Presentation of research from Sharon See (et al) from Ashland University at the Transcultural Nursing Conference in San Antonio in Oct 2018. The premise was to test the simulation BaFa' BaFa' as a cultural awareness tool. The title of the presentation was "The Influence of a Cultural Simulation on Perceptions and Intent to Act".

1. The Influence of a Cultural
Simulation on Perceptions and
Intent to Act
Sharon See, MSN, RNC-OB
Patricia Clayburn, MS, RN
Jacqueline K. Owens, PhD, RN, CNE
Brenda DeHaan, MSN, RN
Mark Fridline, PhD

2. Problem/Background
• Prepare nurses to practice in a multicultural
environment (AACN, 2008).
• Often a mismatch between the culture of the nurse and
the patient
• Gaming/Simulation can help students;
• different from traditional teaching methods.
• new understanding could lead to better patient care
(Graham & Richardson, 2008)
• insights into culturally based nursing (Graham & Richardson, 2008)
• raise awareness and develop skills of nursing students
when encountering a patient from an unfamiliar
culture (Fowler & Push, 2010)

3. Aims
• Understand the impact of the BaFa BaFa
cultural simulation game on senior nursing
students’ perceptions about culture and intent to
act in their future practice
• Inform nursing education regarding practices to
incorporate cultural simulation games

4. Pilot Study
• Population: Senior Baccalaureate nursing students
• n=74
• All open ended questions
• Preliminary Findings: Identified increased empathy
toward someone for whom they had no previous
knowledge of their culture
• Goal: Expand narrative data and add a closed ended,
measurable response survey. Students will complete a
Likert scale type survey tool to determine their
perceptions and intent to act.

5. Methods of Current Study
• Convenience sample (n=161)
• Mixed methods, 1 group post test
• 4 student groups, predominately homogenous,
nursing students
• 1 academic year
• Intervention- BaFa BaFa simulation game
• Students randomly assigned to fictitious cultural
group
• Learn new cultural norms
• “visit” another culture and attempt to understand
and assimilate

6. Demographic Composition

7. Quantitative Analysis
Process:
1. Analysis of data using descriptive statistics
2. Questions presented using Likert scale (1-5);
data collapsed to low (1-2), neutral (3), and high
(4-5) with minimal loss of information.

8. LowNeutralHigh
70
60
50
40
30
20
10
0
Percent
62%
28%
11%
Question 1:
The BaFa BaFa simulation will positively impact my future nursing
practice when caring for people of cultures different from my own

9. LowNeutralHigh
70
60
50
40
30
20
10
0
Percent
61%
17%
22%
Question 2:
I felt awkward/uncomfortable when interacting as a visitor to the
other culture.

10. LowNeutralHigh
70
60
50
40
30
20
10
0
Percent
69%
20%
11%
Question 3:
The BaFa BaFa simulation increased my understanding/empathy for
those coming in to a new culture.

11. LowNeutralHigh
70
60
50
40
30
20
10
0
Percent
65%
24%
11%
Question 4:
I will change the way I interact when caring for people of cultures
different from my own based on the BaFa BaFa experience.

12. Question
Q4Q3Q2Q1
Low
N
eutral
H
igh
Low
N
eutral
H
igh
Low
N
eutral
H
igh
Low
N
eutral
H
igh
70
60
50
40
30
20
10
0
Percent
Question Summaries
62%
28%
11%
61%
22%
17%
69%
20%
11%
65%
24%
11%

13. Program AcceleratedTraditional
LowNeutralHighLowNeutralHigh
70
60
50
40
30
20
10
0
Percent
66%
27%
7%
56%
28%
16%
Question 1:
The BaFa BaFa simulation will positively impact my future nursing
practice when caring for people of cultures different from my own

14. Program AcceleratedTraditional
LowNeutralHighLowNeutralHigh
70
60
50
40
30
20
10
0
Percent
64%
20%
57%
24%
19%
16%
Question 2:
I felt awkward/uncomfortable when interacting as a visitor to the
other culture.

15. Program AcceleratedTraditional
LowNeutralHighLowNeutralHigh
70
60
50
40
30
20
10
0
Percent
68%
24%
8%
71%
13%
16%
Question 3:
The BaFa BaFa simulation increased my understanding/empathy for
those coming in to a new culture.

16. Program AcceleratedTraditional
LowNeutralHighLowNeutralHigh
70
60
50
40
30
20
10
0
Percent
72%
22%
6%
54%
26%
19%
Question 4:
I will change the way I interact when caring for people of cultures
different from my own based on the BaFa BaFa experience.

17. Qualitative Analysis
Process:
1. Developed study specific codebook
2. Collapsed open ended questions into 2 categories:
1. Intent to Change Practice (2 questions)
2. Feelings, Perceptions, & Attitudes (6 questions)
3. Read all student feedback for questions. Individually
note common words, use of words (word sense),
sentences, and themes.
4. Met to compare findings and finalize themes as a
group.
5. Decided on supporting quotes.

18. Questions Re:
Intent to Change Practice
Theme: Identification of Specific Actions for
Practice
Keywords: Take your time, slow down, ask, don’t
assume, respect kindness.

19. Questions Re:
Feelings, Perceptions, & Attitudes
Themes:
1. Feelings and New Culture
2. Fluid Appraisal of Cultures
1. Two Subthemes:
1. Appraisal Across Cultures (Both A & B had similar
attributes)
2. Appraisal Within Cultures (A & B each had unique
positive and negative attributes)

20. Feelings and New Culture
Keywords: overwhelmed, uncomfortable, confused,
frustrated, felt used, inferior, scared, helpless
Quotes:
• “I wanted to practice my own culture in their culture.”
• ” We didn’t know how we were perceived by the other
culture.”
• “……It can be scary coming into a new culture and not
knowing.”
• “It felt isolating; easy to give up trying to assimilate.”

21. Fluid Appraisal of Cultures
Participants were able to describe cultures from several
perspectives, including across and within the 2 cultures of
Alpha and Beta.
Subtheme 1: Appraisal Across Cultures (Both A & B had
similar attributes):
A B
“structure/rules” “structure/rules”
Competition (lack of) Competition (too much)
Discomfort with experience Discomfort with experience

22. Subtheme 2: Appraisal Within Cultures (A & B each
had unique positive and negative attributes):
A B
Positive
(advantages)
Negative
(disadvantages)
Positive
(advantages)
Negative
(disadvantages)
 “noncompetitive”  “no chance to improve
status”
 “predetermined”
 “ability to obtain status”  “competition”
 “competitive”
 “everyone out for
themselves”
“pressure to perform””
performance based/individual
based, not community based.”
 “Protection”
 “liked having a leader”
 “felt protected, felt cared
for”
 “I don’t need control-
women were loved,
protected and provided
for.”
 “Less pressure in Alpha,
happier, don’t have to
trade” (male)
 “male dominance”
 “paternalistic”
 “women dependent on
men”
 “Too much work”
(female)
 “can increase status”
 “No limitations of
leadership”
 “independence”
 “equal power for men and
women”

23. Summary
• Quantitative and qualitative results affirm the
Bafa Bafa cultural simulation is an effective
educational strategy
• Engaging way to learn about culture for nursing
students getting ready to practice
• Group differences:
• Greater impact on intent to change practice in
traditional students
• Accelerated students demonstrated less
discomfort with the cultural experience

24. Limitations
Limitations:
• Single site, geographic location
• Non-probability, convenience sampling
• No control group; intervention only
• Homogenous sample
• Limited generalizability

25. Implications
• Further testing of tool for reliability/validity
• Replicate study in different geographic location
with varying diversity
• Consider simulation for practicing nurses in
clinical setting

26. References
American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice.
Washington, DC.
Fowler, S.M., & Pusch, M.D. (2010). Intercultural simulation games: A
review (Of the United States and beyond). Simulation and Gaming,
41(1).
Graham, I., & Richardson. (2008). Experiential gaming to facilitate
cultural awareness: it's implication for developing emotional caring
in nursing. Learning in Health and Social Care. 7,(1)37-45.
doi.org/10.1111/j.1473-6861.2008.00168.x
Shirts, R.G. (1977). BaFà BaFà: A cross culture simulation. Del Mar,
CA: Simile II.

27. Thank you!
Questions?