Dr. Lujan is Regional Dean and Associate Professor, and Ms. Vasquez is Assistant Professor, Texas Tech University Health Sciences Center, Anita Thigpen Perry School of Nursing, El Paso, Texas.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Josefina Lujan, PhD, RN, Regional Dean and Associate Professor, Texas Tech University Health Sciences Center, Anita Thigpen Perry School of Nursing, 4800 Alberta Office 101-B, El Paso, TX 79905; e-mail: firstname.lastname@example.org.
The Institute of Medicine (2002), the U.S. Department of Health and Human Services Office of Minority Health (2002), and the Texas Higher Education Coordinating Board (THECB) (2006) have documented the need to promote the success of Hispanic nursing students so they may join the workforce to decrease disparities in the United States. In addition, several white papers have called for the development and testing of culturally competent teaching methods to promote much-needed success of Hispanic nursing students (Pacquiao, 2007; THECB, 2006; Thomas Rivera Policy Institute, 2007; Vogt & Taningco, 2008). This article responds to this call by analyzing the cultural competence of an innovative teaching method, the Scaffolding Clinical Model (SCM), that has been used during the past 5 years (Tilley et al., 2007).
The analysis will use a case study approach to analyze the SCM in relation to cultural competence needs of Hispanic nursing students. The analysis will be conducted in relation to the four metaparadigms or pillars of Hispanic culture that were conceptualized by Zambrana (1995): conquest, collectivism, personalism, and familism. The analysis will focus on how the SCM validates the metaparadigms of Hispanic culture among the students in the case study to provide cultural competence. The analysis will enable nursing faculty, students, and stakeholders to critically evaluate the SCM for possible use in their own programs.
Scaffolding Clinical Model
The SCM is designed to accelerate clinical competency attainment and acculturation of nursing students (Hogan & Pressley, 1997; Tilley et al., 2007). The SCM is based on scaffolding instruction, which is a technique where social interaction and knowledge are combined to facilitate learning (Chang, Sung, & Chen, 2001; Tilley et al., 2007). The SCM has been used since 2005 in a 12-month accelerated bachelor of science in nursing (BSN) program (second degree program) at five sites of a major U.S. university. More than 125 students have completed the Program, with at least a 90% retention rate and a National Council Licensure Examination for Registered Nurses passing rate above the state standard.
Students are assigned “clinical coaches” at a maximal ratio of one-to-one. The clinical coaches facilitate all clinical practicums for these students for the full length of the 12-month program. The clinical coaches are key members of the teaching-learning team. Clinical coaches are experienced, knowledgeable RNs who meet the following requirements: a minimum of a BSN, current licensure as an RN in the state, a minimum of 2 years experience as an RN in the hosting hospital, a written recommendation for the role from their nurse manager, and a signed agreement of willingness to work with one student for the duration of the 12-month program. The clinical coaches spend an average of 24 hours per week, for approximately 42 weeks of the year, with their students. The clinical coaches receive an extensive preceptor orientation, a personal digital assistant with state-of-the-art nursing practice software, financial assistance for graduate credits, and $3,000 for the 12-month program. An economic comparison of the use of clinical coaches in the SCM, in relation to a traditional model with a 10-student cohort-to-clinical instructor ratio has not been conducted yet.
Master of science in nursing educators serve as the designated clinical coordinators for each cohort of 10 students. The clinical site coordinators (one per cohort) oversee the students’ progress in the clinical setting and facilitate the clinical coach-student team. The clinical site coordinators are charged with recruiting the clinical coaches in a single facility, orienting the clinical coaches, interfacing extensively with the clinical coaches, and facilitating and monitoring the attainment of the clinical competencies by the students.
The education and prescribed weekly clinical objectives are developed by the clinical site coordinators to ensure that the clinical experiences of the students follow objectives that are congruent with BSN education and the associated course material. Mid-semester and final course clinical competency evaluation grades are determined by the clinical site coordinators, who average their grades with those of the clinical coaches.
The ultimate goal of the SCM is the formation of a team consisting of a clinical coach and a maximum of one assigned student in which the clinical coach assists the student in the construction of knowledge from experiences and observations (Tilley et al., 2007). The cultural competency of the SCM is reflected in the five clinical coach-student teams of the students in this case study in the second degree program. The unique characteristics of the five clinical coach-student teams in the case study, as well as the setting for the case study, facilitate the analysis of the cultural competence of the SCM.
The case study for this article is a major city on the United States–Mexico border where 89% of the residents are Hispanic (U.S. Census Bureau, 2006). Therefore, it is not surprising that 80% of the students and 90% of the clinical coaches in the cohort for this case study are Hispanic. The high number of Hispanic individuals in this case study, which is much greater than the current national Hispanic presence in the nursing workforce (2%), facilitates the analysis of the SCM in relation to cultural competence (Health Resources and Services Administration, 2004, 2007; Texas Center for Nursing Workforce Studies, 2007).
The clinical coach-student team, the cornerstone of the SCM, makes the model culturally competent because the model validates the four metaparadigms or pillars of Hispanic culture. This cultural competence translates to a teaching method that can significantly increase the success of Hispanic nursing students, who derive their validation from the metaparadigms of Hispanic culture. A basic understanding of the metaparadigms of Hispanic culture can be valuable in relation to being able to appreciate how the SCM is culturally competent.
Cultural Competence and the SCM
The four metaparadigms of Hispanic culture were conceptualized by Zambrana (1995) as conquest, collectivism, familism, and personalism. These four metaparadigms are the pillars of Hispanic culture that permeate the history and lives of Hispanic individuals, especially those with low acculturation to the United States (Zambrana, 1995). Cultural competence is achieved by understanding, acknowledging, and validating the metaparadigms of Hispanic culture (Zambrana, 1995). Therefore, it is important that each metaparadigm be described and that the SCM be analyzed in relation to how well it acknowledges and validates each of the metaparadigms to infuse cultural competence into education for Hispanic nursing students (Pacquiao, 2007).
The metaparadigm of conquest is based on the history of the Americas that was conquered in a highly militant, and sometimes genocidal, manner by European countries (Purnell & Paulanka, 2003). The century-long battles of the conquest of the Americans ended with the submission of the indigenous residents of countries, such as Mexico, to Spain (Purnell & Paulanka, 2003). Sociologists such as Zambrana (1995) indicate that the conquest caused deep, long-standing impairment of self-esteem of the indigenous residents of the Americas, who are now called Hispanics or Latinos. Zambrana (1995) further suggested that conquest-based self-esteem impairment may explain why significant numbers of Hispanics may demonstrate the following behaviors: a tendency to identify more with their European rather than indigenous ancestors, a reverence for titles and appropriate use of names, and mistrust of non-Hispanic individuals who may be perceived as authority figures. The SCM addresses these behaviors in its clinical coach-student teams, thereby making the SCM a culturally competent teaching method for Hispanic nursing students.
The SCM addresses conquest-based self-esteem impairment among nursing students by offering them clinical coaches as strong role models, who become portals through which confidence is gained by the students. The Hispanic nursing students in the case study cohort were matched with highly successful clinical coaches to form a clinical coach-student team. Ninety percent of the clinical coach-student teams had shared Hispanic ethnicity, with the potential for mutual empathy in relation to self-esteem and the metaparadigms of Hispanic culture.
One Hispanic student reported that she initially felt that the idea of being with one clinical coach for 1 year did not sound very promising because she feared not “being liked by [her] clinical coach.” This comment reflects possible conquest-based self-esteem impairment that is associated with feelings of inadequacy or fear of rejection. However, in her fourth week of the program, the student was convinced that the SCM is superior to the clinical practicum model that is used in traditional nursing programs with a ratio of 1 faculty member per 10 students. This student also reported that the one-to-one teaching approach that the SCM offers has not only helped her grasp the basic concepts of nursing, but it has also helped her accelerated her confidence in being able to interact with her clinical coach, the bedside staff, and patients.
Collectivism is the metaparadigm that proposes that Hispanics value the needs of their cultural group more than those of the individual (Zambrana, 1995). This is different from the United States, where individualism, independence, and, as a result, competitiveness are often admired and promoted (Purnell & Paulanka, 2003). The SCM model validates collectivism through its emphasis on the development and strengthening of the clinical coach-student team.
Collectivism is reflected in the integration of students into the nursing workforce team through the clinical coach-student team. One Hispanic student reported the following:
I was working along several nurses providing care to multiple patients who were admitted to the trauma center at the change of shift.… I worked alongside the bedside nurses that were leaving the center, as well as with those from the oncoming shift. I also assisted the medical residents.
This comment clearly demonstrates student acknowledgement and concern for the nursing workforce team or group or collectivism.
Familism is the value that is placed on family members and explains the behavior of many Hispanics to extend “family” status to nonblood relatives (Zambrana, 1995). The SCM is particularly well-suited to validate familism because of the family-like, almost paternal or maternal filial relationship that is established through the clinical coach-student team. The feeling of being recognized as a family member of the nursing unit is one of the greatest benefits of the SCM-based clinical coach-student team. Students in the case study have reported acceptance on the nursing units as early as the second week of the program. This family-like feeling of acceptance or familism is mediated by the clinical coaches, who confidently introduce nursing students to the bedside staff, as well as to the physicians and ancillary staff. The formal extension of family status by the bedside nurses to the nursing students has taken various forms in the case study. One nursing student was deeply touched by an elaborate and warm baby shower celebration that the bedside nurses enthusiastically provided for her. Frequent verbal expressions of “She is our family” resonated throughout the celebration.
Personalism is the need for a close personal relationship between individuals (Zambrana, 1995). The SCM almost imposes personalism on the clinical coach-student team relationship that is the cornerstone for the model. Personalism is reflected in the comment of one case study Hispanic student, who emphasized the importance of “initiating a professional impression and creating and keeping a good relationship with one’s clinical coach.” Another Hispanic student reported that he found himself “mirroring” the coach’s actions and behaviors when providing patient care. Another Hispanic student reported that she frequently found herself subconsciously emulating her clinical coach’s speech pattern and rhythm. Personalism results in the accelerated acquisition of critical thinking by students who easily accept prioritization of care by clinical coaches, with whom they have a close relationship. The observations of the case study students offer a promising opportunity for future research that will capture and possibly measure possible changes in students’ self-perception of their self-esteem or self-identity.
Conclusion and Recommendations
This article described the SCM and the metaparadigms of Hispanic culture as a way to analyze the cultural competence of the SCM. Although the SCM was not deliberately designed to be culturally competent for Hispanic nursing students, the observations and comments that were offered by Hispanic nursing students in the case study support the SCM as a culturally competent teaching method. The strength of the SCM as a culturally competent teaching method lies in its creation of a long-standing clinical coach-student team. This suggests the need for future research. This research could be beneficial in establishing the SCM as a best practice for the retention of Hispanic nursing students and their successful entry into the workforce to help reduce health disparities.
The experiences that were shared by the students strongly suggest that the effects of the SCM on students, as well as on diverse clinical coaches, needs to be captured through quantitative research. This research may uncover benefits for both diverse nursing students, as well as clinical coaches, who may have a need for the validation of their metaparadigms of Hispanic culture. This could be done through the use of a psychometric tool that would capture program students’ and clinical coaches’ perceptions of the SCM’s cultural competence at baseline and immediately after the program ends. A comparative study could be also conducted to assess the cultural competence of the SCM, as well as its cost effectiveness, in relation to a traditional clinical practicum model, where one faculty member is assigned to a 10-student cohort. Further research of the SCM in relation to cultural competence paves the way for its establishment as a best practice for the cultural competence needs of diverse students throughout the world.
- Chang, K.E., Sung, Y.T. & Chen, S.F. (2001). Learning through computer based concept mapping with scaffolding aid. Journal of Computer Assisted Learning, 17, 21–23. doi:10.1046/j.1365-2729.2001.00156.x [CrossRef]
- Health Resources and Services Administration. (2004). The registered nurse population: Findings from the March 2004 National Sample Survey of Registered Nurses. Washington, DC: Author.
- Health Resources and Services Administration. (2007). Border county health workforce profiles: Texas. Retrieved from http://www.bhpr.hrsa.gov/health-workforce/border
- Hogan, K. & Pressley, M. (1997). Scaffolding student learning: Instructional approaches and issues. Cambridge, MA: Brookline Books.
- Institute of Medicine. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Retrieved from http://www.iom.edu/?id=16740
- Pacquiao, D. (2007). The relationship between cultural competence education and increasing diversity in nursing students and practice settings. Journal of Transcultural Nursing, 18, 28–35. doi:10.1177/1043659606295679 [CrossRef]
- Purnell, L.D. & Paulanka, B.J. (2003). Transcultural health care: A culturally competent approach (2nd ed.). Philadelphia, PA: F.A. Davis.
- Texas Center for Nursing Workforce Studies. (2007). Professional nursing education in Texas demographics & trends: 2007. Retrieved from http://www.dshs.state.tx.us/chs/cnsws/2007_nursing_workforce.pdf
- Texas Higher Education Coordinating Board. (2006). Strategies to increase the number of graduates from initial RN licensure programs: A report to the Texas legislature. Retrieved from http://www.bne.state.tx.us/about/July07/5-3-4.pdf
- Thomas Rivera Policy Institute. (2007). Increasing Latino participation in the nursing profession: Best practices at nursing programs. Retrieved from the United Way Web site: http://www.unitedwayla.org/getinformed/rr/research/pages/increasinglatinoparticipation.aspx
- Tilley, D.S., Allen, P., Collins, C., Bridges, R.A., Francis, P. & Green, A. (2007). Promoting clinical competence: Using scaffolded instruction for practice-based learning. Journal of Professional Nursing, 23, 285–289. doi:10.1016/j.profnurs.2007.01.013 [CrossRef]
- U.S. Census Bureau. (2006). American fact finder, facts sheet census 2004, demographic profile highlights. Retrieved from http://www.factfinder.census.gov/home/saff/main.html?_lang=en
- U.S. Department of Health and Human Services, Office of Minority Health. (2002). National standards for culturally and linguistically appropriate services in healthcare: Executive summary. Washington, DC: Author.
- Vogt, R. & Taningco, M.T. (2008). Latina & Latino nurses: Why are there so few? A TRPI summary report. Los Angeles: Thomas Rivera Policy Institute. Retrieved from http://www.trpi.org/PDFs/Latino%20Nurses_Final.pdf
- Zambrana, R.E. (1995). Understanding Latino families: Scholarship, policy and practice. Thousand Oaks, CA: Sage.