ELEVEN
Case Exemplar: Linking Strategies—Spotlight on the Innovative Field Trip Experience
with contributions from Lenore Bertone, Jo-Ann Douglas, Vivien Li, and Sara Newman
Students must reflect upon their prior learning, present stage as a learner, and future role in order to create one’s own, individualized, and highly relevant practicum.
SNAPSHOT SCENARIO
Professor Frank: Most students who enter nursing are not aware of transcultural nursing, conceptual models, the full scope of nursing practice, and the impact of culturally specific considerations when planning and implementing care.
Professor Light: Yes, this is true across curricula. Even practicing nurses who return to school for an advanced degree and an advanced role are unaware, have limited knowledge, and are novices. Besides, any transition requires some foundational work.
Professor Powers: One consideration across all levels is the need for faculty to consider adult learner characteristics, including cultural diversity and experiences with various different cultural groups. Helping students develop a lifelong commitment to learning and professional values necessitates empirically and conceptually supported strategies that incorporate multiple learner characteristics, aim to engage and empower the learner in taking ownership for one’s ongoing professional learning and role, and incorporate a variety of teaching–learning strategies that can be shared with others to further enhance learning.
Professor Frank: Yes, frequently students complain because they do not see the connection between various teaching–learning strategies and the relevance to their future roles. Many cannot see beyond a 15-week semester to the wealth of opportunities for lifelong collaboration and networking that can optimize one’s own professional self-development at any level. Sometimes students assume passive roles, go through the motions of meeting minimum requirements, and see assignments as a means to a passing grade and nothing more.
Nurse Zeal: Nurse educators must aim to invigorate zeal and instill interest in cultural competence development as a lifelong professional commitment in a variety of future roles sometimes unimaginable upon entry into a nursing course or program.
Professor Quest: I agree, and suggest we search the literature. What strategies have others used that were learner-centered, successful, empowering, and easily adaptable and applicable to our students? I want to leave a positive, lasting impression on my students, instill a zest and a quest for going beyond the minimum, and ignite a passion for lifelong professional learning.
This chapter describes a multidimensional strategy for teaching and learning cultural competence in graduate nursing education with a specific focus on the innovative field trip experience (IFTE). First, a brief overview of the literature in nursing and higher education provides the essential background information underlying strategy development, implementation, and evaluation, including a discussion of how the Cultural Competence and Confidence (CCC) model guided development. Next, an overview of the transcultural nursing core course within the clinical nurse specialist (CNS) curriculum is highlighted. Four case exemplars, supplemented by detailed tables and figures, demonstrate easy application. A discussion of cognitive, practical, and affective learning outcomes and implications for nurse educators concludes the chapter.
BACKGROUND
Transcultural nursing is “a formal area of humanistic and scientific knowledge and practices focused on holistic culture care (caring) phenomena and competence to assist individuals or groups to maintain or regain their health (or well-being) and to deal with disabilities, dying, or other human conditions in culturally congruent and beneficial ways” (1, p. 84). Leininger’s theory of culture care diversity and universality and her illustrative sunrise model (2–4) provide a valuable resource and guide for preparing advanced practice nurses to care for culturally diverse populations. The desired outcome of the model is care customized to fit with the patient’s cultural values, beliefs, and practices. Attaining this outcome requires a systematic assessment of the dynamic patterns and cultural dimensions of a particular culture (subculture or society), including religious, kinship (social), political (and legal), economic, educational, technologic, and cultural values, and how these factors may be interrelated and function to influence behavior in various environmental contexts. Culturally congruent care, however, can only occur when culture care values, expressions, or patterns are known and used competently (4).
Two other frequently used conceptual frameworks are models by Campinha-Bacote (5) and Purnell (6). These models acknowledge that cultural competency is an ongoing, complex learning process that involves continual skill acquisition and refinement. Although scholars support that all individuals, regardless of cultural background, need formalized preparation in transcultural nursing, this goal is not equally valued by all nurses (7–10). Because adult learners are most motivated to engage in activities that they perceive are most relevant, it is important to truly capture students’ interest in cultural competence development. For example, students enrolled in an adult health CNS master’s program generally do not enter the master’s program with the primary goal of developing cultural competency. “The essence of CNS practice is clinical nursing expertise in diagnosing and treatments to prevent, remediate, or alleviate illness and promote health with a defined specialty population…” (11, p. 5). CNS practice aims to achieve quality, cost-effective patient-focused outcomes across three spheres of influence: (a) patient/client, (b) nurses and nursing practice, and (c) organization/system (11). Typically, CNS students are interested in developing clinical competencies in a clinical specialty and obtaining certification in a clinical specialty; therefore, nurse educators are challenged to invigorate zeal and instill interest among these adult learners (12).
Proponents of adult learning theory attest to the marked influence of educational enterprises, motivation, and commitment in relation to immediate career goals (13–20). Adult learners will be most motivated and interested in learning if immediate benefits to career goals and daily professional responsibilities are clearly evident and learning goals are realistic (13–20). With increased globalization and the changing demographics and characteristics within and between cultural groups, it is unrealistic to expect that nurses will become specialists in caring for (or working with) all of the many different cultural groups that they may encounter. To become a specialist in one or more select cultural groups requires a series of specialized transcultural courses and concentrated fieldwork at the graduate level (9, 21, 22). It is realistic to expect that all nurses acquire the basic or generalist transcultural nursing skills needed to provide care for culturally diverse and different patients. A transcultural generalist approach emphasizes broad transcultural principles, concepts, theories, and research findings to care for patients of many different cultures (21). It is also reasonable to expect nurses who have been prepared as generalists to demonstrate commitment and participate in ongoing cultural competence education. Especially pertinent are educational programs designed to expand learning with direct application to specific, targeted priority cultural groups dwelling in surrounding communities.
Despite the numerous educational opportunities available, some nurses are more actively engaged in cultural competence development and direct clinical application while others are not. Some nurses are more motivated to pursue cultural competence development and are more committed to the goal of culturally congruent care than others. Therefore, the consideration of factors that may influence motivation, persistence, and commitment is necessary. Confidence (self-efficacy) is one such factor. According to Bandura (23), the construct of self-efficacy is the individuals’ perceived confidence for learning or performing specific tasks or skills necessary to achieve a particular goal. In learning tasks, inefficacious learners are at risk for decreased motivation, lack of commitment, and/or avoidance of tasks. Learners with a resilient (strong) sense of self-efficacy in a specific domain demonstrate high levels of commitment, persistence at skill development, view difficult skills as challenges to be overcome, and expend extra energy to overcome obstacles. In contrast, supremely efficacious (overly confident) learners view tasks as insignificant and/or requiring little preparation, increasing the risk for poor outcomes. In clinical practice, avoidance of culture considerations, lack of adequate preparation, and/or rendering culturally incongruent care jeopardizes patient safety and health.
What theoretical and empirical frameworks guide the teaching–learning strategies within your course? Within your program? To what extent do the frameworks correspond with the characteristics of diverse adult learners? To what extent do the frameworks correspond with the teaching–learning process of cultural competence? What other frameworks should be incorporated?
CONCEPTUAL FRAMEWORK
The Cultural Competence and Confidence (CCC) model (Figure 3.1) aims to interrelate concepts that explain, describe, influence, and/or predict the phenomenon of learning (developing) cultural competence and incorporates the construct of transcultural self-efficacy (TSE). TSE is the perceived confidence for performing or learning general transcultural nursing skills among culturally different patients. Transcultural nursing skills are those skills necessary for assessing, planning, implementing, and evaluating culturally congruent nursing care. The performance of transcultural nursing skill competencies is directly influenced by the adequate learning of such skills and by TSE perceptions (24–26).
Within the CCC model, cultural competence is defined as a multidimensional learning process that integrates transcultural skills in all three dimensions (cognitive, practical, and affective), involves TSE (confidence) as a major influencing factor, and aims to achieve culturally congruent care. The term learning process emphasizes that the cognitive, practical, and affective dimensions of TSE and transcultural skill development can change over time as a result of formalized education and other learning experiences. Within the context of transcultural learning, cognitive learning skills include knowledge and comprehension about ways in which cultural factors may influence professional nursing care among clients of different cultural backgrounds and throughout various phases of the life cycle. The practical learning dimension is similar to the psychomotor learning domain and focuses on motor skills or practical application of skills. Within the context of transcultural learning, practical learning skills refer to communication skills (verbal and nonverbal) needed to interview clients of different cultural backgrounds about their values and beliefs. The affective learning dimension is a learning dimension concerned with attitudes, values, and beliefs and is considered to be the most important in developing professional values and attitudes. Affective learning includes self-awareness, awareness of cultural gap (differences), acceptance, appreciation, recognition, and advocacy (24–28).
Formalized educational experiences and other learning experiences that: (a) carefully weave together cognitive, practical, and affective transcultural nursing skills; (b) encompass assessment, planning, implementation, and evaluation; and (c) integrate self-efficacy appraisals and diagnostic-specific interventions are considered essential in cultural competence education (24–26). Because TSE perceptions influence a learner’s actions, performance, and persistence for learning tasks associated with cultural competence development, it is important that educators fully understand the vital role of self-efficacy appraisal. Self-efficacy appraisal is an individualized process influenced by four information sources: actual performances, vicarious experiences (observing role models), forms of persuasion (receiving encouragement and judicious praise), and emotional arousal (physiological indices). Actual performances are the strongest source of efficacy information (23). Successful performances can raise efficacy while unsuccessful performances lower it. Lowered self-efficacy can be psychologically stressful and dissatisfying to nurses, thereby adversely affecting motivation, persistence, and cultural competency development. Individuals with low self-efficacy initially can feel devastated by failure or poor performance and further lowered self-efficacy can cause avoidance behaviors (23, 29). Formalized teaching strategies that provide essential background information and facilitate varied opportunities for self-directed, learner-centered interactive activities and experiential learning will be most beneficial. Combining several strategies to create empowering learning environments will promote a stronger sense of meaningfulness in task accomplishment, resilient confidence, and greater control over choices in the learning process in truly learning-centered curricula (10, 20, 30–34).
How can the CCC model provide guidance for designing, implementing, and evaluating teaching–learning strategies in your course? In other courses throughout your program(s)?
COURSE OVERVIEW
“Transcultural Concepts and Issues in Health Care,” a three-credit 15-week graduate core course within the adult health CNS curriculum, was taught at a large urban, public college that serves various student and client cultural groups. The course aimed to provide students with a strong foundation in transcultural nursing that permits purposeful integration of transcultural nursing concepts and skills at higher levels of complexity throughout the curriculum and advanced practice role development. (After completion of the CNS, students could choose to pursue the nurse practitioner option.) Based on current recommendations in the literature, the course focuses on the general philosophy, ethics, concepts, skills, theory, research, and practices underlying transcultural care. Current issues in pluralism, diversity, and health care are explored in relation to culturally competent care of advanced practitioners in multiple health care settings. Leininger’s theory of culture care (2) and other selected theories and research studies are critically appraised for utilization in various practice and management settings. Future directions of transcultural care are discussed with special emphasis on advanced practice roles and how to effectively create the needed transformational changes in health care, education, practice, research, and policy. Course objectives are specifically linked to the course description, course topics, and curriculum objectives, as well as program outcomes (35; contains specific details on transcultural course).
Following an introduction to Leininger’s theory, ethnonursing research methodology, and other conceptual models, students are introduced to various topics concerning health disparities, cultural assessment, ethnicity, race, class, gender, sexual orientation, religion, ethnopharmacology, discrimination and bias, multiple heritage individuals, female circumcision, complementary and alternative medicine, physical assessment, spirituality, and mental health. Students are expected to be active, well-prepared graduate seminar participants who critically discuss assigned chapters, journal articles, class films, lectures, and PowerPoint presentations. Other teaching–learning strategies involve conducting a review of literature (ROL) on a select transcultural topic and a clinical topic (usually chosen to develop the CNS targeted area of specialty); writing an ROL paper, connecting the ROL paper to future CNS role, and writing a CNS paper. Students have a choice of several CNS paper options: (a) cultural assessment enabler; (b) sphere of influence; (c) professional development: conference; (d) leadership: letter to the editor or author; or (e) innovative field trip experience. Methods of evaluation comprise seminar participation (30%), ROL paper (40%), and CNS paper (30%). The reasons behind selection of multidimensional teaching and evaluation strategies are twofold: first, to address varied learning styles among diverse learners, and second, to stimulate learning in the cognitive, psychomotor (practical), and affective domains.
What are the main components, features, topics, and methods of evaluation for your course? To what extent is cultural competence and transcultural nursing and culture topics a visible component? What else could be done?
THE IFTE
The IFTE is a learner-centered, creative strategy that was implemented during the second half of a required transcultural core course in the CNS/NP curriculum. IFTE included prerequisite components (background reading assignments, classroom seminar and films, literature review, and written paper), general required components (student-initiated field trip selection, purpose and objectives, instructor approval, plan, implementation, and written paper), and information-sharing/dissemination components (storytelling and cultural food buffet). Figure 11.1 presents the IFTE components as formal and informal educational experiences within the context of the CCC model.
FIGURE 11.1 Application of Jeffreys’s Cultural Competence and Confidence (CCC) Model: Innovative Field Trip Experience
The prerequisite components were designed to provide students with beginning foundational knowledge in transcultural nursing and in the expected role competencies of the CNS. The background reading assignments provided a common framework for seminar discussion. Films expanded upon reading and prior learning, presenting students with the opportunity to gain a different perspective into the emic (insider) perspective of different cultural groups. By the third week, students selected their own review of literature topics. The process of searching the literature and available resources on both selected clinical and transcultural topics provided students with some essential “holding” knowledge. Leininger (36) described the powerful value of “holding” knowledge prior to interacting with members of a cultural community or engaging in other “immersion” experiences to enhance understanding of the culture.
The student’s self-selection of the field trip option, formulation of purpose and objectives, and planning of the intended experience (see Exhibit 11.1) is consistent with principles of adult learning theory. This process involves reflection. When used appropriately, reflection is an effective teaching method that enhances nursing practice (10, 37–54). “When students are challenged to choose topics about which they are passionate and reflect on their application of research-based evidence to clinical practice, their work reflects scholarly effort” (55, p. 475). Students must reflect upon their prior learning, present stage as a learner, and future advanced practice role in order to create one’s own, individualized, and highly relevant practicum. “A reflective practicum is an experience of high interpersonal intensity. The learning predicament, the students’ vulnerability, and the behavioral worlds created by coaches and students critically influence learning outcomes” (56, p. 171).
EXHIBIT 11.1
Topics, Field Trip Selection, and Purposes/Objectives: Comparison of Four Case Exemplars
Although instructor approval suggests a simple dichotomous approach—the proposed field trip and objectives are approved or they are not—it is not really this simple. Within the context of adult learning theory and reflection-in-action, the role of the instructor is to guide (coach) students to further explore, shape, modify, or revise their intended experience, purposes, and/or objectives and seek a deeper level of potential learning. According to Schon (56), professional education should be focused on enhancing the professional’s ability for “reflection-in-action” or learning by doing and preparing professionals for lifelong learning and problem solving throughout professional practice. Certainly, cultural competence development involves lifelong learning and nurse educators are in a key position to guide students.
Students’ implementation of the planned field trip experience permitted further opportunities to shape the experience and engage in ongoing reflection-in-action (see Exhibit 11.2). For example, interviews, eating traditional foods, wearing traditional clothing, and other components were not preplanned but added a valuable dimension to the experience and further enhanced cognitive, practical, and affective learning. The process of writing the CNS paper encouraged students to further reflect on and evaluate the experience and explore the connections between the field trip experience, prior learning, future learning, and application to future CNS role (see Exhibit 11.3). Preestablished paper grading criteria provided students with a common framework for focus and reflection, such as discussing the most significant component of the field trip experience in relation to: (a) course topics, (b) ROL paper, (c) CNS competencies, and (d) future advanced practice nurse role. Additionally, this aimed to validate learning via the field trip experience by demonstrating immediate and future application to the achievement of an important career goal.
The final component of the IFTE (information-sharing/dissemination through storytelling and cultural food buffet) aimed to further develop several CNS competencies: collaboration, leadership, and education, specifically within the “nurses and nursing practice” sphere of influence. Reflective storytelling is a valuable strategy that facilitates reflective analysis, enhances self-esteem, and enriches cultural sensitivity and understanding (10, 33, 54, 57, 58). The cultural food buffet setting provided a relaxed, informal atmosphere to share stories about the ROL topic and IFTE. After reviewing Leininger’s chapter concerning the cultural meaning of food (59), students took great pride in sharing traditional cultural foods (from either their own culture or researched culture) and in sharing the cultural meanings and significance of the foods. The different tastes, smells, feels, sounds, and looks of the ethnic food evoked sensory stimulation and cultural learning while also promoting positive feelings about the overall “informal presentation” experience. The brief question and answer session encouraged participation and dialogue between students and thereby enhanced opportunities for clarification, collaboration, education, and critical thinking. Distribution of presenters’ abstracts with name and contact information provided a mechanism for ongoing networks, shared information, long-term learning, and validation.
