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A Cultural Immersion Experience for Nursing Students 

 

Anne Marie Jones 
 

Judy Neubrander 
 

Marie Huff 
 

Western Carolina University, USA 
 

Abstract 
 

This research study explores the effects of an intense cultural immersion 
experience on nursing students’ cultural attitudes. Students were exposed 
to an intense ten day clinical cultural experience in a developing country in 
South America. They were pre-tested on their cultural attitudes using 
Cushner's Inventory of Cross-Cultural Sensitivity (ICCS), they completed 
guided journal experiences during the trip, and they took the same 
inventory, post experience. Although quantitative results were not 
statistically significant, their quantitative journals indicate a significant 
change in cultural attitudes. 

 
Introduction 

 
While there is not a tremendous body of research concerning overseas travel courses 
for nursing students, there is agreement in the literature that cultural immersion 
experiences can enhance students’ ability to effectively treat individuals from a variety 
of cultural backgrounds (Button, Green, Tengnah, Johansson, & Baker, 2005; Callister 
& Cox, 2006; Thompson, Boore, & Deeny, 2000; Wood & Atkins, 2006; Lee, 2004). 
Studies show that international immersion experiences promote both personal and 
professional growth and increase students’ levels of cultural competence as they begin 
to examine their own worldviews and develop a more global perspective regarding 
health care systems outside of the United States (Evanson & Zust, 2006; Walsh & 
DeJoseph, 2003). In addition, these experiences help students to have a better 
understanding of the impact that culture has on health care beliefs, practices, 
resources, and access to care (Thompson et al., 2000).  
 
Students are facing shifting demographics and cultures as people from all corners of the 
globe move between and among various communities throughout the world. Thus, 
cultural competence is an important attribute for any discipline that wishes to work 
effectively across these diverse cultures. Becoming culturally competent means 
developing an enhanced awareness of our own cultural assumptions as well as learning 
to interact and communicate respectfully with people who are different from us. While 
classes on cultural diversity and cultural competence are often incorporated into 



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academic curricula, an international travel immersion experience can promote deep and 
meaningful learning as students apply what they have learned in the classroom, engage 
in complex problem solving activities, and observe real world problems. The goal for this 
immersion experience in a developing country was to expose students to cultures 
different from their own and to educate them about health care disparities. A secondary 
goal was to provide health care services to a population that has limited or no access to 
health care (Campbell, Campbell, Krier, Kuehlthau, Hilmes, & Stromberger, 2009). 

 
The literature suggests that there are a number of potential benefits for students who 
participate in international learning experiences. Lee (2004) states, “International 
experiences offer a vital opportunity to explore other ways of thinking and living” (p. 
121). Caffrey, Neander, Markle, and Stewart (2005) found that students participating in 
an immersion experience gained much more in their perceived cultural competencies. 
Students may also expand their awareness of nursing in the global community (Walsh & 
DeJoseph, 2003) as they “broaden their perspectives on nursing practice and its 
culture” (Grant & McKenna, 2003, p.534). Evanson and Zust (2006) as well as Button, 
et al. (2005) concluded that short-term immersion experiences can enhance students’ 
cultural competence as well as have lasting effects on their personal and professional 
lives. Zorn, Ponick, and Peck (1995) found that exposure to cultural diversity through 
international study programs positively influences cognitive development. Through the 
personal challenges involved, students experience development and growth as well as 
build their confidence (Lee, 2004). Heuer and Bengiamin (2001) described many 
aspects of culture shock that students experience during an international experience. In 
addition to experiencing some culture shock, students begin to examine their biases 
and question the values of their society (Levine & Perpetua, 2006). 
 

The Immersion Experience 
 

Setting 
 
Ecuador was chosen as the site for this international experience. Ecuador lies at the 
equator in South America between Colombia and Peru, with the Pacific Ocean as its 
western border. With a population of nearly 14 million people, Ecuador is approximately 
the size of the state of Nevada. It is an ethnically and biologically diverse country of 
stunning beauty. Political instability and corruption have plagued Ecuador’s history and 
contributed to its status as a “developing” country. Access to health care is extremely 
limited for a large majority of the population due to financial issues as well as availability 
of facilities, providers, and resources. Typical diagnoses on the medical mission include 
scabies, parasites, diabetes, hypertension, malnutrition, pneumonia and tuberculosis 
(Lopez-Cevallos & Chi, 2010).  
 
Planning and Preparation 
 
Six months prior to the trip students were oriented to the country of Ecuador, the 
culture, and the history of the country. Students were involved in discussions about 



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cultural diversity and the challenges of entering into a different culture and providing 
culturally sensitive nursing care. Students gathered over-the-counter medications and 
toiletries such as soaps, toothpaste and toothbrushes to donate to the citizens of 
Ecuador. Students were also provided with detailed instructions on what they should 
bring with them, as well as the safety precautions they should follow while in Ecuador. 
 
The Trip 
 
Our team consisted of two nursing faculty and 14 students, including ten undergraduate 
nursing students, two nutrition students, one recreational therapy student and one 
student who was majoring in communications and Spanish. Other team members 
included two physicians, four registered nurses, a medical assistant, and five non-
medical personnel. During the ten days we were in Ecuador, six medical clinics were set 
up in diverse locations including clinics near the coast in a river village, deep in the 
Ecuadorian jungle, and in the mountainous region. The students served in all six 
medical clinics. In addition to clinic days, students experienced sightseeing and 
shopping in Otavalo, home of the largest outdoor market in South America. The last day 
of the trip students were assigned to observe the delivery of healthcare in a large 
hospital in Quito.  
 
Medical clinics consisted of six stations: 
 

 Vital signs/triage station;   

 Assessment/treatment stations; 

 Ear-wash station;  

 Reading-glass dispensary station;  

 Pharmacy;  

 Patient education station 
 
Students were rotated through each station in two hours shifts to provide them the 
opportunity to observe different practitioners’ techniques of assessment as well as to 
get hands-on experience with triage, obtaining patient histories, physical assessment, 
earwashing, assessing the need for reading glasses, and dispensing medications. They 
also conducted patient education on topics such as clean drinking water, handwashing, 
proper care of teeth, prevention and treatment of seborrheic dermatitis and other skin 
conditions, dangers of smoking, and breast self-examination. Prior to the trip students 
had identified pertinent learning needs and created posters and other teaching aids to 
enhance patient learning. Translators were available at each station to assist with 
communication.  

 
Method 

Purpose 
 
The purpose of this research was to assess the impact of an international educational 
experience on nursing students’ cultural attitudes.  



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Participants 
 
Participants included ten Bachelor of Science in Nursing (BSN) students in their first 
year of nursing courses, one recreational therapy student, two nutrition students, and a 
student double majoring in Spanish and Communications from a regional 
comprehensive university in the eastern United States. Participants self-selected by 
registering for a three credit hour course that involved 10 days of international travel to 
Ecuador to participate with a traveling medical unit. All participants were female, aged 
20-22; nine were white of non-Hispanic origin and one student was Hispanic. Two 
students had previously traveled to a developing country. 
 
Fourteen students who did not participate in the travel course volunteered to serve as a 
comparison group. The two groups were very similar in terms of age, gender, ethnicity, 
socioeconomic status, and previous exposure to developing countries. 
 
Inventory 
 
Data collection methods included a demographics questionnaire and Cushner’s (1986) 
Inventory of Cross-Cultural Sensitivity (ICCS).  The ICCS measures five aspects of 
cross-cultural sensitivity using a 7-point Likert scale on a 32 item self-report inventory: 
cultural integration, behavioral scale, intellectual interaction, attitudes towards others, 
and empathy. Loo and Shiomi (1999) state that the Cushner inventory is promising as a 
tool to measure multidimensional conceptualization of cross-cultural sensitivity, although 
it does not demonstrate strong reliability and validity based on its limited use.  

  
Data Collection 
 
After obtaining IRB approval from the university to conduct the study, students were 
provided with informed consent, and written agreement to participate was obtained.   
The inventories were administered to two groups: one group of BSN students who were 
traveling to Ecuador, and a comparison group of BSN students who were not 
participating in the international course. (The nutrition students, however, did not take 
the ICCS). Three weeks after returning from the experience, the inventory was again 
administered to both groups. 
 
In addition to completing the ICCS, students who participated in the course kept a 
reflective journal in which they wrote on a daily basis from departure until the date of 
return to the United States. At the end of the trip, these journals were independently 
reviewed by each researcher to familiarize them with their overall content. The journals 
were then reread a second time and common themes were identified for the purpose of 
organizing and reporting the results. All of the recurring themes identified in the results 
section were those that emerged from the data and from the researchers’ informal 
debriefings with the students while they were still in Ecuador. The Spanish and 
Communication major was not required to journal. 
 



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Results 
 
Results of the ICCS indicated a positive trend in attitudes toward cultural differences in 
the travel group, although not statistically significant. Mean scores on the ICCS for the 
participant group were 155.7 (SD = 18.00) for the pretest and 159.66 (SD = 15.58) for 
the posttest (p = .54). Mean scores on the ICCS for the comparison group were161.00 
(SD = 22.80) for the pretest and 154.91 (SD = 22.62) for the posttest (p = .81). When a 
t-test was performed to compare the two groups’ change in cultural attitudes (as 
measured by the ICCS), there was no significant difference (p = 0.23).  
 
Reflective Journals 
 
Similar to one of the themes identified by Evanson and Zust (2004), a number of 
comments in the students’ journals reflected either confirmation or questioning of their 
choice of nursing as a career. Some examples of student comments are included 
below. 
 

I absolutely love working with those who are truly in need, whether this be 
in America or other places, I know this is what I want to do.  All of the time 
spent thus far has given me a wonderful view of what I want to do with my 
career and that is serving the underserved, those who need it the most. 
 
I have struggled for the past few months in the attempt to discover where I 
am supposed to go within the field of nursing. I think this week God finally 
showed me where I am meant to be. I want to work as a missionary nurse, 
not just in Ecuador, but everywhere. I can’t explain it but something just 
feels so right about this. 
 
I would never want to do pediatrics, but after this trip I believe I may have 
more of a calling for it than I thought. 
 
I have enjoyed the trip and it has been nothing but an amazing 
experience, but I believe that this type of mission nursing is not where I 
need to be with my life. I enjoy bedside nursing too much and that is 
where my heart truly is.  
 

Other themes noted included students’ expression of their new experience of being a 
“minority,” as well as frustration with language barriers when trying to communicate with 
those seeking care.  
 

I realized that for the first time in my life I was the minority. It was strange 
and slightly awkward to see the natives here stare as we made our way 
through the airport with an army of luggage and crew. 
 



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The language barrier makes me nervous. How am I going to be effective 
helping these people learn when I can’t even speak their language? 

 
I love seeing the different people. But at the same time I feel very removed 
from their lives, and not as connected because I can’t speak to them or 
get to know them or comfort them like I would normally do for my patients. 
It is very aggravating! I am determined to make myself learn more 
Spanish! (mas espanol!) 

 
I feel like I could do so much more for them if I knew Spanish. 

 
….but it was very poor, my communication with these people. I now wish I 
would have taken some more Spanish classes or paid better attention! 

 
Many also expressed amazement at the safety hazards for children present 
everywhere. During our bus rides, we often observed small unsupervised children 
playing in the busy roads; others would be playing on high rickety-appearing porches 
with no railing to prevent falls.  
 

It was also shocking to see a little girl, less than two, playing with a 
machete as if it were an umbrella, and no parents running after her. 
 

Another theme that emerged was related to students’ feelings of helplessness. Several 
students commented that they were bothered by our inability to treat many of the 
conditions with which patients presented. For instance, we saw multiple patients 
suffering from tuberculosis, but unfortunately did not have the medications to treat them. 
The students also identified a significant heart murmur while assessing a small girl. The 
physicians diagnosed her with a severe valvular defect. Obviously, our team was 
helpless to treat her at that time. Others expressed concern about the short term “fixes” 
and what happens to these patients after we leave. 
 

That is what I feel so awful about providing health care to these villages. 
We come in and care for them, give them the medicine and the treatment 
they need, and then we leave with the hopes that they will become better 
and that they follow through with the treatment. 
 
I still have to wonder about the people we see who really need further 
medical care. Sure we tell them that they need to be seen by a specialist, 
but I wonder how may of them actually follow through with this advice. 
Like today, we saw a little 6 year old boy with an undescended testicle. He 
was told that he would require surgery, and if not then he may later 
develop cancer. I wonder how many people are actually capable of 
receiving the care which they deserve. I fear for those who never receive 
the care which they need, and what their final outcome will be. I find 



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myself upset and angry knowing that some people will never live the life 
they deserve because of their lack of healthcare resources. 
 

Some students commented on the health disparities they observed and many 
expressed how we (Americans) take so much for granted.   
 

I viewed the life of other peoples’ worlds today and realize, as I have 
before, we in our Americanized society, take so much for granted. I have 
traveled a bit in my life so far experiencing the “uncomforts” of life outside 
our box, however, the lack of “cushy” accommodations continues to leave 
an impression on me every time. We don’t realize how spoiled we can be 
at times. 
 
Along the way there were random houses. They were just one room with 
straw roofs. I’ve always known some people live this way but today made 
it a reality. I thought about how much I take for granted. I get to go home, 
but this is their home and they will be staying. Life will continue to go on 
for them whether I’m there or not. 
 
The conditions that most of the people live in aren’t even fit for animals. It 
absolutely breaks my heart. I wish there was more that I could do for these 
people. I also have to keep in mind that this is their way of life and it 
wouldn’t be right for me to impose my way of life on them just because I 
think it’s better. 
 
America is so blessed! 
 
It’s sad to see their lack of knowledge and healthcare in comparison to us. 
I think it has made us appreciate a lot more and not take as much things 
for granted. 
 
I am thankful for my home and my family, the healthcare system in 
America. I take for granted so many things in life that these people I’ve 
been in contact with will never know of. 
 
I believe Americans take our healthcare system for granted; we should all 
be grateful for the best of doctors and nurses we have in the states. 

 
Journal entries towards the end of our travel reflected student feelings of being changed 
by the experience of the travel course. 

 
I will be forever changed after I leave this journey and I look forward for 
the opportunities that will be presented because of this week. 
 



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I have been challenged as a nurse, as a Christian, and as an individual.  
This has been the most rewarding and amazing experience of my life. 
 
I will definitely leave this trip with some heavy memories, ones that will 
change my life forever. 
 
Part of me wanted to be back at home, and part of me wanted to stay. 
 

Discussion and Implications 
 

Although the ICCS was of limited value in this study and did not show significant change 
in students’ cultural attitudes, the student journal entries told a different story. Changes 
were noted in the areas of personal and professional growth – in confirmation or 
redirection of career choices and goals. Our study supports Wros and Archer’s (2010) 
findings that students who participate in international experiences have opportunities for 
significant personal and professional growth. Students were forced to examine their own 
value systems as they came face to face with the disparity of resources in third world 
countries compared to the plethora of health resources available in the United States. 
Students seem to learn that we all are connected as human beings, despite our cultural 
differences, and some students expressed appreciation for the “simplicity” of life found 
within this culture. They also expressed a newfound appreciation for the material and 
positional wealth of their own cultures. Edmonds (2010) found similar results with 
students traveling to England and Dominica. 
 
Student journaling provided the researchers with a strong indicator of students’ thoughts 
and attitudes related to culture. Tabor, Carter, Kovar, & Ramsing (2008) used both 
journaling and nightly discussions to assess student’s attitudes regarding cross-cultural 
issues. After our experience we offer advice to other educators who are planning to 
facilitate an international travel course and who wish to do research in this area. First, 
researchers/instructors should have a clear idea of their own goals and objectives 
ahead of time. (We were interested in the impact of the trip on student attitudes.) After 
selecting a destination, make sure students spend time learning about the country and 
culture they will be visiting. Instruct students to begin writing their impressions of what 
they have learned through their research, to describe what they hope to learn from this 
experience, and to identify any questions they may have about the people and culture. 
When they return from the trip they can then respond to their pre-trip journal entries as 
they discuss how their travel experience met their expectations.  
 
While “free flow” journaling should be encouraged, instructors may also want to provide 
some guided questions for students to respond to as part of their daily journal entries. 
For example, instructors may ask students to (1) share a daily event (e.g., what 
happened; what they did), (2) write what they thought and felt about this event, and (3) 
write how this experience challenged or validated their own cultural beliefs. Within a few 
weeks of returning from the trip instructors could also meet with the students as a group 
and share the themes that they found within the students’ journals. Students could then 



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share any additional reflective thoughts and feelings they have about their experience 
through a focus group type setting. Providing students with structured questions for the 
journals and setting up a post trip debriefing focus group would strengthen the overall 
qualitative study and provide valuable feedback to the instructors. 
 
An international travel course that provides students hands-on clinical experiences with 
a population that has limited access to healthcare fosters students’ personal and 
professional growth. More opportunities for these types of courses need to be made 
available in nursing and other academic programs. Additionally, it would be beneficial 
for schools to develop a variety of types of experiences, such as in hospitals, 
established clinics, and community health outreaches in conjunction with a cross-
cultural experience. Taking groups of pre-licensure and advanced practice nursing 
students with physical therapy, nutrition, medical, and other health science students 
could enhance interdisciplinary teamwork and provide more comprehensive care to the 
population being served. 
 

References 
 

Button, L., Green, B., Tengnah, C., Johansson, I., & Baker, C. (2005). The impact of 
international placements on nurses’ personal and professional lives: literature 
review. Journal of Advanced Nursing. 50, 315-324. 

Caffrey, R. A., Neander, W., Markle, D., & Stewart, B. (2005). Improving the cultural 
competence of nursing students: Results of integrating cultural content in the 
curriculum and an international immersion experience. Journal of Nursing 
Education, 44, 234-239. 

Callister, L. C., & Cox, A. H. (2006). Opening our hearts and minds: The meaning of 
international clinical nursing electives in the personal and professional lives of 
nurses. Nursing and Health Sciences, 8, 95-102. 

Campbell, C., Campbell, D., Krier, D., Kuehlthau, R., Hilmes, T., & Stromberger, M. 
(2009). Reduction in burnout may be a benefit for short-term medical mission 
volunteers. Mental Health, Religion and Culture, 12, 627-637. 

Edmonds, M. L. (2010) The lived experience of nursing students who study abroad: A 
qualitative inquiry. Journal of Studies in International Education, 14, 545-568. 

Evanson, T. A., & Zust, B. L. (2004). The meaning of participation in an international 
service experience among baccalaureate nursing students. International Journal 
of Nursing Education Scholarship, 1, 1-14. 

Evanson, T. A., & Zust, B. L. (2006). “Bittersweet knowledge”: The long-term effects of 
an international experience. Journal of Nursing Education, 45, 412-419. 

Grant, E., & McKenna, L. (2003). International clinical placements for undergraduate 
students. Journal of Clinical Nursing, 12, 529-535.  

Heuer, L. J., & Bengiamin, M. I. (2001). American nursing students experience shock 
during a short-term international program. Journal of Cultural Diversity, 8, 128-
134. 

Lee, N. J. (2004). The impact of international experience on student nurses’ personal 
and professional development.  International Nursing Review, 51, 113-122. 



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10 

 

Levine, M. A., & Perpetua, E. (2006). Interational immersion programs in baccalaureate 
nursing education: Professor and student perspectives. Journal of Cultural 
Diversity, 13, 20-26. 

Loo, R., & Shiomi, K. (1999). A structural and cross-cultural evaluation of the  
 inventory of cross-cultural sensitivity. Journal of Social Behavior and  
 Personality, 14, 267-278. 
Lopez-Cevallos, D. F., & Chi, C. (2010). Assessing the context of health care utilization 

in Ecuador: A spatial and multilevel analysis. Health Services Research, 10. 
doi:10.1186/1472-6963-10-64 

Tabor, R. G., Carter, D. M., Kovar, M., & Ramsing, R. (2008). International service 
learning, Journal of Dental Hygiene, 82, 49. 

Thompson, K., Boore, J., & Deeny, P. (2000). A comparison of an international 
experience for nursing students in developed and developing countries. 
International Journal of Nursing Studies, 37, 481-492. 

Walsh, L. V., & DeJoseph, J. (2003). “I saw it in a different light”: International  
learning experiences in baccalaureate nursing education. Journal of  
Nursing Education, 42, 266-272. 

Wood, M. J., & Atkins, M. (2006). Immersion in another culture: One strategy for  
 increasing cultural competence.  Journal of Cultural Diversity, 13, 50-54. 
Wros, P., & Archer, S. (2010) Comparing learning outcomes of international and local 

community partnerships for undergraduate nursing students. Journal of 
Community Health Nursing, 27, 216-225. 

Zorn, C. R., Ponick, D. A., & Peck, S. D. (1995). An analysis of the impact of 
participation in an international study program on the cognitive development of 
senior baccalaureate nursing students. Journal of Nursing Education, 34, 67-70. 

 
 
  



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About the Authors 

 
Anne-Marie Jones received her BSN from the University of North Carolina at Chapel 
Hill in 1982 and began her career working in cardiac nursing and stepdown units. After 
several years and assignments in the US Air Force, Ms. Jones completed her MSN with 
a focus in critical care nursing from UTHSC San Antonio. For the past 10 years, she has 
been a nurse educator, working primarily with first year nursing students in foundational 
didactic and clinical courses. She holds the NLN certification for nurse educators, and 
serves as the Junior Team coordinator for the BSN program at Western Carolina 
University.  Besides teaching, Ms. Jones' areas of interest include international nursing 
experiences in developing countries and end-of-life nursing care. She can be reached at 
ajones@email.wcu.edu.  
 
Dr. Judy Neubrander received her Masters of Science in Nursing, with a focus in adult 
health and nursing education from the University of Kansas in 1994. In 2002 she 
received her doctorate in Adult and Community College Education from North Carolina 
State University. She is a certified Hospice and Palliative Care Nurse and a Palliative 
Care Fellow from Harvard School of Medicine. She became an ELNEC trainer in 2001. 
She became a certified nurse educator in 2006. She completed her certification as a 
Family Nurse Practitioner in May of 2009. She currently teaches courses in nursing 
theory, roles and issues, ethics, nursing education, test and measurement and dying 
and palliative care. She serves as the director of the graduate programs at Western 
Carolina University School of Nursing. Her areas of interest and research include end-
of-life care, gerontology, international missionary/volunteer services and adult 
education. One of her goals is to help the neediest of the world both at home and 
abroad.  She can be reached at jneubrander@wcu.edu.  
 
Dr. Marie T. Huff is an Asheville native who came to WCU in 1998. She earned her 
Master of Social Work degree from the University of Georgia in 1986 and her Ph.D. 
from the University of South Carolina in 1998. Before becoming Associate Dean in 
2008, Dr. Huff was a faculty member in the department of social work and served as 
department head from 2006-2008. Dr. Huff has over ten years of social work practice 
experience is in the field of mental health with adolescents and their families. She was 
employed as a clinical social worker and maintained a part-time private practice in 
Georgia. Her teaching and research interest include addictions and cultural competence 
in mental health practice.  She can be reached at mhuff@email.wcu.edu.  

mailto:ajones@email.wcu.edu
mailto:jneubrander@wcu.edu
mailto:mhuff@email.wcu.edu

