This study evaluated the effectiveness of a blended learning workplace violence prevention program for emergency department employees. 120 employees completed the online modules and classroom tabletop exercise. Scores on a 20 question test significantly increased from baseline to immediately post-program and were retained at the 6 month follow up, indicating the program improved knowledge that was maintained over time. The blended approach of online and in-person learning was more effective than online alone at producing long-term knowledge gains. The results provide support for implementing blended learning workplace violence prevention programs in emergency departments.
Effect of Blended Learning Environment Model on High School Studen.docx
1. Effect of Blended Learning Environment Model on High School
Students' Academic Achievement
Author(s):
Kazu, Ibrahim Yasar; Demirkol, Mehmet
Source:
Turkish Online Journal of Educational Technology - TOJET,
v13 n1 p78-87 Jan 2014. 10 pp.
Peer Reviewed:
Yes
ISSN:
1303-6521
Descriptors:
Blended Learning, High School Students, Academic
Achievement, Comparative Analysis, Conventional Instruction,
Gender Differences, Foreign Countries, Science Instruction,
Secondary School Science, Genetics, Biology, Experimental
Groups, Control Groups, Educational Technology, Computer
Uses in Education, Online Courses, Science Achievement,
Pretests Posttests, High Schools, Grade 10, Grade 11
Identifiers:
Turkey
Abstract:
This study analyzes the students' academic performance by
comparing the blended learning environment and traditional
learning environment. It has been observed whether there is a
significant difference between the academic achievement grade
dispersions and the male-female students' grades. The study has
been carried out in Diyarbakir Anatolian High School in 2010-
2011 academic year first semester biology courses. For the
study, two quantitative courses sections have been selected
among the classes formed by secondary school senior students.
Cluster analysis has been conducted to provide the objectivity
when forming the experiment and control groups. The study has
been conducted with 54 participants, 19 males and 8 females for
2. the experiment group and 18 males and 9 females for the control
group. The experiment group continued its education in blended
learning environment and the control group continued its
education in traditional learning environment. The created
learning environments have focused the genetics topic of the
biology course and lasted for 6 weeks. During the study, pre-
test and final-test have been used for the academic achievement
analysis. According to the results acquired at the end of the
study, a significant difference hasn't been found between the
two groups at the end of the pre-test applied to experiment and
control groups. Besides, in accordance with the averages of the
final test grades, the experiment group has been found more
successful than the control group. In both of the learning
environments, female students have turned out to be more
successful than the male students.
Abstractor:
As Provided
Number of References:
33
Number of Pages:
10
Publication Type:
Reports - Research; Journal Articles
Availability:
Full Text from ERIC Available online:
http://www.eric.ed.gov/contentdelivery/servlet/ERICServlet?acc
no=EJ1018177
Sakarya University. Esentepe Campus, Adapazari 54000,
Turkey. Tel: +90-505-2431868; Fax: +90-264-6141034; e-mail:
[email protected]; Web site: http://www.tojet.net
Journal Code:
JAN2017
Entry Date:
2014
Accession Number:
EJ1018177
3. Database:
ERIC
lable at ScienceDirect
Nurse Education in Practice 14 (2014) 468e472
Contents lists avai
Nurse Education in Practice
journal homepage: www.elsevier.com/nepr
A workplace violence educational program: A repeated
measures
study
Gordon L. Gillespie a,*, Sharon L. Farra b,1, Donna M. Gates
a,2
a College of Nursing, University of Cincinnati, P.O. Box
210038, Cincinnati, OH 45221-0038, United States
b Department of Nursing, Wright State University, University
Hall 160, 3640 Colonel Glenn Hwy, Dayton, OH 45435, United
States
a r t i c l e i n f o
Article history:
Accepted 30 April 2014
Keywords:
Hybrid education
Intervention
Online learning
Tabletop
Web-based survey
4. * Corresponding author. Tel.: þ1 513 558 5236.
E-mail addresses: [email protected] (G.L. Gi
edu (S.L. Farra), [email protected] (D.M. Gates).
1 Tel.: þ1 937 775 2519.
2 Tel.: þ1 513 558 5500.
http://dx.doi.org/10.1016/j.nepr.2014.04.003
1471-5953/� 2014 Elsevier Ltd. All rights reserved.
a b s t r a c t
Violence against healthcare employees is a profound problem in
the emergency department worldwide.
One strategy to reduce the risk of violence is prevention
focused education. The purpose of this paper
was to report the learning outcomes of a workplace violence
educational prevention program tailored to
the needs of emergency department employees. A quasi-
experimental design was used to determine the
knowledge retention of program content following a hybrid
(online and classroom) educational inter-
vention. One hundred twenty emergency department employees
that completed the workplace violence
prevention program participated in the study. A repeated-
measures analysis of variance was conducted
to determine if individual test scores increased significantly
between baseline, posttest, and six month
posttest periods. The results indicated a significant time effect,
Wilk’s L ¼ .390, F (2, 118) ¼ 26.554,
p < .001, h2 ¼ .310. Follow-up polynomial contrasts indicated a
significant linear effect with means
increasing over time, F (1, 119) ¼ 53.454, p < .001, h2 ¼ .310,
while individual test scores became
significantly higher over time. It was concluded that the use of
a hybrid modality increases the proba-
bility that significant learning outcomes and retention will be
5. achieved.
� 2014 Elsevier Ltd. All rights reserved.
Introduction
Violence against healthcare employees is a profound problem in
the emergency department setting worldwide (Albashtawy,
2013;
Estryn-Behar et al., 2008; International Labour Organization,
In-
ternational Council of Nurses, World Health Organization, &
Public
Services International, 2002; Knowles et al., 2013). Kowalenko
et al.
(2013) reported that on average an emergency department
employee will experience 4.017 physical threats and 1.510
assaults
per year. A primary prevention strategy, often recommended for
preventing workplace violence (i.e., verbal abuse, threats, and
as-
saults) from patients and visitors, is educational programming
(Beech, 2008; Gates et al., 2011a,b; Gillespie et al., 2010;
Hardin,
2012; Kowalenko et al., 2012; Nau et al., 2009). Before
violence
education becomes the mainstay of a comprehensive violence
management program, it is important to determine if employees’
knowledge increases from the educational content. The purpose
of
llespie), [email protected]
this paper was to report the learning outcomes of a workplace
violence educational prevention program tailored to the needs
of
emergency department employees.
Background
6. The authors found few descriptions of workplace violence
educational programs in the peer-reviewed literature. Two
exem-
plars of workplace violence educational programs were
presented
by Hartley et al. (2012) and Gillespie et al. (2012). The
following
paragraphs provide a brief overview of each program. Hartley et
al.
(2012) detailed an online violence program designed for
healthcare
employees. The program was described as a “mix of text,
videos,
and graphics to create an interactive learning experience”
(Hartley
et al., 2012, p.203). Because the authors did not provide
program
evaluation data for their program it was not possible to
determine
the degree to which employees learned the program content.
Gillespie et al. (2012) conducted a quasi-experimental study
comparing two educational treatment strategies: (1) online
content
and (2) online and classroom-based content. The researchers
found
that both groups had a significant increase in their learning of
the
violence program content. It was not reported if the emergency
department employees were able to retain the new knowledge
over
time.
mailto:[email protected]
mailto:[email protected]
8. Design
A quasi-experimental design was used to determine the
knowledge retention of program content following a hybrid
educational intervention. The hybrid modality included both
online
and classroom components. The researchers hypothesized that
there would be a significant increase in learning retention for
employees who completed the hybrid educational intervention
as
measured by program test scores. Institutional Review Board
approval was granted from the University of Cincinnati and the
two
partnering hospital organizations.
Setting and sample
Participants were recruited from the emergency departments of
two separate healthcare systems in the Midwest United States.
One
system was a pediatric specialty system with two emergency de-
partments, one community based and the other a Level 1
pediatric
trauma center. The other system was a university-affiliated,
teaching system with a Level 1 adult/pediatric trauma center
and
emergency department.
The only inclusion criterion was that participants complete all
components of the hybrid education offered to the employees
during summer 2011. Eligible participants were nurses, social
workers, child life specialists, and unlicensed assistive
personnel
(see Fig. 1 for attrition information). Completing the hybrid
edu-
cation was a requirement of the pediatric health system’s new
9. workplace violence policy and not specific to this study.
Approxi-
mately 83% (n ¼ 197) of 238 employees from the two pediatric
emergency departments completed the training. Completing the
hybrid education at the adult/pediatric system was required for
members of the emergency department’s core workplace
violence
team and optional for all other employees. Approximately 19%
(n ¼ 30) of 156 employees from the adult/pediatric emergency
department participated.
Power analysis
A post hoc power calculation was determined using G*Power
3.0
(Faul et al., 2007). Given effect size .310, a ¼ .05, sample size
120,
and three measurements per participant, our study yielded suffi-
cient power (>95%) to conduct the planned data analyses.
Workplace violence program
Employees received a revised iteration of a hybrid educational
program with online and classroom components designed to
inform emergency department employees about workplace
violence by patients and visitors. The first component included
three asynchronous online modules completed during June and
July 2011. Module 1 focused on workplace violence prevention
and
included topics such as environmental safety, risk assessment,
and
communicating effectively with patients and visitors. Module 2
focused on safely managing workplace violence through a
coordi-
nated team approach. Module 3 focused on the post-incident
response and included topics such as incident reporting and car-
10. ing for victimized workers. Prior to starting Module 1,
employees
were prompted to complete a 20 question pretest on workplace
violence. After completing Module 3, employees were prompted
to
complete a 20 question posttest on workplace violence.
Questions
were identical for the pretest and posttest. The answers were not
given to participants. Employees were able to complete the
training
over multiple sittings with the program resuming where the
employee last left the training.
The second component was an interactive two-hour classroom-
based tabletop exercise during August/September 2011. For this
component, employees watched a series of video vignettes
depicting patient and visitor violence in the emergency depart-
ment. This component prompted employees to discuss, apply,
and
collaborate with their interprofessional colleagues on how to
best
manage the incident of workplace violence depicted in each
video
vignette.
G.L. Gillespie et al. / Nurse Education in Practice 14 (2014)
468e472470
Instrumentation
The study instrument was a 20 question workplace violence test
plus short demographic questionnaire. The test questions were
developed to measure knowledge in preventing, managing, and
reporting incidents of workplace violence. Test development
con-
11. sisted of initial item development by violence and education ex-
perts. The items were then reviewed by a panel of violence
experts
and revised based on their feedback. Questions were leveled to
test
participants at multiple levels within Bloom’s taxonomy of
educa-
tional objectives (Bloom et al.,1956). Examples of test
questions are
presented in Table 1.
Procedures
During May 2011, all employees from the partnering emergency
departments were administratively enrolled into a learning man-
agement system (LMS) for the workplace violence educational
program using the fields of first name, last name, occupation,
study
site, and employee email address. Information for the
demographic
fields was provided by the emergency department administrators
after securing Institutional Review Board approvals.
Beginning June 1, 2011, notifications that the LMS was ready
for
employees to complete the training were initiated by the emer-
gency department educators and automated from the LMS. Edu-
cators were provided weekly Microsoft Access (Redmond, WA)
database reports of employee progression for the online
training.
The LMS closed on July 31, 2011.
Next, employees signed up for a classroom-based tabletop ex-
ercise. Dates and times of the sessions were determined by the
emergency department educators and were scheduled to accom-
modate day shift, evening shift, and night shift employees. All
sessions were led by the study’s principal investigator and/or
12. two
trained department educators for consistency in program
delivery.
Weekly Microsoft Access database reports were emailed to the
emergency department educators to monitor employees’
progression.
From November 2011 to February 2012, the sample was
recruited and signed informed consent documentation for study
Table 1
Sample workplace violence program test questions. Correct
responses are identified
by underlined text.
Question Answer options
What is the emergency department
worker’s first priority when dealing
with an escalating patient?
a. Resolve the situation as quickly
as possible.
b. Remove the patient from the
emergency department.
c. Increase your distance from the
patient.
d. Immediately call the police
department.
What should the emergency department
worker say or do when a patient shows
signs of increasing escalation (e.g.,
derogatory name calling, cursing) and
additional help is needed from the
coworkers standing nearby?
13. a. Use a firm voice and say, “Call
security!”
b. Look at the patient and say,
“You will not talk to me like that.”
c. Document the event in the
medical record.
d. Use a hand gesture to indicate
help is needed.
The physician informed the mother of a
two-year-old critically ill patient that
test results indicate the patient may
have cancer. The mother becomes
verbally and physically violent. After
the violence stops, what intervention
should be performed first?
a. Evict the mother from the
emergency department,
b. Tell your coworkers about the
violent event.
c. Complete an incident/safety
event report.
d. Expedite the patient’s
admission to the pediatric ICU.
participation. Study consent included a provision to allow the
pretest and posttest data completed during their workplace
violence training to be used as research data for analysis in this
study.
Enrolled participants were emailed a link to complete a 6-
month posttest during March 2012. The email and posttest link
were automated from the LMS and were distributed weekly for
three weeks. Twenty participants did not access the 6-month
posttest and three participants started, but did not finish the 6-
month posttest indicating their withdrawal from the study. The
14. data from participants who withdrew were not used in the
analyses.
After data collection was closed, the pretest (Time 1), posttest
(Time 2), and 6-month posttest (Time 3) data were extracted
from
the LMS and imported into IBM SPSS Statistics 21 (Armonk,
NY). All
identifiers (i.e., first name, last name, email address) were
removed
from the database leaving only non-identifiable demographic
var-
iables in the database prior to analysis.
Data analysis
The study sample was described with means and ranges for in-
terval data and frequencies and percentages for nominal and
ordinal
data. Test scores for Time 1, Time 2, and Time 3 were reported
as
means. A repeated-measures analysis of variance (ANOVA)
using
the Wilk’s L statistic was conducted to determine if individual
test
scores changed significantly between Time 1, Time 2, and Time
3.
The Wilk’s L statistic is used to assess changes within subjects
with
a repeated measures study design. Alpha was set at .05.
Results
One hundred twenty employees completed the study pro-
cedures. The majority was female (n ¼ 104, 86.7%), white (n ¼
112,
93.3%), and a registered nurse (n ¼ 86, 71.7%). See Table 2 for
additional demographic data. The mean test score at Time 1 was
15. 58.5% (range 25e85%), Time 2 was 61.8% (range 25e85%), and
Time
3 was 66.8% (range 40e90%). See Fig. 2 for the boxplot
distributions
Table 2
Demographic characteristics of the study sample (n ¼ 120).
N %
Sex
Female 104 86.7%
Male 16 13.3%
Race
White 112 93.3%
Black/Other 8 6.7%
Ethnicity
Hispanic 2 1.8%
Non-Hispanic 110 98.2%
Educational attainment
High school 1 .8%
Some college 16 13.3%
Associate degree 26 21.7%
Bachelor’s degree 69 57.5%
Master’s degree 8 6.7%
Primary work shift
Day shift 49 40.8%
Evening shift 35 29.2%
Night shift 26 21.7%
Variable shift 10 8.3%
Occupation
Registered nurse 86 71.7%
16. Respiratory therapist 6 5%
Child life specialist 2 1.7%
Paramedic 14 11.7%
Patient care assistant 12 10%
Table 3
Summary statistics for participant test scores.
Mean Standard
deviation
Paired difference
(T2 � Tn)
Paired difference
(T3 � Tn)
Time 1 (T1) 58.5 10.6 3.208 8.250
Time 2 (T2) 61.8 10.1 e 5.042
Time 3 (T3) 66.8 9.3 �5.042 e
G.L. Gillespie et al. / Nurse Education in Practice 14 (2014)
468e472 471
of test scores. See Table 3 for summary statistics for the
participant
test scores.
A repeated-measures ANOVA was used to measure the within-
subjects’ effects. The factor measured was time of test measure-
ment (Time 1, Time 2, and Time 3) with the dependent variable
being workplace violence test scores. The results for the
repeated
measures ANOVA indicated a significant time effect, Wilk’s
L ¼ .390, F (2, 118) ¼ 26.554, p < .001, h2 ¼ .310. Follow-up
17. poly-
nomial contrasts indicated a significant linear effect with means
increasing over time, F (1, 119) ¼ 53.454, p < .001, h2 ¼ .310,
while
individual test scores became significantly higher over time.
Discussion
Finding a significant increase in knowledge post completion of
the online modules was an expected result. A similar finding
was
reported by Gillespie et al. (2012) following the completion of
the
original version of this violence program using a sample from
hos-
pitals not affiliated with the health systems of the current
sample.
Given appropriate content and presentation, an increase in
knowl-
edge was anticipated following an online educational
experience.
There is a large body of evidence to support positive learning
out-
comes when active learning strategies (e.g., tabletop exercise)
were
used. A recent meta-analysis, commissioned by the U.S.
Department
of Education, examined rigorous research in online learning and
found that students in online courses tended to perform equal to
those in traditional face-to-face classes (Means et al., 2010).
An important finding of this research is the significant increase
in
learning (test scores) at six months following completion of the
tabletop exercise when knowledge retention may be anticipated
to
18. falter. Means et al. (2010) found in their meta-analysis that
students
in hybrid or blended modalities (combined online and face-to-
face)
had superior learning outcomes to those in the classroom alone.
So
while online learning appears to be equal to, but not superior to
conventional classroom instruction (statistically equivalent),
hybrid
approaches may be superior (mean effect size þ .35, p < .001) to
solely classroom instruction. The authors suggested that
additional
learning materials and the opportunities for collaboration may
result
in the observed learning advantages (Means et al., 2010). This
assertion was supported by the research of Castle and McQuire
(2010) who examined 4038 course assessment summaries for
stu-
dents’ self-reported learning. Findings from the study suggest
that
along with content and instructor competence, those modalities
Fig. 2. Boxplot distributions displaying participant test scores.
providing the highest degree of learner interaction foster the
greatest learning. Gillespie et al. (2013) reported qualitative
findings
using the same population as the current study that there was a
high
degree of facilitated engagement between the instructors and
employee learners during the tabletop exercise sessions.
The use of the tabletop exercise following the online modules
was designed to foster high degrees of interaction and
cooperation
among the participants and the course facilitators. Collaborative
learning, a key active learning strategy in our program, is an in-
tellectual undertaking where participants work cooperatively to
19. become educated on a particular subject (Koehn, 2001). The
Insti-
tute of Medicine Report (Committee on the Robert Wood
Johnson
Foundation Initiative on the Future of Nursing, 2011) on the
future of nursing described the importance of preparing nurses
to
work collaboratively and effectively with other health
professionals
within the healthcare system. Collaborative learning can benefit
participants academically, socially, and psychologically
(Kinyon
et al., 2009; Panitz, 1999). Outcomes of collaborative learning
include enhancement of learning and critical thinking skills
(Feingold et al., 2008; Panitz, 1999). As a result of this
collaborative
experience, learners in the violence program may have been
able to
retain their knowledge long term in the context of how interpro-
fessional colleagues must interact to prevent and manage work-
place violence. This collaborative experience also may have
accounted for the significant increase in the test scores
following
the tabletop exercise.
Other components of the workplace violence course likely
positively affected learning. Reporting on how people learn, the
National Research Council (2000) described the movement from
memorization to understanding as the ability to transfer
knowledge
to situations. Critical to transfer were motivation, contextual
meaning, and active learning strategies. Motivation was linked
to
the usefulness of information learned (National Research
Council,
2000). Participants in the workplace violence program were
20. taught information that was directly applicable to their work
environment. The tabletop exercise provided contextual
meaning
by using video case studies that were both realistic and
applicable to
the environment in which the acquired knowledge would be
applied (Gillespie et al., 2012). Active learning was achieved
through
collaboration in responding to the unfolding case study thus
improving the potential transfer of the information from the
online
modules (Gillespie et al., 2012). The use of these strategies
promoted
learning and potential transfer with enhanced learning retention.
Another critical component of the learning and retention pro-
cess is initial learning. The National Research Council (2000)
described initial learning as the presentation of the foundational
materials which form the basis of the new knowledge. The suc-
cessful transfer of learning is dependent upon the degree of
mastery of the original subject. Without an adequate level of
initial
learning, transfer cannot be expected. The modules offered the
initial basis for learning that was built upon by the discussion
during the tabletop exercise. Using the online modules as prepa-
ration for the tabletop exercise allowed class time to be spent on
application and synthesis of collaborative activities.
The amount of time on task was also critical for learning. Stu-
dents needed both time to learn and time to process information.
G.L. Gillespie et al. / Nurse Education in Practice 14 (2014)
468e472472
Learning cannot be rushed; information integration is a complex
21. activity requiring sufficient time (National Research Council,
2000).
The sequential completion of the online modules and the
tabletop
exercise over a three to four month time period allowed for both
initial learning and transfer. The sequential and prolonged
engagement with the content allowed learners to build upon
knowledge gained in each activity (Gillespie et al., 2013).
Cooper
(1998) recommended “chunking” of information where informa-
tion is presented in smaller units to decrease cognitive load,
because working (short-term) memory is limited and long-term
memory is unlimited. For this purpose, the online program mod-
ules were presented as 15 shorter units. By providing the
content
within each module as short presentations and allowing learners
several weeks to complete the online learning, learners were
more
likely to store program content in their long-term memory.
Using
both strategies resulted in knowledge gains, but the greatest in-
crease to both learning and retention occurred following the
tabletop exercise reflecting the complementarity of the active
learning strategies used in our program.
Conclusion
The use of hybrid modalities increases the probability that
learning outcomes will be achieved. Online learning alone is
effective in obtaining some learning outcomes, but to have
signif-
icant learning and retention hybrid methods are needed.
Implica-
tions for both educators involved in the education of new nurses
and members of staff development are twofold. Students need to
be
22. prepared for learning: initial presentation of materials by
reading,
completing online modules, listening to podcasts, et cetera is
essential. Highest levels of retention are obtained when initial
learning builds upon and is reinforced by collaborative and
active
learning strategies where opportunities to apply and synthesize
concepts is used. Future research is needed to determine if the
synergistic effect of our hybrid program can be replicated with
additional populations and with other hybrid programs.
Funding
This study was funded by the Dean’s Teaching/Learning Project
Award (University of Cincinnati College of Nursing). Dr.
Gillespie’s
time for analyzing the data and writing the manuscript was sup-
ported by the Robert Wood Johnson Foundation Nurse Faculty
Scholars program. The funding sources had no role in the study
procedures or approval of the study findings.
Conflict
The authors declare that they have no competing interests.
Contribution
The authors provided the following contributions to this
manuscript submissiond
Dr. Gillespie was responsible for all aspects of the study
including study conception and design, human subjects pro-
tections, execution of the study, analysis and interpretation of
data,
and preparation and revision of the manuscript.
23. Dr. Farra was responsible for study conception and design,
execution of the study, analysis and interpretation of data, and
preparation and revision of the manuscript.
Dr. Gates was responsible for study conception and design,
interpretation of data, and preparation and revision of the
manuscript.
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31. riculum plan (Mixer, 2008). Thus, there is an ongoing need
to develop and research pedagogical applications that effec-
tively translate cultural learning in nursing school to cultur-
ally competent care in professional nursing practice.
The virtual community is an emerging pedagogy in nurs-
ing education that has been shown to increase student
engagement and links to the learning preferences of under-
represented minority students (Giddens, Fogg, & Carlson-
Sabelli, 2010; Giddens, Shuster, & Roerigh, 2010). It has
also been postulated to be an effective application for cul-
tural education (Giddens, 2008). The purpose of this article
is to present our research findings related to use of a virtual
community teaching application as a mechanism to enhance
cultural awareness (a construct of cultural competence)
among nursing students.
Review of the Literature
A literature review was conducted to learn about current
approaches to teaching culture in nursing education. We
selected 16 recently published articles that describe teaching
and learning approaches. The three themes that emerged
include dedicated culture courses and/or assignments, inte-
grated approaches for culture content, and emerging pedagogy
434061TCNXXX10.1177/1043659611434061
Giddens et al.Journal of Transcultural Nursing
1University of New Mexico, Albuquerque, NM, USA
2Rush University, Chicago, IL, USA
Corresponding Author:
Jean Foret Giddens, College of Nursing, University of New
Mexico,
MSC 09 5350, Albuquerque, NM 87131-0001, USA
Email: [email protected]
32. Using a Virtual Community
to Enhance Cultural Awareness
Jean Foret Giddens, PhD, RN, FAAN1, Sarah North, MS1,
Linnea Carlson-Sabelli, PhD, RN2, Erin Rogers, BA1, and
Louis Fogg, PhD2
Abstract
Purpose: Cultural competence is an expectation of professional
practice, yet effectively teaching this concept to nursing
students is challenging. The purpose of this study was to assess
the use of a virtual community as a teaching application to
foster cultural awareness among nursing students. Method: This
correlational study involved the collection of two surveys
from 342 first-semester students from five baccalaureate
nursing programs that used The Neighborhood virtual
community
during one semester. Descriptive and comparative analyses were
performed. Findings and Conclusions: Results suggest
that use of the virtual community may have contributed to
cultural awareness among student participants. There was a
significant correlation between frequency of use and cultural
awareness. Virtual communities may represent a useful teaching
application for cultural competence in nursing education.
Further research is needed to specifically test cultural
competence
education strategies using a virtual community platform.
Keywords
baccalaureate programs, correlational design, factoral design
Education Department
33. Giddens et al. 199
for culture education. Additionally, a model of cultural com-
petence and related discussion about cultural awareness as a
component of cultural competence are explored.
Dedicated Courses and Assignments
Dedicated courses within a nursing curriculum or specific
learning activities within a course are the common methods
by which culture is taught (Lipson & DeSantis, 2007). For
example, Munoz, DoBroka, and Mohammad (2009) evalu-
ated the benefit of a 7-week pilot multidisciplinary course
created to provide cultural awareness, knowledge, skills,
encounters, and desires among students. Although the
researchers reported growth in acquisition of cultural knowl-
edge, skills, and desire, time limitations resulted in an inabil-
ity to address all the questions raised by students on critical
issues. Sanner, Baldwin, Cannella, Charles, and Parker
(2010) assessed the effectiveness of a 3-hour cultural diver-
sity forum, which included a keynote presentation, shared
meal, and small-group interactions. Although the forum
positively affected students’ openness to diversity, it was
uncertain whether the experience added to the students’ cul-
tural understanding and competency (Sanner et al., 2010).
Service-learning and immersion experiences are common
approaches for teaching culture. Amerson (2010) evaluated
the effectiveness of service-learning projects in a community
health course. Significant increases in the cognitive, practi-
cal, and affective dimensions of perceived cultural compe-
tence were reported among all students after completing the
service-learning project; no differences were noted among
students who completed local projects compared with those
participating in an international experience. Amerson con-
cluded that the service-learning experiences enhanced cul-
34. tural awareness because of the exposure to real-life health
issues from a different perspective. Similar findings related
to service-learning or immersion experiences have also been
reported previously (Kollar & Ailinger, 2002; Mixer, 2008;
St. Clair & McKenry, 1999). Although immersion and
service-learning provide culturally enriching learning expe-
riences, drawbacks include cost, access, and questionable
long-term benefits. Such obstacles limit their adoption in
nursing curricula on a large scale.
Integrated Approach
Teaching culture in an integrated approach across the cur-
riculum is the most frequently cited and desired approach
reported in the nursing literature (Calvillo et al., 2009;
Gebru & Willmam, 2010; Hughes & Hood, 2007; Lipson &
DeSantis, 2007; Liu, Mao, & Barnes-Willis, 2008; Sargent,
Sedlack, & Martsolf, 2005). Calvillo et al. (2009) suggested
that nursing curricula focus on the acquisition of knowledge,
skills, and attitudes of cultural competence, which is best
attained “through a series of cumulative educational pro-
cesses” (p. 138). The careful planning of content in didactic
courses with opportunities to apply this information in clinical
practice is specifically recommended (Calvillo et al., 2009;
Sargent et al., 2005). Without specifically planned learning
activities, cultural competency in an integrated approach is
easily diluted or lost in the midst of other competing vari-
ables within the curriculum. Unfortunately, the lack of con-
tent expertise or dedication among faculty can threaten the
instructional quality or consistency of even the most well-
thought-out plan.
Lipson and DeSantis (2007) reported that many nursing
programs use a culture theory or model for an integrated cur-
riculum approach, including the Purnell Model for Cultural
Competence, Giger and Davidhizar Transcultural Assessment
35. Model, and the Campinha-Bacote Cultural Competence in
Delivery of Healthcare Services model. Gebru and Willman
(2010) described a successful instructive/didactic model
based on Leininger’s Culture Care theory applied over a
3-year nursing program. Despite the presence of cultural
models, Mixer (2008) reported that most faculty who report
teaching culture care do not use an organizing framework.
In an attempt to determine the best approach for teach-
ing cultural competence, Kardong-Edgren and Campinha-
Bacote (2008) compared four nursing curricula. Two
programs based their approach on a transcultural model or
theory, one program integrated culture throughout the cur-
riculum without a specific theoretical approach, and one pro-
gram offered a two-credit culture class. The researchers
found no statistically significant differences in students’ cul-
tural competence regardless of the approach used. It was
suggested that advances in technology would bring forward
new ideas for cultural teaching (Kardong-Edgren &
Campinha-Bacote, 2008).
Emerging Pedagogy for Culture Education
New pedagogical approaches that show promise for teach-
ing cultural content are simulation and virtual experiences.
Rutledge et al. (2008) described an integrated simulation
approach for cultural education. The process includes the
use of a virtual hospital that features culturally focused cases
involving videotaped encounters with virtual patients. The
program allows students to conduct a health history by typ-
ing in a question and obtaining prerecorded videotaped
responses. In addition, students participate in high-perfor-
mance simulation based on the same cases previously
described. Outcomes reported by the authors are limited to
faculty and student feedback about the learning process. A
conceptually similar commercial product, Virtual Clinical
Excursions, is a software series featuring a virtual hospital
36. and ethnically diverse virtual patients. The primary learning
objective is for students to have computer-based clinical
experiences (Tashiro, Long, & Sullins, 2005); it is unclear
what the intent or impact has been related to cultural education.
Another emerging teaching tool that could be useful
for cultural education is the virtual community. A virtual
community is an online teaching application that features
fictional characters in a community setting. Nursing students
200 Journal of Transcultural Nursing 23(2)
learn about concepts through the context of the character
stories within the virtual community. Virtual communities
are unique in that students learn about health care issues
through the diverse perspectives and lived experiences of the
characters, and the character stories evolve over time. Three
virtual communities (The Neighborhood, Stillwell, and
Mirror Lake) are described in the nursing literature (Curran,
Elfrink, & Mays, 2009; Giddens, 2007; Walsh, 2011).
Although it has been postulated that a virtual community can
enhance culture education in nursing (Giddens, 2008), no
research has been conducted evaluating this potential to date.
Cultural Awareness and Cultural Competence
Because the outcome measure for this study focuses on
cultural awareness, it is important to distinguish this concept
from the larger perspective of cultural competence.
Campinha-Bacote (2003) identifies five constructs within
her model of cultural competence: awareness, knowledge,
skill, encounters, and desire. Cultural awareness is a pro-
cess of self-examination of one’s own culture and biases
toward other cultures, as well as becoming aware of racism.
The process of developing a knowledge base about cultur-
37. ally diverse groups is referred to as cultural knowledge. The
construct of cultural skill involves the development of skills
needed to conduct a culturally based assessment, including
history, examination, and preferences. The process of cul-
tural interactions with individuals from culturally diverse
backgrounds is referred to as cultural encounters. Finally,
cultural desire refers to the genuine interest or internal
motivation in becoming culturally competent. Foundational
to this model is gaining an understanding that cultural com-
petence is a continuous process as opposed to reaching a
state of being culturally competent (Campinha-Bacote,
2003). All components are essential to become culturally
competent; developing cultural awareness is a first step in
this journey.
Purpose of the Study
and Research Questions
The literature review reflects many ideas and strategies to
teach culture to nursing students, yet the actual effectiveness
of many approaches is unclear. The purpose of this study
was to explore the benefit of using a virtual community for
culture education among nursing students. Because students
are exposed to diverse perspectives and points of view
among the virtual characters, we were interested to know if
the use of virtual communities would influence cultural
awareness. According to Campinha-Bacote (2003), cul-
tural awareness is the first step in the development of cul-
tural competence. The two research questions for this study
were the following:
Research Question 1: Does the virtual community stim-
ulate cultural awareness among nursing students?
Research Question 2: Is there a difference in cultural
awareness among nursing students based on the
level of virtual community use?
38. Method
Sample and Design
The sample included 350 undergraduate nursing students
enrolled in a first-semester fundamentals or skills course within
five baccalaureate nursing programs. The programs were
located across the country, including two on the East Coast and
one each in the Southeast, Midwest, and West. A power analy-
sis was calculated (power = .99; significance = .05), demon-
strating that we could detect a medium effect size (Cohen,
1988), confirming an adequate sample size for data analysis.
The study design was correlational, examining the rela-
tionship between virtual community use and cultural aware-
ness among nursing students. Faculty agreed to teach the
fundamentals nursing course using the virtual community
intervention for one academic semester. At the end of the
semester, participants completed an exit survey. Analysis
included descriptive and comparative statistics.
We obtained institutional review board approval at each
nursing program prior to beginning the study. To minimize
bias and address concerns associated with a conflict of inter-
est, the lead researcher (who developed the intervention) col-
laborated with researchers from other academic institutions
for data collection and analysis.
The Intervention
The intervention used in this study is a virtual community
known as The Neighborhood. The Neighborhood features
the unfolding stories of 40 characters over three academic
semesters. Community character stories focus on common
health-related issues experienced by individuals and fami-
lies, and the nurse character stories focus on professional
practice issues. The stories are enhanced with photos, video
39. clips, and medical records. A newspaper and community
home page links individual character stories to community
events (Giddens, 2007). Faculty use the stories and other
featured applications as a basis for learning activities with
the intent to draw connections to concepts in didactic and
clinical courses. Because featured characters are diverse,
there are multiple opportunities for learning activities and
discussion related to differences in personal preferences and
decision making among the characters.
Three research studies using The Neighborhood have
been published to date. In a qualitative study involving 40
undergraduate students in one nursing program, emotional
connectedness and engagement were the themes reported
among participants who used The Neighborhood over three
academic semesters (Shuster, Giddens, & Roerigh, 2011).
In another study involving 248 undergraduate baccalaureate
nursing students who used The Neighborhood, the greatest
Giddens et al. 201
perceived benefits were reported among underrepresented
minority students and students who expected to receive a
course grade below an A. The researchers believed that these
differences could be attributed to learning preferences among
students (Giddens, Shuster, et al., 2010). In a third study,
Giddens, Fogg, et al. (2010) reported a significant relation-
ship between frequency of use and perceived benefits among
nursing students who used The Neighborhood—in other
words, the greater the use by faculty, the greater were the
perceived learning benefits among students. The study also
revealed that among frequent users, minority students
reported greater engagement compared with White/Asian
students, F = 2.40(4, 308), p = .05.
40. Instruments
Two surveys were used in the data collection process: a
demographic survey and an exit survey. The student demo-
graphic survey included participant age, gender, race/ethnic-
ity, and previous health care experience. The exit survey was
used to learn about the participants’ personal experiences as
users of The Neighborhood. A total of 22 questions were on
the exit survey. Eighteen items formed four subscales
(engagement in learning, cognitive outcomes, perception of
usefulness, and cultural awareness); one item measured
frequency of use, and three questions were open-ended
responses. The 18 subscale items came from an item bank
known as the Current Student Inventory (CSI), a component
of the Flashlight Evaluation System (TLT Group, 2010).
Prior to being included in the bank, all items undergo exten-
sive content validity testing.
Specific to this study, three items formed the cultural
awareness subscale; participants answered the following
questions based on a 5-point Likert-type scale:
• How often were diverse perspectives (different races,
religions, genders, political beliefs, etc.) included
in class discussions or assignments (1 = never; 5 =
frequently)?
• How often have you tried to better understand some-
one else’s views by imagining how an issue looks
from his or her perspective (1 = never; 5 = frequently)?
• To what extent do you agree or disagree that you
better understand people of other racial and ethnic
backgrounds that differ from your own (1 = strongly
disagree; 5 = strongly agree)?
41. Procedure
Prior to the beginning of the study, faculty members teach-
ing the fundamentals course from each school attended a
2-day workshop to learn how to incorporate the intervention
into their teaching. Information provided at the workshop
included an introduction to the virtual community, peda-
gogical basis for use, learning to log on and navigate the
website, and examples of teaching strategies. A written
resource, the Neighborhood Faculty Guide, which provided
additional orientation information and teaching tips, was
given to each faculty member. Specific learning activities
were left up to individual instructors due to the variability of
curriculum across the five schools; thus, we were unable to
specifically control the frequency or quality of use among
participating programs.
At the beginning of the semester, all participants were
informed that their school was testing a virtual community
for instruction and that faculty would be using the applica-
tion in the fundamentals or nursing skills course. Those
agreeing to participate in the study completed the demo-
graphic survey at the beginning of the semester and the exit
survey at the end of the semester. Both surveys were admin-
istered and collected during a class session by the coinvesti-
gators at each site. The completed surveys were sent to the
research team for analysis. Participant demographic data
were matched to exit surveys with codes; no personal identi-
fiers were included in the data collection procedure.
Findings
A total of 342 participant surveys were collected out of
350 baccalaureate nursing students enrolled in a first-level
course from the five schools previously described. The
high response rate was attributed to the method of data
collection (surveys were completed and collected during
42. class sessions).
Participant Demographics
The majority of study participants were women (86.7%),
and the average participant age was 24.4 years (SD = 6.4;
range = 19-56). The racial/ethnic distribution was 55.4%
White, 18.5% African American, 16.6% Asian, 3.1% Pacific
Islander, 0.6% Native American, and 5.2% mixed race/
other. Nineteen participants did not self-identify race or eth-
nicity. Federal data collection guidelines differentiate race
from ethnicity. For this reason, participants were also asked
to self-identify whether they had an affiliation with Hispanic/
Latino ethnicity. Nine percent of student participants indi-
cated such an affiliation. Fewer than half of the participants
(37.5%) had previous health care experience.
Cultural Awareness and
Level of Virtual Community Use
We were interested in determining whether the context of
personal stories among culturally diverse characters in the
virtual community would be effective in stimulating cultural
awareness among students. The mean cultural awareness
subscale score for all participants was 3.58 (SD = 0.69), with
a range of 1.33 to 5.0. We noted a wide range of virtual com-
munity use by faculty (as reported by participants) across
202 Journal of Transcultural Nursing 23(2)
schools (Table 1), which presented an opportunity for us to
examine differences in cultural awareness based on level of
use. One item on the exit survey asked participants to rate
the frequency of use. Specifically, participants rated the item
“Attended a class where the instructor provided an activity
or assignment based on The Neighborhood” on a 5-point
43. Likert-type scale (1 = never; 5 = very often). This item rep-
resented the level of perceived student use of the interven-
tion. A correlation between level of use and cultural
awareness was significant (r = .246; p < .000). This indicates
that cultural awareness among students appears to increase
with intervention use by faculty.
To investigate this further, participant data were sorted
into one of three groups: high users, or those who reported
use often or very often (n = 78); low users, or those who
reported use rarely or sometimes (n = 203); and nonusers, or
those who reported no use (n = 61). Comparisons were made
based on age, gender, race/ethnicity, and health care experi-
ence. No differences were noted, confirming that the groups
were homogenous on these variables.
An analysis of variance statistical analysis was calcu-
lated on the mean cultural awareness subscale scores and
reported frequency of use; these data are presented in Table 2.
The differences were substantial and were not likely to be
due to chance, F = 11.78(2, 339), p < .001. A post-hoc
Tukey test showed that the largest difference was between
low-use and high-use groups. These results suggest that uti-
lization of The Neighborhood was the main predictor of cul-
tural awareness. From a practical application, this means
that students who experienced high use of the virtual com-
munity were more aware of culture and diversity. It is pos-
sible that the intervention provided more opportunities for
faculty to discuss cultural issues because of the cultural con-
text of the stories.
Discussion
As mentioned previously, cultural awareness involves a
process of self-examination of one’s own culture and biases
that might exist toward individuals of other cultures. Self-
44. awareness also involves a self-recognition of how cultural
attitudes and behaviors interface in professional nursing
practice. The study findings suggest that virtual communi-
ties may be a useful teaching application to enhance the
cultural awareness of nursing students. The fact that these
findings emerged in fundamentals of nursing courses with-
out specific intent to teach cultural awareness as a topic is
especially intriguing. When students read the character sto-
ries, they are exposed to differing perspectives of the same
event through the eyes of multiple individuals. They gain an
understanding of thought processes and choices made by a
character; these are central to the task of developing cultural
awareness. It is possible that many students have never been
exposed to, let alone critically examined, alternative points
of view from such a perspective.
The longitudinal trajectory of evolving character stories
in the virtual community provides a platform on which to
deliver specific culture-based learning activities and assign-
ments. For example, a faculty member might ask students to
reflect on one or more character responses to an event and
compare this with what they think and how they might
respond to the same event. This is a safe way to begin explor-
ing diverse points of view and opens the door for dialog about
increasingly complex—and at times, difficult—situations,
such as evidence of racism.
The cultural awareness subscale used in this study links
only to the first step of cultural competence as described by
Campinha-Bacote (2003). It is unknown whether the virtual
community is effective for further facilitating the process of
Table 1. Participating School Profile
School School Characteristics
Total No. of
45. Participants
Reported
Use Mean
1 College/university without academic health sciences center 62
1.95
2 College/university without academic health sciences center 77
2.40
3 Private, not for profit 102 2.64
4 University within academic health sciences center 66 3.85
5 Private, not for profit 43 2.42
Total 350 2.68
Table 2. Analysis of Variance Applied to the Cultural
Awareness Mean According to Use
Group Reported Use on Survey
Cultural Awareness,
Mean (SD) Analysis of Variance
No use (n = 61) Never (1) 3.39 (0.69) F = 11.78 (2, 339); p <
.001
Low use (n = 203) Rarely or sometimes (2-3) 3.52 (0.70)
High use (n = 78) Often or very often (4-5) 3.81 (0.57)
Giddens et al. 203
becoming culturally competent by addressing other con-
structs, including knowledge, skills, encounters, and desire.
For these reasons, we recognize that the findings should be
interpreted carefully; at best, these findings provide an initial
foundation for future research efforts.
46. A known limitation of this study was the lack of consis-
tency in faculty use of the intervention (dose and efficacy).
We purposefully targeted fundamentals- or skills-type
courses because of the similarity in content found across
multiple programs. Because we were unable to control the
frequency or how the intervention was used, the level of
reported use by participants provided an opportunity to make
comparisons based on use. The comparisons made among
nonusers, low users, and high users may not have been an
optimal approach, but the results certainly provide initial
support for the theoretical assumptions about virtual com-
munity benefits postulated by Giddens (2008).
Implications for Nursing
Education and Recommendations
for Further Research
As the population of the United States continues to become
more ethnically diverse, nurse educators must find ways to
introduce culture and engage students in the process of
becoming culturally competent. Developing an effective
program that is sustainable (in the event of loss of funding
for special projects or loss of faculty with expertise) makes
this a challenge. Technology applications such as the virtual
community may provide a valuable educational enhance-
ment to learning in classroom and clinical settings. An
opportunity may exist to develop virtual cultural immersion
experiences without the limitations associated with real
immersion experiences (cost, scheduling, etc.). This may
especially be helpful given the limited number of faculty
with specific expertise to teach cultural content. For this
reason, such innovative approaches should be rigorously
developed and tested. Specifically, it is recommended that a
planned cultural competence education approach using a
virtual community platform be developed by experts certi-
47. fied in transcultural nursing to ensure the quality of strate-
gies and assignments. This then should be tested to determine
the benefits in terms of cost, sustainability, the ability of
noncertified faculty to implement it effectively, and student
outcomes using a validated instrument. If possible, it would
be beneficial to also determine the outcomes of students
beyond graduation as well, ultimately evaluating the benefit
for translation into practice.
Because this issue extends to all health professions educa-
tion, designing and testing an interprofessional education
approach using a virtual community platform is another
important consideration. Learning activities that include
enriching discussions that reveal the perspective of students
or professionals from nursing, medicine, pharmacy, physical
therapy, and social work, among many other health profes-
sions disciplines, may ultimately be the most advantageous
approach that we could collectively work toward.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of
interest
with respect to the research, authorship, and/or publication of
this
article: Dr. Giddens has a financial interest in The
Neighborhood.
Funding
The author(s) disclosed receipt of the following financial
support
for the research, authorship, and/or publication of this article:
The
research was funded by an intramural grant from the University
48. of
New Mexico College of Nursing.
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![the experiment group and 18 males and 9 females for the control
group. The experiment group continued its education in blended
learning environment and the control group continued its
education in traditional learning environment. The created
learning environments have focused the genetics topic of the
biology course and lasted for 6 weeks. During the study, pre-
test and final-test have been used for the academic achievement
analysis. According to the results acquired at the end of the
study, a significant difference hasn't been found between the
two groups at the end of the pre-test applied to experiment and
control groups. Besides, in accordance with the averages of the
final test grades, the experiment group has been found more
successful than the control group. In both of the learning
environments, female students have turned out to be more
successful than the male students.
Abstractor:
As Provided
Number of References:
33
Number of Pages:
10
Publication Type:
Reports - Research; Journal Articles
Availability:
Full Text from ERIC Available online:
http://www.eric.ed.gov/contentdelivery/servlet/ERICServlet?acc
no=EJ1018177
Sakarya University. Esentepe Campus, Adapazari 54000,
Turkey. Tel: +90-505-2431868; Fax: +90-264-6141034; e-mail:
[email protected]; Web site: http://www.tojet.net
Journal Code:
JAN2017
Entry Date:
2014
Accession Number:
EJ1018177](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)