PRACTICE APPLICATIONS
Topics of Professional Interest
Perspectives of Cultural Competency from an International Service Learning Project Editor's Note: This is the second article in a series from the Nutrition and Dietetic Educators and Preceptors (NDEP) committee on topics of interest in dietetics education. A collection of education articles is available at www. andjrnl.org/content/education.
W
ITH THE INCREASED cultural diversity of the population of the United States and the awareness of marked health care disparities, an understanding of cultural differences is imperative for health care providers. Accordingly, preparing dietetic students to become culturally competent practitioners becomes fundamental. One potential method of enhancing cultural awareness and competence is to incorporate international service learning (ISL) experiences into the curriculum. A critical element of service learning is reflection. The purpose of this survey was to determine the impact of a short-duration ISL program on the cultural awareness and competence of dietetic interns. This survey applied qualitative and quantitative methods to analyze students’ reflective, electronic journals and service-learning surveys to assess the impact of internal service learning on the development of cultural awareness and reflective thinking. The survey involved six dietetic interns enrolled in a combined Master’s degree/dietetic internship program who completed a 1-week service-learning experience in Belize. Interns completed supervised practice experiences in clinical and community settings and blogged their experiences
This article was written by Lauri Wright, PhD, RDN, assistant professor, University of South Florida College of Public Health, Tampa, and Mary Lundy, DPT, assistant professor, University of North Florida, Jacksonville. http://dx.doi.org/10.1016/j.jand.2014.02.028
ª 2014 by the Academy of Nutrition and Dietetics.
each night. In addition, students completed the Health Professions Schools in Service to the Nation (HPSISN) Student Survey to assess changes in cultural awareness and competence. The survey demonstrated that ISL experiences serve to inform dietetic interns’ cultural awareness, competence, and practice. A short-duration ISL is an effective pedagogy that can be integrated in the dietetic education curriculum.
A CASE FOR SERVICE LEARNING TO DEVELOP CULTURAL COMPETENCE A key response to promote effective and appropriate health care is the initiative National Standards for Culturally and Linguistically Appropriate Services.1 Supported by The Joint Commission, Culturally and Linguistically Appropriate Services has significantly enhanced expectations for culturally competent practice by allied health professionals.2 Because health care organizations have increased the emphasis on cultural competence in response to evidence linking it to patient safety and outcomes, medical professionals are increasingly committed to delivering care that is competent, safe, and culturally aware.3,4 As such, dietetics education programs must seek innovative approaches to enhance students’ cultural awareness. Yet it has been difficult to identify interventions that effectively improve cultural competence.5 Unlike clinical skills that are learned, demonstrated, and then performed, cultural competence is an ongoing developmental process requiring experiences and contexts in which to integrate cultural competence constructs.6,7 One potential method of enhancing cultural awareness and competence is to incorporate ISL experiences into the curriculum. Recent literature has provided rich discussion of international immersion experiences where students live and work in communities in other countries. International experiences involve socialization where shared meanings are communicated
within and among diverse groups. Consensus supports that these experiences generally broaden the participants’ world view and contribute to increased cultural awareness and understanding; however, most evidence is anecdotal.8-12 Service learning is a teaching methodology that combines explicit academic learning objectives with community services.1 Service learning expanded to medical education in 1995 through the HPSISN program as part of the Pew Health Professions Commission.13 Service learning is defined as a guided, structured learning experience that engages students in service to a community for the mutual benefit of the student and the community.13 Inherent in the service-learning framework is the belief that students and the local community members are teachers as well as learners.8 Service learning integrates community experience with classroom theory; therefore, students increase their understanding of the communities they serve. With practical experiences and service, students make meaningful connections between what is covered in classroom lectures, readings, and discussions. With the globalization of the health care community and the dependency of health outcomes on health care providers’ level of cultural competency, the number of ISL programs have increased due to their potential to build cultural competence.14 ISL course work is completed at a location outside the country of the enrolling program and is distinguishable from volunteerism by the intentional linking of course content and learning objectives with service project activities. Medical students who have participated in ISL courses have reported feeling more culturally competent and confident in clinical skills than those students who did not participate.13
ISL PROJECT DESCRIPTION This particular project moved beyond anecdotal experiences and applied
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1
PRACTICE APPLICATIONS qualitative and quantitative methods to analyze students’ reflective electronic journals and service learning to assess the impact ISL had on the development of cultural awareness and competence. Six dietetic interns enrolled in a combined Master’s degree/dietetic internship program were the participants. All of the students were women, and ages ranged between 23 and 28 years. One student was Hispanic and the remaining students were white. Two faculty members accompanied the students. All procedures and measures were approved by the university’s Institutional Review Board. In preparation for the trip, the students were introduced and assigned to read selected materials about the country and culture of Belize. The health care needs of the community were explained, and the students planned activities to meet those needs. Specific learning objectives and developmental outcomes as well as instructional strategies and activities to be used to promote reflection and cultural awareness were identified. These guided activities were planned to assist students in making connections between their professional curriculum and real-world experiences. The activities were continuous and challenging in an unfamiliar environment. The goal was for the students to progress from superficial learners to critical reflective thinkers. They would explore the “what,” “so what,” and “now what” to form a comprehensive and integrated discovery learning cycle,15 and come to understand what it means to be culturally competent and how it can impact the quality of health care outcomes. The 1-week ISL project took place in San Ignacio, Belize. San Ignacio is located in the Cayo district of Belize—the far western part of the country near Guatemala. The population of San Ignacio is approximately 10,000 individuals. The population is made up of diverse ethnic groups including Mestizo, Kriol, Mopan, Chinese, and Mennonite. Students lived in cabins run by a Belizean family. All meals were prepared by the family and consisted of traditional Belizean fare. Students were exposed to cultural sites and events including the Mayan ruins, farmers’ market, and an herb/medicinal tour. Students also completed supervised dietetic practice in community, clinical, and wellness settings including a community agency for elderly people, schools, hospital 2
foodservice operation, renal dialysis center, and a health screening and fair for private industry. Every evening during the ISL program, the students and faculty gathered for a “work session.” The agenda included a brief discussion of the day’s events, a group blog session, and planning for the next day’s activities. Photographs from the day’s events were downloaded. The students were instructed to create one group blog entry every evening. It had to be a collaborative effort with all students involved. The entry needed to include a title that represented the impromptu theme for the day and a “quote of the day” that summarized the group’s feelings, thoughts, or a life lesson. All content, blog, title, quote for the day, and photos were unanimously approved by the group. Any differences were debated until consensus was reached. The faculty reviewed the student collaborative blog entry and then published it to the website every evening. In addition, students completed the HPSISN Student Survey to assess changes in cultural awareness and competence. The HPSISN is a 33-item tool that uses a 5-point Likert scale to answer questions about students’ views or attitudes on service, the impact of service learning, and the students’ perspectives on working in a diverse community. Two of the questions specifically address cultural awareness. Students completed the HPSISN survey before traveling to Belize, and once again within a week of their return from Belize. Before-and-after surveys were used to measure changes in cultural awareness and competence.
WHAT WAS LEARNED Group Blog The blog transcript taken from the website archive had six group blog entries. The reflection blogs were reviewed for evidence of cultural competence. Reviewers read each blog independently to identify themes and applied Campinha-Bacote’s model of cultural competence.6 According to Campinha-Bacote,6 cultural competence is a process that is divided into five interdependent constructs: (1) cultural awareness is the ability of health care providers to appreciate and understand their clients’ values, beliefs, lifeways, practices, and problem-solving strategies; (2) cultural
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
knowledge is the ability for health care providers to have an educated knowledge base about various cultures to better understand their clients; (3) cultural skill is the ability for health care providers to conduct an accurate and culturally competent history and physical examination; (4) cultural encounter is the ability for health care providers to competently work directly with clients of culturally diverse backgrounds; and (5) cultural desire is the health care provider’s drive to achieve cultural competence. A clear, common taxonomy emerged through reviewer consensus with the following themes identified:
We Are so Fortunate with What We Have. Students were struck by the degree of food insecurity in the area. In the day spent working with the community agency, interns delivered hot meals to elderly people. The “Belizean Meals on Wheels” consisted of a paper plate of beans and rice that the interns delivered from the back of a pick-up truck. The students later delivered raw chickens to people with acquired immunodeficiency syndrome (AIDS). The community programs provided nutritious food for many people who normally would not have access to such food. This theme reflected the construct of cultural knowledge or an understanding of the community programs available. It also reflected the construct of cultural desire or the drive of the interns to participate in the culture and achieve cultural competence.
Impact of Westernization. Interns found evidence of Westernization even in the most rural areas of Belize. At the school where interns provided education classes, fewer children were going home for lunch now that more women were working outside of the home. Instead, an increasing number of children ate at school, which consisted of a “snack shack” that sold foods such as potato chips and cookies. Accompanying the Western influence was an increasing incidence of obesity and diabetes.16 In fact, during a health fair provided by the interns, it was found that 60% of employees had blood sugars in the prediabetic range. This theme reflected the construct of cultural knowledge or acquired understanding about the how’s and why’s of the changing culture. It also reflected --
2014 Volume
-
Number
-
PRACTICE APPLICATIONS the construct of cultural encounter or the ability to competently work directly with culturally diverse clients such as in the school and the health fair.
Clash between Old and New. Interns saw the contrast between traditional and Westernized medicine. Herbal remedies have a high usage by Belizeans; therefore, Western treatment is often deferred in lieu of traditional medicine.17 One client the interns met with, who had a blood sugar >400 mg/dL, reported treating his diabetes with herbs rather than insulin. This theme reflected the construct of cultural awareness or the interns’ ability to understand, appreciate, and respect the clients’ values and beliefs.
Health Care on a Whole New Level. When the interns worked in the hospital, the staff had to be guided with regard to what a dietetics practitioner can do for the facility. The interns developed and trained the staff on the renal diet in only the second dialysis unit in the country. In this way, interns and those they worked with were teachers as well as learners. This theme reflected the construct of cultural skill or the interns’ ability to provide accurate care within the culture.
Student Surveys Two cultural awareness-specific questions on the HPSISN Student Survey were used to assess changes in cultural awareness and competence. Although there were only six before-and-after surveys to compare, all students reported a positive change. On average, the responses on the two cultural awareness-specific questions increased at least one level on the Likert scale, with all post-test responses strongly agreeing that they “felt more comfortable working with people different than themselves” and “they became more aware of some of their own biases and prejudices.”
IMPLICATIONS FOR DIETETICS EDUCATION The Association of American Colleges and Universities identified selected strategies as “high-impact” because of the “substantial educational benefits they provide to students” and includes ISL as one such strategy.18 The National Survey of Student Engagement (NSSE) --
2014 Volume
-
Number
-
Annual Report provides data indicating that ISL is positively related to integrative learning, reflective learning, and self-reported gains in general education and personal-social development.19 In addition, the NSSE found the experience itself is more important than the length of time spent abroad, supporting the position that travel survey has the potential to be educationally enriching and a self-reflective learning experience without requiring extensive amounts of time. Campinha-Bacote notes that teaching cultural competence is a “journey that reflects an ongoing transformation process.”20 As Mather and colleagues21 explain, the transformational process does not end with the completion of the service-learning experience, but continues to shape a practitioner’s approach, understanding, and interventions well into the future. This shaping process can be facilitated through regular instructor-lead discussions, writings, journal club, and local service projects once the students return. This project confirms the NSSE Annual Report, finding that ISL experiences serves to inform students’ cultural awareness, competence, and practice. On survey, all dietetic interns reported increased cultural awareness after completing the ISL experiences. Furthermore, the increased cultural awareness translated into cultural competence. Short-duration ISL is an effective pedagogy that can be integrated into dietetics education curriculum. Internship programs can implement 1- and 2-week rotations to other countries to facilitate cultural competence and practice. Alternatively, experiences can be planned with immigrants new to this country to enhance cultural competence and practice. Another model for the integration of ISL into the curriculum could be to offer a preparatory course with defined learning and service objectives. Students would take an active part in the planning of service activities based on guide readings similar to the preparation described in this project. For smaller groups of students, the ISL experience could be offered as an independent study course culminating in the creation of culturally appropriate patient education materials, particularly at the graduate level. In a time when acquisition of cultural competence is critical to providing effective health care, this
survey found that ISL is an effective methodology for acquisition of cultural awareness and competence.
References 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
US Department of Health and Human Services Office, Office of Minority Health. National standards on culturally and linguistically appropriate services (CLAS) (2001). http://minorityhealth.hhs.gov/ templates/browse.aspx?lvl¼2&lvlID¼15. 00. Accessed January 6, 2014. The Joint Commission. The Joint Commission 2009 requirement related to the provision of culturally and linguistically appropriate health care. http://www. jointcommission.org/assets/1/6/2009_ CLASRelatedStandardsHAP.pdf. Accessed January 6, 2014. Betancourt JR. Eliminating racial and ethnic disparities in health care: What is the role of academic medicine? Acad Med. 2006;81(9):788-792. Kardong-Edgren S, Campinha-Bacote J. Cultural competency of graduating US bachelor of science nursing students. Contemp Nurse: J Aust Nurs Prof. 2008; 28(1-2):37-44. Jones ME, Cason CL, Bond ML. Cultural attitudes, knowledge, and skills of a health workforce. J Transcult Nurs. 2004;15(4):283-290. Campinha-Bacote J. The process of cultural competence in the delivery of health care services: A model of care. J Transcult Nurs. 2002;13(3):181-184. Zambrana RE, Molnar C, Munoz H, Lopez DS. Cultural competency as it intersects with racial/ethnic, linguistic, and class disparities in managed health care organizations. Am J Manag Care. 2004;10: SP37-SP44. Bentley R, Ellison KJ. Increasing cultural competence in nursing through international service-learning experiences. J Nurs Educ. 2007;32(5):207-211. St Clair A, McKenry L. Preparing culturally competent practitioners. J Nurs Educ. 1999;38(5):228-234. Evanson TA, Zust Bl. The meaning of participation in an international service experience among baccalaureate nursing students. http://www.degruyter.com/ view/j/ijnes. Accessed January 6, 2014. Ryan M, Twibell R, Brigham C, Bennett P. Learning to care for clients in their world, not mine. J Nurs Educ. 2000;39(9):401-408.
12.
Evans E. An elective course in cultural competence for health care professionals. Am J Pharm Educ. 2006;70(3):55.
13.
Drain P, Primack A, Hunt D, Fawzi W, Holms K, Gardner P. Global health in medical education: A call for more training and opportunities. Acad Med. 2007;82(3):226-230.
14.
Hoppes S, Bender D, DeGrace B. Service learning is a perfect fit for occupational and physical therapy education. J Allied Health. 2005;34(1):47-50.
15.
National Council for Excellence in Critical Thinking. The critical thinking community. https://www.criticalthinking.org/pages/ the-national-council-for-excellence-incritical-thinking/406. Accessed January 6, 2014.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
3
PRACTICE APPLICATIONS 16.
Nugent R. Chronic diseases in developing countries: Health and economic burdens. Ann NY Acad Sci. 2008;1136(1):70-79.
17.
Kittler PG, Sucher KP, Nelms M. Food and Culture. 6th edition. Belmont, CA: Wadsworth Cengage Learning; 2012.
19.
once and for all—inclusive. In: Kuh G, ed. High-impact Educational Practices. Washington, DC: Association of American Colleges and Universities; 2008:1-7.
20.
Campinha-Bacote J. Cultural competence in nursing curricula: How are we doing 20 years later? J Nurs Educ. 2006;45(7):243244.
National Survey of Student Engagement. Annual report (2007). http://nsse.iub.edu/ NSSE_2007_Annual_Report/. Accessed January 6, 2014.
21.
Mather P, Karbley M, Yamamoto M. Identity matters in a short-term, international service-learning program. J Coll Character. 2012;13(1):1-14.
18.
Schneider CG. Liberal education and high-impact practices: Making excellence—
4
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
--
2014 Volume
-
Number
-
Topics of Professional Interest
Perspectives of Cultural Competency from an International Service Learning Project Editor's Note: This is the second article in a series from the Nutrition and Dietetic Educators and Preceptors (NDEP) committee on topics of interest in dietetics education. A collection of education articles is available at www. andjrnl.org/content/education.
W
ITH THE INCREASED cultural diversity of the population of the United States and the awareness of marked health care disparities, an understanding of cultural differences is imperative for health care providers. Accordingly, preparing dietetic students to become culturally competent practitioners becomes fundamental. One potential method of enhancing cultural awareness and competence is to incorporate international service learning (ISL) experiences into the curriculum. A critical element of service learning is reflection. The purpose of this survey was to determine the impact of a short-duration ISL program on the cultural awareness and competence of dietetic interns. This survey applied qualitative and quantitative methods to analyze students’ reflective, electronic journals and service-learning surveys to assess the impact of internal service learning on the development of cultural awareness and reflective thinking. The survey involved six dietetic interns enrolled in a combined Master’s degree/dietetic internship program who completed a 1-week service-learning experience in Belize. Interns completed supervised practice experiences in clinical and community settings and blogged their experiences
This article was written by Lauri Wright, PhD, RDN, assistant professor, University of South Florida College of Public Health, Tampa, and Mary Lundy, DPT, assistant professor, University of North Florida, Jacksonville. http://dx.doi.org/10.1016/j.jand.2014.02.028
ª 2014 by the Academy of Nutrition and Dietetics.
each night. In addition, students completed the Health Professions Schools in Service to the Nation (HPSISN) Student Survey to assess changes in cultural awareness and competence. The survey demonstrated that ISL experiences serve to inform dietetic interns’ cultural awareness, competence, and practice. A short-duration ISL is an effective pedagogy that can be integrated in the dietetic education curriculum.
A CASE FOR SERVICE LEARNING TO DEVELOP CULTURAL COMPETENCE A key response to promote effective and appropriate health care is the initiative National Standards for Culturally and Linguistically Appropriate Services.1 Supported by The Joint Commission, Culturally and Linguistically Appropriate Services has significantly enhanced expectations for culturally competent practice by allied health professionals.2 Because health care organizations have increased the emphasis on cultural competence in response to evidence linking it to patient safety and outcomes, medical professionals are increasingly committed to delivering care that is competent, safe, and culturally aware.3,4 As such, dietetics education programs must seek innovative approaches to enhance students’ cultural awareness. Yet it has been difficult to identify interventions that effectively improve cultural competence.5 Unlike clinical skills that are learned, demonstrated, and then performed, cultural competence is an ongoing developmental process requiring experiences and contexts in which to integrate cultural competence constructs.6,7 One potential method of enhancing cultural awareness and competence is to incorporate ISL experiences into the curriculum. Recent literature has provided rich discussion of international immersion experiences where students live and work in communities in other countries. International experiences involve socialization where shared meanings are communicated
within and among diverse groups. Consensus supports that these experiences generally broaden the participants’ world view and contribute to increased cultural awareness and understanding; however, most evidence is anecdotal.8-12 Service learning is a teaching methodology that combines explicit academic learning objectives with community services.1 Service learning expanded to medical education in 1995 through the HPSISN program as part of the Pew Health Professions Commission.13 Service learning is defined as a guided, structured learning experience that engages students in service to a community for the mutual benefit of the student and the community.13 Inherent in the service-learning framework is the belief that students and the local community members are teachers as well as learners.8 Service learning integrates community experience with classroom theory; therefore, students increase their understanding of the communities they serve. With practical experiences and service, students make meaningful connections between what is covered in classroom lectures, readings, and discussions. With the globalization of the health care community and the dependency of health outcomes on health care providers’ level of cultural competency, the number of ISL programs have increased due to their potential to build cultural competence.14 ISL course work is completed at a location outside the country of the enrolling program and is distinguishable from volunteerism by the intentional linking of course content and learning objectives with service project activities. Medical students who have participated in ISL courses have reported feeling more culturally competent and confident in clinical skills than those students who did not participate.13
ISL PROJECT DESCRIPTION This particular project moved beyond anecdotal experiences and applied
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1
PRACTICE APPLICATIONS qualitative and quantitative methods to analyze students’ reflective electronic journals and service learning to assess the impact ISL had on the development of cultural awareness and competence. Six dietetic interns enrolled in a combined Master’s degree/dietetic internship program were the participants. All of the students were women, and ages ranged between 23 and 28 years. One student was Hispanic and the remaining students were white. Two faculty members accompanied the students. All procedures and measures were approved by the university’s Institutional Review Board. In preparation for the trip, the students were introduced and assigned to read selected materials about the country and culture of Belize. The health care needs of the community were explained, and the students planned activities to meet those needs. Specific learning objectives and developmental outcomes as well as instructional strategies and activities to be used to promote reflection and cultural awareness were identified. These guided activities were planned to assist students in making connections between their professional curriculum and real-world experiences. The activities were continuous and challenging in an unfamiliar environment. The goal was for the students to progress from superficial learners to critical reflective thinkers. They would explore the “what,” “so what,” and “now what” to form a comprehensive and integrated discovery learning cycle,15 and come to understand what it means to be culturally competent and how it can impact the quality of health care outcomes. The 1-week ISL project took place in San Ignacio, Belize. San Ignacio is located in the Cayo district of Belize—the far western part of the country near Guatemala. The population of San Ignacio is approximately 10,000 individuals. The population is made up of diverse ethnic groups including Mestizo, Kriol, Mopan, Chinese, and Mennonite. Students lived in cabins run by a Belizean family. All meals were prepared by the family and consisted of traditional Belizean fare. Students were exposed to cultural sites and events including the Mayan ruins, farmers’ market, and an herb/medicinal tour. Students also completed supervised dietetic practice in community, clinical, and wellness settings including a community agency for elderly people, schools, hospital 2
foodservice operation, renal dialysis center, and a health screening and fair for private industry. Every evening during the ISL program, the students and faculty gathered for a “work session.” The agenda included a brief discussion of the day’s events, a group blog session, and planning for the next day’s activities. Photographs from the day’s events were downloaded. The students were instructed to create one group blog entry every evening. It had to be a collaborative effort with all students involved. The entry needed to include a title that represented the impromptu theme for the day and a “quote of the day” that summarized the group’s feelings, thoughts, or a life lesson. All content, blog, title, quote for the day, and photos were unanimously approved by the group. Any differences were debated until consensus was reached. The faculty reviewed the student collaborative blog entry and then published it to the website every evening. In addition, students completed the HPSISN Student Survey to assess changes in cultural awareness and competence. The HPSISN is a 33-item tool that uses a 5-point Likert scale to answer questions about students’ views or attitudes on service, the impact of service learning, and the students’ perspectives on working in a diverse community. Two of the questions specifically address cultural awareness. Students completed the HPSISN survey before traveling to Belize, and once again within a week of their return from Belize. Before-and-after surveys were used to measure changes in cultural awareness and competence.
WHAT WAS LEARNED Group Blog The blog transcript taken from the website archive had six group blog entries. The reflection blogs were reviewed for evidence of cultural competence. Reviewers read each blog independently to identify themes and applied Campinha-Bacote’s model of cultural competence.6 According to Campinha-Bacote,6 cultural competence is a process that is divided into five interdependent constructs: (1) cultural awareness is the ability of health care providers to appreciate and understand their clients’ values, beliefs, lifeways, practices, and problem-solving strategies; (2) cultural
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
knowledge is the ability for health care providers to have an educated knowledge base about various cultures to better understand their clients; (3) cultural skill is the ability for health care providers to conduct an accurate and culturally competent history and physical examination; (4) cultural encounter is the ability for health care providers to competently work directly with clients of culturally diverse backgrounds; and (5) cultural desire is the health care provider’s drive to achieve cultural competence. A clear, common taxonomy emerged through reviewer consensus with the following themes identified:
We Are so Fortunate with What We Have. Students were struck by the degree of food insecurity in the area. In the day spent working with the community agency, interns delivered hot meals to elderly people. The “Belizean Meals on Wheels” consisted of a paper plate of beans and rice that the interns delivered from the back of a pick-up truck. The students later delivered raw chickens to people with acquired immunodeficiency syndrome (AIDS). The community programs provided nutritious food for many people who normally would not have access to such food. This theme reflected the construct of cultural knowledge or an understanding of the community programs available. It also reflected the construct of cultural desire or the drive of the interns to participate in the culture and achieve cultural competence.
Impact of Westernization. Interns found evidence of Westernization even in the most rural areas of Belize. At the school where interns provided education classes, fewer children were going home for lunch now that more women were working outside of the home. Instead, an increasing number of children ate at school, which consisted of a “snack shack” that sold foods such as potato chips and cookies. Accompanying the Western influence was an increasing incidence of obesity and diabetes.16 In fact, during a health fair provided by the interns, it was found that 60% of employees had blood sugars in the prediabetic range. This theme reflected the construct of cultural knowledge or acquired understanding about the how’s and why’s of the changing culture. It also reflected --
2014 Volume
-
Number
-
PRACTICE APPLICATIONS the construct of cultural encounter or the ability to competently work directly with culturally diverse clients such as in the school and the health fair.
Clash between Old and New. Interns saw the contrast between traditional and Westernized medicine. Herbal remedies have a high usage by Belizeans; therefore, Western treatment is often deferred in lieu of traditional medicine.17 One client the interns met with, who had a blood sugar >400 mg/dL, reported treating his diabetes with herbs rather than insulin. This theme reflected the construct of cultural awareness or the interns’ ability to understand, appreciate, and respect the clients’ values and beliefs.
Health Care on a Whole New Level. When the interns worked in the hospital, the staff had to be guided with regard to what a dietetics practitioner can do for the facility. The interns developed and trained the staff on the renal diet in only the second dialysis unit in the country. In this way, interns and those they worked with were teachers as well as learners. This theme reflected the construct of cultural skill or the interns’ ability to provide accurate care within the culture.
Student Surveys Two cultural awareness-specific questions on the HPSISN Student Survey were used to assess changes in cultural awareness and competence. Although there were only six before-and-after surveys to compare, all students reported a positive change. On average, the responses on the two cultural awareness-specific questions increased at least one level on the Likert scale, with all post-test responses strongly agreeing that they “felt more comfortable working with people different than themselves” and “they became more aware of some of their own biases and prejudices.”
IMPLICATIONS FOR DIETETICS EDUCATION The Association of American Colleges and Universities identified selected strategies as “high-impact” because of the “substantial educational benefits they provide to students” and includes ISL as one such strategy.18 The National Survey of Student Engagement (NSSE) --
2014 Volume
-
Number
-
Annual Report provides data indicating that ISL is positively related to integrative learning, reflective learning, and self-reported gains in general education and personal-social development.19 In addition, the NSSE found the experience itself is more important than the length of time spent abroad, supporting the position that travel survey has the potential to be educationally enriching and a self-reflective learning experience without requiring extensive amounts of time. Campinha-Bacote notes that teaching cultural competence is a “journey that reflects an ongoing transformation process.”20 As Mather and colleagues21 explain, the transformational process does not end with the completion of the service-learning experience, but continues to shape a practitioner’s approach, understanding, and interventions well into the future. This shaping process can be facilitated through regular instructor-lead discussions, writings, journal club, and local service projects once the students return. This project confirms the NSSE Annual Report, finding that ISL experiences serves to inform students’ cultural awareness, competence, and practice. On survey, all dietetic interns reported increased cultural awareness after completing the ISL experiences. Furthermore, the increased cultural awareness translated into cultural competence. Short-duration ISL is an effective pedagogy that can be integrated into dietetics education curriculum. Internship programs can implement 1- and 2-week rotations to other countries to facilitate cultural competence and practice. Alternatively, experiences can be planned with immigrants new to this country to enhance cultural competence and practice. Another model for the integration of ISL into the curriculum could be to offer a preparatory course with defined learning and service objectives. Students would take an active part in the planning of service activities based on guide readings similar to the preparation described in this project. For smaller groups of students, the ISL experience could be offered as an independent study course culminating in the creation of culturally appropriate patient education materials, particularly at the graduate level. In a time when acquisition of cultural competence is critical to providing effective health care, this
survey found that ISL is an effective methodology for acquisition of cultural awareness and competence.
References 1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
US Department of Health and Human Services Office, Office of Minority Health. National standards on culturally and linguistically appropriate services (CLAS) (2001). http://minorityhealth.hhs.gov/ templates/browse.aspx?lvl¼2&lvlID¼15. 00. Accessed January 6, 2014. The Joint Commission. The Joint Commission 2009 requirement related to the provision of culturally and linguistically appropriate health care. http://www. jointcommission.org/assets/1/6/2009_ CLASRelatedStandardsHAP.pdf. Accessed January 6, 2014. Betancourt JR. Eliminating racial and ethnic disparities in health care: What is the role of academic medicine? Acad Med. 2006;81(9):788-792. Kardong-Edgren S, Campinha-Bacote J. Cultural competency of graduating US bachelor of science nursing students. Contemp Nurse: J Aust Nurs Prof. 2008; 28(1-2):37-44. Jones ME, Cason CL, Bond ML. Cultural attitudes, knowledge, and skills of a health workforce. J Transcult Nurs. 2004;15(4):283-290. Campinha-Bacote J. The process of cultural competence in the delivery of health care services: A model of care. J Transcult Nurs. 2002;13(3):181-184. Zambrana RE, Molnar C, Munoz H, Lopez DS. Cultural competency as it intersects with racial/ethnic, linguistic, and class disparities in managed health care organizations. Am J Manag Care. 2004;10: SP37-SP44. Bentley R, Ellison KJ. Increasing cultural competence in nursing through international service-learning experiences. J Nurs Educ. 2007;32(5):207-211. St Clair A, McKenry L. Preparing culturally competent practitioners. J Nurs Educ. 1999;38(5):228-234. Evanson TA, Zust Bl. The meaning of participation in an international service experience among baccalaureate nursing students. http://www.degruyter.com/ view/j/ijnes. Accessed January 6, 2014. Ryan M, Twibell R, Brigham C, Bennett P. Learning to care for clients in their world, not mine. J Nurs Educ. 2000;39(9):401-408.
12.
Evans E. An elective course in cultural competence for health care professionals. Am J Pharm Educ. 2006;70(3):55.
13.
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