WEB-BASED TEACHING and learning through. Bridging Culture On-Line: Strategies for Teaching Cultural Sensitivity

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1 Bridging Culture On-Line: Strategies for Teaching Cultural Sensitivity M. CECILIA WENDLER, RN, PHD, CCRN,* AND ROXANNE STRUTHERS, PHD, RN The demand for on-line learning experiences is greatly increasing, especially for place-bound students living in rural areas. Faculty at the University of Wisconsin Eau Claire School of Nursing responded to the need for coursework focusing on cultural competence by offering an elective course at both the undergraduate and graduate level through asynchronous delivery systems. To accomplish this, specific strategies were used in the course on cross-cultural health. These approaches were thoughtfully developed to bridge cultures in an on-line environment for students who do not have cross-cultural experiences easily accessible within their home communities. Strategies included: (1) culturally congruent use of a minority visiting scholar who is a leader in professional nursing and a traditional woman healer within her Native American community to provide wisdom, information, and support to students and faculty, in the novel role of guest listener; (2) requiring participation in cultural enrichment activities, designed to assist the student in discovering the similarities and differences among diverse peoples in their lives; and (3) developing course and faculty evaluations that are congruent with the asynchronous learning environment. (Index words: Cross-cultural health; Cultural diversity education; On-line or Web-based learning) J Prof Nurs 18: , Copyright 2002, Elsevier Science (USA). All rights reserved. WEB-BASED TEACHING and learning through interactive, asynchronous courses has increased significantly within the past several years and *Associate Professor, Nursing Systems, University of Wisconsin Eau Claire, Eau Claire, WI. Assistant Professor, School of Nursing, University of Minnesota, Minneapolis, MN. This course was developed with a grant from the Eastern Wisconsin Area Health Education Center in Summer, A stipend from the University of Wisconsin Eau Claire Indian Health Service Grant and a Visiting Scholars Grant from the University of Wisconsin Eau Claire Office of Research and Sponsored Programs provided funding for Dr. Struthers expertise in the course. Address correspondence and reprint requests to Dr. M. Cecilia Wendler: Associate Professor, Nursing Systems, University of Wisconsin Eau Claire, School of Nursing, 105 Garfield, Eau Claire, WI Copyright 2002, Elsevier Science (USA). All rights reserved /02/ $35.00/0 doi: /jpnu the demand for Internet-based courses is expected to increase (Draves, 2000; Katz, 1999). The changing demographics of the population of the United States require an increasing understanding and sensitivity to cultural issues for all disciplines as well (Andrews, 1995; Leininger & McFarland, 2002; McGee, 1994; Scisney-Matlock, 2000). A Web-based, asynchronous course in cross-cultural health designed to meet the learning needs of undergraduate and graduate students was developed and delivered at the University of Wisconsin Eau Claire through the School of Nursing. The 2-fold purpose of this article is to outline the history and development of the course for asynchronous delivery and to describe educational innovations used to enhance the student experience within the course. Asynchronous Coursework Through the World Wide Web Asynchronous courses are those offered via computer interface with the World Wide Web, and are often presented by using commercial courseware, such as WebCT (Lynnfield, MA), Blackboard (Washington, DC), and others. Asynchronous technologies include use of the live chat or asynchronous course rooms, (Peterson, Hennig, Dow, & Sole, 2001), Internet-based discussion forums, and World Wide Web resources. Web-based instruction is enhanced whenever necessary with direct telephone contact (either among students or between students and faculty). In the asynchronous course room, students enter the class electronically from anywhere with access to the World Wide Web at a time convenient to them. Faculty specify course activity parameters, such as the requirement to come into the course at least twice a week, however, the exact hour and day of participation is at the discretion of the student. The goal of asynchronous courses is to allow access and participation in courses by students who are geographically place-, time-, or financially bound (Olson & Carlson, 2000). This approach offers a viable alternative for students desiring to complete an undergraduate or graduate de- 320 Journal of Professional Nursing, Vol 18, No 6 (November December), 2002: pp

2 BRIDGING CULTURE ON-LINE gree when located many miles from a university or college setting. Cross-Cultural Health Course Development In the mid-1990s, the University of Wisconsin Eau Claire mandated a campus-wide requirement for undergraduate students to have three credits of course content specifically related to cultural diversity. During the same time period, an initiative to redefine the baccalaureate degree was implemented. The School of Nursing developed a course focusing on cultural issues in health and illness as part of both initiatives and in response to a school-identified need for students and faculty to learn about health-related cultural differences among Native American, Asian/Hmong, African American, and Hispanic/Latino/a peoples. The School of Nursing then developed NSYS 389, Cross-Cultural Health, a nursing undergraduate course open to all students from all University campus majors. This three-credit elective was typically offered in a single, 3-hour evening block of time over a semester, usually once every year or every other year. Once the School of Nursing had interactive television capabilities, the course was offered in that mode. The usual course enrollment was between 10 to 15 students, divided unequally between the two sites; the distance site frequently hosted 3 or fewer students. Students completing the course met the three-credit requirement for cultural diversity content. In 1999, an Eastern Wisconsin Area Health Education Center (AHEC) grant supplied funds to develop this course for on-line, asynchronous delivery. One of the goals of the grant was to develop objectives that would allow the University to offer the course as a graduate-level elective, so that both undergraduate and graduate students could learn the content together. After development of graduate-level appropriate objectives and activities, the revised course was approved as a dual-numbered course: NSYS 389/589, Cross-Cultural Health. The AHEC grant provided necessary faculty financial and technical support, allowing time and monies to carefully examine the course objectives, components, and assignments. Faculty very purposefully considered course components and aspects to develop strategies for an effective on-line course. On-campus and university system level instructional technology experts and an expert in instructional design provided critical support for all aspects of course development. A significant amount of faculty and academic staff time and energy were required to retool the course for effective and meaningful delivery, a common problem in the on-line environment (Rosenlund, Damask-Bembenak, Hugie, & Matsumura, 1999). Faculty involved in the original cross-cultural health course development were Caucasian, middle-class nursing faculty who had knowledge and were skilled in working with diverse cultures. The course was delivered for the first time via the World Wide Web in spring of 2001 to 23 students, 22 of whom were undergraduates; one was a graduate student. Spring 2002 enrollment totaled 28, with 22 undergraduate students and 6 graduate students. Objectives for the course are listed in Table 1. Synopsis of the Course The objectives of the cross-cultural health course are taught through modules (Table 2). Students study four cultural groups identified by the University of Wisconsin Eau Claire as the cultural groups of focus. They are African-American, Asian (with a focus on Hmong people, who are a large minority population in central Wisconsin), Hispanic/Latino/a, and Native American peoples. Within the first 2 weeks, students are asked to choose a culture of particular interest. The faculty assign student teams according to their interest. Teams comprise 3 to 4 students who study the selected culture in-depth and share responsibility for the remainder of the course activities. From Module 3 through Module 6 (four units), students work together in on-line, asynchronous teams to learn, in-depth, the historic background, the life transitions, the health-illness approaches grounded in culture and by contemporary TABLE 1. Course Objectives For NSYS 389/589, Cross-Cultural Health (undergraduate and graduate students) Evaluate the impact of culture on health, illness, and wellness. Examine the health responses and patterns of the following cultural groups: African American/Black, Hispanic/Latino/a, Asian/Hmong, and Native American. Compare the similarities and differences among these four cultures as each views health, illness, and wellness. Examine the interrelationships among a pluralistic society, the culturally diverse group within the society, and the health/ illness status and beliefs of the group members, with a specific focus on the peoples of the four listed cultures. In addition, the graduate students must complete these objectives: Analyze the theoretical and conceptual approaches underlying cultural congruency/competence. Synthesize the scholarly literature to facilitate health care planning, implementation, and/or evaluations that are culturally congruent. 321

3 322 WENDLER AND STRUTHERS TABLE 2. On-Line Teaching-Learning Modules, Cross-Cultural Health Course Welcome and introductions: what is health? What is health? How is health affected by cultural background? Which is your chosen cultural group of focus for the course? Conceptual and theoretical foundations What conceptual model of cross-cultural health makes sense to you? Why? What other theories or concepts regarding cross-cultural health are in the literature? Historic perspectives How did African Americans come to be in the United States? Native Americans? Asian Americans? Hispanic peoples? What aspect of U.S. history and politics impacted on the presence of particular cultural groups in the upper Midwest? Culturally specific transitions: developmental life changes What are the significant life transitions for African-American, Native-American, Asian-American, and Hispanic peoples in the United States What rituals can be preserved and which cannot? What aspects of American life can serve as barriers or facilitators to life transition markers for persons of diverse cultural background? For nurses: what aspects of birth and death are marked, or celebrated, in diverse ways in the U.S. health care system? Which of these rituals can be preserved or modified? How is this negotiated? Health-illness systems What are the traditional beliefs regarding health and illness of diverse peoples studied in the course? What culture-bound illnesses are expressed in African- American, Native-American, Asian-American, and Hispanic culture? Which actions can prevent which culture-bound illnesses? What folk remedies commonly are used? For nurses: how do you ask about cultural-bound activities and substances? Which culture-bound activities can mimic physical abuse? What should nurses do about folk remedy use? Current issues and challenges What is contemporary life like for African Americans? Native Americans? Asian Americans? Hispanics? What are some of the common problems and issues related to the four cultural groups? What is cultural brokering? How might it be used in contemporary American life (hospitals, schools, business, and so forth)? What are the mental health patterns for persons of diverse cultural backgrounds? What are the barriers to providing health care for those of diverse cultural backgrounds? How can health care professionals impact and change these barriers? Evaluation Presentation of final papers/projects. Course evaluation activities. Course grades. health-related issues of the culture of interest, working together on course assignments. Through a cocreated process of literature review, critical thinking (Jones & Brown, 1991; Mastrian & McGonigle, 1999), discussion (Peterson et al., 2001), reflecting (Johns & Freshwater, 1999; Wong, Kember, Chung, & Yan, 1995), and writing together in collaboration (Thiele, Allen, & Stuckey, 1999), students develop a scholarly team synthesis document that is posted in the course room and graded by faculty. Students are required to read all the team synthesis documents so that they gain a breadth of understanding of the issues from all four cultural perspectives. To capture the development of student thinking in the course, the students also keep a private, off-line journal. Called the discovery journal, students were asked to capture their early gut reactions to the readings and course activities in an effort to help them discover their hidden biases and assumptions in a safe and nonthreatening way. Students were asked once every other week to reread their discovery journals and place a synopsis of their journals in the on-line classroom. However, students retained complete control of the contents of the discovery journal as well as the contents students chose to share. The journal was never viewed by the faculty and remained a private document for student growth and development during the course. Working together in this way may not be easy, especially during the first weeks of the course as students become familiar with the courseware, learn about each other, and come to understand faculty expectations and course processes. During the early weeks, students need to develop an on-line community (Draves, 2000) and to learn time management in the absence of a regular course schedule. The course is very active, and in the spring of 2002, there were in excess of 1,900 comments or discussion points posted in the course room. Besides ongoing team work and ongoing course discussion, students also participate in cultural-enrichment activities specifically designed to enhance their enjoyment of the course content and to engage their senses in an exploration of cultural experiences. Students earn course grades through active course participation (25 per cent), team synthesis documents (20 per cent), cultural-enrichment activities (10 per cent), and the final, a traditional course paper or project with an executive summary (45 per cent). A diagram of the relationships among the course activities as related to student learning appears as Figure 1. In the past, students enrolled in the conventional classroom typically achieved high grades (mostly As and Bs) and evaluated the course favorably, indicating they would either take the course again or recommend the course to other students. Both offerings of the asynchronous version of the course produced a distribution of grades similar to the classroom grades and student evaluations indicated high satisfaction with the course processes and outcomes, again, including a recommen-

4 BRIDGING CULTURE ON-LINE Figure 1. Interaction of course activities with student-centered learning. dation to other students to take the course. Final scholarly papers or projects were of consistent high quality as well and were developed with similar depth and breadth as those that were presented within the conventional course. In summary, three overarching questions were identified related to moving the cross-cultural health course to an on-line environment. These were: (1) Which activities and strategies might faculty use to promote a sense of respect and acceptance among a group of students who were mostly Caucasian residing in smalltown communities who, in general, had little or no experience with persons outside their own culture? (2) How might students engage in experiential cross-cultural learning within an on-line environment? (3) What is the best way to evaluate the faculty and this asynchronous course that was congruent with the online environment while remaining comparable to University-defined standards of teaching/learning? Strategies Used BALANCING THE NEED TO CONFRONT CULTURAL BIAS WITH THE NEED TO OFFER SUBSTANTIVE INFORMATION In general, faculty were acutely aware of the potential for racism, classism, oppression, cultural conflict, cultural imposition, discrimination, prejudice (Gonser, 2000), and stereotyping within the course. Conventional classroom experience revealed that these issues frequently emerge within the context of the course. In both the traditional classroom and on-line courses, biases, when present, were often subtle and difficult to discern until the students were several weeks into the course. These matters had been managed over the years through role modeling, attending 323 to culturally appropriate gestures, dress and vocabulary (Brown, 2001, p. 17). However, in an on-line environment, faculty worried about their ability to communicate these facets. Speculation arose around matters such as whether the faculty would be able to see the sometimes not-so-hidden biases and whether they could model culturally accepting behavior. To overcome these barriers, faculty used a combination of different approaches (McGee, 1994; Peterson et al., 2001). To begin the course, specific information about culturally acceptable behavior in the four cultures was presented, especially focusing on areas of conversational behaviors. Students were instructed in the appropriate use of words, language, and body language (Brown) to convey respect and caring for one another on-line (Peterson et al.) and in person. Substantive information regarding specific cultural communication preferences for elements such as eye contact or physical touch was presented within the first 2 weeks of the course and provided a foundation for teaching respectful behavior in the absence of direct modeling. Students therefore learned from the outset what appropriate approaches to use to convey a sense of respect and caring, not only in the on-line environment, but also in their direct encounters with persons of diverse cultural background. A shared concern with the class going on-line was how the faculty might be able to identify and gently challenge these issues as they began to bubble up in the course without a physical presence or facial expressions critical, nonverbal cues that guide both students and faculty in dialogue. Likewise, the faculty were interested in overcoming inherent cultural barriers that may be created when persons from one culture teach another culture s health issues. In this instance, it was faculty from the mainstream culture teaching about minority and ethnic health care practices. Previous experience revealed that presentations within the classroom could come perilously close to stereotyping unless effort was expended to shift away from this phenomenon. Finally, although there are excellent textbooks available in cross-cultural health, none provided a perfect fit with the class approach and content, and thus students were given the task of choosing a text from several listed options, thereby leaving the class without a common text. Although this provided a diversity of theory and approaches to the topics covered within the course, some students found the lack of a common text confusing. Two examples might help to show how biases become revealed in an on-line class context. At the beginning of the class, one student, a registered nurse, re-

5 324 WENDLER AND STRUTHERS vealed that she felt ill-equipped to care for her laboring Hispanic client because she did not understand the cultural rituals surrounding this life event. By the middle of the course this labor and delivery nurse stated that, on reflection, her nursing care had not been culturally congruent in that particular instance and she noted to the class that she revised her nursing care to integrate information gained in the course. Faculty provided gentle support in the discussion of the importance of this type of student growth experience. Another common occurrence related to unrevealed biases is the use of othering language. For example, students frequently use the phrase those people or from that culture early in the course during team and class discussions on-line. When this occurs, faculty gently remind the class in general that language like this is off-putting to persons of diverse cultural backgrounds and creates a sense of exclusion during dialogue. In this way, faculty guide students to the realization of the verbal expression of bias, reminding students of the common humanity of all persons while honoring student responses that show self-awareness and growing cultural competence. THE GUEST LISTENER Including a minority faculty voice within the course experience (Brown, 2001; Clark & Robinson, 1999) was a specific strategy used to provide balance within the course. Using a novel and culturally congruent approach, a doctorally prepared Native American nurse was invited to participate in the course as a guest listener. A guest listener is an active course participant whose role is to coach, guide, listen, and to enhance and encourage dialogue from a nonevaluative faculty perspective. Dr. Roxanne Struthers was the invited guest listener for the course. She is an enrolled member of the Ojibwa community, a highly respected member of the Native American community, a widely known and highly respected member of the Native-American and nursing communities, and both a traditional healer and transcultural scholar. Although not on faculty at the University of Wisconsin Eau Claire, Dr. Struthers consults with the School of Nursing in support of an Indian Health Service program grant that serves Eau Claire s Native-American students. Dr. Struthers background and role within the course was introduced to students within the first week of the on-line class, and students were encouraged to use her expertise as a Native-American healer, nurse, and as a certified transcultural nurse. Although Dr. Struthers primarily interacted with students focusing on the Native-American perspective, she also used her transcultural expertise to facilitate other discussions in the course room. Further, Dr. Struthers was consulted by course faculty related to other issues, and faculty together facilitated learning in all the team discussions, serving as coach and consultant as students progressed through the course. For Dr. Struthers, the role of guest listener was attractive because it afforded the following opportunities: (1) use her skills as a certified transcultural nurse, (2) use her acquired knowledge in American-Indian health and health care, (3) implement her skills and expertise in traditional indigenous medicine, (4) draw on her leadership knowledge of American-Indian nursing, and (5) use her past experience as a consultant at the School of Nursing. The on-line format allowed Dr. Struthers to participate in the course from her home out of state, thus making her expertise readily available despite distance from the course site. The course progressed without any unsolvable problems and offered a convenient teaching method because one could participate in the class when time allowed and afforded scheduling around travel and other commitments. This approach enhanced offering the course from a position of nonpower, allowing guidance without being faculty, and offered a diverse perspective that could augment student learning. From a certified transcultural nurse perspective, numerous strengths were evident. Students: (1) developed tolerance to diversity and to peoples different from themselves; (2) integrated the historic perspectives of varying ethnic groups within the United States in a constructive method to assist students to gain a larger perspective of U.S. history; (3) participated in cultural-enrichment experiences, requiring students to actually interface with diverse peoples and cultures; (4) developed and used critical thinking in the course that maximized human potential (Alfaro-LeFevre, 2001), challenged previous assumptions (Jones & Brown, 1991), and was described as an important outcome in nursing education (National League for Nursing Accrediting Commission, 1996). From an American-Indian perspective, inadequate areas exist in cross-cultural health courses that include American-Indian content. Language currently available to define and describe Indian phenomena, including Indian healing or traditions, is not satisfactory (Rhoades & Rhoades, 2000). Many times information on the contemporary lives and health of Native Americans is limited. This may lead scholars and students to use literature that does not pertain to the modern lives of Native Americans. Further, popular media images

6 BRIDGING CULTURE ON-LINE portray Native-American peoples from an historic rather than a contemporary perspective, which may lead one to think that Native Americans still live primitively, which is not the case. An example is the popular movie, Dances With Wolves. Images such as these leave open questions such as: Who are the Native Americans? How do they live? What do they look like? Students familiar with Native-American life are aware of the confusion among these images and appreciate open dialogue about these issues, in relation to all the cultures studied within the course. Further, literature available frequently revolves around issues and problems and, therefore, focuses on the negative aspects of contemporary lives of peoples from diverse cultures. As well, a concern was identified in that students did not seem to fully connect the other to themselves. In other words, they did not perceive the depth and dimensions of their own culture and discovered that they possessed a culture that, many times, is not different from the cultures studied within the course. Lastly, specific strategies using the concept of cultural brokering would be beneficial to the class. According to Jezewski (1995), the theoretical definition of cultural brokering is the act of bridging, linking, or mediating between groups or persons of differing cultural systems for the purpose of reducing conflict or producing change. Two important intervening conditions in the cultural brokering model are cultural background and cultural sensitivity. When cultural brokering is used by nurses, incidences of conflict or breakdown in the health encounter is decreased. After the first offering of the course, faculty determined that an on-line presentation and discussion on the topic of cultural brokering would be advantageous for the students, and this content was added to the course for spring of Cultural-Enrichment Activities Another strategy used in the course was culturalenrichment activities, planned experiential learning activities that provided students with first-hand experience with a culture. The requirement was designed to give students the opportunity to smell, feel, see, hear, taste, savor, think about, and learn through the senses in a way that goes beyond simple reading. The purpose of the assignment was to broaden student horizons, increase awareness of a students own cultural identities and affiliations, and develop an appreciation and respect for cultures different from their own (McGee, 1994). These activities engaged students and enlivened course content, and students were expected to weave reports of these experiences into team synthesis documents or their final projects or papers. Students could choose from a wide variety of options but at least one of the activities required student contact with persons of a diverse cultural background. In this manner, it was expected that initiation of a conversation, partaking in a cultural ritual such as an American-Indian pow-wow, or a meal with foods from other cultures, would be part of an activity. Out of ordinary human nature, people have a tendency to associate with those who look like and act like themselves. When providing health care to individuals, families, or communities of dissimilar cultures, most experience uncertainty and tension (Spence, 2001). In the context of the cultural-enrichment experiences, students were highly encouraged to move outside of their comfort zone, to embrace and experience this cultural tension outside of the health care experience. In addition, students had the freedom to develop individually designed cultural-enrichment experiences once they had secured faculty approval. Examples of cultural-enrichment activities appear in Table 3. For some students, this assignment was particularly illuminating and enriching. For example, one student, who had attended the death of a Hmong patient during student clinicals, witnessed initiation of the funerary rites. Wanting to fully understand the context of end-of-life rituals in the Hmong culture, he asked care- TABLE 3. Examples of Cultural-Enrichment Activities 325 Attend a professional or traditional conference or event specific to the lifeways of a culture. These included such activities as the pow-wow, the Hmong New Year celebration, or ethnic festival. Survey the historic perspective of the chosen culture. Examples included visiting museums in reservation communities or to visit the University of Wisconsin Milwaukee s Multicultural Center. Read a book written from within the culture. Examples included Blue Jay s Dance, Night Woman Flying, A Spirit Strikes You and You Fall Down, or Women Hollering Creek. Evaluate a commercial portrayal (minimum of a 90-min production) addressing the culture. These might include movies such as Smoke Signals, Killing Fields, Amistad, Boys N the Hood, or a theater production, such as The Black Nativity offered by the Pnumbra Theater in St. Paul, MN. Explore health-related issues of people of diverse cultural groups. Examples included visiting a health clinic that serves a diverse population or viewing AHEC-produced videos, such as The Health Effects of Domestic Violence in the Native American Community. Interview, or share a meal with, a member of the chosen cultural group. Students were allowed to interact in this way once they had read the faculty-prepared document on culturally appropriate communication and dialogue.

7 326 WENDLER AND STRUTHERS TABLE 4. Selected Evaluation Comments I can now apply advanced skills in cultural health care, because I had no knowledge of cultures and their practices previously. [I was surprised at] all that I have learned about the subtle changes between cultures that could be mistaken for disrespect but really they are customary and sacred. I know more about the needs and differences of the cultures we studied. I am more aware of being culturally competent. The class brought an enhanced awareness of myself in relation to other cultures. Reading all the articles and books for my paper project gave me much information also. It was a gradual process through the semester and am grateful for my personal final result that others in the class will never see. ful and respectful questions of the family and nursing staff. The student arranged to meet with an elder from the Hmong community and asked specific questions regarding death rituals, inquiring how nurses might support Hmong persons during and after death. The student reported these experiences within the context of the life-transitions unit of the course in the Hmong team s synthesis document. For the final project, the student interviewed a local funeral home director who was very interested in supporting Hmong death rituals, but learned how Hmong death rituals conflict with Wisconsin funerary laws. The student thus obtained a comprehensive understanding of cultural conflicts that may arise within the context of death rituals and rites and developed a deep appreciation for difficulty in meeting cultural needs of diverse peoples. It also was a moving encounter for the faculty who had the privilege of reading the student s final paper, and was shared as a scholarly presentation at a local Sigma Theta Tau chapter event the following semester. Another example of a cultural-enrichment activity occurred when a student in the course received an invitation to visit China on a heath systems study tour. This was, perhaps, the most far-reaching cultural-enrichment activity among the students enrolled in the course, and a report on the health care system of China became the student s final paper topic. These examples show that course content came alive for students, despite the anticipated challenges and potential barriers that may be a part of an on-line environment. Evaluation of the Course and Faculty in the On-Line Environment Identified faculty issues included final course and faculty evaluations. The faculty wondered: What was the best way to evaluate course activities, processes, and outcomes? Three specific strategies were used. First, a shortened version of the standard university evaluation form was offered to students at about the midpoint of the course. Students were encouraged to respond online to the evaluations submitted by the technology support person assigned to the course. Students were given the opportunity to provide information to faculty about what was working well, what was not, and how faculty and technical support personnel might better facilitate the course. Student responses were submitted in confidence to the technology support person, and a summary of information was provided to course faculty. In this way, faculty had an opportunity to correct problems within the course before the course ended. Second, at the end of the course, the standard University evaluation documents were offered to the students in an on-line format, with additional questions regarding the on-line classroom and technology support to evaluate these aspects of the course. In this way, the course and the faculty would be evaluated on the same criteria as the traditional courses on campus. In addition, faculty provided six qualitative questions designed to elicit more in-depth information; selected student comments from qualitative data are shown in Table 4. Third, a reflective faculty and course evaluation was cocreated between the guest listener, Dr. Struthers, and faculty. By using the course objectives as guidelines, course activities, products, and outcomes were summarized in a letter that was provided to the course development funders and the AHEC agency. In addition, it will be used during the School of Nursing cyclic course evaluation process. In general, students rated the course processes, activities, and outcomes highly, by indicating they agreed or strongly agreed to almost all of the course evaluation prompts. Students provided written, , and verbal compliments on faculty members ready availability and support throughout the course. Students achieved the outcomes at their own pace and in their own time, some earlier in the semester than others, and especially appreciated the cultural-enrichment activity assignments and the opportunity to bring course information together in the final paper or project. Although some students initially found the work in teams a barrier to their participation, they appreciated the fact that teamwork limited an excessive amount of reading in the course. The few nonnursing majors in the course commented about the amount learned about health care issues, in general, and expressed gratitude for acceptance of their own disciplinary approach. Further, despite the grounding of the course in nursing, all students related in evaluations how they anticipated applying the information to their lives. Al-

8 BRIDGING CULTURE ON-LINE most all students said they would recommend the course to others. Summary An on-line learning environment may create barriers to learning that are best handled proactively. Indeed, many faculty and student roles are redefined in the process of on-line course development and implementation (Halstead & Coudret, 2000). The strategies used in this exemplar constituted innovations that can be used in other on-line or cultural-diversity courses, thereby facilitating the transformation of nursing education and practice (Leininger, 1997a) with the internet as a tool to facilitate learning about diversity and other cultures (Leininger, 1997b). Overall, the experience was compelling for students and faculty and allowed creation of relationships and alliances that may be useful in the future. Acknowledgments 327 The authors recognize the significant contributions of Ms. Anne Alexander Doelle, former assistant professor, University of Wisconsin Eau Claire, and Ms. Kathy Finder, Instructional Technologist, in the development and implementation of this course. References Alfaro-LeFevre, R. (2001). Improving your ability to think critically. Nursing Spectrum: Metro Edition, 2, Andrews, M. (1995). Transcultural nursing: Transforming the curriculum. Journal of Transcultural Nursing, 6, 4-9. Brown, G. (2001). Culture and diversity in the nursing classroom: An impact on communication and learning. Journal of Cultural Diversity, 8, Clark, C., & Robinson, T. (1999). Cultural diversity and transcultural nursing as they impact health care. Journal of National Black Nurses Association, 10, Draves, W. (2000). Teaching On-Line. River Falls, WI: LERN Books. Gonser, P. A. (2000). Culturally competent care for sexual minorities. Journal of Cultural Diversity, 7, Halstead, J., & Coudret, N. (2000). Implementing Webbased instruction in a school of nursing. Journal of Professional Nursing, 16, Jezewski, M.(1995). Evolution of a grounded theory: Conflict resolution through cultural brokering. Advances in Nursing Science, 17, Johns, C., & Freshwater, D. (1999). Reflective Nursing Practice. London: Blackwell Science. Jones, S., & Brown, L. (1991). Critical thinking: Impact on nursing education. Journal of Advanced Nursing, 16, Katz, R. N. (Ed.). (1999). Dancing with the devil: Information technology and the new competition in higher education. San Francisco: Jossey-Bass. Leininger, M. (1997a). Transcultural nursing research to transform nursing education and practice. Image: Journal of Nursing Scholarship, 29, Leininger, M. (1997b). Future directions in transcultural nursing in the 21st century. International Nursing Review, 44, Leininger, M., & McFarland, M. (2002). Transcultural nursing concepts, theories, research and practice (3rd ed.). New York: McGraw-Hill. Mastrian, K., & McGonigle, D. (1999). Using technology-based assignments to promote critical thinking. Nurse Educator, 24, McGee, P. (1994). Educational issues in transcultural nursing. British Journal of Nursing, 3, National League for Nursing Accrediting Commission. (1996). Criteria for evaluation of baccalaureate and higher degree programs in nursing. New York: National League of Nursing. Olson, D., & Carlson, V. (2000). Technology enhanced learning from occupational and environmental health nursing: A global perspective. AAOHN Journal, 48, Peterson, J., Hennig, L., Dow, K., & Sole, M. (2001). Designing and facilitating class discussion in an internet class. Nurse Educator, 26, Rhoades, E. R., & Rhoades, D. A. (2000). Traditional Indian and modern Western medicine. In E. R. Rhoades (Eds.), American Indian Health: Innovations in health care, promotions, and policy (pp ). Baltimore, MD: The John Hopkins University Press. Rosenlund, C., Damask-Bembenak, B., Hugie, P., & Matsumura, G. (1999). The development of on-line courses for undergraduate nursing education. Nursing and Health Care Perspectives, 20, Scisney-Matlock, M. (2000). Systematic methods to enhance diversity knowledge gained: A proposed path to professional richness. Journal of Cultural Diversity, 7, Spence, D. G. (2001). Prejudice, paradox, and possibility: Nursing people from cultures other than one s own. Journal of Transcultural Nursing, 12, Thiele, J., Allen, C., & Stuckey, M. (1999). Effects of Web-based instruction on learning behaviors of undergraduate and graduate students. Nursing and Health Care Perspectives, 20, Wong, F., Kember, D., Chung, L., & Yan, L. (1995). Assessing the level of student reflection from reflective journals. Journal of Advanced Nursing, 22,

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