Does a Culturally Infused High-Fidelity Human Simulation (HFHS) Scenario Accurately Depict the Culture?

Purpose: The United States (U.S.) is rapidly becoming a multi-cultural, pluralistic society. The U.S. Census current U. S. Census (2010) reported that 72% of the US population origins were from White European ancestry, 14% from African ancestry, 17.3 % from Hispanic Ancestry, 4.8% from Asian Ancestry and 0.9% Native American ancestry. The U.S. Census (2010) projects for the year 2020, 53% will be from White European decent and there will be a threefold increase in the Hispanic American and Asian American population. Providing culturally competent care in the 21^st century is critical to excellent patient outcomes.This study sought to determine the outcomes of teaching a culturally infused nursing process to Foundation of Nursing students in an Associate Degree Nursing program. Nurse Educators usually write simulation scenarios to teach patient care and procedure skills. Opportunities to expose students from predominately white communities to cultural variations varies with in the US. Simulation scenarios with a cultural component provide a valued learning experience for students. The U.S. Department of Labor, Bureau of Labor Statistics (2016) reports that 81.9% of the 3 million licensed Registered Nurses identify themselves as white. The American Association of Colleges of Nursing (AACN) Enhancing Diversity in the Nursing Workforce (2015) recognizes the need to recruit people from diverse backgrounds into the nursing profession to educate our students in diversity and culture. Nurse Educators need to employ qualitative methods to evaluate the cultural component, ensure the objectives of the simulation are met, and disseminate their findings. The need for inclusive educational practices will also be congruent with the National League for Nursing (NLN) Outcomes and Competencies for Graduates of nursing programs (2010) recommendations for education programs graduate outcomes for inclusion of “the uniqueness, dignity, diversity, freedom, happiness, and holistic well-being of the individual within the larger family, community, and population. The nurse helps the individual in efforts to reclaim or develop new pathways toward human flourishing” (pg. 33). These data support the need to incorporate culturally infused human simulations into nursing program curriculums. However, Nurse Educators need to change the processes of writing and the evaluation of the culturally infused simulations. Representatives from the culture need to be participants in the development and evaluation of simulations to ensure a true representation of the culture or ethnic group. 

Methods: A quantitative, quasi-experimental, 2 x 2 factorial design was used to measure two points in time with a pre-test and post-test to measure student performance on the use of the nursing process in one point in time and at the end of the course. Four groups of students were randomized and taught the nursing process: Group #1 - case study and concept mapping; Group #2 - case study, concept mapping with a pocket reference; Group #3 - case study, two hours HFHS, concept mapping with a pocket reference; or Group #4 - four hours of HFHS, concept mapping with a pocket reference. The Simulation Design Scale (SDS) was used to measure the perceptions of the four student groups for the design elements.

Results: The National League for Nursing (NLN) PAX-RN entrance examination had a significant correlation with students’ passing onto the second semester in a nursing program (p < .001). The four-hour group (Group #4) mean was significantly lower on both the importance of the objectives and information and importance of fidelity design elements (p < .05). This suggests that as time in a simulation increases more attention to these elements is required. There was not a significant difference between the four study groups on the Nursing Process or the Assessment Technology Institute (ATI) RN Fundamentals 2010 Assessment Form B examinations individual scores. Two sub-categories on the ATI were significant. Planning was significantly higher for fall 2012 (Groups 2, 3, and 4) cohort (p = .024) and analysis/diagnosis was almost significant for fall 2011 (Group 1) cohort (p = .054). The results for Factorial Groups were not significant. The ATI results of students were the same without regard to the Factorial Group assigned in relation to instructor employment status of full time versus part time.

Nurse Educators are challenged to provide students with opportunities to care for diverse ethnic populations when the community and student population are predominately white (Irwin, 2013). Consideration was given in this study for recognizing differences in patient populations (National League for Nursing, 2010). The simulation exposed students to a patient situation requiring them to care for a migrant worker, from Mexico with English as a second language. A professional fluent in both English and Spanish recorded the vocals for the simulation. The patient was a field worker with heat exhaustion who was of Mexican heritage. The occupation is irrelevant. What matters is he is a migrant worker, from Mexican heritage. The importance is the simulation gave beginning nursing students the opportunity to experience the “other” by infusing culture into the scenario. Textbooks that describe culture were used to develop the scenario. Students were required to use listening skills and etiquette to understand the patient’s responses based upon this textbook information. Cultural considerations were included that anticipated response to the assessment questions students might ask (Zoucha & Zamarripa, 2008). However, the researcher did not recognize the need to evaluate if in fact the simulation was correct for the Mexican culture. Representatives from the portrayed culture were not included in the evaluation process. This discovery sheds new light on the way Nurse Educators are composing cultural simulations.

Conclusion: It is not sufficient to just make changes in a nursing curriculum without a plan to evaluate the impact on program outcomes. However, this study was focused on learning of the nursing process and the presence and importance of the design elements of simulation. In reflecting back on the study, the researcher identified a missing element: the need to evaluate the simulation for the cultural presence or accuracy of portrayal using qualitative research methods. This discovery could influence how Nurse Educators proceed in the development of culturally infused simulation scenarios. No evidence of this concept was found in the nursing literature. This researcher is recommending Nurse Educators have representatives of the cultural group being portrayed in the simulation to participate in the development and evaluative phases of writing the simulation.