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The Pew Research Center (2015) estimates that by 2050, one in five Americans will be foreign born and 82% of the nation’s population growth from 2005 to 2050 will be among new immigrants and their descendants. Despite these increases, inequities and disparities in healthcare continue to persist, particularly among ethnic minority populations (Center for Disease Control, 2013). Cultural competency has been the emphasis in healthcare for more than a decade. There is, however, a paucity of literature examining the effectiveness of education and training programs given the persisting cultural gaps in our systems. The current gap in provider and patient cultural congruence is growing, but how effectively we train students to work with diverse populations in healthcare settings continue to warrant attention.
Creative solutions to diversity training have led us to employ BaFa’ BaFa’, a gaming tool to develop cultural awareness among healthcare trainees. Gaming in cultural awareness training, a form of low fidelity simulation has been used for decades in business, foreign affairs, and the military (Chin, Dukes, & Gamson, 2009; Hofstede, de Caluwé, & Peters, 2010). Existing literature shows that group interactive gaming entails the use of cognitive, social, sensory, and emotional aspects of a person in the learning process, making a simulated situation real or a lived experience (Hofstede, et al., 2010; Raybourn, 2011; Roberts & Roberts, 2014). Gaming is most effective when used as part of larger training program that includes reading of literature, and most importantly, the utilization of guided debriefing or reflection on the simulated experience. The purpose of this paper is to present the results of a qualitative study on the effectiveness of experiential learning, in the form of gaming in raising cultural awareness among students of health professions.
Methods:
Participants included 34 graduate nursing students and 11 doctoral clinical psychology students from a private Jesuit university in the San Francisco Bay Area. Students were asked to participate in the BaFa’ BaFa’ exercise and following completion were asked to write a brief reflection of their experiences during the exercise: What did they learn about culture from the exercise, and how did the learning make them feel. The writing reflections were analyzed and coded using a thematic analysis framework which assists in identifying, organizing and understanding the data rather than focusing on counts or frequencies (Braun & Clark, 2006; Taylor & Bogdan, 1998). Two trained members of the research team coded each written reflection using NVivo software. A third member of the team reviewed coding of reflections that had discrepancies.
Procedure. BaFa’ BaFa’ is an interactive game that calls for participants to be divided into two tribes. The participants do not know about their tribal affiliation until the game begins. Each tribe must learn rules of a given culture and do not know the cultural rules of the other tribe. Upon learning and “living” the culture, participants from each tribe are given the opportunity to visit the other tribe for a short period of time, thus experiencing the other’s culture. The visits are akin to interactions in real life when people from different cultures meet for the first time without prior awareness of any cultures (or cultural rules) beyond the person’s own.
Results:
Students had a wide range of reactions to the exercise and four main themes emerged from the data: awareness of cultural differences with a sub-theme of self-awareness; cultural humility with a sub-theme of empathy; insider-outsider; and recognizing the importance of culture. The significant commonality is such that awareness is raised when cultural differences are made apparent, and students shared their reflections on how cultural humility can be developed from the experience of being an insider or outsider.
Conclusion:
In order to decrease health disparities and deliver quality healthcare to diverse populations, we need to move away from the traditional didactic approach to teaching culture and assume competency by taking a multiple-choice test. Healthcare as an industry must invest in creative programs that may impact student’s learning and assist in developing cultural awareness and humility in the next generation of healthcare professionals. The study on using gaming to develop critical cultural awareness supports the importance of involving cognitive, social, sensory, and emotional aspects of a person in learning. Debriefing provided the opportunity to reflect, allowing the student to critically process the meaning of culture and its impact on a person, perceptions of health and healthcare, provider-provider relations, and most importantly, provider-patient relations.