In the past decade, interest in providing international educational experiences for nursing students has reemerged with a heightened sense of urgency (Edmonds, 2010; Kulbok, Mitchell, Glick, & Greiner, 2012). Traditional study abroad programs have been difficult for nursing students to participate in, given the highly structured and time-consuming nature of nursing programs and the financial resources needed for a long sustained period of time abroad (McKinnon & Fitzpatrick, 2011). Short-term service-learning immersion experiences in another country represent one way to address this challenge (Johansen, 2006; Larson, Ott, & Miles, 2010; Smith-Miller, Leak, Harlan, Dieckmann, & Sherwood, 2010).
An essential component of any learning abroad experience must involve the students in reflecting on their experiences (Forsey, Broomhall, & Davis, 2012; Riner, 2011; Vande Berg, 2007). Although a number of instructional models for reflective practice have been developed in nursing, the models are rarely used in international educational programs (Lyons, 2010; Snyder, 2014). One reflective method by Kim (1999), critical reflective inquiry (CRI), is especially appealing for this purpose, given its structure and breadth in addressing both cognitive and affective domains. The aim of this qualitative study was to explore the value of CRI in guiding nursing students’ reflection on an international service-learning experience in the Dominican Republic.
The importance of international educational experiences is well recognized in nursing (Kulbok et al., 2012). These experiences have been available in the United States since the early 1970s, although they were initially limited in number (Greatrex-White, 2008; Lindquist, 1986). During the past decade, interest in developing international programs has grown considerably due to a number of factors (Kulbok et al., 2012). Demographic changes have led to greater cultural, racial, and ethnic diversity and globalization calling for culturally competent nurses (Harrison & Malone, 2004; Kirkham, Van Hofwegen, & Pankratz, 2009). Internationally, a variety of study abroad approaches are being used to address this need. A recent review of 23 current programs included traditional study abroad programs on university campuses and medical centers, exchanges, and study tours, as well as a range of short-term immersion service-learning experiences (Kulbok et al., 2012). The service-learning approaches have been attracting considerable attention because they can accommodate “the academic constraint of nursing curricula as well as the practical constraints of nursing students who must arrange for an extended absence from family or employment obligations” (Smith-Miller et al., 2010, pp. 19–20).
Kim’s (1999) CRI model was derived from action science and critical philosophy. The model focuses on understanding the nature and meaning of practice to practitioners, refining and improving one’s practice through self-reflection and criticism, and generating models of good practice. CRI consists of three phases: descriptive, reflective, and critical/emancipatory. In the first phase, a comprehensive description is written about a specific example arising from clinical practice. In the second phase, the nurse or nursing student identifies and examines one’s underlying beliefs, assumptions, knowledge, and intentions in relation to the situation. In the third phase, thought is given to what could have been done differently and what one might change in the future.
The cultural immersion, international service-learning experience in the Dominican Republic was a three-credit course and included five pretrip seminars, 2 weeks of in-country service-learning experiences with debriefings, and three post-trip meetings. The 2-week in-country service-learning component included nursing assessments at rural clinics, evening seminars, and student-directed rural projects. Examples of these projects included a children’s day camp, health education presentations, agricultural initiatives, and participation in a 3-day urban, intercultural academic program focused on public health with representation from medicine, nursing, and the United States Agency for International Development. Curtin, Martins, Schwartz-Barcott, DiMaria, and Soler Ogando (2014) provided a more detailed description of the program.
A qualitative descriptive research design, including content analyses of students’ posttrip CRIs, was used to examine the usefulness of the model in helping students reflect on a significant aspect of their experience. The university’s institutional review board approved the study prior to departure. The CRIs were collected 3 months postexperience; 3 months was selected to provide students additional time to reflect more deeply on the experience. Students were asked to submit one reflection on an experience that stood out in their mind from their 2-week international service-learning experience in the Dominican Republic using the critical reflective exercise as their guide. All of the students had been introduced to and completed an initial CRI during practicums in childbearing and reproductive health nursing, medical–surgical nursing, and psychiatric and mental health nursing. In addition, the students’ pretrip reading list included two articles focused on CRI (Kim, 1999; Kim, Lauzon Clabo, Burbank, Leveillee, & Martins, 2010).
A template organizing style of content analysis as described by Crabtree and Miller (1999) was used to analyze the students’ CRIs. The template for this analysis included the three phases of CRI (descriptive, reflective, and critical/emancipatory). In the first step, three of the five researchers read the entire text (which included all of the CRIs) as a whole to become familiar with the text and discuss initial impressions, as well as to corroborate the relevance of the template. Next, a detailed analysis was completed by one of the researchers. This included rereading the text and segmenting and grouping of content by each phase. Subsequently, each phase was examined individually. In the descriptive phase, content was coded in relation to the circumstances and features of the situation and the student’s thoughts, feelings, and actions. In the reflective phase, the focus was on content related to the student’s reexamination of the situation, in terms of standards, theories, and knowledge, as well as the student’s intentions, attitudes, values, and emotions, and how they might have influenced the outcomes. In the critical/emancipatory phase, the focus shifted toward correcting and changing less than good or ineffective practice or moving forward to future assimilation of new innovations emerging from practice. This analysis and the findings then were reviewed, discussed, and corroborated by all five of the researchers.
Efforts were made to enhance the trustworthiness, confirmability, and transferability of the findings, criteria established by Guba and Lincoln (1994) to judge the credibility of qualitative research. Trustworthiness was enhanced by the use of an audit trail, and confirmability was strengthened by the interactive comparison by each researcher based on the initial reading of the text and subsequent final analyses of the data related to the three phases. In addition, transferability was fostered through presentations and panel discussions by the nursing faculty at national public health conferences.
Five senior and two junior female baccalaureate nursing students, ranging in age from 20 to 25, completed CRIs. Six students were Caucasian, and one student was African American. Six students had little to no Spanish language skills, and three of the participants had no international experience. Four students had vacationed abroad; one of these students also had participated in a short-term study tour abroad. All of the students expressed interest in understanding different cultures; two students explicitly stated they wanted to “make a difference.”
Students’ Critical Reflective Inquiries
The students were asked to submit one reflection on an experience that stood out in their mind from the 2-week experience in the Dominican Republic, using CRI as their guide. All of the students selected an experience from the rural rather than the urban setting for their CRIs. The students’ time in the “campo” (countryside) clearly provided the greatest contrast with their own lives, and this is where they had the most intimate contact with the Dominican people. Six of the seven students addressed aspects of all three phases of the CRI. The remaining student covered aspects of the descriptive and reflective phases, but not the critical/emancipatory phase.
Descriptive Phase. The students’ descriptions were extraordinarily compelling and powerful even though they did not always follow the CRI model tightly. The brevity of narratives seemed to resemble the conciseness, succinctness, and focus one might use when reporting to an instructor about one’s thinking (reasoning) and actions with an assigned patient. For example, one student started by setting the stage. She wrote that it was her second day in the “campos” and described how much more encouraging it was than the first day. She noted that “much of the disorganization from the first day had subsided,” and that “identified weaknesses in medication administration had been corrected, and assessment and education took a larger focus than previous.” The student then provided a brief but clear and poignant description of her encounter with a boy who was approximately 12 years old:
He was brought unattended to the station with the complaint of gripe [cold symptoms], a common complaint at the daily health clinics. The RN with whom I was stationed had me initiating assessment, and implementing teaching; she serving [sic] the role of collaborative support, overseeing my assessment and giving guidance as needed.
For this young boy...my initial general survey did not corroborate with his statement. In the general survey, he exhibited no signs of rhinitis, chapped lips, or hoarse voice, all indicative of gripe. I began the objective portion of the assessment by visualizing the back of the throat and palpating the cervical chain lymph nodes. However, the throat was not erythematous, and the lymph nodes were not tender and not enlarged.
It was then that I moved to auscultate the lung sounds. Immediately upon auscultation, I heard a profound expiratory wheeze. The RN with whom I was paired confirmed this finding, and the nurse practitioner when called over also confirmed the finding.
A rescue albuterol inhaler and steroidal inhaler were allocated. Teaching, through translator, on use was provided by me. The nurse practitioner provided teaching on the vital importance of seeing a doctor, as the med [medications] we were giving would run out and he was in desperate need of them.
The teaching was provided to the boy and a neighbor, as the boy’s primary caregiver, his grandmother, was at home attending to younger charges. The neighbor explained to us that an inhaler would be next to impossible to replace, as the expense far exceeded the resources of the boy’s family. The nurse practitioner empathized and again stressed the imminent need, and the boy was on his way.
Reflective Phase. All of the students identified and analyzed a core belief or knowledge related to their written narrative. In addition, they reexamined some aspect of the situation and their initial intentions. For example, in the case described above, the student’s analysis focused on the sustainability and efficacy of the intervention given in relation to her knowledge of asthma:
The knowledge that for this young boy, with severe asthma: there would be no continuity of care, the inhalers we were giving him would serve him for a short time and the adverse effects associated with improperly managed corticosteroid discontinuation were probable, was difficult cognitively. It is very difficult to weigh the efficacy of such an intervention. Without assurance of continuity of care, the potential adverse effects of an improperly discontinued corticosteroid far outweigh the benefits of a single prescription. The knowledge we gave the boy of his condition instills a small vestige of hope, but in reality could have no impact whatsoever in his condition.
The student also reflected that:
The neighbor woman, who patiently took in all of the teaching provided, served as a community mother of sorts. I observed her escorting many of the villagers to the health clinic and in one instance providing Creole to Spanish translation. It was... encouraging to see the impact that one invested community member can make. This community member was single-handedly ensuring that all the infirm in her community were receiving the medical attention proffered by the health clinic. Transformational was the word that came to mind when reviewing her role.
Similarly, other students followed the same progression in phase two. However, they tended to merge the descriptive and the reflective phases.
Critical/Emancipatory Phase. Students in this phase clearly began to identify specific strategies for changing practice. For example, in the case described above, the student began to think about what she would have done differently and how she would change practice in the future. She wrote:
In retrospect, during this interaction, I would have provided more teaching as to health promotion behaviors for asthma, i.e., más agua (more water), minimize dairy, and the benefit of strong coffee or tea for improving an acute asthma attack. The interaction also increased my passion for the institution of sustainable health care infrastructures in developing countries. Missions such as this one are integral but not enough and end up falling short, and in some instances, such as cited in corticosteroid discontinuation, have the potential to do harm rather than good. Working in collaboration with community members to build existing resources is an essential component in assuring continuity of care and indeed may be paramount.
Additional examples included the need for active listening, resources, and sustainable interventions. At a more profound level, students revealed a change in conception of practice that reflected a deeper appreciation and understanding of the variability in the human condition and the strengths patients bring to the encounter.
Discussion and Nursing Implications
Most immersion programs are credited with enhancing personal and professional role development as demonstrated by general themes but rarely linked to specific patient care situations in actual practice. Kim’s (1999) CRI model was particularly helpful in promoting in-depth description and reflection on underlying assumptions and values, as well as identifying beginning strategies for emancipation in specific patient care situations. The CRI model helps students make a link between the personal growth that occurred and its potential impact on their role as nurses. In addition, it may be this link that can help explain the association between awareness and increasing cultural competence, a link that is often cited as needing further understanding in the literature (Ash, Clayton, & Atkinson, 2005; Eyler, 2000; Eyler & Giles, 1999; Forsey et al., 2012; Riner, 2011; Rolfe, Freshwater, & Jasper, 2001; Vande Berg, 2007).
Reflection is about developing new insights through thinking about experiences and their meaning. It is through this process that students understand the reason behind practice and professional decisions. The challenge is how to assist students in moving from the descriptive and reflective phases of CRI to the critical/emancipatory phase, in which students begin to self-critique and change practice. Perhaps reflection should be externalized through a dialogue with two or more individuals to facilitate this process. The work of Kim (1999) and Asselin, Schwartz-Barcott, and Osterman (2013) with staff nurses would lead one to think that the learning of CRI might be enhanced by group discussion. Conducting CRI in a group context may produce a more comprehensive description of the actors, action, and context of any one situation. This may lead to a clearer articulation and a greater in-depth understanding of the underlying values and beliefs, as well as a more thorough consideration of what may have been done differently and potential future changes in nursing practice.
- Ash, S.L., Clayton, P.H. & Atkinson, M.P. (2005). Integrating reflection and assessment to capture and improve student learning. Michigan Journal of Community Service Learning, 11(2), 49–60.
- Asselin, M., Schwartz-Barcott, D. & Osterman, P.A. (2013). Exploring reflection as a process embedded in practice: A qualitative study. Journal of Advanced Nursing, 69, 904–914. doi:10.1111/j.1365-2648.2012.06082.x [CrossRef]
- Crabtree, B.F. & Miller, W.L. (1999). Using codes and code manuals: A template organizing style of interpretation. In Crabtree, B.F. & Miller, W.L. (Eds.), Doing qualitative research (2nd ed., pp. 163–178). Thousand Oaks, CA: Sage.
- Curtin, A.J., Martins, D.C., Schwartz-Barcott, D., DiMaria, L. & Soler Ogando, B.M. (2013). Development and evaluation of an international service learning program for nursing students. Public Health Nursing, 30, 548–556.
- Edmonds, M.L. (2010). The lived experience of nursing students who study abroad: A qualitative inquiry. Journal of Studies in International Education, 14, 545–568. doi:10.1177/1028315310375306 [CrossRef]
- Eyler, J. (2000). What do we most need to know about the impact of service-learning on student learning?Michigan Journal of Community Service Learning, Fall (Special Issue), 11–17.
- Eyler, J & Giles, D.E. (1999). Where’s the learning in service-learning? San Francisco, CA: Jossey-Bass.
- Forsey, M., Broomhall, S. & Davis, J. (2012). Broadening the mind? Australian student reflections on the experience of overseas study. Journal of Studies in International Education, 16, 128–139. doi:10.1177/1028315311407511 [CrossRef]
- Greatrex-White, S. (2008). Uncovering study abroad: Foreignness and its relevance to nurse education and cultural competence. Nurse Education Today, 28, 530–538. doi:10.1016/j.nedt.2007.09.005 [CrossRef]
- Guba, E.G. & Lincoln, Y.S. (1994). Competing paradigms in qualitative research. In Denzin, N.K. & Lincoln, Y.S. (Eds.), Handbook of qualitative research (pp. 105–117). Thousand Oaks, CA: Sage.
- Harrison, L. & Malone, K. (2004). A study abroad experience in Guatemala: Learning first-hand about health, education, and social welfare in a low-resource country. International Journal of Nursing Education Scholarship, 1(1), Article 16. doi:10.2202/1548-923X.1040 [CrossRef]
- Johansen, L. (2006). The implementation of a study abroad course for nursing. Nurse Educator, 31, 129–131. doi:10.1097/00006223-200605000-00010 [CrossRef]
- Kim, H.S. (1999). Critical reflective inquiry for knowledge development in nursing practice. Journal of Advanced Nursing, 29, 1205–1212. doi:10.1046/j.1365-2648.1999.01005.x [CrossRef]
- Kim, H.S., Lauzon Clabo, L.M., Burbank, P., Leveillee, M. & Martins, D. (2010). Application of critical reflective inquiry in nursing education. In Lyons, N. (Ed.), Handbook of reflection and reflective inquiry: Mapping a way of knowing for professional reflective inquiry (pp. 159–171). New York, NY: Springer. doi:10.1007/978-0-387-85744-2_8 [CrossRef]
- Kirkham, S.R., Van Hofwegen, L. & Pankratz, D. (2009). Keeping the vision: Sustaining social consciousness with nursing students following international learning experiences. International Journal of Nursing Education Scholarship, 6(1), Article 3. Epub January 17, 2009.
- Kulbok, P.A., Mitchell, E.M., Glick, D.F. & Greiner, D. (2012). International experiences in nursing education: A review of the literature. International Journal of Nursing Education Scholarship, 9(1), 1–21. doi:10.1515/1548-923X.2365 [CrossRef]
- Larson, K.L., Ott, M. & Miles, J.M. (2010). International cultural immersion: En vivo reflections in cultural competence. Journal of Cultural Diversity, 17(2), 44–50.
- Lindquist, G.J. (1986). Programs that internationalize nursing curricula in baccalaureate schools of nursing in the United States. Journal of Professional Nursing, 2, 143–150. doi:10.1016/S8755-7223(86)80059-X [CrossRef]
- Lyons, N. (2010). Reflection and reflective inquiry: Critical issues, evolving conceptualizations, contemporary claims and future possibilities. In Lyons, N. (Ed.), Handbook of reflection and reflective inquiry: Mapping a way of knowing for professional reflective inquiry (pp. 3–21). New York, NY: Springer. doi:10.1007/978-0-387-85744-2_1 [CrossRef]
- McKinnon, T.H. & Fitzpatrick, J. (Eds.) (2011). Global service-learning in nursing. New York, NY: National League for Nursing.
- Riner, M.E. (2011). Globally engaged nursing education: An academic program framework. Nursing Outlook, 59, 308–317. doi:10.1016/j.outlook.2011.04.005 [CrossRef]
- Rolfe, G., Freshwater, D. & Jasper, M. (2001). Critical reflection for nursing and the helping professions: A user’s guide. Basingstoke, United Kingdom: Palgrave.
- Smith-Miller, C.A., Leak, A., Harlan, C.A., Dieckmann, J. & Sherwood, G. (2010). “Leaving the comfort of the familiar”: Fostering workplace cultural awareness through short-term global experiences. Nursing Forum, 45, 18–28. doi:10.1111/j.1744-6198.2009.00163.x [CrossRef]
- Snyder, M. (2014). Emancipatory knowing: Empowering nursing students toward reflection and action. Journal of Nursing Education, 53, 65–69.
- Vande Berg, M. (2007). Intervening in the learning of U.S. students abroad. Journal of Studies in International Education, 11, 392–399. doi:10.1177/1028315307303924 [CrossRef]