Nurse Educator
Nurse Educator Vol. 40, No. 6, pp. 285-288 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Teaching Strategies to Increase Cultural Awareness in Nursing Students William Lonneman, DNP, RN Cultural competence education is essential for all nurses to better prepare them to address the underlying social environment of patients, families, and communities. This article describes a study with second degree nursing students that tested 6 teaching strategies for their effectiveness in raising cultural awareness, a key aspect of cultural competence. The results demonstrated that the interventions had a positive effect. Keywords: cultural competence; health disparities; nursing students; social determinants of health; teaching strategies
I
n 2008, the American Association of Colleges of Nursing (AACN) formally called for cultural competence education to begin attending to the underlying social environment of patients, families, and communities.1 Their rationale included the persistent disparities in health, especially racial and ethnic disparities, that continue to lead directly to poorer health and shorter lifespans for tens of millions of Americans. The AACN challenged nursing educators to develop curricula that equip students to work toward the elimination of such disparities. This article reports on a study using 6 teaching strategies as an intervention that was designed to promote growth in nursing students’ cultural awareness.
Cultural Awareness and the Social Determinants of Health Cultural awareness is 1 of the foundational concepts in cultural competence. Campinha-Bacote2 stresses that this awareness should be bidirectional: toward the other (patient) and also toward oneself (student). To facilitate awareness of the patient’s health beliefs and practices, educators may teach students how to use 1 or more of the many cultural assessment tools to gain relevant information at the bedside. However, the amount of information that these tools include about the socioeconomic and political realities that are affecting the patient varies and may not be sufficient for helping students appreciate the impact of the social determinants on health and health behaviors. For this to occur, students must be taught a comprehensive framework that pushes them beyond a narrower perspective of patient choice, biology, and genetics. Fortunately, the determinants of health framework, promoted Author Affiliation: Assistant Professor, School of Health Sciences, Mount St. Joseph University, Cincinnati, Ohio. The author declares no conflicts of interest. Correspondence: Dr Lonneman, Mount St. Joseph University, 5701 Delhi Rd, Cincinnati, OH 45233-1670 ([email protected]). Accepted for publication: April 1, 2015 Published ahead of print: May 19, 2015 DOI: 10.1097/NNE.0000000000000175
Nurse Educator
in Healthy People 2020, provides this perspective by including the social and physical environments, as well as access to health care, as equally important contributors to the patient’s health.3 Cultural awareness also means self-awareness, the student discovering more about his/her own culture, including biases and prejudices. This aspect is critical in nursing education because unconscious (silent) bias on the part of health care providers remains a contributing factor in why minorities and the poor continue to receive lower quality health care, even when insurance status and access to care are equal.4,5
Current Approaches for Increasing Cultural Competence Nursing educators have used a wide variety of strategies to increase cultural competence in students, including lecture, guest speakers, group discussions, written reports, clinical experiences, simulations, role playing, journal keeping, immersion experiences (including study abroad), and educational partnerships in community settings.6 Because of the variety of instruments used and research methods used, it is difficult to say how effective these strategies have been. There is some evidence that threading cultural competence education across a curriculum, rather than relying on 1 course, is more effective,7,8 and this approach is also recommended by the AACN.1 The work done by Tuck et al is of particular interest because it used an interdisciplinary approach and integrated knowledge and experiences to enhance students’ understanding of the social determinants on health. Their results shed some light on the difficulties that both faculty and students encounter when a serious commitment is made to this material in a nursing curriculum.8 This study attempted to answer the AACN challenge to increase cultural competence by using 6 teaching strategies to raise nursing students’ cultural awareness about (1) the effects of the social determinants on health and (2) their own attitudes, beliefs, and values regarding people of different race, ethnicity, and social class. Volume 40 & Number 6 & November/December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
285
Pedagogical Framework The intervention strategies for this study were chosen for their reliance on principles from 2 theories, Critical Pedagogy and Transformative Learning. Critical Pedagogy aims ‘‘to foster a critical consciousness in students that will enable them to question, challenge, and change structures of domination and states of hegemonic dominance.’’9(p2) This kind of pedagogy is difficult yet potentially liberating, using social analysis and critical self-reflection to lead the student (and teacher) into a new awareness of social power and its effects. Transformative Learning complements this approach. Mezirow10 states that although persons are ‘‘relentlessly socialized’’ into the values and beliefs of their culture, they are able to assert their individuality due to each one’s ‘‘unique social biography, perspectives, and awareness of different interpretive schemes.’’(p2) Critical incidents in one’s life, moments when there is tension between established understandings and new experiences, offer opportunities for transformation and growth. Reflection on these incidents can result in either confirmation of previously held beliefs or some degree of transformation. However, when critical reflection is introduced to examine social forces and constructs such as race, racism, and social class, the pedagogic methods used to facilitate this process must be chosen carefully.11 For this reason, Brookfield11 recommended 3 strategies: (1) having students use their own experiences to reflect on; (2) using an indirect approach, one of discovery, rather than a head-on approach; and (3) moving from the specific to the general.(pp180,181) The strategies chosen for the intervention in this study reflect these recommendations.
Study Method Design This study used a quasi-experimental design using a nonprobability convenience sample of second degree students enrolled in an entry-level nursing program at a Midwestern, Catholic university. Three previous cohorts of students in the same program served as the control groups. The author taught the intervention group and control group 2, whereas another faculty member taught control groups 1 and 3; a similar curriculum was used in all 3 cohorts. All students in this MSN program have earned bachelor’s degrees and are returning to school to become nurses; ages of those in the study ranged from the early 20s to the 50s. The population-focused, community health course in which the intervention was introduced occurred during the second semester of their full-time, 4-semester program. The study was approved by the institutional review board at the author’s university. Procedures The intervention in this study used 6 teaching-learning strategies that were chosen specifically for 2 reasons: (1) their grounding in Critical Pedagogy and/or Transformative Learning and (2) their potential, both individually and as a coherent set, to increase bidirectional cultural awareness. In keeping with the learning principles discussed earlier, the strategies involved the students in a variety of activities including direct participation, observation of others’ experiences, interviews with patients, group discussion, and private reflection. All 40 students in the intervention group participated in each activity. 286
The first activity was designed to raise issues related to racism, classism, and privilege and to establish these concerns as a lens for the course. Titled ‘‘Examining Class and Race: An Exercise,’’12 this kinesthetic, participatory experience begins with the students lined up on the center stripe of a gymnasium. They are told to imagine themselves as about to begin a race, the goal of which is to reach the front of the gym where they will receive the reward of a better job or career opportunity. Before beginning the race, however, the students are told that the starting line needs to be adjusted. They are instructed to listen to a series of statements and to take a step forward or backward depending on whether the statement applies to their own life experience. Statements are then read aloud that are related to social class and race, such as ‘‘If you were raised by a single mother, take 1 step backI If your family owns their home, take 1 step forwardI If you have experienced being stopped by a police officer, partly because of your race, take 1 step back.’’ At the end of about 25 statements, the students are asked to observe quietly where they are standing, in relation to their classmates. The exercise results in a visual depiction of disparity as it has played out in the lives of the students themselves. We then returned to the classroom, quietly journaled about the experience, and then discussed it openly. To help the students deepen their learning and develop a regular habit of self-awareness,13 the second strategy in the intervention was to assign journal entries to be completed each week. The entries consisted of 2 to 3 paragraphs of personal thoughts, feelings, or actions based on the content and activities of that week’s class session. The last 10 minutes of each class period was set aside for reflection. Students began by journaling about the first experience in the gymnasium. The third teaching-learning strategy of the intervention was a personal history reflection paper, inviting the student to do an analysis of a personal critical incident. The author followed Kennedy’s model14 using these instructions: (1) Probe back into your life and identify some moment or event when you became aware that you had been living in a particular, closed cultural and ideological cocoon. Describe what happened when you ‘‘broke through,’’ had an ‘‘ah-ha!’’ experience, and became conscious that you now saw things in a new way. Briefly describe the event; (2) Locate yourself at that time in your life, for example, in regard to socioeconomic class, family situation, and educational or work setting; and (3) Analyze the forces that were keeping you in your cocoon and those that helped the breakthrough occur.14(pp102,103) In responding to the third question, Kennedy recommends consideration of 7 categories of social forces: global, national, and historical events; family; schooling; religion; social group; work; and media.14 In describing the assignment, the instructor gave a personal example from his own life to illustrate the meaning of a critical incident for the students. The fourth strategy for the intervention entailed the use of several videos including segments from Race: The Power of an Illusion; Dollars and Dentists, a Frontline episode on dental care for the poor, and Unnatural Causes, a series that examines the effects of racism and classism on health. Several of these video segments contain stories from individuals who have experienced health disparities, rooting what can be an abstract problem in real experiences. The videos provided opportunities for the students to reflect on these
Volume 40 & Number 6 & November/December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
topics indirectly, while still being able to relate personally on some level, a method supported by several authors.11,15 The students continued reflecting on these experiences in their journals. The fifth strategy required the student to interview someone of their choice from a vulnerable population. The interview and subsequent written report engaged the student directly with another’s experience. The student asked the patient about his/her specific experiences with health care providers and the health care system, his/her biggest heath challenges, and the impact of the patient’s environment (social, natural, and built) on his/her health. The students then reflected on the interview experience and what they had learned. The sixth strategy of the intervention was a purposeful exploration of cultural differences, social constructs, and health disparities related to 3 topics discussed in class: environmental health, sexually transmitted infections, and disaster care. Homecare and parish nurses working in the city also came as guest lecturers to share their experiences in caring for people affected by poverty and racial/ethnic minority status.
Research Instruments The effectiveness of the intervention for increasing cultural awareness was assessed using 2 instruments. The first instrument was the third section of the Transcultural Self Efficacy Tool (TSET). Research using the TSET has consistently demonstrated the instrument’s construct validity, with internal consistency scores ranging from .94 to .98.16(p71) Reliability results for the TSET’s internal consistency are high (Cronbach’s ! of .92-.98), and measures of test-retest stability have also been good (0.63-0.75).16(p78) The third section of the TSET reliably measures perceived self-efficacy in the affective dimensions of cultural competence, including awareness, acceptance, appreciation, and recognition.16 Because the intervention strategies did not specifically address cultural knowledge or skills, the first 2 sections of the TSET, the author chose to use only the third section. The author administered the 30 items from this section of the TSET to all of the students in the intervention group both at the beginning of the course and at the end. The survey uses a 10-point Likert scale on which the student rates his/her confidence or certainty for each question. Their preintervention and postintervention scores were then compared with the same scores of 3 control cohorts. It should be noted that the post-TSET was administered to the control groups at the end of their full program of study (2 semesters later than the intervention group), which is the usual practice in this nursing program; the author hypothesized that this later testing of the control groups might result in higher overall scores for these groups. The second tool used for evaluation was a researcherdesigned survey, which asked the students to rate their experience of each of the 6 teaching strategies for its effectiveness in raising their cultural awareness, using a 10-point Likert scale. Finally, the students were also invited to supply written comments on each intervention.
Results On average, the students in the intervention group (n = 34) gained 25.8 (SD, 29.9) points from the pre- to the post-TSET, Nurse Educator
a change of 8.6%. In the control group, the mean gain was only 17.1 (SD, 36.6), a change of 5.7%. There was a significant difference (P = .054) between the 2 groups. Findings from the second instrument, which asked for specific ratings for each of the 6 strategies, confirmed the positive indications from the TSET scores. The students receiving the intervention rated all of the teaching strategies as effective in raising cultural awareness, with scores ranging from 6.8 to 8.2 on the 10-point Likert scale. To examine the stability of the change in cultural awareness among the students who had the educational intervention, the author retested the intervention group 8 months later, at the end of their program. The group’s scores on the third section of the TSET increased again, on average by another 7 points, or 2.8%. This suggests that in addition to growth in perceived cultural awareness during the course that included the intervention, the students continued to grow in cultural awareness throughout their final 2 semesters in the program.
Implications for Educators The teaching strategies used in this intervention seemed to be effective in increasing students’ cultural awareness and are also useful in improving other essential nursing skills, such as communication, ethical reflection, and critical thinking. This dual benefit might be encouraging to some faculty members, who are already responsible for a large amount of content in their courses and may be concerned with adding to their burdens by integrating cultural awareness activities. Some faculty members might still be skeptical, considering cultural competence to be specialized content that is best taught in a separate course. On a curricular level, some studies have examined whether a stand-alone culture course has advantages over the threading of cultural competence throughout the curriculum.7,8 The approach favored by these studies and endorsed by the AACN is the integration of such education across an entire curriculum,1 rooting cultural competence in the entire faculty and giving the students multiple encounters with the material through a variety of experiences. The strategies used in this study could be spread out over several courses. In the first nursing courses, such as those on nursing roles and responsibilities, cultural awareness could begin to be addressed through a frank and open exposition of the challenges that social constructs, stereotyping, and bias pose to all health care professionals. One or more of the teaching interventions in this study, such as the gymnasium exercise, could be used in such courses to begin cultural awareness education. A population health course, such as the one in which this study occurred, can serve as an appropriate context for deeper exploration because issues of health disparities based on race/ethnicity, socioeconomic status, and other categories of oppression will naturally occur. Nursing ethics courses, and all levels of clinical courses, could contain content and exercises to help increase cultural awareness and competence. Spreading out the teaching strategies designed to increase cultural competence over an entire program could serve to unite the faculty in accomplishing this goal, decrease the burden on any 1 course, and highlight the importance of this area in the minds and hearts of the students. Every course in the nursing curriculum can integrate Volume 40 & Number 6 & November/December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
287
and reinforce these lessons, helping students to see individual patients, and themselves, through the lens of cultural context. This study was limited in its scope, the cultural diversity of the students, and the sample size. Because it included second degree students, further studies using these teaching strategies with other prelicensure and RN-BSN students is needed. Further studies are also needed to explore the relationship between perceived improvements in cultural awareness and increased effectiveness in clinical performance, as well as differences in the perceived effectiveness of the interventions based on the students’ cultural background.
Summary The results from this study indicate that significant growth in nursing students’ perceived self-efficacy in cultural awareness can be achieved by the use of specific teaching strategies. A variety of learning activities may be used, from personal reflection to lively interaction, discussion, and field work. Nursing students usually rise to a challenge, especially when the challenge is based in the real context of patients’ lives and the potential impacts on health outcomes are clearly and persuasively explained. In the face of ongoing health disparities, nursing faculty members should redouble their efforts to raise cultural awareness.
References 1. American Association of Colleges of Nursing. Cultural Competency in Baccalaureate Nursing Education. Washington, DC: Author; 2008. 2. Campinha-Bacote J. The Process of Cultural Competence in the Delivery of Healthcare Services: The Journey Continues. Cincinnati, OH: Transcultural CARE Associates; 2007. 3. US Department of Health and Human Services. Healthy People 2020 Framework. Healthy People 2020. Available at http://www.
288
healthypeople.gov/sites/default/files/HP2020Framework.pdf. Accessed March 18, 2015. 4. Institute of Medicine. Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academy Press; 2002. 5. Agency for Healthcare Research and Quality. National Healthcare Disparities Report. Rockville, MD: Author; 2012. Available at http:// www.ahrq.gov/research/findings/nhqrdr/nhdr11/nhdr11.pdf. Accessed March 18, 2015. 6. Long TB. Overview of teaching strategies for cultural competence in nursing students. J Cult Divers. 2012;19(3):102
Nurse Educator Vol. 40, No. 6, pp. 285-288 Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Teaching Strategies to Increase Cultural Awareness in Nursing Students William Lonneman, DNP, RN Cultural competence education is essential for all nurses to better prepare them to address the underlying social environment of patients, families, and communities. This article describes a study with second degree nursing students that tested 6 teaching strategies for their effectiveness in raising cultural awareness, a key aspect of cultural competence. The results demonstrated that the interventions had a positive effect. Keywords: cultural competence; health disparities; nursing students; social determinants of health; teaching strategies
I
n 2008, the American Association of Colleges of Nursing (AACN) formally called for cultural competence education to begin attending to the underlying social environment of patients, families, and communities.1 Their rationale included the persistent disparities in health, especially racial and ethnic disparities, that continue to lead directly to poorer health and shorter lifespans for tens of millions of Americans. The AACN challenged nursing educators to develop curricula that equip students to work toward the elimination of such disparities. This article reports on a study using 6 teaching strategies as an intervention that was designed to promote growth in nursing students’ cultural awareness.
Cultural Awareness and the Social Determinants of Health Cultural awareness is 1 of the foundational concepts in cultural competence. Campinha-Bacote2 stresses that this awareness should be bidirectional: toward the other (patient) and also toward oneself (student). To facilitate awareness of the patient’s health beliefs and practices, educators may teach students how to use 1 or more of the many cultural assessment tools to gain relevant information at the bedside. However, the amount of information that these tools include about the socioeconomic and political realities that are affecting the patient varies and may not be sufficient for helping students appreciate the impact of the social determinants on health and health behaviors. For this to occur, students must be taught a comprehensive framework that pushes them beyond a narrower perspective of patient choice, biology, and genetics. Fortunately, the determinants of health framework, promoted Author Affiliation: Assistant Professor, School of Health Sciences, Mount St. Joseph University, Cincinnati, Ohio. The author declares no conflicts of interest. Correspondence: Dr Lonneman, Mount St. Joseph University, 5701 Delhi Rd, Cincinnati, OH 45233-1670 ([email protected]). Accepted for publication: April 1, 2015 Published ahead of print: May 19, 2015 DOI: 10.1097/NNE.0000000000000175
Nurse Educator
in Healthy People 2020, provides this perspective by including the social and physical environments, as well as access to health care, as equally important contributors to the patient’s health.3 Cultural awareness also means self-awareness, the student discovering more about his/her own culture, including biases and prejudices. This aspect is critical in nursing education because unconscious (silent) bias on the part of health care providers remains a contributing factor in why minorities and the poor continue to receive lower quality health care, even when insurance status and access to care are equal.4,5
Current Approaches for Increasing Cultural Competence Nursing educators have used a wide variety of strategies to increase cultural competence in students, including lecture, guest speakers, group discussions, written reports, clinical experiences, simulations, role playing, journal keeping, immersion experiences (including study abroad), and educational partnerships in community settings.6 Because of the variety of instruments used and research methods used, it is difficult to say how effective these strategies have been. There is some evidence that threading cultural competence education across a curriculum, rather than relying on 1 course, is more effective,7,8 and this approach is also recommended by the AACN.1 The work done by Tuck et al is of particular interest because it used an interdisciplinary approach and integrated knowledge and experiences to enhance students’ understanding of the social determinants on health. Their results shed some light on the difficulties that both faculty and students encounter when a serious commitment is made to this material in a nursing curriculum.8 This study attempted to answer the AACN challenge to increase cultural competence by using 6 teaching strategies to raise nursing students’ cultural awareness about (1) the effects of the social determinants on health and (2) their own attitudes, beliefs, and values regarding people of different race, ethnicity, and social class. Volume 40 & Number 6 & November/December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
285
Pedagogical Framework The intervention strategies for this study were chosen for their reliance on principles from 2 theories, Critical Pedagogy and Transformative Learning. Critical Pedagogy aims ‘‘to foster a critical consciousness in students that will enable them to question, challenge, and change structures of domination and states of hegemonic dominance.’’9(p2) This kind of pedagogy is difficult yet potentially liberating, using social analysis and critical self-reflection to lead the student (and teacher) into a new awareness of social power and its effects. Transformative Learning complements this approach. Mezirow10 states that although persons are ‘‘relentlessly socialized’’ into the values and beliefs of their culture, they are able to assert their individuality due to each one’s ‘‘unique social biography, perspectives, and awareness of different interpretive schemes.’’(p2) Critical incidents in one’s life, moments when there is tension between established understandings and new experiences, offer opportunities for transformation and growth. Reflection on these incidents can result in either confirmation of previously held beliefs or some degree of transformation. However, when critical reflection is introduced to examine social forces and constructs such as race, racism, and social class, the pedagogic methods used to facilitate this process must be chosen carefully.11 For this reason, Brookfield11 recommended 3 strategies: (1) having students use their own experiences to reflect on; (2) using an indirect approach, one of discovery, rather than a head-on approach; and (3) moving from the specific to the general.(pp180,181) The strategies chosen for the intervention in this study reflect these recommendations.
Study Method Design This study used a quasi-experimental design using a nonprobability convenience sample of second degree students enrolled in an entry-level nursing program at a Midwestern, Catholic university. Three previous cohorts of students in the same program served as the control groups. The author taught the intervention group and control group 2, whereas another faculty member taught control groups 1 and 3; a similar curriculum was used in all 3 cohorts. All students in this MSN program have earned bachelor’s degrees and are returning to school to become nurses; ages of those in the study ranged from the early 20s to the 50s. The population-focused, community health course in which the intervention was introduced occurred during the second semester of their full-time, 4-semester program. The study was approved by the institutional review board at the author’s university. Procedures The intervention in this study used 6 teaching-learning strategies that were chosen specifically for 2 reasons: (1) their grounding in Critical Pedagogy and/or Transformative Learning and (2) their potential, both individually and as a coherent set, to increase bidirectional cultural awareness. In keeping with the learning principles discussed earlier, the strategies involved the students in a variety of activities including direct participation, observation of others’ experiences, interviews with patients, group discussion, and private reflection. All 40 students in the intervention group participated in each activity. 286
The first activity was designed to raise issues related to racism, classism, and privilege and to establish these concerns as a lens for the course. Titled ‘‘Examining Class and Race: An Exercise,’’12 this kinesthetic, participatory experience begins with the students lined up on the center stripe of a gymnasium. They are told to imagine themselves as about to begin a race, the goal of which is to reach the front of the gym where they will receive the reward of a better job or career opportunity. Before beginning the race, however, the students are told that the starting line needs to be adjusted. They are instructed to listen to a series of statements and to take a step forward or backward depending on whether the statement applies to their own life experience. Statements are then read aloud that are related to social class and race, such as ‘‘If you were raised by a single mother, take 1 step backI If your family owns their home, take 1 step forwardI If you have experienced being stopped by a police officer, partly because of your race, take 1 step back.’’ At the end of about 25 statements, the students are asked to observe quietly where they are standing, in relation to their classmates. The exercise results in a visual depiction of disparity as it has played out in the lives of the students themselves. We then returned to the classroom, quietly journaled about the experience, and then discussed it openly. To help the students deepen their learning and develop a regular habit of self-awareness,13 the second strategy in the intervention was to assign journal entries to be completed each week. The entries consisted of 2 to 3 paragraphs of personal thoughts, feelings, or actions based on the content and activities of that week’s class session. The last 10 minutes of each class period was set aside for reflection. Students began by journaling about the first experience in the gymnasium. The third teaching-learning strategy of the intervention was a personal history reflection paper, inviting the student to do an analysis of a personal critical incident. The author followed Kennedy’s model14 using these instructions: (1) Probe back into your life and identify some moment or event when you became aware that you had been living in a particular, closed cultural and ideological cocoon. Describe what happened when you ‘‘broke through,’’ had an ‘‘ah-ha!’’ experience, and became conscious that you now saw things in a new way. Briefly describe the event; (2) Locate yourself at that time in your life, for example, in regard to socioeconomic class, family situation, and educational or work setting; and (3) Analyze the forces that were keeping you in your cocoon and those that helped the breakthrough occur.14(pp102,103) In responding to the third question, Kennedy recommends consideration of 7 categories of social forces: global, national, and historical events; family; schooling; religion; social group; work; and media.14 In describing the assignment, the instructor gave a personal example from his own life to illustrate the meaning of a critical incident for the students. The fourth strategy for the intervention entailed the use of several videos including segments from Race: The Power of an Illusion; Dollars and Dentists, a Frontline episode on dental care for the poor, and Unnatural Causes, a series that examines the effects of racism and classism on health. Several of these video segments contain stories from individuals who have experienced health disparities, rooting what can be an abstract problem in real experiences. The videos provided opportunities for the students to reflect on these
Volume 40 & Number 6 & November/December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Nurse Educator
topics indirectly, while still being able to relate personally on some level, a method supported by several authors.11,15 The students continued reflecting on these experiences in their journals. The fifth strategy required the student to interview someone of their choice from a vulnerable population. The interview and subsequent written report engaged the student directly with another’s experience. The student asked the patient about his/her specific experiences with health care providers and the health care system, his/her biggest heath challenges, and the impact of the patient’s environment (social, natural, and built) on his/her health. The students then reflected on the interview experience and what they had learned. The sixth strategy of the intervention was a purposeful exploration of cultural differences, social constructs, and health disparities related to 3 topics discussed in class: environmental health, sexually transmitted infections, and disaster care. Homecare and parish nurses working in the city also came as guest lecturers to share their experiences in caring for people affected by poverty and racial/ethnic minority status.
Research Instruments The effectiveness of the intervention for increasing cultural awareness was assessed using 2 instruments. The first instrument was the third section of the Transcultural Self Efficacy Tool (TSET). Research using the TSET has consistently demonstrated the instrument’s construct validity, with internal consistency scores ranging from .94 to .98.16(p71) Reliability results for the TSET’s internal consistency are high (Cronbach’s ! of .92-.98), and measures of test-retest stability have also been good (0.63-0.75).16(p78) The third section of the TSET reliably measures perceived self-efficacy in the affective dimensions of cultural competence, including awareness, acceptance, appreciation, and recognition.16 Because the intervention strategies did not specifically address cultural knowledge or skills, the first 2 sections of the TSET, the author chose to use only the third section. The author administered the 30 items from this section of the TSET to all of the students in the intervention group both at the beginning of the course and at the end. The survey uses a 10-point Likert scale on which the student rates his/her confidence or certainty for each question. Their preintervention and postintervention scores were then compared with the same scores of 3 control cohorts. It should be noted that the post-TSET was administered to the control groups at the end of their full program of study (2 semesters later than the intervention group), which is the usual practice in this nursing program; the author hypothesized that this later testing of the control groups might result in higher overall scores for these groups. The second tool used for evaluation was a researcherdesigned survey, which asked the students to rate their experience of each of the 6 teaching strategies for its effectiveness in raising their cultural awareness, using a 10-point Likert scale. Finally, the students were also invited to supply written comments on each intervention.
Results On average, the students in the intervention group (n = 34) gained 25.8 (SD, 29.9) points from the pre- to the post-TSET, Nurse Educator
a change of 8.6%. In the control group, the mean gain was only 17.1 (SD, 36.6), a change of 5.7%. There was a significant difference (P = .054) between the 2 groups. Findings from the second instrument, which asked for specific ratings for each of the 6 strategies, confirmed the positive indications from the TSET scores. The students receiving the intervention rated all of the teaching strategies as effective in raising cultural awareness, with scores ranging from 6.8 to 8.2 on the 10-point Likert scale. To examine the stability of the change in cultural awareness among the students who had the educational intervention, the author retested the intervention group 8 months later, at the end of their program. The group’s scores on the third section of the TSET increased again, on average by another 7 points, or 2.8%. This suggests that in addition to growth in perceived cultural awareness during the course that included the intervention, the students continued to grow in cultural awareness throughout their final 2 semesters in the program.
Implications for Educators The teaching strategies used in this intervention seemed to be effective in increasing students’ cultural awareness and are also useful in improving other essential nursing skills, such as communication, ethical reflection, and critical thinking. This dual benefit might be encouraging to some faculty members, who are already responsible for a large amount of content in their courses and may be concerned with adding to their burdens by integrating cultural awareness activities. Some faculty members might still be skeptical, considering cultural competence to be specialized content that is best taught in a separate course. On a curricular level, some studies have examined whether a stand-alone culture course has advantages over the threading of cultural competence throughout the curriculum.7,8 The approach favored by these studies and endorsed by the AACN is the integration of such education across an entire curriculum,1 rooting cultural competence in the entire faculty and giving the students multiple encounters with the material through a variety of experiences. The strategies used in this study could be spread out over several courses. In the first nursing courses, such as those on nursing roles and responsibilities, cultural awareness could begin to be addressed through a frank and open exposition of the challenges that social constructs, stereotyping, and bias pose to all health care professionals. One or more of the teaching interventions in this study, such as the gymnasium exercise, could be used in such courses to begin cultural awareness education. A population health course, such as the one in which this study occurred, can serve as an appropriate context for deeper exploration because issues of health disparities based on race/ethnicity, socioeconomic status, and other categories of oppression will naturally occur. Nursing ethics courses, and all levels of clinical courses, could contain content and exercises to help increase cultural awareness and competence. Spreading out the teaching strategies designed to increase cultural competence over an entire program could serve to unite the faculty in accomplishing this goal, decrease the burden on any 1 course, and highlight the importance of this area in the minds and hearts of the students. Every course in the nursing curriculum can integrate Volume 40 & Number 6 & November/December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
287
and reinforce these lessons, helping students to see individual patients, and themselves, through the lens of cultural context. This study was limited in its scope, the cultural diversity of the students, and the sample size. Because it included second degree students, further studies using these teaching strategies with other prelicensure and RN-BSN students is needed. Further studies are also needed to explore the relationship between perceived improvements in cultural awareness and increased effectiveness in clinical performance, as well as differences in the perceived effectiveness of the interventions based on the students’ cultural background.
Summary The results from this study indicate that significant growth in nursing students’ perceived self-efficacy in cultural awareness can be achieved by the use of specific teaching strategies. A variety of learning activities may be used, from personal reflection to lively interaction, discussion, and field work. Nursing students usually rise to a challenge, especially when the challenge is based in the real context of patients’ lives and the potential impacts on health outcomes are clearly and persuasively explained. In the face of ongoing health disparities, nursing faculty members should redouble their efforts to raise cultural awareness.
References 1. American Association of Colleges of Nursing. Cultural Competency in Baccalaureate Nursing Education. Washington, DC: Author; 2008. 2. Campinha-Bacote J. The Process of Cultural Competence in the Delivery of Healthcare Services: The Journey Continues. Cincinnati, OH: Transcultural CARE Associates; 2007. 3. US Department of Health and Human Services. Healthy People 2020 Framework. Healthy People 2020. Available at http://www.
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