The value of international service learning (ISL) programs in exposing students to diverse cultures and ways of living is well recognized in nursing. What is lacking is a sufficient body of knowledge regarding the effectiveness of these programs in enhancing cultural competency. Effective evaluation tools are needed to understand the impact of students' experiences in ISL programs in order to justify the validity of these programs in an undergraduate curriculum. Several instruments exist to measure cultural competency and transcultural self-efficacy pre- and postexperiences (Bentley & Ellison, 2007; Caffrey, Neander, Markle, & Stewart, 2005; : Green, Comer, Elliott, & Neubrander, 2011; Kuehn et al., 2011; St. Clair & McKenry, 1999), however there has been less development of instruments to quantitatively evaluate the impact of ISL programs.
Measuring the impact of ISL programs has become of keen interest among current researchers and nurse educators. Bringle and Hatcher (1996) noted that most of the evidence on learning outcomes is based on self-report measures of attitudes and beliefs. They suggested that researchers move to more genuine forms of evidence, such as structured narrative reflection prompts that capture more closely the impact of student service learning experiences in higher education. A mixed methods approach that includes a quantitative instrument and a structured reflective model may be useful in quantifying and more precisely understanding the nature of the impact (Curtin, Martins, Schwartz-Barcott, DiMaria, & Soler-Ogando, 2013; Martins, Curtin, & Schwartz-Barcott, 2013). This study addresses this need by using a mixed methods approach combining the international educational survey (IES) and critical reflective inquiry (CRI) narratives to evaluate the impact of an ISL program in the Dominican Republic (DR) for baccalaureate nursing students.
Given the trend in globalization, the challenge for nurse educators is how to prepare nurses for the care of patients from diverse cultures. Bentley and Ellison (2007) argued that “the combination of an international immersion experience with a service learning methodology provides an excellent opportunity for students to develop cultural competency skills and may be a valuable method for nursing faculty to use in meeting the challenge of providing nurses prepared to deliver quality care to our increasing multicultural society” (p. 210). It is important to consider the implications of this pedagogy, especially in terms of its value and measureable outcomes (Bosworth et al., 2006; Forsey, Broomhall, & Davis, 2012; McKinnon & Fealy, 2011; Shultz, 2011).
Research has shown that nursing students who participate in an international nursing experience benefit greatly, including but not limited to increased cultural sensitivity, increased self- awareness of one's own cultural values, critical thinking, problem solving, increased self- confidence, and the ability to navigate and communicate in an unfamiliar environment (Bosworth et al., 2006; Edmonds, 2012; Larson, Ott, & Miles, 2010; Levine, 2009; Maltby & Abrams, 2009; Ruddock & de Turner, 2007; Walsh & DeJoseph, 2003; Wood & Atkins, 2006). The generalizability of these results, however, has been limited due to small sample size, differences in program content, methods, and evaluation criteria. More information is needed on existing programs, and research is needed to explore and document the outcomes of cultural immersion programs to establish curriculum guidelines for institutions nationwide (Leffers & Mitchell, 2011; Maltby & Abrams, 2009).
The international service learning program in the DR. This program is offered by the College of Nursing at the University of Rhode Island as a three credit course that aligns with Riner's (2011) framework for globally engaged nursing education and consists of institutional and program mission and goals, global health core content, preexperience, on-site, and postexperiences (Curtin et al., 2013).
The international education survey. A long-standing quantitative instrument used for measuring the impact of international educational experiences is the IES (Zorn, 1996). It was initially developed to measure the long-term impact of a range of international study abroad experiences offered for baccalaureate nursing students at the University of Wisconsin from 1979 to 1993. Since then the instrument has been used in a variety of international programs, including developed and developing host countries, and different levels of nursing education (DeDee & Stewart, 2003; Smith & Curry, 2011; Thompson, Boore, & Deeny, 2000).
The IES consists of 29 items, grouped according to four dimensions: professional nursing role (5 items), international perspectives (7 items), personal development (13 items), and intellectual development (4 items) (Zorn, 1996). Questions related to the professional nurse role dimension focus on the degree to which the international education experience (1) had an impact on professional practice, (2) was relevant to the professional career, (3) enhanced effectiveness as a professional nurse, (4) improved efficiency as a professional nurse, and (5) affected progress as a professional nurse. The focus in the international perspective was on global understanding or changed perspectives about one's own or the host culture, while the questions related to the personal development dimension covered the impact on personal decisions and philosophy, values, and beliefs. The intellectual development dimension focused on critical or systematic thinking, language study, and change in reading habits. Participants responded on a 7 point Likert scale, ranging from 1 (low/small) to 7 (high/large). The instrument was reviewed by content experts before its initial administration. Zorn (1996) reported an alpha coefficient of 0.97 for the administration of the instrument, with 0.88 for the professional nurse role, 0.89 for international perspective, 0.94 for personal development, and 0.85 for intellectual development.
Overall, Zorn (1996) and others (DeDee & Stewart, 2003; Smith & Curry, 2011; Thompson et al., 2000) have reported a positive long-term impact (anywhere from 3 months to 15 years) of international experiences on nursing students. Scores on each dimension also have highlighted the positive impact, although the rank order of dimensions has varied across studies. Means across studies ranged from M = 5 to M = 6 for the international perspective, M = 4.1 to M = 6.2 in the professional nurse role, M = 4.4 to M = 6.1 in personal development, and M = 3.5 to M = 5.4 in intellectual development.
In terms of factors influencing the level of impact, Zorn (1996) found a positive correlation with length of program. Zorn (1996) and DeDee and Stewart (2003) reported decreases in impact based on time since graduation. Thompson et al. (2000) found that program location had an impact, with it being stronger in developing versus developed countries. Age of student was correlated with level of impact but in contradictory directions, being positive in Zorn's study and negative in DeDee and Stewart's study.
Critical reflective inquiry. Many researchers and educators (Bringle & Hatcher, 1996; Edmonds, 2010, 2012; Larson et al., 2010; Maltby & Abrams, 2009; Mezirow & Taylor, 2009; Riner, 2011) strongly recommend structured reflection as an important component in the personal and professional development of students and as a method to evaluate the impact of ISL experiences. Kim's model for CRI (1999) is a useful approach for this purpose. It was first published in 1999 as a guide for structured reflection and to enhance reflective thinking among practicing nurses. Subsequently, it has been used to teach baccalaureate nursing students how to reflect on their clinical experiences and become “reflective practitioners” (Kim, Clabo, Burbank, Leveillee, & Martins, 2010). In addition, Curtin et al. (2013) analyzed student narratives from a CRI assignment to gain an in-depth understanding of the impact of an ISL program.
CRI was derived from action science and critical philosophy and aimed at understanding the nature and meaning of practice to practitioners, correcting and improving one's practice through self-reflection and criticism, and generating models of good practice (Kim, 1999). It consists of three phases: descriptive, reflective, and critical/emancipatory. In the first phase, a comprehensive description is written of a specific instance of practice. In the second, one identifies and examines one's underlying beliefs, assumptions, knowledge, and intentions related to the situation. Lastly, one considers what could have been done differently and what one might change in the future. By linking the reflection process to intended learning objectives and goals, students can then begin to articulate learning about global engagement, cultural differences, personal and professional growth (Mezirow & Taylor, 2009; Riner, 2011).