Nursing students’ experience of a transformative approach to teaching cross cultural clinical decision making

Theoretical basis to course

Tanner’s Judgment Model 4], [5], [6 was used to guide development and delivery of this course. Tanner’s model provided a framework to assist students to focus on a consistent set of aspects to guide decision-making through noticing, interpreting, responding, and reflecting as groups of cross university teams explored meanings through cross-cultural understandings, for case study patients and family members. Leininger’s theory was applied to emphasize how nursing students considered creating culturally congruent, safe, and meaningful care (2002). Each case study was intended to help study groups consider in each country’s cultural context of whether to: (a) support preservation/maintenance of their current suggested care; (b) suggest accommodation through negotiation within student groups for suggested care; or (c) explore how to re-pattern and restructure the proposed care. Mezirow’s theory was used to assist learning evolution at three levels (1) instrumental (focusing on managing their learning environment to recognize, to interpret and to act together for their decision-making), (2) communicative (focusing on their understanding and interpretation of meanings of each other’s views), and (3) epistemic assumptions (considering known evidence, and experiences to challenge previously held assumptions, formulating and acting on alterations for their proposed cross-cultural care). These three reflective levels were applied to support an active, student-centered approach to their guiding meanings shared within learning experiences [7]; and (b) develop learning structures and processes to facilitate cross-cultural cooperation, and participation among student groups.

The authors set an assumption that meaningful learning could be created if facilitators provided students freedom and confidence to learn in an online classroom, to develop their own solutions to nursing, health system and family problems through sharing their CDM knowledge and skills [8]. Our approach was to foster students’ discovery and deeper understanding of concepts and issues that could challenge their fundamental cultural beliefs for new perspectives.

Course design

Course designers and facilitators paid attention to key course design aspects to allow for shared decision-making outcome among students (see Table 1 for course learning goals).

To achieve course objectives four goals were set to: (1) provide a cross-cultural online learning experience for groups of students; (2) stimulate their learning transformation of previous knowledge, skills, and decision-making; (3) focusing learning on three cultures – country cultures (Canada and Rwanda), health system cultures, and nursing practice cultures; and (4) assess the impact of the learning activities provided.

Learning environment

Group problem-based learning was provided through use of case studies that became connectors for the entire course. Case studies focused on primary care contexts designed to encourage students to gain insights into how health and social issues within families need to be addressed in their nursing care planning (see Table 2 for case study scenarios below).

To ensure students were exposed to cross-cultural experiences they were required to focus on cultures from both country perspectives. To achieve this goal student groups were required to meet virtually and focus on the three levels of cultures stated earlier. To set the direction in their CDM, at the end of each case study a scripting was provided to facilitate student shared group work. The student groups had a two-week timeframe to complete each case and were required to both develop and provide an online presentation of their shared group work for each case study.

Facilitators were available to support students in their assigned groups (4–5 groups). Facilitators along with all students in their assigned groups were expected to listen to each group’s presentation and carry out shared evaluations on group creativity, and total group participation. At the end of the course all students were required to submit their overall course reflection on their learning. The next part of the paper will present the qualitative analysis of the students’ final reflections.

Design

A qualitative descriptive thematic analysis using Clarke and Braun’s [9] six steps of thematic analysis– familiarization with data; coding; searching for themes; reviewing themes; defining and naming themes; and writing was employed in analysis of the students’ final course reflections related to their perceived meeting of both the four overall course goals and learning.

Student reflections

All students submitted reflections of their learning as per course requirements. Student reflections were linked to a course grade. However, of 146 student reflections submitted only a total of 94 (67.1 %) were considered as having sufficient detail for this qualitative analysis. Each reflection ranged from two to five pages in length with an average of four pages.

Theme 1: becoming more open-minded and curious

After completing the course, students shared what the course learning provided for them. Students talked about how they became more open-minded and curious to others’ views. The course stimulated their focus on dealing with uncomfortableness in the provided online environment, and how their group work and case studies facilitated their learning. Initially there was discomfort about working online with their group members; students from WU wondered how well online communication would be with students from UR and were surprised to learn “they were familiar with using “What’s App” (Site 1). What’s App became a common means many of the student groups used throughout the course. Other students also commented on the need to overcome connecting challenges associated with language and time differences to work effectively together in their groups. A student shared: “I think we worked well as a group, however the time difference made communication difficult at times. Our group solved this issue by planning designated times in the day to discuss the case study” (WU). Many students also expressed feeling discomfort initially and shared the need to “keep an open mind to fully understand and interpret others’ views” (UR) as the case studies were discussed.

Students also shared how keeping an open mind to alternative views and approaches to care was transforming. “Before the course, I had in my mind what are done in Rwanda only. After completing all case studies, I have learned many things according to different ways used in answering all cases, such as assessment, setting goals and planning. I have gained much in the way others shared their views” (UR). Another student stated being open-minded also led “to see our patient or family as a whole and consider different approaches to implementing health intervention. It also helped me to see how each person fits in the family and how they contribute to the health problem the patient is facing” (UR).

Students mentioned as they moved through cases, they became more curious about what they could learn and share with each other. As one student shared “I am interested in gaining a greater understanding of the different social services available in Rwanda during our next case study (WU). Another student remarked on how being curious about their group members was helpful “I learned to ask questions before rejecting [ideas]” (WU).

Overall, a consistent comment from students was about the value of the case studies in their learning. Students shared “there are some nursing interventions that I didn’t know about. The case studies increased my knowledge” (Site 2); “as we learned more about the Rwandan culture and resources available our decisions improved as we could make more realistic and feasible suggestions” (WU).

Working through the cases helped the student groups gain a more in-depth understanding about how health care differed between their two countries. Sharing their personal knowledge and listening to others’ perspective also led to an increased awareness of each other’s approaches to managing diseases and social issues in families. They commented on how they now see value in using cultural considerations in CDM. In summary within this theme students shared how the course assisted them in achieving the course goals of experiencing online learning experiences with cross-cultural nursing students (goal #1) and how focusing of learning on three cultures was valuable to their learning (goal #3).

Theme 2: transformation following learning

The second theme related to what students shared about their new learning and how it led to changes in how they now viewed their own nursing practice. Moreover, the learning helped them in their working with clients who are from other cultures. Several categories were captured within this theme including increased critical thinking, realization of similarities in nursing practice across cultures; enhanced teamwork; acknowledging prejudices; and being aware of beliefs.

Students shared that course work helped “gain increased reasoning and deeper thinking skills because I needed to think and recall what we discussed and come with” (Site 2). Another stated “before the course, I had in my mind what are done in Rwanda only. After completing all case studies, I … learned many things … used in answering all cases, such as assessment, setting goals and planning” (Site 2). “I have gained [from] the way others shared their views” (Site 2). One student reflected “up to this point I had never worked through such complex cases in my nursing education. Clients in these case studies not only had … health issues, but there were numerous social factors that needed to be addressed in order for the client to heal” (WU).

What changed in the last 13 weeks “relates to improving decision-making in delivering care to patients by actively involving patients in decision-making” (UR) and another shared the importance of focusing “… on patient ability, whether financially or psychosocial, because sometimes they are unable to participate … due to one of those issues” (WU). “I realized that being able to interpret the health of the patient relies heavily on family and cultural context. Without being aware of these, it can hinder care from being culturally competent and culturally safe” (WU). Students also discussed development of more refined researching skills than previously learning in their programs. “I learned the importance of in-depth interviews and time with the client. This has reinforced the idea that each client is different and has different social factors that influence their health and decision-making processes” (WU). “This intercultural course helped me increase my knowledge in doing research. It stimulated my mind to work hard by improving my critical thinking from the time we started exchanging ideas and reflecting on case studies” (UR). “I have learned something important in this course on how the Canadian Healthcare System works and what we can imitate to improve care delivery here in Rwanda” (UR).

The sense of personal growth was shared by another student “We have become experts in managing cases, which is helpful as it will help us provide quality care to the clients in our country and worldwide because we have learned so many things concerning cultures and nursing norms of different countries” (Site 2). Another student shared “this course helped me … to learn that nurses are the first point of contact in the healthcare system, and then if needed they can refer to a doctor. A system like this could be very beneficial in Canada” (WU). Students shared how their teamwork evolved as they worked through cases. Groups reported how they utilized online social media platforms to ensure consistent communication among team members while working on case studies and preparing presentations. These platforms helped groups keep an important focus on fair allocation of responsibilities in case study work. A student commented “I had to learn to be patient to get enough information from the Rwandan students and consider their challenges with connectivity and workload … These considerations [helped me] to remember to be flexible with other peer’s schedules” (WU).

Critically reflecting on the content and teamwork involved in each case study led to students evaluating their own biases, and how these could impact their perspectives when working through the cases. One student remarked “as we moved through the case studies, I was able to effectively evaluate my own biases and how they impacted my perspectives when analyzing the cases” (WU). Another student commented “this course helped to improve awareness of my own and other cultures. I developed the knowledge of how using the culture consideration in CDM and sometimes to develop the immediate care plan played a major function to achieve the goals of providing effective care to the patients” (WU). And another felt “better educated on the differences of health care from areas of the world with different health care systems. My pre-existing beliefs regarding the different cultures were that there would be many differences between Canada and Rwanda” (WU).

In summary, students openly shared what they learned from the course and how they will use this learning in their future nursing practice. Their beliefs about each other’s health systems and nursing practice did change from entry into the course. They realized there were more similarities than differences in nursing interventions chosen for the case studies, no matter whether they were from Canadian and Rwandan nursing programs. Changes in themselves were also shared as one student shared as “previously being very opinionated, and not respecting others’ ideas” (WU). Some students shared how they learned to be more careful before verbalizing and asking questions to guard against criticizing or rejecting other group members’ ideas. They reported learning to negotiate variations in CDM for patients’ care and giving control to colleagues that allowed for prioritizing their ideas leading to perceived better patient care. Their open-mindedness allowed them to gain an enhanced capacity in their future practice to see patients and their family for their care. They concluded these aspects helped them to become greater experts in managing cases that they reported would help to give quality care to clients everywhere as they enter their nursing practices.

Becoming more open-minded and curious

Learning about and from each other evolved from shared curiosity. Curiosity, as a concept encompasses an inquisitive mind, a desire to acquire new knowledge, and a drive to explore, that is linked to intrinsic motivation to enhance learning [14, 15]. In nursing education, curiosity for learning is considered a prerequisite to critical thinking and caring 16], [17], [18. Clearly, the course provided a vehicle for a shared curiosity that drove the students to participate in the course.

Following the first case study, almost all students reflected on their curiosity and eagerness to know more about the other students in their group. Thus, the shared cross-cultural members in each group provided opportunities to engage with each other through teamwork that helped them to consider each other’s viewpoints and gain new insights on CDM.

The case study discussions in the groups may have created an information gap [14] that may have stimulated students’ desire to fill the gap by their ongoing group inquiries and seeking more knowledge through reading and asking questions. Reacting to their information gaps seemed to stimulate students’ open-mindedness for seeking different approaches to sharing ideas about case nursing care planning to develop. The case studies also guided students to integrate patients with their families in the care planning. This integration may have caused them to consider both health and psychological issues to address symptoms presented. Furthermore, sharing of perspectives on each case study likely forced them to keep an open mind to understand and interpret other’s views to arrive at a shared plan of care.

Student sharing of differences in cross-cultures and practices in their respective countries seemed to help them adapt to learning environments of both countries, and being able to harness creativity from these cross-cultural experiences may have led to an openness as suggested by Woo et al. [19] and enhance creativity [20] that can evolve from both divergent and convergent thinking processes within the groups.

It was anticipated that students in both sites would experience frustrations and stress with connectivity and there was worry that this might cause students to withdraw from the course [21]. Only one student from Site 1 withdrew once the course began across both years of its delivery. The desire to learn from each other led students to find coping strategies to be able to connect and work through the cases to develop their group presentations. Christensen et al [22] suggested if learning experiences stimulate high order aspects of intellect and open-mindedness among learners’ engagement, they are more likely to continue. Hence the requirement to repeat their group work for each case study may have helped their continuing engagement through the course. In the course presentations the criterion for creativity seemed to stimulate openness and curiosity as well and helped to stimulate their high order learning and insights gained.

Although it was expected that students would experience stress in the course, the acquisition of new knowledge and skills, novelty of the design and its perception as valuable to their ongoing nursing professional practice may have been sufficient to keep it at a level that was manageable in students. Two aspects that might have lessened stress during the course may have evolved from first the flexibility they had for carrying out their group work and the openness and flexibility by group facilitators and their availability online.

Transformation following learning

The second theme shared by the students was how the consequences of what they gained from the course could contribute to their nursing practice. In any learning course it is always the goal of educators to produce an environment that adds to students learning in a meaningful way. While the course delivery from a connectivity perspective was fraught with problems, the course reflections were limited in that criticism. Students worked to find solutions to overcome issues experienced and achieve a level of learning that seemed to be valued for their future practice.

The focus on production of presentations of their case study group learning work seemed to drive students toward solutions from connectivity problems. Site 1 students gained more appreciation of limitations in connectivity outside of industrialized societies.

The students experienced transformative learning and revealed development of their instrumental and communicative learning. Students from Canada and Rwanda affirmed that their learning interactions helped them understand more the differences and similarities between Canadian and Rwandan health systems, and remove bias each had toward the other country, that they reported improved their cultural competencies. The facilitator support, group interactions and work may have led to the outcomes of the course [13, 23].

Other authors found that when students perceived course material to be relevant to real word applications, they engaged in their learning, and students’ engagement in the course and active participation in learning was one of the crucial facilitators for their reported positive learning environment [23–25]. Students’ responses to the opportunities for learning seemed to stimulate their curiosity, open-mindedness, and transformation of their beliefs into new perspectives that they reported they planned to use in their future nursing practice [22].

Implications for International Audience

The findings from this study can assist other nursing educators in understanding the importance of paying attention to the design of learning provided to stimulate Mezirow’s three levels of reflection. Creating a learning environment to stimulate open-mindedness, and exploration of culture among students is critical in planning of patient and family care and key to enhance the future of nursing practice impacting on the health of communities. Students’ experiences of learning gained through this course inform other nurse educators on the benefits of this transformative approach using online learning as a means to facilitate cross-cultural clinical decision-making skills acquisition without the need of students traveling across countries.