcultural nursing (23–26) and andragogy (27, 28) were integrated throughout the students’ learning. Several goals were sought and carried through the course. They incorporated the relevancy of cultural assessment to immediate career goals, discovery, and immediate feedback by interaction with a culturally different client, and collaborative relationships between nursing student and client and nursing student and instructor, as well as ongoing collaboration with the librarian. The Cultural Discovery learning activities have been implemented over an 8-week period with associate degree nursing students enrolled in the first nursing course at a large, northeastern urban public college. Typically, 140 to 200 first semester students are enrolled annually yielding diverse demographic profiles such as: 68% women; 32% men; mean age 32; 61% White; 20% Black; 11% Latino; 4% Asian; 4% other; and 12% to 30% nonnative English speakers. Within each demographic category, numerous cultural groups are represented. Cultural Discovery has direct relevance and easy application for entry-level baccalaureate students. Components of Cultural Discovery are easily adaptable to other target audiences such as graduate nursing students, students in health science professions, nurses in practice settings, and other health care professionals. The chapter presents background information, learning activity components, and implications for future use in a variety of settings. Two exhibits in the “Application to Health Care Institutions” conclude the chapter. BACKGROUND What diversity exists within your nursing course? Within your program? How are your learners diverse in their experiences with learning about and interacting with individuals, groups, and families who are culturally different? Leininger’s transcultural care model (23-26) offers nurse educators a conceptual framework from which to guide transcultural nursing practice, research, and education. Consideration of student background characteristics is also important (21, 29–31). Background variables describe student characteristics upon entry into college. Such characteristics provide information on the composition of the student group that is integral to determining the special needs of the students and individualizing learning (32). Determining special needs of students on entry to the program leads to student success when faculty intervene early with direction and guidance in utilizing evidence-based strategies (33). Background characteristics may include the cultural identity and background of the students as well as their beliefs, values, and practices. It is well-documented that the applicant pool for nursing has been changing with more nontraditional students entering nursing (12). Typically, the entry point for nontraditional students has been via associate degree nursing programs (34–40). As associate degree programs prepare the greatest number of nurses for entry into practice, it is imperative to address the needs of this group (41). Hansen (32) described the associate degree student population as traditionally older students, men, and minority students. Moccia (13) defined the nontraditional student population as adults with family responsibilities, of different cultures where English is a second language, having more varied educational preparation, and more likely to attend school part-time. Grosset (35) identified age as a student characteristic that often distinguished the associate degree student from the baccalaureate student. “Students today include traditional college-age learners, first-time adult learners, and second-degree students” (42, p. 348). Associate degree programs continue to reflect great diversity in academic preparedness, age, immigration, economic, and cultural diversity with predictions that anticipate similar demographics in the near future (43, 44). Clearly, this student composition reflects a change from the traditional (typical) nursing student of years ago. This is consistent with Montag and Gotkin’s expectations that associate degree nursing programs would attract individuals who could not otherwise enter nursing (45). Merrill et al. (46) noted in their baccalaureate student population that, “Nontraditional students are multitask individuals who are forced to become self-directed learners with limits on time available for course and personal family responsibilities” (p. 109), and so it is with associate degree students. Associate degree nursing programs, therefore, are challenged to accommodate the needs of such a diverse student population (15, 43, 44, 47–49). Moreover, the time constraints imposed by the 2-year programs inspire the design of innovative philosophical approaches and learning activities that: (a) aim to provide nurses with a beginning foundation of transcultural nursing knowledge, skills, and values; (b) stimulate a desire to pursue advanced learning in transcultural nursing; and (c) motivate learners to actively advocate culture-specific nursing care in practice settings. To disregard the various cultures and needs of these nontraditional, diverse students may result in inadequately preparing nurses to function holistically in a multicultural society. Leininger (12) stated that the time has come for the nursing profession to commit to major changes in all aspects of nursing as it shifts from a unicultural to a multicultural focus. For nurse educators, the focus must turn to meeting the different needs of diverse student groups and to transform nursing through the preparation of culturally competent nurses. Not only must nurse educators recognize the diversity in students, they must develop interventions targeted at enhancing transcultural nursing skills. Furthermore, accreditation guidelines specifically stipulate the inclusion of educational activities and experiences designed to prepare associate degree nursing students in meeting the needs of culturally diverse patients, families, and communities and in working productively and harmoniously within a multicultural workforce (50, 51). Such stipulations are also evidenced in baccalaureate program guidelines with clear expectations to build upon foundational cultural competence knowledge and skills in nursing graduate education (51–58). To what extent is cultural competence development addressing the diversity of your learner population? What else could be done? What theoretical and empirical frameworks guide the teaching–learning strategies within your course? Within your program? What guides teaching–learning strategies specifically targeting cultural competence education? What else could be done? SIGNIFICANCE OF LEININGER’S ACCULTURATION ENABLER With the use of Leininger’s Acculturation Health Care Assessment Enabler1 for Cultural Patterns in Traditional and Nontraditional Lifeways (22, 23, 26), nurse educators can stimulate cultural awareness and implementation of a focused and complete cultural assessment technique. The beginning associate degree nursing student is often overwhelmed by having to perform a cultural assessment on any client, especially with an individual of a different cultural background. Even more difficult may be their addressing multiple aspects of cultural influences. For example, there is the need to distinguish between universal similarities and differences in individuals and cultures, as well as the degree to which clients may be quite traditional in some aspects, yet nontraditional in other instances. Beginning students often have difficulty knowing how to effectively approach a culturally different client and conduct a systematic assessment. Mareno and Hart (59) suggest that as a “first step, it is imperative to increase cultural awareness and knowledge among nursing students … followed by opportunities for students to practice these cultural skills and gain comfort in cultural encounters” (p. 87). Cultural assessment skills, if not introduced in the first nursing course, may limit an effective integration throughout the curriculum and ultimately throughout later nursing practice (3, 59). Because a strong commitment to transcultural nursing is integral to providing quality health care to culturally diverse individuals and to student learning, the inability to perform a basic cultural assessment may lead to an avoidance of cultural considerations in planning and implementing nursing care. Beginning associate degree nursing students often have great difficulty focusing on all dimensions of the assessment when using Leininger’s Sunrise model (60) or a broad holistic nursing theory and then sorting through seemingly overwhelming amounts of patient information to identify client needs. Without help at this initial stage, students find it extremely difficult to learn transcultural nursing principles and concepts, and the opportunity to provide holistic care for their clients is impeded. As students enter nursing, their journey of discovery begins. Faculty and professional nursing staff guide the students’ experiences through innovative strategies to assist them to reach the threshold of their own personal discoveries. The major aim of the Cultural Discovery philosophical approach and related learning activities was to facilitate student self-discovery regarding the interplay of culture, aging, and health. To facilitate this discovery, the student’s interview and cultural assessment of a healthy, noninstitutionalized elderly person utilizing Leininger’s enabler was used (22). Additionally, students were instructed to interview individuals of different cultural backgrounds and identities other than their own. How are cultural assessment skills introduced in the first nursing course? How are they integrated in a scaffolded fashion throughout subsequent courses? How do you assist learners who are beginning their journey of Cultural Discovery and cultural competence? BEGINNING THE COURSE: READING AND CLASSROOM COMPONENT Beginning with an introduction to necessary theoretical principles and skills, the first part of the course focused on the cognitive domain through the background reading assignment. The desired cognitive learning outcomes included basic knowledge and skills concerning communication, culture, aging, and health. First, an understanding of the normal biological changes of aging as well as basic human needs as described by Maslow and others contributed other dimensions of learning to this discovery experience. According to Andrews (61), “To achieve an appropriate balance, nurse educators ought to begin by emphasizing the universal human experience and common needs of all people of the world” (p. 7). Second, an understanding of the nursing goals of health promotion, maintenance of health, and prevention of illness added impetus and significance to this experience. Third, holistic care is another concept introduced at the beginning of the nursing experience. Inherent in this concept is the deliverance of culturally congruent care. Familiarity with broad transcultural principles, concepts, theories, and research findings for clients of diverse cultures is essential. Completion of select reading assignments on culture, aging, and health and wellness promotion provided these nontraditional adult learners with common background knowledge. Through lecture and classroom discussion, students were encouraged to explore the interaction of culture, aging, and health and wellness promotion. The faculty facilitated expansion of this knowledge base by further emphasizing the relevance of cultural assessment to the students’ career goal of professional nursing. The role of transcultural nursing in meeting the health care needs of culturally diverse client populations was discussed. Dialogue included a sharing of cultural beliefs and traditional health and caring practices that the students and their families practiced. Additionally, students described some of their experiences with culturally diverse clients in the clinical setting. Because the student group reflected much diversity in cultural background and previous health care experience, much reflection, collaboration, and sharing ensued. Through this reflective sharing process, students became more aware of their own cultural similarities and differences. “Cultural awareness is recognition of one’s own attitudes and assumptions toward similarities and differences in others, acknowledging racism, bias and stereotyping” (59). Guided by Leininger’s theory of culture care diversity and universality (22), similarities and differences between their own beliefs, values, and practices and those of their family members or members of their own cultural group were also recognized. Mareno and Hart (59) note the importance of increasing cultural awareness and knowledge by providing opportunities to interact with diverse populations and encouraging self-reflection on what went well and how future encounters could be improved. This awareness and recognition suggested that affective learning outcomes were achieved through the classroom activity component and use of the general theory to examine cultural differences and similarities (22). Once affect was aroused, students were eager to learn how to accurately assess cultural beliefs, values, practices, and needs of clients. Next, Leininger’s enabler,1 the culture care theory, and the sunrise model were used to assess health care influencers in such categories as worldview, language, cultural values, kinship, religion, politics, technology, education, and environmental context (22). A description of each category, followed by sample questions, provided the framework for beginning discovery. The importance of asking questions using culturally acceptable verbal and nonverbal communication skills was emphasized in discussion sessions. Students participated by sharing their own similarities and differences in acceptable communication behavior. What beginning reading is essential in your course? What subsequent face-to-face and/or online or other distance education teaching–learning strategies will assist students to actively engage in applying beginning reading to subsequent course activities and to immediate and future clinical practice? USE OF VIDEOTAPES, LIBRARY, AND COLLABORATION TO INCREASE UNDERSTANDING Next, students were encouraged to view the videotape Transcultural Nursing: Cultural Care Assessment of an American Polish Client (62). The film provides a guide to cultural assessment and serves to illustrate the use of Leininger’s enabler while also providing a succinct yet comprehensive overview of the underlying theoretical principles that guide its practical application. Student feedback concerning the film was positive, suggesting that this instructional medium constituted a transitional bridge between theory and practical application. Initially, the film was shown at set times in the Nursing Skills Laboratory outside of class time; however, in recent years, advanced technology provided an innovative solution to accommodate students’ multiple role responsibilities outside class time. Collaboration with media specialists in the library yielded a well-received solution. After receiving permission from the film’s copyright holder, the media specialists digitalized the video onto a DVD format and created a password protected link via the course’s web page (Blackboard) so that students could access the video via the Internet within a specified 4-week period. Written reflective statements from students following the pilot of this new initiative indicated that, overall, students were pleased with the flexibility of viewing times and the option to individually pause the film, take notes, and/or review essential points. In order to further prepare the student for this discovery experience, collaboration of faculty is necessary. As Leininger (12) recommended, students and faculty should be coparticipants in the learning and teaching process. All nursing faculty involved should be conversant with Leininger’s enabler that provides a basis for student discovery of a culture other than their own. Prior to meeting, all course instructors reviewed Leininger’s culture care theory (60, 62, 63), Leininger’s Acculturation Health Care Assessment Enabler for Cultural Patterns in Traditional and Nontraditional Lifeways (22), course objectives, and student prerequisite assignments. During the meeting, the role of the faculty in facilitating the Cultural Discovery was discussed and agreed upon. Full-time classroom faculty and adjunct clinical faculty work together and with the students. Together, faculty guide students in learning the knowledge, skills, and values necessary for the discoveries that lead to culturally sensitive care. An added dimension to this collaborative approach involved support and assistance from the librarian. Students attended a library orientation program designed by nursing faculty and the librarian. The program has two major components: (a) 1-hour library instruction to help students gain knowledge and skills necessary for cultural and transcultural nursing research; and (b) the use of Blackboard to extend library instruction in support of Cultural Discovery (see Exhibit 10.1). Several library instruction sessions were available to allow for small group work and hands-on experience with the computer and database search. The small class size of 20 students enabled the librarian to answer students’ questions and respond to those who needed extra help. The use of the Blackboard learning system helped support students’ Cultural Discovery beyond the limited one-hour library instruction. Web pages containing course-related resources, including transcultural nursing resources, tutorial for searching the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and writing resources were developed and integrated into the Nursing Blackboard course website. These resources, accessible anytime, helped reinforce what was taught in the library instruction session, and allowed students, especially those who needed extra help, to learn at their own pace. Library instruction continued with students posting their research questions on the discussion board, and seeking help for information sources for specific cultures. The online discussion forum became a learning community where the students, professors, and the librarian came together to help each other, and to share their experiences in Cultural Discovery. EXHIBIT 10.1 Components of the Library Orientation Program a. One-hour library instruction to help students gain knowledge and skills necessary for cultural and transcultural nursing research. Topics and activities include: • Introduction of cultural and transcultural nursing resources posted on the Nursing Blackboard course website. • Library databases available to search for cultural and transcultural nursing information, with major emphasis on CINAHL. • Demo by the librarian of how to search CINAHL on a select cultural topic, and methods of obtaining articles selected from CINAHL search. • Hands-on practice by students in conducting a CINAHL search on the culture and health of an ethnic group of his or her choice. • Methods of locating books related to culture and transcultural nursing: library catalogs, books on reserve, and interlibrary loan. • Use of reliable websites for cultural and transcultural nursing research. • How to access library’s electronic resources off campus. b. Use of Blackboard to extend library instruction in support of Cultural Discovery. • Develop course-related library resources and integrate them into the Nursing Blackboard course website. These include library databases related to nursing, tutorials, bibliography of books and articles on specific cultures, websites of interest in transcultural nursing, American Psychological Association’s (APA) style guides, and plagiarism prevention resources. • Create discussion forums to provide opportunities for students to discuss their work, and ask questions related to library research and finding resources for their Cultural Discovery research paper. • Provide research assistance to students at their point of need via discussion board, e-mail, phone, and in-person consultation. Several institutional review board (IRB)-approved research studies evaluating the program’s effectiveness indicated that the library orientation program was helpful, and that students became more skilled in utilizing the resources of the library for cultural research, and in writing a literature-supported research paper. Faculty-librarian collaboration helped create positive and effective learning experiences for students. The “field trip” students took to the library not only helped improve their skills for transcultural nursing research, but also gave them the opportunity to interact with librarians and the library environment so that they were comfortable coming to the library or seeking librarians’ help online and in person (64). The first library orientation program survey drew 80 respondents (a 92% response rate), with three close-ended questions and two open-ended questions with room for qualitative comments. Responses to the library program were largely positive, and the majority of the respondents agreed that the library program made them more aware of the resources available for nursing, especially transcultural nursing research (64). Evaluation of the program’s effectiveness continued using a variety of methods, including a library instruction pre-test and post-test survey at the end of the library instruction session and a survey at the end of students’ 8-week Cultural Discovery. Survey questions were distributed in print format, but also made available online and via the Nursing 110 Blackboard course website. Nursing faculty encouraged their students to participate, and helped with the in-classroom data collection, which greatly improved student response rates. Data continue to provide empirical support for ongoing and revised strategies and to guide curricular and library program development. Merrill et al. (46) state that “the use of technology in nursing education in the 21st century is a permanent change that will continue to impact learning outcomes of the nontraditional students as well as the traditional student” (p. 109). The use of technology in this activity is an important aspect of this activity and introduces the student to valuable resources for the course. What interdisciplinary and collaborative partnerships and strategies are necessary to optimize a multidimensional, multistep integrated cultural competence teaching–learning strategy? How can various forms of technology enhance the depth of learning and create a supportive, caring learning environment that fosters collaboration and an appreciation for the process of completing the overall assignment and a shift from the product of the assignment (paper)? INTERVIEW AND LITERATURE REVIEW Kurz (65) notes that experiential approaches have an important role in changing attitudes and increasing sensitivity to problems stemming from cross-cultural misunderstanding. Shattell, Nemitz, Crosson, and Zackeru et al. (66) suggest carefully planned teaching/learning strategies and curricular design that may lead to greater student and faculty cultural understandings and positive outcomes. During the interview, culture care, values, expressions, patterns, and health beliefs become apparent to the student. Students were instructed to write a paper based on two main components. These components were: (a) an interview with a healthy, non-institutionalized elderly person of a different cultural background and identity than their own; and (b) a review of current nursing (including transcultural nursing) and allied health literature related to the culture of the person being interviewed. Typically, students have interviewed neighbors, senior citizen club members, friends, relatives, and elderly college students. Because the interview often took place in the client’s home where symbols of the culture might be evident, this added yet another dimension of discovery to the experience. Use of Leininger’s enabler assisted the student to assess all dimensions of culture systematically. To address the issue of aging, students examined the individual’s perceptions, feelings, and attitudes of aging as well as noted any physical signs of aging. Recognizing that the primary aims of nursing include the promotion of health, prevention of disease, maintenance of health, and consolation of the dying—students explored the elder person’s experience with health. Waters (67) stated that “using community and culturally based strategies that fit into the context of peoples’ everyday lives may increase the quality and duration of a healthy life and eliminate health disparities … it gives voice to the people” (pp. 66, 67S). Cognitive, affective, and practical (psychomotor) learning outcomes were achieved through the interview experience (see Figure 10.1). Following each interview, the student reviewed the literature concerning the cultural heritage of each person. For persons of multiple cultures, students were referred to resources concerning multicultural (multiple heritage) individuals. Due to the limited available information concerning multicultural individuals, students also had the option of researching one of the interviewee’s cultural groups. Students were encouraged to review resources from nursing and other disciplines. Collaboration between faculty, students, and librarian often occurred during the literature search and review, because many students were inexperienced in writing a literature-supported paper. Ongoing communication occurred in-person, and over telephone, e-mail, and/or discussion board. Student peer mentor-tutors were also available to assist students individually and/or in small group sessions in the Nursing Student Resource Center (NSRC) and the Nursing Student Test Prep Center (NSTPC) (43, 44, 48). Additionally, an online tutorial, specifically designed by the librarian, helped students not only find relevant literature for their research, but also integrate these sources effectively and ethically into their paper (see Exhibit 10.2). As the student analyzed and integrated the research and experience, discovery of how an individual’s culture influences health care beliefs, needs, and practices emerged. Students were encouraged to draw upon their theoretical knowledge concerning the cultural group to further enhance their ability to examine similarities and differences. In this way, awareness and sensitivity to individuals from a particular cultural group can be enhanced.
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