International Interprofessional Learning: Evaluating Advanced Practice Nurses’ Cultural Competencies


Pamela Willson, PhD, RN, FNP-BC, CNE, FAANP

Dinorah Martinez-Anderson, MSN, FNP-C

Susan K. Lee, PhD, RN, CNE

Vivian Dawkins, PhD, RN, NEA-BC

Corresponding author: Pamela Willson


Phone: 512-365-0979


International service learning offers students an enriched quality education. Interprofessional collaboration in an international setting fosters the development and integration of cultural competencies. Fifteen Family Nurse Practitioner (FNP) students participated in rural community/home based clinics in collaboration with Nicaraguan public health regional physicians. Phenomenological evaluation of the experience was undertaken.

Keywords: Advance practice nurse, cultural competencies, service learning, evaluation


Advanced Practice Nurse (APN) faculty have the daunting task of developing and evaluating learning opportunities that recognizes cultural diversity and the patient as a full partner in decision-making (NONPF, Nurse Practitioner Core Competencies Content, 2014). Additionally, the latest research agenda has charged educators to understand the outcomes of integrating interprofessional activities within APN curriculum (Roberts & Goolsby, 2017). Multiple teaching/learning strategies, assignments, and assessments are implemented to support cultural awareness, knowledge, and skills attainment across the nurse practitioner curriculum. The key concepts of mutual respect, empathy, and mutual trust that incorporate the patient’s cultural and spiritual preferences, values and beliefs are difficult to evaluate. Determining the student’s desire to translate cultural competences into practice is a daunting challenge. One strategy for achieving the outcome of cultural competent healthcare service delivery is international service learning. Faculty designed and implemented an international service learning experience that used an interprofessional team to immerse students in cultural encounters.


Campinha-Bacote’s (2002) model of Cultural Competence in the Delivery of Healthcare Services framed the 40-hour clinical experience. Each didactic and clinical activity was planned to address the model concepts of cultural awareness, cultural knowledge, cultural skills, and cultural encounters, and were leveled for graduate students. Campinha-Bacote’s (2002) fifth construct is cultural desire and is defined as the nurses’ motivation to “want to” engage in becoming culturally aware, knowledgeable, and skillfully engaged in cultural encounters and was an outcome of this learning opportunity (Campinha-Bacote, 2003). The cultural desire construct reflects the translation of the previous four concepts into practice.

Cultural awareness, knowledge, and skills were woven throughout the clinical didactic sessions and clinical practicums. For the APN students to be culturally competent the didactic review of Nicaraguan disease epidemiology by the physician medical director was directly implemented into practice as APN students interviewed, examined, and managed treatment for topical illnesses such as Dengue fever.

Evaluation of the learning objectives and whether they met the concepts of Camphia-Bacotes model was undertaken by reflective journaling. Students were asked to reflect on their experience, and at one week and two weeks after their return, answer the following question: “During the past week, how did your experience in Nicaragua affect your practice, for example, in patient assessment, treatment, education, screening, interpersonal patient interactions, etc.?”



Foundational preparation for the cultural clinical immersion experience involved a module entitled, “The Intersection of Advanced Nursing Practice Healthcare Delivery with Culture”. The content presented provided a brief overview of geographical location, tentative schedule of service learning experiences, downloadable Spanish eBooks, language boards, clinical hours earned, and scholarship opportunities. International Service Learning (ISL) was the organization that provided the local support for this clinical service learning experience in partnership with the university. During preparation activities with ISL, the need of advanced level interprofessional collaboration of nursing students was established and programming was designed based on the knowledge of nurse practitioner students. This was a critical component because Nicaragua does not have APNs as primary providers. Thus, physicians worked with NP students as they would medical residents.

Population and Sample

The population for this study was all the students enrolled in the FNP program at a state university in central Texas (N=75). The sample was convenient and included the students that were eligible and able to participate in an international service learning experience in Nicaragua.

The program was finalized with 15 APN students scheduled to work interprofessionally with two bilingual (Spanish/English) Nicaraguan physicians. Each group of three students had access to four-five local translators. The ISL experience began for students upon arrival when Nicaraguan support staff picked up the group at the airport and culminated with healthcare delivery in rural regional clinics, homes, orphanages, and long-term care facilities. The purpose of this ISL experience was to establish a desire in the students to learn more, do more, advocate more and become more sensitive to culture in their day-to-day practice.


The student’s narrative reflections at the end of their first week home, and again at the end of their second week home, were read and re-read searching for themes that would support the conceptual framework, and the outcome of cultural desire. Constant comparison was the approach taken to search for themes and establish coding. There were 35 themes that were identified across students. Nine major themes emerged from the narrative reflections:

  1. Awareness of the impact of poverty on policy and healthcare,
  2. Self-awareness,
  3. Listening,
  4. General communication,
  5. Relationship and trust building,
  6. Role responsibilities of the NP,
  7. Need for a thorough assessment,
  8. Need to evaluate patient understanding of education, and
  9. Provision of patient centered care.

An interesting note was that all but one of the narratives identified listening as a critical component of care. Perhaps this was related to the language barrier between students and patients; however, listening was identified as being most meaningful for the students. Listening is a critical skill needed for effective communication between patients and providers. Communication is a fundamental competency for the delivery of patient centered care embedded in a cultural context.

Each theme that emerged was then compared to Campinha-Bacote’s (2002) model. The Table demonstrates how the individual themes were related to the concepts of Campinha-Bacote’s model: cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desire. The student’s reflections fit neatly into the conceptual framework and support attainment of culture desire competencies.

Table. Application of Campinha-Bacote Model’s Concepts (2002) and Narrative Themes

Cultural Awareness Cultural Knowledge Cultural Skills Cultural Encounters Cultural Desire
Shared learning Understanding of complementary therapy Listening Changed my life as a nurse Learn Spanish
Self-awareness Importance of health history Observation Presence Expressed desire to engage in global service
Assess with no labs Standards for practice Thorough assessment Building trust Awareness of need
Insight into health policy, poverty Role awareness and responsibilities Assess health literacy Relationship building Continuing education
Internal assumptions Patient centered care Patient education Compassion
Lack of resources Holistic thinking Evaluating patient understanding Caring
Service as caring Time Inter-professional collaboration Efficient care
Patience Interactions with families
Communication Gathering information
Therapeutic touch
Use of senses to assess
Complementary treatment
Critical thinking


Garneau and Pepin (2015) used a constructivist perspective to define culture as “A complex know-act grounded in critical reflection and action, which the health care professional draws upon to provide culturally safe, congruent, and effective care in partnership with individuals, families, and communities living health experiences, and which takes account of the social and political dimensions of care” (p. 12). The student narratives clearly demonstrate a social constructivist perspective as cultural awareness grew in proportion to the time spent with the people of a different cultural. The students, interprofessional team, and the patients together constructed the reality of the student’s cultural awareness, knowledge, skills, and encounters while creating cultural desire. The students learned about the impact of poverty on politics and healthcare and how to conduct a thorough assessment without all the usual tools and instruments and to do so in a safe environment. Student narratives reflect the partnership they developed with patients, families and other professionals as they provided culturally congruent care. The most enlightening reflections were about the need to listen, and listen carefully, to provide efficient, efficacious, and safe care. Exposure to culture’s whose primary language is different from the students contributed to the strong use of active listening, presence, caring, and relationship building, all skills needed to ensure the concepts of Campinha-Bacote’s model are fulfilled. The implications for engaging students in their own learning through service opportunities are extraordinary. Immersing the students in another culture with an interprofessional service learning team provided an invaluable medium to teach and assess cultural competency.


Garneau, A. B., & Pepin, J. (2015). Cultural Competence: A constructivist definition. Journal of Transcultural Nursing, 26(1), 9-15. doi: 10.1177/1043659614541294

Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare       services: A model of care. Journal of Transcultural Nursing, 13(181), 181-184. doi:     10.1177/10459602013003003

Campinha-Bacote, J. (2003). Cultureal desire: The key to unlocking cultural           competence. Journal of Nursing Education42(6), 239-240.

National Organization of Nurse Practitioner Faculty (NONPF). 2014. Nurse Practitioner Core      Competencies Content: A delineation of suggested content specific to the NP core           competencies. Retrieved at

Roberts, M. E., & Goolsby, M. J. (2017). Nurse Practitioner Research Agenda Roundtable,           October 2015. American Association of Nurse Practitioners, 29(1), 7–11.    doi: 10.1002/2327-6924.12420