• international education;
  • international service learning;
  • nursing education;
  • reflection


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References


To examine the impact of an international service learning experience (ISL) using a quantitative and qualitative approach.

Design and Sample

A descriptive study was used to explore the impact of an ISL experience on global awareness, professional and personal growth with 11 baccalaureate nursing students in the Dominican Republic.


Students participated in a three credit ISL program in the Dominican Republic which included pre- and postexperience seminars and a 2-week, on-site immersion experience.


The International Education Survey (IES) was used as the quantitative measure. Content analysis of Critical Reflective Inquiry (CRI) narratives was used as the qualitative method.


Students reported a high overall impact (M = 5.9) using the IES with high means for the Professional Student Nurse Role (M = 6.10, SD: 0.74), Personal Development (M = 6.08, SD: 0.76), International Perspectives (M = 6.03, SD: 0.71), and a lower mean for Intellectual Development (M = 5.40, SD: 0.69). CRI narratives revealed specific areas of impact, for example, increased empathy and ability to communicate effectively with patients from life situations very different from their own.


Further exploration of the usefulness of various evaluation tools and methodological designs is warranted to understand this type of pedagogy and its' impact on student learning outcomes short- and long-term.

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).

Research questions

The following research questions were used to examine the impact of this program using IES and narratives from CRI:

  1. What is the level of impact reported overall and in each of the four dimensions of the IES by students 3 months after completion of the ISL program in the DR?
  2. What are the ways the students' reflective narratives enhance understanding of the program's impact?


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Design and sample

A descriptive study including IES and CRI was used to examine the impact of the service learning experience in the DR with a cohort of 11 baccalaureate nursing students. Students applied through the Office of International Education at the University of Rhode Island. Eligibility requirements included completion of junior medical-surgical nursing and at least 21 years of age. Spanish language skills were preferred, but not required. The University's Institutional Review Board approved the study. All the students gave permission and completed demographic data and pre- and postexperience questionnaires. The IES and CRI were collected 3 months postexperience. As noted earlier, students were asked to submit one reflection on an experience that stood out in their mind from their 2 week ISL experience in the DR using the critical reflective exercise as their guide. De-identified IESs and CRIs were submitted to a research assistant.


In the academic year 2012–2013, the preexperience included mandatory attendance at four, 2-hr seminars and a final 3 hr informal dinner meeting. Seminars included Riner's (2011) “global health core content” with a major focus on country specific knowledge, service learning, and social consciousness. Students were assigned readings, a book critique and presentation, and development of health educational projects based on the host country's needs. In addition, students' Spanish conversational skills were assessed by faculty and by questionnaire.

The 2-week, on-site experience took place during winter break in the rural southwest area of the DR. Students stayed in pairs with host families, mostly retired nurses and teachers who lived and worked in the community. Host families provided two meals, Dominican style, daily, sleeping arrangements, and intercultural exchange for students.

In collaboration with a Dominican nurse from the public hospital, faculty arranged sites for students and partnered with community agencies. Students were arranged in work groups with a Dominican nurse, public health faculty, and at least one student highly proficient in Spanish. Monday through Thursday of the first week, students participated in five different student service learning activities at four different sites: (1) prenatal and well child clinics at the public hospital, (2) adult day health program, (3) “head start” program, (4) labor and delivery at the public hospital, and (5) primary care clinics. Students conducted nursing assessments, health teaching with interpreters, and presented their health education projects at each site. On Friday, students worked with the nutrition center staff and traveled to the Haitian border to provide nursing assessments and care to a rural community with few resources. On Saturday, students traveled to another campo (countryside) to learn about the community's sustainable health, agricultural, and economic projects for women. The last day, students offered a day camp for over 100 children in a small barrio (crowded, low income, neighborhood) outside of town. The final week, students joined a group of political science students from the same University to participate in a 4-day intercultural academic program focused on public health with representation from medicine, nursing, and social services in the DR. Students completed daily journals and participated in debriefing seminars every other evening to reflect on their experiences.

The posttrip seminar included three sessions, the first being scheduled 2 weeks after the trip. During the sessions, faculty facilitated discussion and assisted students in processing their emotions and reflecting on and evaluating the experience. Three months postexperience, students completed the IES and wrote a narrative reflection, using CRI as a guide, on an experience that stood out in their minds from their 2 weeks in the DR. Three months was selected to provide students additional time to reflect more deeply on the experience. All of the students had been introduced to and completed an initial CRI in practicums in Childbearing and Reproductive Health Nursing, Maternity Health Nursing, Medical-Surgical Nursing, and Psychiatric/Mental Health Nursing. The structuring of the program followed the National Association of International Educators' Statement of Ethical Principles (NAFSA, 2009).


The IES was modified with permission from the author to capture the short-term rather than the long-term impact of the ISL in the DR (C. Zorn, personal communication, October 22, 2012). Questions were modified to reflect the participants' current status as students and not yet professional nurses. In the professional nurse role dimension the phrase “professional nurse” was changed to “student nurse” (Q1, Q3, Q4, Q5) and “professional career” to “nursing career” (Q2). Under personal development “since graduation” was omitted from Q12, “professional” omitted from Q15, and “since graduation” changed to “after graduation in Q20. The overall alpha coefficient was 0.913. Alpha coefficients for the four dimensions were as follows: professional nurse role, 0.898, personal development, 0.859, international perspective, 0.724, and intellectual development, 0.373. The low reliability score on this last dimension is related to one of four questions (To what extent has your international education experience as a student affected your selection of reading materials?) in a survey where the scales were already determined. The response distribution for this question ranged from 1 to 7 and definitely looks like a bell curve centered at 4. The other three questions for this dimension have responses that are clustered at the upper end (4–7) with most responses being at 5, 6, and/or 7.

Analytical strategy

Descriptive statistics (means and standard deviations) were generated for the individual items and the four dimensions in the analysis of the IES data. Scale reliability for this sample was assessed using Cronbach's alpha as a measure of internal consistency. SPSS v21 (IBM, 2012) was used for all analyses.

Students' posttrip CRIs were analyzed using Crabtree and Miller's (1999) template organizing style of content analysis. The template for this analysis included the three phases of CRI (descriptive, reflective, & critical/emancipatory) in relation to the four dimensions of the IES. First, two of the three authors read the entire text (which included all of the CRIs) as a whole, to become familiar with the text and discuss initial impressions as well as corroborate the relevance of the template. Next, a detailed analysis was completed by one of the author's. This included a rereading of the text and segmenting and grouping of content by each phase and dimension. Subsequently, each phase was examined individually. In the descriptive phase, content was coded according to circumstances and features of the situation and the student's thoughts, feelings, and actions. In the reflective phase, focus shifted to the student's reexamination of the situation, in terms of standards, theories, and knowledge, as well as the student's intentions, attitudes, values, and emotions and how they might have influenced the outcomes. In the critical/emancipatory phase, attention focused on correcting and changing less than good or ineffective practice or moving forward to future assimilation of new innovations emerging from practice. Lastly, the above steps were repeated for each of the four dimensions of the IES. This analysis and the findings were then reviewed, discussed, and corroborated by all three authors.

Efforts were made to enhance the trustworthiness, confirmability, and transferability of the findings, criteria established by Lincoln and Guba (1985) to judge the credibility of qualitative research. Trustworthiness was enhanced by the use of an audit trail and interactive comparison of findings by each researcher. Confirmability was addressed by sharing the analysis with researchers involved for agreement. In addition, nursing faculty at national conferences shared their ISL experiences and findings suggesting transferability.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Eleven female, Caucasian, senior (N = 7) and junior (N = 4) nursing students, aged 21–24 years, participated in the ISL program. Other than 1 repeat participant, 80% (N = 8/10) of the students reported international travel to countries for vacation, but no travel to developing countries for service learning. Seventy-two percentage (N = 8/11) had “minimal to some” Spanish language skills, 18% (N = 2) with intermediate Spanish language skills, and one (9%) had proficient Spanish language skills. All of the students reported interest in studying abroad and being immersed in the culture.

International education survey

Students reported a high overall impact (M = 5.9). As shown in Table 1, they also reported similarly high means for the Professional Student Nurse Role (M = 6.10, SD: 0.74), Personal Development (M = 6.08, SD: 0.76), International Perspectives (M = 6.03, SD: 0.71), and a slightly lower mean for Intellectual Development (M = 5.40, SD: 0.69). The means for the 29 items ranged from 4.0, with regard to the extent to which the ISL experience affected one's reading material (Q 26) to 6.91 with respect to reassessing one's life in the United States (Q 17).

Table 1. Professional Student Nurse Role
To what degree has your international education experience as a studentMean SD Range
Had an impact on your practice as a student nurse?6.360.815–7
Been relevant to your nursing career?6.360.925–7
Enhanced your effectiveness as a student nurse?6.180.755–7
Improved your efficiency as a student nurse?5.911.044–7
Affected your progress as a student nurse?6.090.835–7
Grand mean6.100.745–7

As noted above, the professional nurse development role had the highest mean of the four dimensions. In terms of individual items, the highest means (M = 6.36) related to the program's impact on one's practice as a student nurse and relevancy to one's nursing career. The lowest mean (M = 5.91) referred to the improvement in one's efficiency as a student nurse.

In relation to personal development, the highest mean (M = 6.91) related to reassessing one's outlook on life in the United States The lowest mean referred to the impact of the experience on family decisions (See Table 2).

Table 2. Personal Development
To what extent has your international education experience as a studentMean SD Range
Affected your interaction with people from other cultures?6.360.815–7
Affected your travel or study abroad plans?6.550.825–7
Increased the likelihood that you would practice nursing in another country?6.001.553–7
Influenced your practice of nursing?6.270.654–7
To what degree would you encourage all university students to participate in international education?6.820.416–7
Made you reassess your outlook on your life in the United States?6.910.306–7
Affected your family decisions (partner, parents, etc.)?5.182.140–7
Affected your interpersonal relationships (friends, family)?5.551.572–7
Influenced career decisions you will make after graduation?5.911.143–7
Facilitate an intercultural dimension in your volunteer activities?6.181.253–7
Facilitate an international dimension in your social or religious activities?5.821.602–7
Facilitate an intercultural dimension in your social or religious activities?5.551.645–7
Contributed to your level of self-confidence?5.910.835–7
Grand mean6.080.764–7

Regarding intellectual development, the highest mean (6.27), was on enhancing one's motivation and/or after returning to the United States The lowest mean (4.00) reflected the impact of the program on one's selection of reading materials (See Table 3).

Table 3. Intellectual Development
To what extent has your international education experience as a studentMean SD Range
Affected your selection of reading materials?4.001.731–7
Affected your ability to speak/read languages other than English?5.640.924–7
Influenced your intellectual development?5.640.924–7
Enhanced your motivation and/or ability to learn a foreign language after returning to the United States?6.271.014–7
Grand mean5.400.694–7

In terms of international perspectives, the highest mean (M = 6.45) obtained related to the level to which the program influenced one's discussion of international and transcultural issues with other people. The lowest mean (M = 4.82) referred to the degree to which the program enhanced one's understanding of U.S. politics (See Table 4).

Table 4. International Perspectives
To what extent has your international education experience as a studentMean SD Range
Enhanced your understanding of U.S. culture?6.000.895–7
Enhanced your understanding of U.S. politics?4.821.473–7
Influenced your understanding of nursing and health care in other countries?6.360.815–7
Influenced your discussion with other people about international and transcultural issues?6.450.825–7
Facilitated an international or intercultural dimension in your work activities?6.271.353–7
Facilitated an international dimension in your volunteer activities?6.271.014–7
Grand mean6.030.715–7

Critical reflective inquiries

All students selected examples from their first week in the campo where they had the closest contact with Dominicans. Seven students focused on the day spent in a remote, resource poor community 5 min from the Haitian border. Here is how one student described the community.

This was the most devastating village I have ever seen in person. This village had no access to running water, electricity or plumbing. They were currently experiencing a drought and had next to no water available. These people were starving, dehydrated, sick and exhausted.

I found it difficult to even comprehend the lack of resources in this community. Many of the people that came to see us that day were dirty. Most of the children did not have shoes, some not even clothes. They had a layer of filth on them and a lack of water means no way to clean up. Many … told us they were hungry. It broke my heart when elderly woman after elderly woman came in saying they hadn't eaten in days.

Two additional students focused on the setting up and running of rural clinics and two others on the all day “field day” the students held for children in Las Matas. The following is an example of one student's narrative from a clinic.

Proximo! … was called out and up stepped a young girl who appeared to be somewhere in her early teens … She greeted us with a quiet “Hola” in a very timid voice, told us her name and age, politely smiled and took a seat. We started with the general questions … and any other concerns she may have … She explained that she thought she had a vaginal infection. From there we asked about her sexual history, to which she answered yes, she was having sex-and that she was also about 2 months pregnant. The look on her face … hit me hard, as she seemed so confused, lost and scared all at once. Unfortunately, due to the circumstances, there was obviously no way we could run the type of tests we have in clinics and healthcare facilities at home … We were only able to give her a 30 day supply of prenatal vitamins and strongly urge her to try as hard as she could to get to the clinic in Las Matas to be examined and diagnosed as well as to get prenatal care. As we drove home that day back to Las Matas, my mind kept going back to this girl and this moment. I know we provided her with the best care we could given the situation we were in, but I couldn't help but feel as though my heart was heavy with sadness. I tried to put myself in her shoes, tried to imagine the burden of being pregnant at (…such a young age…). On top of that, she had told us the father of the baby was her 20 year old boyfriend, something that was also shocking. I couldn't fathom what she was going through; when I was (…her age…), these were things that never crossed my mind. I know that at such a naïve age, I would not have been able to handle it as calmly and collectively as she did when she talked to us. All of this made me wish I could do more for her and others in situations like her … it made me realize just how much we have to be thankful for when it comes to healthcare in the U.S. That I know I am able to go to the doctors when I have a problem, get a diagnosis, the correct medication and be cured of my symptoms (usually) is amazing in itself.

The IES was of value in providing an initial measurement of the students' views of the relevant, short-term impact that the ISL program had on their professional careers and on their effectiveness and efficiency as professional student nurses. As the above examples illustrate, the CRIs (or qualitative component) tended to bring out more specific areas of impact, for example, the increase in empathy and nonjudgmental attitudes toward clients and ability to communicate effectively with patients from life situations very different from their own.

With regard to the four dimensions, the following involves a student's reflections related to the professional student nurse role.

…I learned the importance of not judging people, especially your own patients. I learned how to look at different cultures, as well as languages and stay calm as opposed to automatically becoming anxious over the barrier. I learned that a language barrier means nothing in the large spectrum of life. People are people and every person matters. Every person should be treated equally. I will give all my clients the same care, compassion and support because that is what every human deserves.

The IES covered major points of impact that were also seen in the CRIs, for example, interaction with people from other cultures, assessment of outlook on life in the United States, and increased level of self-confidence. The CRIs also illuminated how intertwined the impact can be between professional role and personal development. They provided more in-depth information on how this may have come about. It seemed as though in any one situation, the student would move from an emotional and highly personal reaction to a comparison of this situation with those she had encountered in the United States and then to implications for her role as a professional nurse. The following is an example of a student's reflection related to her personal development.

We have clean amazing healthcare facilities, with experienced ranges of staffs, machines on hand, labs within the hospital and so many more reasons to be appreciative to have the system of health care we do in this country. It may be flawed in areas and there may be a lot more to figure out about it, but not enough Americans realize how great we have it … I know because of this day, this experience, I will not only be aware of how lucky I am for the care I receive, but will also be keen to make sure I give the best care I can, wherever I am. I will give all my clients the same care, compassion and support because that is what every human deserves.

The IES captured the very important impact students described in CRIs with regard to an increased motivation to learn and ability to speak another language. In the CRIs, however, students described learning a great deal more than simply learning to speak or read another language. They learned a lot about how to actually communicate with others with another language. They learned how to work with a translator and how one at times can actually communicate quite effectively with minimal or no ability to speak in the patient's (or other's) language.

The most important dimension in the CRIs related to the International Perspective was the enhanced understanding of the U.S. culture. The CRIs gave an intimate sense of how this occurred and thus provided more direct information on how instructors might be able to help facilitative this kind of growth.

There were several other areas related to intellectual development that were not mentioned in the IES, e. g. how people with very low resources cope with illness (including use of indigenous plants and remedies), the diverse range of human experiences, and how basic access to food and water influence the health status and kind of problems encountered (role of economic and social factors in types and frequencies of health problems) and one's ability to cope with these. As one student stated:

…I learned the importance of not judging people, especially your own patients. I learned how to look at different cultures, as well as languages and stay calm as opposed to automatically becoming anxious over the barrier. I learned that a language barrier means nothing in the large spectrum of life. People are people and every person matters. Every person should be treated equally.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Implementing an ISL program in a developing country requires long-range planning by qualified faculty members. It also offers students an opportunity to work with a culturally diverse population and to begin to critically reflect while creating positive and sustainable responses to solutions to international issues. There are several major points to be highlighted in regards to the empirical findings and the use of qualitative and quantitative approaches to measure the impact of ISL programs.

Overall, the students' scores on the IES were very high when compared to Zorn (1996) and others (DeDee & Stewart, 2003; Smith & Curry, 2011; Thompson et al., 2000) (See Table 5), where participants were surveyed 3 to 15 years postexperience. Only one study (Thompson et al., 2000) included participants who had not graduated (N = 31, 42%). In Thompson's study, the students did not respond to professional role development items, whereas in this study survey questions were modified to include the professional role of the student nurse. The higher scores may indicate the initial impact of the experience, but the question remains as to whether these responses will hold over time.

Table 5. Comparison of IES Results Reported for Overall Means on Four Dimensions of the Survey in Five Nursing Studies
Research studySample sizeHost countryProfessional nurse roleInternational perspectivePersonal developmentIntellectual development
Zorn (1996)N = 27England, Denmark, Scotland and Russia4.
DeDee and Stewart (2003)N = 38Brussels, Paris, and London4.
Smith and Curry (2011)N = 36Ecuador5.
Thompson et al. (2000)N = 51Developed4.
Thompson et al. (2000)N = 23Developing5.
This Study (2013)N = 11Dominican Republic6.

Another factor that may influence IES scores is the small sample size. Also, students who participated in ISL may be qualitatively different from students who select more traditional classroom experiences or international travel. In this study, the participants were highly motivated and committed to the experience and a majority had previously traveled internationally.

Other factors that might influence scores are the length of the international learning experience, the type of experience (service learning, study tour, study abroad), and the location of the international experience (developed vs. developing). Thompson et al. (2000) learned that although all students benefited from their immersion experience, those in a developing country gained significantly more in intellectual development, personal development, and global culture perspectives. It may be that the greater the contrast between one's own and the host country, the greater the stimulation of one's thinking, feeling, and development. This could be one reason for the high scores across all dimensions on the IES in this study. Kollar and Ailinger (2002) concurred with Thompson et al. (2000) that these experiences offer unique challenges that cannot be duplicated in developed nations and can leave a lasting imprint on how nurses learn more about cultural competence in providing nursing care for individuals from diverse cultures.

Some modification in the survey may be helpful in enhancing the validity of the dimension on intellectual development. Adding items on increasing social consciousness and global awareness might capture the student's ability to respond to the challenges of globalization and would align well with Riner's (2011) globally engaged nursing education framework. In addition, comparing IES scores of former graduates would provide further information on the usefulness of the quantitative instrument for measuring short- and long-term impact.

The CRI was particularly valuable in capturing the perspective transformation of individual students. It provided rich description and data about the diverse voices of the individual participants and their reflections on the experience. The CRI may be most useful in evaluating the intermediate impact of the students' experience 3 months posttrip whereas the IES may be most beneficial postgraduation in measuring the impact of the experience on nursing practice and professional role development.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References

Program supported by the Ocean State Job Lot/URI President's Partnership Fund. Appreciate the support of the URI Office of International Education especially Dr. Dania Brandford-Calvo and Kelly Watts.


  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Acknowledgments
  7. References
  • Bentley, R., & Ellison, K. J. (2007). Increasing cultural competence in nursing through international service-learning experiences. Nurse Educator, 32(5), 2072011.
  • Bosworth, T., Haloburdo, E., Hetrick, C., Patchett, K., Thompson, M., & Welch, M. (2006). International partnerships to promote quality care: Faculty groundwork, student projects and outcomes. The Journal of Continuing Education in Nursing, 37(1), 3238.
  • Bringle, R. G., & Hatcher, J. A. (1996). Implementing service learning in higher education. Journal of Higher Education, 67, 221239.
  • Caffrey, R. A., Neander, W., Markle, D., & Stewart, B. (2005). Improving the cultural competence of nursing students: Results of integrating cultural content in the curriculum and an international immersion experience. Journal of Nursing Education, 44(5), 234240.
  • Crabtree, B., & Miller, W. (1999). Doing Qualitative Research (2nd ed.). Thousand Oaks, CA: Sage Publication Inc.
  • Curtin, A., Martins, D., Schwartz-Barcott, D., DiMaria, L., & Soler-Ogando, B. (2013). Development and evaluation of an international service learning program for nursing students. Public Health Nursing, 30(6), 548556.
  • DeDee, L., & Stewart, S. (2003). The effect of student participation in international study. Journal of Professional Nursing, 19(4), 237242.
  • Edmonds, M. L. (2010). The lived experience of nursing students who study abroad: A qualitative inquiry. Journals of Studies in International Education, 14(5), 545568.
  • Edmonds, M. L. (2012). An integrative literature review of study abroad programs for nursing students. Nursing Education Perspectives, 33(1), 3034.
  • Forsey, M., Broomhall, S., & Davis, J. (2012). Broadening the mind? Australian studies reflections the experience of overseas study. Journal of Studies of International Education, 16(2), 128139.
  • Green, S., Comer, L., Elliott, L., & Neubrander, J. (2011). Exploring the value of an international service learning experience in Honduras. Nursing Education Perspectives, 32(5), 302307.
  • IBM Corporation. (2012). IBM SPSS statistics for windows (Version 21.0). Armonk, NY: IBM Corporation.
  • Kim, H. S. (1999). Critical reflective inquiry for knowledge development in nursing practice. Journal of Advanced Nursing, 29(5), 12051212.
  • Kim, H. S., Clabo, L., Burbank, P., Leveillee, M., & Martins, D. (2010). Application of critical reflective inquiry in nursing education. In N. Lyons (Ed.), Handbook of reflection and reflective inquiry: Mapping a way of knowing for professional reflective inquiry (pp. 159172). New York: Springer Publishing Company.
  • Kollar, S. J., & Ailinger, R. (2002). International clinical experiences: Long term impact on students. Nurse Educator, 27, 2831.
  • Kuehn, A., Chricop, A., Downe-Wamboldt, B., Sheppard-LeMoine, D., Wittstock, L., Herbert, R., et al. (2011). Evaluating the impact of a North American nursing exchange program on student cultural awareness. International Journal of Nursing Education Scholarship, 8(1), 115.
  • Larson, K., Ott, M., & Miles, J. (2010). International cultural immersion: En vivo reflections in cultural competence. Journal of Cultural Diversity, 17(2), 4450.
  • Leffers, J., & Mitchell, E. (2011). Conceptural model for partnership and sustainability in global health. Public Health Nursing, 28(1), 91102.
  • Levine, M. (2009). Transforming Experiences: Nursing education and international immersion programs. Journal of Professional Nursing, 25(3), 156169.
  • Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. Beverly Hills, CA.: Sage.
  • Maltby, H., & Abrams, S. (2009). Seeing with new eyes: The meaning of an immersion experience in Bangladesh for undergraduate senior nursing students. International Journal of Nursing Education Scholarship, 6(1), 115.
  • Martins, D., Curtin, A., & Schwartz-Barcott, D. (2013). Utilizing quantitative and qualitative approaches to evaluate an international service learning program. Presentation at the Association of Community Health Nursing Educators/American Public Health Nursing Joint Meeting, Evidence-based Population Nursing, June 6–8, Carey, NC.
  • McKinnon, T. H., & Fealy, G. (2011). Core concepts for developing global service-learning programs in nursing. In T. McKinnon, & J. Fitzpatrick (Eds.), Global service-learning in nursing (pp. 1529). New Yok: National League for Nursing.
  • Mezirow, J., & Taylor, E. (2009). Transformative learning in practice. Insights from community, workplace and higher education. San Francisco, CA: Jossey-Bass.
  • NAFSA. Association of International Educators (2009). Statement of ethical principles. Retrieved from
  • Riner, M. (2011). Globally engaged nursing education: An academic program framework. Nursing Outlook, 59, 308317.
  • Ruddock, H. C., & de Turner, S. (2007). Developing cultural sensitivity: Nursing students' experiences of a study abroad programme. Journal of Advanced Nursing, 59(4), 361369.
  • Shultz, C. (2011). Global service-learning and nursing education: Merging with the world through pedagogy. Nursing Education Perspectives, 32(2), 73.
  • Smith, K., & Curry, K. (2011). Is it worth it? Measuring the long-term effects of an international experience for nursing students in Ecuador. Journal of Community Health Nursing, 28, 1422.
  • St. Clair, A., & McKenry, L. (1999). Preparing culturally competent practitioners. Journal of Nursing Education, 38(5), 228234.
  • Thompson, K., Boore, J., & Deeny, P. (2000). A comparison of an international experience for nursing students in developed and developing countries. International Journal of Nursing Studies, 37, 481492.
  • Walsh, L., & DeJoseph, J. (2003). “I saw it in a different light”: International learning experiences in baccalaureate nursing education. Journal of Nursing Education, 42(6), 266272.
  • Wood, M., & Atkins, M. (2006). Immersion in another culture: One strategy for increasing cultural competency. Journal of Cultural Diversity, 13(1), 5054.
  • Zorn, C. (1996). The long-term impact on nursing students of participating in international education. Journal of Professional Nursing, 12(2), 106110.