Providing an adequate cultural care is one of the most important challenges in healthcare, since there is a significant increase in multicultural and multilingual population all over the world. Israel is a home to a widely diverse population of over eight million citizens from many ethnic, religious, cultural, and social backgrounds (Israel Ministry of Foreign Affairs [MFA], 2018). The Central Bureau of Statistics [CBS] (2018) reported that the Jewish population comprises 74.7% and the Arab population is 20.3%. The Arab population, by religion, is noted as Moslem, Christian, and Druze. In addition, Israel is known as a land of immigration and home for Jews from all continents of the world. Thus, the immigrants’ country of origin also contributes to Israel’s cultural diversity.
Israeli nurses, belonging to different cultures from those of the patients, find it difficult to treat them in culturally appropriate manner, since they do not undergo proper training for this purpose (Rosh & Popescu, 2013). Such situations create tensions between the nursing staff and the patients and their families. Therefore, cultural competence, which aims to provide relevant, effective, and culturally responsive healthcare services, has gained recognition as an important component of nursing education and practice (Noble, Nuszen, Rom, & Noble 2014; Shen, 2015).
Clinical simulation is becoming a recognized teaching method in nursing education that can facilitate application and integration of knowledge in a controlled environment (Sagar, 2014). By enhancing clinical simulations to include culturally significant variables such as information about cultural background, race, or ethnicity, students can achieve practical experience in a safe, controlled environment that they may not receive when experiencing practice in the actual clinical setting (San, 2015).
The nursing academic program in Yezreel Valley College, located in North Israel, includes clinical simulation training during the first, second, and third academic years. The students participate in simulated patient care scenarios within a specific clinical environment, gaining experience, learning and refining skills and developing competencies. These are accomplished without fear of harm to a ‘real’ patient.
Prior to their first clinical practice in health care settings, third year nursing students participate in training sessions of simulation, which includes different scenarios based on common health care conditions of medical and surgical nursing. Caring for the patient with diabetes is among the more important clinical conditions, because the prevalence of this disease is rising all over the world (World Health Organization [WHO], 2017). In Israel, the prevalence is particularly high among the Arab population (Jaffe et al., 2017). In order to address this challenge and prepare the students, who represent different cultures of Israeli populations, we developed the simulation scenario, incorporating clinical and cultural aspects of nursing care of the diabetic patient. The objectives of the simulation-based training were: (1) to identify cultural aspects, which are vital for providing safe and effective nursing care for the diabetic patient; (2) to develop critical thinking, using cultural safe communication strategies when administering medications, and (3) to exercise and discuss strategies that promote cultural competence.
The simulation session included three scenarios based on role-playing. In the first scenario, nursing students were asked to perform a clinical assessment of a patient who arrived to an internal medicine ward due to acute pneumonia. The patient was a 65 years old Moslem Arab man, who is very religious and barely speaks Hebrew. During the phase of history taking and assessment, the student had to identify high blood sugar levels and a diabetic foot ulcer, which had developed as the patient had difficulty drying his feet properly after Islamic prayer. The second scenario aimed to develop critical thinking and decision making and was based on patient assessment and interaction with him and his family members. The nursing students were expected to decide whether they should administer rapid action Insulin, as ordered by the physician, while the patient is fasting due to religious obligations of Ramadan fasting. Finally, during the third scenario, the students were asked to perform their communicative and clinical skills, providing discharge instructions regarding self-care, nutrition, and blood glucose level monitoring, maintaining skin integrity and insulin administration, considering patient’s and his family member’s cultural background. Immediately, after each scenario session, the nursing simulation mentor conducted a debriefing session with the student participants, using video based debriefing in order to help them reflect on and evaluate their performance in the scenario. The results of the debriefing and reflection processes were used to assess whether and how the objectives of the simulation training were attained.
During the debriefing and the reflection phases, the students discussed their role, focusing on the simulation objectives. Many students reported that they had never considered all the possibilities and concerns that could occur while providing nursing care to patients of different cultural backgrounds. The students indicated experiencing an improvement in their cultural competence and that they found the simulation-based experience valuable. Moreover, even those students who self-identified as belonging to the same culture of the patient in the scenario reported gaining greater awareness of cultural aspects in nursing care. This project is still ongoing and therefore, a final assessment of its effectiveness has not been conducted yet.
In sum, the ability to communicate and to take care of patients from diverse cultures and their families is one of the most important components of the nurse’s work. Using a simulation scenarios in nursing education, educators can enhance the culturally competencies of future nurses.
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