INTERNATIONAL SERVICE–LEARNING: AN OPPORTUNITY TO ENGAGE IN CULTURAL COMPETENCE PAMELA KOHLBRY, RN, PHD, CNL⁎
AND
JOANN DAUGHERTY, RN, PHD, CNL
One-day international service–learning projects are an opportunity for nursing students to engage in learning cultural awareness, knowledge, and skills. At XXX University, faculty developed these international service–learning projects in Mexico where students participated in health promotion teaching for children and families and providing health care for older adults. The purpose of this article is to describe 3 types of student experiences gained during 1-day international service–learning projects. We named these experiences cultural communication, cultural confidence, and cultural surprise. (Index words: Cultural competency; Service–Learning; International; One day) J Prof Nurs 31:242–246, 2015. © 2015 Elsevier Inc. All rights reserved.
R
ESEARCH HAS DEMONSTRATED that cultural competency education for health care workers can overcome barriers to cultural competency (Amerson, 2010; Bentley & Ellison, 2007; Kardong-Edgren et al., 2010; McAuliffe & Cohen, 2005). These barriers include lack of knowledge about cultural needs, lack of cultural sensitivity, and lack of skills in working with diverse cultures and backgrounds (Maltby & Abrams, 2009; Waite & Calamaro, 2010). Cultural competency is typically viewed as the process of effective care which the nurse provides for individuals, families, and communities within their cultural context (Campinha-Bacote, 2013). In nursing education, providing the student with experiences to build skills of cultural competency is fundamental for professional practice (American Association of Colleges of Nursing, 2008a). In the baccalaureate nursing program at XXX University, faculty created 1-day international service–learning projects in Mexico. The students' learning outcomes of this program were to enhance the following: (a) the students' cultural awareness and (b) the students' cultural knowledge by offering cultural encounters while being immersed in Mexican culture and to provide for the needs of the community (Kohlbry & Daugherty, 2013). The program evaluation methods included debriefing meetings after each visit for the students to reflect on experiences and learning (Larson, Ott, & Miles, 2010). The purpose of this article is to describe three types of student experiences California State University San Marcos. Address correspondence to Dr. Kohlbry: 1980 Falling Leaf Ct., San Marcos, CA 92078. E-mail: [email protected] 8755-7223 242 http://dx.doi.org/10.1016/j.profnurs.2014.10.009
gained through an international service–learning project: cultural communication, cultural confidence, and cultural surprise (Bosworth et al., 2006; Reising et al., 2008; Walsh, 2003). These experiences illustrate beginning development of the constructs of cultural competency (Pretorius & Small, 2007).
International Immersion Project in a Mexican Community One-day immersion visits took place between fall 2008 and spring 2010 in Tijuana, Mexico, near the California border. Four visits took place. Each trip involved 8 to 15 students; however, it was not always the same 8 to 15 students. In all 37, students participated in at least one trip with a few students participating in two. Students were allowed to choose between two sites for their immersion experience. The first choice was to teach health promotion at a Kid's Club in a colonia located near the community garbage dump in Tijuana. The second opportunity was to provide health care in a homeless shelter for indigent older adults, many of whom had chronic diseases. Residents are cared for by a salaried, missionary registered nurse (RN), lay health care workers, and volunteers from a faith community group. The older adults are brought to the shelter by family members who cannot afford to care for them, hospitals who have nowhere to refer homeless patients upon discharge, and/or by individuals who find them living on the streets. In general, clients have a variety of health challenges including diabetes, leg ulcers, recent surgical incisions, dementia, and mental illness. The shelter receives donations of food, clothing, and supplies.
Journal of Professional Nursing, Vol 31, No. 3 (May/June), 2015: pp 242–246 © 2015 Elsevier Inc. All rights reserved.
INTERNATIONAL SERVICE–LEARNING
Collaboration with on-site teams is essential for sustainable and ongoing health care for shelter patients and children at the colonia. Hope Without Borders is a faith community group that makes monthly trips to the sites (Latin American Evangelist, 2010). Hope Without Borders has staff in Mexico that provide support before and after the student visits. At the homeless shelter, an RN works full time with the residents along with the lay volunteers. One of the authors has an affiliation with Hope Without Borders, which fostered collaboration between the professional and lay health care staff on site. Our students' participation expanded the health care for patients and support for the RN and lay staff. This was a mutually beneficial experience for patients, staff, and students. Students helped identify health care needs of patients that were followed up by the RN and lay staff. An example of these experiences include assisting the RN to organize documentation of treatments for follow up by organizing notecards that listed wound descriptions and treatment needs on the cards. Documentation remained locked in the staff RN's office. A second example included assisting lay workers with activities of daily living (ADLs). The lay workers were routinely overwhelmed with the number of patients needing assistance and could not meet everyone's needs daily. Student assistance meant that all patients would receive attention that day. The RN on staff provided guidance on which patients needed priority assistance. Prior to each of the four trips, meetings were held to introduce students to the immersion project and help them plan the service–learning activities. For the first two trips, students were self-selected to participate in the projects. The student selection for these trips changed over time. As interest in the experience grew in popularity, the number of participants had to be limited because of coordination and transportation issues. As a result, on the fourth trip, faculty capped the number of participating students and developed a selection process. Students were required to submit an essay on reason/motivation for participation and personal goals for the experience. Faculty selected the students based on essay submissions. Students were not required to have previous international experience. Over the course of time, selected students became more involved in planning, organizing, and conducting subsequent trips and projects with minimal direction from faculty. To determine the health promotion activities taught at the Kid's Club, the local community leaders and an organizer from Hope Without Borders were consulted. Recommended health promotion activities that students implemented were hand washing, dental care, making healthy food choices, and engaging in physical activity. To determine community needs at the homeless shelter, students not only met with leaders of Hope Without Borders but also utilized the information obtained by the students who went on the first two trips. Identified needs included assisting with ADLs, nutrition and feeding, and chronic and postsurgical wound care. Many patients at the long-term homeless shelter were discharged from hospitals and physician offices with no follow-up
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instructions or care plan. In response to this, the students and faculty worked in teams to identify and implement care. Health conditions along border areas are often more severe than generally found beyond the distance of the border area (Kohlbry, 2011). After the last two immersion experiences, the students debriefed on their perspective of the learning experience as a group with the faculty. Debriefing occurred 1 week after the experience to give students time to reflect on their experiences and organize their thoughts. Student responses such as “I’m so glad we got to talk about this. I’m glad I got to hear others’ experience” demonstrate the value of debriefing. In the debriefing process, students processed the experience and expressed a greater understanding of cultural care. The students' reflections highlighted experiential learning that was meaningful to them. They expressed that they grew in their level of confidence regarding their professional development as a nurse and their ability to provide culturally sensitive care.
Three “Cs” of Cultural Experience This immersion experience program was evaluated through a series of debriefings with students, faculty, and Hope Without Borders leaders. Student feedback became incorporated into program improvement and evaluation. One program improvement was having students from past trips provide peer orientation to students on subsequent visits. Common areas of experiences became apparent from student comments during the trip and debriefing and informal observations from faculty. Some students published journal entries in the school of nursing's newsletter describing the details of their experiences (Manguil, 2009). The three common experiences that were described were categorized as cultural communication, cultural confidence, and cultural surprise. These experiences support the building of cultural knowledge and cultural skill, which contribute to the development of cultural competency. As part of program review, these observations regarding common experiences are not intended to be a qualitative study. Rather, these observations are intended to summarize what we believe are the successes of the learning outcomes.
Cultural Communication Two areas of cultural communication that proved important in the immersion experiences were the communication with the children, families, and elderly residents being served and with the local site coordinators in Mexico. The first area of cultural communication dealt with the need to overcome language barriers for communication with clients. To compensate for the language barrier, among the nonSpanish speaking students, we created student teams that included at least one Spanish-speaking student per team. Team teaching was especially valuable in doing health promotion teaching with the children and addressing specific psychosocial needs for elderly residents (Hughes & Hood, 2007). As part of the planning, Spanish-speaking students created a user-friendly card of Spanish words and phrases for fellow students to use. Regardless of language proficiency, students learned to communicate
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compassionately with children, families, and residents through small words and phrases, touch, and other nonverbal communications in a way that transcended language barriers and cultural differences. The second area of cultural communication that was highlighted was the need to communicate more thoroughly in the planning stages with other leaders, such as Mexico site coordinators. In planning the first trip, the group coordinated their experiences with the faith-based director in the United States (who worked with both sites). Leaders did not speak directly with the Mexico site coordinator for the homeless facility. In organizing the nursing care schedule for the first visit, the plan was to first perform ADLs and wound care, followed by serving breakfast. Once on site, the residents' coordinator informed the group that residents usually eat breakfast before receiving care. The group learned the importance of communicating plans with the site coordinator prior to the trip and remaining flexible to the needs of the community. From this experience, the group realized that there was not only a communication gap, but also, it reflected a cultural bias on our part. The bias was reflected in the expectation that residents' schedules could be arranged to accommodate our limited time on site. The group failed to appreciate that the residents' cultural perspective of “present orientation” of time was not congruent with the group's “future orientation” of time. Because the group's advanced planning was not culturally relevant, they did not want to change their schedule to accommodate the group. On future trips, leaders communicated immediately with the site coordinator on arrival and were flexible in providing care around the residents' needs and expectations. The wisdom of this approach became evident on our last trip. Upon crossing the border into Mexico, one student who is fluent in Spanish noticed a local newspaper headline stating that the residential facility, where we were headed, had burned down during the night. Everything about the planned experience changed. The team was directed to a nearby gymnasium where residents had been relocated. The students had to reorganize priorities around obtaining and offering emergency care that was culturally supportive rather than providing assistance with ADLs as originally planned. Students also had to figure out how to communicate and work with the Mexican relief personnel to coordinate care. Spanish-speaking students in our group helped translate roles and abilities to facilitate meeting the displaced residents' care needs. The students' sensitivity and flexibility were evidenced by the formation of “instant clinics,” which were small teams of students meeting the most pressing needs of the residents by providing support and personal care for the evacuees and caring for chronic wounds.
Cultural Confidence During the project preparation, the immersion experience(s), and the reflection time, students developed an understanding about their experience and became more confident and culturally aware. For example, as the immersion experience progressed and students worked with the individual clients,
families, and children, they developed more confidence in initiating care and teaching. For example, initially some students with limited Spanish skills were hesitant to participate in the health promotion teaching activities with the children. However, after initial observations and encouragement from peers, their interaction increased, which in turn increased their confidence. They became more willing to “jump in” and initiate teaching. Another valuable learning experience that students articulated was their self-discovery of the capacity to care when understanding the needs of someone from a different culture. Their self-discovery was a building block to cultural awareness and cultural competence (Campinha-Bacote, 2007). Broadening of their perspectives and world view was evident. One student who demonstrated growth in the awareness stated, “I don't think we are in Kansas anymore,” meaning what was a familiar understanding was replaced by new cultural perspectives. He experienced the realization of the unconscious ethnocentricity. In addition to growth in cultural confidence, the students' confidence in decision making led to the emergence of student leadership in planning the immersion projects. For the initial trips, faculty planned and organized the effort. Eventually, students took over the planning and coordinating of the trips. Their confidence further extended to obtaining donations of supplies such as wound dressing materials and food. Student leaders emerged and expanded the project beyond what faculty had started by developing community partnerships with hospitals, local businesses, and other health care professionals. In thinking about the continuation of these trips after they graduated, students created resource materials with organizational and cultural considerations for future students. As a part of their learning activities to meet program outcomes, students wrote reflective journals about their experiences. Several students submitted quotes from their journals to the XXX University School of Nursing newsletter (see Student A comments under “Cultural Confidence” in Table 1). That particular issue of the newsletter had a tremendous impact on the faculty and students who did not participate in the projects. The experiences described were moving, meaningful, and allowed the entire student body to learn from the cultural insights of these students.
Cultural Surprise Several experiences that students described could be categorized as “cultural surprises.” One of the RNBachelor of Science students stated that he had clinical experience but limited educational training in the area of cultural care. The student noted that, in his previous nursing program, he had seen only a single page handout describing cultural care. There was a concern about being “out of his comfort zone.” The student teamed up with a traditional 4-year Bachelor of Science students student who had completed cultural education via the school's nursing fundamentals course (American Association of Colleges of Nursing, 2008b). By working together to assist one of the residents, the student with limited
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Table 1. Student Reflections on a 1-Day International Experience and the Three Cs * Cultural confidence
Cultural surprise
Cultural communication
“During this trip, I gleaned several significant memories; one was the image of a delicate, feeble elderly woman, who thanked me profusely for giving her a blanket. That woman…grounded me …I chose nursing to make a tiny difference in at least one life and I got my wish.”
“I learned how to improvise in unexpected circumstances, how to use alternative comfort measures when there is a lack of pain medications.”
“When we arrived, I saw that the gymnasium was packed with frail, elderly people, many in wheelchairs, all with grave and solemn expressions…our group immediately began to help in every way we could…we helped pass our food and water, offered attention to hygiene, provided wound care, cared for our patients in a soothing manner…” (formed instant clinics in response to displaced residents). †
“At first glance, it was hard to see my place in helping and felt overwhelmed by the need. But as the morning unfolded, I gained the confidence that I indeed had something to offer.” “[This experience] really made me realize there are greater things going on in the world outside of our sheltered lives…the experience I had was big…like there is more that I could do, more that we should do.” (self-discovery) “I enjoyed being able to help, apply what I learned in nursing school and give back to the global community.”
“I was surprised by how much we could do, by how much difference we could make with the limited supplies and resources we had.” “[serving] in Mexico was a meaningful experience because it has made me see the conditions that people of another country live in and endure.”
* Comments †
were selected from student publications in the school newsletter. These reflections occurred after the Mexico trip when the group discovered that the residential facility for the homeless older adults had burned down.
cultural awareness education stated that his comfort level had increased. Through this experience, the student was surprised by the fact that what seemed to be the smallest contribution to a resident's care and comfort had such a tremendous impact in that culture of poverty. A second experience area that led to cultural surprise began as a concern among students and their families about traveling in a foreign country. Students who had never traveled abroad were apprehensive about navigating the border crossing, the transportation, what to do if separated from group, and general cultural differences. Students were offered reassurance in pretrip sessions by faculty. Students learned that the experience was organized with established practices and processes. The faculty members on the trip were sensitive to students with heightened concerns and made additional efforts to support them, once in Mexico. The pretrip discussions and the posttrip opportunity to debrief on this topic after the experience gave the students time to process their feelings and observations and build cultural awareness. Students were surprised by the feeling of “culture shock” or the feeling of being disoriented by the culture and the living conditions of extreme poverty. In addition, they were surprised in debriefing when they discovered and identified their own cultural biases. Table 1 displays the selected
student reflections on a 1-day international experience and the three Cs.
Conclusions In conclusion, 1-day international service–learning projects are a unique opportunity for students and faculty to work with people from different cultures and to develop cultural awareness, knowledge, and skills. From participation in these projects, faculty identified common experiences around cultural communication, cultural confidence, and cultural surprise. This type of opportunity expanded the students' capacity to care for individuals who have a different world view. In addition, these visits enhanced our students' clinical and professional growth. Although only 1 day in duration, these rich experiences encompassed learning opportunities in the areas of caring for patients from another culture, collaborating with teams, and contributing to sustained efforts to improve health care for those individuals we encountered. Further research is needed to validate international service–learning projects as a means of teaching constructs of cultural caring, which contribute to the process of building cultural competency. Nursing education is well served by implementing international service–learning projects to help students on the road to cultural competency.
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References American Association of Colleges of Nursing (2008). Cultural competency in baccalaureate nursing education. Retrieved April 10, 2010, from , http://www.aacn.nche.edu/Education/pdf/ competency.pdf 2008. American Association of Colleges of Nursing (2008). Tool kit of resources for cultural competent education for baccalaureate nurses. Retrieved April 10, 2010, from , http://www.aacn.nche. edu/Education/pdf/toolkit.pdf 2008. Amerson, R. (2010). The impact of service-learning on cultural competence. Nursing Education Research, 31, (1), 18–22. Bentley, R. & Ellison, K. (2007). Increasing cultural competence in nursing through international service-learning experiences. Nurse Educator, 32, (5), 207–211. Bosworth, T., Haloburdo, E., Hetrick, C., Patchett, K., Thompson, M. & Welch, M. (2006). International partnerships to promote quality care: Faculty groundwork, student projects and outcomes. The Journal of Continuing Education in Nursing, 37, (1), 32–38. Campinha-Bacote, J. (2007). The process of cultural competence in the delivery of healthcare services, the journey continues. (5th ed.). Cincinnati, OH: Transcultural C.A.R.E. Associates. Campinha-Bacote, J. (2013). The process of cultural competence in the delivery of healthcare servicesIn Transculutral C.A.R.E Associates (Ed.). (Retrieved August, 2013, from , http://www.transculturalcare.net/). Hughes, K. & Hood, L. (2007). Teaching methods and an outcome for measuring cultural sensitivity in undergraduate nursing students. Journal of Transcultural Nursing, 18, (1), 57–62. Kardong-Edgren, S., Cason, C., Brennan, A., Reifsnider, E., Hummel, F., Mancini, M., et al (2010). Cultural competency of graduating BSN nursing students. Nursing Education Perspectives, 31, (5), 278–285.
Kohlbry, P. (2011). Border health: Its hidden issues and implication for nursing care. Home Health Care Management and Practice, 23, (3), 193–200. Kohlbry, P. & Daugherty, J. (2013). Nursing faculty roles in interntional service-learning projects. Journal of Professional Nursing, 29, (3), 163–167. Larson, K., Ott, M. & Miles, J. (2010). International cultural immersion: En vivo reflections in cultural competence. Journal of Cultural Diversity, 12, (2), 44–50. Latin American Evangelist (2010). Latin American mission a beacon of hope in Tijuana. Latin American Evalgelist, 4–7. Maltby, H. & Abrams, S. (2009). Seeing with new eyes: The meaning of an immersion experience in Bangladesh for undergraduate senior nursing students. International Journal of Nursing Education Scholarship, 6, (1), 1–15. Manguil, W. J. (2009). Student reflections on international projects. The jouRNey. the jouRNey: California State University San Marcos, School of, Nursing, 2. McAuliffe, M. & Cohen, M. (2005). International nursing research and educational exchanges: A review of the literature. Nurse Outlook, 53, 21–25. Pretorius, L. & Small, L. (2007). Trans-cultural nursing: Exploring the experiences of international students visiting Namibia. Health SA Gesondheid, 12, (1), 12–20. Reising, D., Shea, R., Allen, P., Laux, M., Hensel, D. & Watts, P (2008). Using service-learning to develop health promotion and research skills in nursing students. International Journal of Nursing Education Scholarship, 5, (1), 1–15. Waite, R. & Calamaro, C. (2010). Cultural competence: A systemic challenge to nursing education, knowledge exchange, and the knowledge development process. Perspectives in Psychiatric Care, 46, (1), 74–80. Walsh, L. (2003). International service learning in midwifery and nursing education. Journal of Midwifery & Women's Health, 48, (6), 449–454.
AND
JOANN DAUGHERTY, RN, PHD, CNL
One-day international service–learning projects are an opportunity for nursing students to engage in learning cultural awareness, knowledge, and skills. At XXX University, faculty developed these international service–learning projects in Mexico where students participated in health promotion teaching for children and families and providing health care for older adults. The purpose of this article is to describe 3 types of student experiences gained during 1-day international service–learning projects. We named these experiences cultural communication, cultural confidence, and cultural surprise. (Index words: Cultural competency; Service–Learning; International; One day) J Prof Nurs 31:242–246, 2015. © 2015 Elsevier Inc. All rights reserved.
R
ESEARCH HAS DEMONSTRATED that cultural competency education for health care workers can overcome barriers to cultural competency (Amerson, 2010; Bentley & Ellison, 2007; Kardong-Edgren et al., 2010; McAuliffe & Cohen, 2005). These barriers include lack of knowledge about cultural needs, lack of cultural sensitivity, and lack of skills in working with diverse cultures and backgrounds (Maltby & Abrams, 2009; Waite & Calamaro, 2010). Cultural competency is typically viewed as the process of effective care which the nurse provides for individuals, families, and communities within their cultural context (Campinha-Bacote, 2013). In nursing education, providing the student with experiences to build skills of cultural competency is fundamental for professional practice (American Association of Colleges of Nursing, 2008a). In the baccalaureate nursing program at XXX University, faculty created 1-day international service–learning projects in Mexico. The students' learning outcomes of this program were to enhance the following: (a) the students' cultural awareness and (b) the students' cultural knowledge by offering cultural encounters while being immersed in Mexican culture and to provide for the needs of the community (Kohlbry & Daugherty, 2013). The program evaluation methods included debriefing meetings after each visit for the students to reflect on experiences and learning (Larson, Ott, & Miles, 2010). The purpose of this article is to describe three types of student experiences California State University San Marcos. Address correspondence to Dr. Kohlbry: 1980 Falling Leaf Ct., San Marcos, CA 92078. E-mail: [email protected] 8755-7223 242 http://dx.doi.org/10.1016/j.profnurs.2014.10.009
gained through an international service–learning project: cultural communication, cultural confidence, and cultural surprise (Bosworth et al., 2006; Reising et al., 2008; Walsh, 2003). These experiences illustrate beginning development of the constructs of cultural competency (Pretorius & Small, 2007).
International Immersion Project in a Mexican Community One-day immersion visits took place between fall 2008 and spring 2010 in Tijuana, Mexico, near the California border. Four visits took place. Each trip involved 8 to 15 students; however, it was not always the same 8 to 15 students. In all 37, students participated in at least one trip with a few students participating in two. Students were allowed to choose between two sites for their immersion experience. The first choice was to teach health promotion at a Kid's Club in a colonia located near the community garbage dump in Tijuana. The second opportunity was to provide health care in a homeless shelter for indigent older adults, many of whom had chronic diseases. Residents are cared for by a salaried, missionary registered nurse (RN), lay health care workers, and volunteers from a faith community group. The older adults are brought to the shelter by family members who cannot afford to care for them, hospitals who have nowhere to refer homeless patients upon discharge, and/or by individuals who find them living on the streets. In general, clients have a variety of health challenges including diabetes, leg ulcers, recent surgical incisions, dementia, and mental illness. The shelter receives donations of food, clothing, and supplies.
Journal of Professional Nursing, Vol 31, No. 3 (May/June), 2015: pp 242–246 © 2015 Elsevier Inc. All rights reserved.
INTERNATIONAL SERVICE–LEARNING
Collaboration with on-site teams is essential for sustainable and ongoing health care for shelter patients and children at the colonia. Hope Without Borders is a faith community group that makes monthly trips to the sites (Latin American Evangelist, 2010). Hope Without Borders has staff in Mexico that provide support before and after the student visits. At the homeless shelter, an RN works full time with the residents along with the lay volunteers. One of the authors has an affiliation with Hope Without Borders, which fostered collaboration between the professional and lay health care staff on site. Our students' participation expanded the health care for patients and support for the RN and lay staff. This was a mutually beneficial experience for patients, staff, and students. Students helped identify health care needs of patients that were followed up by the RN and lay staff. An example of these experiences include assisting the RN to organize documentation of treatments for follow up by organizing notecards that listed wound descriptions and treatment needs on the cards. Documentation remained locked in the staff RN's office. A second example included assisting lay workers with activities of daily living (ADLs). The lay workers were routinely overwhelmed with the number of patients needing assistance and could not meet everyone's needs daily. Student assistance meant that all patients would receive attention that day. The RN on staff provided guidance on which patients needed priority assistance. Prior to each of the four trips, meetings were held to introduce students to the immersion project and help them plan the service–learning activities. For the first two trips, students were self-selected to participate in the projects. The student selection for these trips changed over time. As interest in the experience grew in popularity, the number of participants had to be limited because of coordination and transportation issues. As a result, on the fourth trip, faculty capped the number of participating students and developed a selection process. Students were required to submit an essay on reason/motivation for participation and personal goals for the experience. Faculty selected the students based on essay submissions. Students were not required to have previous international experience. Over the course of time, selected students became more involved in planning, organizing, and conducting subsequent trips and projects with minimal direction from faculty. To determine the health promotion activities taught at the Kid's Club, the local community leaders and an organizer from Hope Without Borders were consulted. Recommended health promotion activities that students implemented were hand washing, dental care, making healthy food choices, and engaging in physical activity. To determine community needs at the homeless shelter, students not only met with leaders of Hope Without Borders but also utilized the information obtained by the students who went on the first two trips. Identified needs included assisting with ADLs, nutrition and feeding, and chronic and postsurgical wound care. Many patients at the long-term homeless shelter were discharged from hospitals and physician offices with no follow-up
243
instructions or care plan. In response to this, the students and faculty worked in teams to identify and implement care. Health conditions along border areas are often more severe than generally found beyond the distance of the border area (Kohlbry, 2011). After the last two immersion experiences, the students debriefed on their perspective of the learning experience as a group with the faculty. Debriefing occurred 1 week after the experience to give students time to reflect on their experiences and organize their thoughts. Student responses such as “I’m so glad we got to talk about this. I’m glad I got to hear others’ experience” demonstrate the value of debriefing. In the debriefing process, students processed the experience and expressed a greater understanding of cultural care. The students' reflections highlighted experiential learning that was meaningful to them. They expressed that they grew in their level of confidence regarding their professional development as a nurse and their ability to provide culturally sensitive care.
Three “Cs” of Cultural Experience This immersion experience program was evaluated through a series of debriefings with students, faculty, and Hope Without Borders leaders. Student feedback became incorporated into program improvement and evaluation. One program improvement was having students from past trips provide peer orientation to students on subsequent visits. Common areas of experiences became apparent from student comments during the trip and debriefing and informal observations from faculty. Some students published journal entries in the school of nursing's newsletter describing the details of their experiences (Manguil, 2009). The three common experiences that were described were categorized as cultural communication, cultural confidence, and cultural surprise. These experiences support the building of cultural knowledge and cultural skill, which contribute to the development of cultural competency. As part of program review, these observations regarding common experiences are not intended to be a qualitative study. Rather, these observations are intended to summarize what we believe are the successes of the learning outcomes.
Cultural Communication Two areas of cultural communication that proved important in the immersion experiences were the communication with the children, families, and elderly residents being served and with the local site coordinators in Mexico. The first area of cultural communication dealt with the need to overcome language barriers for communication with clients. To compensate for the language barrier, among the nonSpanish speaking students, we created student teams that included at least one Spanish-speaking student per team. Team teaching was especially valuable in doing health promotion teaching with the children and addressing specific psychosocial needs for elderly residents (Hughes & Hood, 2007). As part of the planning, Spanish-speaking students created a user-friendly card of Spanish words and phrases for fellow students to use. Regardless of language proficiency, students learned to communicate
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compassionately with children, families, and residents through small words and phrases, touch, and other nonverbal communications in a way that transcended language barriers and cultural differences. The second area of cultural communication that was highlighted was the need to communicate more thoroughly in the planning stages with other leaders, such as Mexico site coordinators. In planning the first trip, the group coordinated their experiences with the faith-based director in the United States (who worked with both sites). Leaders did not speak directly with the Mexico site coordinator for the homeless facility. In organizing the nursing care schedule for the first visit, the plan was to first perform ADLs and wound care, followed by serving breakfast. Once on site, the residents' coordinator informed the group that residents usually eat breakfast before receiving care. The group learned the importance of communicating plans with the site coordinator prior to the trip and remaining flexible to the needs of the community. From this experience, the group realized that there was not only a communication gap, but also, it reflected a cultural bias on our part. The bias was reflected in the expectation that residents' schedules could be arranged to accommodate our limited time on site. The group failed to appreciate that the residents' cultural perspective of “present orientation” of time was not congruent with the group's “future orientation” of time. Because the group's advanced planning was not culturally relevant, they did not want to change their schedule to accommodate the group. On future trips, leaders communicated immediately with the site coordinator on arrival and were flexible in providing care around the residents' needs and expectations. The wisdom of this approach became evident on our last trip. Upon crossing the border into Mexico, one student who is fluent in Spanish noticed a local newspaper headline stating that the residential facility, where we were headed, had burned down during the night. Everything about the planned experience changed. The team was directed to a nearby gymnasium where residents had been relocated. The students had to reorganize priorities around obtaining and offering emergency care that was culturally supportive rather than providing assistance with ADLs as originally planned. Students also had to figure out how to communicate and work with the Mexican relief personnel to coordinate care. Spanish-speaking students in our group helped translate roles and abilities to facilitate meeting the displaced residents' care needs. The students' sensitivity and flexibility were evidenced by the formation of “instant clinics,” which were small teams of students meeting the most pressing needs of the residents by providing support and personal care for the evacuees and caring for chronic wounds.
Cultural Confidence During the project preparation, the immersion experience(s), and the reflection time, students developed an understanding about their experience and became more confident and culturally aware. For example, as the immersion experience progressed and students worked with the individual clients,
families, and children, they developed more confidence in initiating care and teaching. For example, initially some students with limited Spanish skills were hesitant to participate in the health promotion teaching activities with the children. However, after initial observations and encouragement from peers, their interaction increased, which in turn increased their confidence. They became more willing to “jump in” and initiate teaching. Another valuable learning experience that students articulated was their self-discovery of the capacity to care when understanding the needs of someone from a different culture. Their self-discovery was a building block to cultural awareness and cultural competence (Campinha-Bacote, 2007). Broadening of their perspectives and world view was evident. One student who demonstrated growth in the awareness stated, “I don't think we are in Kansas anymore,” meaning what was a familiar understanding was replaced by new cultural perspectives. He experienced the realization of the unconscious ethnocentricity. In addition to growth in cultural confidence, the students' confidence in decision making led to the emergence of student leadership in planning the immersion projects. For the initial trips, faculty planned and organized the effort. Eventually, students took over the planning and coordinating of the trips. Their confidence further extended to obtaining donations of supplies such as wound dressing materials and food. Student leaders emerged and expanded the project beyond what faculty had started by developing community partnerships with hospitals, local businesses, and other health care professionals. In thinking about the continuation of these trips after they graduated, students created resource materials with organizational and cultural considerations for future students. As a part of their learning activities to meet program outcomes, students wrote reflective journals about their experiences. Several students submitted quotes from their journals to the XXX University School of Nursing newsletter (see Student A comments under “Cultural Confidence” in Table 1). That particular issue of the newsletter had a tremendous impact on the faculty and students who did not participate in the projects. The experiences described were moving, meaningful, and allowed the entire student body to learn from the cultural insights of these students.
Cultural Surprise Several experiences that students described could be categorized as “cultural surprises.” One of the RNBachelor of Science students stated that he had clinical experience but limited educational training in the area of cultural care. The student noted that, in his previous nursing program, he had seen only a single page handout describing cultural care. There was a concern about being “out of his comfort zone.” The student teamed up with a traditional 4-year Bachelor of Science students student who had completed cultural education via the school's nursing fundamentals course (American Association of Colleges of Nursing, 2008b). By working together to assist one of the residents, the student with limited
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Table 1. Student Reflections on a 1-Day International Experience and the Three Cs * Cultural confidence
Cultural surprise
Cultural communication
“During this trip, I gleaned several significant memories; one was the image of a delicate, feeble elderly woman, who thanked me profusely for giving her a blanket. That woman…grounded me …I chose nursing to make a tiny difference in at least one life and I got my wish.”
“I learned how to improvise in unexpected circumstances, how to use alternative comfort measures when there is a lack of pain medications.”
“When we arrived, I saw that the gymnasium was packed with frail, elderly people, many in wheelchairs, all with grave and solemn expressions…our group immediately began to help in every way we could…we helped pass our food and water, offered attention to hygiene, provided wound care, cared for our patients in a soothing manner…” (formed instant clinics in response to displaced residents). †
“At first glance, it was hard to see my place in helping and felt overwhelmed by the need. But as the morning unfolded, I gained the confidence that I indeed had something to offer.” “[This experience] really made me realize there are greater things going on in the world outside of our sheltered lives…the experience I had was big…like there is more that I could do, more that we should do.” (self-discovery) “I enjoyed being able to help, apply what I learned in nursing school and give back to the global community.”
“I was surprised by how much we could do, by how much difference we could make with the limited supplies and resources we had.” “[serving] in Mexico was a meaningful experience because it has made me see the conditions that people of another country live in and endure.”
* Comments †
were selected from student publications in the school newsletter. These reflections occurred after the Mexico trip when the group discovered that the residential facility for the homeless older adults had burned down.
cultural awareness education stated that his comfort level had increased. Through this experience, the student was surprised by the fact that what seemed to be the smallest contribution to a resident's care and comfort had such a tremendous impact in that culture of poverty. A second experience area that led to cultural surprise began as a concern among students and their families about traveling in a foreign country. Students who had never traveled abroad were apprehensive about navigating the border crossing, the transportation, what to do if separated from group, and general cultural differences. Students were offered reassurance in pretrip sessions by faculty. Students learned that the experience was organized with established practices and processes. The faculty members on the trip were sensitive to students with heightened concerns and made additional efforts to support them, once in Mexico. The pretrip discussions and the posttrip opportunity to debrief on this topic after the experience gave the students time to process their feelings and observations and build cultural awareness. Students were surprised by the feeling of “culture shock” or the feeling of being disoriented by the culture and the living conditions of extreme poverty. In addition, they were surprised in debriefing when they discovered and identified their own cultural biases. Table 1 displays the selected
student reflections on a 1-day international experience and the three Cs.
Conclusions In conclusion, 1-day international service–learning projects are a unique opportunity for students and faculty to work with people from different cultures and to develop cultural awareness, knowledge, and skills. From participation in these projects, faculty identified common experiences around cultural communication, cultural confidence, and cultural surprise. This type of opportunity expanded the students' capacity to care for individuals who have a different world view. In addition, these visits enhanced our students' clinical and professional growth. Although only 1 day in duration, these rich experiences encompassed learning opportunities in the areas of caring for patients from another culture, collaborating with teams, and contributing to sustained efforts to improve health care for those individuals we encountered. Further research is needed to validate international service–learning projects as a means of teaching constructs of cultural caring, which contribute to the process of building cultural competency. Nursing education is well served by implementing international service–learning projects to help students on the road to cultural competency.
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