Transformational Processes in Developing Cultural Understanding: Nursing Students' Experiences in Swaziland

Purpose:

The purpose of this study was to explore the experiences of an overseas service-learning health care delivery program in a group of Bachelor of Science in nursing (BSN) students.  According to the United States (US) Census Bureau, minorities made up 37% of the US population in 2012. However, only 19% of minority backgrounds were represented in the Registered Nurse (RN) workforce, and only 12.3% of nursing faculty self-identified as an ethnic or racial minority (AACN, 2014). In 2014, a group of nursing students were accompanied by their university professor to Swaziland, Africa for an overseas study experience. The students worked with children and adults in a variety of hospital and community-based settings.  After their return, the students were interviewed about their experiences. This paper is a study of their personal and professional growth following this experience. 

Methods:

Swaziland is a small country in the sub-Saharan region of the continent of Africa approximately 17,000 km² in size with a population of 1,231,000 (World Health Organization [WHO], 2014).  The average life expectancy in SZ in 2012 is 52-years for men and 55-years for women (WHO, 2014).   The primary reason for this shortened life span is a lack of adequate healthcare. Infectious diseases are the primary cause of death of all age persons in SZ, and SZ has the highest human immunodeficiency virus infection (HIV) rate of any country in the world:  26.5% of adults aged 15-49 years (GHO, 2014) and 39% of pregnant women aged 15-24 years are HIV positive  (MOH, 2010).

            Six BSN nursing students participated in this study.  All were female, unmarried, without children, and in their early 20’s. Three of the students were entering junior year, and three were seniors.  All were from the same academic program. The senior students had completed 90-hours each in pediatrics and obstetrics/gynecological nursing.  All of the students had completed fundamental nursing skills, health assessments, medical-surgical nursing and pharmacology. The hospital’s Nursing Education Coordinator was provided with a list of skills that the students had mastered as well as the goals and objectives for the program.  Nursing students rotated through two days in a hospital labor and delivery, two days in pediatrics and were assigned to varied observational experiences, e.g., the intensive care unit, renal dialysis, the child vaccination clinic and the Baylor University Clinic for Children with HIV infection.  Other than hospital work, the nursing students and their instructor also helped to implement five community-based health clinics that provided health assessments and outpatient treatment to over 340 adults and children.  Institutional board approval was received by the university. This was approved as an exempt study.  All participants agreed to full participation, and consented to both audio-video taping and photography. Students were interviewed individually one month after returning from Africa.  Interviews were audio-taped and transcribed.  The researcher used a semi-structured interview format that started with six questions, but used probes to encourage elaboration. Data was transcribed from the audio-tapes and the interviews were analyzed line-by-line assigning codes to the salient points in each sentence or phrase.  Narrative analysis methods were used in order to identify the four overarching themes of Transition, Perceptions, Internalization and Incorporation. Seven sub-categories were identified.

Results:

Students experienced transition stress primarily in the areas of language and communication, and emotional reactions. Perceptions of healthcare in Swaziland as compared to the United States, and nursing care in Swaziland were the source of most of their cultural dissonance.  This cultural dissonance was perceived as: 1) responsibility for the care of the patient; 2) responsibility for education of the patient; 3) the role of the nurse in terms of hands-on care; 4) maintenance of patient safety and infection control; and, 5) importance placed by nurses on empathy and interpersonal communication.  Cultural dissonance activated internal processes in students that forced them to utilize transformational coping mechanisms to deal with this stress.  Students used four main processes in this study which served to internalize and then incorporate changes in their values, beliefs and attitudes, and to facilitate growth.  They used meaning-making through narration (story-telling), and comparing and contrasting of social issues and nursing care/nursing education. As they moved towards incorporation, students demonstrated more reflection and reframing.  By the end, students were able to understand reasons why things occurred, even if they still did not fully agree. 

Conclusion:

The purpose of this study was to examine the experiences of six nursing students following a service-learning experience in Swaziland, Africa.  Students provided hands-on care in both hospital and community settings. Following the program, the students were interviewed and the interviews were analyzed utilizing narrative methods. The results of this study closely follows other research that has been published on the value of overseas study as a curricular tool in teaching nursing student’s cultural understanding. Students went through stressful transitions, adapted to these and utilized internal coping strategies and personal strengths to accomplish a remarkable degree of personal and professional growth in a relatively short period of time.  Experiencing mild hardship and culturally dissonance activates coping strategies within students that enable change and promote transformation. This transformative process led to greater cultural understanding and both personal and professional growth.

            The challenge for nurse educators is to try and find ways to incorporate the same processes of cultural dissonance that will provoke activation of coping strategies without the financial barriers. This may be possible by assigning students to clinical placements that are outside of their comfort zone but are not as physically distant, e.g. a disaster recovery zone, a rural health clinic, or an urban setting.

American Association of Colleges of Nursing (AACN). (2014, Jan. 21). Enhancing diversity in the workforce. Retrieved online from http://www.aacn.nche.edu/media-relations/fact- sheets/enhancing-diversity

Global Health Observatory of the World Health Organization (2014). Data on the size of the HIV/AIDS epidemic: Number of adults, women and children living with HIV by country. Retrieved from http://apps.who.int/gho/data/view.main.22300

Ministry of Health (2010). Essential health care package for Swaziland.World Health Organization.

World Health Organization. (2014). WHO African region: Swaziland statistics summary 2002-present. Retrieved from http://www.who.int/countries/swz/en/