According to the U.S. Census Bureau, minorities comprised 37% of the U.S. population in 2012; however, only 19% of minority backgrounds were represented in the RN workforce, and only 12.3% of nursing faculty self-identified as an ethnic or racial minority (American Association of Colleges of Nursing, 2015). People have specific and often hidden values, attitudes, and beliefs that inform how they care for their own health care and how they care for the health of their families. Health care as a profession has its own culture as well, and health care providers, including nurses, have sets of core beliefs about the care they provide. Encounters with health care practices that are different than one’s own can provoke anxiety and other emotions in both recipients and providers of that care (Koskinen & Tossavainen, 2004).
In 2014, a group of nursing students were accompanied by their university professor to Swaziland, Africa, for an overseas study experience. The students worked with children and adults in a variety of hospital and community-based settings. After their return, the students were interviewed about their experiences. This article is a study of their personal and professional growth following this experience.
An increasingly diverse population requires that nursing education closely scrutinizes how culture is taught within nursing programs. Current practice tends to emphasize what is different about ethnic minorities rather than what is the same (Duffy, 2001; Koskinen & Tossavainen, 2004). This ethnocentrism is reflected in the nursing literature as well, where racial and ethnic groups are reduced into stereotyped generalizations (Button, Green, Tengnah, Johansson, & Baker, 2005; Duffy, 2001). International experiences are a means of exposing nursing students to cultural differences within environments where the dominant beliefs, values, attitudes, and behaviors are likely to be different than their own. International exposure allows students to increase their global understanding of health care within a context of social, political, and economic pressures (Button et al., 2005; Grant & McKenna, 2003; Koskinen & Tossavainen, 2004). Button et al. (2005) reviewed 43 reports of overseas study programs in nursing and identified four main benefits from international placements:
- Learning about cultural differences.
- Comparing differing health care systems.
- Comparing alternative forms of nursing practice.
- Personal development in students.
Nursing students in overseas study programs go through transitional periods during which they report myriad emotional reactions and uncomfortable sensations (Koskinen & Tossavainen, 2004; Lee, 2004; Smith & Curry, 2011). In addition, students may struggle with language difficulties and practical problems during placements (Grant & McKenna, 2003; Koskinen & Tossavainen, 2004; Smith & Curry, 2011). Discomfort appears to be important in creating an opportunity for students to activate coping strategies that are essential in potentiating growth (Grant & McKenna, 2003; Kokko, 2011; Ruddock & Turner, 2007; Taylor, 2007). Nursing students demonstrate cultural shifts in nursing care during overseas service-learning. Grant and McKenna (2003) found that students initially focused on skill-based activities, then later they were able to discuss and reflect on the larger experience of the nurse’s roles in the greater context of the organization and the sociopolitical structure of the country.
Little has been published on the long-term effects of an overseas study experience on nursing practice. Lee (2004) said that international experiences appeared to help students adjust to the complex roles of the staff nurse and contributed to a deeper understanding of “alternative ways of practicing nursing” (p. 119). Smith and Curry (2011) interviewed students who participated in an overseas study program and found a positive long-term impact of the experience on professional role development; students reported an increased understanding of nursing and health care in other countries, and they felt better able to discuss international and transcultural issues with other people. Finally, overseas immersion experiences have been demonstrated to have positive effects in relatively short periods of time on students’ attitudes, beliefs, and knowledge (Diesel, Ercole, & Taliaferro, 2013).
The purpose of this study was to explore the personal and professional growth reported by bachelor of science in nursing (BSN) students following an overseas service-learning health care delivery program experience.
Swaziland is a small country in the sub-Saharan region of Africa with an area of approximately 17,000 km2 and a population of 1.23 million people (World Health Organization [WHO], 2013). Most people in Swaziland speak some English and siSwati, both official languages of the country. Only 5.34% of Swazi citizens are age 60 or older, and more than half are younger than age 19 (Global Health Observatory [GHO], 2014c).
In 2012, the average life expectancy in Swaziland was 52 years for men and 55 years for women (WHO, 2013). The primary reason for this shortened life span is a lack of adequate health care. Infectious diseases are the primary cause of death for all age groups, and Swaziland has the highest human immunodeficiency virus infection (HIV) rate of any country in the world: 26.5% of adults ages 15 to 49 (GHO, 2014b) and 39% of pregnant women ages 15 to 24 years are HIV positive (Ministry of Health, 2010).
Nursing students rotated through 2 days in a hospital labor and delivery unit. Although infant mortality in Swaziland is high with a rate of 30 per 1,000 live births, maternal mortality rates have been declining slowly due to increasing hospital-based births attended by skilled health professionals, primarily nurse midwives (GHO, 2014a, 2014c).
Nursing students also rotated through 2 days of inpatient pediatric care. Approximately 4.7% of all Swazi children younger than age 15 live with chronic HIV infection (GHO, 2014b). Primary causes of mortality in infants and children younger than age 15 include complications related to HIV and acquired immunodeficiency syndrome (AIDS), acute respiratory infections, diarrhea, and protein energy malnutrition (WHO, 2011).
Nursing students also were assigned to varied observational experiences, such as the intensive care unit, renal dialysis, the child vaccination clinic, and the Baylor University Clinic for Children With HIV infection. In addition to hospital work, the nursing students and their instructor helped to implement five community-based health clinics that provided health assessments and outpatient treatment to more than 340 adults and children. These clinics were coordinated through the assistance of a community health partner.
Finally, the students were scheduled for several cultural excursions that included trips to a traditional village, a museum, a community market, and a jungle excursion. This provided a sense of time and place that gave students a historical context to Swazi culture, as well as a more well-rounded sense of the country and its people.
Six BSN students participated in this study. All of the participants were women, unmarried, White, without children, and in their early 20s. Half of the students were entering their junior year, and half of the students were seniors. All of the students were from the same academic program. Students were enrolled in an elective course in global studies in health care offered during the summer for which they received three graded, academic credits. Requirements for enrollment were a grade point average of 3.0 or above and good academic standing. Applications were reviewed by nursing faculty prior to acceptance. Students paid for their own overseas travel expenses and had varying summer tuition assistance.
Clinical experiences with ethnically diverse populations were limited in the student group prior to this program; one student had previous African travel experience through a church group, and the remainder had only practiced in rural or semiurban hospital settings. Students came from three cities located in one midwestern state where the overall population is described by census data as 86% White, 9.5% Black, and 6% Hispanic (U.S. Census Bureau, 2015). Studies have shown that students consistently had more positive experiences in overseas study programs when they were prepared for the experience with some knowledge about what they may encounter, as well as some practical information about the country and traditions of the people with whom they would be living and working (Button et al., 2005; Duffy, 2001; Koskinen & Tossavainen, 2004; Riner, 2011). Students attended three, 2-hour orientation sessions with faculty and completed country-specific reading and written assignments prior to the experience. In addition, all of the students had received diversity and cultural content as a component of their nursing curriculum courses.
The senior students had completed 90 hours of course-work in both pediatrics and obstetrics/gynecological nursing. All of the students had completed fundamental nursing skills, health assessments, medical–surgical nursing, and pharmacology. The Swaziland hospital’s nursing education coordinator was provided with a list of skills that the students had mastered as well as the goals and objectives for the program. During the experience, students met daily after the evening meal for group discussion and debriefing. In addition, they were given written reflection assignments every 3 to 4 days in which they were asked to describe their experiences, thoughts, and feelings. There was no formal debriefing at the completion of the overseas study program. Students said their “good byes” to the instructor and one another at the airport, and did not encounter each other again until they were interviewed for this study.
This study was approved by the university’s institutional review board as an exempt study. All of the participants agreed to full participation and consented to both audiotaping and photography. The study was completed 1 month by the instructor after the course was completed and after final grades were submitted. Participation was voluntary.
Narrative methods were used to obtain the data for this study. Students were interviewed individually after returning from Africa. Interviews were audiotaped and then transcribed verbatim. The researcher used a semistructured interview format that started with seven questions and then used open-ended probes to encourage elaboration (Table 1). Interviews lasted an average of 45 minutes.
Semistructured Interview Questions
Data were analyzed using thematic techniques described by Ewick and Sibley (as cited in Reissman, 2008). In this approach, a series of interviews are used to “...unmask how sociological concepts work in everyday life” (p. 59). The data analysis was guided by a literature review. Particular attention was given to ways in which the students experienced cognitive dissonance and discomfort when they encountered cultural differences in attitudes, values, and beliefs systems, and in how they demonstrated evidence of coping strategies in response to these stressors.
Initially, the researcher combined all of the interviews into one document and re-read them to become familiar with the content and context. A nominal examination then was performed line-by-line by assigning surface codes to the salient points in each sentence or phrase. Next, the document was reviewed again for categories and phrases that linked together more generally to the concepts of interest as identified in the literature review. This process resulted in clear theme emergence.
In the next step, contrasting or counter examples and related topics were identified and either incorporated into the main themes or placed into separate categories. The final stage in analysis was a return to the literature for comparative purposes. Overarching concepts were pulled out of the categories. The literature supported a final determination of four overarching themes.
The four overarching themes identified were: transition, perceptions, internalization, and incorporation. Subthemes were identified for each overarching theme. The overarching themes and subthemes are summarized in Table 2 and the Figure.
Thematic Content Analysis of Transformational Processes in Developing Cultural Understanding
Transformative cultural education of nursing students. SZ = Swaziland; US = United States.
Language and Communication. Language and communication difficulties were clear. Language barriers could be frustrating, and in the community setting, there was often a lack of adequate translators. In the hospital, students noted that they felt alienated from nurses who chose to speak only in their native language. Even though many patients spoke English or they had translators, medical terminology did not interpret easily and English words sometimes had different meanings ascribed to certain terms. One student commented:
Even when you do have a translator, they have different terms. Like, what did they call an ulcer?.... So the translator would tell you in English, but you wouldn’t know what that meant.
When performing patient education, several students commented that the need to explain things in more simplistic terminology and to use more nonverbal indicators actually made them think more carefully about what they were teaching the patient.
An Emotional Journey. Students reported feeling a wide range of emotional experiences. They were surprised to come home feeling frustrated about the perceived futility over their interventions in the community setting. Several students believed that they were unable to do enough for the patients. One student said:
I’ll never forget that family that had five kids, the five orphans, and their grandmother’s taking care of them and all the kids are complaining of a stomachache.... I’m trying to ask all these questions to understand what’s causing the stomachache, and I realize it’s because they’re hungry. They’re asking me for food and the only thing I have is an apple. I mean, I gave them the apple, but I don’t know what to do.... That was a hard, hard thing to deal with.
Other students were shocked by some of the conditions they encountered in the clinical settings and were uncomfortable with the relationships they witnessed between patients and nurses in the hospital. One student commented:
The lady that I was with, the patient, she was threatened by a nurse. She was told that she was going to slap her if she didn’t get off the floor. She was, I guess, misbehaving. She was in a lot of pain and she was crawling on the floor, and the nurse threatened to slap her a couple of times.
Students also experienced personal hardships, such as a lack of hot water in the hotel room and homesickness. Sadness was a common theme as illustrated by the following comment:
When we finally left, it was so hard to leave them that final time we left on the bus, and all those kids were out there. That was the hardest thing because I really didn’t want to go.
Health Care Systems. Swaziland health care systems were perceived by the students as having a pronounced lack of resources, and the resources that were available were of poor quality or were rationed. Conversely, the students almost universally recognized the ingenuity of the Swazi people in “making do” with the resources that they did have and in wasting very little. Students saw poverty as a barrier to access to health care; traveling into the rural areas and seeing how people lived helped students to experience this firsthand. Transportation also was seen as a barrier to care. Rural roads are not paved in Swaziland, and to make clinic visits, students often had to get out of the bus and walk while carrying medical supplies. Students recognized that physician usage is infrequent in Swaziland due to the lack of providers. Many people still turn to traditional healers, and the nursing students saw harmful evidence of this. A recurring theme when discussing the health care system in Swaziland was the perceived lack of patient education. One student commented that people in Swaziland “...put blind trust in the health care workers and didn’t ask questions,” and as a result, she saw very little patient education. She contrasted this to the United States where “people are more mistrusting and ask more questions.”
In comparison, students perceived that U.S. health care is easy to access but may not be affordable for all and that providers in the United States may have become complacent in trying to find more economical ways of providing care. One student described this when she returned home to find a disposable metal suture kit being used and thought, “Why can’t we autoclave this and reuse this just like they do in Swaziland?”
Nursing Culture. The students’ perceptions of nursing in Swaziland generated a great deal of discussion in the first week of the immersion experience. The highly emotional nature of this had dissipated into a more critical and reflective examination of nursing culture by the end of their experience. In general, nurses in Swaziland were perceived as more restricted in their practice. They seemed to have less personal contact with patients, and they seemed to demonstrate less empathy. One student noted:
I never saw a nurse with a stethoscope or do an assessment. The only thing the nurses did...was sit in the office and talk, and do a temperature or respirations, and give medicines.
Patient education was another area that stood out to the students as absent in comparison to what they were being taught in the United States. One student said, “In nursing school, we write goals for education everyday...and there they don’t even talk about it.”
A third major theme that was consistent through most of the interviews was patient responsibility. The students felt strongly that accountability for the patient in the United States defaulted to the nursing staff, whereas in Swaziland, this remained with the family. One student noted, “I wasn’t expecting the moms to have so much impact of care on their kids...I feel like in the United States it would be mostly the nurse’s job.”
Students had concerns about safety and infection control issues in the hospital setting—areas that they thought were the nurses’ responsibilities as well. One student stated:
Like with sterile technique, when we were doing the bandages with the girl with the burns, there were many times when they broke sterile procedure. It was hard for me not to say anything.
Students believed that nurses in the United States have more direct responsibility for assessing, planning, directing, and providing patient care. They also thought that interpersonal communication and empathy is necessary and expected to carry out these nursing functions and that patient education is an essential role of the professional nurse. In general, the students perceived that nurses in the United States are “held to a higher standard” than nurses in Swaziland.
Transformative Learning. Overwhelmingly, students used storytelling to make sense of their experiences. According to Maynes, Pierce, and Laslett (2008), stories can be used to interpret the actions of others as representing underlying meanings, as highlighted in the following student’s comments:
I was in a situation where I had to help a dog bite victim who was 8 or 10...We were changing his dressings, and I had to step away for a minute. She [the nurse] told me to get some sheets. She probably saw that I was getting ready to cry. But, I came back and got ahold of myself and was able to do it. I was able to help her, and afterwards I was able to sit and talk to him, and see that he was a normal kid.
This student interpreted the nurse’s action as compassion, and she interpreted her own response as strength to be able to complete the task despite her emotions. Later on, the student would say that this experience cemented her desire to be a pediatric nurse because she now knew she had the strength to be able to “take it” when children were in pain.
Another student said:
I didn’t expect to meet a girl who had been left at the hospital because her parents didn’t want to take care of her anymore. That was very...I didn’t expect those kinds of things.
The student was saddened and shocked that parents could and would abandon a sick child in a hospital, and also that there could exist a country without child protection services to step in and force the parents to live up to their responsibilities. This shook up the student’s own core beliefs in family and social values and forced her to reflect on some negative feelings that this situation evoked in her.
Students also used comparing and contrasting as another method that helped them to process the cultural differences between the United States and Swaziland. The students often compared social issues, health care, and nursing in both countries.
A third method that students used to transform their thinking was reframing their experiences. In this process, events or situations that initially appeared to be unusual or strange to the students became more normalized, as in the following example:
In the United States, having a baby is an event, and it’s kind of like it’s cushioned. You get your epidural, and your family is all there, and its lovely and great. Then you go somewhere in Africa, and it’s like, what you’re supposed to do as a woman and a wife...It’s natural. It happens naturally.
Students used reflection in processing many of their experiences. Reflection forces students to closely examine their own discomfort, which often arises from challenges to their personal values, beliefs, or attitudes (Duffy, 2001; Grant & McKenna, 2003; Riner, 2011). Reflection came through in their informal conversations and stories, as well as in their interviews.
Personal Growth. Personal growth was clearly demonstrated by the students. Students said that their awareness of how other people lived was heightened and that the experience helped them to grow as a person. The most frequent comments had to do with having developed a greater appreciation for life in the United States and more compassion for others. One student said:
It’s made me so much more open, and I feel like I have a more broadened perspective of health care and public health, and seeing things differently, the problems that people are having in a different country.
Professional Growth. Students identified many ways in which this experience helped them to develop as nurses. From a curricular and program outcomes perspective, this was a strong result for this study. The students noted that they gained more experience and learned a great deal more about nursing. Students also stated that the experience allowed them to be more resourceful and flexible. In this way, they learned what it was to work as a Swazi nurse did, and how to use the resources that they had readily available. One student noted, “One of the biggest things I learned while I was there is that there is more than one way to tackle a problem.” Students reported that this experience helped them to sharpen their critical thinking skills. They used language such as “...thinking on our feet.” Students were able to relate this back to the nursing process of assessment, planning, implementation, and evaluation. One student said, “One thing I noticed... at the start of nursing school was trying to put together the whole picture, and this trip definitely helped with that.”
Improved communication skills was an area of professional growth that students said was facilitated by this experience. Students reported that they felt more comfortable in asking patients about specific cultural practices and that they would be better able to take a step back and reevaluate how to broach a topic if their current approach did not seem to be working.
Trustworthiness and Credibility of the Research
Interviewing students about their experiences is inherently subjective and cannot be assumed to be the reality of health or nursing care in Swaziland. However, this study is about the transition and change that occurs within nursing students as a result of these experiences; thus, it is, by necessity, subjective. In narrative analysis, the researcher becomes an active agent, or co-constructionist, in the creation of the narrative and in interpreting the meaning of the words spoken or actions taken (Maynes et al., 2008). To offset researcher effects, the analysis was first presented to the research participants in a process of member checking to determine reasonableness of the conclusions and to see if the findings were credible and communicated the students’ experiences accurately. The participants indicated that the investigator’s interpretation of their interviews agreed with their own impressions. In an additional step, the results of the data analysis were compared to what was already known about this topic in the literature and were found consistent with previous studies.
Nursing in the United States is a health care profession that has its own distinct culture. Students were provided with an initial structure that was familiar to them. These familiar patterns provided the students with a sense of security (Grant & McKenna, 2003). They quickly experienced cultural dissonance, which was perceived as responsibility for the care of the patient, responsibility for education of the patient, the role of the nurse in terms of hands-on care, maintenance of patient safety and infection control, and importance placed by nurses on empathy and interpersonal communication.
There may be evidence to support some of the perceptions of the students. In a study of 941 adolescent students from three different regions of Swaziland, participants reported that they preferred receiving health education, and in particular HIV/AIDS education, from nurses as opposed to their parents or the media (Buseh, Glass, McElmurry, Mkhabela, & Sukati, 2002). However, in their description of the state of nursing and nursing education in Swaziland, Klopper and Uys (2013) stated, “The general public is concerned that nurses are not as compassionate as they would like them to be” (p. 323). This may suggest there is room for change within the nursing culture in Swaziland that could serve as a target for future intervention or future research consideration.
Cultural dissonance activated internal processes in students that forced them to use coping mechanisms to deal with this stress. Students were encouraged in daily group discussions and informal instructor one-to-one sessions to explore their thoughts and feelings about encounters. It was found that students used four main processes in this study, which served to internalize and incorporate changes in their values, beliefs, and attitudes, and to facilitate growth. They used meaning-making through narration (storytelling) and comparing and contrasting of social issues and nursing care. As they moved toward incorporation, students demonstrated more reflection and reframing. By the end of the experience, students were able to understand reasons why things occurred, even if they still did not fully agree. Riner (2011) reiterated the importance of guided reflection following experiences as an intentional learning strategy designed to help move students toward internal transformation.