Nurses must be able to care for an increasingly ethnically and culturally diverse population. Between 2000 and 2010, the non-White population increased between 12% to 43%, depending on race ethnicity (U.S. Census Bureau, 2010). To address this change, nursing education reform is necessary to prepare students to apply an understanding and sensitivity to their nursing practices with patients from different backgrounds (Frenk et al., 2010; Levi, 2009). Therefore, developing cultural competence is critical for nurses to provide patient-centered care. Further, nursing students, nurse educators, and practitioners need to recognize that developing cultural competence is an ongoing lifelong process that requires continuous learning and personal development (Jeffreys, 2010).
Although developing cultural competence is an inherent objective of education abroad, a comprehensive global curriculum also addresses cultural competence development in domestic on-campus curricula and extracurricular activities. Literature on cultural competence and global learning often focuses on the more than a thousand international learning experiences available in higher education (Berg, Paige, & Lou, 2012). This skill building is less emphasized on domestic campuses (Hanson, 2010). If educators focus on global learning both abroad and at home, students will gain experience and knowledge in how cultural competence can be utilized in international and domestic settings.
With a portfolio of international opportunities already established for students in all degree programs (Baernholdt, 2014), the school of nursing discussed in this article began its work to develop a comprehensive global curriculum. This article outlines how a task force began development of a global curriculum through faculty development. First, this article describes the development of a framework to establish the foundation for the curricular work. Second, it describes the planning and implementation of two workshops. Finally, it discusses the outcomes of the workshops and implications for other institutions.
A Global Framework
Beginning in 2012, the task force examined the global environment in the school of nursing through a survey of school of nursing faculty, a content analysis across current course curricula, and a literature review. The faculty survey and course content analysis found that around 13% of faculty had some form of global content, such as cross-cultural knowledge development or international perspectives, in their lecture-based or clinical course. However, this content was primarily placed in the undergraduate nursing students’ fourth year and in less than half of the graduate-level courses. With this apparent lack of a global focus across the entire nursing curriculum, the task force created the framework described here to guide the inclusion of global learning objectives more broadly and consistently into all the program’s curriculum. This framework addressed the following: the meaning of the term global for stakeholders at the university and the school; why a global curriculum is important; the intended student learning objectives with a global curriculum; and teaching strategies and activities faculty can use to achieve the intended learning objectives.
Through the faculty surveys and task force discussions, it became clear that the terms global and international are often used interchangeably in higher education. However, it became clear that the ways in which these two terms are used—such as with concepts like global learning versus international learning—had to be distinguished to properly define the task force’s framework. For the school of nursing faculty, international implied being away from one’s home country. Global was seen as a term more inclusive of domestic diversity, cross-cultural interactions and education abroad experiences. The American Council on Education’s definition of global learning best described the school’s definition of the term global and why a global curriculum was important for its students: “global learning is the knowledge, skills, and attitudes that students acquire through a variety of experiences that enable them to understand world cultures and events; analyze global systems; appreciate cultural differences; and apply this knowledge and appreciation to their lives” (Olson, Green, & Hill, 2006, p. v).
Through a brief literature review, the task force identified the need to address three learning domains: cognitive, attitude, and skill (Jeffreys, 2010; Olson et al., 2006; Riner, 2011). In particular, students should be expected to increase their knowledge of other cultures’ health care systems and practices (cognitive), further develop critical thinking skills and application of culturally congruent care (skill), and show greater cultural sensitivity (attitude). Further, the surveyed faculty and the task force observed that students are exposed to diverse populations in their home community, as well as during the many opportunities for international study. Thus, global learning encompasses all three learning domains of cognitive, attitude, and skill development to work in both local and international contexts.
The task force concluded the framework with a list of specific strategies to address the three learning domains. For example, to address a knowledge-based learning domain, faculty need to teach students about the Millennium Development Goals (United Nations, n.d.) and link the Millennium Development Goals and other major international health initiatives to domestic health issues. To enhance attitude and skill learning domains, faculty can include cultural diversity case studies with a reflective debriefing to promote cultural awareness and sensitivity.
Workshop #1: Cultural Awareness
For students to achieve cultural competence, the task force found it necessary to examine the curriculum’s teaching and learning approaches through a lens of cultural awareness. Using Jeffrey’s (2010) Teaching Cultural Competence in Nursing and Health Care as a guide, the first faculty development workshop aimed to help faculty have a better understanding of how cultural values and beliefs influence teaching and learning, as well as to consider their own level of cultural competence and awareness. The workshop lasted 4 hours and took place in January 2013. This workshop had two objectives:
- Participants will have a better understanding of how cultural values and beliefs influence teaching and learning.
- Participants will leave with strategies and ideas for integrating global aspects into their courses.
To begin the workshop, participants discussed the complexity of the term culture and cultural self-awareness and the influence of cultural values and beliefs on teaching and learning was presented to the group using a short video about conceptualizations of culture and its influence on values and beliefs (Harvard Business Review, 2011). The discussion was further informed by the article by Downey et al. (2006) that posits how people characterize cultures as distinct groups that are different from one another and confined within a geographical boundary. However, due to globalization, those cultural boundaries are becoming blurred within the geographical lines. Further, not every individual from a culture is the same as another. Culture can then be a problematic term when referring to people from different cultures.
To further highlight cultural self-awareness and the influence of cultural values and beliefs on teaching and learning, participants performed an exercise in examining stereotypes by considering the assumptions we make about individuals, given certain information. The greater university’s international study’s office lent an instructor who teaches in the office Cultural Orientation, Reflection and Engagement (CORE) program. CORE is a series of seminars designed for students preparing to and having returned from study abroad.
The last part of the workshop focused on strategies and instructional activities to enhance cultural competence development into current courses. The task force provided participants with a list of teaching resources, such as videos, Web sites, and TED Talk clips focusing on global health issues. For example, using the film Lost in Translation (Coppola, 2003), one facilitator demonstrated the use of popular media to illustrate the importance of cross-cultural communication. To be intentional about the selected teaching strategies, participants were urged to consider the diverse learning needs of students by identifying student-centered learning techniques (Jeffreys, 2010).
After the workshop, the 15 participants completed an evaluation. All participants agreed or strongly agreed that the workshop adhered to its two learning objectives. In addition, participants highly valued the discussion portions and the session on stereotypes and self-awareness. Participants suggested that workshop improvements include more time devoted to individual topics and more practical information be provided about ways in which to develop cultural competence in their students.
Workshop #2: Developing a Global Learning Objective
Based on feedback from the first workshop, the task force developed a longer workshop on how to incorporate, support (through learning activities), and evaluate a global learning objective into a course. This workshop took place in September 2013. The beginning of the workshop included sections on definitions of concepts related to global learning. Next, participants considered how each of their courses are part of the larger curriculum within the school of nursing and how a specific global learning objective can be tailored to meet needs across a course, a program, and the total curriculum. The last part of the workshop focused on learning strategies and assessment tools to develop and evaluate cultural competence.
First, participants discussed the overarching goals of nursing education in the United States, at the university level, in the school of nursing, and within each course. To include the global context, the workshop participants read and discussed definitions of global learning, cultural competence, and internationalization chosen from a variety of sources. The purpose of this activity was to demonstrate the complexity of concepts and for participants to consider why and how to include a global learning objective in their courses. Facilitators then asked participants to consider the curriculum as two spheres—the formal (in-class) and informal (extracurricular activities) (Leask, 2012)—as well as in various layers of context, such as global, national, regional, institutional, and individual (Knight, 2004; Sanderson, 2010; Leask, 2012) for the global learning objective to be well integrated and purposeful.
To further enforce the need for each instructor to look at his or her own course and global learning as a piece of the larger nursing curriculum, as well as the university’s overall mission of educating students, the participants completed an activity called Zoom. This activity uses the children’s book, Zoom (Banyai, 1998), where each page’s image zooms out farther from the previous image, gradually showing a picture from a further distance until the reader ends in outer space looking at the earth. Participants are given a page and told to place themselves and their pages in the correct order without speaking. Besides reinforcing how a global learning objective is part of a whole, participants gained a better understanding of how details are viewed differently, or how pieces of a whole can be interpreted differently by each individual.
Next, participants worked in groups on drafting a global learning objective for each of their courses. Specifically, participants discussed how to weave the objective throughout course content to avoid making it appear disjointed from the rest of the curriculum (Jeffreys, 2010; Saroyan & Amundsen, 2004). An example of a generic global learning objective used in a course with a clinical component was: The student will be able to describe, demonstrate, or perform at the institutional, local, national, and global level how to deliver cultural competent care to a patient, a group of patients, or a population. Finally, participants shared their global learning objective with the larger group to ensure inclusive language was used, and that the objective was congruent with the rest of the course, the program curriculum, and the school of nursing, as well as the greater university’s overall missions.
To support a course’s global learning objective, facilitators offered a list of teaching strategies that included various types of activities focusing on cultural competence development through the learning domains discussed in the global framework. Examples of teaching strategies and activities included inviting guest speakers from diverse backgrounds and other countries; using technology, such as Skype™, to connect with a university or organization abroad; and using popular television shows that depict a conflict between cultures. The facilitator showed a clip from Grey’s Anatomy (Rhimes & Tinker, 2005) as an example that can be used to discuss how different cultural traditions can conflict with traditional Western health care practices.
In addition, facilitators presented assessment tools and methods of evaluation of cultural competence. Each participant received a copy of the book Teaching Cultural Competence in Nursing and Health Care (Jeffreys, 2010), which contains multiple assessment toolkits, including self-perception tests on cultural competence development in both classroom and clinical settings. Facilitators also shared additional assessment resources, such as the American Association of Colleges and Universities’ (2013) Global Learning Value Rubric as an example of a tool with clear definitions and benchmarks or outcomes. To conclude the workshop, participants received instructions on logistical next steps and a timeline for implementing their global learning objective through the school of nursing policy and procedures for course content and learning objectives.
The participants who completed the workshop evaluation (seven of 15) agreed that the workshop met the objectives of leaving with a draft of a global learning objective and an understanding of the next steps for implementing the objectives. Overall, participants valued the structure of the workshop, including discussions and group work, but found the length of time (5.5 hours) to be too long.
Discussion and Implications
As the school of nursing’s work toward a global curriculum continues, it will be imperative for faculty to focus on assessment of students’ cultural competence development and whether students are meeting courses’ global learning objectives. It is important to recognize the difficulty in assessing cultural competence development. Certain assessment tools or learning activities, such as reflective journaling, may focus on students’ self-perception of how they feel, rather than concrete evidence of whether their cultural competence has indeed improved (Riner, 2011). Nonetheless, self-assessment can prove to be valuable for data collection. Students’ self-efficacy in working with issues around cultural sensitivity and culturally congruent care is critical (Jeffreys, 2010). In addition to the tools found in Jeffreys’ (2010) book, other tools for measuring cultural competence development could include the Intercultural Development Inventory (Hammer, Bennett, & Wiseman, 2003), which is based on the theoretical framework of the Developmental Model of Intercultural Sensitivity (Bennett, 1993) and the Cultural Competence in Action Tool (Papadopoulos, Tilki, & Lees, 2004).
This school’s journey toward a global curriculum can inform other schools of nursing on how to pursue a similar endeavor. One limitation to address is how to ensure higher faculty representation. Although each workshop had diverse faculty representation, from clinical instructors to core course faculty from both undergraduate and graduate programs, the number of participants in each workshop was low relative to the number of nursing faculty (12 and 15 of approximately 90 full- and part-time faculties). Further, identifying the best time and length for a workshop is critical. Although the first workshop evaluation included comments about wanting more time, participants in the second workshop cited that 5.5 hours was too much time. Ongoing faculty commitments (teaching, practice, research, and committee work) made it challenging to schedule both workshops, but the format of an extensive period of time (4 hours or 5.5 hours) focused on a specific subject was liked by all.
As a result of these workshops, five additional graduate courses have new global learning objectives. Further, as the school was in the midst of a complete revision of its undergraduate curriculum, the faculty decided to incorporate at least one global learning objective into all new undergraduate courses moving forward. Using a task force to assess course content, faculty knowledge, and planning, two workshops to pursue a global curriculum proved successful for this school of nursing. Although students’ learning is the primary driving force for this work, faculty development and faculty self-awareness of their own cultural values and beliefs are important first steps to develop global learning objectives, teaching strategies, and assessment of learning and outcomes.
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