An international focus in nursing education is, as yet, little developed. However, individual contributions of American nurses to practice, teaching, consultation and research in the world health arena are being documented more frequently in nursing literature (Dennis, 1985; Gosnell, 1985; Meléis, 1985). This kind of sharing of experiences for purposes of examination by colleagues is a prerequisite to a more systematic development of the concept of intercultural competency, a concept that is foundational to living and working in a pluralist society such as the United States. The educational effort presented in this article is one approach toward shaping a conceptual framework for introducing an international focus into nursing curricula.
To develop a theoretical and experiential focus on intercultural competency, the authors have collaborated in designing and implementing a credit course entitled "Comparing Health Care Systems in an Intercultural Context." The course was offered in Austria and Yugoslavia in order to present health care as that part of the public life of a country which, more than any other part, is a function of its sociopolitical conditions and aspirations. Health care is understood as a dynamic system of interactions between providers and users, embedded in a cultural context.
The course was designed to meet three objectives: 1 ) to expand the students' knowledge base for assessing health care systems; 2) to expand the students' options for understanding the relationship between providers and users of health care resources; 3) to expand the students' leadership skills through the development of intercultural competency. In attempting to meet these objectives, two approaches to learning were integrated: the comparative and the contextual.
Comparative approaches to learning emphasize similarities and differences. Students compare external factors such as technologic advances, nursing practice roles, the organization and delivery of services, management and economics of health care and education for the health professions.
The methodology of a comparative approach is the presentation and analysis of information about the health care system which will enable the student to draw some conclusions about its resources and limitations, its problems, issues, tasks, structures and functions. The outcome of this kind of learning is primarily cognitive. The student will learn new approaches to health care, and wiì develop the skills of assessment, planning, implementation, and evaluation.
Another approach to learning is what the authors have termed a contextual approach. Our use of this term differs from its usual, more limited meaning as "circumstances" external to action or behavior. When we use the word "context," we refer to the world of relationships - familial, societal and cultural - which construct, humanize and personalize action or behavior and bind people to each other over time.
A contextual approach to learning includes comparative data but goes beyond the presentation of information and attempts to stimulate the psychosocial sensibilities of the student. The emphasis is on the student's creative interaction with a society different from his or her own, enabling that individual to "step out" of his- or herself and view all previous experience, professional and otherwise, from a new and truly critical vantage point. Ideally, after such an experience, the student would be able to accept different social, ideological, and psychological conditions of a society as resources rather than obstacles to shared goals and commitments. The authors maintain that the psychological acceptance of a foreign culture, a radical willingness to adopt, if only for a time, a different pattern of thought and response, is one of the potentials of international education that is only beginning to be recognized in nursing education.
The course was offered as an elective course in the School of Nursing and was open to both graduate and undergraduate students. In addition to participation in the fieldwork experience, a paper comparing some aspect of the health care systems under study was required in order to receive credit for the course. Sixteen students, two faculty members from the University of Pennsylvania and one faculty member from Graz University participated in the program.
The duration of the program was two weeks, the first week of which was spent in Graz, Austria, a city of 250,000 inhabitants in Austria's southeast. Austria is a small neutral nation, a free-market country which has been shaped by a social-democratic government for the past 15 years. Graz is its second largest city. The second week was spent in two Yugoslavian cities located in Slovenia, a state in northern Yugoslavia: Ljubljana, the capital city of Slovenia, and Maribor, a city in the northeast. Yugoslavia, one of the leaders of the non-aligned movement, is a society based on the principle of self-management, providing for social rather than party control in public life.
The stay in each of these countries was designed to give students insight into typical and recurrent features of life and health care. Therefore, average rather than outstanding cities were selected as sites for closer examination.
Extensive advance faculty preparation for this course began about one year before its actual implementation. On the American side, the course was planned so that students could complete the spring semester, take the course and return in time to begin summer school. The cooperation of the faculty was needed so that students could arrange to complete final examinations before departing.
Students were given an extensive bibliography in advance of their departure. A pre-departure seminar was given by a guest lecturer with expertise in Central and East European studies. Several predeparture meetings between students and faculty coordinators were held so that questions and concerns could be addressed and the group could begin to form itself.
One of the authors, a faculty member from the Department of American Studies at Graz University, who is also working in the field of international exchange, coordinated the European part of the program. He planned the field experiences and the academic program, and arranged for the families with whom the students would be living while they were in Austria.
Dimensions of Learning
The integration of comparative and contextual approaches to learning described above has three major dimensions: academic, humanistic-relational, and experiential.
The academic content of the program included lectures, on-site visits and formal and informal seminars. Lecture content ranged from general introductory material, e.g., the sociopolitical context of health care in Austria and Yugoslavia, the history of nursing and medical education and the administration of health care, to content lectures focused on health problems, e.g., care of the terminally ill, domestic violence, psychiatric care and care of the physically disabled.
The academic content was selected on the basis of interests expressed by the students and faculty and the availability of learning experiences. In addition, the faculty considered approaches to health care in each of the countries which might be viewed as innovative from the perspective of the American students.
On-site lectures and visits to Graz Hospital, the largest in central Europe (3500 beds, 1200 nurses), the Graz psychiatric hospital, and medical and surgical outpatient clinics in Austria were part of the academic program. In Yugoslavia, the students visited two health care centers, each serving a population of approximately 40,000 citizens.
There were opportunities for both formal and informal dialogue among the American and European students and faculties of nursing throughout the program. Among the recurrent themes in these discussions were questions about the legal and ethical responsibility of nurses for their practice and the nature and quality of relationships between clients, physicians, and nurses.
Academic contacts with Austrians and Yugoslavs were also made on levels not immediately related to health care and nursing. The Americans participated in several of the regular classes offered by the Department of American Studies in Graz. They also met with Yugoslavian students at the School of Economics at Maribor. These discussions covered a variety of topics such as international politics, differences in economic systems, the position of women in European societies, and the role of religAon in these societies.
The humanistic-relational dimension of learning was facilitated by intensive contacts between Americans and Austrians. The 16 students spent their first week living with Austrian families or students. In many cases, this stay provided students with an opportunity for discussion and tested their understanding of what they had heard and seen in the course of lectures and field experiences.
Learning on a humanistic-relational level was also facilitated through a network of student and university contacts. Apart from the European coordinator who accompanied the group throughout their stay, at least two, and sometimes as many as four Austrian and Yugoslavian student associates, were with the Americans at all times. They provided logistical support, assisted with translation, arranged special events which were not originally part of the program, and provided the companionship of student peers.
The experiential dimension of learning was shaped by creative interactions; that is by opportunities which stimulated the students to move beyond the traditional confines of professional discipline, experience and vision to critically examine their own thinking. This kind of learning is most easily facilitated in the clinical practice environment. Therefore, students had the opportunity to spend one clinical day on the wards with their Austrian counterparts from the School of Nursing in Graz.
The student evaluations indicated that the program was largely successful in meeting student and faculty expectations. Most students not only profited from the program in terms of increased knowledge of the European context, but also came to rethink their own, American, context. The students were impressed by the different ways in which societies assume responsibility for health care in material, human and organizational terms. They grew to understand the significance of preventive programs in a developing country such as Yugoslavia which has limited financial and technological resources. Students recommended that the course should be lengthened and that a clinical day on the wards with Yugoslavian students should be built into the program. They also recommended increased content in the social -political - historical aspects of the European countries they visited.
Our experience suggests two significant benefits of shaping an international education focus in a nursing curriculum. First, a genuine understanding and appreciation of a foreign health care system is strengthened by identification of and confrontation with the socio-political context in which it is embedded. The second, and perhaps most fundamental benefit, is not so easy to verbalize. This involves the participant's personal confrontation with another culture. What is external, the experience of a foreign culture, translates into an encounter with the foreign territory of one's own thinking. The participant is challenged to overcome the traditional limitations of professional discipline, experience and vision and to move toward notions of world community and human solidarity. It seems to us that the development of concepts, resources and methods to move American nursing in the direction of greater solidarity with the world health care community is a legitimate task for nursing education.
- 1. Dennis, L.I. (1985). Nursing witKin the Soviet health care system. International Nursing Review, 32(4), 149-153.
- 2. Gosnell. D. J. (1985). The international implications of nursing education and practice. International Nursing Review, 32141, 1 05-X08.
- 3. Meléis, A.L. <1985>. International nursing; A force for knowledge development. Nursing Outlook, 3313), 144-147.