Journal of Nursing Education

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"I Saw it in a Different Light": International Learning Experiences in Baccalaureate Nursing Education

Linda V Walsh, PhD, CNM; Jeanne DeJoseph, PhD, CNM, FAAN

Abstract

ABSTRACT

Health care providers in the United States are faced with delivering care to an increasingly diverse population. Nursing leaders and their respective organizations long have recognized the need to prepare nurses who understand the effects of the growing global community. Inclusion of cultural content in theory courses and clinical assignments in diverse settings are two ways to increase student nurses' cultural competency. This study explored the experiences of nursing students and faculty mentors who sought to increase their cultural competence through participation in a short-term immersion learning project in Central America. Analysis of data gathered through interviews and journal entries identified three themes - being "other," "I was already a nurse," and expanding my worldview.

Abstract

ABSTRACT

Health care providers in the United States are faced with delivering care to an increasingly diverse population. Nursing leaders and their respective organizations long have recognized the need to prepare nurses who understand the effects of the growing global community. Inclusion of cultural content in theory courses and clinical assignments in diverse settings are two ways to increase student nurses' cultural competency. This study explored the experiences of nursing students and faculty mentors who sought to increase their cultural competence through participation in a short-term immersion learning project in Central America. Analysis of data gathered through interviews and journal entries identified three themes - being "other," "I was already a nurse," and expanding my worldview.

Health care in the United States is being provided to an increasingly diverse population. Migration by choice or force dramatically has changed the Tace" of communities in many geographical areas. In the past decade, the number of refugees displaced by war, environmental crisis, or economic collapse has increased 60% to 48 million (Institute of Medicine, 1997). Health care providers are challenged by necessity to understand the many cultural factors that influence individuals' response to health and illness and must develop attitudes and skills that will help them behave in culturally appropriate ways. Green (1982) indicated that culturally competent workers are those who know, appreciate, and use the culture of another group to help with problem resolution. Culturally competent health care professionals accept and work with cultural differences using an open, sincere approach without condescension or patronization.

Nursing leaders and organizations long have recognized the need to prepare nurses who understand the effects of the growing global community. Cultural competence in nursing first was addressed by Leininger as transcultural nursing in the late 1970s. However, the definitions and descriptions of behaviors associated with cultural competence continue to be developed (Leininger, 1978, 1995; St. Clair & McKenry, 1999). The American Academy of Nursing (AAN) recommended using the term "cross-cultural health care," rather than transcultural or intercultural care, because it is a more global and interdisciplinary term. Cross-cultural nursing care is defined as "care provided to individuals, families, or groups that are considered (by self or others) a minority because of race, culture, heritage, or sexual orientation" (AAN Expert Panel on Culturally Competent Nursing Care, 1992, p. 278). In the 1990s, the term "cultural competence" in health care replaced earlier terms.

Cultural competence is an essential element of professional nursing practice because the cultures of medicine and nursing may conflict with patients' beliefs, values, and practices related to health and illness. Nurse educators have proposed a variety of ways to integrate cultural aspects of care into the academic environment. Inclusion of cultural content in theory courses and clinical assignments in communities rich in cultural diversity commonly are included in baccalaureate nursing curricula. In addition, it has been suggested that immersion experiences in which students live and work in other countries to experience the daily Ufe of others contribute to increased cultural awareness and sensitivity (St. Clair & McKenry, 1999). This study explored the experiences of nursing students and faculty mentors who participated in a short-term immersion learning project in Central America to identify conceptual themes that may contribute to development of cultural competence.

LITERATURE REVIEW

Although many secondary sources suggest use of immersion experiences in nursing programs as a way to increase students' cultural awareness, relatively little research has been conducted on the process and outcomes of such programs. Zorn, Ponick, and Peck (1995) found that students in a study-abroad group demonstrated significantly more cognitive growth, compared to students who did not study abroad. Zorn (1996) also studied the long-term effects of participation a study-abroad program by surveying alumni who had participated in international study during their baccalaureate nursing education and found that study-abroad participants reported increased personal development and perspectives regarding the global community. In addition, students who studied abroad for 12 to 16 weeks demonstrated greater longterm effects than students who participated in short immersion projects. St. Glair and McKenry (1999) explored whether there was a difference in the achievement of cultural self-efficacy between nursing students who participated in a short-term international project and those who did not. The findings suggested that living in a culture different from their own challenged participants' beliefs and values, increased their awareness of self and others, and helped them recognize their own ethnocentrism (St. Clair & McKenry, 1999).

Haloburdo and Thompson (1998) explored the similarities and differences between students' international learning experiences in developed and developing countries. Students' reflections identified similarities in experiences, regardless of the country of study. The investigators suggested that length of time for the experience may not be as critical as the experience itself for learning outcomes and that a short-term immersion enhanced participation in a student group with many personal and work responsibilities (Haloburdo & Thompson, 1998).

Several other investigators explored the effects of working with community members as a learning experience (Kavanaugh, 1998; Simoni & McKinney, 1998). It has been suggested that development of cultural competence can be promoted further through concepts and commitments that have come to be defined as service learning, which is a "reciprocal relationship between students and communities in which both parties engage in service and learning" (Peterson & Schaffer, 1999, p. 208). Inherent in service learning is the belief that students and community workers are considered to be teachers and learners together. Although many nursing programs provide students with experiences working in and with communities, they have not always recognized the effects of true collaboration among community members, faculty, nursing school staff, and students.

METHOD

Design

This exploratory descriptive study aimed to identify key experiences of students and faculty that may influence development of cultural competence for nursing practice.

Sample

Selected participants included 10 students and 2 faculty members from a Jesuit and Roman Catholic university in the western United States. Students interested in participating in the immersion experience were required to complete an application that included short essay questions addressing the applicant's strengths related to community building in the group, commitment to work in diverse communities, and interest in increasing knowledge about other cultures. A faculty panel reviewed the applications and ranked applicants for selection. Although fluency in Spanish was not required, applicants who spoke Spanish were given preference for participation. Prior to the immersion experience, participants were required to attend several planning meetings involving an introduction to the community and culture and a discussion of the service-learning process. Students were expected to develop and implement fund-raising initiatives to provide donations of medical supplies to the community.

Setting

San Lucas Tollman, Guatemala, is a community located on the southeast shore of Lake Atitlan and serves approximately 20,000 people in surrounding pueblos (C. de Castellanos, personal communication, June 24, 2000). Approximately 82% of the inhabitants are indigenous Mayan people, and the remainder are "Ladino," or mixed indigenous and Spanish races (C. de Castellanos, personal communication, June 24, 2000). Most residents support their families though agricultural work on land belonging to wealthy landowners or on small tracts of their own land. Although the Ladino population speaks Spanish, the indigenous population speaks a variety of Mayan dialects, with Cakchiquel being the most common in this community. More than 80% of the population lives in extreme poverty (Lang & Elkin, 1997). Substandard housing is the norm, with many families living in houses constructed of wooden planks or lashed-together cornstalks, with dirt floors and open fires for heat and cooking. Pit toilets may or may not be available to occupants.

Most births are attended by comadronas (i.e., indigenous midwives), who provide care in homes and have little formal education. Accurate vital statistics are not available, but governmental statistics based primarily on urban populations indicate unacceptably high infant and maternal mortality rates. National statistics suggest an infant mortality rate of 51.3 per 1,000 live births (Lang & Elkin, 1997), compared to the United States infant mortality rate of approximately 8 per 1,000 live births. A community review of infant deaths in San Lucas Tollman in 1999 suggested a neonatal death rate of 98.8 per 1,000 live births (de Castellanos, 2000). One study identified the maternal mortality rate as 152.6 deaths per 100,000 live births (Keatler & Ramírez, 2000), compared to a rate of 7.5 per 100,000 live births in the United States (Centers for Disease Control and Prevention, 1998).

In 1999, the local government appointed a committee to investigate the unacceptably high mortality rates and develop interventions to decrease preventable deaths in San Lucas Toliman. Committee members included community physicians, nurses, and comadronas. During a spring break immersion project with non-nursing students, the first author (L.V.W.) was approached by the committee chair and asked to collaborate with the community as they provided prenatal care services and training for the comadronas.

Project activities were determined by community members. During the immersion experience for this study, participants were split into two teams, each accompanied by a faculty member and a community health worker who was a nurse. Encounters tended to follow a pattern. After travel to remote rural communities, the team would be introduced to a comadrona, who talked about her training and current practice. The team then would visit the comadona's clients, either in their homes or in community settings. The comadronas demonstrated their empirical knowledge of pregnancy care, and the students and faculty assessed the clients using tools not readily available to comadronas (e.g., stethoscope, sphygmomanometer, fetoscope).

Instruments

For this study, a demographic data sheet was developed to obtain information about participants' ages, ethnicities, and birthplaces, as well as languages they spoke and their previous international experiences. Three interview schedules were developed - one for students and one for faculty prior to the immersion experience and one for both after the experience. The students' preimmersion interview included questions related to the reasons they had applied and their knowledge, attitudes, and skills. They also were asked about their preparations for living in another country and the strengths and fears they brought to the experience. Faculty mentors were asked questions related to how they became involved in the project, their previous experiences with immersion projects, their strengths, and their expectations for the trip.

After the experience, all participants were asked to "tell me about your trip." It was assumed that participants would select the most memorable parts of the experience to relate during the interview. Based on participants' answers, prompts for additional information included questions about the most memorable part of the experience, what annoyed them most, what emotional and physical challenges they faced, what moved their spirits, and if and how they had been changed by the experience. They also were prompted to discuss their participation in the research project. Finally, participants were asked to describe reentry into the United States after the experience. Other data sources included students' applications; journals kept by all participants during the 2-week immersion experience, which were mailed directly to the research associate on return to the United States; a 2-hour postimmersion focus group interview; and a written evaluation of the experience.

Procedures

After university Institutional Review Board approval was obtained, the 10 students and 2 faculty mentors were asked to participate by a research associate, who had no commitments to the university and was unknown to all of the students and one of the faculty mentors. The research associate (J.D.) was a doctorally prepared nurse midwife with extensive interviewing and qualitative research experience.

All participants were asked to select a pseudonym that was used to identify them in all aspects of data collection and analysis, except for the onsite discussions, the postimmersion focus group interview, and the anonymous written evaluation. Data collection began with audiotaped, semistructured interviews prior to leaving the United States, which were conducted by the research associate at a time and in a place convenient for participants. All interviews were transcribed by the research associate to maintain anonymity during data analysis.

Data Management and Analysis

The principal investigator (L.V.W.) was both a participant and data analyst. The research associate collected, transcribed, and analyzed all interview data to protect participants' anonymity and to serve as a relatively objective observer and analyst. The principal investigator and research associate each reviewed the students' applications and evaluations to provide background information about participants. Each investigator then reviewed all participants' interview transcripts and journals.

The primary data sources for this analysis were the interview transcriptions and journals. A process of analytic induction, as described by Huberman and Miles (1994), was employed by both investigators. Each investigator reviewed the documents and generated field notes, including marginal notes and remarks. As themes were identified, verification processes were initiated by reading across data sources to modify first impressions based on subsequent ones. In this way, data were reduced, and tentative conclusions were reached. Each investigator prepared preliminary thematic analyses for a joint meeting. During that meeting, each theme generated in relation to specific data segments were reviewed. Through an iterative process of data reduction, three themes were identified - being "other," "I was already a nurse," and expanding my worldview.

RESULTS

Sample

Twelve women were selected to participate in the immersion experience. AU agreed to participate in the research project as well. Three participants withdrew from the research project before the preimmersion interview (i.e., the first data collection period), one because of illness and two for undisclosed reasons. The median age of the 9 participants was 28.4, with a range of 21 to 52 (mode =s 24). Two participants were faculty members, two were recent graduates of the baccalaureate program, and five were upper division undergraduate students. Most (n = 7) had been born ZD the United States. Five participants identified themselves as European American, 3 were Latina, and 1 selected "other." Most participants (n = 6} spoke both English and Spanish, and the remainder spoke English only. Three participants had no international experience, 3 stated they had "some," and 3 reported a "great deal" of international travel. All participants contributed to most of data sources.

Themes

Being "Other." One rationale for the use of immersion experiences is that living in a community different from one's own increases awareness of the experience of being "other." Immersion experiences enhance participants' ability to recognize their own ethnocentrism, while developing an understanding of the conflicts experienced by minority and immigrant populations in the United States. Participants in this study quickly recognized that they were clearly the minority. One participant noted in her journal:

I had, for the first time, the very real feeling of being the other here - much larger, lighter in color, and speaking a different language. As I went through [the market] and made a purchase, I was struck by how stressful it was to be dealing in a foreign land with money, language, and culture unfamiliar I reflected on the patients Tve cared for from countries other than the U.S. - how much more stressful that feeling of otherness must be when coupled with illness.

Another participant noted, "One of the difficult things is that we stick out so much as people of privilege. Just coming here from the U.S. indicates that we have a lot of money by Guatemalan standards." Participants whose families were from Mexico and Central America learned they were considered "other" because of their identification as Americans, rather than Latinas.

The language barrier faced by most participants also contributed to their experience of being "other." After the first few days of providing care, one participant wrote:

It's been hard for me also because I don't speak much Spanish, so I can't talk to the women during the examinations. This makes it quite difficult for me, for that's a major part of nursing - to build that relationship.

Another participant, who had basic Spanish skills, wrote, "I feel badly that I can't express myself better in Spanish. I'm understanding more, but it is so frustrating to not know words for things."

Even participants with conversational Spanish skills faced language barriers when communicating with women and families who spoke Cakchiquel. One participant, who provided translation services for those who did not speak Spanish, wrote:

It's very tough being the translator because I hear things I don't want to believe.... [One of the community workers] was trying to convince the local Mayan ladies of the importance of going to the clinic, and then she began to use scare tactics.... And I almost think that she told them that the baby would die, but she said this in the Mayan language, which is so difficult to understand.

One positive outcome of being identified as "other" was that, on return to the United States, a common reflection among participants was that "being able to work with a culture other than my own was very enlightening and gave me the opportunity to become more comfortable in a situation where I was a minority."

"I Was Already a Nurse." In the preimmersion interviews, participants identified specific fears as they prepared for the experience. Fear of the unknown was noted by several participants. One student noted that she was "most afraid of what I am going to see." Participants shared fears related to possessing inadequate nursing knowledge and skills. One participant said, "I know how to be safe as a nurse here. What if it's not enough? What if something still goes wrong?" Another participant feared "getting stranded by myself with a health crisis and not knowing what to do."

After one of the first days of service, one student noted in her journal, "My fears of not being competent enough are coming true, but I'm working on it and asking questions, trying to learn as much as I can." By the fourth day of work, students demonstrated increased confidence in their abilities to assess and intervene appropriately. Another student wrote, "Each day that we are here, I think we build more trust and are able to help others more and more because of that."

Facing the severe poverty experienced by many families was disturbing to almost all participants. AU of them wrote about one particular case in their journals. For example, one participant wrote:

We had an interesting case today. There was a lady who had a 4 year old, a 17 month old, and a 4-day-old infant.... We were told that she [the mother] had a fever, and that's all they [the community nurses] knew. Upon entrance to her house, we could tell she [the woman] as extremely poor, poorer than previous families. Her house was one room, with flies all over. She could barely sit up when we came [because] she was too tired and weak. We wanted her to go to the clinic for IV [intravenous] antibiotics, but she said she couldn't because her husband works long days, and nobody would be there to take care of the kids.

The woman's sister eventually was found to watch the two oldest children, and the team transported the woman and her infant child to the hospital for medical treatment. The woman responded quickly to intravenous fluids and antibiotics. However, one participant summarized the feelings of many in the group when she wrote, "It was really depressing today. Don't know what we can do!! Feel so helpless." Another participant wrote, "It's pretty sobering to realize that without treatment, she [the woman] could have very well died, leaving three small kids and a husband who pushes a... cart in the streets from 7 a.m. to 7 p.m."

At the end of the 2-week experience, students recognized they did have the knowledge and skills to provide care and that they had developed a community of their own, which nurtured and supported its members. One student noted in a postimmersion interview:

In nursing school, it is easy to look somewhere else to find the answer. One can look up lab values or another nurse's SOAP [form of recordkeeping, which stands for subjective, objective, assessment, plan] notes. But, this experience made us look within [ourselves] and made us seek out the answer from what we had learned in school.

Other students noted, "We worked as a team, and we learned a lot from each other," "We learned to lean on each other," and "We each had a little bit of information and we put it together. We all pulled together and figured it out."

Other students discussed their amazement at their knowledge and skills. One student stated:

[The experience] helped build my confidence and allowed me to practice hands on what I have been learning in school so far. It pushed me to another level in my abilities and made me realize that I have a much larger knowledge and skill base than I had thought.

Other participants' comments included, "I pushed myself to do things I didn't know I could," and "I've never been so surprised at my abilities and so proud of myself."

The students recognized they were ready to practice as professional nurses and expressed confidence in their abilities to move from the role of student to graduate. One student stated, "I realized that I was already a nurse." Another participant summarized a common thread of recognizing the essence of nursing:

[I learned] what it really means to be a nurse. It's not about making sure that you chart every little thing or that the monitors are working right. It is about the people. Not only is it about the people [clients] you are working with, but it is about your fellow workers as well.

One of the most moving comments offered during the postimmersion interview was, "We grew up so much in 2 weeks."

Another example of how the immersion experience affected students' growth as professional nurses was related to their perception of the spirituality of the comadrona role. Participants noted that the comadronas "all spoke of a spiritual calling to their role in this community and the honor of serving in that role." In the postimmersion interview, students reported that recognizing this aspect of the care provider role resurrected their own sense of "calling" into nursing. One student stated, The trip brought up my calling. . . . With this calling and the skills I developed through my education, I feel my head and heart are in sync."

Expanding My Worldview. Being in an environment different from their home challenges travelers to assess their view of the world. Participants began this process during preparation for the trip. One participant said, "It's not so much what I'll do for them, it's that they are going to be molding who I am and will become." Another participant shared, "The function of this 2 weeks is that it will knock me off center."

Participants' journal entries and postimmersion interviews demonstrated that they did begin to view the world in a different way. Almost all participants expressed what was written by one, "Being culturally sensitive is harder than I had imagined." One student reflected on one encounter in a small remote community:

How do we help change [practice] and still fully respect their culture and beliefs? An example I found interesting today was that they suspected twins because the woman was having pains while working the previous day. The rationale threw me off, and I chuckled about it.... I don't understand the indigenous beliefs, and since they are far off from what we are taught in the U.S., I automatically thought it [their beliefs] were worse.

Another students wrote, "It has been a great experience seeing how the comadronas work here. I had imagined it totally different than it is. It's been quite a lesson for me." One student also shared that one of the most important things she experienced was "the ability to learn from this culture and to realize that there are different ways of doing things." Participants recognized that as they began seeing life around them differently, they themselves changed. This process was exemplified by one participant's reflection after returning to the United States. She said, "I was changing myself and making a dent in someone else. I left a piece of myself and gained a piece of them."

When asked to describe the experience at a postimmersion meeting with university administrators and faculty, one student summarized:

We went to the fincas [coffee plantations] every day. We earned the [comadronas'] trust, and they turned their patients over to us. We were partners with them. We let them draw conclusions and stay in charge.... After a while we were just all women together.

Another participant stated, "I didn't want to bring technology to them because it brings such problems. I wanted them to bring their world to us."

Perhaps the most powerful reflection on the change in worldview was expressed by one student during the postimmersion interview. She said:

It's like when you close your eyes when you're looking at the sun. Then you look away, and when you open your eyes, everything seems brighter. When I got home and looked around, everything was the same, only I saw it in a different light.

Although all participants were struck by the poverty and lack of resources, they recognized and celebrated the strengths of the community and culture. Almost all participants noted the culture's value of children in their journals and postimmersion interviews. One participant remarked:

I was very struck by the happiness of the children. Yes, they were dirty, but they were obviously well loved - all were dressed and played with the abandon of happy children everywhere.

Participants also found themselves comparing and contrasting communities in rural Guatemala with those in the United States. One participant said:

It took a look at another country to see how much the U.S. needs. You can live in an area all your life and take it for granted. I never noticed the spiritual poverty in the U.S. before. In Guatemala, they are physically poor but not homeless. Families are there for each other.

Another participant noted, "I now realize the difference between poverty and impoverishment."

A clear example of the ways the experience broadened participants' worldviews was in their developing an appreciation for the differing concepts of time between cultures. One participant stated, "I also learned that life doesn't need to be so scheduled." By the end of the 2-week experience, participants were comfortable with a more open flow of life, which could be considered unstructured by Western standards. One participant noted, Tm more open minded now. Time is different. I know that people can live fine without a schedule."

The interview and journal data provided evidence of the importance of having a knowledgeable community member who could help participants interpret experiences through the community's own cultural lens. During this project, an American Roman Catholic priest who had lived in San Lucas Toliman for more than 30 years provided this necessary link. He was instrumental in helping participants understand the culture, as well as the role of women in society - an important concept for health care providers working with childbearing women. Although an initial impression of the culture is that men exercise significant power in the family and community, a deeper exploration of relationships and roles shows that women are central in the home and community. Mayan culture recognizes women as the bearers and sustainers of Ufe. The priest told many stories from his experience to help the students and faculty grasp the powerful role of women in the community.

DISCUSSION

Findings from this exploratory study suggest that short-term international immersion projects are useful in enhancing students' and faculty members' awareness of the global community. The growth experienced by participants in this study is particularly significant given that they were students and faculty in a nursing program that already incorporates many cross-cultural learning experiences into its curriculum. The community-based curriculum uses clinical sites throughout a diverse urban area, which offer student nurses the opportunity to care for individuals and families who do not share language or culture with the students For example, during the Family Health semester, students work in sites that include a "Mommy Van," which provides care to Spanish-speaking, undocumented women; an outreach clinic providing care to primarily Spanish-speaking farm workers; a hospital with a high proportion of recent Asian immigrants; and several teaching hospitals that provide care to a diverse population of recent immigrants. In addition, many students live in culturally diverse neighborhoods. However, not until the immersion experience did participants report they truly felt they were living and working in a community different from their communities of origin. This finding most likely demonstrates that even when individuals live and work in diverse communities, their surrounding family and friends provide a cocoon of inclusion. It is possible that when individuals leave behind their daily personal and professional relationships and responsibilities to experience immersion in another culture, they are better able to take in the lived experience of another community.

The finding that participants experienced both personal and professional growth is consistent with other evaluations of immersion projects. Kavanaugh (1998) noted that immersion experiences change everyone involved, including participants' significant others. In this study, one participant shared, "It's difficult for others to understand the emotional parts of this work." Participants' increased self-confidence and independence may alter their relationships on reentry into their home communities. A shifting of personal priorities may strain relationships. Returning participants also face the loss of the close community of the group during the experience. One participant shared that "for a couple of days [after returning] I was out of sync. I talked and cried. It was an emotional let down and release." Another participant noted, "I was looking forward to getting home, then I wished I was back there. Everyday I learned something new. It was the best experience I've ever had." A third participant reflected on how she was changed by the experience. She said:

Little things dont bother me like they used to before I went to Guatemala. I've been spending more time thinking about community, how much personal power we have, we have time and we have what we need. So now I need to do something.

Transition from a simpler way of life to the typical, busy American schedule also is difficult for participants in immersion projects in areas without the resources available in most American communities (Kavanaugh, 1998). Participants in this project experienced disequilibrium on reentry, similar to that reported by other investigators. One participant reflected, "I was glad to come home and glad that the people there don't have to put up with our world. It is so noisy here, cars and everything." Another participant said, "When I first came back, I was disoriented. There was almost too much stimulation here. I have more of a sense of calm now."

Whether or not a short-term immersion project is associated with long-term effects on participants' personal and professional lives is not well understood (Zorn, 1996). However, findings from this study suggest the short-term effects of increased confidence and belief in one's abilities as a nurse are important outcomes for individuals transitioning from students to graduates.

CONCLUSION

Findings from this study suggest an international immersion project is associated with participants' personal growth and professional identification as nurses. Participants' resulting appreciation for a culture different from their own increases their ability as nurses to be open to the various beliefs and values found in diverse communities. Further research will help nurse educators understand which components of immersion experiences are most associated with participants' personal and professional growth and whether there is a long-term effect on their practice.

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