INCORPORATING CULTURAL CONTENT IN NURSING SIMULATION SCENARIOS. A Project Presented to the Faculty of California State University, Stanislaus

Transcription

1 INCORPORATING CULTURAL CONTENT IN NURSING SIMULATION SCENARIOS A Project Presented to the Faculty of California State University, Stanislaus In Partial Fulfillment of the Requirements for the Degree of Master of Science in Nursing By Mahsa Takhsha May 2015

2 CERTIFICATION OF APPROVAL INCORPORATING CULTURAL CONTENT IN NURSING SIMULATION SCENARIOS by Mahsa Takhsha Signed Certification of Approval page is on file with the University Library Dr. Carolyn Martin Associate Professor of Nursing Date Jean Ann Britt Assistant Professor of Nursing Date Debra Millar Assistant Professor of Nursing Date

3 2015 Mahsa Takhsha ALL RIGHTS RESERVED

4 DEDICATION This project is proudly dedicated to my beloved parents who supported and encouraged me to pursue my dreams and to move beyond boundaries all through my most overwhelming moments away from home. You are my source of strength, inspiration, and everlasting love. Words are not enough to express my gratitude towards you both. To my only family members here in the United States, my dearest sister and her family, who built a comfort zone for me by their side and warmly supported me in my personal and academic endeavors. To my precious siblings in Iran who not only supported me emotionally, but also financially in time of need. Above of all, thank you God for surrounding me with wonderful family and friends, for all your blessings on me, and for helping my dreams come true. iv

5 ACKNOWLEDGEMENTS I would like to gratefully acknowledge my project coordinator and chair, Dr. Carolyn Martin, for her extraordinary support, guidance, and patience throughout my culminating experience and the graduate program. Her enthusiasm, encouragement, and faith in me brightened all the unknown paths and helped me to passionately pursue my academic goals. Thank you for being such a great role model in my life. I would also like to acknowledge my committee members for this project, Jean Ann Britt, PhDc and Debra Millar, MSN, APHN for their kind advice and feedback. I truly enjoyed this experience with your collaboration and I am so grateful for your support of my project idea. Gratitude is also extended to the entire family of the California State University, School of Nursing. To all faculty and friends who helped me live and experience the life of my dreams. v

6 TABLE OF CONTENTS PAGE Dedication... Acknowledgements... iv v Abstract... viii CHAPTER I. Introduction... 1 Overview of the Problem... 1 II. Review of the Literature... 4 Background and Significance... 4 Models of Cultural Competence... 7 Simulation... 8 Cultural Simulation Methods Simulation Games Standardized Patient Health Initiatives Medium to High-Fidelity Simulation Benefits of Utilizing Cultural Simulation Methods Barriers of Utilizing Cultural Simulation Methods Financial Barriers Inaccessibility of Standardized Patients Faculty, Time, Space, and Technological Difficulties Limitations/Future Studies Conclusion III. Methodology Literature Review Madeleine Leininger Madeleine Leininger s Culture Care Theory Sunrise Enabler Model and Application to Cultural Simulation Scenarios Conclusion IV. Results vi

7 The Process of Designing a Simulation Scenario A Culturally Designed Simulation Scenario Template Scenario Overview Curriculum Integration Scenario Script Conclusion V. Discussion and Recommendations References Appendices A. Culturally Designed Simulation Scenario Template B. Sub-Items for the Cultural and Social Structure Dimensions of Leininger s Sunrise Model vii

8 ABSTRACT Ongoing change in population s health needs due to a multicultural society make cultural competence a salient health topic. Therefore, providing safe and effective nursing care to a culturally diverse population necessitates preparing culturally competent nurses. As the quality of nursing instruction improves, nursing schools aim to extend the use of simulation across the curricula. Simulation provides novice nursing students with a safe environment which allows them to learn from their mistakes without fear of causing any harm to patients. The main focus of current simulation scenarios is on biomedical aspects of nursing care and important aspects such as cultural contexts are largely overlooked. Moreover, current simulation based studies lack representation of specific culturally designed scenarios or guidelines for nurse educators. Hence, the purpose of this project is to create a culturally oriented simulation scenario template, using Madeline Leininger s culture care diversity and universality theory. Also, specific components of Islamic culture, which is consistent with the religious background of the author, are integrated as examples in the design of the scenario template. The template is created with the ultimate goal of preparing culturally competent future nurses via an experiential learning method of simulation. Undoubtedly, redesign of transcultural nursing teaching/learning paradigm can be achieved via simulated experiences, where students cultural misconceptions and biases can be safely suspended. viii

9 CHAPTER I INTRODUCTION Overview of the Problem Culturally diverse countries face various healthcare challenges, influencing both patients and healthcare providers. Data from the 2010 United States (U.S.) Census Bureau s report reveals considerable growth in racial and ethnic diversity of the U.S. population during the past decade (Humes, Jones, & Ramirez, 2011). Also, the U.S. Census Bureau (2012) projects that, minorities (all but the single-race, non- Hispanic white population) will be more than doubled, increasing from 37 percent to 57 percent by the year Undoubtedly, ongoing change in the population s health needs due to a multicultural society will make cultural competence a salient health topic (Koskinen, Abdelhamid, & Likitalo, 2008). Providing safe and effective nursing care to a culturally diverse population necessitates preparing culturally competent nurses. According to Purnell (2005), cultural competence includes characteristics of both cultural knowledge and skills in providing competent care to patients. Cultural competence is defined as: An individualized plan of care that begins with performing an assessment through a cultural lens (Purnell, 2005, p. 2). In other word, cultural competence includes accepting and respecting one s cultural beliefs and differences while being involved in acquiring cultural skills and knowledge in the provision of healthcare (Roberts, Warda, Garbutt, & Curry, 2014). 1

10 2 Schools of nursing have developed various teaching/learning strategies in an effort to integrate the essential core element of cultural competence in their academic curriculum. As the quality of nursing instruction improves, nursing schools have incorporated simulation modalities in their curriculum in order to enrich transcultural courses and to prepare culturally competent future nurses. However, the nursing literature lacks culturally designed simulation scenarios or guidelines to assist nurse educators accomplish this task. McCaughey and Traynor (2010) described simulation as a complement to traditional training. Simulation can provide the students with a safe and controlled setting in which they can learn from mistakes without fear of causing any harm to patients (Gore, Hunt, Parker, & Raines, 2011). Decker, Sportsman, Puetz, and Billings (2008) depicted the spectrum of simulation typology based on complexity and fidelity which ranges from partial task trainers (low-tech simulators) to full-scale simulation (medium to high fidelity). Current simulation modalities that have been utilized by colleges of nursing for improving novice nursing students cultural competence and awareness of diverse populations include cultural simulation games, standardized patients, High-Fidelity Patient Simulation (HFPS), and low-tech simulation (Graham, & Richardson, 2008; Grossman, Mager, Opheim, & Torbjornsen, 2012; Koskinen et al., 2008; Ruth-Sahd, Schneider, & Strouse, 2011; Rutledge, Garzon, Scott, & Karlowicz, 2004; Rutledge, Barham, Wiles, & Benjamin, 2008; Spinner-Gelfars, 2013). In order to evaluate the effectiveness of each of the culturally designed simulation modalities in preparing

11 3 culturally competent student nurses and to present a culturally oriented simulation scenario template, the author has conducted a comprehensive review of literature. This project discusses the findings from this systemic review of the relevant nursing literature. Furthermore, the appropriate integration of cultural domains of care in developing a simulation scenario template, utilizing Madeleine Leininger s cultural care theory, will be presented and offered in this culminating experience. The author believes that the simulation milieu has potential for depicting culturally diverse patient encounters and can be utilized for the ultimate goal of preparing culturally competent future nurses.

12 CHAPTER II REVIEW OF THE LITERATURE Background and Significance Globalization and cultural diversification in the United States (U.S.) have created substantial healthcare challenges, which highlight the need for further focus on topics such as culture and culturally competent care. Culturally competent care is defined in detail later in this chapter. Culture is defined as the learned, shared, and transmitted values, beliefs, norms, and lifeway's of a particular culture that guides thinking, decisions, and actions in patterned ways and often intergenerationally (Leininger, 1991, p. 47). As the complex concept of culture manifests in different ways and levels of depth in each group of people, identifying and acknowledging patients cultural differences are of high priority in providing most efficient care. The Office of Minority Health (OMH) considers delivery of equitable and respectful care to the culturally diverse population as a means of eliminating healthcare disparities, and as a principal standard of the National Culturally and Linguistically Appropriate Services (OMH, 2013). Health disparities are the reflection of differences in socioeconomic status, ethno racial background, and level of education, which create a gap in the quality of health and healthcare (National Institute of Allergy and Infectious Diseases, 2013). Many issues such as access to healthcare and high risk of diseases from underlying environmental and biological 4

13 5 factors contribute to health disparities (National Institute of Allergy and Infectious Diseases, 2013). Minorities (all but the single-race, non-hispanic white population) will constitute more than half of the U.S. general population by the year 2060 (U.S. Census Bureau, 2012). Roberts, Warda, Garbutt, and Curry (2014) reviewed three reasons for the significance of demographic change in the nation s population, which include lack of diversity in the nursing workforce, burden of chronic diseases among minorities, and social factors such as institutional discrimination. They also discussed current initiatives to address diversity and cultural competency in the provision of healthcare. Among all the aforementioned reasons, lack of diversity in the U.S. nursing workforce and underrepresentation of the ethnically and culturally diverse population are the most important culture related health topics in the nursing profession. According to the U.S. Department of Health and Human Services, Health Resources, and Services Administration (2010), white, non-hispanic Registered Nurses (RNs) comprised almost 82% of all the employed nurses, whereas Black/African American, Hispanic/Latino, and Asian RNs respectively represented 5.6%, 3.9%, and 5.8% of all the employed nurses. Lack of nursing workforce diversity further impacts upcoming healthcare challenges that arise from the persistent growth in the minorities population. This results in the deprived capacity of culturally and ethnically diverse nursing staff to address this issue. One of the current initiatives to rectify the problem is to integrate

14 6 application of culture in the nursing curricula in addition to the promotion of minority students enrollment in the colleges of nursing (Roberts et al., 2014). The concept of cultural competence in the provision of healthcare has emerged as in an attempt to reduce prevailing substantial health disparities among the nations minority population (Roberts et al., 2014). Clearly, preparation of culturally competent and diverse nursing students who share parallel patient beliefs and values will result in high quality nursing care and further positive patient outcomes. In an effort to apply the theoretical concept of culture in nursing practice, academicians have considered simulation as a component of the nursing curricula. Although integration of simulation modalities into the didactic education of cultural content is limited, review of nursing literature revealed growing utilization of simulation as a means of changing academic pedagogy and improving delivery of culturally competent care in the nursing profession. Current simulation modalities vary in terms of technological advancement and fidelity. However, nursing research lacks comparison and identification of the most effective simulation approach. The aim of this chapter is to present findings from the literature review on the integration of simulation methods in the training of culturally competent nursing students and to answer the first proposed question of this project: How can simulation effectively prepare culturally competent nurses? First, the significance of the term cultural competence in relation to nursing practice will be discussed using Purnell s and Campinha-Bacote s cultural competence models (Campinha-Bacote, 2002; Purnell, 2005).

15 7 Models of Cultural Competence Ongoing change in population s health needs due to a multicultural society make cultural competence a salient health topic (Koskinen, Abdelhamid, & Likitalo, 2008). It is imperative that nurses consider the cultural background and differences of their patients in an effort to provide fair and culturally competent care. According to Roberts et al. (2014), cultural competence includes accepting and respecting one s cultural beliefs and differences while being involved in acquiring cultural skills and knowledge in the provision of healthcare. Likewise, nurses should consider the concept of cultural awareness. Cultural awareness is an engagement in the process of self-examination and exploration of cultural background by the healthcare professionals (Campinha-Bacote, 2002). Recognizing preexisting biases and assumptions about other cultures will assist healthcare professionals in impeding the effect of those feelings on the provider-patient relationship (Rutledge, Garzon, Scott, & Karlowicz, 2004). In other words, engaging in the cultural awareness process, as well as having a desire to honor client s values and beliefs assist in leading to nurses cultural competency (Foisy- Doll, 2013). The process of cultural competence in the delivery of healthcare services is one of the models of service care delivery that defines cultural competence as an ongoing process, which consists of five cultural constructs (Campinha-Bacote, 2002). An interdependent relationship between five constructs that include cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire

16 8 is the major tenet of this model. It requires the healthcare providers to address and/or experience all five constructs when they enter the process of cultural competence. In fact, the intersection of these cultural constructs reveals the process of cultural competence. Through in-depth consideration and internalization of all five constructs, the intersection will become larger, thus culturally responsive healthcare services will be rendered (Campinha-Bacote, 2002). Similar to Campinha-Bacote s model (2002), the Purnell model for cultural competence (2005) focuses on becoming culturally competent rather than being culturally competent. Based on Purnell s model, cultural competence is a process that extends from unconscious incompetence to the unconscious competence stage, where clients of diverse cultures are being automatically provided with the culturally congruent care (Purnell, 2005). In other words, an acquired skill, such as culturally appropriate communication, can be easily rendered without occupying one s conscious thoughts and with minimal chance of errors or offense. The Purnell model for cultural competence consists of 12 domains of culture, through which healthcare providers will be able to analyze cultural data and plan for culturally competent interventions (Purnell, 2005). Simulation The healthcare profession is continuously evolving and training must advance with it. The nursing discipline is not an exception and strives to incorporate innovative teaching/learning strategies into the curriculum and evolves with today s rapidly changing healthcare environment. Simulation is one of the opportunities that

17 9 provide more hands-on training in a safe and controlled environment, which has been used in many professions such as aviation, medicine, and nursing. The modern era of clinical simulation originates in the latter half of 20 th century (Bradley, 2006). Until now, simulation was primarily used by medical students (Bearnson & Wiker, 2005). Since 2000, it has expanded to nursing programs (Megel et al., 2012). According to Bambini, Washburn, and Perkins (2009), simulation provides novice nursing students with a safe environment that mimics the real world and real obstacles of nursing care. Live actors, written scenarios, simulation games, computer simulations, simple mannequins, and human patient simulator are different simulation strategies that have been utilized in healthcare education (Megel et al., 2012). High-fidelity, medium-fidelity, and low-fidelity are three simulation modalities than can be used to teach/learn a variety of skills. Smith and Roehrs (2009) described fidelity as a realism of the experience. Hence, high-fidelity simulators are the most realistic computer-driven mannequins in the both terms of appearance and reactions. Mannequins can even interact with students verbally and provide them with feedback on appropriateness of the interventions that the students may apply (Kuehster & Hall, 2010). Various cultural aspects should be considered when conducting a culturally representative simulation scenario including religious issues, dietary restrictions, language concerns, and family dynamics (Haas, Seckman, & Rea, 2010). Also, proper culture related alternatives can be employed during the simulation scenario such as calling the patient with a culturally specific name, and dressing the

18 10 mannequins with appropriate attire. Hence, nursing students will successfully achieve clinical competence and confidence by experiencing the culturally adjusted simulation scenarios prior to their actual clinical placements (Haas et al., 2010). Cultural Simulation Methods As previously discussed, a variety of simulation strategies are utilized to teach the concepts of cultural competency and awareness in nursing schools such as cultural simulation games, standardized patients, High-Fidelity Patient Simulation (HFPS), and low-tech simulation (Graham, & Richardson, 2008; Grossman, Mager, Opheim, & Torbjornsen, 2012; Koskinen et al., 2008; Ruth-Sahd, Schneider, & Strouse, 2011; Rutledge, Barham, Wiles, & Benjamin, 2008; Rutledge et al., 2004; Spinner-Gelfars, 2013). The following section will discuss findings from a literature review on the effectiveness of each simulation method in preparing culturally competent nursing students. Also discussed earlier, cultural awareness is identified as one of the major constructs of the process of cultural competence in a model by Campinha-Bacote (2002). Hence, improving nursing students cultural awareness, as a basis for progressing towards cultural competence and should be highly considered by nursing programs. Simulation Games Successful utilization of experiential learning methods such as cross-cultural simulation games like Bafa Bafa and Barnga, with the goal of learning cultural awareness in nursing, have been discussed in the studies by Graham and Richardson

19 11 (2008), and Koskinen et al. (2008). Through three phases including orientation, game playing, and debriefing, both games are aimed at stimulating the encounters of culturally diverse people (Koskinen et al., 2008). The value of these simulation games is embedded in identification of self by nursing students which is the prerequisite for holistic nursing care. In other words, upon processing their own cultural knowledge deficit via game playing, students will be able to perceive the world from their patients cultural perspective (Koskinen et al., 2008). Standardized Patient The standardized patient is another simulation method, which is used to improve nursing students culturally competent care of diverse populations. Rutledge et al. (2004) defined a standardized patient as an individual (actor) who has been trained to demonstrate characteristics of a patient. A standardized patient provides students with immediate feedback on history gathering and physical exam conduction. In terms of cultural competence, the feedback will include appropriate or offensive cultural encounters with the nursing students (Rutledge et al., 2004). In order to improve cultural competency of nurse practitioner students, Rutledge et al. (2004) conducted a study using standardized patients to simulate the cultural aspect of patient care. The researchers utilized Campinha-Bacote s cultural competency model (2002) to enhance cultural skills of nurse practitioner students. The cultural competence of the students was evaluated via the development of three formats of standardized patients including group interview, group physical examination, and one-on-one format (Rutledge et al., 2004). Findings from this study

20 12 revealed that students were satisfied with their learning experiences related to standardized patients. Also, increased student comfort levels when encountering culturally diverse populations was evident. Health Initiatives The Health Resources and Services Administration (HRSA) funded nursing programs to increase cultural competence. This initiative incorporated culturally simulation methods, such as standardized patients, in cultural competent training of nursing students with both university-based and distance learning strategies (Rutledge et al., 2008). This program was also based on the cultural competency model by Campinha-Bacote (2002). Nursing students reported positive outcomes for programs using simulated patients. The outcomes included providing increased opportunity for on-line encounters with patients of certain cultures and enhancement of students cultural competence and confidence levels (Rutledge et al., 2008). Medium to High-Fidelity Simulation McCaughey and Traynor (2010) conducted a descriptive study to evaluate the role of medium to high-fidelity simulation in the preparation of nursing students for clinical experience and transition to the role of staff nurse. The findings from the study indicated that the majority of the students report that simulation enhances their patient care competency in clinical settings. Spinner-Gelfars (2013) reported a favorable effect of the HFPS activity in promotion of therapeutic communication skills with culturally diverse nursing students. The HFPS strategy was integrated into a psychiatric-mental health nursing

21 13 course with the goal of enhancing oral communication competency while fulfilling course objectives. Student comments and faculty observational feedback on the HFPS activity were positive. Students indicated that they felt better prepared for real life patient encounters. Benefits of Utilizing Cultural Simulation Methods Overall the benefits of culturally designed simulation methods include improving clinical competence and skills, enhancing patient safety and quality of care, promoting students cultural awareness, decreasing students anxiety and increasing confidence levels, creating an environment of teamwork, and providing a costeffective method for nursing education (Graham, & Richardson, 2008; Haas et al., 2010; Koskinen et al., 2008; Kuehster & Hall, 2010; Rutledge et al., 2008; Rutledge et al., 2004). In addition to aforementioned benefits, the simulation method can provide students with frequent practice of high-risk situations and retention of clinical skills (Kuehster & Hall, 2010). Nursing students may have exposure to multiple patient problems in simulated settings. Hence, they will be more competent in providing safe and effective patients care in future actual clinical experiences. Barriers of Utilizing Cultural Simulation Methods Given the increased use of simulation as a teaching/learning strategy, identifying benefits and barriers of applying this educational method by nursing programs is necessary. Benefits of culturally designed simulation methods are documented in various nursing literature and discussed previously. This section will discuss the barriers to utilizing cultural simulation methods.

22 14 Financial Barriers Rutledge et al. (2004) discussed the cost of simulation methods as a barrier. A standardized patient experience may cost around $400 per student, depending on the objectives of the simulation scenario (Rutledge et al., 2004). Also, it has been estimated that the actual simulator may cost even more than $200,000 (Kuehster & Hall, 2010). However, Rutledge et al. (2008) believed that a simulated environment can be considered a cost-effective educational modality when clinical sites are at a premium and expensive for educating nursing students. Likewise, Kuehster & Hall (2010) estimated that the price of one medical error is higher than the price tag of a mannequin. Inaccessibility of Standardized Patients According to Rutledge et al. (2004), accessibility of an existing standardized patient program is not easy and some schools have to recruit members of the community to meet their simulation needs. In order to assure the realism of the simulation scenario, standardized patients should be selected from different cultural backgrounds and this is feasible with the assistance of community organizations or focus groups (Rutledge et al., 2004). Faculty, Time, Space, and Technological Difficulties Nursing schools try to incorporate simulation into their curricula as a supplement to didactic education, but various factors such as availability of specialized faculty, technical issues, time, and space to establish a simulation center can challenge fulfillment of this goal. Considering a specialized faculty for clinical

23 15 management of the scenario, as well as a facilitator who acts as an observer of students clinical performance is vital for accomplishing the simulation s learning objectives (Waxman, 2010). It is the responsibility of the faculty and the facilitator to manage timing of the scenario, depending on the scenario s objectives and completion of the required skills (Waxman, 2010). Since simulation activities require extended class hours, time efficacy should be considered when integrating simulation into curricula (Spinner-Gelfars, 2013). Another limitation of conducting a simulation scenario, technical ability difficulty, requires both faculty and the facilitator to have technological knowledge of the simulation and to consider alternative activities in the case of complete technical failure (Spinner-Gelfars, 2013). Limitations/Future Studies The comprehensive review of simulation based studies revealed positive outcomes from integrating culturally simulated strategies into didactic education in various nursing programs. However, multiple limitations were highlighted in the reviewed studies. The small sample size and choosing students from one nursing program are the major common limitations that may negatively influence the generalizability of the findings. Also, self-reported data from the qualitative themes of many studies and self-evaluative nature of instruments used for cultural competency are the other limitations. Larger sample sizes, affordability of highfidelity simulation experiences, more reliable evaluative instruments, and evidence on transferability of achieved cultural knowledge and skills from simulation methods to the clinical practice should be considered in future simulation-based studies.

24 16 Conclusion This chapter highlighted the significance of preparing culturally competent nursing students in view of the ongoing growth in the multicultural character of the country and resulting culturally sensitive healthcare needs of the population. The significance of the term cultural competence in provision of nursing care is presented in this chapter, using Purnell s and Campinh-Bacote s cultural competence models (Campinha-Bacote, 2002; Purnell, 2005). Also, the findings from a current literature review revealed little evidence of the utilization of simulation methods in teaching the element of cultural competence in nursing schools. Although many challenges exist for the use of simulation modalities in nursing education, the documented benefits substantiate consideration of simulation as a means of changing pedagogy and providing nursing students with more hands-on experiences. In other words, simulation is a helpful tool in narrowing the know vs. do gap. (Cant & Cooper, 2010, p. 12).

25 CHAPTER III METHODOLOGY Knowledge about the complex concept of culture and its impact on health and well-being of the nation is vital for nurses in all levels of nursing practice. The demographic change of the nation toward considerable growth in minorities population and the cultural diversity by the year 2060, as reflected in the United States (U.S.) Census Bureau s report (2012), denotes the significance of ethnocentric approaches in the provision of nursing care. Considering the fact that healthcare professional demographics do not mirror the change in ethnically and culturally diverse population (Mareno & Hart, 2014), the concept of culturally competent nursing care has emerged in an attempt to eliminate further health disparities (Roberts, Warda, Garbutt, & Curry, 2014). As nurses bring their own cultural backgrounds and views of education into the professional setting, nurse-patient encounters include the interaction of both the culture of the nurse and culture of the client. Therefore, it is imperative that the nurses in clinical practice expand their knowledge of other cultures and also, recognize their own preexisting cultural assumptions in an effort to provide fair and culturally competent nursing care. The Joint Commission on the Accreditation of Healthcare Organizations obligate healthcare organizations to integrate cultural competence into their educational curriculum (Glittenberg, 2004). To meet this requirement, schools of 17

26 18 nursing have utilized various didactic approaches. One of the approaches to accomplish the objective is the growing utilization of simulation as an innovative teaching/learning strategy to teach cultural aspects of care and to apply this theoretical concept in nursing practice. Although, nursing research lacks comparison and identification of the most effective simulation modality in this regard, utilization of cultural simulation games, standardized patients, High-Fidelity Patient Simulation (HFPS), and low-tech simulation are discussed in the literature. An important step in the process of designing clinical simulation is writing an objective-driven, evidence-based scenario, which promotes achievement of optimal students learning outcomes such as critical thinking, self-confidence, performance, and satisfaction (Waxman, 2010). Representative patient care scenarios, as well as a setting that closely mimics a real clinical environment, are essential components in enhancing learners belief and acceptance of a simulated clinical experience (Waxman, 2010). However, according to Lipson and Desantis (as cited in Roberts et al., 2014), the main focus of current simulation scenarios is on biomedical aspects of nursing care leaving psychological, environmental, cultural, and socioeconomic dimensions largely overlooked. In regards to cultural context, current simulation based studies lack representation of specific culturally designed scenarios or guidelines for nurse educators. Communication is an important cultural domain that has been addressed rarely in nursing simulation research (Chan, 2014; Kameg, Howard, Clochesy, Mitchell, & Suresky, 2010; Kuehster & Hall, 2010; Spinner-Gelfars, 2013). Nursing scholars

27 19 have not considered this topic from the cultural competency perspective. In particular, simulation based research has not specifically addressed language barriers as a major issue of concern when dealing with culturally diverse patient encounters. However, other objectives such as limiting medical errors, enhancing patients safety, and promoting therapeutic relationships have included integration of communication into the nursing simulation studies (Kameg et al., 2010; Kuehster & Hall, 2010). This chapter will discuss the second proposed question of this project: What cultural content should be addressed in simulation scenarios? This question is answered using the perspective of Madeleine Leininger s theory of culture care diversity and universality. Findings from limited simulation based studies that focus on the cultural aspect of care are summarized in this chapter. Literature Review In an effort to incorporate the core element of cultural competence into nursing curriculum, Seckman and Diesel (2013) conducted a study in which nursing students from a baccalaureate program in the Midwest were recruited to attend a culturally diverse simulation scenario as part of an immersion experience. The scenario represented Islamic cultural context through incorporating the specific artifacts of Arabic culture and engaging an Arabic interpreter in the HFPS scenario. Following the simulated experience, 18 senior level students electively enrolled in an immersion experience outside the U.S., to apply acquired knowledge and skills from the simulated setting to a real patient encounter. Findings from this study reported

28 20 students satisfaction from both simulated and immersion experiences which are applicable to their nursing practice (Seckman & Diesel, 2013). Studies by Seckman & Diesel (2013) and Rutledge, Garzon, Scott, and Karlowicz (2004), discussed in chapter II, are the only documented research which specifically incorporate components of culture care in a simulated scenario with the aim of promoting cultural competency levels in nursing students. Clearly, there is definite need for addressing this important topic in the modern pedagogy of simulation. Madeleine Leininger Nurse theorist and cultural anthropologist, Madeleine Leininger, developed the concept of transcultural nursing (Miller, 2007). Dr. Leininger is well-known for her contribution to the nursing profession and is the founder of Transcultural Nursing Society, the International Association of Human Caring, ethnonursing research method, and particularly, the theory of culture care diversity and universality (Leininger, 2007; Miller, 2007). According to the theorist, caring is the core element of nursing and the term transcultural nursing is conceptualized in caring for people of diverse cultural contexts (Ansuya, 2012). Transcultural nursing has been defined by Madeleine Leininger as a formal area of study and practice focused on comparative human care (caring) differences and similarities of the beliefs, values, and patterned life ways of cultures to provide culturally congruent, meaningful, and beneficial healthcare to people. (Ansuya, 2012, p. 5).

29 21 Dr. Leininger s initiative in defining care within the context of culture and establishing the discipline of transcultural nursing started when she noticed the missing link of culture in nursing care during her clinical nursing experience on a pediatric psychiatric unit (Steefel, 2004). She was inspired by the diversity of the children and their parents in terms of language, sleep patterns, and food preferences, and how differently they expressed themselves in their cultural life context (Steefel, 2004). Hence, the theorist postulated that the culturally based care should be regarded as the basis of the future nursing science knowledge. She was determined to substitute current care practices, which were dominantly focused on medical and pathophysiological conditions, with culturally based ones (Leininger, 2007). Madeleine Leininger s Culture Care Theory Madeleine Leininger conceptualized the theory of culture care diversity and universality in the late 1950s (Leininger, 2007). The theory was directed toward supporting transcultural nursing as a newly initiated field of study and practice in the profession (Leininger, 2007). The synthesis of two major concepts of caring and culture resulted in the evolution of the theory (Nelson, 2006). According to Leininger (2007), the theory is a holistic, culturally based care theory that incorporates broad humanistic dimensions about people in their cultural life context (p. 9). As mentioned earlier, Leininger recognized the importance of the missing element of cultural care in the profession of nursing. Hence, the concept of cultural care served as a foundation of her theory and was directed toward providing culturally sensitive care (Nelson, 2006).

30 22 The uniqueness of the theory of culture care diversity and universality is embedded in incorporation of social structure factors as influential determinants of the culture care phenomena. The factors include religious, political, economic, and geo-environmental, as well as cultural history, life span values, kinship, and philosophy of living (Leininger, 1991). Provision of effective care is the ultimate task of nurses. Therefore, as healthcare providers who have direct interactions with patients, having knowledge and understanding of cultural values, beliefs, and practices of the patients, along with biomedical aspects of care are vital to providing effective and culturally congruent care. In the early 1960 s, Madeleine Leininger coined the term culturally congruent care which served as a distinctive feature of her culture care theory (Leininger, 2007). Also, the theorist focused on two concepts of emic and etic care phenomena in the proposed theory. Emic/indigenous and etic/outsider are respectively representative of generic and professional systems of care (Bailey, 2009). Emic care knowledge can be directly derived from informants of a culture who hold their indigenous cultural knowledge and practice, whereas, etic care knowledge originates from the outsider s/healthcare professional s non- indigenous care perspective (Leininger, 2007). The aim of the culture care diversity and universality theory is discovering meaningful (congruent) emic and etic care phenomena within a cultural context of diverse people (Leininger, 2007). Madeleine Leininger (2007) envisioned that provision of culturally congruent care, which is the tenet of her theory, would not

31 23 only promote health and welfare of individuals, families, or groups, but also, would be appreciated by all cultures and subcultures. Moreover, Madeleine Leininger s theory uniquely featured three categories of nursing interventions through which provision of culturally congruent care could be accomplished (Leininger, 2007). The three culturally based interventions include culture care preservation which focuses on the maintenance of emic care system, culture care accommodation which involves integration of emic and etic care systems, and culture care repatterning which is based on implementing etic or professional care (Bailey, 2009). The theorist envisioned that the application of these three modalities of care would direct practitioners away from traditional and culturally inappropriate care practices, which are not desirable to diverse cultures. Therefore, therapeutic culturally based interventions would be practiced in a safe and conflict free environment where cultural informants would be regarded as active decision makers in the process of care (Leininger, 2007). Major concepts of Madeleine Leininger s culture care theory is summarized in Table 1.

32 24 Table 1 Leininger s Theory of Culture Care - Major Concepts 1 Human care/caring 2 Culture 3 Culture care 4 Culture care diversity 5 Culture care universality 6 Worldview 7 Cultural and structural dimensions 8 Environmental context 9 Ethnohistory 10 Emic 11 Etic 12 Health 13 Transcultural nursing 14 Culture care preservation and/or maintenance 15 Culture care accommodations and/or negotiation 16 Culture care repatterning and/or reconstructuring 17 Culturally competent nursing care (Bailey, 2009, p. 23) Sunrise Enabler Model and Application to Cultural Simulation Scenarios People s perception of health and well-being is largely influenced by their cultural life background and context. In order to better comprehend the contributing factors of this whole process and to perform thorough cultural assessment of a person, Dr. Leininger s Sunrise Enabler model (Figure. 1) can be referred as the most helpful scientific tool.

33 25 Figure 1. Leininger s Sunrise Model to depict theory of culture care diversity and universality, by Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York: National League for Nursing Press. Copyright 1991 by the National League for Nursing Press. Reprinted with permission.

34 26 Madeleine Leininger developed the Sunrise model with the aim of visualizing the interaction of her theory s components (Nelson, 2006). In fact, this model is one of the five enabler guides that were included in Dr. Leininger s innovative ethnonursing research method. Through utilization of these enablers, discovering covert cultural care values and practices of the informants can be facilitated (Leininger, 1991). The upper level of the Sunrise model, which can be viewed as a rising sun, portrays cultural and social dimensions of the culture care as symbolized rays of the sun (Bailey, 2009). The cultural and social structure dimensions include technological, religious and philosophical, kinship and social, cultural values and life ways, political and legal, economic, and educational factors. These factors represent the basic elements of a cultural assessment (Nelson, 2006, p. 50). The assessment process at this level should be viewed and focused in the broad context of environment, language, and ethnohistory. The distinctive care expressions, patterns, and practices of individuals, families, groups, and communities result from the integration of the aforementioned factors or rays into a central core of the model (Nelson, 2006). The mid-level of the Sunrise model depicts nursing care practices as a circle, which is overlapped by two other circular components, representing generic (emic/indigenous) and professional (etic/outsider) systems of care. In other words, the model suggests that the integrated knowledge of both generic and professional systems of care should be the foundation of decisions and actions of nursing care (Nelson, 2006).

35 27 The Sunrise Enabler model portrays three modes of culturally based nursing strategies in its lower portion, which include culture care preservation, culture care accommodation, and culture care repatterning. The desired outcome of culturally congruent care will be achieved by deliberate culturally based assessment, planning, and implementation of nursing strategies (Nelson, 2006). According to Leininger (2007), nursing scholars have acknowledged the Sunrise Enabler model as the most useful care constructs of Madeleine Leininger s theory in terms of discovering universal and diverse care phenomena. Also, the model can be utilized for the purposes of teaching and administering transcultural nursing care (Leininger, 2007). Therefore, Madeleine Leininger s Sunrise Enabler model is a substantially sound and holistic research based approach for developing culturally based nursing simulation scenarios. Various cultural contents from each level of the model can be derived and focused for this reason. The contents include cultural and social structure dimensions at the upper level, generic and professional care systems and integration of them as nursing care practices at the mid-level, and lastly three modes of nursing interventions at the lower level of the model. This model serves as a beneficial guide for directing nursing students in planning and provision of culturally congruent nursing care. Through utilization of the Sunrise model, a culturally sensitive nursing process can be initiated by thorough cultural assessment of the client and can be accomplished by practicing appropriate culturally based nursing interventions.

36 28 Conclusion Demonstrating excellence in cultural competence should be considered as an ongoing mission for all nurses in every level of the nursing profession. In an effort to apply cultural knowledge to clinical settings, nurse educators have to incorporate sound and innovative teaching/learning strategies into the curriculum such as simulation, which mimics realistic culturally diverse encounters in a risk-free environment. Nursing theories are easily applied when developing clinical simulation scenarios, especially models such as Madeleine Leininger s culture care theory and its unique feature, the Sunrise Enabler model. The ultimate goal of this theory is the provision of culturally congruent care to individuals, families, and groups. This goal can be met through utilization of a simulation platform, where frequent cultural exposures are feasible for nursing students.

37 CHAPTER IV RESULTS Considering more interactive teaching/learning strategies, as an alternative to traditional classroom lectures is a challenging aspect of education for nurse educators. In other words, instructors aim to change their role from sole knowledge dispensers to facilitators, who guide learners in the process of obtaining nursing knowledge and skills development. Changes in pedagogy is inevitable with today s world continually evolving as a result of many factors such as technology, globalization, and new socio-cultural trends. Hence, nursing scholars need to focus on incorporating advanced technology and innovative instructional methods, like simulation, into the curricula. Simulation, as an immersive and active learning experience, can foster learner-centered education (Kamerer, 2012). Also, simulation is an appealing educational tool to assist learners with visual, kinesthetic, or auditory learning styles (Kamerer, 2012). Exposing nursing students to clinical experiences other than an actual clinical setting, as well as evaluating their competency levels can be achieved through designing simulated healthcare environments (Husson, Zulkosky, Fetter, & Kamerer, 2014; Kamerer, 2012). Various simulation modalities can be employed to replicate real-life clinical experiences. Decker, Sportsman, Puetz, and Billings (2008) depicted simulation typology on the basis of fidelity and complexity. The typology include partial task 29

38 30 trainers (low-tech simulators), peer-to-peer learning, screen-based computer simulations, virtual reality, Haptic systems (tactile feedback), Standardized Patients (SPs), and full-scale or medium to high-fidelity simulation (Decker et al., 2008). Depending on the purpose and learning objectives of the simulation, the most relevant modality are selected by the nurse educator (Waxman, 2010). Full-body mannequins, commonly known as human patient simulators, are the most familiar simulation modalities (Kamerer, 2012). However, use of SPs are valued by nursing students from the reality standpoint (Kim-Godwin, Livsey, Ezzell, & Highsmith, 2013). To date, application and design of simulation experiences are driven by objectives such as promotion of critical thinking and communication skills, development of procedural skills, management of crisis, and development of team dynamics (Kamerer, 2012). In general, biomedical dimensions of care are the predominant focus of nursing simulation experiences (Roberts, Warda, Garbutt, & Curry, 2014). Clearly reflected in the nursing literature, there is limited research that focus on other aspects of care, such as culture and preparing culturally competent nursing students using a simulation milieu. Furthermore, nursing research not only lacks identification of the most effective simulation method for teaching the concept of cultural competence, it also does not offer a specific culturally oriented simulation scenario or template. Madeleine Leininger, the pioneer of transcultural nursing, strived to substitute common nursing and medical beliefs with culturally-based care knowledge of areas related to pathophysiology, symptoms, and medical management of diseases

39 31 (Leininger, 2007). According to this theorist, effective use of cultural knowledge in promotion of health and well-being would be achieved by training nurses in transcultural nursing (Leininger, 2007). Hence, nursing curricula can provide students with frequent, hands-on practice of cultural knowledge via culturally designed simulation scenarios. By doing so, a student s pathway toward the provision of the meaningful and acceptable cultural care in the actual clinical environment would be paved. The aim of this chapter is to present a culturally-based simulation scenario template in an attempt to address the third proposed question of this project: What is an example of effective simulation for preparing culturally competent nursing students? This simulation scenario template is based on Madeleine Leininger s culture care diversity and universality theory concepts (Leininger, 1991). Also, specific components of Islamic culture, which is consistent with the religious background of the author, are integrated as examples in the design of the scenario template. The Process of Designing a Simulation Scenario It is imperative to develop evidence-based scenarios or guidelines in an effort to modify nursing pedagogy via simulation (Waxman, 2010). Nursing faculty face challenges in creating new simulation scenarios. Waxman (2010), addressed the factor of time restraint as one reason for faculty reluctance to create their own scenarios.

40 32 A comprehensive review of the nursing literature revealed a step by step process of simulation scenario development, which academicians can follow to create the most beneficial and effective simulation experience. Evidence-based prewritten scenarios are considered more favorable in terms of validity and reliability (Waxman, 2010). However, utilization of prewritten or prepackaged scenarios, which are offered by many publishing companies, may not meet the specific needs of the nursing curricula or the simulations objectives (Kamerer, 2012; Waxman (2010). As an example, the concept of cultural competency is one of the missing components of existing simulation scenarios, which should be addressed properly to simulate a multicultural image of the healthcare system. Transcultural nursing faculty aim to enhance students cultural knowledge and awareness by incorporating cultural lectures, presentations, interviews, and field trips into their course syllabi. A simulation strategy can serve as a complement to the current course objectives and nurtures students cultural skills. Hence, development of an evidence-based, culturally oriented simulation scenario is an essential step in the redesign of the transcultural teaching/learning paradigm. Middleton (2012) identified three phases for effective management of a simulation experience. The phases include outlining the simulation s learning objectives, designing a case scenario, and organizing the simulation activity (Middleton, 2012). Undoubtedly, defining the learning objectives is the most important step in planning a simulation experience. An effective simulation scenario involves three or four key objectives, which are clear and pertinent, and it is the

41 33 responsibility of the instructor to confirm the achievement of those during the scenario (Middleton, 2012; Waxman, 2010). Also, the knowledge level of the students or groups should be considered in this phase (Waxman, 2010). Following a sound framework, which consists of essential elements is imperative in designing an effective simulation scenario (Smith, 2009). According to Waxman (2010), those elements include learning objectives, level of fidelity, complexity, supporting references, instructor/facilitator, and debriefing. Upon defining the learning objectives, the simulation scenario s level of fidelity or realism should be identified (Smith & Roehrs, 2009; Waxman, 2010). The purpose of the scenario determines the use of low, medium, or high-fidelity in the simulation. For instance, task-training purposes require utilization of low-fidelity simulation methods. While, in order to improve certain skills such as communication, high-fidelity methods are preferred (Waxman, 2010). Level of complexity is the next important element in creating a simulation scenario. In order to evaluate students problem solving skills, faculty should highly consider their level of experience in this step (Waxman, 2010). Likewise, simplicity of the case scenario should be maintained to enrich learning outcomes (Middleton, 2012). In order to prevent confusion resulting from having a too complex scenario, Waxman (2010) suggested running the simulation with short scenarios initially and to assist progression of the scenario by integrating activities along the way. Incorporation of key concepts in the form of unfolding cases is another strategy to enhance the scenario (Husson et al., 2014).

42 34 Another essential element in formulating a simulation scenario is the application of sound and evidence-based references (Waxman, 2010). The instructor should outline key references as theoretical foundations for the scenario s objectives. Furthermore, accuracy, reliability, and alignment of the scenario with the standards of nursing practice should be assured via the peer review process (Waxman, 2010). Kamerer (2012) believes that a new perspective needs to be considered for selection of the simulation topic or content. The content can be based on case studies, real experiences, course content students seem to struggle with understanding, test scores, or exam blueprints. (Kamerer, 2012, p. 10). In other words, students didactic needs/gaps should be identified and tackled in the simulated environment. Among all the aforementioned elements, the faculty and the facilitator have unique roles to accomplish during the simulation scenario. Given the fact that simulation activity attempts to replicate real life clinical experiences, having the knowledge of when to intervene appropriately is essential in the continuity of the scenario s flow. According to Rudolph, Simon, Raemer, and Eppich (2008), the instructor should observe for a performance gap throughout the scenario, which is defined as the difference between the desired actions and the trainee s/actual actions (p. 1011). As the scenario unfolds, the facilitator should cautiously allow progression of the scenario and evaluate the best time to interrupt students inappropriate performance (Waxman, 2010). In fact, students independent problem solving skills need to be facilitated by providing them with supportive clues (Waxman, 2010). In

43 35 terms of reactivity, Kamerer (2012) also recommended utilization of the simulators feedback or ancillary staff/actors as prompting tools during the scenario. Students can be signaled via alteration of the simulator s vital signs or by a phone call from a healthcare personnel/actors (Kamerer, 2012). Time management issues by the instructors, discussed in chapter II, are also of high importance in running a simulation scenario. The final element of a simulation scenario includes a reflective debriefing session, which needs to be managed thoughtfully by the nursing instructors. Debriefing provides both students and instructors with the opportunity of reflection on activity outcomes and the critical thinking skills acquired during the simulated experience (Kamerer, 2012). It is recommended that the debriefing session occurs instantly upon completion of the scenario, while engaging of all the students (Cantrell, 2008; Waxman, 2010). There are some essential components that should be highly considered for conducting a successful debriefing session. The components include location, timing, confidentiality, utilization of an expert facilitator, and careful selection of the type of proposed questions posed during this critical session (Kamerer, 2012; Waxman (2010). According to Waxman (2010), debriefing should not occur at the simulation site and an equal time frame or twice the length of time of the simulation session should be considered. Presence of an expert facilitator is important for exploring students reflection on learning via open-ended questions, which direct them toward intended simulation outcomes (Waxman, 2010). Also, the participants need to be

44 36 ensured of a safe simulated environment, which includes providing them with a privacy/confidentiality agreement (Kamerer, 2012; Waxman, 2010). It is clear that accomplishing an ideal simulation scenario necessitates consideration of each of the above-mentioned elements. The ultimate goal of a simulation scenario includes connecting the acquired knowledge in the simulated setting to the real world (Middleton, 2012). A Culturally Designed Simulation Scenario Template As described earlier, there is a need for the incorporation of cultural domains of care into nursing simulation scenarios. The lack of availability of a culturally oriented scenario template in the realm of simulation pedagogy has led the author of this culminating experience to design an exemplar (Appendix A). The author employed Madeleine Leininger s culture care diversity and universality theory as an underpinning framework in the development of the template (Leininger, 1991). The following section includes a detailed description of components of the scenario template, while integrating specific concepts of Islamic culture. The author believes that considering an acquainted culture would contribute to a better conceptualization of the template s features. It should also be mentioned that the biomedical dimensions of care have been purposely eliminated in the design of this culturally-based scenario template. As, there are a plethora of biomedical simulation scenarios and templates available to nurse educators, which can be easily adapted to this culturally-based template.

45 37 Scenario Overview The very first section of the culturally designed template (Appendix A) focuses on a general overview of the scenario including the title, date, institution, faculty s name and credentials, target audience/group, the timing of the actual scenario, and the following debriefing session. Defining the target audience/group of the scenario is essential and will assist the instructors in outlining the intended objectives of the scenario based on the level of the learners. Moreover, there are some unique components in the first section, which reflect the cultural design of the template. The components include Quality and Safety Education for Nurses (QSEN) competencies, focused culture/ethnicity, and cultural and social structure dimensions of the Leininger s Sunrise Model or shining rays (Leininger, 1991; QSEN, 2014a). The term shining rays was coined by the author of this document. In 2005, the Robert Wood Johnson foundation funded the QSEN project (QSEN, 2014a). The project aimed at improving the healthcare systems quality and safety via preparing future nurses who have essential knowledge, skills, and attitudes (KSAs) in their specific professional field. From the six competencies that were defined during the first phase of this project, the two competencies of patientcentered care and evidence-based practice can be used for the purpose of this proposed cultural scenario template (QSEN, 2014a). Considering and respecting patient/family s values, preferences, and needs has been addressed in the definition of these two competencies, substantiating the author s claim for utilization of them in this cultural template (QSEN, 2014b).

46 38 In the first section, the faculty should determine the focused culture/ethnicity of the scenario. Also, one or more cultural and social structure dimensions of the Leininger s Sunrise Model, which are referred as the shining rays throughout the scenario, should be highlighted at this stage. In other words, the selected dimensions serve as the basis for the description of the case scenario. For example, if the Islamic culture with the shining ray of language has been selected by the faculty, important concepts within this culture such as spatial distancing, eye contact, or touch can be addressed when writing the simulated case scenario (De Melo, 2013). The faculty can refer to Appendix B, when they intend to incorporate particular sub-items of the shining rays into their culturally-based scenario. Upon providing a brief description of the case scenario from the cultural perspective, the faculty must list all the utilized references in developing the scenario. Proper consideration of this step is imperative, as the nursing profession is defined by theoretical foundations and evidence-based practice. Curriculum Integration This section contains specific learning objectives of the scenario, critical learner actions, and pre-scenario learner activities. As discussed earlier in this chapter, defining the learning objectives is the most significant step in developing a simulation scenario. From the Islamic cultural perspective, identifying patient/environment s cultural clues such as modesty, considering patient s emic/indigenous care practices and beliefs such as refusal of Western treatment options, and exploring patients preferences such as the request for female/male

47 39 healthcare providers can be considered as learning objectives of the culturally-based scenario. Expected critical learner actions based on Leininger s three modes of nursing interventions or decisions should also be outlined in this section (Leininger, 1991). For instance, culture care preservation and/or maintenance can be accomplished by maintaining the patient s modesty/privacy via restricting unnecessary touch or eye contact (Wehbe-Alamah, 2008). In terms of culture care accommodation and/or negotiation, the learner can accommodate patient s treatment options by requesting alternative alcohol-free medication prescriptions (Wehbe-Alamah, 2008). Likewise, the learner may simply negotiate medical or nursing care preferences of the patient and explore their healthcare needs, particularly when the learner feels lack of knowledge about a certain culture. Lastly, in presence of harmful generic/folk care practices, the learner should take actions by educating their patients about consequences of unhealthy practices and attempt to repattern and/or restructure their life-ways by discovering healthy substitutes in that specific culture (Wehbe- Alamah, 2008). The faculty should consider pre-scenario learner activities prior to exposing students to the simulation experiences. These activities may be sorted into two categories of psychomotor and cognitive competencies (Waxman, 2010). Yet, the designer of this culturally oriented template has decided to exclude psychomotor competencies in the development the scenario. The rationale behind this decision is that in real life nursing practice nurses are exposed randomly to clients of diverse

48 40 cultures without providing them with the opportunity of prior acquisition of relevant cultural skills or attitudes. On the other hand, the learner s cognitive competencies, which are embedded in the template, can be enriched through various resources such as classroom lectures or self-study of the scenario s specific materials (Waxman, 2010). While utilizing this template, nursing educators may choose to prepare students for the culturally-based simulation experience through classroom tutorials about Madeleine Leininger s culture care diversity and universality theory. Likewise, students may be offered hand-outs of the Sunrise Model and the sub-items of each cultural and social structure dimensions (Appendix B). Scenario Script This section mainly covers the detailed summary of the case scenario and its components including actors and environmental modifications, followed by a debriefing guideline. Case description should be expanded by adding key contextual details of the studied culture. In doing so, referring to sub-items of each cultural dimensions might be beneficial (Appendix B). Evaluating simulated case scenarios from the realness standpoint is of high importance (Kamerer, 2012). Nurse educators should employ proper modifications through which realness of the scenario can be developed. Considering an appropriate and relevant simulation modality is a vital step in this regard. Since, High-fidelity Patient Simulators (HFPS) and SPs can provide learners with verbal feedback and can be equipped with relevant cultural clues, such as attire, utilization of these modifications have been recommended in the current template.

49 41 Other steps can be taken to reinforce realism of a simulation experience include, adding various realistic props such as patient s possessions, identification or allergy band, and the chart (Kamerer, 2012). When conducting a culturally oriented simulation scenario, presence of cultural props such as the Holy Book, cultural prayers in the patient s room, alterations in appearance of a manikin, or SPs, like head covering for a Muslim patient, may be considered. Also, the roles of family and healthcare team members other than nurse and physician may be assigned to offer a broader chance for professional communication and enhanced realism in the simulated experience (Kamerer, 2012). It should be mentioned that considering SPs from the same cultural background as the simulated scenario can provide learners with an invaluable opportunity for a realistic patient encounter. The faculty may write scenario events or its expected actions in a chronological order. This step can contribute to better time management of the scenario and assist with training SPs. Last of all, the important phase of debriefing is presented in the template, offering a general plan for nursing educators. Since the ultimate goal of a culturally designed simulation scenario is preparation of culturally competent future nurses, Leininger s three modes of nursing interventions should be addressed during the debriefing phase (Leininger, 1991). Discovering students rationales regarding the approach of a specific mode of action can assist nursing educators in recognition of the learner s pedagogical gap or strength in the field of transcultural nursing.

50 42 Conclusion Incorporation of cultural content into nursing simulation scenarios is a necessary step in redesigning of transcultural teaching/learning paradigm. Learners will realize the importance of providing culturally competent care though simulated experiences, where their cultural misconceptions and biases can be safely suspended. In order to meet this goal, nursing educators should have access to a clear culturallybased scenario template through which diverse cultural nursing scenarios are portrayed. The template developed in this chapter is designed with this intention and is created based on the most reliable culture care theory available.

51 CHAPTER V DISCUSSION AND RECOMMENDATIONS The multicultural character of the nation has prominently highlighted the need for preparing culturally competent healthcare personnel. The nursing profession is attempting to meet this goal through transcultural nursing courses at the academic level. However, the traditional classroom-bound transcultural nursing pedagogy should consider incorporation of more interactive and experiential teaching/learning tools such as simulation into the course syllabi. The immersive learning environment of simulation has the potential of portraying culturally diverse patient encounters, which may not be guaranteed during clinical rotations of nursing students. Realistic opportunities for the nursing care of a diverse population in a simulated environment not only enhances students self-confidence level, but also helps them with better conceptualization of culture s role in the system of healthcare (Seckman & Diesel, 2013). A comprehensive review of the literature revealed limited research on the incorporation of cultural constructs into nursing simulation as well as a lack of representation of culturally-based simulation scenarios or guidelines. Therefore, a culturally oriented simulation scenario template was designed and discussed in this project. Madeleine Leininger s culture care diversity and universality theory served as an underpinning framework of the template (Leininger, 1991). The template reflects unique features of the culture care theory including cultural and social 43

52 44 structure dimensions, referred to by this author as Shining Rays, and three modes of nursing actions and decisions (Leininger, 1991). Debriefing will be used to evaluate students perception of the cultural simulation experience (Appendix A). Also, faculty utilization of this template will be evaluated using open-ended questions such as How would you evaluate the quality of the culturally designed simulation scenario template? How did this template meet expected outcomes of the simulation experience? How helpful was the template in the general preparation for the debriefing session? etc. It is anticipated that the template will be adjusted with consideration of student/faculty feedback to improve utilization. The proposed template can be utilized to highlight specific cultural and social structure dimensions or shining rays with the aim of evaluating students skills in preserving, accommodating, or repatterning cultural values and beliefs of the patients in the system of care. In other words, the template was developed with the ultimate goal of preparing culturally competent future nurses through a simulation arena. More importantly, the concept of cultural desire, which is a significant construct in the process of becoming culturally competent, can be practiced and reinforced via culturally designed simulation experiences (Campinha-Bacote, 2002). Cultural desire has been defined as the healthcare provider s motivation for acquiring cultural awareness, knowledge, and skill throughout the patient encounters. In fact, the importance of having genuine passion and willingness for learning patients cultural differences and similarities in the process of providing culturally congruent care should also be emphasized (Campinha-Bacote, 2002). Clearly, repetitive

53 45 training of such a caring and approachable attitude toward the clients of diverse cultures in a safe simulated environment will nurture students level of unconscious competence prior to real life patient encounters (Purnell, 2005).

54 REFERENCES

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62 APPENDICES

63 55 APPENDIX A CULTURALLY DESIGNED SIMULATION SCENARIO TEMPLATE

64 56

65 57

66 58

67 59