Content area
Background
Cultural competence is an integral component of undergraduate nursing education. However, there is a lack of consensus on the best way to develop students' cultural competence. Although evidence supports short-term study abroad, few studies have used a mixed-methods theory-driven design.
Method
This convergent mixed-methods study measured the change in cultural competence among baccalaureate nursing (BSN) degree students enrolled in an immersive study abroad program. Quantitative data from the instrument were analyzed to compare pre- and postexperience cultural competence scores. Reflective journal transcriptions were analyzed using deductive content analysis.
Results
Results showed a statistically significant improvement in postexperience scores compared with preexperience scores. Major themes included embracing diversity, transformative journeys, emotional engagement, cross-cultural experiences, and joyful appreciation.
Conclusion
This study emphasizes the effectiveness of theory-designed study abroad in enhancing BSN students' cultural competence and analyzes the effects on the individual theoretical constructs of cultural competence. [J Nurs Educ. 2025;64(3):185–191.]
Cultural competence is a vital component of undergraduate nursing education, as it is crucial in a nurse's ability to provide quality care centered around the patient's needs. In today's interconnected society, nurses encounter individuals from diverse cultural, ethnic, and social backgrounds. Cultural competence gives nurses a holistic view of patients' beliefs, values, and practices. By recognizing and valuing cultural diversity among patients, nurses can tailor their plans of care to be more inclusive and responsive to individual needs. However, evidence shows that nurses with a baccalaureate nursing (BSN) degree lack cultural competence skills and are unprepared to care for patients in a global society (Markey & Okantey, 2019). Although BSN programs are aware of the need to integrate cultural competence into curricula, there is limited evidence regarding the most effective way to achieve this (Sjögren Forss et al., 2019).
Background
The literature describes various educational interventions and diverse strategies to enhance the cultural competence of undergraduate nursing students. An integrative review by O'Brien et al. (2021) examined educational interventions to prepare undergraduate nursing students to care for culturally diverse patients. The authors identified two common themes. The first theme was the benefit of developing nursing students' knowledge base, and the second was the development of nursing students' confidence. The authors concluded that lectures, case-based learning, and simulation with standardized patients can increase nursing students' cultural confidence. However, none of the studies in the review described how nursing educators used a theoretical framework to structure the educational interventions.
Several authors have noted nursing education should adopt integral approaches, such as high-fidelity simulation or personal experiences with other cultures, that transcend beyond the mere acquisition of cultural-specific knowledge (Choi & Kim, 2018; O'Brien et al., 2021; Plaza Del Pino et al., 2022). These holistic approaches aim to address the broader challenges that nursing students may encounter when caring for culturally diverse patients. Other studies found that simulation with standardized patients in combination with lecture and case-based learning increased nursing students' cultural competence and allowed students to bridge the gap between theory and real-world application (Byrne, 2020; Qin & Chaimongkol, 2021).
Reflection and debriefing have emerged as pivotal components of most educational interventions and play a crucial role in helping students make sense of their experiences. Reflection allows them to gain new insights regarding cultural awareness and its practical application in nursing (O'Brien et al, 2021; Steppe et al., 2022; White & Louis, 2023).
Despite the emphasis on cultural competence, many nursing students need more confidence in applying their knowledge in clinical practice (Markey & Okantey, 2019). Campinha-Bacote (2023) asserted that the initiation of cultural competence development is rooted in cultural encounters. The literature suggests the benefits of immersion experiences, such as study abroad programs in other cultures, to foster cultural competence (O'Brien et al., 2021). Study abroad programs (accompanied or unaccompanied by faculty) have positive effects on students. However, Morgan (2023) reported that although some nursing students expanded their knowledge related to cultural competence, other participants experienced a reinforcement of their ethnocentric frame of reference.
Internationalization-at-home is a substitute for studying abroad, which integrates intercultural elements into the curriculum without requiring students to leave the university premises. Authors have used web-based intercultural peer-learning seminars, online cultural diversity courses without travel, and service-learning to increase nursing students' cultural competence (Booth & Graves, 2018; Carlson et al., 2017; Gavin Knecht et al., 2019; Levey, 2020). The advantages were offering students opportunities that are more feasible financially and are accessible to larger groups while enhancing cultural competency.
There is a lack of consensus regarding the effectiveness of educational interventions aimed at supporting students' cultural competence. The optimal structure, organization, and facilitation of these interventions are insufficiently understood. Although numerous studies have assessed the overall level of cultural competence in nursing students, few studies have provided empirical evidence on the effectiveness of short-term study abroad programs designed using cultural competence theory and measured with the validated Inventory for Assessing the Process of Cultural Competence Among Health Care Professionals–Student Version® (IAPCC-SV). Moreover, there is a notable scarcity of mixed-methods studies in this area. This convergent mixed-method study evaluated the effects of a short-term, theory-designed study abroad program on the cultural competence of BSN students.
Theoretical Framework
Campinha-Bacote's (2018) model of cultural competence in health care delivery presents a comprehensive framework that underscores the vital role of health care professionals in providing adequate care within diverse cultural contexts. This model emphasizes the fusion of cultural humility and competence, which empower an individual to deliver culturally appropriate care. Cultural competemility is a term coined by Dr. Campinha-Bacote (2018). It refers to the “synergistic process between cultural humility and cultural competence in which cultural humility permeates the five components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters” (Campinha-Bacote, 2018, p. 3). Cultural competemility is not a static concept but an evolving and dynamic process essential for delivering patient-centered and culturally sensitive health care.
At its core, cultural competence is defined as health care professionals' commitment to continually enhance their capacity to navigate and communicate effectively in culturally diverse health care settings (Campinha-Bacote, 2018). This ongoing process is structured around the five constructs of cultural competence: (1) cultural awareness is the foundational step, where health care providers acknowledge their cultural biases, beliefs, and attitudes; (2) cultural knowledge involves acquiring in-depth understanding and information about various cultural groups, including their customs, beliefs, and health practices; (3) cultural skill pertains to applying cultural knowledge effectively in clinical practice; (4) cultural encounters involve direct interactions with patients from different cultural backgrounds; and (5) cultural desire represents the intrinsic motivation and commitment to deliver culturally competent care.
In summary, cultural competence is not a one-time achievement but an ongoing journey for health care professionals underscored by the development of cultural humility. By continuously developing cultural awareness, knowledge, skills, and encounters while maintaining a deep-seated cultural desire, health care providers can offer inclusive and patient-centered care, ultimately improving health outcomes for all individuals regardless of their cultural background (Campinha-Bacote, 2023).
Method
This convergent mixed-methods study aimed to explore whether participation in a short-term theory-designed study abroad followed by reflection would significantly increase BSN students' level of cultural competence as measured by the IAPCC-SV (Campinha-Bacote, 2023).
Design
The study used a convergent mixed-method design that included quantitative and qualitative data. Pre- and posttests were used to measure the change in cultural competence among students enrolled in an immersive study abroad program in Italy, as measured by the IAPCC-SV (Campinha-Bacote, 2023). After the study abroad program, reflective journal transcriptions were used to obtain qualitative data. A mixed-methods design was chosen to help facilitate a deeper understanding of the complementary aspects of a theory-designed study abroad on the cultural competence of BSN students (Denzin, 1978; Patton, 1999).
Participants
This study included students who were enrolled in an elective nursing course in a BSN program in the southeastern United States. Students were informed that assignment submission was a course requirement, but their participation in the study was optional. Additionally, students were informed their overall course grade would not be affected regardless of their choice to participate.
Instrument
The IAPCC-SV was used with permission to measure students' cultural competence. The IAPCC-SV has been widely used, has sound validity evidence, and has consistent reliability, with an average Cronbach's alpha of .78 (Fitzgerald et al., 2009). This tool consists of 20 items that assess the five cultural constructs of cultural awareness, knowledge, skill, encounters, and desire outlined in Campinha-Bacote's (2023) theory. Items are scored using a 4-point Likert scale ranging from 1 = strongly disagree to 4 = strongly agree (Table 1). Students completed the IAPCC-SV before departing for the study abroad program and then again after completing the study abroad program. The results of this assessment categorized students into different levels of cultural competence, including cultural proficiency, cultural competence, cultural awareness, or cultural incompetence, with higher scores indicating a greater level of cultural competence (Table 2).
| Construct | Related Items |
|---|---|
| Cultural awareness | 1. I believe that cultural competence is a continuous learning process |
| 3. I believe there is a relationship between culture and health | |
| 15. I am aware of some of the stereotyping attitudes, preconceived notions, and feelings that I have toward individuals of other ethnic or cultural groups |
| Construct | Scoring Range | M (SD) | Effect | Magnitude |
|---|---|---|---|---|
| Cultural awareness | 3 to 12 | 7.3 (4.9) | 1.49 | Large |
| Cultural desire | 4 to 16 | 12 (5.80) | 2.06 | Large |
| Cultural encounters | 5 to 20 | 8.8 (8.50) | 1.03 | Large |
| Cultural knowledge | 5 to 20 | 10.6 (9.70) | 1.09 | Large |
| Cultural skill | 3 to 12 | 6 (4.40) | 1.38 | Large |
Reflective Journals
During the study abroad program, students were instructed to write daily journal entries detailing their experiences with Italian nursing practice, interactions with the local community, and cultural encounters. They also were encouraged to examine their preconceived notions about Italy's health care system and how their experiences challenged or affirmed those ideas. Additionally, students documented their experiences by taking photographs, which were used for reflective journal presentations submitted by the students at the end of the program.
Students were instructed to integrate the insights, photographs, and personal reflections from their journals into a comprehensive presentation. These presentations, which included voice-over narration, subsequently were transcribed into text. The final presentations comprised photographs taken from the study abroad experience, coupled with the students' introspective analyses and reflections on the overall effects of the program. Feedback from the students regarding this learning activity was overwhelmingly positive, and the students noted they enjoyed reflecting on their experiences through this creative and engaging assignment.
Description of the Study Abroad Program
The elective course included predeparture meetings, in-country study abroad, and postdeparture activities (Table 3). Each element and activity within the study abroad program was chosen to support one or more constructs of cultural competence, leading to a theory-designed program. The 2-week study abroad program took place in Italy, with students spending time in Montepulciano, Siena, and Rome. The group comprised two faculty members, three graduate students pursuing Master of Science in Nursing (MSN) degrees, and 21 undergraduate students pursuing BSN degrees.
| Components of Short-Term Study Abroad | Construct Supported |
|---|---|
| Before departure | Cultural awareness, cultural desire, and cultural knowledge |
| Meeting #1: Overview of course | |
| Meeting #2: International safety and security presentation | |
| Meeting #3: Italian language lesson, cultural competence overview, and service-learning overview | |
| Complete preassessment: IAPCC-SV | |
| In country | Cultural awareness, cultural desire, cultural encounters, cultural knowledge, and cultural skill |
| Seminar #1: Scholarly Writing | |
| Seminar #2: Cultural Competence | |
| Seminar #3: Reflective Journal Skills | |
| Italian language lessons | |
| Traditional Italian cooking lesson | |
| Community dinners with students and faculty | |
| Exploration of local farm and vineyard—family's historic wine | |
| Service-learning experience—community blood pressure screening in a local market | |
| Clinical experience in acute care and outpatient settings | |
| Visits to cultural landmarks—Vatican, St. Peter's Basilica, Sistine Chapel, Siena Cathedral, the Roman Forum, and the Colosseum | |
| Postdeparture | Cultural awareness, cultural knowledge, and cultural skill |
| Postdeparture meeting—reflection of experience and debriefing session | |
| Pecha Kucha presentations—reflective analysis of study abroad experience | |
| Scholarly paper submission—compare and contrast Italian vs. United States health care |
The students gained valuable insights into Italian health care and culture through immersive experiences in acute care hospitals and outpatient settings. In addition to their clinical exposure, students were immersed in various elements of Italian culture through Italian language lessons, a traditional Italian cooking lesson, and a tour of a local family-owned farm and the family's historic wine. The program also highlighted the unique art, architecture, food, music, lifestyle, and culture of Italy through tours of significant landmarks. Didactically, the course included seminars on Campinha-Bacote's model, the underpinnings of cultural competence, and how to develop reflective journal presentations.
The undergraduate and graduate nursing students also participated in a community service-learning experience in Montepulciano. With the help of faculty, a hired Italian-English language translator, and the city of Montepulciano, the students hosted a free blood pressure screening in the local market. Community residents received a blood pressure screening and appropriate health education and guidance. This service-learning project was an immense success; the students served more than 100 local community members.
Ethical Aspects
The study was deemed exempt by the university's Institutional Review Board. All study-related data were deidentified and stored on password-protected computers.
Results
Demographics
The single criterion for study inclusion was enrollment in the study abroad course in Italy. All of the students (n = 21) in the course were invited to participate in this study; however, only students who completed all of the data (n = 20 [95%]) were included in the study. All of the participants identified as female and were ages 18 to 24 years.
Quantitative Methods and Results
This study aimed to determine whether nursing students' cultural competence, as measured by the IAPCC-SV, improved after a study abroad experience. A paired t test was performed to compare pre- and postexperience cultural competence scores. Of the 20 students who completed the IAPCC-SV both before and after the experience, the postexperience scores (M = 73.55 [SD = 3.82]) were significantly higher than the preexperience scores (M = 64.30 [SD = 6.35]) (t = 5.88, p < .001). Predeparture IAPCC-SV scores revealed that all of the students were either culturally aware or competent at baseline, with most of the students improving to the culturally proficient level following the completion of the study abroad experience.
Although assessing the change in cultural competence scores was of considerable interest, it was equally important to investigate variations in scores across the individual constructs of cultural competence. The mean change in pre- and postintervention scores are summarized in Table 2; the cultural desire and cultural awareness constructs yielded the most significant improvements in postintervention scores. The changes in the scores were all considered to be large effects (d > 0.8) (Sullivan & Feinn, 2012).
Qualitative Analysis and Results
The students' reflective journal presentations were recorded and transcribed using the transcription application in Power-Point®. The transcriptions then were evaluated and edited to ensure transcription accuracy. Transcriptions were assessed and edited, and then uploaded to Atlas.ti® for qualitative code analysis. Using artificial intelligence (AI)-driven software, data were systematically coded to identify key themes. A hierarchical coding system then was developed to categorize recurring patterns. Advanced search and query functions helped explore relationships between codes and discover co-occurring themes. These codes were associated with specific quotations from the transcriptions, and were collated and organized by the prevalence of the code. Faculty removed duplicate codes and consolidated similar codes for ease of analysis. Throughout the analysis, memos were written to document reflections and insights. Finally, reports were generated and exported to present findings in a clear and efficient manner. After analyzing the journals, the following major themes emerged: (1) embracing diversity; (2) transformative journeys; (3) emotional engagement; (4) cross-cultural experiences; and (5) joyful appreciation.
Embracing diversity. A prominent theme was the students' growing appreciation for cultural diversity. Students expressed how their experiences in Italy led them to embrace cultural diversity. This sentiment was reflected in various ways. One student noted:
One of the things that I kept on saying when I was there was how much I felt like we [are] rushed as Americans at home. Time here in Italy was really savored and used to talk and spend time together....That was one thing that I took back from this trip, that we should savor time more with each other.
This sense of gratitude also extended to the students' cultural experiences. A visit to the Colosseum and Forum left a lasting effect on another student, who commented:
The tour guide mentioned that these walkways were thousands of years old. That means we were walking the same path that the Romans did and the millions of people who passed through this during the year. There is so much history in just one walkway.
Despite the initial culture shock, students ultimately felt enriched by their cross-cultural experiences, recognizing the value of understanding and appreciating differences. One student who highlighted the challenges of language barriers said:
There was definitely a large language barrier. We actually had to attend a language school while we were there. It was a little bit difficult for me to understand because I have never learned a foreign language in my life.
Another student who reflected on the differences in nursing practices between Italy and the U.S. stated, “I feel like I learned a lot about the differences in nursing in Italy compared to the U.S.”
Transformative journeys. The experiences in Italy also led to significant personal growth and transformation. Students described their journeys as transformative, with cultural immersion playing a key role in driving meaningful change. One student recounted:
The blood pressure screening...was one of my favorites because it was one of the times that you got to directly interact with residents of the town and people that actually lived there. You could just see how excited they were that we were providing this service for them and totally free....Being able to provide education was really special.
These hands-on experiences allowed the students to deepen their cultural knowledge and understanding, particularly in health-related practices. One student who openly shared her personal growth said, “I learned a lot about other countries' culture along with learning things about myself, such as being open to others' opinions andopening up to people I don't know.”
Emotional engagement. The theme of emotional engagement captured the range of feelings students experienced, from enthusiasm and fascination to more complex emotions. These emotional responses were tied to the students' ability to conduct culturally sensitive assessments and provide care that was mindful of their patient's physical, spiritual, and psychological needs. One student, reflecting on the deep connection formed through shared meals, noted:
Growing up in a southern household, I know that the kitchen is where generations of memories are made and traditions are passed down. I couldn't help but feel like we were getting a small glimpse into the Italians' kitchen, and I could feel the love that goes into making a meal from scratch for the ones that you love the most.
Another student who shared having emotional connection to Rome said, “I think Rome was the most memorable for me throughout this trip, just because of all the history that is there and getting to understand another country and culture that isn't America.”
Cross-cultural experiences. Cross-cultural experiences were crucial to the students' learning, helping them build cultural competence through direct interactions. Shadowing nurses in local hospitals provided insights into the intersection of culture and health care delivery. One participant who cherished the opportunity to shadow a home health nurse stated:
I was so fortunate enough to experience riding around to all the smaller towns of Montepulciano and getting to shadow a home health nurse. I really enjoyed seeing how the nurse interacted with patients and their families, and getting to go into the locals' homes and see what their life looks like. It's something I will always cherish.
Additionally, students appreciated the kindness and hospitality of the Italian nursing staff. One student noted, “Being so welcomed by the Italian nursing staff was such a great feeling.It was such a pleasant surprise. I will cherish every nurse I met forever.”
Another student said:
Visiting the hospital in Montepulciano has absolutely been one of my most favorite clinical experiences in this nursing program to date. I genuinely enjoyed touring the hospital and visiting different departments.[I] also enjoyed partnering up with the community health nurse.
Joyful appreciation. Lastly, the students enthusiastically appreciated their opportunities and experiences in Italy. This theme of gratitude and enthusiasm underscored their motivation to seek out cultural encounters and embrace new experiences. One student said:
While we were [in] Montepulciano, we had the privilege to shadow some of the nurses at the hospital outside of town....Another privilege that we were offered while we were in town was the chance to take a real cooking class and make homemade pasta from a real Italian chef.
The students' appreciation for Italy's historical sites further reflected this heartfelt recognition of life's blessings. One student, reflecting on visiting the Trevi Fountain, noted:
Before coming to Italy, I had previously heard of the Trevi Fountain and I've seen it in multiple TikToks, but I didn't think too much of it. But seeing it in person was a completely different thing versus seeing it in pictures. It is very grand, very beautiful, and it was one of my favorite landmarks that I saw.
Overall, these themes highlight the profound effect of cultural immersion on the students, shaping their perspectives, fostering personal growth, and deepening their appreciation for cultural diversity.
Mixed-Methods Analysis
The mixed-methods analysis revealed convergence between the constructs measured by the IAPCC-SV and the themes uncovered from the qualitative journal analysis. The quantitative improvement in cultural competence scores was supported by the experiences described in the students' journals, and the themes aligned with many of the constructs of cultural competence outlined in Campinha-Bacote's (2018) theory. The joyful appreciation theme uncovered during qualitative analysis is synergistic with the construct of cultural desire, as students expressed a genuine appreciation and enthusiasm for seeking out new cultural experiences. Similarly, the theme of cross-cultural experiences supports the development of students' cultural skill and their understanding of the effects of culture on health care delivery. Notably, the theme of embracing diversity demonstrates the influence of studying abroad on students' cultural awareness, as they described an awareness of their preconceived notions and how the experience caused a reframing of beliefs. Integrating quantitative and qualitative findings provides a comprehensive understanding of the effects of this short-term study abroad program. The significant improvement in cultural competence scores, with exceptional increases in the constructs of cultural desire and cultural awareness, is enriched by the qualitative understanding of the student experience.
Discussion
The quantitative analysis suggests both statistical and practical significance, emphasizing the substantive effect of the study abroad program on enhancing cultural competence among nursing students. The results highlight the potential of immersive study-abroad experiences as a valuable tool in promoting cultural competence, with specific attention to the constructs of cultural desire and awareness. Identifying these significant changes provides educators, curriculum developers, and policymakers valuable insights into refining nursing education programs to prepare students for culturally diverse health care environments.
The study abroad program was intentionally designed with activities that supported each of the five constructs of cultural competence. The diverse elements of this study abroad program and which constructs each activity supports are outlined in Table 3. The authors thought it was necessary to infuse various activities into the program so that each construct of cultural competence could be developed. Activities that supported cultural awareness included predeparture meetings, reflective activities in-country, community dinners, and reflective journal presentations. Reflection and debriefing sessions in these activities were crucial in helping students gain new insights regarding their experiences. These results are similar to results reported by other authors and emphasize the importance of reflection and debriefing in educational experiences (O'Brien et al., 2021; Steppe et al., 2022; White & Louis, 2023). This self-awareness is also crucial in preventing potential biases from affecting patient care. The results indicate the students' cultural awareness improved significantly, unlike findings reported by Morgan (2023), as a result of the purposefully chosen activities throughout the study abroad.
Activities that supported cultural knowledge included pre-departure meetings, cultural competence seminars, nursing clinical experiences in Italy, and visits to historical landmarks. These cultural knowledge findings substantiate those that found by O'Brien et al. (2021) in their integrative review. Cultural skill, or the ability to provide culturally appropriate care, includes adapting communication styles, treatment plans, and interventions to align with patients' cultural preferences and needs. Activities supporting cultural skill included the service-learning experience, nursing clinical rotations, and Italian language lessons.
Students' cultural encounters in the study abroad program included the service-learning experience, nursing clinical rotations, and their day-to-day interactions with residents of the local community. Although internationalization at home has financial and logistical advantages, the effect on cultural competence is not as profound (Booth & Graves, 2018; Carlson et al., 2017; Gavin Knecht et al., 2019; Levey, 2020).
Lastly, cultural desire is the aspiration and commitment to become culturally aware and deliver culturally competent care. It signifies a genuine eagerness to embrace diversity and make every effort to meet patients where they are, ensuring their health care experiences are respectful, accessible, and aligned with their cultural values. Activities that supported cultural desire during the study abroad included the service-learning experience, nursing clinical rotations, and predeparture meetings. However, it is essential to note this elective study abroad course was optional for the BSN curriculum. This element of choice demonstrated these students already possessed cultural desire; the results indicate the chosen activities and immersive experience improved students' cultural desires even further than other constructs.
Limitations
Although these results are promising, this study had limitations. The cohort of nursing students was small and included only female students, limiting generalizability. The study was conducted at a single site within one elective nursing course. Additionally, this nursing elective was only open to some students in the school of nursing, given that only a limited number of spots were available, and placement was awarded based on completion of prerequisite requirements and the timeliness of applying for the elective study abroad experience. Finally, the procedure of this study only allowed for an assessment of students' cultural competence at one point in time, soon after the completion of the study abroad experience. The data do not represent students' capacity for cultural competence over time, and the data cannot confirm the long-standing foundation of cultural competemility. Acknowledging the dynamic nature of cultural competence, which may diminish without continued reinforcement, is crucial. Longitudinal studies are essential to assess the longevity and effectiveness of these interventions in maintaining cultural competence among nursing graduates. Despite these limitations, this study provides promising information regarding how nursing faculty can foster cultural competence in undergraduate nursing students using comprehensive theory-designed short-term study abroad experiences.
Conclusion
This study highlights the efficacy of theory-designed study abroad programs in enhancing BSN students' cultural competence. Supporting the development of students' cultural competence has been a long-standing challenge within nursing education. However, preparing BSN students to care for patients in a diverse society is vital. This study is unique in that the educational activities within the study abroad were designed to support each construct of cultural competence. This study goes beyond the broad evaluation of cultural competence and analyzes individual constructs within the IAPCC-SV. This in-depth approach allows for greater insight into the effects of educational activities on the specific constructs of cultural competence. In turn, these results can provide valuable information for educators looking to develop interventions that can have a maximum effect on students' cultural competence.
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From WellStar School of Nursing (KSL, AW) and School of Data Science and Analytics (AB), Kennesaw State University, Kennesaw, Georgia.
Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.
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