547201
research-article2014
TCNXXX10.1177/1043659614547201Journal of Transcultural NursingArbour et al.
Education Department
Strategies to Promote Cultural Competence in Distance Education
Journal of Transcultural Nursing 2015, Vol. 26(4) 436–440 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614547201 tcn.sagepub.com
Megan Arbour, PhD, RN, CNM1, Rita W. Kaspar, PhD, RN, FNP2, and Alice M. Teall, MS, FNP, PNP2
Abstract Cultural competence is a mainstay in health care and nursing education. With the expansion in the number of distancebased nursing programs across the country, innovative teaching methods for distance learning faculty are required to instill cultural competence in students. Faculty must be deliberate when planning distance-based learning activities that incorporate cultural experiences. This article describes several such strategies including the creative use of blogging, recorded lectures, the online synchronous classroom, social media, and cultural immersion projects. These methods capitalize on existing information technologies and offer distance-based students the opportunity to connect with one another, as well as develop the awareness, sensitivity, and respect that is required when providing culturally competent care. These teaching methods are modifiable to meet the teaching and learning needs of the faculty and the students, thereby allowing educators to support the integration of cultural competence into patient care for distance students. Keywords transcultural health, education, cultural competency The term culture broadly refers to human patterns of communication, thought processes, behaviors, traditions, values, and philosophy. Cultural competence as elegantly defined by Cross, Bazron, Dennis, and Isaacs (1989) is “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 (p. 13).” Culturally competent health care providers are vital in today’s health care arena and play a critical role in reducing health disparities and improving health outcomes. Disease susceptibility, reactions to and efficacy of medications, as well as health management strategies and beliefs vary by cultural group. In the United States, cross-cultural situations are an everyday patient-care reality, particularly as racial and ethnic diversity increases. Since the 1980s, nearly every type of community in the United States, whether rural or urban, has become more racially and ethnically diverse (Lee, Iceland, & Sharp, 2012). In fact, the 2010 U.S. Census projects that in 2043 there will be no single majority racial group in the country as a whole (Humes, Jones, & Ramirez, 2011). Development of cultural competence begins with the basic understanding that culture is beyond a reference to ethnicity, race, religion, or creed. Cultural barriers may arise between the health care provider and the patient or family when there is misconception and misunderstanding of an individual’s socioeconomic status, physical capabilities, or educational background. In nursing education, the importance of teaching cultural competence is universally
recognized and is an expectation of faculty, with the intended goal to maximize the ability of future nursing providers to identify, respect, and address the diverse needs of patients. Nurse educators employ a variety of strategies to promote the development of skills in providing culturally congruent care by which the patient’s own values, perceptions, and expectations to health care encounters are appreciated (Schim & Doorenbos, 2010). A single class, assignment, or activity will not make a student culturally competent. However, with repeated exposure to various assignments and learning activities, faculty can help students increase their cultural competence when providing patient care. Methods for teaching cultural competence in health science disciplines are well documented for faculty who teach in the traditional classroom setting (Ghaddar, Ronnau, Saladin, & Martinez, 2013; Long, 2012). Examples include case study assignments, reading assignments, role play, podium and poster presentations, film, service learning, interprofessional collaborations, and international cultural
1
University of Cincinnati, Worthington, OH, USA The Ohio State University, Columbus, OH, USA
2
Corresponding Author: Megan Arbour, PhD, RN, CNM, College of Nursing, University of Cincinnati, 6829 Alloway St. E., Worthington, OH 43085, USA. Email: [email protected]
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Arbour et al. immersion (Bhugra, 2003; Edmonds, 2011; Horvat, Horey, Romios, & Kis-Rigo, 2014; Wood & Atkins, 2006). At the same time, the literature regarding methods for teaching cultural competence in distance-based settings is scarce. With more than 100 distance-based nursing programs at the graduate-level alone across the United States and the number increasing (Bacow, Bowen, Guthrie, Lack, & Long, 2012), the need to optimize cultural competence teaching methods tailored for distance students is significant. Educators have concerns that this format of learning can limit the cultivation of a supportive community that effectively fosters student cultural competence (Todhunter, 2013). Is it possible for distance students to develop the awareness, sensitivity, and empathy, which together form the essential foundation for providing culturally competent care? In this article, teaching methods that take advantage of existing technologies provide distance-based educators with ways to support the integration of cultural competence in distance nursing education. These strategies may be applied or modified to suit the needs of undergraduate or graduate nursing students.
Embracing the Online Environment Students have opportunities for nursing education as never before primarily because their geographic location is no longer a barrier. Prior to the expanded use of information technologies, distance students were recognized as those who lived away from the college campus, and traditional students indicated those who were able to commute to college campus easily to attend classes. Online education has blurred those lines. Often, traditional classroom instructors have the opportunity to enhance their courses and content for web-based delivery, or to deliver their materials in a hybrid fashion in which course activities that occur online replace a certain amount of face-to-face time (Baker, 2010). Meanwhile, distance courses ordinarily refer to courses in which student– instructor interactions occur in a manner that is not face-to-face and may be asynchronous. These courses can now strategically incorporate synchronous components to allow real-time and often face-to-face conversations through the use of a webcam. To ensure that the online environment is conducive to the development of cultural competence, it is important to recognize the barriers to learning experienced by distance students. Students who have a lower sense of community or connectedness with faculty and other classmates have a higher level of frustration with online learning (Moore, 2014). In a recent analysis, undergraduate and graduate nursing students from distance education programs agreed that productive online learning is achievable given adequate time management skills, sense of peer engagement and participation, proficiency, and confidence in writing (McIntyre, McDonald, & Racine, 2013). On the other hand, technical obstacles, insufficient supervision, and limited
communication are noted problems with online instruction (Horiuchi, Yaju, Koyo, Sakyo, & Nakayama, 2009; McMullan, Jones, & Lea, 2011). To overcome these hurdles, the technologies used by graduate and undergraduate students ought to be intuitive and user-friendly, and it is helpful for instructor feedback to be frequent, meaningful, and timely.
Teaching Cultural Competence in a Distance Format In order to create online learning environments conducive to learning, nursing faculty can implement teaching methods to increase student awareness of individual biases, improve assessment of cultural perspectives, and practice cultural competence in classroom and clinical settings. To successfully implement these methods, faculty can begin by guiding their online students to reflect on their own cultural perspective. This first step is crucial, before students advance to further learning activities aimed at the promotion of delivering culturally competent patient care. Self-awareness of one’s own cultural perspective is important enough to be incorporated as an objective of every teaching strategy as the student progresses through the curriculum. Exemplary teaching approaches offered in the following sections take full advantage of technologies to implement cultural competence in distance education. These methods include a creative use of blogging as a tool to build cultural competence; recorded lectures, which provide convenient and unlimited student access to didactic materials; use of the synchronous classroom with virtual patients; cultural immersion projects that place students into diverse communities; and use of social media for culturally responsive educational efforts.
Blogging A blog is online space where messages are chronologically organized with a primary function of voicing opinions and sharing ideas. Using a private blog exclusively accessible by class members and faculty, students can safely share and identify their personal cultural perspectives. Sample topics and questions on which students can blog about their own cultural beliefs include the following: (a) Medications: Do I believe that most health problems can be cured through use of medications? Do I find it difficult myself to take medications as prescribed? (b) Poverty: What are my perceptions about why people are poor? Has anyone in my family ever had to rely on a government assistance program, even temporarily? What would I do if I ever became homeless, and could this ever be a possibility? (c) Mental Health: How would I react if a family member committed suicide? Do I believe that counseling is only for people in a crisis? Would I personally ever see a counselor? To respond to such questions, students are pushed to start a conversation with their own core values, assumptions, and
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biases. Some topics are indeed very sensitive and personal and require an inviting and nonjudgmental atmosphere in which sharing and listening are for the common and sole purpose of self-growth and developing skills to appreciate cultural differences. Blogging assignments often include a requirement for students to post their own blog and to respond to other blogs to improve student interaction. Students are typically surprised by how they respond to a question themselves, and even more so when they hear perspectives from others who are from the same culture. At the end of these activities, students typically express that the word, culture, means so much more than ethnicity, geography, and language. Topics for blogging are recommended to expand in a stepwise manner from self-assessment, to sharing clinical experiences related to providing culturally sensitive patient care, including difficult encounters related to conflicts of cultural beliefs and pearls learned.
Recorded Lectures Just as in the traditional classroom where a professor delivers a lecture regarding cultural assessment or a specific cultural group, lecture recordings are a way for students across time zones to asynchronously retrieve didactic content related to ethnicities and cultural assessment. The format of a recorded voice narration and screen-casting uploaded to the class website can be easily accessed by students at their convenience. Students have the advantage of being able to rewind and relisten to particular portions of a lecture as often as needed. Students can still see the lecturer’s face and gestures as in real life if the lecturer’s image is recorded and presented concurrently with lecture materials such as PowerPoint slides. This very method itself is learner-centered and culturally considerate for students with varying learning needs. Indeed, students in a medical-surgical nursing course demonstrated improved grades, critical thinking, teacher effectiveness, and overall learning with the utilization of a lecture recording technology Camtasia® (Carpenter, Theeke, & Smothers, 2013). The instructor is free to break down content into separate 20-minute sessions to best fit average adult learners’ attention span for optimal learning outcomes (Chaney, 2005). Periodic webinars or webcasts are also a convenient and inexpensive tool to deliver recorded lectures, and instant interactions are even possible when they are streamed to the students live.
Synchronous Classroom By definition, the synchronous online classroom is established when students and instructors are logged on to a conferencing site, such as AdobeConnect® or Blackboard Collaborate®, at the same time. The real-time, off-site communication arrangement allows students to hear and see their peers while their input gets rewarded with instant peer or faculty feedback, thus mimicking the face-to-face experience of an actual classroom. Not surprisingly, the synchronous
classroom as a distance education technology in nursing and nonnursing student bodies have received positive appraisal (Koch, Fischer, Tipold, & Ehlers, 2012; Zukowsky et al., 2011). One method of using a synchronous classroom as a teaching and learning tool for the development of cultural competence involves the use of virtual patients. The virtual patient case can be developed by the faculty. Individual students are assigned as interviewer and patient. During the patient case, classmates listen in as the interviewer (student) interacts with the patient (student), and are then asked to provide feedback, to determine patient-centered and culturally competent management options, as well as to provide health coaching. If both parties (the interviewer and the patient) activate their webcams, the rest of the class can see and hear this interview. The expected outcome from such an activity is not only for the student to be able to address the patient’s needs but also to be able to initiate the most culturally sensitive interactions and provide the most culturally appropriate solutions. In this virtual clinic environment, a variety of clinical cases can highlight different cultural realms that can then be simulated and discussed. Students may also take on a variety of professional roles, such as pharmacist, social worker, dietician, and physical therapist, to learn to think differently to resolve issues for the same virtual patient. Using the synchronous classroom in this manner, a “flipped classroom” is created, in which students gain the opportunity to apply the didactic content from asynchronous lecture during synchronous class time (The Sloan Consortium, 2013).
Cultural Immersion Capitalizing on the fact that students in distance programs can be from urban or rural settings, from in-state, out-ofstate, or overseas, a wealth of information on various cultural practices can be garnered simply through student discussions. Video conferencing technologies, such as Skype, FaceTime, and Google Hangout, help increase the cultural awareness among students and allow students to recognize the social and cultural differences face-to-face via a webcam (Stephens & Hennefer, 2013). Stephens et al. note that students prefer face-to-face connections with international colleagues versus blogging or asynchronous techniques. The use of Skype technology between nursing students in two different countries allowed students to recognize the social and cultural differences between practices in the two countries (Stephens & Hennefer, 2013). When students are able to travel internationally, cultural competence is enhanced through cultural immersion. Students who are able to participate in international immersion experiences grow in many ways including cultural competence, awareness of other cultures, as well as ways of living and managing health care (Wood & Atkins, 2006). Living, learning, and serving in the host community not only stimulate the student’s inquiry of contrasting mindsets, ethics, and values but also result in
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Arbour et al. profound lifelong compassion and acceptance of other cultures. In Levine’s interviews with baccalaureate nursing students who participated in internal immersion programs, students thought that although experiencing prejudice from others was painful, the experience helped them realize their own stereotyping and prejudices, which is empowering and liberating (Levine, 2009). Many years later, these students still undergo the life-changing effects professionally and personally in which they are flexible and innovative when facing diverse cultural encounters. For those students in distance-based programs who are able to come together for a cultural immersion trip, the connections and bonds between students who have only ever chatted online are enhanced. The students learn well together and bring their own unique perspectives to the new cultural setting. It is important to note that self-awareness of cultural bias or norms is crucial in this activity in order to allow students to learn and grow as fully as possible. In distance-based programs where students live in geographically varied cohort groups, the students can be given an assignment to explore a minority group in which they do not self-identify, in their region. The history of the minority group, its origination, language, health care cultural practices, and preferences, as well as dietary habits and lifestyle considerations can all be included in this assigned exploration. By presenting this information to their colleagues either using asynchronous or synchronous technologies, students not only learn of a different culture and gather pearls of information but also become more aware of cultural considerations that must be made when providing culturally competent care. PowerPoint presentations, videos, lectures, case studies, and papers are examples of assignments that students might submit to display their newly learned information about the local minority group. Students report satisfaction with learning about a cultural group about which they were not familiar, but for whom they will likely provide care in the future. Many report carrying this information into clinical practice in future semesters and are appreciative of the requirement to learn about their community.
Social Media A very effective way to nurture cultural competence in distance students is to assign them to use social media as the means to reach out to a community. For students in distancebased programs, their community can be defined as any online population of interest (e.g., cancer survivors who use the Internet). The emphasis on the online community is justified given recent increased use of Internet and social media by patients and caregivers when looking for health care information such as self-care and life style advice, including discussion forums (66%), social networking sites (14.8%), and blogs (14.1%; Hamm et al., 2013). Students learn that reaching out to a defined population with specific health information using social media is an
effective way to spread health care education. Popular social media platforms such as Facebook, Twitter, WordPress, YouTube, Google+, and PatientsLikeMe are excellent tools through which students are able to reach out to their online community. An example is the Multicultural Media Outreach program (MMO) developed by the National Cancer Institute (Alexander, Kwon, Strecher, & Bartholomew, 2013). Taking advantage of YouTube, the MMO has created a series of educational video feeds, “Lifelines™,” that probe culturally sensitive topics ranging from the African American men’s perspective on prostate cancer, to the American Indian physician’s attitude toward cancer treatment, and perception of cancer in the Asian and Pacific Islander communities. For a community educational project using social media, direct students to the Guide to Writing for Social Media published by Center for Disease Control (U.S. Department of Health and Human Services: Centers for Disease Control and Prevention, 2012). The ultimate goal of using this guideline is to develop a culturally responsive, evidence-based educational effort tailored for their identified community. During the process of completing a social media project, students become immersed in online communities and learn to appreciate the strengths and needs of their identified cultural groups with great depth.
Conclusion Incorporating strategies to implement cultural competence in distance education involves taking full advantage of new technologies. Student blogging, access to recorded lectures, participation in synchronous classes, immersion into diverse communities, and using social media for educational efforts are examples of specific activities that can be used to foster an online environment where shared learning and cultural competence is the expectation. Culturally competent care is the goal and the priority as educators guide distance students to integrate cultural competence into patient care. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References Alexander, J., Kwon, H. T., Strecher, R., & Bartholomew, J. (2013). Multicultural media outreach: Increasing cancer information coverage in minority communities. Journal of Cancer Education, 28, 744-747. doi:10.1007/s13187-013-0534-5 Bacow, L. S., Bowen, W. G., Guthrie, K. M., Lack, K. A., & Long, M. P. (2012). Barriers to adoption of online learning systems in US higher education. New York, NY: Ithaca S&R. Baker, J. (2010). What is a “hybrid”? Community College Journal, 81(1), 41.
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Bhugra, D. (2003). Using film and literature for cultural competence training. Psychiatric Bulletin, 27, 427-428. Carpenter, R., Theeke, L., & Smothers, A. (2013). Enhancing course grades and evaluations using distance education technologies. Nurse Educator, 38(3), 114-117. doi:10.1097/ NNE.0b013e31828dc2d7 Chaney, W. R. (2005). Top-of-hour break renews attention span. The Teaching Professor, 19(6), 1-5. Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: Georgetown University Child Development Center. Edmonds, M. L. (2011). The use of film in teaching multiculturalism to future nurse educators. Journal of Nursing Education, 50, 544. doi:10.3928/01484834-20110819-02 Ghaddar, S., Ronnau, J., Saladin, S. P., & Martinez, G. (2013). Innovative approaches to promote a culturally competent, diverse health care workforce in an institution serving Hispanic students. Academic Medicine: Journal of the Association of American Medical Colleges, 88, 1870-1876. doi:10.1097/ ACM.0000000000000007 Hamm, M. P., Chisholm, A., Shulhan, J., Milne, A., Scott, S. D., Given, L. M., & Hartling, L. (2013). Social media use among patients and caregivers: A scoping review. BMJ Open, 3(5), 1-9. doi:10.1136/bmjopen-2013-002819 Horiuchi, S., Yaju, Y., Koyo, M., Sakyo, Y., & Nakayama, K. (2009). Evaluation of a web-based graduate continuing nursing education program in japan: A randomized controlled trial. Nurse Education Today, 29, 140-149. Horvat, L., Horey, D., Romios, P., & Kis-Rigo, J. (2014). Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, (10), CD009405. doi:10.1002/14651858.CD009405 Humes, K. R., Jones, N. A., & Ramirez, R. R. (2011). Overview of race and Hispanic origin: 2010 (No. C2010BR-02). Washington, DC: U.S. Department of Commerce; Economics and Statistics Administration; U.S. Census Bureau. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-02. pdf Koch, M., Fischer, M. R., Tipold, A., & Ehlers, J. P. (2012). Can online conference systems improve veterinary education? A study about the capability of online conferencing and its acceptance. Journal of Veterinary Medical Education, 39, 283-296. doi:10.3138/jvme.0911-097R
Lee, B. A., Iceland, J., & Sharp, G. (2012). Racial and ethnic diversity goes local: Charting change in American communities over three decades (US2010 Project). Retrieved from http:// www.s4.brown.edu/us2010/Data/Report/report08292012.pdf Levine, M. (2009). Transforming experiences: Nursing education and international immersion programs. Journal of Professional Nursing, 25, 156-169. Long, T. B. (2012). Overview of teaching strategies for cultural competence in nursing students. Journal of Cultural Diversity, 19(3), 102-108. McIntyre, M., McDonald, C., & Racine, L. (2013). A critical analysis of online nursing education: Balancing optimistic and cautionary perspectives. Canadian Journal of Nursing Research, 45(1), 36-53. McMullan, M., Jones, R., & Lea, S. (2011). The effect of an interactive e-drug calculations package on nursing students’ drug calculation ability and self-efficacy. International Journal of Medical Informatics, 80, 421-430. doi:10.1016/j. ijmedinf.2010.10.021 Moore, R. L. (2014). Importance of developing community in distance education courses. TechTrends: Linking Research and Practice to Improve Learning, 58(2), 20-24. Schim, S. M., & Doorenbos, A. Z. (2010). A three-dimensional model of cultural congruence: Framework for intervention. Journal of Social Work in End-of-Life & Palliative Care, 6, 256-270. doi:10.1080/15524256.2010.529023 The Sloan Consortium. (2013). The Sloan Consortium. Retrieved from http://sloanconsortium.org/ Stephens, M., & Hennefer, D. (2013). Internationalising the nursing curriculum using a community of inquiry framework and blended learning. Nurse Education in Practice, 13, 170-175. doi:10.1016/j.nepr.2012.08.010 Todhunter, B. (2013). LOL—limitations of online learning—are we selling the open and distance education message short? Distance Education, 34, 232-252. U.S. Department of Health and Human Services: Centers for Disease Control and Prevention. (2012). CDC’s guide to writing for social media. Retrieved from http://www.cdc.gov/socialmedia/ tools/guidelines/pdf/guidetowritingforsocialmedia.pdf Wood, M., & Atkins, M. (2006). Immersion in another culture: One strategy for increasing cultural competency. Journal of Cultural Diversity, 13(1), 50-54. Zukowsky, K., Swan, B. A., Powell, M., Frisby, T., Lauver, L., West, M. M., & Marsella, A. (2011). Implementing an MSN nursing program at a distance through an urban-rural partnership. Advances in Neonatal Care, 11, 114-118.
Downloaded from tcn.sagepub.com at Duke University Libraries on November 15, 2015
research-article2014
TCNXXX10.1177/1043659614547201Journal of Transcultural NursingArbour et al.
Education Department
Strategies to Promote Cultural Competence in Distance Education
Journal of Transcultural Nursing 2015, Vol. 26(4) 436–440 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614547201 tcn.sagepub.com
Megan Arbour, PhD, RN, CNM1, Rita W. Kaspar, PhD, RN, FNP2, and Alice M. Teall, MS, FNP, PNP2
Abstract Cultural competence is a mainstay in health care and nursing education. With the expansion in the number of distancebased nursing programs across the country, innovative teaching methods for distance learning faculty are required to instill cultural competence in students. Faculty must be deliberate when planning distance-based learning activities that incorporate cultural experiences. This article describes several such strategies including the creative use of blogging, recorded lectures, the online synchronous classroom, social media, and cultural immersion projects. These methods capitalize on existing information technologies and offer distance-based students the opportunity to connect with one another, as well as develop the awareness, sensitivity, and respect that is required when providing culturally competent care. These teaching methods are modifiable to meet the teaching and learning needs of the faculty and the students, thereby allowing educators to support the integration of cultural competence into patient care for distance students. Keywords transcultural health, education, cultural competency The term culture broadly refers to human patterns of communication, thought processes, behaviors, traditions, values, and philosophy. Cultural competence as elegantly defined by Cross, Bazron, Dennis, and Isaacs (1989) is “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 (p. 13).” Culturally competent health care providers are vital in today’s health care arena and play a critical role in reducing health disparities and improving health outcomes. Disease susceptibility, reactions to and efficacy of medications, as well as health management strategies and beliefs vary by cultural group. In the United States, cross-cultural situations are an everyday patient-care reality, particularly as racial and ethnic diversity increases. Since the 1980s, nearly every type of community in the United States, whether rural or urban, has become more racially and ethnically diverse (Lee, Iceland, & Sharp, 2012). In fact, the 2010 U.S. Census projects that in 2043 there will be no single majority racial group in the country as a whole (Humes, Jones, & Ramirez, 2011). Development of cultural competence begins with the basic understanding that culture is beyond a reference to ethnicity, race, religion, or creed. Cultural barriers may arise between the health care provider and the patient or family when there is misconception and misunderstanding of an individual’s socioeconomic status, physical capabilities, or educational background. In nursing education, the importance of teaching cultural competence is universally
recognized and is an expectation of faculty, with the intended goal to maximize the ability of future nursing providers to identify, respect, and address the diverse needs of patients. Nurse educators employ a variety of strategies to promote the development of skills in providing culturally congruent care by which the patient’s own values, perceptions, and expectations to health care encounters are appreciated (Schim & Doorenbos, 2010). A single class, assignment, or activity will not make a student culturally competent. However, with repeated exposure to various assignments and learning activities, faculty can help students increase their cultural competence when providing patient care. Methods for teaching cultural competence in health science disciplines are well documented for faculty who teach in the traditional classroom setting (Ghaddar, Ronnau, Saladin, & Martinez, 2013; Long, 2012). Examples include case study assignments, reading assignments, role play, podium and poster presentations, film, service learning, interprofessional collaborations, and international cultural
1
University of Cincinnati, Worthington, OH, USA The Ohio State University, Columbus, OH, USA
2
Corresponding Author: Megan Arbour, PhD, RN, CNM, College of Nursing, University of Cincinnati, 6829 Alloway St. E., Worthington, OH 43085, USA. Email: [email protected]
Downloaded from tcn.sagepub.com at Duke University Libraries on November 15, 2015
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Arbour et al. immersion (Bhugra, 2003; Edmonds, 2011; Horvat, Horey, Romios, & Kis-Rigo, 2014; Wood & Atkins, 2006). At the same time, the literature regarding methods for teaching cultural competence in distance-based settings is scarce. With more than 100 distance-based nursing programs at the graduate-level alone across the United States and the number increasing (Bacow, Bowen, Guthrie, Lack, & Long, 2012), the need to optimize cultural competence teaching methods tailored for distance students is significant. Educators have concerns that this format of learning can limit the cultivation of a supportive community that effectively fosters student cultural competence (Todhunter, 2013). Is it possible for distance students to develop the awareness, sensitivity, and empathy, which together form the essential foundation for providing culturally competent care? In this article, teaching methods that take advantage of existing technologies provide distance-based educators with ways to support the integration of cultural competence in distance nursing education. These strategies may be applied or modified to suit the needs of undergraduate or graduate nursing students.
Embracing the Online Environment Students have opportunities for nursing education as never before primarily because their geographic location is no longer a barrier. Prior to the expanded use of information technologies, distance students were recognized as those who lived away from the college campus, and traditional students indicated those who were able to commute to college campus easily to attend classes. Online education has blurred those lines. Often, traditional classroom instructors have the opportunity to enhance their courses and content for web-based delivery, or to deliver their materials in a hybrid fashion in which course activities that occur online replace a certain amount of face-to-face time (Baker, 2010). Meanwhile, distance courses ordinarily refer to courses in which student– instructor interactions occur in a manner that is not face-to-face and may be asynchronous. These courses can now strategically incorporate synchronous components to allow real-time and often face-to-face conversations through the use of a webcam. To ensure that the online environment is conducive to the development of cultural competence, it is important to recognize the barriers to learning experienced by distance students. Students who have a lower sense of community or connectedness with faculty and other classmates have a higher level of frustration with online learning (Moore, 2014). In a recent analysis, undergraduate and graduate nursing students from distance education programs agreed that productive online learning is achievable given adequate time management skills, sense of peer engagement and participation, proficiency, and confidence in writing (McIntyre, McDonald, & Racine, 2013). On the other hand, technical obstacles, insufficient supervision, and limited
communication are noted problems with online instruction (Horiuchi, Yaju, Koyo, Sakyo, & Nakayama, 2009; McMullan, Jones, & Lea, 2011). To overcome these hurdles, the technologies used by graduate and undergraduate students ought to be intuitive and user-friendly, and it is helpful for instructor feedback to be frequent, meaningful, and timely.
Teaching Cultural Competence in a Distance Format In order to create online learning environments conducive to learning, nursing faculty can implement teaching methods to increase student awareness of individual biases, improve assessment of cultural perspectives, and practice cultural competence in classroom and clinical settings. To successfully implement these methods, faculty can begin by guiding their online students to reflect on their own cultural perspective. This first step is crucial, before students advance to further learning activities aimed at the promotion of delivering culturally competent patient care. Self-awareness of one’s own cultural perspective is important enough to be incorporated as an objective of every teaching strategy as the student progresses through the curriculum. Exemplary teaching approaches offered in the following sections take full advantage of technologies to implement cultural competence in distance education. These methods include a creative use of blogging as a tool to build cultural competence; recorded lectures, which provide convenient and unlimited student access to didactic materials; use of the synchronous classroom with virtual patients; cultural immersion projects that place students into diverse communities; and use of social media for culturally responsive educational efforts.
Blogging A blog is online space where messages are chronologically organized with a primary function of voicing opinions and sharing ideas. Using a private blog exclusively accessible by class members and faculty, students can safely share and identify their personal cultural perspectives. Sample topics and questions on which students can blog about their own cultural beliefs include the following: (a) Medications: Do I believe that most health problems can be cured through use of medications? Do I find it difficult myself to take medications as prescribed? (b) Poverty: What are my perceptions about why people are poor? Has anyone in my family ever had to rely on a government assistance program, even temporarily? What would I do if I ever became homeless, and could this ever be a possibility? (c) Mental Health: How would I react if a family member committed suicide? Do I believe that counseling is only for people in a crisis? Would I personally ever see a counselor? To respond to such questions, students are pushed to start a conversation with their own core values, assumptions, and
Downloaded from tcn.sagepub.com at Duke University Libraries on November 15, 2015
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biases. Some topics are indeed very sensitive and personal and require an inviting and nonjudgmental atmosphere in which sharing and listening are for the common and sole purpose of self-growth and developing skills to appreciate cultural differences. Blogging assignments often include a requirement for students to post their own blog and to respond to other blogs to improve student interaction. Students are typically surprised by how they respond to a question themselves, and even more so when they hear perspectives from others who are from the same culture. At the end of these activities, students typically express that the word, culture, means so much more than ethnicity, geography, and language. Topics for blogging are recommended to expand in a stepwise manner from self-assessment, to sharing clinical experiences related to providing culturally sensitive patient care, including difficult encounters related to conflicts of cultural beliefs and pearls learned.
Recorded Lectures Just as in the traditional classroom where a professor delivers a lecture regarding cultural assessment or a specific cultural group, lecture recordings are a way for students across time zones to asynchronously retrieve didactic content related to ethnicities and cultural assessment. The format of a recorded voice narration and screen-casting uploaded to the class website can be easily accessed by students at their convenience. Students have the advantage of being able to rewind and relisten to particular portions of a lecture as often as needed. Students can still see the lecturer’s face and gestures as in real life if the lecturer’s image is recorded and presented concurrently with lecture materials such as PowerPoint slides. This very method itself is learner-centered and culturally considerate for students with varying learning needs. Indeed, students in a medical-surgical nursing course demonstrated improved grades, critical thinking, teacher effectiveness, and overall learning with the utilization of a lecture recording technology Camtasia® (Carpenter, Theeke, & Smothers, 2013). The instructor is free to break down content into separate 20-minute sessions to best fit average adult learners’ attention span for optimal learning outcomes (Chaney, 2005). Periodic webinars or webcasts are also a convenient and inexpensive tool to deliver recorded lectures, and instant interactions are even possible when they are streamed to the students live.
Synchronous Classroom By definition, the synchronous online classroom is established when students and instructors are logged on to a conferencing site, such as AdobeConnect® or Blackboard Collaborate®, at the same time. The real-time, off-site communication arrangement allows students to hear and see their peers while their input gets rewarded with instant peer or faculty feedback, thus mimicking the face-to-face experience of an actual classroom. Not surprisingly, the synchronous
classroom as a distance education technology in nursing and nonnursing student bodies have received positive appraisal (Koch, Fischer, Tipold, & Ehlers, 2012; Zukowsky et al., 2011). One method of using a synchronous classroom as a teaching and learning tool for the development of cultural competence involves the use of virtual patients. The virtual patient case can be developed by the faculty. Individual students are assigned as interviewer and patient. During the patient case, classmates listen in as the interviewer (student) interacts with the patient (student), and are then asked to provide feedback, to determine patient-centered and culturally competent management options, as well as to provide health coaching. If both parties (the interviewer and the patient) activate their webcams, the rest of the class can see and hear this interview. The expected outcome from such an activity is not only for the student to be able to address the patient’s needs but also to be able to initiate the most culturally sensitive interactions and provide the most culturally appropriate solutions. In this virtual clinic environment, a variety of clinical cases can highlight different cultural realms that can then be simulated and discussed. Students may also take on a variety of professional roles, such as pharmacist, social worker, dietician, and physical therapist, to learn to think differently to resolve issues for the same virtual patient. Using the synchronous classroom in this manner, a “flipped classroom” is created, in which students gain the opportunity to apply the didactic content from asynchronous lecture during synchronous class time (The Sloan Consortium, 2013).
Cultural Immersion Capitalizing on the fact that students in distance programs can be from urban or rural settings, from in-state, out-ofstate, or overseas, a wealth of information on various cultural practices can be garnered simply through student discussions. Video conferencing technologies, such as Skype, FaceTime, and Google Hangout, help increase the cultural awareness among students and allow students to recognize the social and cultural differences face-to-face via a webcam (Stephens & Hennefer, 2013). Stephens et al. note that students prefer face-to-face connections with international colleagues versus blogging or asynchronous techniques. The use of Skype technology between nursing students in two different countries allowed students to recognize the social and cultural differences between practices in the two countries (Stephens & Hennefer, 2013). When students are able to travel internationally, cultural competence is enhanced through cultural immersion. Students who are able to participate in international immersion experiences grow in many ways including cultural competence, awareness of other cultures, as well as ways of living and managing health care (Wood & Atkins, 2006). Living, learning, and serving in the host community not only stimulate the student’s inquiry of contrasting mindsets, ethics, and values but also result in
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Arbour et al. profound lifelong compassion and acceptance of other cultures. In Levine’s interviews with baccalaureate nursing students who participated in internal immersion programs, students thought that although experiencing prejudice from others was painful, the experience helped them realize their own stereotyping and prejudices, which is empowering and liberating (Levine, 2009). Many years later, these students still undergo the life-changing effects professionally and personally in which they are flexible and innovative when facing diverse cultural encounters. For those students in distance-based programs who are able to come together for a cultural immersion trip, the connections and bonds between students who have only ever chatted online are enhanced. The students learn well together and bring their own unique perspectives to the new cultural setting. It is important to note that self-awareness of cultural bias or norms is crucial in this activity in order to allow students to learn and grow as fully as possible. In distance-based programs where students live in geographically varied cohort groups, the students can be given an assignment to explore a minority group in which they do not self-identify, in their region. The history of the minority group, its origination, language, health care cultural practices, and preferences, as well as dietary habits and lifestyle considerations can all be included in this assigned exploration. By presenting this information to their colleagues either using asynchronous or synchronous technologies, students not only learn of a different culture and gather pearls of information but also become more aware of cultural considerations that must be made when providing culturally competent care. PowerPoint presentations, videos, lectures, case studies, and papers are examples of assignments that students might submit to display their newly learned information about the local minority group. Students report satisfaction with learning about a cultural group about which they were not familiar, but for whom they will likely provide care in the future. Many report carrying this information into clinical practice in future semesters and are appreciative of the requirement to learn about their community.
Social Media A very effective way to nurture cultural competence in distance students is to assign them to use social media as the means to reach out to a community. For students in distancebased programs, their community can be defined as any online population of interest (e.g., cancer survivors who use the Internet). The emphasis on the online community is justified given recent increased use of Internet and social media by patients and caregivers when looking for health care information such as self-care and life style advice, including discussion forums (66%), social networking sites (14.8%), and blogs (14.1%; Hamm et al., 2013). Students learn that reaching out to a defined population with specific health information using social media is an
effective way to spread health care education. Popular social media platforms such as Facebook, Twitter, WordPress, YouTube, Google+, and PatientsLikeMe are excellent tools through which students are able to reach out to their online community. An example is the Multicultural Media Outreach program (MMO) developed by the National Cancer Institute (Alexander, Kwon, Strecher, & Bartholomew, 2013). Taking advantage of YouTube, the MMO has created a series of educational video feeds, “Lifelines™,” that probe culturally sensitive topics ranging from the African American men’s perspective on prostate cancer, to the American Indian physician’s attitude toward cancer treatment, and perception of cancer in the Asian and Pacific Islander communities. For a community educational project using social media, direct students to the Guide to Writing for Social Media published by Center for Disease Control (U.S. Department of Health and Human Services: Centers for Disease Control and Prevention, 2012). The ultimate goal of using this guideline is to develop a culturally responsive, evidence-based educational effort tailored for their identified community. During the process of completing a social media project, students become immersed in online communities and learn to appreciate the strengths and needs of their identified cultural groups with great depth.
Conclusion Incorporating strategies to implement cultural competence in distance education involves taking full advantage of new technologies. Student blogging, access to recorded lectures, participation in synchronous classes, immersion into diverse communities, and using social media for educational efforts are examples of specific activities that can be used to foster an online environment where shared learning and cultural competence is the expectation. Culturally competent care is the goal and the priority as educators guide distance students to integrate cultural competence into patient care. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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