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doi:10.1016/j.ec

Clinical Simulation in Nursing (2012) 8, e341-e346

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Featured Article

A Bi-national Simulation Study to ImproveCultural Awareness in Nursing Students

Sheila Grossman, PhD, APRN-BC, FNPa,*, Diana Mager, DNP, RN-Cb,Helene M. Opheim, MA, RNc, Astrid Torbjornsen, MSc, RNc

aFamily Nurse Practitioner Track Coordinator, Fairfield University School of Nursing, Fairfield, CT 06824, USAbDirector of the Robin Kanarek Learning Resource Center, Fairfield University School of Nursing, Fairfield, CT 06824, USAcOslo University College School of Nursing, Oslo, Norway

KEYWORDScultural competency;cultural awareness;Transcultural SelfEfficacy Tool;

undergraduate nursingstudents;

multi-national studies;bi-national;simulation

ng author: sgrossman@f

e front matter � 2012 Int

ns.2011.01.004

student cultural awareness using simulation technology. Students practiced skills including culturalassessment using simulated scenarios. Scenarios were developed by project faculty, and depicted

Abstract: A School of Nursing in North America and one in Norway collaborated in examining

one patient with respiratory failure and the other with a systemic infectious process. While bothschools used the same scenarios, the Norwegians specifically tailored their scenario around Muslimand Somalian patients/families while the Americans focused on Muslim and Italian/Catholic patients/families. Presimulation, both groups had the lowest score with perceived skill in obtaining culturaldata. Individual paired t tests found statistically significantly improved scores in cultural awareness us-ing The Transcultural Self-Efficacy Tool after practicing with simulation scenarios focused on culturaldifferences. Students perceived increased practice with simulated patients improved confidence in cul-tural awareness. The two cohorts in this study showed an improvement in their cultural awareness afterparticipation in a simulation experience. This finding suggests that simulation may be a useful teachingmethodology for use in American and international nursing schools. A Cultural Assessment Checklistwas developed to assist students in collecting cultural assessment data on their simulated and realpatients. Collaboration between the faculties of the two countries continues and will focus on graduatestudent education including simulation pedagogy in the future.

Cite this article:Grossman, S., Mager, D., Opheim, H. M., & Torbjornsen, A. (2012, October). A bi-national simulationstudy to improve cultural awareness in nursing students. Clinical Simulation in Nursing, 8(8), e341-e346. doi:10.1016/j.ecns.2011.01.004

� 2012 International Nursing Association for Clinical Simulation and Learning. Published by ElsevierInc. All rights reserved.

Health care providers must provide quality care todiverse populations with varying cultural characteristics(Joint Commission, 2008), and need to be educated to pro-vide safe care to all (Institute of Medicine, 2002; Qualityand Safety Education for Nurses, 2010). An ability to

airfield.edu (S. Grossman).

ernational Nursing Association for Clinica

care for the whole patient with an awareness of their cul-tural needs is part of a communication skill that can bepracticed by nursing students during simulation. Indeed,the Accreditation Council for Graduate Medical Educationhas suggested that communication is equal in importance toclinical knowledge or acumen (Calhoun, Rider, Meyer,Lamiani, & Truog, 2009).

l Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Simulation Technology Impacts Cultural Awareness e342

The purpose of this binational study was to evaluate theeffect of using two medicalesurgical simulation scenariosincorporating cultural content on two groups of nursingstudents, one in Norway and one in the United States. Thispilot study was part of the Norwegian Centre forInternational Cooperation, which paired senior nursingstudents in a northeastern American School of Nursingwith students from an Oslo, Norway School of Nursing.

The project began with an idea that two schools fromdifferent parts of the world could produce a useful projectwith outcomes valuable to both. Faculty from Oslo andFairfield agreed to collaborate and work on teachingcultural awareness with simulation pedagogy because ofsparse literature being identified regarding using simulationto teach cultural awareness. Using a tool that capturesstudents’ perceptions of cultural awareness, the Transcul-tural Self Efficacy Tool (TSET) (Jeffreys, 2000), wemeasured students’ self-efficacy perceptions for performingcognitive (knowledge), practical (interview), and affective(attitudes, values, and beliefs) transcultural nursing skills.

Background and Literature Review

Importance of Cultural Awareness

For the purpose of this study, ‘‘cultural awareness’’ wasdefined as being aware of one’s own thoughts and feelingsand having the ability to reflect on how these affect one’sinteractions with others (Giger & Davidhizar, 2007).Reeves and Fogg (2006) found that students had weak cul-tural knowledge and many had little exposure to cultural di-versity, so that when they were assigned to diverse patients,they had difficulty assessing cultural needs. The literaturealso suggested that lack of cultural knowledge can causemiscommunication between patient and nurse (Momeni,Jirwe, & Emami, 2008). Despite the need for teachingstudents how to be culturally aware, historically it hasbeen difficult to integrate this training into the curricula,and many programs often focus on teaching culturalcompetency rather than cultural awareness.

Methods of Teaching Cultural Awareness

Gebru and Willman (2010) suggested that with the influx ofimmigrant nurses since the 1990s, the teaching of culturallycompetent care to nursing students is necessary. Nursingprograms have attempted to teach culturally competentcare through use of ‘‘free-standing cultural courses, immer-sion, and international experiences’’ (Kardong-Edgren &Campinha-Bacote, 2008). After using a variety of methods(use of theory/model; integrated approach; free-standingculture course) to teach cultural competency to senior nurs-ing students, Kardong-Edgren and Campinha-Bacote(2008) evaluated student level of cultural competency.

pp e341-

Findings indicated that despite the method of teachingcultural competency, students scored in the ‘‘culturallyaware,’’ not the ‘‘culturally competent’’ range. Kardong-Edgren, Cason, Brennan, et al. (2010) found in their studyof 515 graduating students from six different BSN pro-grams in the United States that the average student scoredin the culturally aware range using the same standard cul-tural competency test. Each of the programs used a differentpedagogy for teaching cultural competency and generatedsimilar outcomes; however, none used simulation.

Using Simulation to Teach Cultural Awareness

Simulation in nursing curricula has been increasing exponen-tially over the past several years and is recognized asa beneficial teaching method (Jeffries, 2007; Kaakinen &Arwood, 2009). Simulations can be used as a ‘‘clinical en-hancement, substitute, or adjunct’’ (Jeffries, 2008) and allowstudents to practice in risk-free environments (Jeffries, 2008).By enhancing simulations to include culturally significant fac-tors, students can get hands-on experience in the laboratory set-ting that they may not get to experience in the clinical setting.According to Haas, Seckman, and Rea (2010), human patientsimulators canbeused to incorporate cultural diversity into sce-narios by setting the stagewith culturally specific names, dress,visual cues (written materials in other languages), and otherenhancements, such as interpreter services. By participatingin activities that include cultural components and its impacton health, students should improve their ability to care for di-verse patients (Rutledge, Garzon, Scott, & Karlowics, 2004).Rutledgeet al. (2004) designed simulated cases using standard-ized patients to incorporate cultural situations into patient care,with the goal of improved cultural skills of nurse practitionerstudents. Much more research will be needed in this area byblending the use of simulation pedagogy with the skill of mas-tering cultural assessment and measuring outcomes.

Research Questions

The following research questions were developed: (a) Doesthe use of simulation with cultural content have an effect onstudents’ cultural awareness based on TSET scores? (b)Whatis the difference between Norwegian and American students’perceived cultural awareness based on TSET scores postsi-mulation? (c) How doNorwegian andAmerican students per-ceive the meaning of ‘‘cultural awareness’’? (d) How doNorwegian andAmerican students perceive themost effectiveways for them to increase their own cultural awareness?

Methodology

Both of the universities’ institutional review boards deter-mined that the study met the exempt category. Written in-formed consent was obtained from each student. Faculty

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Figure 1 Simulation study design.

Simulation Technology Impacts Cultural Awareness e343

developed two scenarios focused on cultural aspects of pa-tient care (Figure 1 and Appendices A and B). While eachschool used identical scenarios in a senior medicalesurgi-cal course, the cultural focus varied based on which cul-tures students had identified as a learning need during thefirst class discussion. Norwegians requested more assign-ments incorporating Somalian culture because they wereseeing more patients from Somalia for clinical care anddid not feel they had experience to care for them. BothAmericans and Norwegians asked for more exposure toworking with Muslims and stated that they were caringfor increasing numbers of Muslims in their clinical rota-tions and did not feel prepared. Americans identifieda learning need concerning Italian Catholics because

pp e341-

many had not previously worked with Italian patients,which were a large population in long-term care facilities.

During the first week of classes, students completeda demographic form, a pretest, and two open-ended questionsdesigned to assess their perception and ideas to increase theircultural awareness. Each student participated in the twosimulation scenarios during the semester, followed by a 20-minute debriefing sessionwith the course instructor. Studentscompleted a posttest during the last class of the semester.

Sample

All students in the American senior class (n ¼ 48) and 75%of Norwegian seniors (n ¼ 25) volunteered to participate in

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Table 1 Demographics of the Sample

Norwegian Seniors American Seniors

Simulation Technology Impacts Cultural Awareness e344

the study which equaled a total sample of 73. Students’responses were coded and described as aggregate data toprotect anonymity.

(n ¼ 25) (n ¼ 48)

Age, years18e21 0 79% (38)22e28 60% (15) 21% (10)29e35 20% (5) 036e40 4% (1) 041e50 16% (4) 0

EthnicityNorwegian 84% (21) 0American 0 92% (44)Hispanic 0 4% (2)Other European 8% (2) 0African 0 2% (1)Russian 4% (1) 0Other 4% (1) 2% (1)

Religion

Instrumentation

The TSET (Jeffreys, 2000) was used to measure students’self-efficacy perceptions for performing cognitive, practi-cal, and affective transcultural nursing skills. The 83-itemtool used a 10-point Likert scale response ranging fromnot confident (0) to totally confident (10). The tool takesapproximately 25 minutes to complete and is composedof the three subscale scores and a total perceived culturalawareness score. Use of the tool in previous studiesproduced Cronbach’s alpha reliability coefficients rangingfrom 0.92 to 0.98 and both construct and content validity(Jeffreys, 2000).

Catholic 24% (6) 92% (44)Protestant 16% (4) 6% (3)Muslim 16% (4) 0Other 4% (1) 0Agnostic 40% (10) 2% (1)

Practice religionRegularly 20% (5) 67% (32)Occasionally 44% (11) 6% (3)Not at all 36% (8) 27% (13)

GenderMale 20% (5) 4% (2)Female 80% (20) 96% (46)

Marital statusSingle 48% (12) 100% (48)Married 48% (12) 0Divorced 4% (1) 0

Findings

Table 1 describes the student demographics. Students fromNorway were older than American students, the majority ofparticipants were from their own country’s ethnic group,and the Norwegian group was more diverse regarding reli-gious grouping. In addition, 33% of both groups did notpractice their religion, the majority of all participantswere female, and all of the American seniors were singlewhile half of the Norwegians were single.

Descriptive statistics and paired t tests were used to an-alyze the data. The TSET data were scored to determineself-efficacy strength and level. Table 2 indicates the statis-tically significant differences in the three TSET scales andtotal calculation of self-efficacy strength scores. No stu-dents selected a ‘‘1’’ or ‘‘2’’ response on any of the 83 itemsduring pre- or posttesting. Rather, students chose a ‘‘3’’through ‘‘10’’ response consistently equating with a moder-ate to high self-efficacy level.

There were no missing responses in the Americansample, but four of the Norwegian students did notcomplete posttests. Table 2 presents the results that illus-trate that the Americans produced statistically significantdifferences when pretest scores were compared to posttestscores for each subscale and the total score (p < .01).The Norwegian students’ scores also had statistically sig-nificant differences in all posttest scores except for the‘‘Practical’’ subscale. In this situation, the use of culturalcontent during simulation increased students’ perceptionsof cultural awareness based on scores using the TSET.

American students showed the most difference betweentheir scores with the ‘‘Practical’’ and ‘‘Total’’ subscaleposttest scores, but the differences in these scores were notstatistically significant. Norwegian students had higherpretest scores than American students, although there wasno statistically significant difference between groups.

pp e341-

Americans had higher posttest scores than the Norwegianson all subscales and on the total score. Both groups’ scoreson the ‘‘Practical’’ subscale posttest were lower than the‘‘Cognitive’’ and ‘‘Affective’’ subscale posttest scores.There were differences between American and Norwegianstudents’ TSET scores, but the differences were not statis-tically significant.

The qualitative data were analyzed by identifying majorthemes from students’ responses regarding their perceptionof cultural awareness and the most effective ways to in-crease their cultural awareness. Norwegian and Americanstudents’ responses were remarkably similar regardingwhat constituted cultural awareness with the followingthemes most commonly identified: awareness/knowledgeabout people’s background; identification of more thanjust ethnicity when performing cultural assessment;awareness that people are different; and the ability tocommunicate to people with different beliefs/values. WhileNorwegian students emphasized the importance of beingmultilingual, Americans focused on the ability to commu-nicate verbally and nonverbally in order to facilitate patientunderstanding. While Norwegians are perhaps more likely

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Table 3 Cultural Assessment Checklist

1. CommunicationdLanguages spoken and understood?English speaking? Is English your second language?

2. Family involvementdExtent? Partner? Friends? Who makesthe decisions?

3. EthnicitydForeign-born? Visiting from outside of USA?Specifics impacting health? Beliefs about health?Community involvement?

4. Socioeconomic statusdSelf-paying, insurance, government

Table 2 Pre- and Posttest Perceived Cultural Awareness Scores

Norwegian Seniors American Seniors

Pretest Posttest Pretest Posttest

Cognitive score 6.67 � 1.4 7.37 � 1.13 6.09 � 1.21 7.76 � 0.88t ¼ 2.00446; p < .02 t ¼ 10.99319; p < .01

Practical score 6.81 � 1.27 7.16 � 1.22 5.96 � 1.31 7.74 � 0.98t ¼ 1.47625; p < .07 t ¼ 10.28576; p < .01

Affective score 7.42 � 1.18 7.76 � 1.03 7.56 � 1.16 8.65 � 0.77t ¼ 2.31066; p < .02 t ¼ 9.001456; p < .01

Total score 20.92 � 3.0 22.30 � 3.13 19.62 � 2.86 24.19 � 2.1t ¼ 2.33617; p < .02 t ¼ 14.29885; p < .01

Note. Cognitive score ¼ perceived knowledge; practical score ¼ perceived interview skills; affective score ¼ attitudes, beliefs, and values.

Simulation Technology Impacts Cultural Awareness e345

to be multilingual given their country size and proximity toother countries, Americans also felt communication, bothverbally and/or nonverbally, to be a high priority skill.Americans also recommended the need for a checklist touse when conducting cultural assessments, perhaps becauseAmericans tend to be goal focused. Both groups identifiedglobalization, traveling, immersing oneself in other geo-graphic areas, and interacting with different people as themajor themes important to increasing cultural awareness.

program? Discharge?5. ReligiondPracticing? Beliefs? Understanding of death?

Spirituality? Support from church, temple, etc.?6. SexualitydBeliefs? Significant other?7. Work culturedHow much impact on the individual’s health?8. OtherdRestrictions on diet or medical treatment?

Discussion

This study revealed that teaching cultural content withsimulation pedagogy can influence senior baccalaureatenursing students’ perceived cultural awareness as measuredby the TSET. It is not known what factors contributed to thedifferences in scores between American and Norwegianstudents, but one would surmise that Norwegians travel tomore countries than Americans. However, Americans, de-pending on whether they are living in an urban or ruralarea, may be exposed to more diverse individuals. This isan area ripe for more research.

All students agreed that practicing cultural assessmentskills during the simulation improved their ability to performa cultural assessment. Based on student request duringdebriefing for the first simulation, faculty created a pilotCultural Assessment Checklist (Table 3) for students to use inthe next simulation and clinically. A discussionwas heldwithstudents prior to the second scenario, to emphasize that cul-ture included more than ethnicity and race (Appendix B, in-fectious disease).More research is needed to determine if thistool helps students to obtain cultural assessment data. Havingexperiential learning greatly improves confidence in one’sability to perform specific skills and validates further the im-portance of students having simulation practice caring formulticultural patients (Kolb, 1984).

This pilot study should be replicated by faculty involvedin simulation pedagogy. Findings from this study suggestimprovement in students’ perceived cultural awareness. Af-ter participating in two simulations focused on clinical

pp e341-

skills, decision-making, communication, and cultural as-pects of care, there was improvement in student perceivedcognitive, practical, and affective cultural assessment skills.Students had not participated in other complex scenariosimulations during their education. Using one’s own expe-riential background of working with diverse patients, andthe pilot Cultural Assessment Checklist as a bedside cultur-ally focused resource, this study should be replicated bydeveloping scenarios with cultural content and use of mou-lage. The use of props, such as clothing, wigs, ethnic-oriented jewelry, language, and mannerisms can creatediversity with any mannequin or role player. Future studiesfocused on learning strategies regarding cultural awarenessduring simulation are needed for undergraduate and gradu-ate programs.

Limitations

Limitations in this pilot study include the use of a conve-nience sample, small sample size (n ¼ 73), a predominantlyCatholic American cohort, and no use of a control group.All students were afforded the same opportunity to partici-pate in the simulated learning experiences even if they de-clined participation in the study.

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Conclusion

This study was the first step in an international initiative toexamine how simulation with cultural content can influenceperceived cultural awareness. Simulation technology usingscenarios with embedded cultural variables were used andsuccessfully increased perceived cultural awareness scoresfor this sample. Further research should be conducted withboth subjective and objective evaluative measures todetermine if cultural awareness components are influencedby simulation. Likewise, it is important to study ifexperience and knowledge gained from participating insimulated scenarios in nursing education will be carriedover to the practice setting.

Acknowledgements

The authors thank Dr. Jeffreys for giving permission to usethe TSET, the Norwegian Centre for International Co-operation for funding this project, and Suzanne Bancel,MA, Oslo University College for her assistance. TheNorwegian Centre for International Cooperation in HigherEducation Funding Partnership funded this project.

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