The Impact of International Service-Learning on Nursing Students’ Cultural Competency

Authors: Pamela Wolfe Kohlbry PhD, RN, CNL

Abstract

Purpose

This article reports research findings on the effect of an international immersion service-learning project on the level and components of cultural competence of baccalaureate (BSN) nursing students.

Design

A triangulated methodology was used to determine changes in components and level of cultural competence pre- and postexperience. The theoretical model The Process of Cultural Competence in the Delivery of Healthcare Services was used. It identifies five central constructs in the process of becoming culturally competent: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. The sample of 121 BSN nursing students was gathered from three southern California universities. Data were collected from 2009 to 2013.

Methods

Using the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version© and Cultural Self-Efficacy Scale, constructs of cultural competency were measured in pre- and posttest participants who participated in international service-learning immersion experiences. A demographic survey and open-ended qualitative questions were completed at the posttrip meeting. Mean, frequencies, and correlations with demographic data and survey data were calculated. Pre- and posttrip means were analyzed. Qualitative analysis from six open-ended questions completed at the posttest were coded and themes emerged.

Findings

The research findings demonstrated the impact of the international service-learning project on building cultural competency in nursing students. Quantitative findings revealed statistically significant differences between pre- and posttest surveys for two of the five constructs of cultural competence. Qualitative analysis supported the quantitative findings in cultural competency constructs found in the model.

Conclusions

The research findings support nursing education program use of international service-learning immersion experiences to foster cultural competence in nursing students. Findings from student participants demonstrated and articulated that these program experiences strengthen the process of becoming culturally competent. The research findings support the inclusion of international service-learning experiences with debriefing and reflective learning as effective teaching strategies. Researchers have demonstrated that poor healthcare outcomes are a result of health disparities, which are then compounded by healthcare workers not being prepared to care for clients from differing cultures. The American Association of Colleges of Nursing identified innovative ways for nursing students to develop skills in cultural competency, which included international experiences.

Clinical Relevance

In nursing education, this study demonstrated that international service-learning immersion experiences are of value as they impact and improve cultural competency. Nurses graduating with enhanced cultural understanding will contribute to decreased health disparities and improved patient care quality and safety. Further research that examines nurses’ cultural competency in the patient care setting who have had previous education in international nursing could further inform nursing education and contribute to the understanding of patient satisfaction.

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Researchers have demonstrated that a lack of cultural competence contributes to health disparities and poor health outcomes (Betancourt, Corbett, & Bondaryk, 2014; Institute of Medicine, 2002). Healthcare disparities create healthcare issues that are costly for patients and families as well as healthcare systems. This deficiency in cultural competency creates a gap between the nurse and safe patient-centered care. An essential dynamic of quality care is the nurse's level of cultural competency (Campinha-Bacote, 2013). Analysis of the impact of growth in ethnic populations and global immigration demonstrates the need for healthcare workers to be educated in cultural competency in order to decrease health disparities and achieve quality patient-centered care (Delgado et al., 2013; Vaughn, 2009; Waite & Calamaro, 2010). Healthy People 2020 (2015) highlights the need to address the social determinants of health, including cultural competency. Challenges to cultural competency, such as a deficiency in cultural understanding and skill and an absence of cultural sensitivity, have been identified (Clifford, McCalman, Bainbridge, & Tsey, 2015; Kwong, 2009; Maltby & Abrams, 2009). As nursing education prepares future nurses who are culturally sensitive and aware, consideration of effective teaching strategies that foster cultural competency is essential.
The American Nurses Association and American Association of Colleges of Nursing (AACN) Baccalaureate Essentials mandate nursing education to focus on diversity due to increased globalization with the expectation that for nurses to provide safe high-quality care requires cultural understanding and sensitivity (AACN, 2008a; Dolansky & Moore, 2013). Numerous investigators have described opportunities in nursing education to overcome cultural competency barriers by using national and/or international service-learning projects (Amerson, 2010; Bentley & Ellison, 2007; Kaddoura, Puri, & Dominick, 2014; Kardong-Edgren et al., 2010). Nursing education findings recommend various pedagogies to prepare future nurses to care for diverse individuals, families, and populations from cultures different from their own (Hughes & Hood, 2007; Jenkins, Balneaves, & Lust, 2011; Kardong-Edgren & Campinha-Bacote, 2008). Teaching strategies include a traditional format with classroom education and workshop training, reflective journaling, role play in simulation, and community service-learning projects (Gallagher & Polanin, 2015; Kohlbry & Daugherty, 2013; Kohlbry & Daugherty, 2015; Worrell-Carlisle, 2005).
The AACN (2008a) has identified three qualities of culturally competent baccalaureate nurses: (a) assessment of cultural variations; (b) cultural skill in communication and assessment; and (c) awareness of personal attitudes, culture, behaviors, and beliefs (Calvillo et al., 2009). Based on these qualities, the AACN established competencies and developed the AACN Tool Kit of Resources for Cultural Competent Education for Baccalaureate Nurses (AACN, 2008b). The tool kit, with various teaching strategies to improve cultural competency, identified experiential learning through immersion experiences within diverse communities as a recommendation.
The Quality and Safety Education in Nursing (QSEN) initiative by Robert Wood Johnson Foundation and the AACN further emphasized the need for education in cultural competency to elevate quality care. QSEN competencies were developed with cultural competence as a central aspect of patient-centered care (Disch, 2010). The QSEN knowledge, skills, and attitudes for nursing student graduates include: knowledge to “describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values”; skills to “provide patient-centered care with sensitivity and respect for the diversity of human experience”; and attitudes that “recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds” as well as “willingly support patient-centered care for individuals and groups whose values differ from own” (Cronenwett et al., 2007, p. 123).
Nursing education, founded on evidence-based teaching practices, has a responsibility to “build the capacity of students” through experiences that foster cultural understanding (Hall & Guidry, 2013, p. e6). The nursing literature describes international cultural immersion programs of varying lengths of time and their value to help students appreciate global factors, expand their worldview, and understand different cultures (Hunt, 2007; Larson, Ott, & Miles, 2010).
Service-learning contributes to a student's development of cultural sensitivity, social justice, collaboration, and problem solving (Bosworth et al., 2006; Reising et al., 2008). The differences among service-learning, community clinical experiences, and volunteerism are discussed elsewhere (Kohlbry & Daugherty, 2013; Kohlbry & Daugherty, 2015). The reciprocal value of service-learning experiences are embedding student learning in facilitating goals of the community host country (McAuliffe & Cohen, 2005). The opportunities for collaboration with social service programs and community partners maximize learning and develop cultural competence (Pretorius & Small, 2007). For example, service-learning opportunities can be found in communities near international border areas where health conditions are often more severe than generally found beyond the distance of the border area (Kohlbry, 2011). Allen, Smart, Odom-Maryon, and Swain (2013) found a significant increase in perceived cultural competency and self-efficacy in cultural knowledge, skills, and attitudes among participants in a service-learning immersion activity in Peru.
Student learning often occurs in the reflective opportunities in the experience, such as debriefing (Laplante, 2007). It is often in the reflection process that assimilation of ideas and development of understanding around the experience take place. Debriefing is a valuable teaching tool in “cementing” the students’ learning and drawing out students’ understanding of their own worldview to help develop cultural awareness.
Research, anecdotal articles, and author experience identified that students found immersion experiences worthwhile and included comments, such as “this is why I wanted to go into nursing to make a difference” (Kohlbry & Daugherty, 2015, p. 245). However, there have been few studies of rigor to provide evidence of the effect and value of immersion service-learning on cultural competency. This article reports research findings on the effect of an international immersion service-learning project on the level and components of cultural competence of baccalaureate nursing students.

Theoretical Framework

Both the AACN's and QSEN's recommendations for cultural competency used Campinha-Bacote's (2013) model, The Process of Cultural Competence in the Delivery of Healthcare Services, as a framework for the development of cultural competence recommendations for nursing education. The model emphasized that cultural competence is a process of becoming based on cultural encounters or face-to-face experiences, motivated by cultural desire for those experiences. The five central constructs in the process of becoming culturally competent are cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. This model emphasizes the need for students to develop skills in communication and understanding of those from other cultures. It provides a framework for innovative teaching strategies for students to engage in the process. Nursing education is an important time to begin that process in a comprehensive way.

Methodology

A triangulated method using quantitative pre- and posttrip surveys and a qualitative questionnaire post-immersion experience were utilized to measure cultural competency and cultural self-efficacy. The study was conducted with nursing student participants from three universities with schools of nursing in California. Undergraduate students participated in service-learning type healthcare-focused trips, utilizing their nursing skills and collaborative abilities.

Data Collection Process

Institutional review board (IRB) approval was obtained from each participating university. Once the research was IRB approved by the participating university, the faculty leading an international trip invited the researcher to a trip-planning meeting. The researcher explained the purpose of the research and surveys, the rights of the participants, the pre- and postimmersion nature of the study, and invited students to participate. Participants were informed that their participation was not related to eligibility for the trip, class requirements, or grades. Informed consent was obtained and their confidentially was maintained. Demographic and pretrip surveys were completed. All research documents were of the paper and pencil format. Within 2 weeks of the participants’ return from the experience, they completed the posttrip surveys and the written qualitative questionnaires at a posttrip meeting. However, not all students attended the posttrip meetings; therefore, fewer posttrip responses than pre-trip responses were gathered.

Instruments

Two survey instruments were used to collect quantitative data on levels of cultural competence and cultural self-efficacy. The first tool, the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version (IAPCC-SV©), measured cultural competence in students and is based on Campinha-Bacote's (2013) model. The tool, found in numerous studies, was used with permission. The IAPCC-SV is a 20-item Likert 4-point scale with responses ranging from “strongly agree” to “strongly disagree.” The five constructs of the model measured are cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. The IAPCC-SV scores four levels of cultural competence. They are culturally proficient, culturally competent, culturally aware, or culturally incompetent. Cronbach's alpha reported in various studies averaged .87 (Capell, Veenstra, & Dean, 2007).
The second tool used in the study was the Cultural Self-Efficacy Scale (CSES), developed by Bernal and Froman (1993). It measures the participant's confidence level in caring individuals from different cultures, knowledge of cultural concepts, comfort in performing cultural nursing skills, and knowledge of cultural patterns among four subscale ethnic groups: African American, Hispanic, Native American, and Asian. This tool was used with permission and is in the public domain (Coffman, Shellman, & Bernal, 2004). The tool is a 30-item Likert-type 5-point scale, with 1 equaling “very little confidence” and 5 equaling “quite a lot of confidence.” An integrative review of cultural competency tools by Loftin, Hartin, Branson, and Reyes (2013) included the CSES’ Cronbach's alpha coefficient range of .86 to .98. Content validity of both tools was determined by an expert panel.
The qualitative data were gathered using an interview schedule with six open-ended questions:

• What were your expectations of the service-learning project?
• What did you learn about your perceptions of individuals from another culture?
• What were the positive experiences you remember?
• What were the challenges you remember?
• Do you feel the length of your trip was sufficient to change your worldview related to culture? If so, why; if not, why not?
• Describe new knowledge that you learned about transcultural nursing.

These questions were chosen to provide a focused review. The subsequent themes would add to the quantitative findings by “exploring different dimensions of the respondents’ experiences” (Jackson & Trochim, 2002, p. 307). The responses to the interview schedule were uploaded into Atlas.ti version 7 (Thomas Muhr Developer, Berlin, Germany). Open coding was conducted by reading over the data. Each response was reviewed, color highlighted, and carefully coded. Words and quotations were analyzed for frequency and meaning. Similar codes were grouped together. The code groups were analyzed, and reviewed for patterns and commonality, and themes emerged. Themes were examined for relationships and linkages. Demographic data were gathered from a survey on age, sex, marital status, work status, ethnicity, university, length of trip, and country visited.
Mean, frequencies, and correlations with demographic data and survey data were calculated. The pre- and posttrip surveys were grouped, as individual students were not tracked before and after trips. SPSS version 19.0 (IBM Corp., Armonk, NY, USA) was used for pre- and posttrip survey analysis for the IAPCC-SV and CSES. Qualitative data analysis of the quotations identified codes and themes using Atlas-ti version 7.

Findings and Discussion

The demographic results of the participants are summarized in Table 1. A total of 161 pretrip students and 121 posttrip students were analyzed. The majority of the participants were female (91%) and in the age range of 21 to 30 years (79%). Student ethnicity was primarily non-Hispanic White (54%). Depending on the university, the duration of the trip varied from 1 day to 3 weeks, and locations included Mexico, Belize, Lesotho, Vietnam, Jamaica, Dominican Republic, Swaziland, and Ghana.

Table 1. Demographic Results

Age ranges (years)
21–30	79%
31–40	16%
41–60	5%
Ethnicity
Hispanic American	11%
African American	2%
Other: Filipino, Pacific Islander, Asian	32%
Non-Hispanic White	54%

Age was correlated with the IAPCC-SV. Using a Spearman rho, a significant correlation (rho = 0.18) was found with the age of respondent in the cultural encounters construct (Table 2). The older the respondent, the stronger the correlation. This could be explained by the fact that with age comes more encounters, which builds the process of cultural competency. A significant correlation was found with the CSES scale and age. The CSES areas of “African American” and “Other” questions were significant at the Spearman rho < .01 (see p value) level with age of respondent (Table 3). With age potentially comes more flexibility and face-to-face encounters. Campinha-Bacote (2007) determined that more face-to-face cultural encounters influence the process in the healthcare professional in which the interactions with clients from culturally diverse backgrounds help to modify existing beliefs about a cultural group and to prevent possible stereotyping. Nursing students are novices and are more adaptable, which is reflected in the correlation of age and IAPCC-SV total score.

Table 2. Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version Correlated With Age

Construct	Spearman's rho	p
*p < .05.
Awareness	−0.005	.93
Knowledge	0.06	.30
Skill	0.03	.66
Encounters	0.18	.00*
Desire	0.11	.06
Total	0.14	.025*

Table 3. Cultural Self-Efficacy Scale Correlated With Age

CSES Areas	Spearman's rho	p
*p < .05.
African American	0.15	.02*
Hispanic	0.07	.24
Asian	0.05	.46
Native American	0.09	.13
Other	0.17	.007*

In measuring pre- and posttrip means, both surveys demonstrated an increase in overall means in all constructs of cultural competence and cultural self-efficacy (Table 4). Significant pre- and posttest means on the IAPCC-SV survey were demonstrated on the constructs of cultural knowledge (F = 12.3, p = .001) and skill (F = 8.1, p = .005) and were significant at p = <.01. Pre- and posttest CSES means were significantly different in two of the ethnic subscales (p < .01)—African American (F = 10.2, p = .002) and Hispanic (F = 3.8, p = .05)—and on questions related to comfort in performing cultural care (F = 7.6, p = .00).

Table 4. Pre- and Postimmersion IAPCC-SV Means of Cultural Competency Constructs

	Preimmersion	Postimmersion
Construct	mean	mean	F	p
Note IAPCC-SV = Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version. *p < .01.
Awareness	3.55	3.6	1.74	.19
Knowledge	2.9	3.08	12.3	.001*
Skill	2.94	3.11	8.1	.005*
Encounters	3.26	3.32	2.7	.10
Desire	3.56	3.61	1.08	.298

There was no significance found between pre- and posttrip levels of cultural competency. The majority of students were at the culturally competent level pre- and postexperience, with a smaller number at the culturally aware level and a few at the culturally proficient level. None were at the culturally incompetent level. While there was movement between levels on students’ post-trip surveys, several unexpected findings were noted. On several questions students rated themselves higher on the pretrip survey than on the posttrip survey. One explanation of these findings is that students have a particular mindset or worldview before their experience. After their experience, perhaps they realized that their worldview, assumptions, and understanding were more limited. This type of experience helps students expand their worldview and requires them to ask themselves if they clearly understand the needs of an individual from another culture. The finding that most students identified themselves as culturally competent before the trip may indicate that the awareness of these students was heightened by the experience.
Every posttrip participant filled out an interview survey. All survey data were reviewed. The qualitative data gathered from the interview surveys were reread, codes were established, subsequent findings were attributed to commonality and patterns, and emerging themes were identified. Each question, answer, related phrase, and quotation was color coded using the Atlas ti version 7 software and given a code label. After rereading the data and codes, similar codes were clustered or grouped together. Because of the volume of qualitative data, repeated or similar quotations and codes were reviewed for frequency, meaning, similarity, or pattern. There were numerous quotations and phrases supporting each code. The code groups were further analyzed, and six themes emerged. The six themes were examined to determine relationships and linkages. The themes and relationship among the themes were found to be reflective of Campinha-Bacote's (2013) model.
Interestingly, three of the themes—cultural knowledge, cultural skills, and cultural awareness—directly reflect the constructs described in Campinha-Bacote's (2013) model. These themes were identified in Category 1 and directly reflected model constructs. The first theme of cultural knowledge reflected student's inclusion of learning language, cultural perceptions, customs, and beliefs. In the second theme, cultural skills, students identified the need to be creative and take into account others’ cultural beliefs. The third theme of cultural awareness had some of the most frequent codes from quotations that students articulated. They described that experiences challenged their preconceptions and stereotypes of culture, and opening up their worldview. Table 5 identifies Category 1 themes and quotations with corresponding student participant and university number.

Table 5. Category 1 Themes, Supporting Student Quotations and Corresponding to Campinha-Bacote's Model Constructs: University and Student Participant Numbers Noted

Theme	Student quotations
Cultural knowledge	“Learn, connect, care, learning language, learning customs and beliefs, giving hugs, encouraging others, praying for receptive individuals, [and] giving.” (U1S401)
	“Individuals from other cultures perceive many of the same basic values as I do—family, community etc.” (U2S414)
	“Different cultures have different healthcare norms that they use and make work. It was interesting [and] educative to see how the Vietnamese healthcare system functions similarly and differently from ours.” (U1S466)
Cultural skills	“You have to keep being creative to come up with solutions that
	[will] take their beliefs into account and still try to help.” (U1S416)
	“Patience is key. Education is most effective.” (U1S474)
	“I have to work with local health beliefs and adapt accordingly.” (U1S418)
	“How to ask questions more carefully and ensure I properly interpret responses.” (U1S472)
Cultural awareness	“Keep an open and non-judgmental mind.” (U2S412)
	“I learned to not assume anything about others in another culture, because often times I was wrong.” (U3S446)
	“I learned that I grew tremendously after doing [a lot of] works at being culturally aware.” (U3S445)

The next three themes that emerged from the data were cultural sensitivity, cultural self-efficacy, and identifying cultural barriers. While these themes were not identical to the model, they support its constructs and were identified in Category 2. In the second category, the fourth theme of cultural sensitivity was identified as a greater appreciation of the value of the beliefs and opinions of other cultures about health and medication. The fifth theme described reflected self-efficacy. An example of a student response within the theme of self-efficacy described the realization that the student could make a difference, “There was a great need and feeling like I was making a difference to meet this need by working at community clinics.” The sixth theme that emerged was cultural barriers, which centered on language and gender roles. These three themes support the cultural competence model constructs of cultural encounter and cultural desire. Developing cultural sensitivity and self-efficacy contribute to building cultural desire. Through the involvement in cultural encounters, one learns about cultural barriers and how to work with those from a different culture. Table 6 identifies Category 2 themes and quotations with corresponding student participant and university number.

Table 6. Category 2 Themes, Supporting Student Quotations and Corresponding Campinha-Bacote's Model Constructs: University and Student Participant Numbers Noted

Theme	Student quotations
Cultural sensitivity	“I think this trip made me appreciate and value the beliefs and opinions of other cultures about health and medicine even more than before.” (U1S427)
	“Giving education based on their cultural beliefs.” (U1S442)
	“More patience is needed for some culture[s].” (U2S410)
Cultural self-efficacy	“I learned that things in other countries are often done very differently but it does not mean it is wrong or that care is jeopardized. I learned that other countries often provide minimal care regularly instead of full care when symptoms are horrible. I also learned that people do not go to the doctor for things unless it is interfering with how they [feel].” (U1S458)
	“Learning from the clients as much as they learned from me.” (U1S403)
	“I had expectations similar to media representations that were very often inaccurate.” (U3S448)
Cultural barriers	“Language barrier and getting services that they need.” (U2S410)
	“The gender role conflict with women being treated are lesser equal men.” (U1S404)

Limitations

One limitation of the study was the inability to determine optimal length of time for an immersion experience. A second limitation was not being able to study gender differences because of the limited number of men who participated in the study. Another limitation would be any pretrip education, orientation, or special cultural content for the international experiences that would vary according to trip, country, faculty, and university. This could prevent generalization.

Implications for Nursing Education, Practice, and Research

The findings from this research support important implications for nursing education, practice, and research. The research indicates that the teaching strategies using international service-learning immersion projects contribute to students’ cultural encounters, knowledge, skills, awareness, sensitivity, self-efficacy, and understanding of cultural barriers. These types of experiences differ from study abroad by including faculty oversight and student contributions to the healthcare in communities where the students are situated. Students are not observers of cultures; they are participants coming alongside individuals and families who live in a different culture. The students gain insight into their own responses to others’ worldviews. To enhance this learning, focused debriefings that highlight and review cultural experiences in light of cultural encounters, skills, knowledge, self-efficacy, and awareness should be fostered. These opportunities contribute to student growth and in seeking to have students understand cultural differences and barriers to providing care and support to patients from a different culture. The findings from this study support the recommendation of using international service-learning in nursing education.
Future research on patient perceptions of nurses who have participated in international service-learning projects as students is needed to further understand how this type of learning experience potentially impacts nurses’ cultural sensitivity. Research on faculty experience in international service-learning projects, methods of effective debriefing, and how these projects are integrated into the curriculum would further expand teaching strategies.

Conclusions

The research findings in this study describe the impact and value of an international immersion experience on the level of cultural competency of nursing students. Nursing education is charged with the responsibility to educate students in a way that fosters the development of cultural competency. Graduating future nurses who are experienced in the process of cultural competence have the potential to improve nursing practice and improve care.
In summary, cultural competency is a process that nursing education must initiate with effective teaching strategies such as international service-learning immersion experiences. When students have an opportunity to experience and learn in this type of setting, they are engaged in the learning process and the multifaceted experience imprints an understanding that potentially influences their future practice.

Acknowledgments

The author would like to thank Sigma Theta Tau International's Zeta Mu chapter and Phi Theta chapter for research grant funding and California State University San Marcos for funding through the University Professional Development grant.

Clinical Resources

• American Association of Colleges of Nursing. Tool kit of resources for cultural competent education for baccalaureate nurses: http://www.aacn.nche.edu/Education/pdf/toolkit.pdf
• CLAS Standards: https://www.thinkculturalhealth.hhs.gov/content/clas.asp
• Transcultural C.A.R.E Associates: http://www.transculturalcare.net/