Nurses' Attitudes Toward Continuing Formal Education

C o n T I n u I n g E d u C AT I o n / n u R S I n g E d u C AT I o n R E S E A R C H

Nurses’ Attitudes Toward Continuing Formal Education: A Comparison by Level of Education and Geography

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(Institute of Medicine, 2011). However, only 50 percent of the current RN workforce is prepared with a bachelor of science in nursing (BSN) or graduate degree (American Association of Colleges of Nursing [AACN], 2011). Even in countries that have adopted the BSN as a requirement for entry into practice, such as Canada, many nurses are practicing with associates degrees (ADN) or diplomas in nursing. The three educational routes to become an RN in the United States are unique for a profession and lead to concern that RNs may be seen as undereducated when compared with other members of the health care team (Donley & Flaherty, 2002). Megginson (2008) stated that the educational mobility of ADN and diploma nurses “to the BSN level is crucial to positive patient outcomes, creation of a credible professional identity and to cohesion among nurses” (p. 48). Understanding nurses’ attitudes is key to achieving the goal of “enticing and enabling nurses to achieve higher educational levels consistent with the trends of other health care professionals” (Hilton, 2004, p. 14). The Theory of Planned Behavior (TPB) (Ajzen, & Fishbein, 1980) was the organizing framework for this study. It has proven reliability and validity and proposes a connection between the concepts of attitude toward behavior, subjective norms (social pressures), and perceived behavioral control. This study examined the attitudes of nurses initially registered with an ADN or diploma toward continuing to the BSN level and/or beyond. The goal was to provide direction for change. Four research questions were asked: • What are the attitudes of ADN and diploma nurses toward continuing formal education? nuRSES EngAgE In lIfElong lEARnIng

• Do attitudes change over time as determined by years of nursing practice? • How do the attitudes of those who return to school for a BSN or higher differ from those who have not returned or from those planning to return? • Do attitudes differ according to geographical location (west vs. east)? Background and literature Search Patient outcomes are a

primary reason to encourage continuing formal education. The literature is replete with research and anecdotal support for the contention that patient health care outcomes are linked to nursing education. Researchers have identified: a) improved patient safety and lower rates of patient morbidity and mortality (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005; Friese, Lake, Aiken, Silber, & Sochalski, 2008; Tourangeau et al., 2007), b) lower levels of medication errors and procedural (or practice-related) violations (AACN, 2008; Delgado, 2002), and c) fewer disciplinary actions for BSNs (Delgado). The knowledge needed by practicing nurses increases as medical knowledge evolves and becomes ever more complex. “Undereducated nurses often fail to recognize their disadvantage and do not aspire to graduate education” (Neese, Majka, & Tennant, 2007, p. 160). The nursing faculty shortage is another reason to encourage continuing education for ADN- and diploma-prepared nurses. From 1995 to 2004, the number of RNs with master’s or doctorates who were nurse educators dropped from 15 percent to 11 percent (Cleary, Bevill, Lacey, & Nooney, 2007). Raising BSN program enrollment would be a first step to addressing the faculty shortage. A number of studies have investigated nurses’ motivations for

RESEARCH

ABSTRACT

The education of nurses has an influence on patient safety and outcomes, the nursing shortage, the faculty shortage, and

nurses’ attitudes and actions. This article reports on a dissertation study designed to examine the attitudes of nurses, initially registered with an associate degree or diploma in nursing, toward continuing formal education. Actively licensed registered nurses in the eastern and western United States (n = 535) participated. The main finding of this study was that, although nurses held positive attitudes overall, attitudes ranked barely above neutral. The findings suggest that work needs to be done to improve nurses’ attitudes toward continuing formal education and research needs to be undertaken to understand what would entice nurses back to school. Implications for nursing practice and education are discussed along with suggestions for future research.

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engaging in (Bahn, 2007; Hayajneh, 2009; Joyce & Cowman, 2007; Jukkala, Henly, & Lindeke, 2008; Megginson, 2008) and continuing formal education (Hughes, 2005; Joyce & Cowman; Megginson; Roche, 1990). While most studies concluded that motivation and attitude affect participation in, and the outcomes of, education (Steginga et al., 2005), only two studies found nurses to have positive attitudes toward continuing education (Hughes; Roche). In Waddell’s (1993) meta-analysis of 22 studies, motivational orientations explained 46 percent of the variation in RN participation. When level of education and attitudes were evaluated together, nurses with lower initial educational levels participated less and had poorer attitudes toward education (Alquraini, Alhashem, Shah, & Chowdhury, 2007; Penz et al., 2007; Roche, 1990). Diploma graduates were the least likely to participate. The current study is partially based on a study by Roche (1990) that examined relationships between attitudes toward BSN education, self-esteem, the incidence of perceived life events, and the decision about whether to return to school for a BSN. Roche showed that attitudes contributed significantly (two-tail, p < .001) to differences between RNs who did and did not return to school. Reasons for pursuing the BSN are related to internal or intrinsic factors (Megginson, 2008), personal achievement or satisfaction (Delaney & Piscopo, 2004; Reilley, 2003), career advancement (Delaney & Piscopo; Reilley), the improvement of clinical judgment (Hughes, 2005; Joyce & Cowman, 2007), and increased knowledge (Hughes). Megginson identified factors that lead to continuation of formal education: the right time in life, working with options, personal goals, credible professional identity, encouragement from contemporaries, and user-friendly RN-BSN programs. Reasons for not returning to school were found to include: time away from family and having multiple roles or responsibilities (Delaney & Piscopo, 2004; Hughes; Megginson; Reilley), a negative ADN or diploma school experience (Megginson), and cost (Bahn, 2007; Delaney & Piscopo; Megginson; Penz et al., 2007). Professional reasons identified were: no different treatment or recognition at work (Hughes; Megginson), no extra earning power, and work schedules (Hughes; Reilley). Gaps in the literature were identified. Sample sizes, although varied, rarely met statistical sizes necessary for generalization. The questionnaires used often provided less depth than other instruments. And the research was mainly focused on eastern states. Although it is recommended that recruitment into RN-BSN programs start younger, no clear demarcation was identified as to when RNs changed their perceptions toward returning to school. No study attempted to address how attitudes affect behavior or whether particular attitudes have a greater impact on action. An understanding of nurses’ attitudes is needed in order to develop methods to entice them to pursue further education.

method

This exploratory, comparative, descriptive study used a mailed questionnaire to survey a random sample of actively licensed RNs, initially educated below the BSN level, in three states: California, New Jersey, and Pennsylvania. The states were chosen by size of the RN population (to ensure equal numbers from the east and west) and the types of nursing programs offered (to ensure inclusion of diploma RNs). An Internet search of state board licensing sites showed that the two eastern states had the highest proportion of diploma to ADN programs in the country. Sample size was determined by power analysis (80 percent power, alpha = .05), consideration of an expected response rate (20 percent), and prediction of the number ineligible (33 percent BSN or equivalent). Finally, questionnaires were mailed: 1,350 RNs were selected from California, 482 from New Jersey, and 868 from Pennsylvania. The Duquesne University Institutional Review Board approved the study. Comprehensive information was sent to participants to ensure informed consent; data were received, recorded, and stored to ensure confidentiality. Return of the survey indicated informed consent. INSTRUMENTS Two instruments were used: the 19-item Attitudes Toward BSN Education (ATBSNE) scale (Roche, 1990) and a sociodemographic questionnaire adapted from Roche. The focus of the ATBSNE on the affective and cognitive aspects of attitude enhances content validity. A seven-point semantic differential scale is used to measure bipolar adjectives. The original scale had proven reliability and validity determined by: a panel of experts in two phases, a pilot study (test-retest reliability: r = .78, p < .001), factor analysis, and Cronbach’s alpha = .94). The sociodemographic questionnaire contained 34 questions: open ended (n = 7), forced/multiple choice (n = 18), and dichotomous (n = 9). Cronbach’s alpha coefficient was .96. DATA ANALyS IS Initial analysis used simple descriptive statistical tests. Subsequent analysis included a multivariate analysis of variance (MANOVA) and 19 analyses of variances (ANOVAs) on the adjective pairs by degree (ADN vs. diploma) to examine the first research question and ANOVAs to examine the remaining questions. Assumptions of normality and homogeneity of variance were assessed. Statistical significance was considered at p < .05. When statistical significance was borderline (p < .10), findings were evaluated based on the evidence against the null hypothesis. S AMPLE

Results and discussion The response rate was 33.9 percent; however, only 19.8 percent of the questionnaires (n = 535) were appropriate for data analysis, more than needed as determined by power analysis. Data were compared to findings from the National

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Sample Survey of Registered Nurses March 2004 (Health Resources & Services Administration, 2006). This report is referred to as the National Sample without reference at each occurrence. BASIC DEMOGRAPHICS Most participants were female (93.3 percent), married (71.1 percent), Caucasian (85.2 percent), and over 50 years of age (54.3 percent); only 14.6 percent were under 40. Their average number of years as an RN was 24.81 (SD = 13.55, range 0.5 to 62). Participants were employed in nursing either full-time (56.6 percent) or part-time (21.3 percent), and 43.2 percent worked as staff nurses. The study sample closely resembled the National Sample in gender, age, marital status, family status, and employment. The study sample was older, was slightly more ethnically diverse, and more nurses were employed in hospitals. INITIAL EDUCATION The state breakdown of participants was: California, 44.3 percent; Pennsylvania, 40.2 percent; and New Jersey, 15.5 percent. More than half of the participants, 53.3 percent, originally graduated from diploma programs. When categorized by initial education, 69.6 percent of ADNs and 21.8 percent of diploma nurses lived on the west coast. While the proportion of ADNs to diploma nurses does not represent the general population of nurses as shown in the National Sample, which reported 25.5 percent diploma nurses, the final ratio of east to west (1 to 0.8) was sufficient to allow for comparisons. CONTINUING EDUCATION Information on participants’ continuing education was consistent with the National Sample. However, more RNs had earned their BSNs or higher (42.3 percent) and fewer had a diploma as their highest degree. Only 26.3 percent were interested in returning for further education. Slightly more diploma nurses (54.5 percent) compared with ADNs returned to school. This study had double the percent of advanced practice nurses (APNs) (16.9 percent) than the National Sample, yet only 15 participants (approximately 2.8 percent) were educators compared to 1.67 percent in the National Sample. These findings are indicative of the growing faculty shortage. Top reasons selected for not pursuing higher education included: too old, won’t earn more money, not needed by hospitals, and not needed to give good care. This last reason contradicts the primary reason found in other research (Bahn, 2007; Joyce, & Cowman, 2007). The nursing shortage, with contingent job security and opportunities that traditionally required a BSN, likely influenced the findings. It is possible that nurses are not aware of, or do not believe, current research on patient outcomes. As in previous research (Delaney & Piscopo, 2004; Penz et al., 2007), cost was cited as an impediment for not returning to school; it was the second top reason in the “other” category. To receive tuition reimbursement, 46.4 percent of respondents needed to be 1 6 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s

working full-time; 42.5 percent reported the amount reimbursed was based upon hours worked; and 18 percent did not know if their employer offered tuition reimbursement. Fewer participants were eligible for partial tuition reimbursement (≤ $4,000 per year) than found by Roche (1990): 23.5 percent versus 76 percent. Given the expense (e.g., tuition, books) and the time required, $4,000 per year is inadequate for pursuing continuing education. Only 52.4 percent reported being encouraged to continue their formal education during their initial licensing program, suggesting that faculty either do not promote the BSN or do not consider career counseling their responsibility. Faculty do not consistently model a positive attitude toward continuing formal education. The main motivator to pursue further education came from “personal desire,” which is consistent with the literature (Delaney & Piscopo, 2004; Reilley, 2003). The majority of participants (79.6 percent) did not feel social pressure to obtain a BSN, and those that did said that it would be more effective if accompanied by flexible schedules, better tuition reimbursement, financial rewards, and recognition. In previous research, RNs reported pressure to return to school from their immediate work environment and society (Reilley), as well as for professional growth and career prospects (Delaney & Piscopo; Hughes, 2005). Given today’s job market and the nursing shortage, these findings are not surprising. FINDINGS FOR RES EARCH QUES TIONS

1) What are the attitudes of ADN and diploma nurses toward continuing formal education? A significant attitude difference was found between ADN and diploma nurses (F = 1.82, p = .02, 2 = .08, power = .97). While both groups had slightly positive attitudes, ADNs held more positive attitudes (M = 4.02, SD = 1.43) than diploma nurses (M = 3.99, SD = 1.49). This is supported by the literature (Alquraini et al., 2007; Hughes, 2005; Roche, 1990). Two items on the ATBSNE scale accounted for 25 percent of the variance in the model: item 15 (inappropriate to appropriate) and item 17 (unsuccessful to successful). Positive attitudes were expected given the high number of participants who had returned to school, but the numbers were disappointing. The mean scores for both groups were only slightly positive, with the highest item averaging 5.36, suggesting that RNs return to school for reasons other than the value of the BSN. With the high number who had returned, still more wanting to return, and only moderately strong positive attitudes toward the BSN, something else must be enticing RNs. 2) Do attitudes change over time as determined by years of nursing practice? There were no significant differences (F = 2.11, p = .06, 2 = .02, power = .70) found on ATBSNE scores by age group. Attitudes remained relatively constant, suggesting that encouragement to continue formal education may occur at any time during a nurse’s career. Consistent with the literature (Cleary et al., 2007;


Delaney & Piscopo, 2004; Roche, 1990), participants cited age as an obstacle to returning. Roche also found that those licensed for a shorter period were more likely to return to school. 3) How do the attitudes of those who return to school for a BSN or higher differ from those who have not returned or from those planning to return? The number of participants planning to return to school was too small for a meaningful comparison with either those who had returned or will not return. Thus, it was dropped from analysis. The ANOVA was significant (F = 17.17, p < .001, partial 2 = .04, power = .99). As expected, those who had returned to school scored significantly higher on the ATBSNE scale (M = 5.17, SD = 1.13), indicating more positive attitudes, than those who had not returned (M = 4.74, SD = 1.04). This is consistent with Roche (1990). 4) Do attitudes differ according to geographical location (west vs. east)? The ANOVA for this question was not significant (F = 3.07, p = .08, partial 2 =.01, power = .42). No difference was found in ATBSNE scores between RNs on the east and west coasts. This finding was unexpected as there has been a resurgence of diploma programs in the east and no known diploma programs in California (only 22.1 percent of the diploma participants resided on the west coast). Although the finding may be explained by movement between states, it is more likely that it reflects existing attitudes. limitations The study used a descriptive, comparative design,

with a self-report, mailed questionnaire. The survey length was shorter than ideal for use of a semantic differential scale, and the concept was measured indirectly. However, certain limitations were reduced through the assumptions of, and methodological choices for, the study. Randomized sample selection was used to control for extraneous variables, reduce bias, and aid in attaining a representative sample. Thus, while generalizations about the findings to all United States nurses must be done with caution, they may be made based on the even distribution of participants, instrument reliability, the adequate sample size, and the demographic similarity to the National Sample. Conclusions and Recommendations The attitudes of all nurses toward BSN education require improvement. Nurses who had returned to school had the most positive attitudes about BSN education, with positive attitudes related to personal reasons, social pressure, and experience. ADN nurses had slightly more positive attitudes than diploma nurses overall, but both groups ranked barely above neutral. Many participants who had not returned to school cited not needing a BSN education to give good care. Such ignorance can be overcome only through returning to school, where the advantages of a BSN should become evident. “Undereducated nurses often fail to recognize their disadvantage” (Neese et al., 2007, p. 160).

Employers do exert some pressure but they appear not to have improved their support. Many nurses are unaware of tuition reimbursement and, if it exists, the amount is low. Aside from the perception that a BSN is not required for employment or to provide good care, reasons not to return to school included age and cost. Chronological age may influence behavior separate from attitude; thus, further research is needed. Diploma and ADN faculty are not encouraging students to continue their formal education, which may be seen by students as a negative attitude. The salaries of APNs are well above those of the average staff nurse and a BSN degree is the first step toward APN education, which may be a motivator. More research is needed on how and when to best improve the attitudes of nurses and nurse faculty. A suggested next step is a longitudinal (prospective) mixed-modal study of a group of new graduates to delve into their current attitudes and determine if attitudes change during the course of a nurse’s career. In accordance with the TPB, methods to entice RNs to return to school should not only be focused on changing attitudes, but should also increase subjective norms. Employers, nurse educators, and experienced RNs need to take a more active role in promoting and supporting the continuation of formal education. Employer support must be increased, concrete, and advertised. Employers need to improve communications about reimbursement, increase the amount of financial commitment, provide flexible schedules, and provide monetary rewards and/or recognition for those nurses who complete advanced education. The use of career ladders, with the attainment of a BSN as a step, could be one method used. In addition, although older RNs tended to have more positive attitudes toward BSN education, they see age as an impediment and might benefit from mentoring by younger nurses. It appears from this study that negative attitudes are being modeled by faculty. Students need greater encouragement, more information, and mentoring during their initial nursing education. To understand what faculty convey to students, a survey of ADN and diploma faculty is needed. Finally, as many nurses do not appear to value the BSN, research on the benefits of a BSN education needs to be repeated for validation and better disseminated. Dissemination of this research needs to be done in a positive manner that does not devalue the contributions of ADN and diploma nurses, and it should be directed toward nurses who do not have research experience. Quality in health care is a priority. Nurses need the scope and depth of knowledge, skill, and judgment attained through baccalaureate education in order to teach and/or to provide optimal quality care to complex patients. Attitudes March / April Vo l . 3 3 N o . 2 / / /


toward continuing formal education are poor and need improvement. The commitment to lifelong learning is a professional values and a hallmark of all professions. NLN

About the Author

Tanya K. Altmann, PhD, RN, is an associate professor at Sacramento State University School of Nursing, Sacramento, California. The author is grateful to the National League for References Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Silber, J. H. (2003). Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association, 290, 1617-1623. Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall. Alquraini, H., Alhashem, A. M., Shah, M. A., & Chowdhury, R. I. (2007). Factors influencing nurses’ attitudes towards the use of computerized health information systems in Kuwaiti hospitals. Journal of Advanced Nursing, 57, 375-381. American Association of Colleges of Nursing. (2008). Fact sheet: The impact of education on nursing practice. Retrieved from www.aacn.nche.edu/Media/FactSheets/ImpactEd NP.htm American Association of Colleges of Nursing. (2011). Nursing shortage. Retrieved from www.aacn.nche.edu/media-relations/factsheets/nursing-shortage Bahn, D. (2007). Orientation of nurses towards formal and informal learning: Motives and perceptions. Nurse Education Today, 27, 723-730. Cleary, B., Bevill, J. W., Lacey, L. M., & Nooney, J. G. (2007). Evidence and root causes of an inadequate pipeline for nursing faculty. Nursing Administration Quarterly, 31, 124-128. Delaney, C., & Piscopo, B. (2004). RN-BSN programs: Associate degree and diploma nurses’ perceptions of the benefits and barriers to returning to school. Journal of Nursing Education, 20, 157-161. Delgado, C. (2002). Competent and safe practice. Nurse Educator, 27, 159-161. Donley, R., & Flaherty, M. J. (2002). Revisiting the American Nurses Association’s first position paper on education for nurses. Online Journal of Issues in Nursing. Retrieved from www.nursing-

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Nursing Foundation and Sacramento State University for financial support for this study; Dr. E. M. Roche for use of her instrument; and the members of her dissertation committee, Drs. Lynn Simko, Gladys Husted, and Robyn Nelson. For more information, contact Dr. Altmann at [email protected]. Key words Nurse Attitudes – Nursing Education – RN-BSN Education – Postregistration

world.org/MainMenu Categories/ ANAMarketplace/ANAPeriodicals/OJIN/ TableofContents/ Volume72002/No2May2002/ RevisingPostiononEducation.html

Jukkala, A. M., Henly, S. J., & Lindeke, L. L. (2008). Rural perceptions of continuing professional education. Journal of Continuing Education in Nursing, 39(12), 555-563.

Estabrooks, C. A., Midodzi, W. K., Cummings, G. G., Ricker, K. L., & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30day mortality. Nursing Research, 54, 74-84.

Megginson, L. A. (2008). RN-BSN education: 21st century barriers and incentives. Journal of Nursing Management, 16, 47-55.

Friese, C. R., Lake, E. T., Aiken, L. H., Silber, J. H., & Sochalski, J. (2008). Hospital nurse practice: Environments and outcomes for surgical oncology patients. Health Services Research, 43(4), 1145-1163. Hayajneh, F. (2009). Attitudes of professional Jordanian nurses toward continuing education. Journal of Continuing Education in Nursing, 40(1), 43-48. Health Resources & Services Administration. (2006). The registered nurse population: National sample survey of Registered Nurses March 2004: Preliminary findings. Merrifield, VA: US Department of Health and Human Services, Bureau of Health Professions, Division of Nursing. Hilton, L. (2004). Aiken study supports pro-BSN stance. Nursing Spectrum (Greater Philadelphia/TriState Edition), 12, 14-15. Hughes, E. (2005). Nurses’ perceptions of continuing professional development. Nursing Standards, 19, 41-49. Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Joyce, P., & Cowman, S. (2007). Continuing professional development: Investment or expectation? Journal of Nursing Management, 15, 626-633.

Neese, R., Majka, G., & Tennant, G. G. (2007). The ultimate challenge: Three situations call American nurses to think and act globally. In M. H. Oermann & K. T. Heinrich, Eds., Annual Review of Nursing Education, 5, 153-171. Penz, K., D’Arcy, C., Stewart, N., Kosteniuk, J., Morgan, D., & Smith, B. (2007). Barriers to participation in continuing education activities among rural and remote nurses. Journal of Continuing Education in Nursing, 38(2), 58-66. Reilley, J. L. (2003). The educational participation of the female registered nurse baccalaureate student: Motivation, barriers, and persistence to complete the degree. Unpublished doctoral dissertation, Widener University, Wilmington, DE. Roche, E. M. (1990). The relationship of attitude toward BSN education, self-esteem, life events and RN’s decision to return to school to earn a BSN. Unpublished doctoral dissertation, Widener University, Chester. PA. Steginga, S. K., Dunn, J., Dewar, A. M., McCarthy, A., Yates, P., & Beadle, G. (2005). Impact of an intensive nursing education course on nurses’ knowledge, confidence, attitudes, and perceived skills in the care of patients with cancer. Oncology Nursing Forum, 32, 375-381. Tourangeau, A. E., Doran, D. M., McGillis Hall, L., O’Brien Pallas, L., Pringle, D., Tu, J. V., & Cranley, L. A. (2007). Impact of hospital nursing care on 30-day mortality for acute medical patients. Journal of Advanced Nursing, 57, 32-44. Waddell, D. L. (1993). Why do nurses participate in continuing education? A meta-analysis. Journal of Continuing Education in Nursing, 24, 52-56.

S T u dy A B R oA d / n u R S I n g E d u C AT I o n R E S E A R C H

Assessing Outcomes o f a Study Abroad Course for NURSING STUDENTS

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An InCREASIngly gloBAl SoCIETy, gRowIng numBERS of CollEgE STudEnTS lEAvE CAmpuS EACH yEAR To STudy ABRoAd

(Belyavina & Bhandar, 2012). However, there is little research that explores the link between nursing students’ experiences in international programs and changes in their cultural competence (Evanson & Zust, 2006). A course titled Spanish for Healthcare Professionals, described by Bloom, Timmerman, and Sands (2006), was adapted into a study abroad experience in Guadalajara, Mexico, for a baccalaureate nursing program at the University of Texas at Austin. This article reports on findings from a descriptive study conducted to assess outcomes of the experience. Two research questions were asked: • How has the study abroad experience influenced the participants’ awareness, sensitivity, knowledge, and skills related to culture of the people in Guadalajara? • How has the study abroad experience influenced participants’ clinical practice as nurses? Background and Significance To meet the health care needs of individuals from diverse cultural and ethnic backgrounds and deliver appropriate care, nurses must be aware of, and sensitive to, cultural issues and differences among various groups of patients. This study was guided by the conceptualization of cultural competence as having four components: cultural awareness (affective dimension), cultural sensitivity (attitudinal dimension), cultural knowledge (cognitive dimension), and cultural skills (behavioral dimension) (Rew, Becker, Cookston, Khosropour, & Martinez, 2003). In choosing strategies for developing cultural competence that fit into otherwise full nursing programs and creating mechanisms to evaluate the results, nurse educators have been guided by the document “Cultural Competency in Baccalaureate Nursing Education”

AlExAndRA A. gARCIA

(American Academy of Colleges of Nurses [AACN], 2008a) and its accompanying toolkit of resources (AACN, 2008b). The toolkit offers an extensive list of integrative classroom and clinical learning strategies, references, and web resources to foster cultural competency. The National League for Nursing toolkit on innovations in curriculum design (2011) also offers suggested strategies to enhance development of cultural competence. The Guadalajara experience described in this article illustrates the use of some of the suggestions found in these toolkits, for example, offering an immersion experience, participating in community activities, arranging field trips, and encouraging students to keep a journal. Study abroad is one way to broaden American college students’ worldview, but nursing curricula are sequential and crowded with essential content and practice competencies; thus, nursing students rarely have the luxury of spending a semester abroad to experience another culture. Depending on the location of the nursing program and available clinical experiences, students may be exposed to patients from diverse cultures, but such experiences are random. Although a recent search cited the existence of more than 220 study abroad programs for nursing students (Nursing Study Abroad, 2012), many nursing students are unaware of opportunities outside the prescribed curriculum. Previous studies support the value of international experiences for preparing nursing students to incorporate cultural competence into clinical practice (Evanson & Zust, 2006; Wood & Atkins, 2006). Studies have demonstrated positive short-term outcomes, including gains in substantive knowledge, changes in values, improved communication skills, and the development of culturally focused practice (Caffrey, Neander, Markle, & Stewart, 2005; Evanson & Zust; Ryan, Twibell, Bighman, & Bennett, 2000; Wood & Atkins). In Evanson and Zust’s study, nursing students showed long-term benefits in the form of increased understanding as well as uncomfortable, lingering, unsettled feelings resulting from the awareness of inequities in resources. The current study combines

RESEARCH

ABSTRACT

There is little debate about the importance of preparing nursing graduates to provide culturally sensitive care to an increas-

ingly diverse society. However, it is difficult for nurse educators to fit learning experiences that help students develop cultural competence into already full programs and create mechanisms to evaluate the results. This article describes a study to assess the impact of a study abroad program on developing cultural competence, including cultural awareness, sensitivity, knowledge, and skills. Results from the Cultural Awareness Survey, reflective journals, and interviews illustrate how the study abroad experience influenced the development of components of cultural competence and might influence clinical practice. Results suggest effective teaching strategies to assist students in becoming culturally competent are experiential in nature and include role modeling, reflective activities, and group discussion.

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