Cultural consciousness is the purposeful and appropriate integration of health care delivery with cultural knowledge, sensitivity, and understanding (Shultz & Baker, 2017). It bridges the awareness gap inherent in cultural hegemony. Changes in the health care delivery system toward community-based nursing require a refocus of student learning to increase cultural consciousness or awareness. This article describes the success of a cultural immersion service-learning (CISL) experience in facilitating cultural consciousness among two cohorts of nursing students.
A reciprocal service-learning model engages students in situations that foster reflection and critical thinking about health care and social disparity (Kozub, 2013; Murray-Garcia, Harrell, Garcia, Gizzi, & Simms-Mackey, 2014; Rew, 2014). As nursing students share technical knowledge and skills, community participants share their culture, belief systems, perspective, and worldview with the students. As noted by Jean Watson (2008), “To care for someone…I must be able to bridge the gap between myself and the other” (p. 7).
Service-learning methods are commonly used to engage college students in community projects (Taylor, Pruitt, & Fasolino, 2017). Unfortunately, service-learning experiences that immerse students in an off-campus community remain difficult to develop within typical course parameters. Gillis and McLellan (2010), in reviewing service-learning with vulnerable populations, noted several common barriers for faculty: insufficient time, heavy workloads, and faculty incentive policies that maintain the status quo. Yet, faculty who are designing service-learning experiences can benefit from the insights gleaned from the previous successes of others.
Students who understand social determinants of health are better equipped to appreciate the factors that contribute to health disparities for vulnerable populations and dismantle them (Leininger, 1988). Standards for social justice, advocacy, and commitment to reducing health care disparities are explicitly addressed through the Accreditation of Baccalaureate and Graduate Nursing Programs standards for teaching the skills needed for culturally competent care (Commission on Collegiate Nursing Education, 2018). However, for the majority of the 170,000 nursing students in the United States, nursing education remains steadfast to models that have been used for decades (Robert Wood Johnson Foundation, 2014). Innovative programs of study that include CISL experiences are the exception even though public policies encourage culturally competent care for vulnerable patient populations (Patient Protection and Affordable Care Act, 2010).
The geographic isolation of American Indian reservations often results in unaffordable or inaccessible health care. In addition, poverty and high health care provider turnover contribute to limited health care access and extreme health disparities. The median age of death on the reservation is 22 to 25 years earlier than for White residents of the same state (Robert Wood Johnson Foundation, 2014). Youth suffer from a high incidence of preventable illness, including diabetes, obesity, and tooth decay. Smoking, alcohol abuse, and drug abuse are rampant. Suicide has reached epidemic levels.
Providing culturally diverse clinical experiences for nursing students at universities situated in areas with a homogenous demography is challenging. Patient diversity in such communities is constrained (Rodriguez-Garcia, Medina-Moya, Gonzalez-Pascual, & Cardenete-Reyes, 2018). One potential way to overcome this challenge is to provide nursing students access to patients from diverse backgrounds, such as American Indian reservations, through CISL experiences.
Thirty-two students enrolled in Nursing Care of Children and Family, a required junior-level baccalaureate nursing course, engaged with a rural American Indian reservation community for a 1-week CISL experience. The students attended a state university located in a rural state with a predominantly racially homogenous population. Of the 32 students, 29 students were women; 30 students were Caucasian, one student was Asian American, and one student was Native American.
Procedures and Description of Intervention
Clinical experiences outside of the traditional clinical environment challenged the students to consider the complexities of health inequalities and their impact on American Indian children and families who reside in a reservation community. Each academic year, up to 32 nursing students traveled in groups of eight with their instructor 480 miles to an American Indian reservation where the students lived and worked for 1 week. The CISL experience sought to deconstruct the technical processes of health and illness, and demonstrate the social impact of limited access to health care. Four learning objectives guided the CISL experience:
- To demonstrate an understanding and appreciation of culture practiced by two Northern Plains Indian tribes.
- To evaluate the impact of historical trauma on healthy lifestyles, well-being, and social justice.
- To analyze the complex link between poverty and health.
- To work collaboratively to achieve the stated short-term goals provided by community Elders.
The objectives and guidelines were thoroughly reviewed and discussed prior to the experience at the beginning of the semester. In addition, the nursing students completed a modified version of the White Racial Identity Attitude Scale (WRIAS) (Helms & Carter, 1990) during the first week of the course. In the weeks leading up to the CISL experience, the American Indian community's health programs director visited the campus and provided an orientation lecture. Other guest speakers shared tribal customs and values during classroom lectures. Prior to departure, the nursing students identified health education topics, then developed teaching materials to implement the lessons. Health education topics were based on the needs of children on the reservation and were developed in collaboration with the community's health programs director.
The students and the instructor collaboratively identified expected behaviors and developed group norms to prevent unnecessary tension when sharing common space. Students mutually agreed on a set of behaviors, attitudes, and conduct expectations that expressed needs for privacy, dress preferences (modesty), special dietary needs, and other individual concerns of students. Developing group norms prevented unnecessary tension when sharing common space. Establishing group norms and expected behaviors allowed students to take control of issues important to their feelings of security and comfort. Transposing these norms into written guidelines ensured that the dialogue was respectful to student peers and members of the partnering community. The implementation of peer-mediated group norms encouraged student ownership of the experience.
A written norms contract allowed struggling students to explore new ideas with professionalism and cultural responsiveness. For example, one student observed significant levels of tooth decay and reflected with her peers, “Why don't they just brush their teeth?” It is important to help students understand the layers of social and policy issues that contribute to tooth decay, such as access to care, healthy food, and cultural expectations. The group norms contract allowed students to explore negative comments in a safe environment and navigate beyond awkward moments. With firm ground rules in place, the instructor may avoid overcorrecting or embarrassing a student learner. This is an important point because the CISL experience does not allow for the same degree of privacy as other clinical experiences and because a student who feels overly criticized may hamper the group's willingness to share and to explore difficult topics during the remainder of the experience.
During each 1-week CISL experience, eight nursing students departed the campus at 9:00 a.m. on Sunday and arrived at the reservation at approximately 5:00 p.m. Upon arrival, students participated in an orientation led by the community program director and received their school clinic assignments. Each day thereafter, the nursing students were immersed in the community 12 to 14 hours per day providing care to children in six tribal schools and participating in cultural events. Throughout the school day, the students provided health care education, performed health screenings and physical examinations, and tended to minor injuries and acute illnesses as needed to children in preschool, grade school, and high school.
In the evenings, students participated in cultural events such as discussions with Elders, beading, arrow making, archery, horseback riding, and meal sharing. These evening activities encouraged the students to see the strengths of the community. On Friday evening, students were honored with traditional dancing exhibitions by the children. The community hosts taught the nursing students traditional dances. Students returned to the university's campus on Saturday.
Nursing students participated in a daily reflective clinical postconference meeting with the instructor. A reflection guide was provided to facilitate students' written in situ reflections and discourage negative dialogue. Students discussed their clinical experiences and possible misconceptions during an evening group reflection activity. The daily group reflection was not graded and allowed the group to help each other process the day.
Students received individual feedback from the faculty and the community throughout the CISL experience. Upon returning to campus, students participated in a debriefing reflection about the CISL experience; verbal feedback was followed with a written summary of student performance. During the last week of the course, students were asked to provide a written reflection of their CISL experience and completed the modified version of the WRIAS again.
The WRIAS was modified for use within a Native American community. The original WRIAS instrument includes 50 items that are scored on a 5-point Likert scale; the instrument was designed to assess attitudes along a continuum of five stages of White racial identity development within an African American community (Helms & Carter, 1990). Modifications included changing the word Black to Native American throughout the instrument and reducing the number of questions from 50 to 25 by removing items that did not apply within a Native American context.
Content validity was established by three expert reviewers prior to administering the modified scale. In addition, comparing the quantitative results collected from the modified WRIAS with qualitative results obtained from student reflections provided evidence of concurrent validity. Cronbach's alpha was .795 on the modified instrument, indicating internal reliability. A t test was performed to compare pre- and posttest student scores on the modified WRIAS. The project received exemption from the university's institutional review board (IRB). All of participants were volunteers and signed an IRB-approved informed consent detailing the purpose, benefits, and risks of the study.
Student feedback was overwhelmingly positive. Interestingly, only one student demonstrated cultural consciousness in her reflections during the CISL experience; however, 24 of the 32 students who participated in the CISL experience demonstrated cultural consciousness in their written reflections at the end of the semester. In analyzing the reflections, there seemed to be a link between the themes of recognition of privilege, suspension of judgement, reframing the situation, and demonstrated cultural consciousness. The following student quote provides an example of the recognition of privilege theme: “Although I learned a lot regarding the impact of poverty, I learned more regarding the social injustices present in this community.” The theme, suspension of judgment, is represented in the following statement made by another student:
We talk about how important getting adequate meals and nutrition is, but these kids have no control over what type of food is provided for them. It doesn't matter how many toothbrushes or toothpaste tubes we give children, if they don't have running water at home, there is no point.
The theme of reframing the situation is demonstrated by the following comment:
The conversation we had about cutting of hair really demonstrated this. I did not know that sometimes Native Americans cut their hair when a loved one passes away. This really showed me how easy it would be to assume this child cut her hair due to lice or simply to change their hairstyle. I would be mortified if I told someone their “haircut looked great, and I love getting my haircut” only to find out they did so because someone passed away.
The evidence for demonstrating culturally conscious health care varied among students. One student noted, “I observed the importance of culturally sensitive care and how a community's culture can both augment and impede the development of a community health program.” Another student wrote, “There are many missed opportunities in health care if caregivers are simply treating what is on the surface.” Another student connected cultural consciousness to health disparities more explicitly with the following comment, “Due to the poverty and cultural/historical trauma, these children do not have the means to be supported through these life issues, which in turn leads to higher rates of illness and decreased health and well-being.”
Quantitatively, postexperience scores on the modified WRIAS (Helms & Carter, 1990) were statistically significant (t = 7.906, df = 31, p < .0001). Twenty-five of the 32 participants demonstrated more than a 10-point difference between their pretest and posttest WRIAS scores. This related well with the qualitative results, with 24 of the 32 students demonstrating evidence of cultural consciousness in their final reflections of the CISL experience. Finally, the effect size of the CISL intervention was calculated at 1.902. Typically, an effect size of 0.8, even with a small sample, is considered a worthwhile process to replicate.
Lessons learned from this project support the possibility that transformational learning of cultural consciousness may occur when students participate in a well-designed CISL experience. Interested faculty may find that a similar experience could benefit their student learning communities, especially university communities with limited diversity. On the other hand, creating a CISL experience is time and resource intensive. Interested faculty members who have the support of their college or university, their dean, and their colleagues, as well as the collaborative interest of a partnering community are encouraged to develop CISL experiences.
Students who deliberately engage in service-learning purposefully select, voluntarily engage, and are committed to the CISL experience financially and emotionally. Conversely, students who participate in a CISL experience imbedded within a required course do not self-select the experience. In the latter case, the instructor can be challenged to convince students that the experience is worthwhile. This can be particularly challenging for adult learners, who may have established false preconceptions and biases about the community participants.
Clearly written course objectives are essential to support the CISL experience. Faculty considering embedding a CISL experience within a required course must consider the diverse levels of student interest in providing the service. Initially, two individuals in the newly developed CISL experience were partially resistant. Their reflections focused on a perceived inconvenience and on what they had given up to participate in the mandatory clinical experience. However, at the end of the experience, these students were self-congratulating their volunteerism and achievements.
The connection between course objectives and self-perceptions affect the experience of the students, peers, and community members. The following critical questions clarify the development of the CISL objectives: What student needs must be addressed before initiating a CISL experience? What curriculum gaps exist in preparing the students both emotionally and in skill development for the CISL experience? How do nursing students perceive cultural consciousness?
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