NINE
Enhancing Cultural Competence: Clinical Settings, Immersion Experiences, Service-Learning, Simulation, and Nursing Skills Laboratory
with contributions from Roxanne Amerson, Susan Fancher, Rachelle Larsen, Polly M. McArthur, Sandra J. Mixer, LuAnn Reif, and Monique Rogers-Walker
Interaction with culturally diverse patients, families, communities, health care professionals, and health care workers is essential for cultural competence development in nursing and health care. Despite cultural diversity within a clinical, service-learning, or cultural immersion setting, the instructor is pivotal in guiding students to new levels of cultural competence development.
SNAPSHOT SCENARIO
Professor Quick lands at the airport the night before the 10-day overseas immersion experience is scheduled to begin and quickly nods a greeting to the eight undergraduate nursing students registered for the elective course. She thinks, “If I weren’t up for tenure next year, if my dean wasn’t a transcultural nursing advocate, if the new university president wasn’t pushing global learning, and if I didn’t need the extra income, I certainly wouldn’t be here. I only volunteered to fill in for the professor who usually does this because she’s on maternity leave. I usually coordinate the simulation lab and focus on the technical skills in nursing. Thank goodness that she left me her course syllabus and that I took a few courses to know the language basics of this country. Fortunately none of the students were sitting near me on the flight so I could quickly cram the syllabus and complete the pre-assigned readings. Who knew there was a 50-year history of the transcultural nursing field! Fortunately the eight students are all ready to graduate and will be eager to finish these 10 days quickly and get back home. I think the best approach will be to immerse them right into the clinical experience and interaction with the host faculty, staff, and clinic patients and their families. In just the blink of an eye, we’ll all be back on the plane heading for home and I can read over the daily journals on the flight back, give everyone a passing grade who completes a daily entry, and submit my grades once we land. Besides, none of this immersion and transcultural stuff will be on the licensing exam.”
On the first day at the host clinic, here are some of the students’ thoughts:
Jill: I’m one of three students of my cultural background and I stick right out in this clinic. At least Jack and Harriet are with me so we can stick together. It’s frightening to be here and not be able to understand what people are saying. Although I listened to the podcasts concerning the common medical terms and basic language, I’m not confident enough to try and talk. Professor Quick gave us a 15-minute orientation to the clinic and today’s objectives, but I’m so anxious I can’t remember much of anything.
Jack: I didn’t expect to see such poverty, hunger, overcrowding, and lack of clean supplies. The food is different and I don’t know the names of the local foods for these lower socioeconomic groups. Because I studied their language in high school, I can understand most of what’s being said but I don’t know how to teach patients and I’m guessing health literacy and literacy in general may be an issue. I wish I’d completed the suggested readings listed in the syllabus. I didn’t download them to my computer and no one else did either. Professor Quick said not to worry, and that the staff would take care of everything; but now I’m disappointed that my learning is limited.
Carla: I emigrated from this country 15 years ago and was overly confident that this immersion experience would be a quick and easy three credits before graduation and would look good on my resume and job application. Things are so different and I feel ill-prepared. I also feel overwhelmed and burdened because Professor Quick and many of my classmates look to me as the token authority for transcultural nursing and cultural competence in this rural clinic. I was born in a big city. I don’t even understand some of the dialects spoken here. I was unconsciously incompetent earlier, but now feel consciously incompetent. It seems like there was some theory or model that explained this phenomenon but Professor Quick was unfamiliar with this when I asked her about it. I also thought preserving and maintaining cultural values, practices, and beliefs whenever possible is important. I wonder if there is a way to systematically assess cultural dimensions.
In contrast, Professor Best applied for a small institutional grant and received 3 hours release time to design a multiphase immersion experience. Because the literature often did not clearly distinguish between immersion experiences and service-learning experiences, Professor Best reviewed the literature under both search terms. Following a review of the conceptual and empirical literature, she contacted two published researchers concerning immersion experiences and service-learning. Reaching to the researchers via e-mail and a pre-arranged conference call resulted in much encouragement and some practical suggestions of “dos and don’ts” that would optimize the immersion experience for teachers, learners, and those in the host culture (patients, families, and health care providers). In addition, two referrals to transcultural experts with clinical, practical, and linguistic experience in the host culture led to a collaborative, colleague-type venture. Consistent with recommendations of Leininger and other transcultural scholars, Professor Best concluded that adequate preparation of faculty and students could be implemented via a multidimensional, multiphase strategy with concentrated emphasis on nuances of the host culture at the clinic setting and partnership groups. Formation of a subcommittee consisting of faculty teaching courses the semester prior to the immersion experience yielded some innovative ideas.
Professor Sims: Let’s design, implement, and evaluate role-play and simulation incorporating several different scenarios based upon what students would be exposed to in the host country across the life span. Let’s also incorporate various gender roles, intergenerational roles, extended family roles, clergy, and traditional healers. Some examples could be a childbirth—labor and delivery scenario, pediatric scenario, immunization clinic, prenatal clinic, postpartum breastfeeding practices, and so on. We could even create various versions of the same clinical and/or technical skill scenario for some other cultural groups to permit “compare and contrast” discussions during debriefing.
Professor Broad: That’s a good idea. That would broaden learning and be relevant to students who will be in one of the alternate clinical experiences with local cultural groups. First, I will broaden my book, journal article, and Internet/website search to identify best practice recommendations for simulation design, implementation, and evaluation. I will also look for reliable educational resources concerning the host culture and its health care system. We can decide on the next steps after that.
Professor Blend: Yes, it will also be important to blend evidence-based strategies about cultural competence education with the multidimensional learner-centered strategies we select to implement and evaluate for the preimmersion experience course components. Blending cultural competence and best practices in teaching and learning should optimize student learning and make sure the immersion experience yields the best possible outcomes for all involved.
Professor Ponder: Shouldn’t all of our students’ learning experiences consider cultural implications among diverse populations? Is there a systematic way to ascertain what and how students are exposed to diverse patients and clinical topics via actual or simulated experiences? Is there a way to determine if cultural assessments and culturally congruent or culturally specific care is appropriately and consistently implemented in clinical settings and simulations?
What feelings and thoughts are evoked as you read each character? What is the potential impact of each scenario on faculty and students’ cultural competence development, transcultural self-efficacy, motivation, and professional development? What is the potential future impact on patients, families, and communities?
Interaction with culturally diverse patients, families, communities, health care professionals, and health care workers is essential for cultural competence development in nursing and health care (1–6). Such interaction must be partnered with an integration of general transcultural skills, knowledge, and values. Although educators can make a tremendous difference individually, the greatest impact will be accomplished through a coordinated, group effort integrated through all courses and course components in a complementary, scaffolded, and comprehensive fashion.
As mentioned in Chapters 7 and 8, close scrutiny at the course level (undergraduate and graduate) should assess whether cultural competency development is emphasized substantially, equally, and symmetrically in all dimensions and course components. This can begin by examining all components of the course syllabus: course description, course objectives, course topics, student learning outcomes, learning activities, course assignments, and methods of evaluation. Using the general questions depicted in Figure 7.3 and in Jeffreys 2016 Toolkit Item 20, nurse educators can conduct a systematic inquiry, make a decision, choose an action, and then develop innovations (7). For example, if a nurse educator decides that “care of culturally diverse clients” mentioned in the course description is “barely visible” in the other course syllabus components, the action chosen should be to make major revisions, develop innovations, and reevaluate within a specified time period. Collaboration with other faculty teaching in the nursing program and outside experts will be essential to the overall curricular goals and process. As a second example, a nurse educator may decide that the course topics present cultural competence as an “add-on” or a “disconnected attachment.” Thereafter, the chosen action will be to connect together, or better still, to integrate it as a visible, horizontal thread.
Inquiry at the course level also includes all instructional media (e.g., textbooks, films, videos, movies, computer-based learning, journal articles, web page, and PowerPoint), course components (e.g., classroom, nursing skills laboratory, simulation, clinical, service-learning, and/or immersion experience), teaching–learning activities, and methods of evaluation (e.g., written assignments, presentations, and examination questions). Chapter 7 presented a general overview for faculty self-assessment and curriculum evaluation. Chapter 8 presented strategies for enhancing cultural competence via face-to-face classrooms, hybrid, and online courses and addressed various types of instructional media. This chapter highlights several select course-level components: clinical settings, service-learning, immersion experiences, simulation, and nursing skills laboratory settings. Major emphasis is placed on individual instructor appraisal, course-level appraisal, and innovations. It is beyond the scope of this chapter to detail all elements. Readers are encouraged to critique the innovations presented, modify, adapt, and create new innovations for the teaching and learning of cultural competence. Figures, tables, TSET Research Exhibits, and the “Educator-in-Action” vignette provide supplementary information to expand upon narrative text features. (See Chapters 10 to 12 for spotlights on combination and multidimensional approaches.)
CLINICAL SETTINGS
How is cultural diversity within clinical experiences and clinical settings appraised within your course, prerequisite courses, subsequent courses, and throughout the curriculum? When was the last time a systematic appraisal of clinical experiences and settings was conducted? For cultural competence and cultural diversity? When should it be conducted?
Clinical settings and experiences provide great opportunities for students to engage in all aspects of cultural competence development, especially through engagement and interaction with diverse patients, families, communities, populations, health care professionals, and health care workers. Although great differences in types of clinical settings, learning experiences, and instructor involvement exist, there are certain criteria that should be considered. One consideration is the clinical setting’s cultural diversity of clients, nurses, and other agency personnel in relation to the surrounding community and to the nursing student population. Unless faculty purposely set out to systematically appraise the various dimensions of culture, they will not have comprehensive data to utilize and substantiate the benefits and limitations that each setting offers. For example, the Clinical Setting Assessment Tool–Diversity and Disparity (CSAT–DD) is a user-friendly tool to systematically collect data about the clinical practicum/agency site, specifically focusing on descriptions of diverse client populations (Part I) and clinical problems (Part II) that can guide decision making and planning of future clinical learning experiences, placements, and assignments. The 15 items in Part I gather information about the demographic make-up of the client population (age, ethnicity, languages spoken, religion, etc.) as well as identifying the most prevalent characteristics represented. Supplementing and complementing the realities of the clinical setting with case studies, simulation, and other interactive experiences will better prepare students for caring for many different types of diverse patients (see Chapter 6, Exhibit 6.2, and Jeffreys 2016 Toolkit Item 7) (7).
A second consideration involves students’ perceptions concerning diversity. Routine collection and analysis of data from a “student evaluation of clinical experience” questionnaire can provide valuable insight, especially if items solicit information concerning client characteristics and the students’ perception about the clinical setting’s cultural diversity inclusive of patients and employees (8). A mismatch between instructor and student perceptions concerning diversity in the clinical setting alerts faculty that additional measures may be needed to bridge the gap between clinical instructors and students. In contrast, congruency between instructor and student perceptions concerning the adequacy (or inadequacy) of diverse clients in the clinical setting, with specific details, provides valuable information about what areas may need further development or additional attention through simulation, unfolding case scenarios, and/or other modalities.
Interaction with culturally diverse patients, families, communities, and health care providers in the clinical setting offers a wealth of learning opportunities for students. Providing opportunities for students to interact with culturally diverse clients and personnel must be appropriately partnered with cultural competence development as an integral course and curricular component. Students must have the general transcultural nursing skills, knowledge, and values to successfully achieve positive learning outcomes for cultural competence development. As mentioned previously, transcultural self-efficacy (TSE) perceptions (confidence) will directly influence a student’s commitment, motivation, and persistence with transcultural skills. Because interactions may result in “cultural mistakes,” inefficacious students may avoid cultural considerations when planning and implementing care. Overly confident students may never exercise the task of “preparing” to engage in culturally congruent patient interactions, assessments, planning, or interventions.
Students’ cultural values and beliefs (CVB) also influence interactions between patients, families, communities, peers, instructor, and staff members. CVB influence learning, self-efficacy, and motivation for engaging in the ongoing process of cultural competence development. Without appropriate guidance and feedback, students’ TSE perceptions may adversely affect student learning, performance, and outcomes, as well as cause negative effects in patient care and patient outcomes. “Consideration of the student as a whole person demands a culturally congruent approach to advisement and helpfulness” (9) that also must extend into all aspects of the clinical experience and environment (see Table 9.1, Figure 3.2, and Chapter 12). Debrew et al (10) report that Eurocentric expectations in the clinical environment, feelings of isolation experienced by nontraditional students (e.g., older, male, minority, foreign-born, disabled), subtle racism (norms compared to Eurocentric or White norms), lack of awareness about cultural differences and similarities, and mismatched expectations of teacher-student role and communication lead to differences in clinical outcomes, with culturally “different” students or “outsiders” adversely affected.
Initial and ongoing student assessment must include transcultural knowledge, skills, values, and confidence. Nurse educators can develop individual and group diagnostic-prescriptive educational interventions based on assessment findings. Anecdotal notes should include regular entries describing student strengths, weaknesses, and client description (6, 11–15). Often, clinical instructors keep anecdotal notes detailing clinical skills or tasks performed by students and patients’ medical diagnoses. This information is then used to rotate students through various clinical skills, tasks, and medical diagnoses. A proactive action for enhancing cultural competence development expands anecdotal notes to include details about patients’ cultural dimensions and the transcultural skills learned and/or performed by the student.
Clinical instructors have unlimited opportunities to effectively weave in cultural competence development throughout the clinical learning experience. Although some learning experiences may be preplanned, clinical instructors must be prepared to be flexible and to adapt learning objectives to the ever-changing situation. Because the clinical setting is not a “controlled” environment, clinical instructors must always be ready to expect the unexpected. Unexpected situations will present new learning opportunities for students’ professional growth; some of these unexpected situations may be rich opportunities for expanding cultural competence. Despite the cultural diversity within a clinical setting, the instructor is pivotal in guiding students to new levels of cultural competence development. The clinical instructor can supplement actual clinical experiences with case studies representing different cultural groups, values, beliefs, behaviors, and/or practices. A guided postclinical conference whereby students work together or in small groups to critically appraise information and propose a culturally congruent plan of care is another option. Regardless of whether care plans, concept maps, or care maps are the selected strategies to assist in clinical decision making (16), visible inclusion of cultural dimensions of care throughout all phases of the nursing process should be incorporated (and expected) routinely.
TABLE 9.1 Faculty Helpfulness in Nursing Skills Laboratory, Simulation, and Clinical Setting: Examples of Culturally Incongruent and Congruent Approaches
SITUATION | CULTURALLY INCONGRUENT | CULTURALLY CONGRUENT |
Nursing Skills Laboratory: After a detailed skills laboratory class on injections, it is now Lee’s turn to administer an intramuscular injection into the skills laboratory mannequin for the first time. Lee’s cultural values beliefs (CVB) makes her view the teacher as an authority figure. Less than perfect performance would poorly reflect on the teacher and cause embarrassment for the teacher in front of the other students. Lee is fearful that she will not demonstrate the skill perfectly and feels that she must “save face,” yet Lee does not want to refuse the professor’s request to “inject.” Anxiously, she asks if she can first practice with her peers. | Professor wants to help all students equally and aims to “treat all students alike.” Professor insists that Lee administer the injection. Result: Lee feels increasingly anxious and pressured that she must perform the injection perfectly. Additionally, she feels cultural pain because she believes that she initiated conflict with an authority figure. Lee attempts the injection but when she forgets to aspirate, she becomes even more anxious and experiences cultural pain because she has now “embarrassed her teacher.” Lee feels much dissatisfaction and stress; she questions her ability to complete the nursing program. | Professor recognizes that Lee’s anxiety may not be related to lack of academic readiness, but due to underlying CVB. Professor reassures Lee that she does not expect perfection on the first attempt; however, she still notes nonverbal cues of anxiety (facial tension, shaking hands, flushed appearance). Professor pairs Lee with a strong student who has already performed the injection and allows privacy for several practice injections. Result: Lee does not feel pressured to “save face” and can relax enough with her peer to perfect her skill prior to observation by the instructor. After demonstrating the injection to the professor accurately, Lee experiences satisfaction. |
Simulation: Lou’s performance with a standardized patient was the best in the class. She achieved the highest grade. Lou has group orientation rather than individual orientation, and therefore is uncomfortable with individual praise. | Professor intends to be helpful, acknowledge strong performance, and motivate other students. Professor verbally praises Lou’s performance, announcing her name and exceptional performance. Result: Lou is embarrassed and feels ashamed at being singled out in the class. | Professor intends to be helpful and acknowledge strong performance and motivate other students, yet is aware of CVB that impact upon a culturally congruent approach. Professor verbally acknowledges the outstanding performance demonstrated by several students without mentioning their names. Result: Lou feels satisfied and comfortable with the knowledge that her performance and that of others in the group has been appreciated. |
Clinical: During clinical post-conference, one student (Jane) assertively questions the clinical instructor’s statement about a medication. Jane’s CVB openly encourage assertiveness and equally view teachers and learners as co-participants in the teaching–learning process. Several students with different CVB are obviously uncomfortable by the perceived confrontation. | Professor’s CVB consider the preservation of group harmony and “saving face” as a priority. She sees the discomfort of two other students in the group and aims to help the group avoid conflict. Professor’s response is to evade answering Jane’s question and dismiss the post-conference early. Result: Jane is still confused and feels stressed about the medication. She is dissatisfied with the professor’s actions. | Professor recognizes differences between an individual versus group orientation. Although her own CVB are group orientation, Professor realizes that Jane’s behavior is appropriate. Professor answers Jane’s question and uses this opportunity to discuss various differences in communication patterns, values, and beliefs among different cultures. Result: Jane and the other students receive clarification about the statement and receive new information about culture and values clarification, enhancing academic outcomes and promoting positive psychological outcomes. |
Adapted from Jeffreys, M. R. (2004). Nursing student retention: Understanding the process and making a difference. New York, NY: Springer Publishing.
Preplanned learning objectives that incorporate cultural competence development may or may not be shared with students at the onset of the clinical experience. For example, if self-discovery or group learning through discovery is an intended outcome, telling students about the desired outcomes would be inappropriate. Guided discussion and shared information during a clinical postconference can help students discover the diverse patient groups represented that day and how similar or different CVB affected the implementation of culturally congruent nursing care, clinical skills, and actual/potential patient outcomes (see Chapter 2, “Educator-in-Action” vignette). Postconference summary of the student’s cognitive, practical, and affective learning outcomes will be beneficial to future learning activities designed to incorporate this prerequisite learning. Besides comparison of the same clinical skill, other possibilities are cultural similarities and differences between patients with the same signs, symptoms, medical diagnoses, nursing diagnoses, diagnostic procedures, treatments, or prognoses. Positive, realistic instructor feedback and vicarious learning (by observing others) will help improve TSE perceptions. Cultural sensitivity, cultural inclusiveness, and cultural competence must extend to include diverse students in clinical settings (10) (see Table 9.1).
In clinical settings where the clinical instructor is not present (such as home visits or internships), preset learning objectives, including cultural competence, must be clearly delineated. Instructor comments on weekly journal entries, peer comments on course web page discussion boards, and/or postclinical conferences and seminars will further assist students as they connect together experiences in their cultural competence development. E-mentoring has the potential to connect nurses, students, and instructors “to a learning, sharing environment while crossing the barriers of distance, agency isolation, and busy schedules” (17). Asynchronous and/or synchronous postconference discussion (e.g., 24 hours after the clinical experience) via various distance education modalities (online discussion board, wiki, teleconference, Skype, conference call, blog, journal, etc.) can first engage students in individual retrospective reflection-on-action with expansion toward reflection-for-action when encountering future similar clinical situations (18). Reflection is particularly important in the development of values foundational to the nursing profession (6, 12, 19, 20). The sharing of individual reflections and ideas can provide a springboard for further learning and innovation that is intentionally shaped with collaborative contributions, questions, and comments from peers, preceptors, and instructors via an open, caring environment. Such self-reflection and feedback should be shaped to assist students in reaching the expected levels of achievement or competencies within the clinical practicum necessary for professional role development and practice.
Systematic formative and summative evaluations specifically targeting behaviors, knowledge, skills, and values should be detailed, precise, and specific (12). In addition, “legal, ethical, and accreditation mandates demand theoretically-based, valid, comprehensive tools to assess aspects of culturally specific care” (21, p. 88). Until recently, a comprehensive, valid approach for measuring culturally specific care provision, cultural assessments, and the development of culturally sensitive and professionally appropriate attitudes, values, and beliefs within (or as a result of) the clinical practicum experience has been missing in the literature. The Cultural Competence Clinical Evaluation Tool (CCCET) is a user-friendly tool that meets this need. The CCCET can be applied in a variety of ways and for multiple purposes with individual students, including self-evaluation, formative evaluation, and summative evaluation. Data can also be aggregated to guide course and curricular decisions and innovations. (See Chapter 6 for details about the CCCET, Chapter 6 “Educator-in-Action” vignette, Exhibit 6.3, and Jeffreys 2016 Toolkit Items 3–6) (7).
To what extent is cultural competence and cultural diversity emphasized and integrated in clinical experiences within your course? How are they connected to the didactic course, co-requisite, prerequisite, and subsequent courses? What else can be done?
IMMERSION EXPERIENCES AND SERVICE-LEARNING: LOCAL, COMMUNITY, AND INTERNATIONAL
What do you know about the effects of local, community, and international immersion experiences and service-learning on the development of cultural competence? What are the recommended best practices to enhance learning opportunities and optimize cultural competence development?
Positive learning experiences have been reported from immersion experiences, international public health exchange projects, service-learning, study abroad courses, medical missions, and short-term community placements with diverse populations and settings (5, 6, 12, 14, 22–50). International service-learning or international learning opportunities with a specific focus on cultural competence has also been implemented in occupational therapy (51), in physician assistant education (52), in physical therapy (53, 54), and in dentistry (55). The aforementioned terms have sometimes been used interchangeably and the literature often does not accurately distinguish between the various terms; hence, they are included together here. Readers are encouraged to review the literature using various search terms. Although each term is unique and contains specific nuances that distinguish one from the other, several underlying issues and essential elements for successful experiences are common and are presented in the following sections.
Despite the reported benefits, it is crucial that immersion experiences (or service-learning) in cultural communities or international clinical experiences of any length are sufficiently linked with prerequisite and on-site comprehensive learning about the host culture. In addition, experiences should contain sufficient patient-nurse interaction and should be followed up with a reflective component to enhance long-term positive learning impact on students (5, 12, 14, 22–26, 34, 36, 40, 42, 46–48). It’s also important to consider that “increasing cultural competence does not require foreign travel, but it does necessitate that students are challenged to move outside their comfort zone and work directly with diverse populations” (26, p. 175). For example, Bickes and Schim report the positive affective, cognitive, and practical learning outcomes achieved when students are challenged to move outside their comfort zone during short-term cultural immersion experiences involving three 4-day weekend immersions in a nearby Native American community (56). (Also see TSET Research Exhibits 9.1, 9.2, and 9.3 and Exhibit 6.3 [TSET and CCCET comparing domestic and international service-learning experiences].) To effectively move out of one’s comfort zone and yield optimal results, adequate preparation and support during the immersion experience must also incorporate effective coping strategies (39).
TSET RESEARCH EXHIBIT 9.1
Evaluating the Effectiveness of an Immersion Experience on Cultural Competence
Developing and Measuring Cultural Competence in Nursing Students
Rachelle Larsen, PhD, RN, Professor
LuAnn Reif, PhD, RN, Professor
College of St. Benedict/St. John’s University
St. Joseph, MN
Abstract
The purpose of this study was to determine the impact of immersion experiences on nursing students’ transcultural competence. Fourteen baccalaureate nursing students who were participating in a study abroad experience completed the Transcultural Self-Efficacy Tool (TSET) online, 1 week before and immediately following their immersion experiences. Nursing students not participating in a study abroad experience (n = 25) acted as a control group and completed the instrument at the same times. Findings from the study indicate students who participated in an immersion experience had significantly higher post-test transcultural self-efficacy (TSE) scores (p < .001); when compared with the control group, the immersion students had significantly higher post-test scores (p < .001). Data collected from seven student journals revealed four themes: insight into the culture, insight into the migrant journey, how will I explain this experience, and rollercoaster of emotions. Recommendations for faculty include encouraging student participation in immersion experiences to enhance transcultural competence.
Purpose: To determine the impact of immersion experiences on nursing students’ transcultural competence.
Research Report
Research questions:
1. Nursing students who participate in a May-term cultural immersion experience will have increased TSE scores.
2. Nursing students who participate in a May-term cultural immersion experience will have higher change scores when compared with those who do not participate in this experience.
3. What is the relationship of number of cultures interacted with and number of cultural classes taken to pre-test and post-test subscales scores?
Study design: Quasi-experimental nonequivalent control group, cross-sectional
Sample:
Size: 39 junior nursing students: 14 students were in the intervention (immersion group) and 25 were in the control group (those who did not participate in an immersion)
Type of learner: Bachelor of science in nursing SN students
Demographics: Caucasian n = 39, female n = 33, participated in an immersion experience (n = 15). Did not collect age data as all of our students were traditional nursing students between the ages of 20 and 21.
TSET data collection:
Pre-test: Data was collected online prior to the May-term immersion experience.
Post-test: Data was collected online immediately following the immersion experience.
Educational interventions/Teaching–learning strategies: The 14 students participating in an immersion completed a one-credit cultural selective class to prepare for the immersion experience. These students then either spent 2 weeks in El Paso, Texas/Juarez, Mexico or 2½ weeks in South Africa. Both groups of students experienced the culture by living in the communities and providing health care to the population. The control group did not participate in either the classroom preparation or the immersion experience.
TSET Reliability (Cronbach’s alpha):
Total TSET: | 0.994 |
Cognitive Subscale: | 0.982 |
Practical Subscale: | 0.989 |
Affective Subscale: | 0.990 |
Data analysis:
Results question 1: TSE scores increased significantly from pre-test to post-test for nursing students who completed a May-term cultural immersion experience.
TSE scores (n = 14):
Results question 2: Nursing students who participated in a May-term cultural immersion experience had significantly greater positive change scores on each subscale when compared with those students not participating in a May-term cultural immersion experience.
Change scores:
Control (n = 25) Treatment (n = 14)
Results question 3:
• Total number of cultures the students reported interacting with was not correlated with pre-test TSE scores on the Cognitive or Practical Subscale, but was correlated with the Affective Subscale (r = 0.40, p = 0.011). (The more cultures a student reported working with, the greater the pre-test confidence in the student’s cultural values, beliefs, and attitudes.)
• Total number of cultures the students reported interacting with was not correlated with post-test TSE scores on the Cognitive Subscale, but was correlated with the Practical Subscale (r = 0.33, p = 0.042) and Affective Subscale (r = 0.45, p = 0.004). (The more cultures a student reported working with, the greater the post-test confidence in the student’s ability to interview clients of different cultural backgrounds and in his or her cultural values, beliefs, and attitudes.)
• There is no correlation between the number of cultural classes a student completes and TSET pre-test or post-test scores.
Qualitative data analysis of journals completed by seven of the students revealed four themes:
• Insight into the culture
• Insight into the migrant journey
• How this will be explained to someone else
• Rollercoaster of emotions
Curricular implications:
1. Change way of offering cultural education classes to include immersion experiences for all students.
2. Continue collecting data using TSET.
TSET RESEARCH EXHIBIT 9.2
Evaluating the Effectiveness of a Community Health Course and Service-Learning on Students’ Transcultural Self-Efficacy
Assessment of Transcultural Self-Efficacy of Senior Level Nursing Students Enrolled in a Baccalaureate Nursing Program
Roxanne Amerson, PhD, RN, BC, CTN-A, CNE, Associate Professor
Clemson University, Clemson, SC
Abstract
Service-learning introduces students to clients of different cultural backgrounds, facilitates the awareness of issues these clients face related to culture and health care, and provides opportunities to teach culturally appropriate care. The Transcultural Self-Efficacy Tool (TSET) was used to evaluate self-perceived cultural competence in a convenience sample of 60 baccalaureate nursing students enrolled in a community health nursing course following the completion of service-learning projects with local and international communities. Pre- and post-surveys were analyzed based on total scores and subscale (Cognitive, Practical, and Affective) scores. Paired-sample t-tests demonstrated a significant increase between the mean of pre-test and post-test total scores. In addition, paired-sample t-tests demonstrated a significant increase in each subscale. A one-way multivariate analysis of variance (MANOVA) was calculated examining the effect of clinical section on each subscale pre- and post-score. A significant effect was found for the cognitive scores, although no significant effect was found with practical or affective scores, or total scores.
Research Report
Purpose: To evaluate self-perceived cultural competence in a convenience sample of 60 baccalaureate nursing students enrolled in a community health nursing course following the completion of service-learning projects with local and international communities.
Research question: What is the effect of a community health nursing course with a service-learning component on senior students’ perceived confidence for performing general transcultural nursing skills among diverse populations?
Study design: Pre-test and post-test design
Sample:
Size: 60 nursing students
Type of learner: Bachelor of science in nursing students enrolled in a community health nursing course
Demographics: The demographics profile consisted of 56 females, 4 males; 62% = 21 years old; 32% = 22 years old; 6% > 23 years old; 92% White; 5% African American; 2% Asian; 1% Other
TSET data collection:
Pre-test: Data were collected at the beginning of the semester on the first day of class.
Post-test: Data were collected at the end of the semester following completion of service-learning projects with local and international communities.
Educational interventions/Teaching–learning strategies: The study involved a community health nursing course with a service-learning component (local and international communities). Each clinical section worked with a selected subpopulation to conduct a community assessment including windshield surveys, statistical data, and interviews with community leaders. Based on the findings from the assessment, a health education need was identified. Students worked with community leaders to provide health education programs based on the unique needs of the target population. The students worked with local communities over a 7-week period, while the international clinical section worked a very intensive 1 week in remote villages of Guatemala.
Six clinical sections completed service-learning projects with local communities. One additional clinical section completed an international service-learning project. All students enrolled in the course were required to meet the same service-learning objectives, although the specific health education program varied based on the community’s need.
Clinical Group A conducted a community assessment in a local, urban area at the request of a community task force to address the health needs of a predominantly African American neighborhood. Students interviewed community leaders and attended the monthly task force meeting to meet with participants. Articles from nursing literature related to health and diet practices of African Americans were required reading. Statistical data were obtained related to the community to include population trends, education levels, socioeconomic status, religious influences, occupation rates, birth and death rates, morbidity and mortality rates, infectious diseases, health agencies, governmental influences, and recreational facilities. Based on the information gained from statistical data and community informants, a health fair was planned and implemented at a local school for a Saturday morning. The health fair provided screenings for glucose, height/weight and body mass index, and blood pressure. In addition, health education tips to control blood pressure and heart disease along with nutrition information were made available. Students from the university’s nutritional science and public health departments assisted with door prizes and preparing healthy food choices. The health fair was perceived as a success by community leaders, although the number of participants was relatively low. The community leaders requested that nursing students repeat the health fair next year.
Clinical Group B participated in a short-term medical mission trip to Guatemala. Students conducted similar community assessments using statistical data available via the Internet and library resources. Key informant interviews were conducted with members of previous medical missions. The cost of phone calls was prohibitive for interviews with community leaders in Guatemala. The availability of technology remains very limited and sometimes nonexistent in remote regions of Guatemala, so interviews via the Internet were not feasible as well. Students were required to read several articles from nursing and medical literature that explored current health problems in Guatemala. Based on the information obtained, students prepared educational materials to focus on basic hygiene, handwashing, food and water safety, and dental care.
Students collected toothbrushes, soap, and other hygiene products to be distributed during the trip. As part of the preparation for the trip, students participated in introductory sessions of medical Spanish. All of the students had previous experience with high school or college-level Spanish. No student was considered fluent in Spanish. The trip took place over the spring break vacation and consisted of a total of 8 days. Three days were spent in travel via airline and personal vehicles. Four days were spent conducting medical clinics in remote regions, many of which were only accessible by four-wheel drive. Once in-country, students conducted cultural assessments and interviews with community leaders to learn their perceptions of current health problems within their villages. Each clinical day involved setting up a make shift clinic, providing triage, administering deworming medications and vitamins, preparing prescriptions in pharmacy, assisting physicians with procedures, making house calls to people unable to walk to the clinic site, and teaching basic hygiene and dental care. Each clinic day began at 6:00 a.m. and came to a close at approximately 10:00 p.m. An additional day was spent sight-seeing in Antigua. The sight-seeing opportunities included visiting local cathedrals; shopping in a local, native market; touring historical sites; and dinner in a former convent, which has been converted to a restaurant and hotel.
TSET Reliability (Cronbach’s alpha):
Total TSET: Pre-test = 0.974; post-test = 0.986
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
