Diversity and Democracy

Educating Culturally Competent Nurses at Home and Abroad

The patient looked at me with questions in her eyes. It was clear that even though I knew what treatment and care she needed to get better, I could not start any of it without making sure she understood and agreed to the health care team’s plan. Not only did we speak different languages, she also originated from a part of the world I knew very little about. My education had not prepared me to care for this patient.

The nurse I have imagined in this scenario could be practicing anywhere in the United States. In a world where populations within countries are becoming more diverse as people are regularly moving across borders, today’s nurses must be able to care for patients from socioeconomic, ethnic, racial, and cultural backgrounds that are different from their own. To do so successfully, they must develop greater appreciation for, understanding of, and sensitivity to people’s differences, as well as the ability to apply these capacities to their nursing practices (Levi 2009). It is thus critical that today’s nursing students receive educations that improve their cultural competence, giving them the confidence to provide patient-centered care that takes into account their patients’ cultural beliefs, behaviors, and needs (Papadopoulos 2003).

Cultural competence is a key aspect of the broader concept of global learning. At the University of Virginia’s School of Nursing (SON), we follow the American Council on Education in defining global learning as “the knowledge, skills, and attitudes that students acquire through a variety of experiences that enable them to understand world cultures and events; analyze global systems; appreciate cultural differences; and apply this knowledge and appreciation to their lives as citizens and workers” (Olson, Green, and Hill 2006, v). Both in the classroom and in their clinical practica, our nursing students acquire knowledge of diverse perspectives and health care systems that they can incorporate into their nursing practices. This learning can take place at home or abroad, and it encompasses skills, knowledge, and attitudes that are necessary for work in both local and international contexts.

Global Learning at Home

The SON aims to address global learning goals across the entire nursing curriculum. By involving nursing faculty in retreats, surveys, curricular analysis, and workshops, we have implemented global learning objectives in a wide variety of courses, at academic levels from undergraduate to doctoral. We are now in the midst of completely revising our undergraduate nursing curriculum, an opportunity we are using to infuse global learning objectives into all undergraduate nursing courses.

In most courses, the SON’s global learning objectives relate to developing cultural competence at one of four levels, from the most basic (having cultural awareness, knowledge, and sensitivity) to the most advanced (being a culturally competent practitioner) (Papadopoulos 2003). Most nursing students practice these learning objectives at home in the United States, through clinical experiences at more than three hundred domestic sites. Many of these sites provide care for underserved vulnerable populations, requiring students from different backgrounds to display a great deal of cultural competence as they deliver patient-centered care.

The lessons nursing students learn on site and in the classroom are augmented by globally focused on-campus activities like the monthly International Forum, where students, faculty, alumni, visiting scholars, and community partners present on topics like “UVA School of Nursing Global Health Impact in Malawi” and “Current Issues in Global Health Policy.” The forums are arranged by the SON’s Global Initiatives (GI) office, which is housed within the school’s Rural and Global Health Care Center. The GI office also arranges for international visiting scholars—including students, clinicians, and faculty members—who offer perspectives from other cultures while learning about US health care systems. In any given year, the SON hosts up to eight exchange students from Denmark, New Zealand, and Australia, and in 2013, 6.6 percent of all SON enrollees were international students.

Global Learning Abroad

The GI office helps develop and support the school’s international work through programs that intertwine education, research, practice, and service. Through the GI office, the SON offers international experiences as part of the core curriculum across all nursing programs, undergraduate through doctoral, allowing students to fulfill core requirements through an international experience. Graduate students can engage in either a practicum or a research experience that ranges from two weeks to several months long. Undergraduate students can choose between a two-week experience (held between semesters), a mentored independent research project (held over the summer), and a semester exchange (during the fall semester of the student’s final year) (Baernholdt et al. 2013). In the 2012–13 academic year, fifty-two students (7 percent of all SON students) participated in international learning experiences across sixteen countries.

These international opportunities depend on networks and partnerships guided by the principles of mutuality and reciprocity (Hanson 2010). We strive to create win–win situations where students gain important educational experiences and partners receive a final product that meets their needs, such as a community needs assessment or a solution to a specific problem with which they have wrestled. Students have created patient education materials in Denmark and Ethiopia, developed radio commercials for a clinic in Honduras, and helped develop a children’s summer camp on the Grand Bahama Island. With our university partners, we operate reciprocal student exchanges that require no extra academic fees. To cover the additional costs of travel, we offer international scholarships funded largely through alumni donations. Students who receive these international scholarships must serve as ambassadors of their specific sites for future students and must be willing to present at one of our international forums. All students who travel abroad participate in a post-trip debriefing where they reflect in small groups, evaluate their experiences, and suggest improvements.

International Lessons, Domestic Applications

Students often choose to study abroad because they want to experience life in another culture. But they come back to campus with so much more than that. Their understanding of and respect for cultural differences increases exponentially as they practice nursing in another country. They develop cultural competence that relates directly to their nursing practice in the United States. As one student wrote, “In Malawi I learned about primary care nursing at its best, how I believe it should be. I learned to function using my basic nursing assessment skills in a way that few nurses use anymore while practicing in America today.” Another noted, “I created memories for a lifetime and have a new appreciation for the global community of nurses. We are all treating patients with the same kind of issues but with different health systems in place. There are loads of ideas taken from the Danish health care system that I would love to implement into our current system right here in the United States!”

By offering a globally focused curriculum with local and international opportunities to learn cultural competence, the SON will graduate students who are well-informed and better equipped to engage with and serve a multicultural community.

References

Baernholdt, Marianne, Emily Drake, Frederic Maron, and Kirsten Neymark. 2013. “Fostering Internationalization: An American-Danish Semester-Long Under-graduate Nursing Student Exchange Program.” International Nursing Review 60 (2): 221–27.

Hanson, Lori. 2010. “Global Citizenship, Global Health, and the Internationalization of the Curriculum: A Study of Transformative Potential.” Journal of Studies in International Education 14 (1): 70–88.

Levi, Amy. 2009. “The Ethics of Nursing Student International Clinical Experiences.” Journal of Obstetric, Gynecologic, and Neonatal Nursing 38 (1): 94–99.

Olson, Christa, Madeleine Green, and Barbara Hill. 2006. A Handbook for Advancing Comprehensive Internationalization: What Institutions Can Do and What Students Should Learn. Washington, DC: American Council on Education.

Papadopoulos, Irena. 2003. “The Papadopoulos, Tilki and Taylor Model for the Development of Cultural Competence in Nursing.” Journal of Health, Social and Environmental Issues 4 (1): 5–7.


Marianne Baernholdt is director of the Rural and Global Health Care Center and associate professor in the School of Nursing and the Department of Public Health Sciences at the University of Virginia.

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