Journal of Practical & Professional Nursing Category: Clinical Type: Review Article

Promoting Understanding of Cultural Competence through a Transformative International Mentoring Program

Sharon Elizabeth Metcalfe1*
1 School of nursing, Western Carolina University, North Carolina, United states

*Corresponding Author(s):
Sharon Elizabeth Metcalfe
School Of Nursing, Western Carolina University, North Carolina, United States
Tel:+1 8287767108,
Fax:+1 8286456534

Received Date: Jun 20, 2019
Accepted Date: Jun 27, 2019
Published Date: Jul 04, 2019


In today’s diverse and multicultural healthcare environment, nursing professionals must be prepared to care for patients in acute and community settings with an awareness and understanding of cultural competence. Despite the advent of the internet and video conferencing, nursing research has shown that students both need and desire travel abroad courses to further enlighten their global perspective of caring for patients from backgrounds that are unique and different from their own. This programmatic review describes and details an international collaborative program that focused upon developing nursing students understanding of caring for pediatric patients in different countries through a mutually beneficial study abroad program that was based upon the transformational learning theory of Mezirow. The partnership was founded between two university schools of nursing and two children’s hospitals located in the United States and the United Kingdom, and have been in existence since 2007.


Cultural competence; International; Nursing education; Transformative


With the increasing diversity of the world’s population, today’s schools of nursing and health care educators are faced with the challenge of preparing the next generation of nurses with a broader awareness to provide care with the knowledge of cultural competence towards patients of all backgrounds [1]. Nursing students must be aware of the goals of the healthy people 2020 referendum that promotes knowledge of cultures regarding health disparities, prevention of diseases, illnesses, and early death, create social and physical environments that promote good health for all, and promote quality of life, and healthy behaviors across all life stages [2]. Cultural competence and congruent health care is defined as providing health care that is customized to provide nursing care with the patient’s cultural values, beliefs, traditions, practices, and lifestyles [3]. Cultural competence results from the synthesis of four distinct constructs: cultural awareness, cultural knowledge, cultural skill and cultural sensitivity [4]. Learning to appreciate and care for patients from another culture includes understanding its specific health beliefs, wellness and illness characteristics that are different than one’s own beliefs [5]. Nurses need to have full range of understanding of the world’s cultures and people to care for the many individuals that are immigrating to countries throughout the globe and provide care with respect [6]. This is evident not only in the United States with its overwhelming influx of migration of people, but also is evident in every nation with increasingly alarming rates. Nurses of the future must be prepared and educated to care for a global society of patients in the next decades [7].


Despite the advent of the Internet, as well as global communication such as email and video learning, the reality of caring for patients from a variety of cultural backgrounds is difficult to understand for students without the lived experience of being able to travel and care for patients abroad [8]. Wihlborg et al., explored the use of an international research course exchange with two universities in Sweden and the United States [9]. There were ninety students enrolled in the online course. The results of the course found that students embraced the virtual learning with their peers across the globe, but also longed to learn about the culture of the other country personally through an international travel exchange.

Long T found that nursing schools must now contain curriculum that includes cultural competence training which goes beyond traditional teaching strategies in the classroom [10]. Lectures and readings that were educational mainstays of the past alone are no longer sufficient to prepare nursing students for a global health care which requires knowledge of the diversity of patient’s needs and cultural preferences. Study abroad opportunities allow novice students to engage in active learning and critical reflection regarding their individualized patient care experiences. These opportunities allow once in a lifetime experiences for students to reflect on both the similarities and the differences they witness in healthcare within a different country from their own [11].


The conceptual theoretical model of Dr. Larry Purnell, the Purnell Model for Cultural Competence, is a framework model for assessing the cultural foundation for the delivery of nursing care in a global society. The model is conceptualized as a circle with an outlying rim representing global society, a second rim representing community, a third rim representing family, and an inner rim representing the person [12]. There are twelve additional cultural domains that reinforce the components of the circle model, and include such cultural facets as language, environment, home and family care, mental health care, physical needs, nutrition and social needs. This model has been in existence since 2014 and has become one of the major and pivotal cultural competence models that are taught in nursing schools throughout the United States and Europe. This model provides guidance to faculty and students in understanding how to approach patient care from an individual client’s cultural needs and perspectives. This model will be the foundation for preparation of the nursing students for care of pediatric patients in an international travel clinical mentoring program which will be described in this paper for nursing educators to utilize for potential international service learning programs of their own.

The theoretical framework of Mezirow’s transformative learning may be used as the underpinning of the foundation for nursing educators to embrace international learning [13]. Mezirow’s classic theory is used to describe how people develop and use critical self-reflection to consider their beliefs and experiences, and change their own unique perspectives of the world and its people over time [14]. Mezirow believed that a person would change their world view of both people and a situation when facing a “disorienting dilemma”, which is an experience that doesn’t fit into the person’s current beliefs about the world. Brown and Schmidt found that reflection is a critical component in nursing education to understanding global cultures and people as it develops critical thinking and social awareness that are necessary in providing culturally competence in delivery of care [15].

Students often discover that international travel experiences in which they learn to care for a population of patients that are different and unique from one’s own is a transformative experience that enriches their world perspective and increases their knowledge base of cultural nursing care [16]. Walters et al., conducted a study in which six short-term international study abroad programs were assessed through students’ reflections through journaling with cultural experiences with people in Haiti [17]. Reflection scores were found to be highest for journaling and supported the use of Mezirow’s transformative learning theory for supporting the educational benefits of study abroad programs. Brown and Boateng found that study abroad programs have significant benefits such as promoting cultural understanding and acknowledging the differences in healthcare settings, policies and practices [18]. Bamber found that pedagogical approaches such as utilizing international service learning opportunities with students helps to develop and cultivate a cosmopolitan orientation to the world and healthcare [19]. Cosmopolitanism is considered the acquisition of becoming other-wise for gaining cultural awareness and cultural competence.


Development of international program

This review describes the design of a unique and collaborative transformative global mentoring partnership for nursing educators to glean information for initiating a similar program with their clinical and university institutions. The program has been developed between two universities and two pediatric hospitals in the United Kingdom and the United States. Zanchetta et al., found that mentoring provided transformative learning experiences and broadened the scholarly foundation for understanding cultural competence for both mentees (students) and mentors (faculty) in an intellectual international partnership in a Canadian university [20]. Mentoring relationships for nursing pedagogy have been prominent in clinical curriculum in nursing education for many decades. However, there has been a dearth of evidence in the literature that supports the use of mentors and mentoring with international study abroad programs. The following review of a transformative international nursing program that explored the use of mentoring and its impact upon reflection and understanding of cultural competence with new patients from another country will be explored and described.

Based upon the clinical nursing research findings that have been evident in the nursing literature, an international transformative educational pediatric program and collaboration was initiated in 2007. The program has been in existence for twelve years and has engaged over 120 nursing students in learning and understanding cultural competence of children and families of both socialized and capitalized health care systems through care of pediatric patients in the United Kingdom and the United States. This program is presented each academic year, and students from the United States travel to the United Kingdom over Spring Break, and students from the United Kingdom travel to the United States during the winter break for their clinical education.

Mentoring program development

The program was initiated during the fall of 2007 when a joint meeting and mutual venture convened which included the nursing faculty of both universities and nursing administration leaders of the children’s hospital in the United Kingdom. Faculty from the United Stated sought to develop a collegial mentoring partnership that would allow students from both the United States and the United Kingdom to travel to each other’s country and participate in learning to care for critically ill children at the children’s hospitals in both countries. The nursing administrator of the children’s hospital in the United States participated through a conference call during the joint meeting. A learning contract was established for both universities and children’s hospitals. The focus was upon the use of clinical nursing staff mentors that would have the responsibility of showing and teaching their individual student the special patient nursing care needs and the cultural differences of both the native culture of the child and his or her family. The unique differences and similarities of the culture of nursing that pertained to each individual country was also a focus and highlight for the program’s development and learning goals for each student involved in the mentoring program.

Curriculum goal of transformative knowledge of cultural competence

The primary goal of this program has been to facilitate the acquisition of knowledge of cultural competence of families and care delivery of pediatric patients from a different country than one’s own for the nursing students. This goal has been accomplished through facilitating novice nursing students in developing an understanding of differences and similarities in pediatric patient care through family dynamics, society, social structures and healthcare delivery systems in socialized and privatized societies. These pedagogical goals have been realized through students having five clinical days with their nursing staff mentor in both countries. Achieving understanding of prioritized cultural awareness needs in each country with children has been the overarching curriculum goal for each School of Nursing and for each country in this mutually beneficial program.

Pediatric cultural patients and mentoring of nursing care

Throughout the years of the transformative mentoring program, students from the United States have been exposed to the care of children and their families from the United Kingdom and immigrants from the Eastern European nations since the advent of the European Union. This has allowed students to learn from their mentors the art of caring for children that are natives of other countries and cultures, as well as with other languages than English. Students from the United Kingdom have had the interesting and novel experience of learning to care for children and their families from a Native American reservation that is located twenty miles from the location of the children’s hospital in the United States, as well as children from families that have immigrated from Central America. For both groups of students from the United States and the United Kingdom, the students have reflected that caring for these special populations of pediatric patients and their families has been the most insightful experience during their clinical mentoring course. Both sets of nursing students from the United States and the United Kingdom have had the advantage of learning to care for children in nursing from medical health care systems such as the National Health Trust and the insurance based health systems which are the foundations of health care in both countries. This is often an awakening and eye-opening experience for all the nursing students involved in the program.

To understand the living conditions and cultural venues of both countries, student tours are arranged to view local and regional sites. The purpose of these activities is to align the curriculum goal of understanding the culture of the pediatric patients and their families in the environment in which the children reside. These activities allow a better understanding towards meeting the goal of cultural appreciation for a culture that is different than the one of the visiting students in their home countries. These tours comprise tours to medical and nursing museums, citywide tours of both host cities, and day long excursions to view the housing and schools in which children and their families reside. Students from the United Kingdom that participate in the mentoring program in the United States additionally visit the Native American community through touring the museum, visiting local hospital community agencies such as mental health and diabetes clinics, and partake in home visits with public health nurses to understand family life. These students also travel to the countryside and participate in the regional clinic for migrant farm workers and their families with the faculty from the United States. Both groups of students have especially enjoyed these special opportunities to more fully understand the culture of the children and families that they are learning to care for with their nursing mentor. It is a once in a lifetime experience.

Clinical nursing mentors and student global presentations

Students are assigned clinical staff nursing mentors for one week for caring for pediatric patients. Clinical nursing mentors in both countries are supervised by the nursing managers on each ward and the mentors provide careful instruction on pediatric care for the specialized children that they are assigned to care for with the nursing student. Students prepare for the day of mentoring clinical with pediatric care plans and are instructed to reflect on their experiences after dinner each evening to share with their peers and faculty. They are also assigned a delivery of a formal presentation on a topic of interest regarding pediatric health care issues. Students are always thrilled to learn that they will be presenting a lecture to an international audience of their nursing peers. 

These course requirements are required for both groups of students from the United States and the United Kingdom. Topics such as childhood obesity, diabetes, respiratory illnesses, issues surrounding vaccination of childhood illnesses, mental health issues, and autism found prevalent in pediatric care worldwide are presented to their peers in the host country. Presentations are made to audiences in both countries at the local children’s hospital, and are prepared for a twenty-minute length. Students prepare their own Power Point presentation and rehearse with their peers at a pre-course trip seminar prior to the overseas excursion. In many years, the students have presented to clinical nursing administrators from throughout each of the wards of the hospitals, as well as interprofessional providers such as physicians, nutritionists, child life therapists, physical therapists, mental health providers, and palliative care specialists.

International faculty involvement

Nursing faculty from each of the university schools of nursing, as well as the nursing administrators for the children’s hospitals, has traveled to one another’s countries. Special educational conferences have been developed to highlight the benefits of the mentoring program for students and health care providers. These conferences have been well-attended in both the United Kingdom and the United States, and have allowed mutual reflection on the rewards of caring for both cultures of children and families as nurses. Participants at these conferences are from a variety of pediatric and family care specialty backgrounds and are from throughout the regions in which both children’s hospitals are located. This international program has grown throughout the years and many clinical and academic nursing faculty from each country has traveled to both countries. Faculty and clinical leaders experience their own transformation of caring for children in another country that is different from their own through participating in the nursing conferences, as well as enjoying the tours of the children’s hospitals, community pediatric agencies and day long cultural excursions exploring the region by bus through rural communities. Additionally, faculties are always amazed at the similarities and differences in nursing and medical procedures with pediatric care in a health care system that is unique and presents a new perspective to their professional careers.

Narrative reflective journaling for transformative development

To meet the major curriculum goal of helping students to transform in their understanding of cultural competence, students are assigned in-depth reflective journals that consist of insightful questions regarding the acquisition of knowledge of the patients and families that they are caring for in another country. Using reflective journals, students can pause and contemplate the value of their learning in the overseas course and broaden their perspective of cultures and people that are different than their own. Reflective journals are read by the faculty at the end of the course trip and evaluated for the transformation of the students’ cultural awareness of caring for children in a country that is far different in health care system, as well as populations of people. Students from both countries are also able to bring home new knowledge to share with other students, faculty and nurses regarding the pediatric care delivery that they have learned on their journey.

Students from the United States are amazed to learn that in the United Kingdom, pediatric wards consist of long rows of beds, with the children being cared for side by side with families able to visit with one another throughout their child’s hospital stay. Student nurses from the United Kingdom often reflect upon the seemingly isolation of solitary rooms in which pediatric units are designed to care for children within the United States. Both groups of students are surprised to learn that patients in the United Kingdom participate in the National Health Trust which pays for their hospitalization, and children in the United States must private pay, use insurance, or be placed on Medicaid for fees for service. Students from the United States are additionally interested in learning that nurse’s wear bright orange medications beware vests in the United Kingdom to help prevent interruptions and ensure safe administration of medication to children on the wards. Likewise, students from the United Kingdom are generally in dismay when they observe nurses administering medications in the children’s rooms with a medication cart that is based upon a computer cart for documentation. Lastly, students from the United Kingdom are surprised to learn that when a child is hospitalized at the Native American hospital on the reservation, often the entire extended family comes and stays in the room with the child and the nuclear family until the child returns home. These interesting examples of students’ cultural awareness for both nursing care of pediatric patients and their families helps them to grow and mature in having an increased understanding of both the culture of nursing and the culture of the country they are visiting.

Reflective essays and cultural presentations

Both undergraduate and graduate students additionally compose a five-page essay on the value of the mentoring program and their understanding of the care and culture of another country through caring for children and their families. Graduate students are also required to present an individual presentation to a special interest group in which they are employed. Faculty attends these presentations to assess the transformative learning and progress of the student from attending the course trip. These presentations have been warmly received by all nursing and community agencies. Communities participants have had the privilege of listening to the graduate students reflect on their many positive experiences in learning to care for children in another country. Through these presentations, it has been noted over the years that the understanding of another culture has been promoted and many nurses have benefited from these outstanding discussions.

Transformative daily debriefing sessions

During the many years of the program, students have had daily evening debriefing sessions with faculty and with each of the other trip participants. In these sessions, each student relays the many interesting patient care and family experiences that they have had in learning during the day with their pediatric nursing staff mentor. Each student is assigned to the clinical care preference of their choice during the week, such as the Operating Theater, the Accident & Emergency Center, the Oncology Ward, Neurosciences, General Pediatric Ward, Pediatric Intensive Care Unit, Neonatal Intensive Care Unit and Community Pediatric Care Services. Each evening prior to dinner, the students discuss the highlights of their learning during the day on their special ward or unit. A major focus is placed upon each student to reflect on the transformation of their global perspective of pediatrics with caring for children in both the United States and the United Kingdom. Students are asked to reflect upon the cultural differences and similarities that they have been exposed to as they care for children and families during the clinical week of training.


International educational nursing programs such as the pediatric mentoring program provide a wealth of novel experiences and adventures. These experiences help nursing students to view the world in different perspectives and viewpoints when learning to care for pediatric patients. In this international collaborative program, nursing students have had the opportunity for individualized and intensive mentoring with a clinical nursing mentor that has helped and facilitated their learning into one of being truly transformative. This achievement by the nursing students was noted in their learning goal and assignment of writing pre-and post-experience observations with the culture of the pediatric patients and their parents in another country and with the type of health care system (socialized or privatized). From these clinical and cultural observations students, have had the ability to embrace new ways of understanding and changing their own ways of thinking to learn transcultural beliefs, values, and cultural awareness in traveling and participating in this international program.

Students that have participated in this international clinical mentoring program have been able to utilize the Purnell Model for Cultural Competence to assess their overall understanding of meeting the learning objectives of understanding a pediatric patient and their family’s culture in another country [12]. Each student has utilized the conceptual model’s wheel and twelve facets of cultural life to help them to prepare their journals, their evening debriefing presentations, and their formal presentations that they share with their peers from another country. The use of this model and its application to provision of nursing care has been specially designed for ease with nursing students, and the students base their observational and written journal assignments on the merits of the cultural competence model. Students have additionally been able to compare the Purnell Model for Cultural Competence with the Jeffreys Cultural Competence and Confidence Model with assessing their pediatric patients and nursing care [3,12]. Using this additional conceptual model, nursing students have been able to analyze their patients and their culture by assessing the patient’s cultural values, beliefs, traditional practices and lifestyles. The Jeffrey’s Cultural Competence and Confidence Model has become one of the most well-known conceptual models for learning to care for patients in a global society with an understanding of cultural competence [3]. Both renown models are utilized by nursing educators around the world, and the university and clinical nursing faculty for this international clinical mentoring program have found them to be successful in providing guidance and understanding for both undergraduate and graduate nursing students.

Both university schools of nursing and pediatric hospitals have also been enriched by the years of valuable experiences and professional collegial friendships that have developed. It is hoped that this program review will both interest and encourage other schools of nursing and pediatric hospitals to inquire and initiate programs of this nature. These programs are invaluable to student learning with the many aspects of cultural awareness and an understanding of cultural competence in the delivery of holistic nursing care. Transformative adventures such as these help students to prepare for their future as nurses and the responsibility of caring for a variety of cultures of pediatric patients within a global society.




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Citation: Metcalfe SE (2019) Promoting Understanding of Cultural Competence through a Transformative International Mentoring Program. J Pract Prof Nurs 3: 012.

Copyright: © 2019  Sharon Elizabeth Metcalfe, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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