The American Association of Colleges of Nursing’s (AACN) report (2008) challenges educators to provide students with experiences that address the development of cultural competence, which is a prerequisite to patient centeredness and quality improvement in health care delivery. Nurse educators are expected to provide students with opportunities for self-reflection, to articulate the value of lifelong learning, and to ignite a desire to seek out new opportunities. Opportunities for students to explore and respect patient beliefs and diverse backgrounds requires a milieu whereby students can engage with people from around the world to find common ground to confront their own biases and assumptions from a disciplinary perspective. International experiences help to foster students’ appreciation of diversity because students are removed from their own cultural comfort zone and are immersed in the life ways of others, which often differ greatly from those they know. Caring for others outside of the United States can open students’ eyes to the scarcity of health resources, as well as to increase their awareness of health disparities and discrimination.
As nursing faculty members, the authors participated in three short-term course abroad trips, accompanying a total of 35 nursing students to Jamaica. In reading students’ reflective journals and listening to their follow-up comments, the authors have been repeatedly struck by how meaningful and humbling the course abroad experience is, despite the short duration of the trip. One student wrote:
This once-in-a-lifetime study abroad opportunity has helped me understand many concepts related to nursing. It helped me [to] open up a new perspective and understanding of different cultures and health care systems. I came to the conclusion that learning about different countries and their lack of supplies and primary prevention is not the same as actually visiting that country and seeing it through one’s [own] eyes.
Each year, journal reflections, small-group discussions, and posttrip debriefings validate the impact of this experience on students’ multiple ways of knowing. Hartrick Doane and Varcoe (2015) reported on relational inquiry and indicated that “the bringing together of empirical, ethical, sociopolitical, and perhaps other forms of knowing into a coherent whole constitutes the aesthetics of practice” (p. 268) and that “personal knowing is not a separate category but penetrates all forms of knowing” (p. 240). Planning a course abroad through this framework allows both faculty members and nursing students the opportunity to engage in a rich learning experience and return to their community and practice with an increased awareness of the complexities of nursing practice. The purpose of this article is to report on a pilot study that evaluates the impact of a study abroad trip on nursing students’ ways of knowing.
Background and Feasibility
This short-term (1-week) course abroad experience was initiated by the department chairperson of a newly established baccalaureate in nursing program in a public university in New England. Memmott et al. (2010) noted the importance of congruence between the program offering the experience and the mission and values of the parent institution. According to Memmott et al., support from state-run institutions is often difficult to attain. The authors’ university includes international education as an element of distinction, has been recognized for its strong commitment to international education, and was supportive of the nursing department’s plan to offer the experience. Administrative support from the dean and university assistance in the form of scholarships, travel arrangements, and advanced communication with Jamaican Customs and the Ministry of Health were crucial elements in making this experience possible. This support served to facilitate the experience and made it possible to offer the trip to the first three cohorts of students in the new baccalaureate program.
Memmott et al. (2010) also postulated that shared understanding, trust, and input from international partners is important to ensure the success of course abroad experiences—a belief that has held true for this experience. Throughout the planning process, faculty members were in frequent contact with their Jamaican partners to best meet the needs of both the host agencies and the students. Frequent e-mail communication served to build a rapport prior to the trip. Ideas for health education sessions and health fair booths were determined after consultation with key stakeholders in Jamaica so that appropriate topics and activities were chosen. Repeat course trips have served to build trust and secure the existing relationships, which appear to be mutually beneficial, based on partner agency feedback.
Memmott et al. (2010) recommended that international experiences extend over a period of no less than 4 weeks. However, according to Edmonds (2012), short-term intensive cultural immersion programs have provided a viable alternative to the traditional lecture as a way to foster cultural competence. In addition, it is believed that by offering short-term programs, more students would be able to take advantage of the course abroad opportunity. Faculty resources, curriculum design, and cost are major factors that can influence the length of the experience, and may be important factors for nursing programs that are considering offering this opportunity for the first time. Because of competing clinical and course expectations, a 1-week experience provided a possible solution.
Overview of the Experience
Both junior and senior nursing students participated in the week-long trip to Jamaica during their spring break. As part of a family seminar course, junior students traveled to a local hospital in Montego Bay, were paired with Jamaican nursing students, and spent 2 days on several different hospital floors, including gynecology, pediatrics, and the men’s ward. They were able to observe nursing and health care and learn from their partner students. They expressed appreciation for what the hospitals in the United States have to offer, but they also commented on the true art of nursing when technology is absent.
The senior students, who were involved in a community health rotation, spent 2 days at a local outpatient clinic, where they experienced high-risk pregnancy nursing care and well-child visits in an outpatient setting. Students were exposed to the health promotion activities at the clinic and were introduced to the public health care system of a different country as a result of this experience.
In addition to the hospital and clinic experiences, students also provided health education talks to approximately 150 area school children in grades one through six. Topics were chosen after consultation with the school principal to ensure relevance and need. The topics included healthy eating, dental care, exercise, self-concept/self-esteem, safety, and bone health. Because the talks were delivered to various age groups, students were required to adapt the content to the developmental stage of the learner. They also needed to be mindful that the content of their talks was culturally appropriate. For example, when providing nutrition education, students researched local and commonly consumed food options to prepare for their talk. They also learned that string is often used in place of dental floss in Jamaica, and they incorporated this knowledge into their health education.
The students also conducted two large health fairs—one in a mountain village and one at a local college. More than 300 Jamaican residents of all ages attended these health fairs, where they had the opportunity to receive stroke screenings, vision assessments, blood pressure checks, and diabetes testing. Booths were set up to provide information, including hands-on activities and written information, on sexually transmitted infections, breast and testicular self-examinations, and substance abuse. At both events, the attendees were observed spending a significant amount of time at each booth. They asked relevant questions, participated in hands-on activities, such as palpating breast models for lumps, and took numerous free samples and health education pamphlets.
In addition, the course abroad trips included an opportunity for students to socialize and spend time with their Jamaican student peers. Shared activities included class presentations, health fair participation, afternoon receptions, and evening dinners at a famous local restaurant. The student-to-student bonds have remained strong, and a few Jamaican students have traveled to the United States to visit their new friends.
Carper’s (1978) fundamental patterns of knowing, along with Chinn’s and Kramer’s emancipatory knowing (2011), is the lens that frames the current pilot study. Over the years, nurse researchers have continued to critique and expand on nursing’s ways of knowing. However, what has remained a constant is that an understanding of the complexity of human relationships in nursing is enhanced by an integration of multiple ways of knowing. As nursing faculty members anticipating the fourth course abroad with nursing students, the authors continue to be struck by the richness of the experience to foster knowing from an aesthetic, empirical, ethical, personal, and emancipatory perspective.
Utilizing the definitions and conceptual overview of Chinn and Kramer (2011), aesthetic knowing involves connecting with the human experience and “an appreciation of the meaning of a situation” (p. 9). Empiric knowing is expressed in practice as scientific competence. Ethical knowing focuses on clarifying conflicting values and guides the nurse to reflect on how to behave in a specific situation, integrating “disciplinary knowledge and situational factors to achieve a morally acceptable result” (p. 8). Personal knowing is knowing oneself, as well as oneself in relation to others. The last perspective considered is emancipatory knowing—the social, cultural, and political context in which care is provided—allowing the nurse to begin to question and raise awareness of and critically reflect on inequities and injustices.
Studies that address the benefits of international exchange between nursing schools cite the benefits of moving students beyond the structured and practice-directed curricula to a novel experience that expands the boundaries of nursing beyond the national view of their country of origin. Students are challenged to develop a global perspective predicated on international cooperation and social justice (Amerson, 2014; Christoffersen, 2010; Memmott et al., 2010). Christoffersen (2010) commented that “The students all have a deeper appreciation of their privilege in the world…” (p. 85). During study abroad courses, students are able to focus on cultural competency and caring for people from different cultures (Amerson, 2014; Grant & McKenna, 2003; Hegedus et al., 2013; Saenz & Holcomb, 2009).
Few studies have explored the value of the study abroad experience on a students’ future practice through the lens of ways of knowing. Evanson and Zust (2006) conducted a descriptive qualitative study that examined the effects of an international experience on students’ personal and professional lives 2 years after return. Written narratives and a focus group were used to gather data from six participants. Three supporting themes emerged from data analysis—Coming to Understand, Unsettled Feelings, and Advocating for Change. Although their study included a small convenience sample, their findings showed that a short-term international student nurse experience could have lasting effects on these students’ later personal and professional lives.
International experiences are gaining in popularity in many nursing programs, and research findings are emerging on the impact of such an experience on the students who participate (Amerson, 2014). However, despite the positive feedback from the students who participated over the 3 years of the current study, faculty recognized the need to formally evaluate the experience to determine whether the time and expense put forth assisted in meeting program objectives. Although published studies exist on the merit of international courses (Edmonds, 2012), few published studies have focused on the impact of ways of knowing on students’ future practice. Therefore, a study was conducted to examine the impact of a short-term international nursing student experience on participants’ nursing practice and professional growth upon return to their local community through the lens of ways of knowing.
Study Design and Sample
The current study was a descriptive quantitative study, utilizing a convenience sample. Junior- and senior-level baccalaureate nursing students who were enrolled in this program at a state university were invited to participate. Approval to conduct the study was obtained from the appropriate university human studies council. A total of 35 students who had gone on the trip were invited to participate through a mailing that contained a questionnaire and a letter explaining the purpose of the study. The students were provided with informed consent in the cover letter, and a return of the survey constituted agreement to participate. A return envelope was provided with the researcher’s (L.D.W.) name so that anonymity would be maintained. Returned surveys were coded according to the participant’s age, and an alphabetical letter was assigned if more than one participant was the same age. One mailing was returned with address unknown.
Measures and Data Analysis
A 10-question survey, which was developed by the authors, was used. The questions were derived from the previously determined course outcomes and were reflective of the five ways of knowing previously discussed and are shown in the Table. The questions were developed with input from a nurse expert in quantitative research and were measured through the use of a visual analog scale (VAS). Two nurses with expertise in survey development and community engagement in nursing education reviewed the tool for content validity. According to DeVellis (2012), a VAS “presents the respondent with a continuous line between a pair of descriptors representing opposite ends of a continuum” (p. 96). One advantage to using this instrument is that it is more sensitive to scoring and is a relatively quick tool to administer. A 10-mm line was drawn, and the participant was asked to rate a response by placing an “X” on the area of the line that best represented his or her self-evaluation of the statement. The line represented 0 to 100 points, with 0 = no impact and 100 = high impact. One researcher (L.D.W.), using a metric ruler, analyzed all of the returned surveys. Using the ruler, the score was determined by measuring the distance from 0 to the midpoint of the X, providing a range of scores from 0 to 100. The mean and standard deviation was calculated for each question.
Impact of Students’ (N = 20) Short-Term Course Abroad Experience on Ways of Knowing
Results and Discussion
Of the 35 students who participated in the course abroad, 20 responded to the survey, yielding a response rate of 57%. All surveys were completed entirely. The Table provides an overview of the survey items, along with their association to the ways of knowing, as well as means and standard deviations on the VAS.
Mean scores ranged from 79 to 93 on the individual survey items. These results suggest that, overall, students believe the short-term course abroad experience had a positive impact on their personal knowing as experienced through empirical, ethical, sociopolitical, and aesthetic knowing. The highest mean score on the VAS was 93. This was reported for item nine, which assessed students’ ability to differentiate between the caring of nursing and the technology of nursing. This item also showed the lowest standard deviation, suggesting widespread agreement among participants. Technological advances in health care currently, especially in the United States, are having a major impact on nursing practice. The ability of nurses to distinguish and maintain the human essence of caring while immersed in patient care technology has been discussed in the literature (Almerud, Alapack, Fridlund, & Ekebergh, 2008; Radhakrishnan, 2008). Nursing care in countries with lower-level technological interventions may serve to remind students of the great potential that use of the self has on healing.
Students also indicated that their comfort level of providing care to a patient of Jamaican descent was high, with a mean response score of 91 on the VAS. Perhaps this was a result of the friendships that students made with many residents they encountered during the week. Perhaps it was a reflection of spending 1 week in Jamaica and learning about the health issues and health care delivery system of that country. Experiences such as this may serve as a way to make a therapeutic connection with patients due to newly established familiarity with a country other than their own. Further research is needed to determine whether these enhanced comfort levels may translate to confidence in ability to care for other individuals of Caribbean descent as well.
This pilot study was limited by several factors. A major limitation was the self-developed tool that was created based on course objectives. This tool had not undergone extensive reliability and validity testing. In addition, outcomes were measured using the VAS, which provide a rough estimation of the participants’ feelings in regard to statements. DeVellis (2012) commented that “a mark placed at a specific point along the line might not mean the same thing to different people, even when the end points of the line are identically labeled for all respondents” (p. 96).
Another major limitation of the current study is the descriptive posttest (posttrip) design. Without a measurement of pretrip data related to knowledge, attitudes, and skills, it is difficult to accurately assess the impact of the students’ experience. Further studies are planned to assess participants before and after the short-term course abroad experience. This planned change in methodology to analyze future data with a paired sample t test will adjust for limitations of subjective marking of the line. Convenience sampling and small sample size also limits the generalizability of the study. Finally, the overall experience of the course abroad trip may mask the true application of the intended cultural appreciation of caring for individuals of diverse backgrounds, as well as the complexity of multiple ways of knowing.
The purpose of this pilot study was to evaluate the impact that a short-term course abroad experience may have on nursing students’ ways of knowing related to care delivery to individuals having cultural backgrounds different from their own. Although baseline data were not obtained prior to the experience, it appears that short-term course abroad experiences may be a feasible and valuable means of enhancing nursing students’ professional development. Qualitative studies and reflective journals have provided evidence of the impact of these trips, but more research is needed to add to the outcome data regarding the time and effort that planning such an experience takes on faculty resources.
As educators, it is our responsibility to provide experiences for students that allow them to use all ways of knowing in their caring practice. Seeking to understand the other first includes a willingness to participate in travel abroad to a developing country (personal knowing); an examination of the juxtaposition of power dynamics, such as poverty and race, while enjoying the beauty of the island (sociopolitical, aesthetics); participating in a shared meal, song, and prayer by the host residents (aesthetics, ethics); and a critical examination of values and tradition (ethics), both their own and those from a different background. By giving students opportunities to provide care internationally through health education, health screening, and observation (empirics), it is anticipated that their ability to integrate all ways of knowing will be supported and facilitated.
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Impact of Students’ (N = 20) Short-Term Course Abroad Experience on Ways of Knowing
|Ability to differentiate between the “caring” of nursing and the “technology” of nursing (aesthetics)||93||9.1|
|Comfort level with providing care to patients of Jamaican descent in the United States (ethics, personal knowing)||91||11.3|
|Awareness of how countries do more with fewer resources (emancipatory knowing)||88||11.2|
|Knowledge of health disparities of individuals and families (ethics, empirics)||85||14.6|
|Ability to gather information about health care issues of a particular country (empirics)||82||9.9|
|Ability to provide health education to diverse populations in the United States (all)||81||19.2|
|Frequency of seeking out cultural experiences that sensitize to differing world views (personal knowing, emancipatory knowing)||80||22|
|Knowledge of social justice (emancipatory knowing)||79||14.8|
|Knowledge of the health care delivery system in a developing country (empirics)||78||14|