See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/225055190

Nurses' Attitudes Toward Continuing Formal Education: A Comparison by Level

of Education and Geography

Article in Nursing Education Perspectives · March 2012

DOI: 10.5480/1536-5026-33.2.80 · Source: PubMed

CITATIONS READS

19 4,620

1 author:

Tanya Altmann
California State University, Sacramento
9 PUBLICATIONS 319 CITATIONS

SEE PROFILE

All content following this page was uploaded by Tanya Altmann on 23 May 2014.

The user has requested enhancement of the downloaded file.

 C o n T I n u I n g E d u C AT I o n / n u R S I n g E d u C AT I o n R E S E A R C H

Nurses’ Attitudes Toward Continuing Formal Education:

A Comparison by Level of Education and Geography
TA n yA K . A lT m A n n

I T IS RECommEndEd THAT nuRSIng STRIvE foR A

woRKfoRCE CompRISEd of 80 pERCEnT BAC-

• Do attitudes change over time as determined by years of nurs-
ing practice?
CAlAuREATE-pREpAREd REgISTEREd nuRSES By 2020 And THAT • How do the attitudes of those who return to school for a BSN or
nuRSES EngAgE In lIfElong lEARnIng (Institute of Medicine, higher differ from those who have not returned or from those plan-
2011). However, only 50 percent of the current RN workforce is ning to return?
prepared with a bachelor of science in nursing (BSN) or graduate • Do attitudes differ according to geographical location (west vs.
degree (American Association of Colleges of Nursing [AACN], east)?
2011). Even in countries that have adopted the BSN as a require-
ment for entry into practice, such as Canada, many nurses are prac- Background and literature Search Patient outcomes are a
ticing with associates degrees (ADN) or diplomas in nursing. primary reason to encourage continuing formal education. The liter-
The three educational routes to become an RN in the United ature is replete with research and anecdotal support for the con-
States are unique for a profession and lead to concern that RNs may tention that patient health care outcomes are linked to nursing edu-
be seen as undereducated when compared with other members of cation. Researchers have identified: a) improved patient safety and
the health care team (Donley & Flaherty, 2002). Megginson (2008) lower rates of patient morbidity and mortality (Aiken, Clarke,
stated that the educational mobility of ADN and diploma nurses “to Cheung, Sloane, & Silber, 2003; Estabrooks, Midodzi, Cummings,
the BSN level is crucial to positive patient outcomes, creation of a Ricker, & Giovannetti, 2005; Friese, Lake, Aiken, Silber, &
credible professional identity and to cohesion among nurses” (p. Sochalski, 2008; Tourangeau et al., 2007), b) lower levels of medica-
48). Understanding nurses’ attitudes is key to achieving the goal of tion errors and procedural (or practice-related) violations (AACN,
“enticing and enabling nurses to achieve higher educational levels 2008; Delgado, 2002), and c) fewer disciplinary actions for BSNs
consistent with the trends of other health care professionals” (Delgado). The knowledge needed by practicing nurses increases as
(Hilton, 2004, p. 14). medical knowledge evolves and becomes ever more complex.
The Theory of Planned Behavior (TPB) (Ajzen, & Fishbein, “Undereducated nurses often fail to recognize their disadvantage and
1980) was the organizing framework for this study. It has proven do not aspire to graduate education” (Neese, Majka, & Tennant,
reliability and validity and proposes a connection between the con- 2007, p. 160).
cepts of attitude toward behavior, subjective norms (social pres- The nursing faculty shortage is another reason to encourage con-
sures), and perceived behavioral control. This study examined the tinuing education for ADN- and diploma-prepared nurses. From
attitudes of nurses initially registered with an ADN or diploma 1995 to 2004, the number of RNs with master’s or doctorates who
toward continuing to the BSN level and/or beyond. The goal was to were nurse educators dropped from 15 percent to 11 percent (Cleary,
provide direction for change. Four research questions were asked: Bevill, Lacey, & Nooney, 2007). Raising BSN program enrollment
• What are the attitudes of ADN and diploma nurses toward con- would be a first step to addressing the faculty shortage.
tinuing formal education? A number of studies have investigated nurses’ motivations for

RESEARCH

ABSTRACT The education of nurses has an influence on patient safety and outcomes, the nursing shortage, the faculty shortage, and
nurses’ attitudes and actions. This article reports on a dissertation study designed to examine the attitudes of nurses, initially registered with an
associate degree or diploma in nursing, toward continuing formal education. Actively licensed registered nurses in the eastern and western United
States (n = 535) participated. The main finding of this study was that, although nurses held positive attitudes overall, attitudes ranked barely above
neutral. The findings suggest that work needs to be done to improve nurses’ attitudes toward continuing formal education and research needs to
be undertaken to understand what would entice nurses back to school. Implications for nursing practice and education are discussed along with
suggestions for future research.

1 4 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s
 C o n T I n u I n g E d u C AT I o n / n u R S I n g E d u C AT I o n R E S E A R C H

engaging in (Bahn, 2007; Hayajneh, 2009; Joyce & Cowman, 2007; method S AMPLE This exploratory, comparative, descriptive
Jukkala, Henly, & Lindeke, 2008; Megginson, 2008) and continuing study used a mailed questionnaire to survey a random sample of
formal education (Hughes, 2005; Joyce & Cowman; Megginson; actively licensed RNs, initially educated below the BSN level, in
Roche, 1990). While most studies concluded that motivation and three states: California, New Jersey, and Pennsylvania. The states
attitude affect participation in, and the outcomes of, education were chosen by size of the RN population (to ensure equal numbers
(Steginga et al., 2005), only two studies found nurses to have positive from the east and west) and the types of nursing programs offered
attitudes toward continuing education (Hughes; Roche). In Waddell’s (to ensure inclusion of diploma RNs). An Internet search of state
(1993) meta-analysis of 22 studies, motivational orientations board licensing sites showed that the two eastern states had the
explained 46 percent of the variation in RN participation. highest proportion of diploma to ADN programs in the country.
When level of education and attitudes were evaluated together, Sample size was determined by power analysis (80 percent
nurses with lower initial educational levels participated less and had power, alpha = .05), consideration of an expected response rate (20
poorer attitudes toward education (Alquraini, Alhashem, Shah, & percent), and prediction of the number ineligible (33 percent BSN
Chowdhury, 2007; Penz et al., 2007; Roche, 1990). Diploma gradu- or equivalent). Finally, questionnaires were mailed: 1,350 RNs
ates were the least likely to participate. The current study is partial- were selected from California, 482 from New Jersey, and 868 from
ly based on a study by Roche (1990) that examined relationships Pennsylvania.
between attitudes toward BSN education, self-esteem, the incidence The Duquesne University Institutional Review Board approved
of perceived life events, and the decision about whether to return to the study. Comprehensive information was sent to participants to
school for a BSN. Roche showed that attitudes contributed signifi- ensure informed consent; data were received, recorded, and stored
cantly (two-tail, p < .001) to differences between RNs who did and to ensure confidentiality. Return of the survey indicated informed
did not return to school. consent.
Reasons for pursuing the BSN are related to internal or intrinsic INSTRUMENTS Two instruments were used: the 19-item
factors (Megginson, 2008), personal achievement or satisfaction Attitudes Toward BSN Education (ATBSNE) scale (Roche, 1990)
(Delaney & Piscopo, 2004; Reilley, 2003), career advancement and a sociodemographic questionnaire adapted from Roche. The
(Delaney & Piscopo; Reilley), the improvement of clinical judgment focus of the ATBSNE on the affective and cognitive aspects of atti-
(Hughes, 2005; Joyce & Cowman, 2007), and increased knowledge tude enhances content validity. A seven-point semantic differential
(Hughes). Megginson identified factors that lead to continuation of scale is used to measure bipolar adjectives. The original scale had
formal education: the right time in life, working with options, person- proven reliability and validity determined by: a panel of experts in
al goals, credible professional identity, encouragement from contem- two phases, a pilot study (test-retest reliability: r = .78, p < .001),
poraries, and user-friendly RN-BSN programs. Reasons for not factor analysis, and Cronbach’s alpha = .94).
returning to school were found to include: time away from family and The sociodemographic questionnaire contained 34 questions:
having multiple roles or responsibilities (Delaney & Piscopo, 2004; open ended (n = 7), forced/multiple choice (n = 18), and dichoto-
Hughes; Megginson; Reilley), a negative ADN or diploma school mous (n = 9). Cronbach’s alpha coefficient was .96.
experience (Megginson), and cost (Bahn, 2007; Delaney & Piscopo; DATA ANALyS IS Initial analysis used simple descriptive sta-
Megginson; Penz et al., 2007). Professional reasons identified were: tistical tests. Subsequent analysis included a multivariate analy-
no different treatment or recognition at work (Hughes; Megginson), sis of variance (MANOVA) and 19 analyses of variances
no extra earning power, and work schedules (Hughes; Reilley). (ANOVAs) on the adjective pairs by degree (ADN vs. diploma) to
Gaps in the literature were identified. Sample sizes, although var- examine the first research question and ANOVAs to examine the
ied, rarely met statistical sizes necessary for generalization. The remaining questions. Assumptions of normality and homogeneity
questionnaires used often provided less depth than other instru- of variance were assessed. Statistical significance was consid-
ments. And the research was mainly focused on eastern states. ered at p < .05. When statistical significance was borderline (p
Although it is recommended that recruitment into RN-BSN programs < .10), findings were evaluated based on the evidence against
start younger, no clear demarcation was identified as to when RNs the null hypothesis.
changed their perceptions toward returning to school. No study
attempted to address how attitudes affect behavior or whether partic- Results and discussion The response rate was 33.9 percent;
ular attitudes have a greater impact on action. An understanding of however, only 19.8 percent of the questionnaires (n = 535) were
nurses’ attitudes is needed in order to develop methods to entice appropriate for data analysis, more than needed as determined by
them to pursue further education. power analysis. Data were compared to findings from the National

March / April Vo l . 3 3 N o . 2 / / /
 C o n T I n u I n g E d u C AT I o n / n u R S I n g E d u C AT I o n R E S E A R C H

Sample Survey of Registered Nurses March 2004 (Health working full-time; 42.5 percent reported the amount reimbursed
Resources & Services Administration, 2006). This report is was based upon hours worked; and 18 percent did not know if their
referred to as the National Sample without reference at each employer offered tuition reimbursement. Fewer participants were
occurrence. eligible for partial tuition reimbursement (≤ $4,000 per year) than
BASIC DEMOGRAPHICS Most participants were female (93.3 found by Roche (1990): 23.5 percent versus 76 percent. Given the
percent), married (71.1 percent), Caucasian (85.2 percent), and expense (e.g., tuition, books) and the time required, $4,000 per
over 50 years of age (54.3 percent); only 14.6 percent were under year is inadequate for pursuing continuing education.
40. Their average number of years as an RN was 24.81 (SD = Only 52.4 percent reported being encouraged to continue their
13.55, range 0.5 to 62). Participants were employed in nursing formal education during their initial licensing program, suggesting
either full-time (56.6 percent) or part-time (21.3 percent), and 43.2 that faculty either do not promote the BSN or do not consider career
percent worked as staff nurses. The study sample closely resem- counseling their responsibility. Faculty do not consistently model a
bled the National Sample in gender, age, marital status, family sta- positive attitude toward continuing formal education.
tus, and employment. The study sample was older, was slightly The main motivator to pursue further education came from “per-
more ethnically diverse, and more nurses were employed in hospitals. sonal desire,” which is consistent with the literature (Delaney &
INITIAL EDUCATION The state breakdown of participants was: Piscopo, 2004; Reilley, 2003). The majority of participants (79.6
California, 44.3 percent; Pennsylvania, 40.2 percent; and New percent) did not feel social pressure to obtain a BSN, and those that
Jersey, 15.5 percent. More than half of the participants, 53.3 per- did said that it would be more effective if accompanied by flexible
cent, originally graduated from diploma programs. When catego- schedules, better tuition reimbursement, financial rewards, and
rized by initial education, 69.6 percent of ADNs and 21.8 percent recognition. In previous research, RNs reported pressure to return
of diploma nurses lived on the west coast. to school from their immediate work environment and society
While the proportion of ADNs to diploma nurses does not rep- (Reilley), as well as for professional growth and career prospects
resent the general population of nurses as shown in the National (Delaney & Piscopo; Hughes, 2005). Given today’s job market and
Sample, which reported 25.5 percent diploma nurses, the final ratio the nursing shortage, these findings are not surprising.
of east to west (1 to 0.8) was sufficient to allow for comparisons. FINDINGS FOR RES EARCH QUES TIONS
CONTINUING EDUCATION Information on participants’ con- 1) What are the attitudes of ADN and diploma nurses toward
tinuing education was consistent with the National Sample. continuing formal education? A significant attitude difference was
However, more RNs had earned their BSNs or higher (42.3 percent) found between ADN and diploma nurses (F = 1.82, p = .02, 2 =
and fewer had a diploma as their highest degree. Only 26.3 percent .08, power = .97). While both groups had slightly positive attitudes,
were interested in returning for further education. Slightly more ADNs held more positive attitudes (M = 4.02, SD = 1.43) than
diploma nurses (54.5 percent) compared with ADNs returned to diploma nurses (M = 3.99, SD = 1.49). This is supported by the lit-
school. erature (Alquraini et al., 2007; Hughes, 2005; Roche, 1990).
This study had double the percent of advanced practice nurses Two items on the ATBSNE scale accounted for 25 percent of
(APNs) (16.9 percent) than the National Sample, yet only 15 par- the variance in the model: item 15 (inappropriate to appropriate)
ticipants (approximately 2.8 percent) were educators compared to and item 17 (unsuccessful to successful). Positive attitudes were
1.67 percent in the National Sample. These findings are indicative expected given the high number of participants who had
of the growing faculty shortage. returned to school, but the numbers were disappointing. The
Top reasons selected for not pursuing higher education mean scores for both groups were only slightly positive, with the
included: too old, won’t earn more money, not needed by hospi- highest item averaging 5.36, suggesting that RNs return to
tals, and not needed to give good care. This last reason contradicts school for reasons other than the value of the BSN. With the high
the primary reason found in other research (Bahn, 2007; Joyce, & number who had returned, still more wanting to return, and only
Cowman, 2007). The nursing shortage, with contingent job securi- moderately strong positive attitudes toward the BSN, something
ty and opportunities that traditionally required a BSN, likely influ- else must be enticing RNs.
enced the findings. It is possible that nurses are not aware of, or do 2) Do attitudes change over time as determined by years of nurs-
not believe, current research on patient outcomes. ing practice? There were no significant differences (F = 2.11, p =
As in previous research (Delaney & Piscopo, 2004; Penz et al., .06, 2 = .02, power = .70) found on ATBSNE scores by age group.
2007), cost was cited as an impediment for not returning to school; Attitudes remained relatively constant, suggesting that encourage-
it was the second top reason in the “other” category. To receive ment to continue formal education may occur at any time during a
tuition reimbursement, 46.4 percent of respondents needed to be nurse’s career. Consistent with the literature (Cleary et al., 2007;

1 6 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s
 C o n T I n u I n g E d u C AT I o n / n u R S I n g E d u C AT I o n R E S E A R C H

Delaney & Piscopo, 2004; Roche, 1990), participants cited age as Employers do exert some pressure but they appear not to have
an obstacle to returning. Roche also found that those licensed for a improved their support. Many nurses are unaware of tuition reim-
shorter period were more likely to return to school. bursement and, if it exists, the amount is low. Aside from the per-
3) How do the attitudes of those who return to school for a BSN ception that a BSN is not required for employment or to provide
or higher differ from those who have not returned or from those plan- good care, reasons not to return to school included age and cost.
ning to return? The number of participants planning to return to Chronological age may influence behavior separate from attitude;
school was too small for a meaningful comparison with either those thus, further research is needed. Diploma and ADN faculty are not
who had returned or will not return. Thus, it was dropped from encouraging students to continue their formal education, which
analysis. The ANOVA was significant (F = 17.17, p < .001, partial may be seen by students as a negative attitude. The salaries of
2 = .04, power = .99). APNs are well above those of the average staff nurse and a BSN
As expected, those who had returned to school scored signifi- degree is the first step toward APN education, which may be a
cantly higher on the ATBSNE scale (M = 5.17, SD = 1.13), indicat- motivator.
ing more positive attitudes, than those who had not returned (M = More research is needed on how and when to best improve the
4.74, SD = 1.04). This is consistent with Roche (1990). attitudes of nurses and nurse faculty. A suggested next step is a
4) Do attitudes differ according to geographical location (west vs. longitudinal (prospective) mixed-modal study of a group of new
east)? The ANOVA for this question was not significant (F = 3.07, graduates to delve into their current attitudes and determine if
p = .08, partial 2 =.01, power = .42). No difference was found in attitudes change during the course of a nurse’s career.
ATBSNE scores between RNs on the east and west coasts. This In accordance with the TPB, methods to entice RNs to
finding was unexpected as there has been a resurgence of diploma return to school should not only be focused on changing atti-
programs in the east and no known diploma programs in California tudes, but should also increase subjective norms. Employers,
(only 22.1 percent of the diploma participants resided on the west nurse educators, and experienced RNs need to take a more
coast). Although the finding may be explained by movement between active role in promoting and supporting the continuation of
states, it is more likely that it reflects existing attitudes. formal education. Employer support must be increased, con-
crete, and advertised. Employers need to improve communi-
limitations The study used a descriptive, comparative design, cations about reimbursement, increase the amount of finan-
with a self-report, mailed questionnaire. The survey length was cial commitment, provide flexible schedules, and provide
shorter than ideal for use of a semantic differential scale, and the monetary rewards and/or recognition for those nurses who
concept was measured indirectly. However, certain limitations complete advanced education. The use of career ladders, with
were reduced through the assumptions of, and methodological the attainment of a BSN as a step, could be one method used.
choices for, the study. Randomized sample selection was used to In addition, although older RNs tended to have more positive
control for extraneous variables, reduce bias, and aid in attaining a attitudes toward BSN education, they see age as an impedi-
representative sample. Thus, while generalizations about the find- ment and might benefit from mentoring by younger nurses.
ings to all United States nurses must be done with caution, they It appears from this study that negative attitudes are being
may be made based on the even distribution of participants, instru- modeled by faculty. Students need greater encouragement,
ment reliability, the adequate sample size, and the demographic more information, and mentoring during their initial nursing
similarity to the National Sample. education. To understand what faculty convey to students, a
survey of ADN and diploma faculty is needed.
Conclusions and Recommendations The attitudes of all Finally, as many nurses do not appear to value the BSN,
nurses toward BSN education require improvement. Nurses who had research on the benefits of a BSN education needs to be
returned to school had the most positive attitudes about BSN educa- repeated for validation and better disseminated.
tion, with positive attitudes related to personal reasons, social pres- Dissemination of this research needs to be done in a positive
sure, and experience. ADN nurses had slightly more positive atti- manner that does not devalue the contributions of ADN and
tudes than diploma nurses overall, but both groups ranked barely diploma nurses, and it should be directed toward nurses who
above neutral. Many participants who had not returned to school do not have research experience.
cited not needing a BSN education to give good care. Such ignorance Quality in health care is a priority. Nurses need the scope
can be overcome only through returning to school, where the advan- and depth of knowledge, skill, and judgment attained
tages of a BSN should become evident. “Undereducated nurses often through baccalaureate education in order to teach and/or to
fail to recognize their disadvantage” (Neese et al., 2007, p. 160). provide optimal quality care to complex patients. Attitudes

March / April Vo l . 3 3 N o . 2 / / /
 C o n T I n u I n g E d u C AT I o n / n u R S I n g E d u C AT I o n R E S E A R C H

toward continuing formal education are poor and need Nursing Foundation and Sacramento State University for finan-
improvement. The commitment to lifelong learning is a profes- cial support for this study; Dr. E. M. Roche for use of her instru-
sional values and a hallmark of all professions. NLN ment; and the members of her dissertation committee, Drs. Lynn
Simko, Gladys Husted, and Robyn Nelson. For more information,
About the Author contact Dr. Altmann at altmannt@csus.edu.
Tanya K. Altmann, PhD, RN, is an associate professor at
Sacramento State University School of Nursing, Sacramento, Key words Nurse Attitudes – Nursing Education – RN-BSN
California. The author is grateful to the National League for Education – Postregistration

References world.org/MainMenu Categories/ Jukkala, A. M., Henly, S. J., & Lindeke, L. L. (2008).
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, ANAMarketplace/ANAPeriodicals/OJIN/ Rural perceptions of continuing professional
D. M., & Silber, J. H. (2003). Educational levels of TableofContents/ Volume72002/No2May2002/ education. Journal of Continuing Education in
hospital nurses and surgical patient mortality. RevisingPostiononEducation.html Nursing, 39(12), 555-563.
Journal of the American Medical Association, 290, Estabrooks, C. A., Midodzi, W. K., Cummings, G. Megginson, L. A. (2008). RN-BSN education: 21st
1617-1623. G., Ricker, K. L., & Giovannetti, P. (2005). The century barriers and incentives. Journal of
Ajzen, I., & Fishbein, M. (1980). Understanding impact of hospital nursing characteristics on 30- Nursing Management, 16, 47-55.
attitudes and predicting social behavior. Englewood day mortality. Nursing Research, 54, 74-84. Neese, R., Majka, G., & Tennant, G. G. (2007).
Cliffs, NJ: Prentice-Hall. Friese, C. R., Lake, E. T., Aiken, L. H., Silber, J. H., & The ultimate challenge: Three situations call
Alquraini, H., Alhashem, A. M., Shah, M. A., & Sochalski, J. (2008). Hospital nurse practice: American nurses to think and act globally. In M.
Chowdhury, R. I. (2007). Factors influencing Environments and outcomes for surgical oncol- H. Oermann & K. T. Heinrich, Eds., Annual Review
nurses’ attitudes towards the use of computer- ogy patients. Health Services Research, 43(4), of Nursing Education, 5, 153-171.
ized health information systems in Kuwaiti hos- 1145-1163. Penz, K., D’Arcy, C., Stewart, N., Kosteniuk, J.,
pitals. Journal of Advanced Nursing, 57, 375-381. Hayajneh, F. (2009). Attitudes of professional Morgan, D., & Smith, B. (2007). Barriers to par-
American Association of Colleges of Nursing. Jordanian nurses toward continuing education. ticipation in continuing education activities
(2008). Fact sheet: The impact of education on Journal of Continuing Education in Nursing, 40(1), among rural and remote nurses. Journal of
nursing practice. Retrieved from 43-48. Continuing Education in Nursing, 38(2), 58-66.
www.aacn.nche.edu/Media/FactSheets/ImpactEd Health Resources & Services Administration. Reilley, J. L. (2003). The educational participation of
NP.htm (2006). The registered nurse population: National the female registered nurse baccalaureate student:
American Association of Colleges of Nursing. sample survey of Registered Nurses March 2004: Motivation, barriers, and persistence to complete
(2011). Nursing shortage. Retrieved from Preliminary findings. Merrifield, VA: US the degree. Unpublished doctoral dissertation,
www.aacn.nche.edu/media-relations/fact- Department of Health and Human Services, Widener University, Wilmington, DE.
sheets/nursing-shortage Bureau of Health Professions, Division of Roche, E. M. (1990). The relationship of attitude
Bahn, D. (2007). Orientation of nurses towards Nursing. toward BSN education, self-esteem, life events and
formal and informal learning: Motives and per- Hilton, L. (2004). Aiken study supports pro-BSN RN’s decision to return to school to earn a BSN.
ceptions. Nurse Education Today, 27, 723-730. stance. Nursing Spectrum (Greater Philadelphia/Tri- Unpublished doctoral dissertation, Widener
Cleary, B., Bevill, J. W., Lacey, L. M., & Nooney, J. State Edition), 12, 14-15. University, Chester. PA.
G. (2007). Evidence and root causes of an inade- Hughes, E. (2005). Nurses’ perceptions of con- Steginga, S. K., Dunn, J., Dewar, A. M., McCarthy,
quate pipeline for nursing faculty. Nursing tinuing professional development. Nursing A., Yates, P., & Beadle, G. (2005). Impact of an
Administration Quarterly, 31, 124-128. Standards, 19, 41-49. intensive nursing education course on nurses’
Delaney, C., & Piscopo, B. (2004). RN-BSN pro- Institute of Medicine. (2011). The future of knowledge, confidence, attitudes, and perceived
grams: Associate degree and diploma nurses’ skills in the care of patients with cancer.
nursing: Leading change, advancing health.
perceptions of the benefits and barriers to Oncology Nursing Forum, 32, 375-381.
Washington, DC: National Academies Press.
returning to school. Journal of Nursing Education, Tourangeau, A. E., Doran, D. M., McGillis Hall, L.,
Joyce, P., & Cowman, S. (2007). Continuing pro-
20, 157-161. O’Brien Pallas, L., Pringle, D., Tu, J. V., & Cranley,
fessional development: Investment or
Delgado, C. (2002). Competent and safe practice. L. A. (2007). Impact of hospital nursing care on
expectation? Journal of Nursing Management,
Nurse Educator, 27, 159-161. 30-day mortality for acute medical patients.
15, 626-633.
Journal of Advanced Nursing, 57, 32-44.
Donley, R., & Flaherty, M. J. (2002). Revisiting the
American Nurses Association’s first position Waddell, D. L. (1993). Why do nurses participate
paper on education for nurses. Online Journal of in continuing education? A meta-analysis. Journal
Issues in Nursing. Retrieved from www.nursing- of Continuing Education in Nursing, 24, 52-56.

1 8 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s
 S T u dy A B R oA d / n u R S I n g E d u C AT I o n R E S E A R C H

Assessing Outcomes o f a Study Abroad Course

for NURSING STUDENTS
l I n dA J . C A R p E n T E R And AlExAndRA A. gARCIA

A S HIgHER EduCATIon InSTITuTIonS SEEK wAyS To

pREpARE gRAduATES To lIvE In And ConTRIBuTE To
An InCREASIngly gloBAl SoCIETy, gRowIng numBERS of Col-
(American Academy of Colleges of Nurses [AACN], 2008a) and its
accompanying toolkit of resources (AACN, 2008b). The toolkit
offers an extensive list of integrative classroom and clinical learn-
lEgE STudEnTS lEAvE CAmpuS EACH yEAR To STudy ABRoAd ing strategies, references, and web resources to foster cultural com-
(Belyavina & Bhandar, 2012). However, there is little research that petency. The National League for Nursing toolkit on innovations in
explores the link between nursing students’ experiences in interna- curriculum design (2011) also offers suggested strategies to
tional programs and changes in their cultural competence (Evanson enhance development of cultural competence. The Guadalajara
& Zust, 2006). experience described in this article illustrates the use of some of
A course titled Spanish for Healthcare Professionals, described the suggestions found in these toolkits, for example, offering an
by Bloom, Timmerman, and Sands (2006), was adapted into a study immersion experience, participating in community activities,
abroad experience in Guadalajara, Mexico, for a baccalaureate nurs- arranging field trips, and encouraging students to keep a journal.
ing program at the University of Texas at Austin. This article reports Study abroad is one way to broaden American college students’
on findings from a descriptive study conducted to assess outcomes of worldview, but nursing curricula are sequential and crowded with
the experience. Two research questions were asked: essential content and practice competencies; thus, nursing stu-
• How has the study abroad experience influenced the participants’ dents rarely have the luxury of spending a semester abroad to expe-
awareness, sensitivity, knowledge, and skills related to culture of the rience another culture. Depending on the location of the nursing
people in Guadalajara? program and available clinical experiences, students may be
• How has the study abroad experience influenced participants’ exposed to patients from diverse cultures, but such experiences are
clinical practice as nurses? random. Although a recent search cited the existence of more than
220 study abroad programs for nursing students (Nursing Study
Background and Significance To meet the health care needs Abroad, 2012), many nursing students are unaware of opportunities
of individuals from diverse cultural and ethnic backgrounds and outside the prescribed curriculum.
deliver appropriate care, nurses must be aware of, and sensitive to, Previous studies support the value of international experiences
cultural issues and differences among various groups of patients. for preparing nursing students to incorporate cultural competence
This study was guided by the conceptualization of cultural compe- into clinical practice (Evanson & Zust, 2006; Wood & Atkins,
tence as having four components: cultural awareness (affective 2006). Studies have demonstrated positive short-term outcomes,
dimension), cultural sensitivity (attitudinal dimension), cultural including gains in substantive knowledge, changes in values,
knowledge (cognitive dimension), and cultural skills (behavioral improved communication skills, and the development of culturally
dimension) (Rew, Becker, Cookston, Khosropour, & Martinez, focused practice (Caffrey, Neander, Markle, & Stewart, 2005;
2003). Evanson & Zust; Ryan, Twibell, Bighman, & Bennett, 2000; Wood
In choosing strategies for developing cultural competence that & Atkins). In Evanson and Zust’s study, nursing students showed
fit into otherwise full nursing programs and creating mechanisms to long-term benefits in the form of increased understanding as well
evaluate the results, nurse educators have been guided by the doc- as uncomfortable, lingering, unsettled feelings resulting from the
ument “Cultural Competency in Baccalaureate Nursing Education” awareness of inequities in resources. The current study combines

RESEARCH

ABSTRACT There is little debate about the importance of preparing nursing graduates to provide culturally sensitive care to an increas-
ingly diverse society. However, it is difficult for nurse educators to fit learning experiences that help students develop cultural competence into
already full programs and create mechanisms to evaluate the results. This article describes a study to assess the impact of a study abroad pro-
gram on developing cultural competence, including cultural awareness, sensitivity, knowledge, and skills. Results from the Cultural Awareness
Survey, reflective journals, and interviews illustrate how the study abroad experience influenced the development of components of cultural com-
petence and might influence clinical practice. Results suggest effective teaching strategies to assist students in becoming culturally competent are
experiential in nature and include role modeling, reflective activities, and group discussion.

March / April Vo l . 3 3 N o . 2 / / /
View publication stats