2. Dissertation
Tracey
Long
2
DEDICATION
This dissertation is dedicated to my supportive husband and family, whose
encouragement and advocacy made the completion of this life goal possible.
I also dedicate this to the many nurses who strive to become culturally competent
in meeting the unique needs of all our patients.
ACKNOWLEDGEMENTS
I wish to acknowledge and express my sincere appreciation to thank Denice Long
and Jason Kelsey for statistical analysis and to Brittany Long for proof reading and
adding her editorial talent. And finally, I wish to thank International Charisma University
for accepting all previously completed graduate work and allowing me to finalize this
doctoral dissertation so that the valuable information expressed therein can be shared
with the world.
3. Dissertation
Tracey
Long
3
ABSTRACT
Assessing the Influence of International Service Learning on Self-Efficacy Toward
Cultural Competence for Associate Degree Nursing Students
Purpose: The purpose of this study was to determine if an international service learning
experience with associate degree student nurses was effective in helping increase self-
efficacy (self-confidence) toward cultural competence.
Methodology: An exploratory study was completed using a mixed-methods approach
using quantitative and qualitative methodology. The quantitative component of the study
utilized the pre-test/post-test design to measure self-efficacy in knowledge and skills in
working with four ethnic groups. The intervention group experienced a two-week
international service learning experience in Belize, Central America and was compared to
a control group of similar nursing students who completed a two-week preceptorship in
the community of the home nursing school. Data were also gathered from self-reflection
journals completed by the nursing students and qualitative post-trip interviews.
Findings: After statistical analysis, data revealed significance between pre and post-
surveys in improvements after the international service-learning trip, compared to the
control group, which showed only mild improvements in self-efficacy towards cultural
competence. Qualitative themes emerged from the reflection journals indicating increases
in feelings of gratitude, recommitments to avoiding prejudices and desire to learn more
about other cultures.
Conclusions: The study data confirm the alternate hypothesis that international service
learning is an effective teaching strategy to increase self-efficacy toward developing
cultural competence for undergraduate associate degree nursing students.
Recommendations: It is advised to continue additional research with repeat studies,
larger sample student populations and with other cultural groups. Results offer
suggestions and considerations to using this pedagogical approach to help undergraduate
nursing students develop cultural competence.
4. Dissertation
Tracey
Long
4
TABLE OF CONTENTS
ABSTRACT …………………………………………………………………………..3
TABLE OF CONTENTS…………………………………………………………...…4
LIST OF APPENDICES………………………...……………………………...……..5
LIST OF TABLES…………….………………………………………………………6
I. INTRODUCTION…………………………………………………………………..7
Background and Context…………………………………………………………..7
Problem Statement……………………………………………...…………………7
Purpose of the Study…………………………………………....…………………7
Significance of the Study………………………………………………………….8
Definition of Terms……………………………………………………………….9
Organization of the Study …………………………………………………...…..12
II. LITERATURE REVIEW……………………………………………………..….14
III. METHODOLOGY………………………………………………………...…….24
Purpose of the Study……………………………………………………………..24
Research Questions………………………………………………………………24
Hypotheses………………………………………………………...……………..25
Research Type and Design……………………………………………………….26
Population……………………………..…………………………………………27
Accessible Population……………………………………………………………28
Sampling…………………………………………………………………………28
Instrumentation……………………………………………………………..……36
Data Collection………………………………………………………………..…37
Data Analysis…………………………………………………………………….38
Validity…………………………………………………………………………..39
Limitations………………………………………………………...……………..39
IV. RESULTS/IMPLICATIONS AND LIMITATIONS …………………………...42
V. DISCUSSION…………………………………..………………………………..57
REFERENCES………………………………………………………………..…65
5. Dissertation
Tracey
Long
5
APPENDICES
Name
Page
APPENDIX A: Study Participant Form 78
APPENDIX B: Belize Journal Self-Reflection Questions 79
APPENDIX C: Community Health Assessment Form 81
APPENDIX D: Belize Trip Schedule 83
APPENDIX E: Informed Consent Release 84
APPENDIX F: Self-Efficacy Scale Instrument 85
6. Dissertation
Tracey
Long
6
LIST
OF
TABLES
Name
Page
Table
1.
List
of
Common
Teaching
Strategies
for
Cultural
Competence
19
Table
2.
Control
Group
Demographics 30
Table
3.
Intervention Group Demographics 33
Table
4.
Qualitative
Themes
in
Intervention
Group
45
Table
5.
Qualitative
Themes
in
Control
Group
46
Table
6.
Four
Shared
Themes
from
Reflective
Journals
47
7. Dissertation
Tracey
Long
7
I. INTRODUCTION
Background and Context
Providing culturally competent care to a diverse population is a necessary and
mandated goal for nurses in the United States. Nursing students must receive instruction
in cultural diversity during their undergraduate curricula. Various teaching strategies have
not been compared adequately to determine how best to prepare nursing students to work
effectively with a growing diverse population in the United States. Empirical evidence is
needed to measure the effectiveness of various teaching strategies for cultural
competence among undergraduate nursing students.
Problem Statement
The problem being addressed in this study is the lack of empirical evidence of using
international service learning as an effective strategy to teach cultural competence to
undergraduate nursing students. The scope of this study is to evaluate the influence of
international service learning (ISL) on self-efficacy (self confidence) of undergraduate
nursing students in an associate degree program toward the development of cultural
competence. Providing culturally competent care to a diverse population is a necessary goal for
new graduates of nursing school.
The Purpose of the Study
After identifying international service learning as a possible strategy towards
teaching cultural competence, empirical evidence to measure its effectiveness was
pursued. The study, which is the focus of this dissertation, presents an original qualitative
8. Dissertation
Tracey
Long
8
and quantitative intervention study of a two-week immersion medical experience with
undergraduate ADN nursing students. Empirical data from surveys and
phenomenological themes was collected and analysed to measure international service
learning (ISL) as an effective teaching strategy for cultural competence training. A
summary of what has been achieved will be identified. After the collection and analysis
of data there was a statistically significant and positive improvement in self-efficacy
scores (self-confidence) of nursing students who experienced a two-week ISL experience
in Belize, Central America. The general conclusion is that using ISL as a teaching
strategy toward developing cultural competence is a valid teaching strategy for nursing
instructors.
Significance of the Study
The value of this study is to assess and evaluate the outcomes of using ISL as an
effective teaching strategy to develop cultural competence. The significance of the study
is the value for both nursing educators and students to know if this learning strategy is
effective or not. If the ISL experience produces positive outcomes towards developing
cultural competence, it can be included in nursing school curricula as an option for those
interested in it. If it is not effective, then the added expense and required time to organize
international trips may not be worth it. Nursing educators seek empirical data to make
such decisions for their schools. This study seeks to present empirical data on which to
base curriculum decisions for nursing instructors looking for methods to effectively teach
cultural competence to nursing students.
The results did conclude ISL as an effective strategy to improve self-confidence in
nursing students towards working with populations different from their own. Knowing
9. Dissertation
Tracey
Long
9
this is an effective teaching strategy will allow nursing instructors to consider its
inclusion in nursing curricula. Students seeking to increase their knowledge, skills and
self-confidence in working with diverse populations can use the ISL experience as a
learning tool.
Definition of Terms
The terms to be identified in this study will include culture, cultural competence,
associate degree nursing student, international service learning and self-efficacy.
Defining what the training consists of begins with clarity of the definition of cultural
competence itself. The Office of Minority Health assists practitioners and educators in
the charge to practice with more cultural competence by defining cultural and linguistic
competence as “a set of congruent behaviors, attitudes and policies that come together in
a system, agency, or among professionals that enables effective work in cross-cultural
situations” (HRSA, 2001).
In the broadest sense, culture is defined as the attributes, language, physical
characteristics, values or behaviors that a group identifies as its own. Culture has also
been defined as that which helps individuals adapt to their environments (Clinton, 1996).
Subcultures beyond race and ethnic groups must also be included such as those who
identify themselves with alternative sexual identities as homosexuals, transgender and
lesbians. Factors such as language, religion, marital status, gender identity, definitions of
health and illness, use of complementary and alternative medicines, food preferences,
socioeconomic status and education all create culture for an individual. Understanding
how all these factors affect a person’s preference and use of medical care is a foundation
of providing culturally competent nursing care.
10. Dissertation
Tracey
Long
10
Specific definitions for culture competence vary among nurse theorists, but
theorists do generally agree on several components including cultural awareness and
respect. Often the terms “cultural awareness” and “sensitivity” are used interchangeably;
however, they are separate components within the definition of cultural competence.
Awareness is being conscious of differences among people partly because of their
cultural backgrounds, and sensitivity is valuing and respecting those differences (Clinton,
1996). “Culturally competent individuals are not only aware of differences in people
based on knowledge of their cultures but respect individuals from different cultures and
value diversity” (Rew, et al 2003). Cultural competence is more than just being kind to
someone of a different culture; however, it is also working with a person within their own
community to validate, collaborate and meet the unique needs of others.
Cultural competence has been defined by various authorities within the nursing
field. The American Academy of Nursing defined cultural competence as “a complex
integration of knowledge, attitudes, and skills that enhances cross-cultural
communication and appropriate effective interactions with others” (Lenburg, et al.,
1995). Developing cultural competence is a process that combines four constructs:
cultural awareness (affective domain), cultural sensitivity (attitudinal domain), cultural
knowledge (cognitive domain) and cultural skills of interpersonal communication and
behavior (psychomotor/behavioral domain), (Lester, 1998, Campinha-Bacote, 1999). In
addition, the construct of self-efficacy or self-confidence, towards developing cultural
competence must be considered.
The term associate-degree nursing student (ADN) is a nursing student who is
enrolled in an associate degree registered nurse program in college. The population used
11. Dissertation
Tracey
Long
11
in this study included full time ADN nursing students enrolled or just graduated from a
community college. An Associate Degree in nursing requires at least two years of a
college level Nursing program beyond the completion of two years of required pre-
requisites. Several studies have been completed measuring cultural competence for
Baccalaureate nursing students (BSN), but none have explored measuring cultural
competence for ADN nursing students using international service learning.
The term international service learning is a term associated with volunteer travel
abroad by students to countries outside their own that allow students to engage with their
host country in community service activities. International service learning may or may
not include college credit but does expand the typical classroom to global education in a
lived immersion setting. The students who traveled to Belize did not receive college
credit, but did receive approved continuing education credits. The organization that the
nursing students in this study traveled with was called International Service Learning,
http://www.islonline.org and organized the infrastructure for the trip, including travel,
lodging, food, networking with community leaders, providing some medications for the
medical clinics and coordination with the local physicians who would work in the
volunteer medical clinics.
The definition of international service learning is a general term used to identify
the learning setting is outside the United States and the focus of learning is provided
through community service engagement by the students. A study abroad is different from
international service learning in that students who travel abroad to study may not be
providing any service, whereas, those on an ISL trip gain their clinical experience
primarily through their service activities. Both a study abroad trip and ISL experience
12. Dissertation
Tracey
Long
12
may vary in length. The students who completed this ISL trip completed two weeks in the
host country and paid for it completely on their own.
The term self-efficacy refers to self-confidence. It is defined as a person’s belief
about their capabilities, which allow them to perform desired activities (Bandura, 1994).
One way of developing self-beliefs, or confidence is through experiences, which bring
success and practice in skill development. Much research exists regarding the cognitive
processes of strengthening self-efficacy and its effects. Cognitive and motivational
processes are involved in strengthening a person’s self-confidence towards skill
development. Measuring self-efficacy towards skill development is one way to measure
the development towards mastery of the skill itself (Schunk, 1989).
Organization of the Study
This original qualitative and quantitative study used the intervention of a two-week
international immersion medical service experience for undergraduate associate degree
(ADN) nursing students to evaluate the teaching strategy of international service learning
towards cultural competence.
The study is quasi-experimental involving the comparison of two equal groups.
The intervention group traveled to Belize, Central America, and the second group served
as a control group, and worked in a local U.S. hospital without additional training in
cultural competence other than the usual random interaction with patients from diverse
backgrounds from the community coming to the hospital. The time period for both
groups was equally two weeks. The intervention group received cultural competence
instruction while they practiced their knowledge and skills working in community and
clinic settings in various rural communities of Belize. The control group received no
13. Dissertation
Tracey
Long
13
additional instruction in cultural competence but worked in a two-week preceptorship in a
hospital setting in their home community of Las Vegas, which is quite diverse.
It was also a mixed-methods study combining qualitative data from pre and post
intervention surveys and qualitative data received from self-reflection journals written by
the nursing students throughout the two-week experience. Both the control and
intervention groups completed both surveys and journals.
14. Dissertation
Tracey
Long
14
II. LITERATURE REVIEW
Background of the Study: The Problem of Ethnic Disparities in Health Care
For decades, experts have documented racial and ethnic disparities in health care and
acknowledged the complex and contributing factors to substandard health care for ethnic
minorities. (Betancourt, 2003; Rust, 2006; Institute of Medicine 2002). Poor patient
outcomes occur when there is a lack of culturally competent care from the health care
provider (Institute of Medicine, 2002; Smedley, 2003). Factors, which impact the quality
of care provided include language barriers, food preferences, cultural beliefs that impact
health care practices, and physical variations among ethnic groups which may alter
correct physical assessments or pharmacological effects.
In addition to the problem of racial disparities in health care is the problem that nurses
who are not well trained to be culturally competent often do not correctly or adequately
assess or address the unique needs and preferences of ethnic minorities. If a nurse is
untrained in assessing, evaluating and adjusting care plans to meet these unique needs,
nursing care and treatment may be compromised. Numerous anecdotal evidences have
been shared in interviews reflecting that the non-English speaking patient had a delay in
receiving needed care such as an incentive spirometer, patient education, physical therapy
and even meals due to language barriers.
Many nurses state that they feel inadequate and uncomfortable in providing culturally
appropriate and sensitive care to clients of an ethnicity different from their own, which
may compound the problem of disparate care for minorities (McHenry, 2007). Research
findings report that students graduating from baccalaureate programs do not feel prepared
15. Dissertation
Tracey
Long
15
to work in a multicultural society (Bernal & Froman, 1987; Blair, 1988; Kulwicki &
Boloink, 1996; Bond, 2001). Based on this research, educators must be aware that many
nursing students have not had adequate training and preparation in the field of cultural
competence during nursing school.
The Proposed Solution of Cultural Competence Training
In response to the concern of increasing diversity that nurses must work with in
their patients, the field of transcultural nursing in health care has emerged over the past
several decades. Policy makers, insurance providers, health care providers, nurse
theorists, researchers, educators and accrediting boards have each made efforts to address
the issues of providing health care that meets needs as diverse as the population,
especially as demographic projections declare a future of larger ethnic diversity in the
United States (Synovate, 2010; US Census, 2010; Wells, 2000).
Cultural competence training therefore has become a strongly proposed solution
to decrease ethnic health disparities. A major goal of the Health Resources and Services
Administration is to use cultural competence training to improve the quality of health
care for diverse populations and add value to managed care (HRSA, 2001, 2003).
Cultural competence training for allied health care workers, nurses, physicians and other
health professions has demonstrated positive results with improvements in attitude,
communication skills and behaviors (Campinha-Bacote, 2003). Culturally appropriate
interventions and care result in positive health outcomes for patients from any cultural
background and have become a mandated component in nursing education (Cooper-
Brathwaite, 2005). Most hospitals now acknowledge the mandate from the Joint
Commission to improve communication between health care providers and patients to
16. Dissertation
Tracey
Long
16
minimize errors. Nursing students also need training to be in alignment with improved
communication with all patients.
Theoretical Frameworks
The theoretical foundations of the study outlined in this dissertation are based on
Badura’s Social Cognitive Theory, which includes the construct of self-efficacy towards
cultural competence and Transcultural Nursing. Bandura’s Social Cognitive Theory
posits that learning and motivation are directly related to perceptions of confidence
(Bandura, 1994). The framework identifies self confidence is needed to successfully
perform any skills. Transcultural Nursing posits that knowledge of cultural concepts and
cultural variables are also needed to give effective nursing care. Leininger’s theory of
transcultural nursing also served as a foundational premise that nursing students can learn
cultural concepts to change and improve nursing care towards patients different from
themselves (Leininger, 1995). The field of transcultural nursing declares that effective
nursing care must be based on the nurse’s ability to effectively communicate and deliver
customized care to the unique needs of the patient. The inclusion of cultural competence
training for nursing students began by Dr. Leininger in the 1970s even before the
common term was derived.
There is a need for cultural diversity training for nursing students. The rapidly
changing and diverse demographics in the United States require nurses to be culturally
aware, sensitive, knowledgeable and self confident in providing culturally competent
nursing care. Providing culturally competent nursing care begins with the preparation and
effective training of student nurses. Multiple curricular approaches are being used to
teach cultural competence to undergraduate nursing students in the United States in
17. Dissertation
Tracey
Long
17
accordance with mandates to include cultural diversity training by accrediting board
standards (AACN, 2008).
As nurse educators are searching for evidence-based teaching practices, research
is needed to determine the effectiveness of various teaching strategies for the topic of
cultural competence (Long, 2012). Nurse educators must actively seek out, evaluate and
implement strategies to develop culturally competent practitioners. In the era of evidence-
based practice, all clinical practice including teaching strategies requires current research
to validate the effectiveness of the variety of teaching methods being used to teach
cultural competence topics to nursing students (Kardong, 2008). Strategies currently
include traditional lectures, readings, oral reports, group discussions, simulation and role
playing, which are all learning experiences constructed by a hopefully culturally
competent nursing instructor. A less controllable teaching method is relying on the
chance encounter with a patient in a clinical setting who may be of a different ethnicity
than the nursing student.
Pedagogical Approaches to Teaching Cultural Competence
The objective of increasing the number of nurses who are culturally competent
must begin with nursing education at the student nurse level (Wells, 2000). Since 1986,
teaching cultural competence in the delivery of nursing care is an expectation of
accreditation and approval boards for schools of nursing including the American
Association of Colleges of Nursing (AACN), the American Nurses Association (ANA,
1991), the National League for Nursing (NLN, 2005), the American Nurses
Credentialing Center, (ANCC, 2008) and the Joint Commission of Accreditation, (JCA,
2009). In compliance with these national requirements, most nursing schools in the
18. Dissertation
Tracey
Long
18
United States include some reference in their curriculum to their goal of preparing a
culturally competent graduate.
To further assist nurses and educators, two main guides for curriculum
development are the “Culturally Competent Nursing Modules” from the Office of
Minority Health and “Transforming the Face of Health Professions Through Cultural and
Linguistic Competence Education” from the United States Department of Health
Resources and Services Administration. Although much has been discussed about
cultural competence as nursing educators share ideas for incorporating the topic within
the curriculum, it is left to each school of nursing to choose the definition and methods to
teach students about cultural competence as well as how to evaluate that learning. A
variety of teaching and evaluation strategies are being used with only scant research to
determine the most effective methods. Traditionally, lecture and evaluation of learning
through written testing of cognitive facts about ethnic groups in the United States have
been used as the most common teaching and evaluation methods.
The following table outlines a sample of the major teaching methods in use
throughout the United States to teach cultural competence to undergraduate nursing
students. Teaching strategies and outcomes of faculty training are not explored in this
review. The
table
below
summarizes
the
main
teaching
strategies
being
used
by
nursing
schools
to
teach
cultural
competence
topics,
as
found
in
the
literature
of
published
studies.
Key
studies
are
listed,
which
have
explored
the
identified
teaching
strategy.
Advantages
and
disadvantages
of
the
strategy
are
identified
and
any
outcomes
discovered
from
the
study
are
presented.
The
methodology
of
the
study
is
also
listed.
It
is
noted
that
all
studies
have
been
qualitative
and
generally
19. Dissertation
Tracey
Long
19
phenomenological;
it
was
therefore
important
to
include
quantitative
data
in
this
study.
Table
1
Teaching
Strategies
for
Cultural
Competence
for
Undergraduate
Nursing
Students
Teaching
Strategy
Study
Advantages
Disadvantages
Outcomes
Methodology
Assigned
Readings/Module
Lee
(2006)
Knowledge
based
Limited
to
stereotyping
Improveme
nt
in
knowledge
of
selected
health
beliefs
and
practices
Descriptive
qualitative
Clinical
Experience
Chrisman
&
Maretzki
(1982)
Trotter
(1998)
Kardong
(2005)
Real
life
experience
Limited
to
availability
in
clinical
setting
Comfort
in
caring
for
patients
from
diverse
cultures
increased
after
repeated
exposures
to
persons
from
other
cultures.
Descriptive
qualitative
Educational
Partnerships
Jacobs
(2003)
Real
life
experiences
Collaborati
on
within
communit
y
Limited
to
availability
Coordination
required
for
contacts
Improveme
nts
in
attitude
toward
ethnic
groups
Qualitative
reports
Group
Discussion
Zuzelo
(2010)
Interactive
Distractions
from
on-‐task
discussion
Students
desire
a
reflective
communicat
ion
process
to
exchange
ideas
and
build
on
each
other’s
thoughts.
Focus
group
20. Dissertation
Tracey
Long
20
Pedagogy of Cultural Competence in Nursing Education
Based
on
the
foundation
of
traditional
learning
theory,
nurse
educators
have
historically
presented
nursing
didactic
topics
in
their
curriculum
through
lecture
and
readings.
Overall,
a
nursing
school
curriculum
includes
didactic,
laboratory
and
clinical
settings.
Whereas
the
standard
teaching
strategy
for
didactic
topics
is
lecture,
laboratory-‐learning
experiences
have
been
more
“hands-‐on.
”
Students
learn
nursing
skills
first
in
a
safe
laboratory
environment,
and
then
demonstrate
competency
before
they
are
allowed
to
perform
them
in
the
clinical
setting
with
live
patients.
Historically
the
topic
of
cultural
competence
has
been
included
in
lecture
and
reading
format.
With
the
emphasis
on
adult
learning
theory
and
active
learning
principles,
newer
strategies
are
being
included.
Newer
strategies
include
group
discussions,
simulations
and
guided
clinical
selection
of
diverse
patients.
The conclusion, after a systematic review of educational strategies, is that
comparing educational content and programs of varying length in a randomized
controlled fashion would be hugely valuable for educators (Beach, 2005).
Literature Review of Cultural Competence Training
According to the U.S. Census Bureau from 2010, 38% of the American
population consists of persons from ethnic, non-white backgrounds and provides insights
to our racially and ethnically diverse nation. Between the years 2000 and 2010, more than
half of the growth in the total population of the United States was due to the increase in
the Hispanic population (2010 Census). Statistics demonstrate that health care disparities
exist among ethnic and racial groups (AHRQ, 2004). Cultural competency has been
21. Dissertation
Tracey
Long
21
proposed as an effective solution to help reduce health and medical care disparities
(Drevdahl, Canales & Dorcy, 2008, Giger et al., 2007).
As nursing schools comply with regulating agencies to include cultural
competence training in their curriculum, research is lacking in determining which
teaching strategies can increase a student’s measurable cultural competence and
confidence to deal with ethnic and cultural diversity in their nursing care. Traditional
teaching practices of lecture and readings alone are not sufficient to prepare a nursing
workforce that can appropriately respond to the diversity of people’s needs, cultural
preferences and language (Campesino, 2008, Sianz, 2007, Long 2012).
Factors that make up cultural competence include self-awareness, desire,
sensitivity, knowledge and lived real experience with cultures different from one’s own
(Hughes and Hood, 2007; Camphina-Bacote, Jeffreys, 2006). Self-efficacy, or the belief
that one can succeed in performing a desired skill, is needed in order to practice cultural
competence and therefore becomes the link between knowledge and actual success in a
task (Coffman et al., 2004). Factors that affect levels of cultural self-efficacy and
confidence include learning a foreign language, traveling to a foreign country or gaining
previous cultural competence training (Coffman, et al., 2004). Newly graduated nurses
who have gained some cultural competence training, and especially those that have lived
experiences rather than merely listening to a lecture or readings in a textbook, state they
have higher levels of confidence when working with diverse populations (Reeves, 2006,
Hunt, 2007). Travel study programs for nursing students therefore have been proposed as
strategies to help foster cultural competence and their self-efficacy for practicing with
diverse cultures (Bentley, R et al 2007, Fitzpatrick, 2007).
22. Dissertation
Tracey
Long
22
Summary of Literature Review on Study Abroad Trips for Nursing Students
One method of gaining knowledge, skills and experience with different
cultures is through an international immersion experience with training in language,
culture and community nursing. Research studies of nursing students who have a study
abroad experience show students increase in self-awareness, self-confidence and life
experience in dealing with cultures different from their own (Foronda, 2009; Larson,
2010; Wiegerink-Roe, et al, 2008)). This research attempts to demonstrate and provide
evidence of the value of an international service learning activity as an effective teaching
strategy to increase self-efficacy in the pursuit of cultural competence for nursing
students.
Study abroad programs have been used in the United States in undergraduate
programs to help foster cultural competence for students in many fields of study
(Fairchild, Pillai, & Noble, 2006, Levine, 2006). However, immersion programs are
rarely included in the community college curricula due to prohibitive cost, unprepared
faculty and lack of time in the curriculum; therefore used even less for Associate degree
nursing (ADN) students. Graduates of ADN programs represent 60% of entry-level
graduates annually and make up 45% of the RN workforce (U.S. Department of Health
and Human Services, Health Resources and Services Administration, 2013, Mahaffey,
2002). There is paucity of research examining cultural competence training for ADN
nursing students in a study abroad experience. Research shows significant positive results
are gained in self-efficacy in cultural competence even through short study abroad trips
from two weeks to several months (Caffrey, 2005).
23. Dissertation
Tracey
Long
23
The study in this dissertation uses the service-learning model as a specific type of
study abroad experience. Not only would the students be learning about other cultures
through didactic instruction including lecture and readings, but they would have hands-on
clinical experience in community visits and medical clinics as a “living laboratory.” This
framework follows the experiential learning theory, which claims strength in an active
learning and physical environment to enhance retention of material and stronger
emotional connections with the material being learned.
24. Dissertation
Tracey
Long
24
III. METHODOLOGY
Purpose of the Study
This study seeks to compare and contrast the most commonly used teaching
strategies for cultural competence training in undergraduate nursing programs. After
identifying international service learning as a highly effective strategy towards
developing cultural competence, this dissertation presents an original qualitative and
quantitative intervention study of a two-week immersion medical experience with
undergraduate ADN nursing students. Empirical data and phenomenological themes
were collected and analysed to measure international service learning as an effective
teaching strategy for cultural competence training.
The objectives of the study were to:
1) Measure the cultural competence and self-efficacy level of nursing students in the pre-
intervention experience phase.
2) Compare pre-intervention scores to the post-intervention scores.
3) Evaluate the effectiveness of an international service learning experience as a teaching
strategy in strengthening self-efficacy towards developing cultural competence.
4) Identify the phenomenological themes of student nurses in an international service
learning medical experience.
5) Compare the intervention group with a control group of ADN nursing students.
25. Dissertation
Tracey
Long
25
Research Questions
1) How does service learning in an international country affect self-efficacy toward the
development of cultural competence in undergraduate ADN nursing students?
2) How do ADN nursing students value a medical international service learning
experience towards gaining skills in cultural competence?
3) How do ADN students in different semesters compare between each other in self-
efficacy in developing cultural competence?
4) Is there a difference in self-efficacy among ADN students towards cultural competence
who have had prior language or international travel experience?
5) How does the control group compare in self-efficacy towards cultural competence
compared to the intervention group?
Hypotheses
Null hypothesis 1: A two-week international service learning medical trip does not affect
an increase in self-efficacy of cultural competence scores for undergraduate nursing
students.
Null hypothesis 2: There is no difference between the control and intervention group in
post intervention self-efficacy scores.
Alternate hypothesis: There is a difference in self-efficacy scores from the pre and post-
intervention surveys after a two-week international service learning medical experience
for undergraduate associate degree nursing students.
26. Dissertation
Tracey
Long
26
Research Type and Design
The intervention for the control group included a two-week service learning
medical experience in Belize, Central America during the summer and include a total of
18 formal classroom style instructional hours taught by staff and the nursing faculty in
the topics of Medical Spanish, Cultural Competence, Folk Medicine, Tropical Diseases,
Mayan Medicine, Assessment and Triage, and Community Health Nursing. Forty-five
hours of structured volunteer service learning were rendered in three remote villages
including one hospital day of shadowing local nurses. Two bilingual native physicians
accompanied the nursing students during the medical clinics and helped teach the
students about tropical diseases and differential diagnostics during the clinics and
evening presentations.
The location for the control group was in Las Vegas, Nevada in the same
community and hospital where the students had previously completed their clinical
rotations. There was no change in their housing, transportation or food compared to any
other semester in their home community.
For the control group, the two-week international service learning medical trip
occurred in the country of Belize, Central America in the district of Orange Walk.
Students travelled to three communities whose populations were generally about 300
people in very rural settings. The three communities were August Pine Ridge, San Felipe
and Carmelita. Most families did not have running water or public sewer systems and
cooked with wood or coal inside their wooden-walled homes. The students were housed
in a local hotel with running water and electricity and even Internet access. They ate the
local food prepared by native women. They were transported one hour away together by
27. Dissertation
Tracey
Long
27
a local and poorly air-conditioned bus and after arriving in each rural village they walked
to the various homes on dirt roads to complete the home and family health assessments.
The theoretical foundation of the study is based on Badura’s Social Cognitive
Theory, which includes the construct of self-efficacy towards cultural competence.
Bandura’s Social Cognitive Theory published in1994 posits that learning and motivation
are directly related to perceptions of confidence. The framework identifies knowledge of
cultural concepts, knowledge of cultural variables and self-confidence as requirements to
perform certain nursing skills. Leininger’s theory of transcultural nursing also served as
a foundational premise that nursing students can learn cultural concepts to change and
improve nursing care towards patients different from themselves (Leininger, 1995).
Population
The population of interest in this study is undergraduate nursing students in the
United States. Nursing educators seek empirically based research on effective teaching
strategies for the nursing students. It has been mandated and required to include cultural
competence training within the undergraduate Nursing curriculum, as nurses must have
the knowledge and skills to work with a diverse population in the United States. A
smaller convenience sample from the larger population of nursing students was desired
for the advantages of feasibility, ease in working with a smaller population and decrease
expense of the study.
Accessible Population
The accessible population was chosen from over 400 undergraduate associate
degree Nursing students from the Southwestern region of Nevada in Las Vegas,
Nevada during Spring 2014. The sample population became self-selected as only
28. Dissertation
Tracey
Long
28
those who were interested in traveling internationally or who could afford it pursued
the opportunity to be a part of the intervention group study.
Sampling
The sample population was randomly self-selected from a pool of approximately 400
undergraduate nursing students in an associate degree-nursing program from Las Vegas,
Nevada. All study participants came from a school of nursing where the principle
investigator is full-time faculty. In early spring, after a presentation to the student nurses
association and through flyers placed in all student mail boxes, all students were invited
to participate in an international service learning experience for that upcoming summer.
Students were invited to contact the faculty for additional information about the trip
including cost, funding and the proposed agenda. Once the intervention group was
complete with a total of 20 participants, which included two faculty members, the group
was closed.
Later in spring, a control group was invited to participate. The control group was
created after a presentation was given to all last semester nursing students before they
were to begin their final preceptorship. Eighteen students approached the faculty with
interest and were given instructions about the study and the needed forms including the
demographics form and pre-survey. The faculty had contact with all control group and
intervention group participants.
The study was conducted with a convenience population of student nurses seeking
an Associate Degree (ADN) from the College of Southern Nevada in Las Vegas, Nevada
in 2013. The total number of participants included a control group of 18 nursing students
29. Dissertation
Tracey
Long
29
and an intervention group of 18 nursing students from the same nursing school and
program.
Control Group:
The control group originally consisted of 18 ADN students from the same college
nursing program but was reduced to 11 students who completed both surveys and the
self-reflection journals. The control group consisted of fourth semester nursing students
who had completed all the required didactic and clinical experiences together. Attempts
were made so that the control group was ideally matched to the intervention group;
however, several variations occurred. Only 11 students in the control group could be
included in the final analysis because only 11 completed the pre-survey and post-survey,
compared to 17 students in the intervention group. The intervention group had three
males, whereas the intervention group had none. All students in the control group were
last semester nursing students, compared to the intervention group, which only had six
nursing students who had completed their full four semesters. The intervention group had
more variety in the completed training level of nursing students because participants were
at various levels in the ADN nursing program, having completed first, second, third or
fourth semesters of a four semester program. All participants in the control and
intervention group had previously completed all the prerequisite courses before entering
nursing school.
The control group was chosen randomly among all fourth semester nursing students by
random assignment to the principal investigator’s clinical teaching pool. No control
group participants were graded or paid to complete the research project, but they were
given a gift card upon completion of the two surveys and 10 journal entries. Both the
30. Dissertation
Tracey
Long
30
control and intervention group participants were given information regarding the nature
of the study and signed the Institutional Review Board forms, including the voluntary
informed consent process and release of liability for the principal investigator. The
following table displays the demographics of the control group.
Table 2 Control Group Demographics
AGE Ethnicity Gender Prior CC
Training
Prior
Travel
Abroad
Prior
Language
Training
> 50: 1 Caucasian:1
Latino:0
Pacific
Islander: 0
African
American:0
Native
American: 0
Male: 1
Female: 0
Yes: 0
No: 1
Yes:1
No:0
Spanish:0
French:0
German:0
Italian:0
None: 1
40-49: 1 C:1
L:0
PI:0
AA:0
NA:0
Male:0
Female: 1
Yes: 0
No:1
Yes:1
No:1
Spanish:0
French:0
German:0
Italian:0
Japanese:0
None: 1
30-39: 3 C:1
L:0
PI:0
AA:2
NA:0
Male: 0
Female: 3
Yes: 2
No:1
Yes:0
No:3
Spanish:0
French:l
(creole
native)
German:0
Italian:0
Japanese: 0
None:2
20-29: 6 C:1
L:0
PI:5 (All
Filipino)
AA:0
NA:0
Male:1
Female: 5
Yes: 6
No:0
Yes:4
No:2
Spanish:0
French:0
German:0
Italian:0
None:2
English: 4
to learn
English
31. Dissertation
Tracey
Long
31
Age
The mean age of the control group was 31 compared to the mean age of 25 of the
intervention group.
Ethnicity
The key for the table for ethnicities is C=Caucasian (non-Hispanic White),
L=Latino, PI= Pacific Islander, AA= African American and NA= Native American.
Participants were asked what ethnicity they most identified with. Two were African
American, four were Caucasian (non-Hispanic white) and the majority of five were
Asian/Filipino. The control group also had two participants who identified as African
Americans, 14 who were Caucasians, 1 who identified as Hispanic/Latino, and one
Asian/Filipino. The majority of the control group was Caucasians.
Gender
Of the 11 participants in the control group, only three were male. There were no
males in the intervention group.
Prior Cultural Competence Training
All control group participants had received the exact prior education on the topic
of cultural competence throughout their nursing program. This was mostly provided
during their first semester. Similarly all intervention group participants received at least
one lecture since they all had completed at least the first semester of nursing school.
Disturbingly, three of the 11 students in the control group stated they had not received
any prior cultural competence training yet they all completed the same curriculum. Three
students in the control group checked both yes and no for prior cultural competence
training indicating confusion on the question itself, which gives rise to their confidence in
32. Dissertation
Tracey
Long
32
even knowing that term. The !"#$%#!&' investigator was aware of the fact that it is a
mandatory component of their first semester in the form of at least one lecture. All the
control group students who marked yes to having received prior training in cultural
competence stated that it was in the form of lecture and reading. This raises serious
concern to the effectiveness of the lecture and reading teaching strategies when three of
their same group claimed to not have received this training.
Prior International Travel
Five of the control group participants claimed to have had prior international
travel, which included two foreign-born students. Other than the non-native born
students, those who traveled internationally stated they traveled as tourists for only two or
less weeks.
Prior Foreign Language Training
None of the control group participants had foreign language courses before this
study except for four students who were born in different countries and then came to the
United States as children of immigrants. They were both fluent in English but spoke
Creole and Tagalog as those languages were spoken in their homes. Only two claimed to
have foreign travel, although neither of them traveled back to their birth country after
immigrating to the United States.
Location
The location for the control group was in their hometown of Las Vegas, Nevada.
Their two-week experience for data collection included the required ten 12-hour shifts
(120 hours) of their final preceptorship before their graduation. They all worked at the
33. Dissertation
Tracey
Long
33
same acute care hospital but in various units and shifts including in the Emergency
Department, ICU, IMC and Medical/Surgical departments.
They completed the pre-survey before they began their first shift and then
completed the post-survey at the end of their final tenth shift after two weeks. They also
turned in a daily self-reflection journal electronically via email to the instructor/principal
investigator to answer questions about how they assessed and delivered culturally
appropriate care to their hospitalized patients. They were to write what they learned and
how they felt about each clinical experience, just as the intervention group did in Belize
over two weeks.
Intervention Group:
The 17 students in the intervention group volunteered to participate in a 14-day
international service learning medical trip with a non-profit organization, International
Service Learning, to the Central American country Belize. The participants represented a
cross section synonymous with enrollment demographics for the same school of nursing.
The intervention students were self-selected by those willing to volunteer and pay for a
two-week service learning experience in Belize.
Table 3 Intervention Group Demographics
AGE Ethnicity Gender Prior CC
Training
Prior
Travel
Abroad
Prior
Language
Training
> 50: 3 Caucasian:3
Latino:0
Pacific
Islander: 0
African
American:0
Native
Male: 1
Female: 2
Yes: 2
No: 1
Yes:3
No:0
Spanish:1
French:l
German:0
Italian:0
None: 1
34. Dissertation
Tracey
Long
34
American: 0
40-49: 2 C:1
L:0
PI:0
AA:1
NA:0
Female: 2 Yes: 2
No:0
Yes:1
No:1
Spanish:l
French:0
German:0
Italian:0
Japanese:l
None: 1
30-39: 2 C:2
L:0
PI:0
AA:0
NA:1
Female: 2 Yes: 1
No:1
Yes:2
No:0
Spanish:0
French:l
German:0
Italian:0
Japanese: 1
None:l
20-29: 12 C:8
L:1
PI:1
AA:2
NA:1
Female: 12 Yes: 9
No:2
Yes:7
No:5
Spanish:5
French:2
German:0
Italian:1
None: 5
Age
The mean age of the intervention sample was 25.5.
Ethnicity
The participants primarily self-identified as White (60%). Two identified as
African American, one was Asian (Filipino) and one was Latino.
Gender
All 17 participants were female and included six new graduates of an ADN
nursing program and one pre-law nursing student, who was the sister of a new graduate
of the nursing program. Anecdotally, at the end of the trip the pre-law student said she
was going to change her major from pre-law to nursing because she loved the experience
so much.
Prior Cultural Competence Training
35. Dissertation
Tracey
Long
35
Because the group of students represented various completion ranges from first
semester to new graduates, their background training varied. Fourteen students claimed to
have received prior cultural competence training that included lecture, readings or
simulation. Four participants claimed they never received cultural competence training;
however, all nursing students came from the same nursing program, which includes some
reading and one lecture their first semester. This contradiction raises the question of the
effectiveness of the lectures and reading. As a teaching strategy, lecture and readings
have not been shown to produce significant improvements in cultural competency scores
of nursing students (Long, 2012). On a Likert scale of 1-5 where 1 represents no cultural
knowledge to 5 which represents the maximum cultural knowledge about a specific
ethnic group, 100% of the participants scored themselves no more than a 2 for cultural
knowledge on the pre-survey, including those who had just graduated. Alarmingly, there
was no difference in scores between students who had completed different semesters,
including no difference between those who completed their first semester and those who
had just graduated after four semesters of an ADN program.
Prior Foreign Language Training
Ten students reported they received some prior foreign language training in
school other than English, which varied from one year to five years. Eight students had
no prior foreign language training other than English.
The majority of the group had no prior Spanish language training, but all received 8 hours
of medical Spanish during the trip in a formal classroom setting and over 20 hours in
clinical settings. Forms were translated for their use during community home visits and
clinic time, and they were all trained in how to use the forms. 100% of the students stated
36. Dissertation
Tracey
Long
36
in the post survey that their ability to speak basic medical terms, greetings and
assessment questions in Spanish improved in both confidence and skill.
Prior International Travel
Twelve students of the group and both faculty had travelled abroad in some
capacity as either a student or tourist, and one student served on a previous religious
mission trip for two weeks. The pre-intervention scores of those who had travelled
internationally prior to this immersion experience were higher than those who had not
travelled at all, although the highest score was still only 2 on a Likert scale of 1-5.
Instrumentation
This study used both quantitative and qualitative instruments to collect data from
the international service learning experience. Because previous studies in international
study programs were generally phenomenological, a combination of both methodologies
was included in this study. The use of personal journal entries was the instrument for
qualitative data, and a self-scoring self-efficacy pre-survey and post-survey was used for
the quantitative data.
Quantitative data will be collected using the Cultural Efficacy Self scale from a
pre-intervention survey and again as a post intervention on the final day of the trip. The
Cultural Self Efficacy scale by H. Bernal and R. Froman (Bernal and Froman, 1987) was
chosen for its simplicity, measurement of confidence, 26 parameters of culture and four
ethnicities including African American, Hispanic, Asian and Native American. The
Cultural Self-Efficacy scale has an estimated total scale internal consistency of .97
(Bernal and Froman, 1993). In a principal factor analysis, a four-factor structure of
37. Dissertation
Tracey
Long
37
ethnicities was considered conceptually meaningful; additionally, a regression analysis
showed significant relationships between perceptions of efficacy and demographic
variables of race, education and experience. The cumulative score from this scale is at the
interval level data measurement. Because students came from each of the four ethnicities
identified in the instrument, it was also chosen to question whether there would be a
difference in scores based on existing student ethnicities.
Qualitative data was collected from self-reflection journals kept by each
participant every day of the trip and private interviews at the end of the two-week
experience with each student by the principle researcher. Narrative self-reflection
journals allowed the students to express their thoughts and feelings in their own words.
“Narrative methodology results in unique and rich data that cannot be obtained from
experiments, questionnaires or observations” (Leiblich, Tuval-Mashiach, & Zilber,
1998). Because a limitation of the study is the small number of participants (17), a
qualitative method was jointly used to add to the richness and breadth of data.
Researcher bracketing was acknowledged in efforts to not influence the data analysis and
collection process (Chan, Z 2013 et al). Because the students did not receive a college
grade for their work or journal entries, this hopefully minimized any perceived pressure
to produce journal entries to “please the professor.”
Data Collection
The principal investigator maintained qualitative and quantitative data. The pre- and
post-intervention surveys were coded using numbers rather than names for data entry and
statistical analysis. A graduate student helped with the data entry without using the names
to identify the participants, and the data analysis was completed with the same numbering
38. Dissertation
Tracey
Long
38
system. SPSS was used for statistical analysis for the quantitative data. The participants
survey responses was coded using the 1-4 point scale inherent in the survey.
Qualitative data was collected using the participant daily self-reflection journals.
It was analyzed for themes using NVivo software testing for word frequency queries. A
table of most identified themes was created and will be reviewed in the discussion section
of the dissertation.
Data Analysis
Quantitative Data of Control and Intervention Groups
Descriptive statistics was completed to identify mean, medians and modes of the
sample population’s demographics. The quantitative data of both the intervention and
control groups were analysed using SPSS. A one-way Anova was completed between the
control and intervention groups for their pre-tests to identify any significant differences
between the two groups. This was valuable to confirm there were no marked differences
between the two groups, which equalized the two sample populations.
All survey questions were totaled for each participant for a final score, and used for the
Anova and matched paired t-tests. A paired t-test of the control group’s pre and post
survey scores was compared. Another paired t-test was done on just the Hispanic
population questions as this was the ethnic group the intervention students worked with.
This score was compared to the other ethnicities with the intervention group in the
Hispanic/Latino geography of their setting. The assumptions of using a matched pair t-
test can were all met in this study. Because the sample population is less than 30, only
nonparametric tests were completed on the data.
39. Dissertation
Tracey
Long
39
Qualitative Data
The qualitative data collected from the self-reflection journals of the intervention
group were assessed using NVivo software to identify themes and topics expressed by the
students throughout their two-week experience for both the control and intervention
participants. Journals were coded by numbers and input into the software by a graduate
student who did not know the students because the principle investigator traveled with
the intervention group as faculty and did not want to show bias in interpretation of
findings.
Validity
Validity
of
the
study
was
aided
by
the
existing
validity
and
reliability
studies
of
the
survey
instrument
used
for
this
study.
A
concern
for
the
study
however,
is
to
recognize
that
the
instrument
only
measures
the
self-‐efficacy
toward
cultural
competence
and
not
cultural
competence
itself.
The
study
design
of
a
mixed-‐
methods
hopefully
increased
the
validity
of
the
study
by
offering
both
the
empirical
data
from
the
surveys
and
the
rich
text
from
the
self-‐reflection
journals.
Limitations
Completing the self-evaluation instrument to measure cultural competence has an
inherent potential problem of bias. Students may feel they need to rate themselves higher
because they will be aware that a nursing instructor will be reading their journals and
reviewing the data from the surveys. Additionally, prior exposure to cultural competence
training or international travel or foreign language study may influence the test score. It is
also recognized that the inherent human response to score higher in the post-survey is due
to the awareness of the desired topic as students see the topic presented in the pre-survey.
40. Dissertation
Tracey
Long
40
Interpretation of the qualitative journals required the researcher to be aware of
bracketing and personal bias, which has the potential to impact the conclusions.
“Bracketing involves identifying and placing on hold everyday assumptions, beliefs and
previous personal experiences, in relation to the phenomenon under study,” (Lopez,
2004). Efforts were made to avoid bias by coding the journals numerically instead of by
name to help the researcher not identify with the known personality that wrote them to
prevent bias in favor or against the student.
Limitations of the study are the small sample size of 28 total participants,
including 11 in the control group and only 17 in the intervention group. The smaller
sample dictated using nonparametric statistics. Although the original total sample was to
include 18 in each group for a total of 36 participants, the incomplete surveys precluded
using seven students in the control group and one in the intervention group. Another
limitation in the study may be the inherent prior interest and willingness to learn about
cultural competence in the intervention group. Because the students were self-selected,
those who chose to participate in the service- learning medical experience already
showed an interest in learning about other cultures. Data were not collected to measure
any improvement in Spanish-speaking ability after the two-week Spanish immersion
experience. However, students did mention in their journals their improving self-
confidence with the language each day and a desire to return home and learn more
Spanish.
Another limitation of this study is the measurement of self-efficacy towards
developing cultural competence and not true cultural competence. Within the literature
there remains the quest to determine how best to measure cultural competence.
41. Dissertation
Tracey
Long
41
Measuring self-efficacy of working with specific diverse cultures and ethnic groups by
identifying feelings towards developing cultural competence was used in this study.
There are a variety of various instruments to measure cultural competence for nurses and
nursing students, but no standardized tool exists, and reliability scores vary. Additional
studies could be completed using such empirical instruments.
42. Dissertation
Tracey
Long
42
IV. RESULTS: IMPLICATIONS AND LIMITATIONS
Data Analysis
Quantitative Data of Control Group
Descriptive statistics were completed but didn’t result in any new insights to the
two groups. The quantitative data of both the intervention and control groups were
analyzed using SPSS. A one-way Anova was completed between the control and
intervention groups for their pre-tests and resulted in 0.427 declaring no significant
difference. This was valuable to confirm there were no marked differences between the
two groups, which equalized the two sample populations.
All survey questions were totaled for each participant for a final score, and used
for the Anova and matched paired t-tests. The first three questions of the survey were
thrown out as 7 of 10 of the control group didn’t answer them, and 5 of 16 of the
intervention group didn’t answer them. Lessons learned from this were that the primary
investigator needed to more thoroughly review how to correctly complete the survey with
participants and that the survey itself may have appeared confusing by having the first
three questions hidden in the instruction paragraph. All but two participants in the control
group (10 of 12) increased in their post-survey scores, but two students actually
decreased in their overall scores. One student’s pre and post-survey scores stayed the
same.
A paired t-test of the control group’s pre and post survey scores were compared
and resulted in p=.045 which is a significant improvement. Another paired t-test was
done on just the Hispanic population questions and resulted in p=.036, which is also
statistically significant showing improvement after their 2 week preceptor training. This
43. Dissertation
Tracey
Long
43
score is slightly more statistically significant when the questions of other ethnicities were
removed from the analysis to compare with the intervention group in the Hispanic/Latino
geography of their setting.
Quantitative Data of Intervention Group
Descriptive statistics for the pre and post-survey scores showed a larger variance
between the post-survey scores of the intervention group. Two students’ post survey
scores were quite lower than their pre-survey scores. Both of these students voiced on
their surveys that after the two weeks in Belize they believed they overinflated their self-
confidence on the pre-survey, meaning they thought they knew more than they did. After
being in Belize, they realized they had much more to learn about the ethnic populations
and cultural competency so their post-survey scores were lower. A Dixon test for outliers
was considered as their scores would create undue influence on the mean. Even while
using their scores there was statistical significance between the overall group’s pre-and
post-survey scores. A one sample matched pair t-test of means was completed to find the
average score between the pre and post-test of the self-efficacy scale for the
Hispanic/Latino ethnic group. The sample size used was 16, as one student departed from
the main group two days earlier and never turned in the post survey.
The assumptions of the matched pair t-test were all met. The t score mean was
8.957 and p <.001 (value was 6.20x 10 (-8). X=121.94, SD=56.3). The p value <.001
clearly shows how notable the results were and that the cultural immersion
experience/intervention significantly increased the students’ self-confidence in working
with diverse patients. A matched t-test was also completed comparing their overall pre
and post-survey questions for all four ethnic groups, which resulted in p=.073.
44. Dissertation
Tracey
Long
44
The data reveal that for the Latino ethnic group, the p value is less than .05, and
there was a significant effect or improvement in the self-efficacy score of knowledge and
confidence working with a Hispanic ethnic group after a two-week study abroad service
learning medical experience for the ADN nursing students. There was only a moderately
significant improvement in the other ethnic categories of African American, Asian and
Native American. Surprisingly there were no significant differences among age groups,
prior foreign language training or prior international travel.
Qualitative Data
The qualitative data collected from the self-reflection journals of the intervention
group identified common themes such as culture shock, gratitude for the country they
came from, an increased self-awareness and surprise at the poverty of the people they
worked with. Many shared fears and discomfort of not being able to communicate
adequately with the people; therefore, translators were used for community health visits
and the clinics. Comparisons between their own homes, language, food preferences,
safety, health, education and opportunities to those of the people of Belize were made
throughout their journals.
Another theme was the variety of emotions experienced during their study abroad
experience. Surprise and dismay at the variety of health beliefs and practices were themes
that emerged as they wrote in their journals and such sentiments were also verbally
expressed during their post trip interviews. Many shared discomfort when seeing women
publicly breast-feeding or sorrow for poor dental hygiene and living conditions. Many
also expressed anger and embarrassment by their peers whom they judged as culturally
45. Dissertation
Tracey
Long
45
insensitive on several occasions. The personal growth was seen more clearly from their
qualitative journals than could ever have been seen from the quantitative data alone. The
following tables outline the major qualitative themes revealed from their personal self-
reflection journals for both the control and intervention groups.
Table 4 Qualitative Themes for Intervention Group
Major Category Subcategory
Personal development First time away from home
Learning about another culture
Expanding world view
Skills learned Learning Spanish
Learning how to triage patients
Learning to present to a Dr.
Emotional Responses Fears
Joys
Gratitude
Anger
Fun during tourist activities
Amazement
Teamwork Group work valuable
New friends were made
Feelings towards colleagues expressed
Environment New foods
46. Dissertation
Tracey
Long
46
Strange and new sights
Sightseeing
Physical Comfort Level Physical comfort levels challenged
Fatigue from hard work and long hours
Fears of mosquitoes and tropical diseases
Table 5 Qualitative Themes from the Control Group
Major Category Subcategory
Personal development Feeling like a “real nurse”
Skills learned Using skills learned in nursing school but
never practiced on real patients
Learning to give and receive report
Emotional Responses Fears of first day
Joys of success with skills
Frustrations with time management
Surprise at fatigue after 12-hours shifts
Teamwork Feelings towards staff nurses
Environment Hospital unit orientation
Physical Comfort Level Physical comfort levels within normal
47. Dissertation
Tracey
Long
47
range as usual nursing school
Fatigue from hard work during 12-hour
shifts
Table 6 Four major categories shared by control and intervention groups
Clinical
Environment
Equipment Ease to
health care
provider
Comfort level Structure to
setting
Resources
Personal
Development
Skills Emotions Communication Confidence Clinical
Judgment
Satisfaction
View of the
Profession
Teamwork Scope of
practice
Nursing value to
health care
Seeing self
in this
profession
The Patient Quality of
life
Building
relationships
Communication Cultural
differences
48. Dissertation
Tracey
Long
48
Analyses of Research Questions
Research Question 1
How does service learning in an international country affect self –efficacy toward the
development of cultural competence in undergraduate ADN nursing students?
Evaluation of the affect of service learning on the intervention group can be determined
by examining the four domains of learning including affective, behavioral, cognitive and
psychomotor. The affective domain is addressed under personal development, gratitude
and emotional responses. The behavioral domain is addressed under skill development
and teamwork. The cognitive domain is addressed also under skill development and
environment; the psychomotor domain is addressed in the skills development,
environment, and physical comfort categories.
The affective or emotional response to the experiences was revealed through the
students’ own words in their self-reflection journals. Emotional categories were noted in
Table 4 and again here listed with select detailed comments under the topic categories.
Personal
development
& Gratitude
“I learned how much I loved this experience!”
“This trip is such a blessing. I feel like there is so much going on that I will not fully ta
everything in until I am back home reflecting on this time.”
“Today I learned how much I truly take for granted in the U.S. when I complain about
things that aren’t even necessary.”
“I learned so much about myself today and will never forget this amazing experience.”
“I felt so empowered that I overcame my fear of heights and water. We went
zip-lining and cave tubing. It’s been a really long time since I had this much fun.”
49. Dissertation
Tracey
Long
49
“It was a great life-learning experience and I am inspired to do another service trip.
“I really learned how blessed I am to be from the United States and that other
countries do have wonderful people and customs too.”
Skills learned “I learned my Spanish is really lousy.”
“I learned I want to learn more Spanish because I really want to talk to these people.”
“My view of the culture is evolving. I did not know anything before I came here, and
I am being introduced to a mix of several different cultures, and it’s a beautiful thing.”
“We are all getting better at communication as the days go by. Thank goodness for
translators.”
“I will never be impatient with a pharmacy again.” (The students took turns working
in the makeshift pharmacy for each clinic day.)
“I learned I love kids, and am good around them. Also, that I do some pretty good suturing
“We learned a lot from our tropical diseases presentation.”
“I had so much practice that I felt really confident communicating today!”
“I like how the Bush Doctor taught us about the herbal remedies.”
“I loved going door to door and meeting the people.”
“I learned I’m better at doing drug calculation problems that I thought!”
“I had forgotten some of my assessment skills and took a lot of criticism from the doctor b
really appreciated it in the end.”
“I learned I was brave enough to attempt to talk to Spanish-speaking people even though it
is scary and so confusing.”
“I learned that I could be much more effective in my profession by learning to communica
50. Dissertation
Tracey
Long
50
in another language and that I have a genuine interest in becoming fluent in Spanish.”
“I have a new appreciation for the pharmacy.”
“I learned so much from talking with the doctors while interviewing the patient. This is the
best way to gain knowledge.”
“First-hand learning is the best learning.”
Emotional
Responses
“The stories that people shared were horrific about being raped by the men in their
families.”
“It breaks my heart they have so little that I couldn’t say no to them when the children
got to choose a gift from our gift bag.”
“I learned I never want to be a patient in this country.”
:”I am loving every second and every new experience on this trip.”
“I dislike being controlled.”
“I am capable of being a hypocrite which I despise in others too.”
“I learned that I have a lot weaker of a stomach than I thought and I was getting pretty
grossed out at the hospital.” (non-nursing student)
“I was very anxious, but all the anxiety was worth it at the end of the day because I felt so
accomplished because you never know who you can meet and how amazing people are.”
Teamwork “I really needed help from (name of another student nurse) with the children choosing
gifts because I couldn’t say no to any of them.”
“I learned that I was able to make friends with a group of girls that I did not know
iin a short period of time.”
“It almost feels like we’re at camp because we’re all so close together.”
51. Dissertation
Tracey
Long
51
“I am so happy to share this once-in-a-lifetime experience with this group of girls.”
“Today I learned I had to exhibit self-control in a bad situation to maintain
professionalism.”
“I learned that I don’t mind working as a team, but I do not like being ordered around.”
Environment “I was shocked to see where these people lived, how they cooked and what they use
for a toilet.”
“I guess I wasn’t expecting to see so many people of African descent. I was expecting
more Mayan and Mestizo.”
“Eating sweet bread that one of the locals made was the perfect way to end the house
visits.”
“I realized that the different villages had different cultures.”
“I learned that the people of Belize love thick women, which in the States would be
considered overweight.”
“I had no idea that tortilla chips and food could be so tasty without American
preservatives!”
“I learned that the people here are very resourceful and don’t waste anything.”
“It was shocking to see people whose homes were made of sticks and leaves, and the
only bathroom they had was a hole that they dug in the ground.”
“It was so nice to see God’s beauty all around me.”
“We experienced our first jelly fish stings in the water. That was not very fun.”
“The view from the top of the Mayan temple was breathtaking. It was just so peaceful
up there.”
52. Dissertation
Tracey
Long
52
Physical
Comfort
Level
“Today was an eye opener. I learned how fortunate I am to have the things that I do
have, like a toilet with running water.”
“I got a migraine today out in the sun, and it was not fun. It was a miserable trip back to th
hotel, but after a shower and a couple hour nap, I was back to normal.”
“When we got to the hotel after a very hot and uncomfortable bus ride, I was looking for th
gym and then realized, I’m not in the U.S. anymore! Later I felt guilty and just jogged nith
the streets in the morning.”
“It seems very common for the women to pull out their breast and breast feed, which was
really weird. They don’t seem embarrassed about it even though I was.”
Research Question 2
How do ADN nursing students value a medical international service learning experience
in gaining skills towards cultural competence?
Each of the 17 students verbalized in their self-reflection journals and personal
interviews how grateful they were for the trip and that they learned so much. Many of
them plan to be involved in another service learning trip or at least to travel
internationally again. They all highly valued the trip. None of the students expressed
regret for having gone on the trip.
Interestingly, the only student that expressed negative feelings during the trip was the
student who created several arguments among peers and fought with her roommate after
she became intoxicated herself.
53. Dissertation
Tracey
Long
53
Research Question 3
How do ADN students in different semesters compare between each other in self-efficacy
towards developing cultural competence?
Surprisingly, there was no statistical difference between nursing students in
different semesters and their improvement in self-efficacy scores. There should have been
a greater difference between those nursing students who had just graduated and received
some lectures or readings in cultural competence and the newest nursing students who
had only completed one semester, but there was not. This raises serious concern again
about the effectiveness in their cultural competence training as undergraduate nursing
students. All received the same Nursing 101 lectures and readings, which includes some
material on cultural competence. However, it apparently made no measurable difference
or impact. For this study group, previous lecture and readings were ineffective in making
a difference between first and last semester nursing students in both the pre- and post-
intervention surveys.
Research Question 4
Is there a difference in self-efficacy among ADN students towards cultural competence
who have had prior language or international travel experience?
There was not a statistical difference in self-efficacy scores among any of the
ADN students who had previous foreign language training. Of the students who had
foreign language training, only a few of them had traveled internationally, which means
they learned a language by textbook in school and not in an immersion experience.
54. Dissertation
Tracey
Long
54
According to some studies, foreign language training success has been noted to occur
faster and with more retention in immersion-like experiences rather than the classroom.
Research Question 5
How does the control group compare to the intervention group in self-efficacy towards
cultural competence?
The control group did also experience the statistical significance of improvement
in self-efficacy scores as did the intervention group, which points to the influence lived
clinical experiences with populations of different ethnicities as the unique factor in
helping students gain confidence in working with diverse populations. Because the
control and intervention groups came from the same nursing school and received the
same prior education, the only definitive variable is the lived clinical experience and
exposure. The value of having a control group was in creating similar experiences among
similar participants to determine if the intervention made a measurable difference. It
appears it did. Interestingly, both groups had a significant improvement in post-survey
scores. The big question is why? Is it because of the lived clinical experience, or the
expectation of the student to complete the survey with improvements knowing they were
being measured by a pre-and post-survey? Is the reliability and validity of a self-survey
instrument in question?
Null Hypotheses
Null hypothesis 1: A two-week international service learning medical trip does not affect
an increase in self-efficacy of cultural competence scores for undergraduate nursing
students.
55. Dissertation
Tracey
Long
55
The null hypothesis was negative, meaning that a two-week international service
learning medical trip did affect an increase in self-efficacy of cultural competence scores
for undergraduate ADN nursing students.
Null hypothesis 2: There is no difference between the control and intervention group in
post intervention self-efficacy scores.
The value of having a control group is in determining if the intervention truly is
the only factor in creating a statistically significant difference. Originally the statistics
were completed for just the intervention group, and results declared there was a
statistically significant improvement in the students’ post-survey scores. The results
pointed to the positive influence of the international medical service learning experience
and the null hypothesis 1 was rejected. When the statistics were completed for the control
group, the result of the post-survey scores also revealed a statistical improvement,
although less than the intervention group. The null hypothesis could not be rejected if
only the quantitative statistics are considered. If the qualitative data is considered, then
the null hypothesis 2 can be rejected, because of the unique differences in quality of
experiences by the students.
Alternate hypothesis: There is a difference in self-efficacy scores from the pre and post-
intervention surveys after a two-week international service learning medical experience
for undergraduate associate degree nursing students.
The alternate hypothesis was confirmed by the statistical significance of the data.
The difference in self-efficacy scores was positive and demonstrate there is positive value
56. Dissertation
Tracey
Long
56
in using the ISL experience for ADN nursing students to gain self confidence in
developing cultural competence.
57. Dissertation
Tracey
Long
57
V. DISCUSSION
The following is a report on the success in achieving the study objectives.
Objective 1
To measure the cultural competence and self-efficacy level of nursing students in the pre-
intervention experience phase.
This was completed for both the control and intervention groups. All 18 students
in the intervention group completed the pre-survey; however, because one didn’t turn in
the post-survey and self-reflection journals, the data from one student was incomplete
and not included in the data analysis. Only 11 of the 18 control group students completed
the pre-survey as well as the post-intervention survey, so only 11 were included in the
data analysis. The principal investigator could have followed up with the missing control
group students, but emails and names were not received when they initially took a copy
of the study information and survey after showing interest. The principle investigator
learned it is important to have all participant information at the beginning of the study,
even by those prospective participants just showing interest.
Objective 2
Compare pre-intervention scores to the post-intervention scores.
The comparison of scores was completed using a paired t-score for both the
control and intervention groups. True comparison was done with an anova statistical test.
Objective 3
Evaluate the effectiveness of an international service learning experience as a teaching
strategy in strengthening self-efficacy towards developing cultural competence.
58. Dissertation
Tracey
Long
58
This main objective was the true focus of this study and could only be done after
statistical analysis of the empirical data from the pre and post surveys. The statistically
significant improvement in self-efficacy scores of the intervention group for
Hispanic/Latino populations demonstrated that this international service learning trip was
effective in producing improvement in self-confidence towards developing cultural
competence among these nursing students. Because of the small study group, it is
difficult to generalize the results for all ADN nursing students, which is a limitation of
this study. It does, however, encourage nursing educators to explore this strategy in their
own nursing curriculum.
Objective 4
Identify the phenomenological themes of student nurses in an international service
learning medical experience.
Themes identified using the self-reflection journals are valuable for nurse
educators who may choose to use the international service learning strategy. It is
important for both educators and even nursing students to be aware of possible emotional
responses to experiencing international travel, working with diverse populations and
exploring foreign cultures. The phenomenological themes of the intervention group
included heightened emotions when compared to the control group, which also worked
with diverse populations but in a more controlled and familiar environment in their own
home community. By including this qualitative data in this study, the value of this
research is compounded. Previous international studies for nursing students included self-
reflection journals as well, and in this sense, this study serves as a duplicate study, which
59. Dissertation
Tracey
Long
59
revealed the effectiveness of international study in improving self-efficacy towards
cultural competence.
Objective 5
Compare the intervention group with a control group of ADN nursing students.
Having a control group allows the principle investigator to avoid making incorrect
conclusions from the intervention of an international service learning experience. Any
improvements in self-efficacy from the international service learning experience needed
to be compared to the control group. The self-reflection journals of the immersion group
revealed more intense feelings of gratitude and appreciation for their home country than
the control group. Spanish language skills, community nursing, international health
issues, new friendships and overcoming foreign culture fears were spoken of in the
journals of the immersion group, but were not discussed by the control group. The
commonalities of both groups were the new-found joys in their strengthening skills and
their shared fears about new clinical experiences.
Overall, all five objectives were completed successfully in this study.
Perceived Competence of Groups
A common theme seen in both the control and intervention groups was that they
rated themselves higher in the pre-survey than in the post-survey. Several students even
verbalized this as they completed the post-surveys. One student stated emphatically, “I
didn’t realize how much I really didn’t know about these cultures until I took the
survey!” Another student admitted humbly, “I thought I was culturally competent until I
saw the survey and realized there’s more to know about each culture more than ethnicity
and language.”
60. Dissertation
Tracey
Long
60
Quantitative Conclusions
There was a statistical significance in improvement of self-efficacy scores among
the intervention group and not among the control group. This leads to the conclusion of
the value of using an immersion service learning experience to improve self efficacy
among nursing students towards developing confidence and competence in working with
patients of diverse cultures. In efforts to compare the effectiveness of various teaching
strategies, both the empirical and qualitative data received from this study point to the
conclusion that a study abroad, immersion and service learning experience is not only
valuable but effective.
Qualitative Themes and Conclusions
Reflective journaling is one powerful way to process clinical experiences and has
been used by students in health care professions to identify lessons learned and make
conclusions (Findlay, et al, 2010; Crotty, 1996). Qualitative descriptive analysis was used
in the interpretation of the student self-reflection journals for this study. Unlike
phenomenology, qualitative descriptive analysis seeks to describe events purely as the
participant describes, which was chosen as an appropriate methodology for this
component of the research study. Coupled with the empirical data from the pre and post
surveys, it adds to the richness of the study. The systematic reading and coding of the
text from the journals was completed using a sourcebook.
61. Dissertation
Tracey
Long
61
Implications for Nursing Education, Practice and Future Research
This research concludes that a two-week medical service learning experience in
Belize significantly improved self-efficacy, self-confidence, skills and self-awareness
among ADN nursing students towards working with the Hispanic culture and developing
cultural competence. Repeat studies would be needed to generalize the findings to all
ADN nursing students.
Educators need to be aware of several issues including the mandate to teach
cultural competence training to undergraduate nursing students in their curriculum, the
variety of strategies and methods to teach cultural competence training, and resources for
their students who are looking to have a study abroad immersion service learning
experience. Faculty support for students choosing a nontraditional clinical learning
experience such as a study abroad service learning trip can include fund raising,
emotional support of outside programs or even academic support by providing learning
materials or websites and books of where to receive additional preparation in language or
assessment skills. Resources for educators include the National League for Nurses
Diversity Toolkit (2009), and AACN’s Cultural Competence Toolkit (2008).
Nurse educators who prefer not to travel internationally but promote, model, and
advocate for cultural competence training can create clinical experiences with diverse
client populations within their own community, such as veterans groups, prison
populations, HIV centers and any subgroups with an ethnicity different from that of the
nursing students. Additional research could be done comparing the self-efficacy scores
towards cultural competence with two groups: one group that works with ethnically
62. Dissertation
Tracey
Long
62
diverse populations within their own community, and a second group at the same time
period and training level that serves in an international community. Creating a service
learning medical experience locally for nursing students where they can interact with
ethnically diverse patients for a similar learning experience is important as cost is often a
prohibitive factor. This research indicates significant value in purposely positioning ADN
students within a clinical setting with a population different from their own as a strategy
for developing confidence in cultural competence.
Nursing students who want to be competitive in the marketplace as a new
graduate and competent in dealing with the variety of cultural diversity in the United
States population, need to look for opportunities to expand their knowledge and skills in
cultural competence outside of the classroom and textbooks. Because there is a large
variety of how cultural competence is currently being taught in nursing school curricula,
graduates differ in cultural competence and mostly score generally in the self-awareness
level only (Kardong, 2008). Nursing programs may incorporate topics of cultural
diversity and training throughout the curriculum, whereas others may only identify it in a
brief module, and yet both are compliant with the current educational mandates.
By participating in a study abroad and service learning experience, nursing
students can showcase their volunteer work on a resume and stand out in an interview
process when compared to other new graduates who have not participated in such a
program. Additional language and clinical skills may also be gained from a service
learning experience when compared to a traditional clinical learning setting. The skill of
addressing the diverse needs of our current and growing population will enable more
63. Dissertation
Tracey
Long
63
sensitive, patient-focused nurses, to promote a decline in the disparities of current health
care and improve positive patient outcomes.
This research presents implications for practicing nurses as well. All nurses need
additional training in cultural competence to help decrease ethnic disparities and to
increase quality nursing care by effectively meeting the unique needs of our growing
diverse population. Graduated nurses can also take advantage of international service
learning experiences traveling with companies who take groups internationally to serve in
areas around the world
Recommendations for Further Research
1. The nursing profession needs to agree on a definition of cultural competence and how
to train both students and educators towards cultural competence.
2. Nurse educators need to measure the effectiveness of teaching strategies for required
topics in their curriculum, not just cultural competence.
3. Reliable and valid instruments & rubrics need to be created to better compare and
contrast teaching methodologies in nursing education.
4. Nurse educators and students need to be aware of the positive impact of international
service learning on self-efficacy towards cultural competence.
5. Funding resources need to be identified to allow this opportunity for more nursing
students, or to create similar experiences in their local community with diverse
populations.
6. Nurse educators need to create clinical experiences in their own communities where
culturally different cultures exist for patient interactions.
64. Dissertation
Tracey
Long
64
7. More research needs to be completed where actual cultural competence is measured,
rather than just the students’ self-efficacy and confidence.
Final Conclusions
1. The nursing profession needs to agree on a definition of cultural competence and
how to train both students and educators towards cultural competence.
2. Nurse educators need to measure the effectiveness of teaching strategies for
required topics in their curriculum, not just cultural competence.
3. Reliable and valid instruments & rubrics need to be created to better compare and
contrast teaching methodologies in nursing education.
4. Nurse educators and students need to be aware of the positive impact of
international service learning on self-efficacy towards cultural competence.
5. Funding resources need to be identified to allow this opportunity for more nursing
students, or to create similar experiences in their local community with diverse
populations.
6. Nurse educators need to create clinical experiences in their own communities
where culturally different cultures exist for patient interactions.
7. More research needs to be completed where actual cultural competence is
measured, rather than just the students’ self-efficacy and confidence.
65. Dissertation
Tracey
Long
65
References
Agency for Healthcare Research and Quality (AHRQ) (2004). National healthcare
disparities report: Summary. Retrieved December 18, 2013, from
http://www.ahrq.gov
Alpers, R. and Zoucha, R. (1996). Comparison of cultural competence and cultural
confidence of senior nursing students in a private southern university. Journal of
Cultural Diversity 3: 9-15.
American Association of Colleges of Nursing (1997). Diversity and equality of
opportunity. Retrieved April 2, 2014, from
http://www.aacn.nche.edu/Publications/positions/diverse.htm.
American Association of Colleges of Nursing. (2008). Essentials for baccalaureate
education of professional nursing practice. Retrieved from
http://www.aacn.nche.edu/Education/bacessn.htm
http://www.aacn.nche.edu/Education/pdf/toolkit.pdf
American Association of Colleges of Nursing (AACN) (2008) Cultural Competency in
Baccalaureate Nursing Education. Journal of Transcultural Nursing April. 20(2)
137-145.
American Nurses Association. (1991). Cultural diversity in nursing practice: A position
statement. Retrieved from
http://www.nursingworld.org/position/ethics/cultural.aspx
Bandura, A. (1994). Self-efficacy in changing societies. New York: Cambridge
University Press.
Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human
behavior (Vol. 4, pp. 71-81). New York: Academic Press. (Reprinted in H.
