Since Leininger (1978) first described international involvement and transcultural nursing as an important area of practice and study, baccalaureate and higher degree nursing education has experienced an emerging interest in international nursing. May and Meleis (1987) described approaches to promote cultural awareness among nursing students that included contact with international colleagues. Glittenberg (1988a, 1988b) drew attention to nursing's potential role in promoting world health with a clear imperative for education and action. Meleis (1985) provided important reasons for nurses to participate in international nursing: to enhance their own understanding of America's subcultures, to open closed minds by increasing tolerance and sensitivity, and to aid in the development of nursing knowledge. Nursing interest in international programs reflects a more general trend in higher education that many feel offers students a broadened world view, increased self-confidence, and enhanced learning opportunities (Standeven, 1988).
In 1986, Lindquist conducted a survey of more than 300 baccalaureate schools and reported that 14% of the schools had study-abroad programs for students in nursing courses, faculty members of a European exchange program stated that the international experience can enable the student to " 'step out' of his- or herself and view all previous experience, professional or otherwise, from a new and truly critical vantage point" (Cotroneo, Grunzweiz, & Hollingsworth, 1986, p.386).
Although compelling, such descriptions of program benefits are subjective and anecdotal. Since the primary role of curricula is arguably to enhance students' cognitive abilities, international exchange programs might best be assessed by the degree to which they affect thinking and learning. Student development theory provides an objective perspective from which to assess the level of cognition of undergraduate students and to assess whether international experiences promote meaningful cognitive growth. The purpose of this article is to begin an objective assessment of international programs using student development theory comparing cognitive growth in a cohort of senior nursing students, some of whom participated in an international exchange.
Review of the Literature
Perry's (1970) theory of young adult cognitive development is based on a 4-year study of undergraduate students that indicated that students responded to the challenges of the college experience in predictable ways. Perry found that most students described a dissonance resulting from experiences that did not "fit" their world view. Students accommodated the disequilibrium by restructuring their thinking in a manner that moved from simple, concrete thinking patterns to relativistic ones. Perry described discrete steps in thinking evolution that determined positions. There are nine positions, five of which are commonly encountered in college undergraduate students, and students both in nursing and other majors are generally found to be in positions two through four (Colline, 1981; Frisch, 1987; Knefelkamp, 1974; Stonewater & Daniels, 1983; Weiss, 1984).
Both instructional techniques and student services efforts have been evaluated using changes in Perry positions as an outcome measure (Frisch, 1986; Knefelkamp, 1974; Ferratore, 1984; Stonewater & Daniels, 1983; Weiss, 1984). Based on previous studies, the author elected to evaluate Perry positions in a group of nursing students before and after international exchange experience. It was reasoned that exposure to diversity might challenge established views and bring about measurable cognitive change.
In 1988, the Department of Nursing at Southeast Missouri State University offered a student nurse exchange program as an elective option for students taking their senior year course in Community Health Nursing. The exchange, arranged through an agreement with the School of Nursing at the University of the Yucatan in Menda, Mexico, allowed American students and their instructor to study in Mexico for 6 weeks of a 16-week semester and to utilize Mexican facilities and clinical placements.
The instructor traveling with the students was bilingual and had both lived and conducted research in Mexico. In addition to a nursing background in community nursing, she also had graduate-level training in anthropology and was familiar with Mexican culture and customs. The American students and the instructor traveled together and shared accommodations in a small hotel for the 6 weeks spent in Mexico. The instructor provided weekly instruction in English on course content in community health nursing, following the same course outline that the students would have received had they remained at home. Clinical placements in Mexico permitted the American students to attend rural clinics, make client home visits with Mexican nurses, and deliver health teaching projects to school children. In addition to the courserelated activities, the students had much interaction with Mexican student nurses and their families.
The international elective option was open to all students in the senior class; however, because of cost and the preprogram requirement of extra Spanish language study, only 6 students out of a class of 27 participated. All of the students were in their final semester of the program and were in good academic standing. All 6 were female; of those who did not participate in the exchange, 19 were female and 2 were male. Age distribution was comparable in participants and nonparticipants.
The Measure of Epistemological Reflection (MER) was used to measure the students' levels of cognitive development according to Perry's theory. The MER is a paperand-pencil test that presents the subject with a series of questions and calls for short essay responses in six separately scored educational categories (decision making, role of learner, role of teacher, role of peers, evaluation, and view of knowledge, truth, or reality) (Taylor, 1983).
The MER has high inter-rater agreement and internal consistency (Baxter-Magolda & Porterfield, 1985) and requires that two individuals certified in its use score each protocol for each subject. Although scoring is initially done blind to the other rater's results, the two raters meet to reach a consensus on each protocol item where there is disagreement.
The study was designed as a cohort study involving all students in the senior nursing class. Student participation was voluntary; anonymity was assured. The subjects were given the MER once during the second week of the semester and again 15 weeks later. The raters scoring the MER were blind to student identity, to whether individual students had participated in the exchange program, and to whether a given protocol was from the beginning or the end of the semester.
Because of small sample size, the Fisher exact ¿-test was used to compare participant and nonparticipant groups (Siegel, 1956). This test is appropriate for use in evaluating the difference between two groups of ordinal data organized in a 2 x 2 table. Appropriate to a cohort study, relative risk and attributable risk calculations also were done, expressed as follows: relative risk (RR) = probability of cognitive improvement given Mexico exchange participation/probability of cognitive improvement without participation; attributable risk = (RR-I )/RR (Ibrahim, 1985).
Twenty-three of the 27 senior students completed the study, including all six of the Mexico exchange students. All students scored either in Perry position two or three on both early semester and late semester testings, but nine students (five of whom were Mexico exchange students) advanced in their ratings. Using the computation of "relative risk," the Mexico exchange students were 3.5 times as likely to improve on Perry testing than were students who did not participate. Seventy-one percent of the measured cognitive improvement seen in the senior class can be attributed to the Mexico program. These differences in cognitive level also are statistically significant when analyzed by the Fisher exact i-test (p = .018).
This study shows that an international exchange program can have a striking impact on measured student cognitive development. Although euch benefit has been claimed anecdotally, the author is not aware of any previous objective assessments of such programs. The data must be interpreted with considerable caution because of several potential sources of bias. The first and most important is the small sample size. The present study should be regarded as a pilot survey until other studies with larger samples or larger cumulative experience confirm or refute the reported findings.
Second, the study was designed as a cohort study and is subject to the types of biases intrinsic to such studies, the most important of which is related to subject selection. Four students declined to participate in both the Mexico exchange and in the evaluation. Even if each had shown significant cognitive growth during the semester, the exchange students would have been twice as likely to improve as did their colleagues. Although such a result would be less striking than the 3.5 ratio observed, it would still represent a significant difference within the cohort. Of more significance, the students who chose to go to Mexico may differ in some systematic way from those who chose not to go. Since there were financial costs to participation, it actually is likely that such differences do exist. The author does not have data on family socioeconomic status broken down by participation status, but general demographic data for this senior class show striking homogeneity in background, family income, urban-rural origin, and other factors that might provide systematic bias. Another possible bias might arise if the Mexico participants scored unusually low on initial testing and therefore could more easily improve with minimal cognitive stimulation. There was no difference on first test MER scores between participant and nonparticipant groups.
Finally, there was some cognitive growth observed in students who did not participate in the Mexico exchange. The present program was truly an exchange, and Mexican students visited the Missouri campus soon after the Missouri students returned from Mexico. The presence of international nursing students may have influenced students who did not themselves participate in the Student Nurse Exchange Mexico portion of the exchange. If this had occurred, it would have reduced the statistically significant differences between participant and nonparticipant groups but would not otherwise contribute to study bias.
This study provides the first evaluation of students who participated in an international exchange program from a cognitive development perspective and indicates that international experiences can alter the students' thinking toward a more relativistic and more mature level of cognition. As nursing moves toward a global perspective, more international exchange programs may be offered. This author recommends further evaluation of all such programs, attending to the possible positive effects the exchange programs may have on the students' cognitive development.
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