Many studies have discussed the importance of including culturally sensitive education in the undergraduate nursing curriculum; however, few studies have spoken to strategies to effectively accomplish the task. Some undergraduate nursing programs are exploring the option of study abroad to introduce students to cultures outside the United States, with the hope of developing culturally sensitive and competent nurses. To build upon a transformative learning process and provide a safe environment for students to grow, reflective journaling may be added as an intervention to such programs (Taliaferro & Diesel, 2016).
Service-learning while traveling abroad can also give students first-hand experiences related to community engagement among diverse populations. Isaacs et al. (2016) recommended and encouraged including service-learning experience during study abroad to allow nursing students to learn outside the identifying culture while also creating an opportunity for changing perspectives through real-life experience.
METHOD
The setting for the study was a baccalaureate nursing program in a suburban Midwestern region of the United States. Deidentified student pre- and posttravel data were analyzed. For this immersion experience, students were placed in rural subsections of Thailand for a three-week community clinical experience during June 2019.
Fifteen undergraduate third-year students participated in this travel abroad community clinical experience in Thailand. Data collection was conducted by the university for quality improvement purposes between May 2019 and December 2019. Fifteen presurveys and 13 postsurveys were obtained. Permission to use deidentified student data was obtained from the university institutional review board, which determined that the project need not be regulated. Privacy and anonymity were maintained by ensuring that the questionnaires were anonymous and that data were untraceable back to any respondent. Participants in the study were currently enrolled in the third year of undergraduate studies at the university and participated in the travel abroad program to Thailand. Students had fully completed their first and second years of undergraduate studies at the university. Students were required to engage in reflective journaling during the study abroad experience.
Measurement was conducted using the Cultural Intelligence Scale, a seven-point Likert scale and an evidence-based validated tool (Van Dyne et al., 2012). This instrument's reliability and validity were demonstrated in prior research. The instrument defined cultural intelligence as the ability to function competently in culturally diverse settings (Van Dyne et al., 2012). The survey consisted of 20 questions in four categories: Category 1, students' self-awareness of cultural differences (Questions 1-4); Category 2, students' cultural knowledge (Questions 5-10); Category 3, students' interest and emotive responses when interacting during intracultural interactions (Questions 11-15); and Category 4, subjective verbal and nonverbal interactions of students when interacting in intracultural situations (Questions 16-20).
RESULTS
A Cronbach's alpha coefficient was calculated for both the pretest and posttest scales. The pretest ([alpha] = .92) had excellent reliability; the posttest ([alpha] = .82) had good reliability. The mean for all categories at pretest was at least 3/7. No categories decreased on the posttest.
Intellectus Statistics software was used for data analysis. Results of the two-tailed paired samples t-test for the overall pretest mean compared with the overall posttest mean were significant based on an alpha value of .05, t(12) = -4.72, p < .001. The result of the two-tailed paired-samples t-test was significant for Category 1 based on an alpha value of .05, t(12) = -3.47, p = .005, indicating that students' self-awareness of cultural differences increased (Van Dyne et al., 2012). This was the strongest change (d = 0.96). The result of the two-tailed paired-samples t-test was significant for Category 2 based on an alpha value of .05, t(12) = -3.31, p = .006, indicating that students' cultural knowledge increased after traveling abroad (Van Dyne et al., 2012). Category 2 had the second strongest change (d = 0.92). The results of the two-tailed paired-samples t-test was significant for Category 3 based on an alpha value of .05, t(11) = -2.60, p = .025, indicating that students experienced increased interest and emotive responses when interacting during intracultural interactions (Van Dyne et al., 2012). Category 3 had the third strongest change (d = 0.75). For Category 4, the result of the two-tailed paired-samples t-test was not significant based on an alpha value of .05, t(12) = -2.15, p = .052. This result indicated that students experienced increased subjective and nonverbal interactions when interacting in intracultural situations, but the findings did not meet the statistical threshold to be considered significant (Van Dyne et al., 2012).
DISCUSSION
The findings of this project suggest that students not only improved in cultural competency overall but also improved in specific ways related to the four subcategories. Engaging in reflective journaling while traveling abroad increased their cultural competence. The results were statistically significant, both overall and in three of the subcategories, further supporting that study abroad can build upon transformative learning and help enhance personal reflection (Isaacs et al., 2016).
Limitations of the project include the small sample size (n = 15); two posttests were not included in the postanalysis because they were incomplete (pre: n = 15, post: n = 13). For the study abroad program, students were exposed to population or community health settings, not acute care settings. Therefore, the data collected are not generalizable (Polit & Beck, 2017). In addition, the sample demographics were not diverse, which also affected generalizability (Polit & Beck, 2017).
Use of the same quantitative survey before and after the study abroad experience may have sensitized the students to the questions asked in the posttest (Polit & Beck, 2017). On the other hand, having the opportunity to revisit the question may also have helped elicit more rich responses (Polit & Beck, 2017). All data given for this project were deidentified and were reported in the aggregate. No further information was given on participants involved in this project. By not knowing further details about participants, it was difficult to know whether the results can be applied to most third-year undergraduate students across demographics (Polit & Beck, 2017). Future research can elicit additional information regarding the impact of travel abroad experiences for undergraduate students, perhaps investigating whether certain destinations make a difference.
CONCLUSION
Travel abroad for a clinical experience during undergraduate programming can help instill cultural competency in future nurses and can be one method to help build cultural competence. This experience was engaging and helped build a foundation for prelicensure nurses to support interest in culture and to see differences when working with individuals from different cultures. Pairing reflective journaling can further help undergraduate students process and interpret new surroundings and newfound cultural knowledge when providing care and education to individuals of different cultural backgrounds. Allowing undergraduate students to explore culture during these formative years can help foster future interest in patients who may share different cultural practices or beliefs.
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