AN EVALUATION OF THE IMPACT OF AN INTERCULTURAL SERVICE LEARNING EXPERIENCE ON THE DEVELOPMENT OF TRANSCULTURAL SELF-EFFICACY OF NURSING STUDENTS Lynn Marie Schmidt Submitted to the faculty of the University Graduate School in partial fulfillment of the requirements for the degree Doctor of Philosophy in the School of Nursing, Indiana University July, 2015 Accepted by the Graduate Faculty, Indiana University, in partial fulfillment of the requirements for the degree of Doctor of Philosophy. __________________________________________ Angela M. McNelis, PhD, RN, ANEF, CNE, Chair __________________________________________ Kristina Thomas Dreifuerst PhD, RN, CNE Doctoral Committee __________________________________________ Sara Horton-Deutsch, PhD, PMHCNS, RN, ANEF November 6, 2014 __________________________________________ Kathy Lay, PhD ii DEDICATION This work is dedicated to my family. I could not have completed this journey without your unconditional love and support. I hope you know how much I love you and appreciate your patience as I continued my educational journey. Jonathan, you are always there for me, my strength, my best friend, my soul mate, my husband- Thank you for all the encouragement and support. Sarah and Laura—you deserve recognition, your continuing support no matter what your mother decided to do. You have always been my inspiration to be a positive role model and to strive to be a better person. I will always— “love you more”! I further dedicate this work to the students and faculty who have shared their intercultural experiences with me. As the intercultural experiences have positively changed your life, you have absolutely changed mine. It is my hope and dream that this work will positively impact the lives of those in nursing and the patients that they care for. One does not walk this journey alone. Each step along the way, there have been instrumental people who have inspired, encouraged, supported, and motivated me to pick up my sword and walk along this path. I feel so blessed to call you my friends and colleagues. Sally, you were my cheerleader throughout this journey. You always made me feel I was braver, stronger, and smarter than I thought I was. Dear Mother—you left this earth way too soon. But your legacy does carry on—“Do for others and you will do for yourself”. Thank you for being the person who always encouraged me to work harder. My father-in-law, Bill, who was always so proud of what I accomplished and always accepted the advice of “nurse ratchet.” Lee, you iii taught me that even with adversity and strife—there is value and purpose in life—carry on. Most everyone has second chances to do the right thing. iv ACKNOWLEDGEMENTS I would like to first and foremost give all thanks to God for seeing me through this journey. I have been deeply blessed and honored to work with remarkable professors, professional colleagues, and fellow students who supported, encouraged, and inspired me professionally and personally with their presence. My sincere gratitude goes to Dr. Angela McNelis, my dissertation advisor, committee chair, mentor, and friend. Dr. McNelis has provided me with confidence, wisdom, and guidance to complete my doctoral journey. My genuine appreciation also goes to my committee members: Dr. Kristina Thomas Dreifuerst, Dr. Sara Horton-Deutsch, and Dr. Kathy Lay. Each of you has provided me with the encouragement and “pearls of wisdom” for this doctoral study. Special thanks to all of my professional colleagues at Anderson University and Ball State University for your encouragement and support. v Lynn Marie Schmidt AN EVALUATION OF THE IMPACT OF AN INTERCULTURAL SERVICE LEARNING EXPERIENCE ON THE DEVELOPMENT OF TRANSCULTURAL SELF-EFFICACY OF NURSING STUDENTS The increase in diverse populations with unique, culturally specific needs, along with the lack of diverse healthcare providers to deliver culturally competent care, has escalated the need for non-diverse practitioners to gain the knowledge, skills, and attitudes to deliver culturally competent care. Culturally competent care cannot be offered to patients unless nurses understand how cultural values, attitudes, and beliefs impact patients’ response to care. Nurses must develop cultural competence to accurately access, develop, and implement effective nursing interventions. The purpose of this exploratory, quasi-experimental, pretest-posttest study was to explore the impact of an intercultural service learning experience (domestic or international) on pre-licensure nursing students’ perceived development of transcultural self-efficacy. A convenience sample of senior semester nursing students enrolled in a private, faith-based, baccalaureate degree nursing program in the Midwest United States completed the Transcultural Self-Efficacy Tool (TSET), Cultural Competence Clinical Evaluation Tool-Student Version (CCCET-SV), and reflective journals. All students were immersed in an intercultural service learning experience. Eighteen students traveled domestically and 38 traveled internationally. The data revealed that there was not a statistical difference in TSET scores based on location of the intercultural experience. However, there was a statistically significant difference from pretest to posttest for perceived Cognitive, Practical, and Affective vi dimensions of transcultural self-efficacy, in change scores (pretest to posttest), and pretest to posttest for pre-licensure BSN students’ perceived clinical competence behaviors (culturally sensitive and professionally appropriate attitudes, values, and beliefs) following an intercultural service learning experience. Angela M. McNelis, PhD, RN, ANEF, CNE, Chair vii TABLE OF CONTENTS Chapter I Introduction ......................................................................................................... 1 Problem Statement and Research Questions ................................................................... 7 Quantitative Research Questions ................................................................................. 7 Qualitative Research Questions ................................................................................... 8 Purpose of the Study ....................................................................................................... 8 Significance of the Study ................................................................................................ 9 Conceptual and Operational Definitions ....................................................................... 10 Organization .................................................................................................................. 11 Chapter II Review of the Literature .................................................................................. 12 Historical Perspectives .................................................................................................. 12 Kolb’s Experiential Learning Theory ........................................................................ 13 About SL ................................................................................................................... 14 SL in Nursing ............................................................................................................ 15 Self-Efficacy .............................................................................................................. 18 Transcultural Nursing ................................................................................................ 19 Cultural Competence in Nursing Education .................................................................. 20 Nursing Theoretical Models and Frameworks for Cultural Assessment ...................... 22 The Theory of Culture Care Diversity and Universality ........................................... 23 The Process of Cultural Competence in the Delivery of Healthcare Services .......... 24 Giger and Davidhizar’s Transcultural Assessment Model ........................................ 25 The Purnell Model for Cultural Competence ............................................................ 25 viii Andrews/Boyle Transcultural Nursing Assessment Guide ....................................... 26 Cultural Competence and Confidence Model ........................................................... 27 Measurement of Cultural Competence .......................................................................... 30 The Use of the TSET and CCCET-SV in Nursing Education ................................... 33 Findings of Integrative Review ................................................................................. 33 Aim/purpose ........................................................................................................... 34 Method/design ....................................................................................................... 35 Sample/setting ........................................................................................................ 37 Interventions tested ................................................................................................ 39 Effectiveness of interventions ................................................................................ 40 Other limitations of reviewed studies .................................................................... 42 Review of CCCET-SV ........................................................................................... 43 State of the Science ......................................................................................................