- Email: [email protected]
Evaluating Cultural Competence in Undergraduate Nursing Students using Standardized Patients
Teaching and Learning in Nursing 15 (2020) 57e60
Contents lists available at ScienceDirect
Teaching and Learning in Nursing j o u r n a l h o m e p a g e : w w w. j o u r n a l s. e l s ev i e r. c o m / teaching-and-learning-in-nursing
Evaluating Cultural Competence in Undergraduate Nursing Students using Standardized Patients Deborah Byrne, PhD, RN, CNE * La Salle University, 1900 West Olney Avenue St. Benilde Room 4429, Philadelphia, PA, USA
a r t i c l e
i n f o
Article history: Accepted 27 August 2019 Keywords: Cultural competence Simulation Nursing education Standardized patients
a b s t r a c t Background: The need for culturally competent health-care providers is essential in reducing health disparities and ensuring positive patient outcomes. The purposes of this study were to describe the baseline level of self-reported cultural competence of undergraduate nursing students and compare between groups learning this material with lecture only and those learning with lecture and simulation with culturally diverse standardized patients. Method: A mixed method and design was used for this study. Results: There was a statistically significant increase in the level of cultural competence in both groups who participated in the study. Results also present thematically analyzed reactions of participants to the simulation in which several broad themes emerged including participants initially feeling nervous then comfortable during the simulation and finding the simulation extremely valuable. Conclusion: This research suggests that the use of standardized patients is an effective teaching strategy in nursing education particularly as a supplement to traditional lecture. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction Increases in the United States (U.S.) minority populations, health disparities, lack of access to healthcare, and increased incidence of chronic illnesses make it essential for health-care providers to be culturally competent (American Nurses Association [ANA], 2015; National League for Nursing [NLN], 2012; Marion, et al., 2017). It is imperative that undergraduate nursing students develop culturally competent knowledge, awareness, and skills through undergraduate nursing curricula. The use of simulation with standardized patients (SPs) is an effective strategy that could be integrated throughout the curricula to evaluate a student’s cultural competence skills (Ndiwane, Koul & Theroux, 2014). Campinha-Bacote’s (2007) cultural competence model has five interdependent constructs as follows: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. This model guided the development of the specifically designed classroom lecture and simulation using SPs in this study. Campinha-Bacote (2003, p. 8) defines cultural competence as a set of congruent behaviors, attitudes, and policies that come Acknowledgement of financial support: The study was funded with a grant awarded for dissertation research by Pennsylvania Higher Education Nursing Schools, Association, Inc. * Corresponding author. Tel.: 215 951 1667. E-mail address: [email protected].
together in a system, agency, or amongst professionals and enables that system, agency of those professionals to work effectively in cross-cultural situations. The purposes of this study were as follows: 1) describe the baseline level of self-reported cultural competency of undergraduate nursing students; and 2) compare the self- reported level of cultural competency between students learning this material with lecture only and those learning with lecture and simulation with culturally diverse SPs.
Cultural Competence in Undergraduate Nursing Education and Simulation Nursing education has long acknowledged that cultural competence should be a program outcome of baccalaureate programs. The American Association of Colleges of Nursing [(AACN 2008]) has established a set of competencies, learning strategies, and benchmarks that baccalaureate nursing programs can incorporate in their curriculum. However, evidence is lacking on the most effective method of promoting cultural competence in undergraduate nursing students. One well- established teaching strategy is using SPs. The International Nursing Association for Clinical Simulation and Learning (INACSL, 2016) has developed standards of practice for simulation to provide best practices for developing and evaluating simulations (Sittner, 2015). Benefits of simulation using SPs include realistic scenarios, feedback
https://doi.org/10.1016/j.teln.2019.08.010 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
58
D. Byrne / Teaching and Learning in Nursing 15 (2020) 57e60
from SPs, and improved communication. Several studies have evaluated the use of SPs in nursing education in the areas of health assessment, psychiatric care, students’ anxiety, disability, communication, and psychomotor skills (Galloway, 2009; Kim-Godwin, Livsey, Ezzell, & Highsmith, 2013; Smeltzer, et al., 2015). However, there is a paucity of research on using diverse SPs in simulation to assess and evaluate a nursing students’ level of cultural competence. While cultural competence requires a specific set of knowledge and skills, it is the cultural encounter specifically that can enhance a student’s level of cultural competence. SPs allow the student to interact with an individual who represents cultural diversity and receive immediate feedback. Instruments According to Fitzgerald, Cronin, and Campinha-Bacote (2009), the Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals e student version IAPCC-SV© assessment showed an acceptable internal consistency, with a Cronbachs alpha for the overall scale of .78. A study by Chen (2012) reported a reliability pretest score of alpha .66 and an alpha of .76 for the posttest score for the IAPCC-SV© assessment measure. In the current study, the Cronbach alpha coefficient for the pretest was .71 and posttest was .76. These scores are consistent with previous research. This instrument is a 20 question self-report tool with five subsets incorporating the five constructs of the cultural competence model. Method After receiving approval from a university institutional review board, a quasi- experimental mixed method design using IAPCCSV© assessment as a pretest, posttest measure, and demographic data form were used for this study. In addition, an open-ended questionnaire was developed to understand how the participants perceived the effectiveness of the simulation. The study used a convenience sample of 38 undergraduate sophomore-level nursing students enrolled in a four-credit introduction to professional nursing course in a medium-sized, religiousbased university on the East Coast. The sample size was estimated using a medium effect size and determined to require a minimum of n ¼ 28 to achieve statistical significance (Faul, Erdfelder, Lang & Buchner, 2007). The study consisted of a specifically designed lecture and simulation with SPs on cultural competence. Although students participated in the simulation as a course requirement, participation in the study was voluntary. There were two sections of the course as follows: one who received the lecture only (but received the simulation later) and the lecture plus simulation and the other who received the lecture and simulation in close proximity. Classes were randomly assigned to control and experimental conditions. The lecture only and lecture plus simulation groups completed the IAPCC-SV© assessment measure and the demographic information at baseline prior to treatment condition. All participants received the specifically designed cultural competence lecture. The lecture only group completed the IAPCC-SV© assessment posttest one week after the lecture. The lecture plus simulation group received the SP experience approximately one week after the lecture on the topic and completed the IAPCC-SV© assessment after the SP simulation. The same instructor lectured in both sections of this course to provide participants with consistent information. After the simulation, participants were asked three open-ended questions that were later analyzed for significant themes. The questions included were as follows: What was your reaction to the SP once you started interacting with him or her? Was the experience of interacting with a SP in the scenario a valuable experience? If so, why? If not, why? How strongly would you recommend that we continue to have SPs in simulation?
The lecture portion of the study was based on the current curriculum and textbook for the course (Dillon, 2016, Potter & Perry, 2016). The lecture focused on communication with diverse clients and cultural competence. Simulation with SPs focused on a brief health history and mini-nutritional assessment of a client from a culturally diverse background. The simulation content was developed using the five constructs of the Campinha-Bacote model (Campinha-Bacote, 2007). Cultural knowledge was integrated by having the SPs use cultural terms unfamiliar to the students in regards to the diet. The participants acquired knowledge from the specifically designed lecture to ask patients questions about their culture. Cultural skills were integrated by having participants ask culturally appropriate questions during the mini-nutritional assessment. Cultural desire and awareness were achieved when the participant was actively engaged in the simulation. An established simulation content expert reviewed the simulation scenario, script, student checklist, and SP training guide to ensure accuracy and compliance with the student objectives for this simulation. The simulation content expert has published a simulation book of various simulation scenarios with templates, several journal articles, and led the development of the university’s interprofessional simulation center. The content for the script and student checklist was adapted from a health assessment textbook used within the program (Dillon, 2016). The student objectives were established based on the course objectives. Three SPs were used in the study and the inclusion criteria were a culturally diverse background, willingness to participate in a culturally sensitive simulation, and availability. A practice simulation was conducted and videotaped to ensure accuracy and effectiveness of the simulation. Participants were given presimulation work to prepare for the simulation including questions regarding cultural competence, nutritional assessment, and effective communication. On the day of the simulation, participants were prebriefed using the presimulation work, an introduction to the simulation scenario, and a schedule of the day. A debriefing was conducted at the end of each session by the simulation facilitator and lasted approximately 30 minutes using INACSL guidelines for debriefing (INACSL, 2016). The INACSL guidelines for debriefing include having a facilitator who is trained in debriefing, an open learning environment that allows confidentiality, reflection, and self-analysis, a theoretical framework, and the debrief needs to be congruent with the learning objectives. The simulation facilitator used the theoretical model, Debriefing with Good Judgement for this simulation-learning experience (Rudolph, Simon, Dufresne, & Raemer, 2006). Debriefing questions were adapted from a simulation textbook written by the content expert (Gasper & Dillon, 2012). The simulation facilitator has been trained extensively in simulation and holds several simulation certifications. In addition, participants were given an opportunity to ask the SPs questions regarding the scenario and their role as SPs at the end of the simulation experience. Results All participants were between the ages of 17-20 years. Of the 38 subjects, the majority of them were women (92%, n ¼ 37), most spoke English as their first language (94.8%, n ¼ 37), and most were Caucasian (89.5%, n ¼ 37). Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 24. No data were missing on the demographic, open-ended question, or IAPCC-SV© instruments. An analysis of the descriptive statistics for both the lecture only and the lecture plus simulation groups showed a pretest total mean of 58.6 (standard deviation [SD] ± 5.13; range ¼ 20 e 80), which is categorized as culturally aware on the IAPCC-SV© instrument. A
D. Byrne / Teaching and Learning in Nursing 15 (2020) 57e60
posttest total mean for both groups was 65.73 (SD ± 5.21; range 20 -80), which is categorized as culturally competent on the IAPCC-SV© instrument. There was no significant difference between those who received the lecture and those who received the lecture plus simulation F (1,36) ¼ .117, p ¼ .734. There was a statistically significant effect of time (pretest v. posttest) F (1, 36) ¼ 48.81, p <. 001, n2 .576. There was not a significant time x condition interaction: F (1, 36) ¼ .077, p ¼ .782.
Qualitative Analysis of Simulation Experience Three open-ended questions were asked to participants in the lecture plus simulation group about their experiences and the value of the SP in the simulation (see Method section for questions). Phenomenological approaches to qualitative analysis encourage an openended approach towards data analysis, the reduction and identification of preconceived ideas, and development of a list of emergent themes (Creswell & Poth, 2018). Before the start of the analysis, each researcher bracketed (Creswell & Poth, 2018; Moustakas, 1994), or set aside, preconceived ideas to identify the potential influence of previous knowledge or experiences which might influence the identification and interpretation of the phenomenon. The data were then reviewed by two researchers independently using the following process outlined by Creswell & Poth, (2018). First, the researchers read the data several times to develop an understanding of the overall phenomena of interest. Then, careful selection and coding of meaningful statements that reflected the participants’ subjective experiences were selected. Next, researchers independently developed clusters of meaning from significant statements into themes that were representative of the groups’ experience. The two researchers reviewed the significant statements and themes to come to consensus. Two themes emerged in response to the question about interactions with the SPs. The first was that the students felt nervous and anxious at the beginning of the simulation and the second was they became more comfortable during the simulation. Statements supporting this included “My reaction was very nervous as I began, but once I started asking questions I began to feel more comfortable.” Although most students became comfortable during the simulation, one participant wrote “I was very nervous and anxious. I knew what I wanted to ask, but once I walked in my agenda was forgotten.” The experience interacting with SPs fell into four main themes. The first was the participants would know what to expect in the future. Statements supporting this include “First time I saw myself as a true professional” and “Yes, it helped me to know what to expect in the future.” The second theme was the participants felt the simulation experience was very valuable. Statements from participants included “Yes, it was very valuable. I was able to see what I need to work on” and “Yes, it is definitely a valuable experience because next time I will know what to do and what not to do.” The third theme was the participants reported the simulation helped them to learn how to interact with patients. Participants stated, “Yes, it gave me more confidence talking to a patient” and “Yes, I felt like it was valuable. It gave me an insight of what interacting with patient next semester in clinical.” The fourth theme was the participants learned how to approach and talk with the patient. Participants stated, “Yes, because I will learn a lot from it for next time when I go into hospital and have to talk with the patient” and “It was very valuable because I know how to better approach the patients and how to talk to them I feel more comfortable.” One main theme emerged from the question of how strongly participants would continue to have SP in simulation. All of the participants stated it was a very valuable experience. Comments included “On a scale from 1 to 10, I give it a 100” and “I would highly recommend that we continue this. It was very helpful.”
59
Discussion and Conclusion The results of the pretest revealed that participants scored within the culturally aware range. For an individual to reach cultural competence or cultural proficiency, cultural education needs to evolve beyond awareness and develop other constructs of cultural competence (Campinha-Bacote, 2007). The results of the posttest for the lecture only and lecture plus simulation groups revealed an increase in the mean of the group for total score with the participants moving to the culturally competent range. This finding supports the literature that a curriculum or experience that integrates cultural competence will increase the level of cultural competence in undergraduate nursing students (Calvillo et al., 2009; Jeffreys & Dogan, 2012; Mayo, 2014). The findings suggest that there was no significant difference between the lecture only and lecture plus simulation groups. Although this finding does not support simulation with SPs as a more effective strategy for increasing student’s level of cultural competence, it does show that a specifically designed cultural competence lecture or simulation can increase a student’s level of self-reported cultural competence. However, a unique contribution of this study is the additional use of a mixed-methods design incorporating qualitative analysis of post-simulation experience. Analysis revealed both significant anxiety interacting with culturally different patients ahead of time and increased comfort as the simulation progressed. In addition, all participants recommended the simulation with SPs be continued as part of standard educational practice and many recognized it as a very valuable experience in which they learned how to interact, approach, and talk with the patient. Therefore, although there was not a statistically significant difference between the lecture only and the lecture plus simulation conditions using the IAPCC-SV©, the additional qualitative analysis suggests the simulation provided a rich learning experience for students. A limitation of this study was the use of a convenience sample of undergraduate nursing students already enrolled in the nursing program. The sample (n ¼ 37) is considered a small sample size that limits the generalizability of the results. The use of a selfreporting tool and the probability of social desirability bias due to a single encounter with a culturally diverse SP. Social desirability bias refers to the subject answering questions in a manner that is viewed favorable by others. To reduce the change of social desirability bias, the principal investigator maintained strict confidentiality and anonymity. Another limitation is the lack of a specific question on cultural competence in the qualitative survey. A specific question on cultural competence would be added in a future study to ensure the students felt the simulation was also effective in enhancing the participant’s cultural competence. This study adds to the nursing education literature related to cultural competence and simulation with SPs by exploring the effectiveness of using specifically designed classroom lecture and simulation to assess cultural competence. Simulation with SPs has been used in undergraduate nursing education as an effective teaching strategy (Galloway, 2009; Kim-Godwin et al., 2013; Smeltzer, et al., 2015). This is one of the first studies to suggest the effectiveness of using simulation with SPs to evaluate an undergraduate nursing student’s level of cultural competence. Consequently, the findings of this study support the need for future nursing education in the area of cultural competence and simulation with SPs.
References American Association of Colleges of Nursing. (2008). Tool kit for resources for cultural competent education for baccalaureate nurses. Retrieved from http://www.aacn. nche.edu/education-resources/toolkit.pdf.
60
D. Byrne / Teaching and Learning in Nursing 15 (2020) 57e60
American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Washington, D.C: Author. Calvillo, E., Clark, L., Ballantyne, J. E., Pacquiao, D., Purnell, L. D., & Villarruel, A. M. (2009). Cultural competence in baccalaureate nursing education. Journal of Transcultural Nursing, 20, 137e145. http://dx.doi.org/10.1177/1043659608330354. Campinha-Bacote, J. (2003). The process in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), 181e184. Campinha-Bacote, J. (2007). The process of cultural competence in the delivery of healthcare services: The journey continues (5th ed.). OH: Transcultural C.A.R.E. Chen, H. (2012). The impact of service-learning on students' cultural competence. Teaching and Learning in Nursing, 7(2), 67. Retrieved from https://www. sciencedirect.com/science/article/abs/pii/S155730871100120X?via%3Dihub. Creswell, J. W., & Poth, C. N. (2018). Qualitative Inquiry and Research Design Choosing among Five Approaches (4th Edition). Thousand Oaks: SAGE Publications, Inc. Dillon, P. (2016). Nursing health assessment: The foundation of clinical practice (3rd ed.). PA: FA Davis Company. Faul, F., Erdfelder, E., Lang, A.-D., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavioral Research Methods, 39(2), 175e191. http://dx.doi.org/10.3758/BF03193146. International Nursing Association of Clinical Simulation and Learning (INACSL) Board of Directors. (2016). Standards for best practice: Simulation. Clinical Simulation in Nursing, 9(6). Suppl, Sii-Siii. Retrieved from https://www.sciencedirect.com/science/ article/pii/S1876139916301293?via%3Dihub. Fitzgerald, E. M., Cronin, S. N., & Campinha-Bacote, J. (2009). Psychometric testing of the inventory for assessing the process of cultural competence among healthcare professionals - student version (IAPCC-SV© ©). Journal of Theory Construction & Testing, 13(2), 64e68. Retrieved from https://search.proquest.com/docview/ 89253367?pq- origsite¼summon. Galloway, S. (2009). Simulation techniques to bridge the gap between novice and competent healthcare professionals. Online Journal of Issues in Nursing, 14(2), 1e10. Retrieved from https://dbproxy.lasalle.edu:443/login?url¼https://search. proquest.com/docview/22960841 5?accountid¼11999. Gasper, & Dillon. (2012). Nursing health assessment: The foundation of clinical practice (3rd ed.). PA: FA Davis Company. Jeffreys, M. R., & Dogan, E. (2012). Evaluating the influence of cultural competence education on students’ transcultural self-efficacy perceptions. Journal
of Transcultural Nursing, 23(2), 188e197. http://dx.doi.org/10.1177/ 1043659611423836. Kim-Godwin, Y. S., Livsey, K., Ezzell, D., & Highsmith, C. (2013). Home visit simulation using a standardized patient. Clinical Simulation in Nursing, 9(2), e55ee61. Retrieved from https://www.nursingsimulation.org/article/S1876-1399(11) 00165-4/fulltext. Marion, L., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, E., & Bickford, C. (2017). Implementing the new ANA standard 8: Culturally congruent practice. Online Journal of Issues in Nursing, 22(1), 1e14. http://dx.doi.org/10.3912/ OJIN.Vol22No01PPT20. Mayo, R. M. (2014). Preparing for patient-centered care: Assessing nursing student knowledge, comfort, and cultural competence toward the Latino population: 1. Journal of Nursing Education, 53(6), 305. http://dx.doi.org/10.3928/0148483420140428-01. Moustakas, C. E. (1994). Phenomenological research methods. Thousand Oaks, CA, US: Sage Publications, Inc. National League for Nursing. (2012). NLN research priorities in nursing education 20122015. Retrieved from http://www.nln.org/docs/default-source/default-documentlibrary/researchpriorities.pdf?sfvrsn¼2. Ndiwane, A., Koul, O., & Theroux, R. (2014). Using standardized patients to teach and evaluate the cultural competence of graduate nursing students. Clinical Simulation in Nursing, 10, 87e94. Retrieved from https://www.nursingsimulation.org/article/ S1876-1399(13)00162- X/fulltext. Potter, P., & Perry, A. (2016). Fundamentals of nursing. St. Louis, MO: Elsevier. Rudolph, J. W., Simon, R., Dufresne, R. L., & Raemer, D. B. (2006). There’s no such thing as “nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simulation in Healthcare, 1, 49e55. Retrieved from https://journals.lww.com/ simulationinhealthcare/pages/articleviewer.aspx?year¼2006&i ssue¼00110& article¼00006&type¼Fulltext#pdf-link. Sittner, B. J. (2015). INACSL Standards of best practice for simulation: Past, present, and future. Nursing education perspectives, 36(5), 294e298. http://dx.doi.org/ 10.5480/15-1670. Smeltzer, S. C., Mariani, B., Ross, J., Petit de Mange, E., Meakim, C., Bruderle, E., & Nthenge, S. (2015). Persons with disability: Their experiences as standardized patients in an undergraduate nursing program. Nursing education perspectives, 36(6), 398e400. http://dx.doi.org/10.5480/15-1592.
Contents lists available at ScienceDirect
Teaching and Learning in Nursing j o u r n a l h o m e p a g e : w w w. j o u r n a l s. e l s ev i e r. c o m / teaching-and-learning-in-nursing
Evaluating Cultural Competence in Undergraduate Nursing Students using Standardized Patients Deborah Byrne, PhD, RN, CNE * La Salle University, 1900 West Olney Avenue St. Benilde Room 4429, Philadelphia, PA, USA
a r t i c l e
i n f o
Article history: Accepted 27 August 2019 Keywords: Cultural competence Simulation Nursing education Standardized patients
a b s t r a c t Background: The need for culturally competent health-care providers is essential in reducing health disparities and ensuring positive patient outcomes. The purposes of this study were to describe the baseline level of self-reported cultural competence of undergraduate nursing students and compare between groups learning this material with lecture only and those learning with lecture and simulation with culturally diverse standardized patients. Method: A mixed method and design was used for this study. Results: There was a statistically significant increase in the level of cultural competence in both groups who participated in the study. Results also present thematically analyzed reactions of participants to the simulation in which several broad themes emerged including participants initially feeling nervous then comfortable during the simulation and finding the simulation extremely valuable. Conclusion: This research suggests that the use of standardized patients is an effective teaching strategy in nursing education particularly as a supplement to traditional lecture. © 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
Introduction Increases in the United States (U.S.) minority populations, health disparities, lack of access to healthcare, and increased incidence of chronic illnesses make it essential for health-care providers to be culturally competent (American Nurses Association [ANA], 2015; National League for Nursing [NLN], 2012; Marion, et al., 2017). It is imperative that undergraduate nursing students develop culturally competent knowledge, awareness, and skills through undergraduate nursing curricula. The use of simulation with standardized patients (SPs) is an effective strategy that could be integrated throughout the curricula to evaluate a student’s cultural competence skills (Ndiwane, Koul & Theroux, 2014). Campinha-Bacote’s (2007) cultural competence model has five interdependent constructs as follows: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. This model guided the development of the specifically designed classroom lecture and simulation using SPs in this study. Campinha-Bacote (2003, p. 8) defines cultural competence as a set of congruent behaviors, attitudes, and policies that come Acknowledgement of financial support: The study was funded with a grant awarded for dissertation research by Pennsylvania Higher Education Nursing Schools, Association, Inc. * Corresponding author. Tel.: 215 951 1667. E-mail address: [email protected].
together in a system, agency, or amongst professionals and enables that system, agency of those professionals to work effectively in cross-cultural situations. The purposes of this study were as follows: 1) describe the baseline level of self-reported cultural competency of undergraduate nursing students; and 2) compare the self- reported level of cultural competency between students learning this material with lecture only and those learning with lecture and simulation with culturally diverse SPs.
Cultural Competence in Undergraduate Nursing Education and Simulation Nursing education has long acknowledged that cultural competence should be a program outcome of baccalaureate programs. The American Association of Colleges of Nursing [(AACN 2008]) has established a set of competencies, learning strategies, and benchmarks that baccalaureate nursing programs can incorporate in their curriculum. However, evidence is lacking on the most effective method of promoting cultural competence in undergraduate nursing students. One well- established teaching strategy is using SPs. The International Nursing Association for Clinical Simulation and Learning (INACSL, 2016) has developed standards of practice for simulation to provide best practices for developing and evaluating simulations (Sittner, 2015). Benefits of simulation using SPs include realistic scenarios, feedback
https://doi.org/10.1016/j.teln.2019.08.010 1557-3087/© 2019 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
58
D. Byrne / Teaching and Learning in Nursing 15 (2020) 57e60
from SPs, and improved communication. Several studies have evaluated the use of SPs in nursing education in the areas of health assessment, psychiatric care, students’ anxiety, disability, communication, and psychomotor skills (Galloway, 2009; Kim-Godwin, Livsey, Ezzell, & Highsmith, 2013; Smeltzer, et al., 2015). However, there is a paucity of research on using diverse SPs in simulation to assess and evaluate a nursing students’ level of cultural competence. While cultural competence requires a specific set of knowledge and skills, it is the cultural encounter specifically that can enhance a student’s level of cultural competence. SPs allow the student to interact with an individual who represents cultural diversity and receive immediate feedback. Instruments According to Fitzgerald, Cronin, and Campinha-Bacote (2009), the Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals e student version IAPCC-SV© assessment showed an acceptable internal consistency, with a Cronbachs alpha for the overall scale of .78. A study by Chen (2012) reported a reliability pretest score of alpha .66 and an alpha of .76 for the posttest score for the IAPCC-SV© assessment measure. In the current study, the Cronbach alpha coefficient for the pretest was .71 and posttest was .76. These scores are consistent with previous research. This instrument is a 20 question self-report tool with five subsets incorporating the five constructs of the cultural competence model. Method After receiving approval from a university institutional review board, a quasi- experimental mixed method design using IAPCCSV© assessment as a pretest, posttest measure, and demographic data form were used for this study. In addition, an open-ended questionnaire was developed to understand how the participants perceived the effectiveness of the simulation. The study used a convenience sample of 38 undergraduate sophomore-level nursing students enrolled in a four-credit introduction to professional nursing course in a medium-sized, religiousbased university on the East Coast. The sample size was estimated using a medium effect size and determined to require a minimum of n ¼ 28 to achieve statistical significance (Faul, Erdfelder, Lang & Buchner, 2007). The study consisted of a specifically designed lecture and simulation with SPs on cultural competence. Although students participated in the simulation as a course requirement, participation in the study was voluntary. There were two sections of the course as follows: one who received the lecture only (but received the simulation later) and the lecture plus simulation and the other who received the lecture and simulation in close proximity. Classes were randomly assigned to control and experimental conditions. The lecture only and lecture plus simulation groups completed the IAPCC-SV© assessment measure and the demographic information at baseline prior to treatment condition. All participants received the specifically designed cultural competence lecture. The lecture only group completed the IAPCC-SV© assessment posttest one week after the lecture. The lecture plus simulation group received the SP experience approximately one week after the lecture on the topic and completed the IAPCC-SV© assessment after the SP simulation. The same instructor lectured in both sections of this course to provide participants with consistent information. After the simulation, participants were asked three open-ended questions that were later analyzed for significant themes. The questions included were as follows: What was your reaction to the SP once you started interacting with him or her? Was the experience of interacting with a SP in the scenario a valuable experience? If so, why? If not, why? How strongly would you recommend that we continue to have SPs in simulation?
The lecture portion of the study was based on the current curriculum and textbook for the course (Dillon, 2016, Potter & Perry, 2016). The lecture focused on communication with diverse clients and cultural competence. Simulation with SPs focused on a brief health history and mini-nutritional assessment of a client from a culturally diverse background. The simulation content was developed using the five constructs of the Campinha-Bacote model (Campinha-Bacote, 2007). Cultural knowledge was integrated by having the SPs use cultural terms unfamiliar to the students in regards to the diet. The participants acquired knowledge from the specifically designed lecture to ask patients questions about their culture. Cultural skills were integrated by having participants ask culturally appropriate questions during the mini-nutritional assessment. Cultural desire and awareness were achieved when the participant was actively engaged in the simulation. An established simulation content expert reviewed the simulation scenario, script, student checklist, and SP training guide to ensure accuracy and compliance with the student objectives for this simulation. The simulation content expert has published a simulation book of various simulation scenarios with templates, several journal articles, and led the development of the university’s interprofessional simulation center. The content for the script and student checklist was adapted from a health assessment textbook used within the program (Dillon, 2016). The student objectives were established based on the course objectives. Three SPs were used in the study and the inclusion criteria were a culturally diverse background, willingness to participate in a culturally sensitive simulation, and availability. A practice simulation was conducted and videotaped to ensure accuracy and effectiveness of the simulation. Participants were given presimulation work to prepare for the simulation including questions regarding cultural competence, nutritional assessment, and effective communication. On the day of the simulation, participants were prebriefed using the presimulation work, an introduction to the simulation scenario, and a schedule of the day. A debriefing was conducted at the end of each session by the simulation facilitator and lasted approximately 30 minutes using INACSL guidelines for debriefing (INACSL, 2016). The INACSL guidelines for debriefing include having a facilitator who is trained in debriefing, an open learning environment that allows confidentiality, reflection, and self-analysis, a theoretical framework, and the debrief needs to be congruent with the learning objectives. The simulation facilitator used the theoretical model, Debriefing with Good Judgement for this simulation-learning experience (Rudolph, Simon, Dufresne, & Raemer, 2006). Debriefing questions were adapted from a simulation textbook written by the content expert (Gasper & Dillon, 2012). The simulation facilitator has been trained extensively in simulation and holds several simulation certifications. In addition, participants were given an opportunity to ask the SPs questions regarding the scenario and their role as SPs at the end of the simulation experience. Results All participants were between the ages of 17-20 years. Of the 38 subjects, the majority of them were women (92%, n ¼ 37), most spoke English as their first language (94.8%, n ¼ 37), and most were Caucasian (89.5%, n ¼ 37). Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 24. No data were missing on the demographic, open-ended question, or IAPCC-SV© instruments. An analysis of the descriptive statistics for both the lecture only and the lecture plus simulation groups showed a pretest total mean of 58.6 (standard deviation [SD] ± 5.13; range ¼ 20 e 80), which is categorized as culturally aware on the IAPCC-SV© instrument. A
D. Byrne / Teaching and Learning in Nursing 15 (2020) 57e60
posttest total mean for both groups was 65.73 (SD ± 5.21; range 20 -80), which is categorized as culturally competent on the IAPCC-SV© instrument. There was no significant difference between those who received the lecture and those who received the lecture plus simulation F (1,36) ¼ .117, p ¼ .734. There was a statistically significant effect of time (pretest v. posttest) F (1, 36) ¼ 48.81, p <. 001, n2 .576. There was not a significant time x condition interaction: F (1, 36) ¼ .077, p ¼ .782.
Qualitative Analysis of Simulation Experience Three open-ended questions were asked to participants in the lecture plus simulation group about their experiences and the value of the SP in the simulation (see Method section for questions). Phenomenological approaches to qualitative analysis encourage an openended approach towards data analysis, the reduction and identification of preconceived ideas, and development of a list of emergent themes (Creswell & Poth, 2018). Before the start of the analysis, each researcher bracketed (Creswell & Poth, 2018; Moustakas, 1994), or set aside, preconceived ideas to identify the potential influence of previous knowledge or experiences which might influence the identification and interpretation of the phenomenon. The data were then reviewed by two researchers independently using the following process outlined by Creswell & Poth, (2018). First, the researchers read the data several times to develop an understanding of the overall phenomena of interest. Then, careful selection and coding of meaningful statements that reflected the participants’ subjective experiences were selected. Next, researchers independently developed clusters of meaning from significant statements into themes that were representative of the groups’ experience. The two researchers reviewed the significant statements and themes to come to consensus. Two themes emerged in response to the question about interactions with the SPs. The first was that the students felt nervous and anxious at the beginning of the simulation and the second was they became more comfortable during the simulation. Statements supporting this included “My reaction was very nervous as I began, but once I started asking questions I began to feel more comfortable.” Although most students became comfortable during the simulation, one participant wrote “I was very nervous and anxious. I knew what I wanted to ask, but once I walked in my agenda was forgotten.” The experience interacting with SPs fell into four main themes. The first was the participants would know what to expect in the future. Statements supporting this include “First time I saw myself as a true professional” and “Yes, it helped me to know what to expect in the future.” The second theme was the participants felt the simulation experience was very valuable. Statements from participants included “Yes, it was very valuable. I was able to see what I need to work on” and “Yes, it is definitely a valuable experience because next time I will know what to do and what not to do.” The third theme was the participants reported the simulation helped them to learn how to interact with patients. Participants stated, “Yes, it gave me more confidence talking to a patient” and “Yes, I felt like it was valuable. It gave me an insight of what interacting with patient next semester in clinical.” The fourth theme was the participants learned how to approach and talk with the patient. Participants stated, “Yes, because I will learn a lot from it for next time when I go into hospital and have to talk with the patient” and “It was very valuable because I know how to better approach the patients and how to talk to them I feel more comfortable.” One main theme emerged from the question of how strongly participants would continue to have SP in simulation. All of the participants stated it was a very valuable experience. Comments included “On a scale from 1 to 10, I give it a 100” and “I would highly recommend that we continue this. It was very helpful.”
59
Discussion and Conclusion The results of the pretest revealed that participants scored within the culturally aware range. For an individual to reach cultural competence or cultural proficiency, cultural education needs to evolve beyond awareness and develop other constructs of cultural competence (Campinha-Bacote, 2007). The results of the posttest for the lecture only and lecture plus simulation groups revealed an increase in the mean of the group for total score with the participants moving to the culturally competent range. This finding supports the literature that a curriculum or experience that integrates cultural competence will increase the level of cultural competence in undergraduate nursing students (Calvillo et al., 2009; Jeffreys & Dogan, 2012; Mayo, 2014). The findings suggest that there was no significant difference between the lecture only and lecture plus simulation groups. Although this finding does not support simulation with SPs as a more effective strategy for increasing student’s level of cultural competence, it does show that a specifically designed cultural competence lecture or simulation can increase a student’s level of self-reported cultural competence. However, a unique contribution of this study is the additional use of a mixed-methods design incorporating qualitative analysis of post-simulation experience. Analysis revealed both significant anxiety interacting with culturally different patients ahead of time and increased comfort as the simulation progressed. In addition, all participants recommended the simulation with SPs be continued as part of standard educational practice and many recognized it as a very valuable experience in which they learned how to interact, approach, and talk with the patient. Therefore, although there was not a statistically significant difference between the lecture only and the lecture plus simulation conditions using the IAPCC-SV©, the additional qualitative analysis suggests the simulation provided a rich learning experience for students. A limitation of this study was the use of a convenience sample of undergraduate nursing students already enrolled in the nursing program. The sample (n ¼ 37) is considered a small sample size that limits the generalizability of the results. The use of a selfreporting tool and the probability of social desirability bias due to a single encounter with a culturally diverse SP. Social desirability bias refers to the subject answering questions in a manner that is viewed favorable by others. To reduce the change of social desirability bias, the principal investigator maintained strict confidentiality and anonymity. Another limitation is the lack of a specific question on cultural competence in the qualitative survey. A specific question on cultural competence would be added in a future study to ensure the students felt the simulation was also effective in enhancing the participant’s cultural competence. This study adds to the nursing education literature related to cultural competence and simulation with SPs by exploring the effectiveness of using specifically designed classroom lecture and simulation to assess cultural competence. Simulation with SPs has been used in undergraduate nursing education as an effective teaching strategy (Galloway, 2009; Kim-Godwin et al., 2013; Smeltzer, et al., 2015). This is one of the first studies to suggest the effectiveness of using simulation with SPs to evaluate an undergraduate nursing student’s level of cultural competence. Consequently, the findings of this study support the need for future nursing education in the area of cultural competence and simulation with SPs.
References American Association of Colleges of Nursing. (2008). Tool kit for resources for cultural competent education for baccalaureate nurses. Retrieved from http://www.aacn. nche.edu/education-resources/toolkit.pdf.
60
D. Byrne / Teaching and Learning in Nursing 15 (2020) 57e60
American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Washington, D.C: Author. Calvillo, E., Clark, L., Ballantyne, J. E., Pacquiao, D., Purnell, L. D., & Villarruel, A. M. (2009). Cultural competence in baccalaureate nursing education. Journal of Transcultural Nursing, 20, 137e145. http://dx.doi.org/10.1177/1043659608330354. Campinha-Bacote, J. (2003). The process in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), 181e184. Campinha-Bacote, J. (2007). The process of cultural competence in the delivery of healthcare services: The journey continues (5th ed.). OH: Transcultural C.A.R.E. Chen, H. (2012). The impact of service-learning on students' cultural competence. Teaching and Learning in Nursing, 7(2), 67. Retrieved from https://www. sciencedirect.com/science/article/abs/pii/S155730871100120X?via%3Dihub. Creswell, J. W., & Poth, C. N. (2018). Qualitative Inquiry and Research Design Choosing among Five Approaches (4th Edition). Thousand Oaks: SAGE Publications, Inc. Dillon, P. (2016). Nursing health assessment: The foundation of clinical practice (3rd ed.). PA: FA Davis Company. Faul, F., Erdfelder, E., Lang, A.-D., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavioral Research Methods, 39(2), 175e191. http://dx.doi.org/10.3758/BF03193146. International Nursing Association of Clinical Simulation and Learning (INACSL) Board of Directors. (2016). Standards for best practice: Simulation. Clinical Simulation in Nursing, 9(6). Suppl, Sii-Siii. Retrieved from https://www.sciencedirect.com/science/ article/pii/S1876139916301293?via%3Dihub. Fitzgerald, E. M., Cronin, S. N., & Campinha-Bacote, J. (2009). Psychometric testing of the inventory for assessing the process of cultural competence among healthcare professionals - student version (IAPCC-SV© ©). Journal of Theory Construction & Testing, 13(2), 64e68. Retrieved from https://search.proquest.com/docview/ 89253367?pq- origsite¼summon. Galloway, S. (2009). Simulation techniques to bridge the gap between novice and competent healthcare professionals. Online Journal of Issues in Nursing, 14(2), 1e10. Retrieved from https://dbproxy.lasalle.edu:443/login?url¼https://search. proquest.com/docview/22960841 5?accountid¼11999. Gasper, & Dillon. (2012). Nursing health assessment: The foundation of clinical practice (3rd ed.). PA: FA Davis Company. Jeffreys, M. R., & Dogan, E. (2012). Evaluating the influence of cultural competence education on students’ transcultural self-efficacy perceptions. Journal
of Transcultural Nursing, 23(2), 188e197. http://dx.doi.org/10.1177/ 1043659611423836. Kim-Godwin, Y. S., Livsey, K., Ezzell, D., & Highsmith, C. (2013). Home visit simulation using a standardized patient. Clinical Simulation in Nursing, 9(2), e55ee61. Retrieved from https://www.nursingsimulation.org/article/S1876-1399(11) 00165-4/fulltext. Marion, L., Douglas, M., Lavin, M., Barr, N., Gazaway, S., Thomas, E., & Bickford, C. (2017). Implementing the new ANA standard 8: Culturally congruent practice. Online Journal of Issues in Nursing, 22(1), 1e14. http://dx.doi.org/10.3912/ OJIN.Vol22No01PPT20. Mayo, R. M. (2014). Preparing for patient-centered care: Assessing nursing student knowledge, comfort, and cultural competence toward the Latino population: 1. Journal of Nursing Education, 53(6), 305. http://dx.doi.org/10.3928/0148483420140428-01. Moustakas, C. E. (1994). Phenomenological research methods. Thousand Oaks, CA, US: Sage Publications, Inc. National League for Nursing. (2012). NLN research priorities in nursing education 20122015. Retrieved from http://www.nln.org/docs/default-source/default-documentlibrary/researchpriorities.pdf?sfvrsn¼2. Ndiwane, A., Koul, O., & Theroux, R. (2014). Using standardized patients to teach and evaluate the cultural competence of graduate nursing students. Clinical Simulation in Nursing, 10, 87e94. Retrieved from https://www.nursingsimulation.org/article/ S1876-1399(13)00162- X/fulltext. Potter, P., & Perry, A. (2016). Fundamentals of nursing. St. Louis, MO: Elsevier. Rudolph, J. W., Simon, R., Dufresne, R. L., & Raemer, D. B. (2006). There’s no such thing as “nonjudgmental” debriefing: A theory and method for debriefing with good judgment. Simulation in Healthcare, 1, 49e55. Retrieved from https://journals.lww.com/ simulationinhealthcare/pages/articleviewer.aspx?year¼2006&i ssue¼00110& article¼00006&type¼Fulltext#pdf-link. Sittner, B. J. (2015). INACSL Standards of best practice for simulation: Past, present, and future. Nursing education perspectives, 36(5), 294e298. http://dx.doi.org/ 10.5480/15-1670. Smeltzer, S. C., Mariani, B., Ross, J., Petit de Mange, E., Meakim, C., Bruderle, E., & Nthenge, S. (2015). Persons with disability: Their experiences as standardized patients in an undergraduate nursing program. Nursing education perspectives, 36(6), 398e400. http://dx.doi.org/10.5480/15-1592.