Lisa M.
Easterby, DNP, RN, CNE, Barbara Siebert, DNP, CRNP, FNP-BC,
Cynthia J. Woodfield, DNP, RN, CNE, Kathy Holloway, DNP, RN,
Pamela Gilbert, DNP, CHPN, CMS, RN, Richard Zoucha, PhD, APRN EC, CTN-A
and Melanie W. Turk, PhD, RN
A Transcultural Immersion Experience:
Implications for Nursing Education
Abstract: This article is a synthesis and interpretation of
field work from a transcultural nursing immersion experience
in Italy. The main focus of the field work was to understand
the cultural infiuences on health systems with interpretations
related to nursing education. The mafor recommendations of
the paper include strategies for nurse educators to promote
cultural competence throughout curricula by providing students
with meaningful clinical experiences and addressing healthcare
needs of diverse populations in the U.S. and abroad.
Key Words: Transcultural Nursing, Immersion Experience,
Nursing Education, Nursing
Introduction
A s globalization of people around the world increases,
there is subsequent growth in culturally diverse
populations living in the U.S. who require health
care (Smith & Curry, 2011). Therefore, nurses in the United
States (U.S.) nurses need to be skilled at providing culturally
congruent care to a variety of people. The National League for
Nursing Accreditation Commission (NLNAC) mandates that
schools of nursing include "cultural, ethnic, and socially diverse
concepts and may also include experiences from regional,
national, or global perspectives" (NLNAC, 2008, p. 94). The
American Association of Colleges of Nursing (AACN), as cited
in Sanner, et al (Sanner, Baldwin, Cannella, & Parker, 2010)
has identified cultural sensitivity as an essential curricular
component in the preparation of new nurses. Moreover,
the Institute of Medicine's Core Competencies mandate
healthcare providers, "identify, respect, and care about patients'
differences, values, preferences, and expressed needs..."
(Institute of'Medicine, 2003, p. 45). Schools of nursing must
strive to provide students with opportunities to develop and
refine these important skills. Students may feel unconrfortable
or stressed while engaging in clinical experiences within
culturally unfamiliar environments; however, this may be
an effective strategy to promote cultural sensitivity. Such
experiences evoke feelings of vulnerability and allow students
to reflect on the perspectives of diverse patients accessing care
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within the U.S. healthcare system. A trip abroad by nurse
educators serves as the basis for this article. The week-long
immersion in Rome, Italy helped the educators gain insight
into the cultural differences and influences of culture on health
and healthcare practices. The following analysis and synthesis
of field observations and experiences highlights the need to
prepare all nursing students to be culturally competent by
assimilating experiences with diverse populations into nursing
curricula.
THE IMMERSION EXPERIENCE
During the cultural immersion experience, nurse
educators interacted with Italians while conducting daily
business, touring the city, and visiting health care facilities.
The educators explored two hospitals in Rome and
communicated with Italian health care professionals to leam
about their healthcare system. Each educator kept detailed
field notes of observations and experiences, then came together
to discuss the observations and identify common themes.
Analysis of the collective field notes revealed five prevalent
themes and implications for nursing education in the United
States.
The themes identified were:
1. Communication
2. Transportation
3. Culinary Practices
4. Religion
5. F*ublic Environment
Communication
The inability to communicate effectively due to language
barriers may lead to feelings of vulnerability and frustration
for patients and healthcare providers alike. This can result
in miscommunication regarding patients' health conditions,
treatments, medications and important directives. Health care
providers may find it difficult to obtain an accurate health
history, address specific health concerns, obtain informed
consent for medical and surgical treatments or provide
important patient education. "Language difficulties and
nurses' poor knowledge about culture..." have been found to
be major barriers to culturally sensitive practice (Ruddock &
Fall 2012
de Sales, 2007, p. 363). Ail of the participants in the immersion
experience expressed feeling vulnerable in not being able to speak
or understand the Italian language when seeking directions,
purchasing items, ordering food or participating in conversations.
The educators felt most vulnerable when asking for directions. On
the first night in Rome, it took over 2 hours to return to the place
of residence ñ-om the city because the language barrier inhibited
both the educators who spoke only English and the Italians,
who did not speak English, from understanding each other.
Therefore, the ability to obtain clear directions was significantly
hampered. However, it was noted that most business employees
spoke several languages in order to conduct trade with customers
from foreign countries. The educators also found it difficult to
order food in some restaurants, because the waiters did not speak
English. One educator resorted to using her handheld device,
which translated English words into Italian so that the waiter
could understand what she wanted. It became clear to all that
communication is a critical element for assimilating into other
cultures.
Transportation
Transportation was noted to be remarkably different from
the modes of travel used in the U.S. In addition to walking, many
Romans utilized public transportation or rode motorcycles and
scooters. From the perspective of the immersion participants,
utilizing the public bus system was complicated and time
consuming, which might present a number of challenges for
Italians needing healthcare. For example, there was only one
bus route that traveled past the residence where the educators
stayed. The educators typically had to wait at least 25 minutes for
the bus to arrive. Another problem was that the Metro and buses
stopped running in the late evening, making time limitations an
obstacle for people who wished to enjoy an evening in the city.
From the perspective of the group, people who are physically
handicapped, medically debilitated, having to travel with young
children, or financially limited may find public transportation to
be a significant barrier in reaching healthcare appointments in a
timely and efficient manner. Some of these same public access
obstacles are also apparent in the United States, but the law
requires public transportation vehicles to be handicap accessible.
The U.S. government subsidizes transportation services to health
care appointments for eligible citizens who are medically and
physically challenged.
Culinary Practices
Overall, the immersion participants found the Italian diet to
be varied and well-balanced. The portions are smaller than those
served in the U.S., with a greater emphasis on fresh, homemade,
non-processed foods. Restaurant foods were salty, which can
contribute to heart disease, hypertension and edema. Several
times the participants experienced edema in their legs and feet
after a full day of walking, eating in restaurants and coping with
extreme heat. Pasta is a mainstay in the Italian diet and is served
both at lunch and dinner as a first course. Bottled water and wine
are served with lunch and dinner, and beverages are served cool,
not cold. This was a difficult adjustment for those who enjoyed ice
in their beverages. Breakfast generally consists of coffee and milk
with a simple assortment of proteins and carbohydrates including
meat, bread and cereal. Espresso is served in small quantities
and enjoyed throughout the day. These are not typical meals
in the U.S. so nurses must be cognizant of potential differences
in dietary patterns due to cultural practices when planning
meals. Efforts should be made to accommodate patients' dietary
preferences. Finally, meals are a relaxed time for camaraderie
with family and friends. This practice is dramatically different
from the family in the U.S. who often does not eat together and
hurries through meals.
Religion
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The primary religion in Italy is Roman Catholicism, and
it has a strong influence on Italian culture. The educators
observed numerous orders of nuns and priests while
traveling through the city. The care delivered to patients
is consistent with the ethical and moral directives inherent
in the Catholic faith. In the U.S., hospitals may be either
secular or affiliated with a particular faith, but whether they
are sponsored by Catholic, Christian or Jewish organizations,
overt religious practices are tempered so as not to offend
individuals of other faiths. During their visit to the Tiber
Hospital in Rome, the educators observed sculptures, frescos
and statues of various Catholic saints. For example, the
architectural design of one of the hospital conference rooms
still retained the altar, ceiling frescos and sculptures from its
former use as a basilica. It is important for nurses to assess
the role that religion or spirituality plays in patients' lives
and individual healthcare decisions so their spiritual needs
are addressed.
Public Environment
Observation of the Italian culture and environment
revealed practices and behaviors that may relate to
healthcare. Smoking is prevalent among both genders
of all ages and is acceptable in public areas, including
designated areas in hospitals. Smoking does not appear to
be perceived as the health risk that it is seen to be in the U.S.
Drinking alcoholic beverages in public was also frequently
observed even among teenagers. Smoking and drinking
alcohol in excess are well-documented health risks. The
Italians also appear to be comfortable with their sexuality,
expressing their affection in public areas, and accepting
alternative lifestyles. The group observed a number of
couples fervently kissing and showing their affection on
buses, on the streets and in the park. Many people from the
U.S. are not as tolerant of or comfortable with displaying or
observing these behaviors in public. In order to be culturally
congruent, nurses must accept differences among people
without being judgmental, treating all individuals with
respect and dignity. Another common public occtirrence
is the presence of street beggars and peddlers. Beggars sat
on the ground outside of businesses with puppies or played
music in hopes of earning donations. Peddlers brazenly
approached tourists, insisting they buy roses, parasols or
stuffed animals.
The above observations and comparisons raised the
nurse educators' awareness of the differences among people
and cultures. The themes identified through the immersion
experience can serve as a guide for educating students
about planning nursing care that is culturally competent and
individualized. It is critical that nursing faculty address
these issues and prepare students to acquire the skills needed
to become culturally competent caregivers. Instilling
nursing students with the value of considering cultural and
spiritual needs of patients is the first step towards developing
cultural competence. It is imperative that nursing educators
provide opportunities for students to develop these
skills. The authors have synthesized and interpreted their
observations to articulate implications for nursing education
and make recommendations for curriculum development and
implementation.
IMPLICATIONS FOR NURSING EDUCATION
Demographics in the U.S. are shifting decidedly
toward increased diversity, making it essential for nursing
professionals to meet the needs of culturally diverse
populations. The U.S. Department of State estimates
that the present cultural minorities will be the cultural
majorities by 2042 (U.S. Census Bureau, 2007). According
to the Sullivan Commission Report on Diversity, patient
Fall 2012
 populations are becoming more diverse while the practicing
nursing population remains primarily of Caucasian descent (The
Sullivan Commission, 2004). This lack of diversity in the nursing
workforce underscores the importance of providing nursing
students with a foundation for providing culturally sensitive care.
Unfortunately, nursing education is inconsistent with
the presentation of cultural competence and its important role
in improved patient outcomes relative to these vulnerable
populations. Therefore, the challenge for nursing educators is to
determine how cultural content links didactic courses to clinical
practice While some schools of nursing integrate transcultural
nursing concepts into both lecture content and clinical situations,
others offer separate courses in transcultura] nursing that include
an international nursing experience (Smith & Curry, 2011). The
literature suggests that institutions that use active educational
strategies are deliberately providing exposure to culturally diverse
populations to ensure cultural understanding is achieved (Sanner
et al, 2010). Implementing a curriculum that prepares graduating
nursing students to become culturally competent requires the
commitment of faculty and support of academic administration.
Following the cultural immersion experiences, the authors
support the inclusion of cultural competence content throughout
all nursing curricula, including both didactic and clinical
education.
Cultural competence is an ongoing process requiring more
than formal knowledge (Caffrey, Neander, Markle, & Steward,
2005). Development of cultural competence in students and
faculty occurs best in environments supportive of diversity and
facilitated by guided clinical experiences (American Association
of Colleges of Nursing, 2008). Threading cultural competence
throughout a nursing curriculum and reinforcing methods that
meet the needs of diverse populations allows students to build
on previously learned clinical skills. Eaculty with essential
knowledge and expertise in providing care to culturally diverse
patients can develop relevant diverse learning experiences that
are unique to these populations. To assist faculty in implementing
curricular changes that include cultural competencies, the AACN
website offers "Cultural Competency Tool Kit," which provides
academic resources, exemplars, and teaching learning activities
to facilitate integration of cultural competency principles into
nursing courses (American Association of Colleges of Nursing,
2008).
To introduce the topic of culturally congruent care,
beginning nursing students should be guided to explore their
self-perceived knowledge of diversity, attitudes regarding
vulnerable populations, and skills they may need to provide
healthcare to underserved populations. Faculty can facilitate
reflection and exploration of each student's health care beliefs,
biases, prejudices and assumptions regarding practices of
different cultural groups. Eaculty can also provide students with
guided clinical experiences by caring for patients from diverse
and vulnerable populations whenever possible, and by placing
students in clinical settings with nurse preceptors from diverse
backgrounds (Amerson, 2010).
Augmenting nursing students' understanding of diversity
and cultural competence in practice is an important facet of their
education and can be implemented throughout any curriculum
by engaging learners in integrative learning activities using
classroom simulation. Drawing on culturally diverse case studies
with application of cultural competence models is a teaching
strategy faculty can use to emphasize specific cultural preferences
of diverse populations. After identifying healthcare disparities
within the case study, cultural care plans that incorporate unique
healthcare preferences can be developed, implemented, and
evaluated for effectiveness. Integrating best practices and
evidence-based care, within the context of culturally competent
care, is imperative. Engaging students in role play activity to
simulate patient advocacy can improve students' awareness of the
important role they play in ensuring vulnerable populations are
The ABNF Journal
cared for effectively (American Association of Colleges of
Nursing, 2008).
Transcultural nursing courses with an international
clinical experience can enhance cultural sensitivity.
Through global service learning experiences, students
have demonstrated increased self-awareness of their own
cultural values, gained self-confidence, and improved
their communication skills in the clinical setting (Smith &
Curry, 2011). However, these educational opportunities are
typically offered only in baccalaureate rather than associate
degree or diploma nursing programs. According to the U.S.
Department of Health and Human Service (DHHS) national
sample survey of registered nurses' educational preparation,
the majority of nurses were prepared at the associate degree
or diploma level (DHHS, 2008). Therefore, the majority
of new graduate nurses has not participated in global
service learning experiences and is not adequately prepared
to provide culturally competent care. When possible,
nursing students should be encouraged to participate in
a cultural immersion experience. Exploring culturally
specific health practices first hand provides an authentic,
invaluable experience for future nurses. As participants
in a cultural immersion experience, the authors visited a
private and a public health care facility, interacted with
Italian physicians and nurses regarding the health care in
Italy, and gained a meaningful perspective of transcultural
healthcare. While these direct experiences produced feelings
of vulnerability due to communication barriers and other
cultural differences, the authors gained a new perspective
for the need to provide culturally competent care and
to prepare future nurses to effectively care for diverse
populations of patients. According to the AACN (2008),
nurses should have increased awareness of historical,
political and socioeconomic factors that determine health
and disease in patient populations. Through cultural
immersion experiences or classroom simulations, students
can gain important insights concerning the need to attain
cultural competence and recognize how deficits in this area
can perpetuate healthcare disparities.
Glohal Education within the U.S.
Although global health education and international
service-learning experiences have become an important
addition to undergraduate nursing education, the cost
of such experiences is often prohibitive, denying some
students the ability to participate. The increasing diversity
of the U.S. population, through the influx of immigrants
and refugees, can provide nursing students with excellent
opportunities to acquire the skills needed to think and
act globally without the cost of distant travel. Due to
many countries currently experiencing war, economic or
governmental upheaval, identifying cultural experiences
from regional and national communities may be a safer
option (Lenz & Wamer, 2010). Many immigrants and
refugees suffer health disparities due to language and
cultural differences, and receive health services in
community-based settings where health care is easily
accessible (Lenz & Wamer, 2010). Providing students
with hands-on, transcultural clinical experiences within
these community-based settings presents opportunities
for all learners to participate in rich, cultural immersion
experiences while working with diverse and vulnerable
populations within the U.S. (Amerson, 2010). Creating
partnerships with community health departments, local
medical centers and other health care agencies involved in
outreach initiatives addressing access to care for vulnerable
populations can provide students with valuable clinical
insights into the complex healthcare issues affecting these
populations.
Fall 2012
 According to Amerson (2010), community-based, service-
learning requires students to work in state-side communities
addressing health issues affecting specific cultural groups and
applying population-based interventions. Special emphasis is
placed on working with culturally diverse, at-risk populations,
including members of minority groups, the homeless, low-
income school children, victims of domestic violence, and
single-parent families. With community based service-learning,
students become aware of health care issues faced by clients
of different backgrounds and cultures as they learn to provide
culturally appropriate care utilizing resources found within the
U.S. healthcare system (Amerson, 2010). In order to prepare
culturally competent beginning nurses for entry into the
workforce, it is incumbent on nursing program administrators
and faculty to address the following:
• Committing to making cultural competency a priority in
nursing curricula (Pumell, 2007)
• Infusing cultural competency content throughout nursing
programs focusing on attitudes, skills and knowledge
(Campinha-Bacote, 2008)
• Recognizing that a lack of consensus exists on what
should be taught in nursing curricula regarding cultural
competency, lack of standards, limited and inconsistent
specialty courses on culture, and how to link cultural
competency theory into meaningful clinical practice
experiences for alLstudents (Lipson & DeSantis, 2007)
• Increasing cultural competency of students by
offering preceptorship experiences with culturally
diverse preceptors who can demonstrate both cultural
competency and reveal barriers to care (Amerson, 2010)
• Establishing portfolio documentation of culturally
diverse practice experiences obtained by students
throughout the program (The Sullivan Commission,
2004)
CONCLUSION
This cultural immersion experience, with the subsequent
analysis and synthesis of observations and themes, provided
the authors with a deeper appreciation for cultural diversity,
the potential impact of health disparities, and issues of social
injustice in the U.S. The newly acquired insights about
cultural diversity and vulnerable populations gained from this
immersion experience, has prompted the authors to explore
and promote the use of active teaching strategies to present
transcultural content to students in the didactic and clinical
setting. The challenge for nursing faculty is to facilitate
transcultural learning opportunities within culturally diverse and
vulnerable populations present in communities throughout the
U.S. Nursing students who are prepared to care for culturally
diverse populations will help to facilitate access to preventative,
primary, health maintenance, and acute/chronic health care
services for these individuals and families.
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Lisa M. Easterby, DNP, RN, CNE, is the Dean of Our Lady
of Lourdes School of Nursing, 1600 Haddon Avenue, Camden,
NJ 08103, in Camden, NJ. Barbara Siebert, DNP, CRNP,
FNP-BC, is the Associate Dean of Student Affairs at Our Lady
of Lourdes School of Nursing in Camden, New Jersey. Cynthia
J. Woodfield, DNP, RN, CNE, is the Director of Nursing at
Defiance College in Defiance, Ohio.. Kathy Holloway, DNP,
RN, is a Lead Nursing Faculty in the RN to BSN Completion
Program at Franklin University in Columbus, Ohio. Pamela
Gilbert, DNP,RN CHPN, CMS,, 1 Birchwood Drive, Oneonta,
NY 13820. Richard Zoucha, PhD, APRN-BC, CTN-A, is
an Associate Professor at Duquesne University School of
Nursing and coordinates the post master's certificate program
in Transcultural Nursing and is also a Certified Transcultural
Nurse. Melanie T\irk, PhD, RN, is an Associate Professor
at Duquesne University School of Nursing and her research
interests relate to cardiovascular risk reduction among minority
populations via weight loss and weight maintenance.
Fall 2012
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