A Transcultural Immersion Experience: Implications for Nursing Education

Article excerpt

Abstract: This article is a synthesis and interpretation of field work from a transcultural nursing immersion experience in Italy. The main focus of the field work was to understand the cultural influences on health systems with interpretations related to nursing education. The major recommendations of the paper include strategies for nurse educators to promote cultural competence throughout curricula by providing students with meaningful clinical experiences and addressing healthcare needs of diverse populations in the U.S. and abroad.

Key Words: Transcultural Nursing, Immersion Experience, Nursing Education, Nursing


As globalization of people around the world increases, there is subsequent growth in culturally diverse populations living in the U.S. who require health care (Smith & Curry, 2011). Therefore, nurses in the United States (U.S.) nurses need to be skilled at providing culturally congruent care to a variety of people. The National League for Nursing Accreditation Commission (NLNAC) mandates mat schools of nursing include "cultural, ethnic, and socially diverse concepts and may also include experiences from regional, national, or global perspectives" (NLNAC, 2008, p. 94). The American Association of Colleges of Nursing (AACN), as cited in Sanner, et al. (Sanner, Baldwin, Cannella, & Parker, 2010) has identified cultural sensitivity as an essential curricular component in the preparation of new nurses. Moreover, the Institute of Medicine's Core Competencies mandate healthcare providers, "identify, respect, and care about patients' differences, values, preferences, and expressed needs. . ." (Institute of Medicine, 2003, p. 45). Schools of nursing must strive to provide students with opportunities to develop and refine these important skills. Students may feel uncomfortable or stressed while engaging in clinical experiences within culturally unfamiliar environments; however, this may be an effective strategy to promote cultural sensitivity. Such experiences evoke feelings of vulnerability and allow students to reflect on the perspectives of diverse patients accessing care within the U.S. healthcare system. A trip abroad by nurse educators serves as the basis for this article. The week-long immersion in Rome, Italy helped the educators gain insight into the cultural differences and influences of culture on health and healthcare practices. The following analysis and synthesis of field observations and experiences highlights the need to prepare all nursing students to be culturally competent by assimilating experiences with diverse populations into nursing curricula.


During the cultural immersion experience, nurse educators interacted with Italians while conducting daily business, touring the city, and visiting health care facilities. The educators explored two hospitals in Rome and communicated with Italian health care professionals to learn about their healthcare system. Each educator kept detailed field notes of observations and experiences, then came together to discuss the observations and identify common themes. Analysis of the collective field notes revealed five prevalent themes and implications for nursing education in the United States.

The themes identified were:

1 . Communication

2. Transportation

3. Culinary Practices

4. Religion

5. Public Environment


The inability to communicate effectively due to language barriers may lead to feelings of vulnerability and frustration for patients and healthcare providers alike. This can result in miscommunication regarding patients' health conditions, treatments, medications and important directives. Health care providers may find it difficult to obtain an accurate health history, address specific health concerns, obtain informed consent for medical and surgical treatments or provide important patient education. "Language difficulties and nurses' poor knowledge about culture. . ." have been found to be major barriers to culturally sensitive practice (Ruddock & de Sales, 2007, p. 363). All of the participants in the immersion experience expressed feeling vulnerable in not being able to speak or understand the Italian language when seeking directions, purchasing items, ordering food or participating in conversations. The educators felt most vulnerable when asking for directions. On the first night in Rome, it took over 2 hours to return to die place of residence from the city because the language barrier inhibited both the educators who spoke only English and the Italians, who did not speak English, from understanding each other. Therefore, the ability to obtain clear directions was significantly hampered. However, it was noted that most business employees spoke several languages in order to conduct trade with customers from foreign countries. The educators also found it difficult to order food in some restaurants, because the waiters did not speak English. One educator resorted to using her handheld device, which translated English words into Italian so that the waiter could understand what she wanted. It became clear to all that communication is a critical element for assimilating into orner cultures.


Transportation was noted to be remarkably different from the modes of travel used in the U.S. In addition to walking, many Romans utilized public transportation or rode motorcycles and scooters. From the perspective of the immersion participants, utilizing the public bus system was complicated and time consuming, which might present a number of challenges for Italians needing healthcare. For example, there was only one bus route that traveled past the residence where the educators stayed. The educators typically had to wait at least 25 minutes for the bus to arrive. Another problem was that me Metro and buses stopped running in me late evening, making time limitations an obstacle for people who wished to enjoy an evening in the city. From the perspective of the group, people who are physically handicapped, medically debilitated, having to travel with young children, or financially limited may find public transportation to be a significant barrier in reaching healthcare appointments in a timely and efficient manner. Some of these same public access obstacles are also apparent in the United States, but me law requires public transportation vehicles to be handicap accessible. The U.S. government subsidizes transportation services to health care appointments for eligible citizens who are medically and physically challenged.

Culinary Practices

Overall, the immersion participants found the Italian diet to be varied and well-balanced. The portions are smaller than those served in the U.S., with a greater emphasis on fresh, homemade, non-processed foods. Restaurant foods were salty, which can contribute to heart disease, hypertension and edema. Several times me participants experienced edema in their legs and feet after a full day of walking, eating in restaurants and coping with extreme heat. Pasta is a mainstay in the Italian diet and is served both at lunch and dinner as a first course. Bottled water and wine are served with lunch and dinner, and beverages are served cool, not cold. This was a difficult adjustment for those who enjoyed ice in their beverages. Breakfast generally consists of coffee and milk with a simple assortment of proteins and carbohydrates including meat, bread and cereal. Espresso is served in small quantities and enjoyed throughout the day. These are not typical meals in the U.S. so nurses must be cognizant of potential differences in dietary patterns due to cultural practices when planning meals. Efforts should be made to accommodate patients' dietary preferences. Finally, meals are a relaxed time for camaraderie with family and friends. This practice is dramatically different from the family in the U.S. who often does not eat together and hurries through meals.


The primary religion in Italy is Roman Catholicism, and it has a strong influence on Italian culture. The educators observed numerous orders of nuns and priests while traveling through die city. The care delivered to patients is consistent witìi the ethical and moral directives inherent in the Catholic faith. In the U.S., hospitals may be either secular or affiliated with a particular faim, but whetíier tíiey are sponsored by Catholic, Christian or Jewish organizations, overt religious practices are tempered so as not to offend individuals of odier faiths. During dieir visit to me Tiber Hospital in Rome, the educators observed sculptures, frescos and statues of various Catholic saints. For example, me architectural design of one of the hospital conference rooms still retained the altar, ceiling frescos and sculptures from its former use as a basilica. It is important for nurses to assess me role that religion or spirituality plays in patients' lives and individual healthcare decisions so their spiritual needs are addressed.

Public Environment

Observation of me Italian culture and environment revealed practices and behaviors mat may relate to healthcare. Smoking is prevalent among boüi genders of all ages and is acceptable in public areas, including designated areas in hospitals. Smoking does not appear to be perceived as the healm risk that it is seen to be in me U.S. Drinking alcoholic beverages in public was also frequently observed even among teenagers. Smoking and drinking alcohol in excess are well-documented healm risks. The Italians also appear to be comfortable with their sexuality, expressing their affection in public areas, and accepting alternative lifestyles. The group observed a number of couples fervently kissing and snowing dieir affection on buses, on the streets and in the park. Many people from the U.S. are not as tolerant of or comfortable with displaying or observing these behaviors in public. In order to be culturally congruent, nurses must accept differences among people without being judgmental, treating all individuals with respect and dignity. Another common public occurrence is the presence of street beggars and peddlers. Beggars sat on the ground outside of businesses with puppies or played music in hopes of earning donations. Peddlers brazenly approached tourists, insisting they buy roses, parasols or stuffed animals.

The above observations and comparisons raised die nurse educators' awareness of me differences among people and cultures. The themes identified through the immersion experience can serve as a guide for educating students about planning nursing care mat is culturally competent and individualized. It is critical that nursing faculty address diese issues and prepare students to acquire the skills needed to become culturally competent caregivers. Instilling nursing students with the value of considering cultural and spiritual needs of patients is the first step towards developing cultural competence. It is imperative that nursing educators provide opportunities for students to develop these skills. The authors have syndiesized and interpreted their observations to articulate implications for nursing education and make recommendations for curriculum development and implementation.


Demographics in the U.S. are shifting decidedly toward increased diversity, making it essential for nursing professionals to meet me needs of culturally diverse populations. The U.S. Department of State estimates that the present cultural minorities will be the cultural majorities by 2042 (U.S. Census Bureau, 2007). According to the Sullivan Commission Report on Diversity, patient populations are becoming more diverse while the practicing nursing population remains primarily of Caucasian descent (The Sullivan Commission, 2004). This lack of diversity in the nursing workforce underscores the importance of providing nursing students with a foundation for providing culturally sensitive care.

Unfortunately, nursing education is inconsistent with the presentation of cultural competence and its important role in improved patient outcomes relative to these vulnerable populations. Therefore, the challenge for nursing educators is to determine how cultural content links didactic courses to clinical practice While some schools of nursing integrate transcultural nursing concepts into both lecture content and clinical situations, others offer separate courses in transcultural nursing that include an international nursing experience (Smith & Curry, 201 1). The literature suggests that institutions that use active educational strategies are deliberately providing exposure to culturally diverse populations to ensure cultural understanding is achieved (Sanner et al., 2010). Implementing a curriculum that prepares graduating nursing students to become culturally competent requires the commitment of faculty and support of academic administration. Following the cultural immersion experiences, the authors support the inclusion of cultural competence content throughout all nursing curricula, including both didactic and clinical education.

Cultural competence is an ongoing process requiring more than formal knowledge (Caffrey, Neander, Maride, & Steward, 2005). Development of cultural competence in students and faculty occurs best in environments supportive of diversity and facilitated by guided clinical experiences (American Association of Colleges of Nursing, 2008). Threading cultural competence throughout a nursing curriculum and reinforcing methods that meet the needs of diverse populations allows students to build on previously learned clinical skills. Faculty with essential knowledge and expertise in providing care to culturally diverse patients can develop relevant diverse learning experiences that are unique to these populations. To assist faculty in implementing curricular changes that include cultural competencies, the AACN website offers "Cultural Competency Tool Kit," which provides academic resources, exemplars, and teaching learning activities to facilitate integration of cultural competency principles into nursing courses (American Association of Colleges of Nursing, 2008).

To introduce the topic of culturally congruent care, beginning nursing students should be guided to explore their self-perceived knowledge of diversity, attitudes regarding vulnerable populations, and skills they may need to provide healthcare to underserved populations. Faculty can facilitate reflection and exploration of each student's health care beliefs, biases, prejudices and assumptions regarding practices of different cultural groups. Faculty can also provide students with guided clinical experiences by caring for patients from diverse and vulnerable populations whenever possible, and by placing students in clinical settings with nurse preceptors from diverse backgrounds (Amerson, 2010).

Augmenting nursing students' understanding of diversity and cultural competence in practice is an important facet of their education and can be implemented throughout any curriculum by engaging learners in integrative learning activities using classroom simulation. Drawing on culturally diverse case studies with application of cultural competence models is a teaching strategy faculty can use to emphasize specific cultural preferences of diverse populations. After identifying healthcare disparities within the case study, cultural care plans that incorporate unique healthcare preferences can be developed, implemented, and evaluated for effectiveness. Integrating best practices and evidence-based care, within the context of culturally competent care, is imperative. Engaging students in role play activity to simulate patient advocacy can improve students' awareness of the important role they play in ensuring vulnerable populations are cared for effectively (American Association of Colleges of Nursing, 2008).

Transcultural nursing courses with an international clinical experience can enhance cultural sensitivity. Through global service learning experiences, students have demonstrated increased self-awareness of their own cultural values, gained self-confidence, and improved their communication skills in the clinical setting (Smith & Curry, 2011). However, these educational opportunities are typically offered only in baccalaureate rather than associate degree or diploma nursing programs. According to the U.S. Department of Health and Human Service (DHHS) national sample survey of registered nurses' educational preparation, the majority of nurses were prepared at the associate degree or diploma level (DHHS, 2008). Therefore, the majority of new graduate nurses has not participated in global service learning experiences and is not adequately prepared to provide culturally competent care. When possible, nursing students should be encouraged to participate in a cultural immersion experience. Exploring culturally specific health practices first hand provides an authentic, invaluable experience for future nurses. As participants in a cultural immersion experience, the authors visited a private and a public health care facility, interacted with Italian physicians and nurses regarding the health care in Italy, and gained a meaningful perspective of transcultural healthcare. While these direct experiences produced feelings of vulnerability due to communication barriers and other cultural differences, the authors gained a new perspective for the need to provide culturally competent care and to prepare future nurses to effectively care for diverse populations of patients. According to the AACN (2008), nurses should have increased awareness of historical, political and socioeconomic factors that determine health and disease in patient populations. Through cultural immersion experiences or classroom simulations, students can gain important insights concerning the need to attain cultural competence and recognize how deficits in this area can perpetuate healthcare disparities.

Global Education within the U.S.

Although global health education and international service-learning experiences have become an important addition to undergraduate nursing education, the cost of such experiences is often prohibitive, denying some students the ability to participate. The increasing diversity of the U.S. population, through the influx of immigrants and refugees, can provide nursing students with excellent opportunities to acquire the skills needed to think and act globally without the cost of distant travel. Due to many countries currently experiencing war, economic or governmental upheaval, identifying cultural experiences from regional and national communities may be a safer option (Lenz & Warner, 2010). Many immigrants and refugees suffer health disparities due to language and cultural differences, and receive health services in community-based settings where health care is easily accessible (Lenz & Warner, 2010). Providing students with hands-on, transcultural clinical experiences within these community-based settings presents opportunities for all learners to participate in rich, cultural immersion experiences while working with diverse and vulnerable populations within the U.S. (Amerson, 2010). Creating partnerships with community health departments, local medical centers and other health care agencies involved in outreach initiatives addressing access to care for vulnerable populations can provide students with valuable clinical insights into the complex healthcare issues affecting these populations.

According to Amerson (2010), community-based, servicelearning requires students to work in state-side communities addressing health issues affecting specific cultural groups and applying population-based interventions. Special emphasis is placed on working with culturally diverse, at-risk populations, including members of minority groups, the homeless, lowincome school children, victims of domestic violence, and single-parent families. With community based service-learning, students become aware of health care issues faced by clients of different backgrounds and cultures as they leam to provide culturally appropriate care utilizing resources found within the U.S. healthcare system (Amerson, 2010). In order to prepare culturally competent beginning nurses for entry into the workforce, it is incumbent on nursing program administrators and faculty to address the following:

* Committing to making cultural competency a priority in nursing curricula (Purnell, 2007)

* Infusing cultural competency content throughout nursing programs focusing on attitudes, skills and knowledge (Campinha-Bacote, 2008)

* Recognizing that a lack of consensus exists on what should be taught in nursing curricula regarding cultural competency, lack of standards, limited and inconsistent specialty courses on culture, and how to link cultural competency theory into meaningful clinical practice experiences for aiLstudents (Lipson & DeSantis, 2007)

* Increasing cultural competency of students by offering preceptorship experiences with culturally diverse preceptors who can demonstrate both cultural competency and reveal barriers to care (Amerson, 2010)

* Establishing portfolio documentation of culturally diverse practice experiences obtained by students throughout the program (The Sullivan Commission, 2004)


This cultural immersion experience, with the subsequent analysis and synthesis of observations and themes, provided the authors with a deeper appreciation for cultural diversity, the potential impact of health disparities, and issues of social injustice in the U.S. The newly acquired insights about cultural diversity and vulnerable populations gained from this immersion experience, has prompted the authors to explore and promote the use of active teaching strategies to present transcultural content to students in the didactic and clinical setting. The challenge for nursing faculty is to facilitate transcultural learning opportunities within culturally diverse and vulnerable populations present in communities throughout the U.S. Nursing students who are prepared to care for culturally diverse populations will help to facilitate access to preventative, primary, health maintenance, and acute/chronic health care services for these individuals and families.



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[Author Affiliation]

Lisa M. Easterby, DNP, RN, CNE, Barbara Siebert, DNP, CRNP, FNP-BC, Cynthia J. Woodfield, DNP, RN, CNE, Kathy Holloway, DNP, RN, Pamela Gilbert, DNP, CHPN, CMS, RN, Richard Zoucha, PhD, APRN-BC, CTN- A and Melanie W. Turk, PhD, RN

[Author Affiliation]

Lisa M. Easterby, DNP, RN, CNE, is the Dean of Our Lady of Lourdes School of Nursing, 1600 Haddon Avenue, Camden, NJ 08103, in Camden, NJ. Barbara Siebert, DNP, CRNP, FNP-BC, is the Associate Dean of Student Affairs at Our Lady of Lourdes School of Nursing in Camden, New Jersey. Cynthia J. Woodfíeld, DNP, RN, CNE, is the Director of Nursing at Defiance College in Defiance, Ohio.. Kathy Hoiloway, DNP, RN, is a Lead Nursing Faculty in the RN to BSN Completion Program at Franklin University in Columbus, Ohio. Pamela Gilbert, DNP,RN CHPN, CMS,, 1 Birchwood Drive, Oneonta, NY 13820. Richard Zoucha, PhD, APRN-BC, CTN-A, is an Associate Professor at Duquesne University School of Nursing and coordinates the post master 's certificate program in Transcultural Nursing and is also a Certified Transcultural Nurse. Melanie Turk, PhD, RN, is an Associate Professor at Duquesne University School of Nursing and her research interests relate to cardiovascular risk reduction among minority populations via weight loss and weight maintenance.


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