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SUSAN SANNER, P H D , D E E BALDWIN, P H D , KATHLEEN A, S. CANNELLA, P H D , C N S - B C ,

JENNELL CHARLES, P H D , & LILLIAN PARKER, P H D .

Abstract: As the population demographics for the United States (U.S.) shift towards increasing diversity, it is essential that nurses provide culturally competent care. Cultural sensitivity has been identified as a major curricular element in the American Association of Colleges of Nursing's (AACN) The Essentials of Baccalaureate Education for Professional Nursing Practice. Thus it is imperative that nursing faculty use effective strategies to help nursing students develop cultural sensitivity and competence. Educational workshops focusing on cultural diversity are usually designed to increase people's cul- tural sensitivity. The purpose of this study was to assess the effectiveness of a culturaldiversity forum on nursing students'cultural sensitivity as measured by their openness to diversity. A convenience sample of students was recruited from a public university in the southeastern United States. The workshop was designed as a forum that combined a keynote presentation, shared meal, and a small group interactional activity. Cultural sensitivity was measured using the Openness to Diversity I Challenge Scale (ODCS), and was administered to students before and after the forum. A convenience sample of 47 students agreed to participate and completed both the pretest and posttest. Following the workshop, the students had more cultural sensitivity as measured by their scores on the ODCS (Wilcoxin Signed-Rank test z= -3.286, p = 0.001). The findings suggested that an educational format like the cultural diversity forum can promote students' cultural sensitivity. Further research needs to continue to focus on the effectiveness of strategies to increase the cultural sensitivity of baccalaureate nursing students.

Key Words: Cultural Diversity, Students' Openness to Diversity, Impact of Openness

T H E IMPACT OF CULTURAL DIVERSITY FORUM ON STUDENTS' OPENNESS TO

DIVERSITY

INTRODUCTION

Since the 1900s, the population demographics ofthe U.S. have undergone a tremendous trans-formation. According to the U.S. Department of State, U.S. minorities will be the majority by 2042, increasing from 34 percent in 2008 to 54 percent in 2042. Within four states— Hawaii, New Mexico, California, Texas—and the District of Columbia, mi-

Susan Sanner, PhD, is an Associate Professor of Nursing at Clayton State University, 2777 Priscilla Way, Morrow, G A. Dr. Sanner may be reached at: 770-961-4866. Dee Baldwin, PhD, is an Associate Professor of Nursing at Georgia State University in Atlanta, GA. Kathleen A. S. Cannella, PhD, CNS-BC, Jennell Charles, PhD, and Lillian Parker, PhD, are Assistant Professors of Nursing at Clayton State University.

norities currently outnumber non-Hispanic Whites (U.S. Census Bureau). The "American" race continues to evolve to more closely mirror the global face where 75 out of 100 persons represent a non-white ethnicity (U.S. Census Bureau).

While population demographics for the U.S. are shifting significantly towards increasing diversity, members of the nursing profession, however, does not reflect this diversity. Most nurses continue to be of Caucasian descent, while patients are increasingly representative of other racial groups (Sullivan Com- mission Report on Diversity, 2007).

For several decades, the nursing profession has recognized the challenges these differences in demo- grapmcs create in providing high quality nursing care to patient populations. In fact, cultural sensitivity was identified as a major curricular element in The Essentials of Baccalaureate Education for Professional

Journal of Cultural Diversity • Vol. 17, No. 2 Summer 2010

Nursing Practice (AACN, 2008). Therefore, nurse edu- cators riave shouldered the responsibility to raise the cultural sensitivity and awareness of both faculty and students to ensure that as nurses enter the workforce they do so as culturally competent practitioners. To this end, schools of nursing craft initiatives that create both structural and process mechanisms that attract and retain higher numbers of minority faculty and students and result in opportunities for faculty and students from diverse backgrounds to engage in active thinking and dialogue.

This article describes the impact of one school of nursing's initiative on students' openness to diversity experiences. The School has a long-standing commit- ment to promoting cultural sensitivity and cultural competency in its faculty and students and offers both baccalaureate and master degrees in nursing. The School is part of a larger public University which has been described by U.S. News and World Report Rank- ings of Best Colleges and Universities as the most diverse university in the southeastern United States other than the historically Black colleges and universities. Table 1 refiects the nursing program's diverse enrollment data between 2000 through 2007.

First implemented in April 2008, the School's Annual Cultural Diversity Forum (Diversity Forum), used a format that emphasized open discussion between students and a diversity expert as well as a presentation by the expert. This year the expert's presentation was followed by a shared meal and small group interactional activ- ity. All University students were invited to attend and faculty from other disciplines across the University were selected to participate in the meal and small group interactional activity. The Diversity Forum was funded by the School of Nursing's Nursing Workforce Diversity grant, and was one of multiple grant-funded strategies used to recruit and retain minority nurses in the nurs- ing program and promote cultural encounters among students and faculty. Campinha-Bacote (1999) describes cultural encounters as a process that encourages nurses to engage in cross-cultural and cross-ethnic interactions with patients from diverse backgrounds. This process can be applied to faculty and student interactions where faculty takes a direct role in providing opportunities for students to interact with others who represent diverse cultural groups.

The impact of the Diversity Forum on students' openness to diversity experiences was measured by; Pascarella's et al. (1996) 8-item Openness to Diversity and Challenge Scale (ODCS). Pascarella et al. define "operuiess" as "an orientation toward enjoyment from being intellectually challenged by different ideas, values, and perspectives as well as an appreciation of racial, cultural and value diversity" (p. 6). The research ques- tion that guided data collection and analysis was: What is the effect of a combined educational strategy using both a cultural diversity workshop format and small group interaction activity on college students' openness to diversity and challenge?

REVIEW OE LITERATURE The benefits of a racially and ethnically diverse

college experience are clearly supported in tne educa- tional literature. Research of these benefits have been approached in several ways including students' sub- jective assessment of the benefits they received from interacting with diverse peers (Orafield & Whitla, 1999), faculty assessment about the impact of diversity om student learning (Maruyama, et al., 2000), analyses of monetary and non-monetary returns to students and the larger community in terms of graduation rates, attain-i ment of advanced and professional degrees that prepare students to become leaders in underserved communi- ties (Bowen & Bok, 1998), and analyses tying diversity experiences during the college years to a wide variety: of educational outcomes (Astin,1993; Pascarella, et al., 1996). Across these various approaches to research, the; main theme that emerged was that a variety of indi- vidual, institutional, and societal benefits were linked to student diversity experiences.

Using a national survey of 25,000 undergraduates attending 217 four-year colleges and universities. As- tin (1993) examined^ the effects of campus policies and practices on diversity and multiculturalism on students' values and beliefs about other races and cultures. The survey was administered to freshman in the fall of 1985 and again four years later upon graduation in 1989. Three measures of diversity included institutional, fac- ulty, and student diversity experiences. Of the student diversity experiences, taking ethnic studies or women's studies courses, participation in cultural awareness

Table 1. Nursing Program Enrollment Data for 2000 through 2007

BSN Enrollees

Minority/Disadvantaged BSN Enrollees

Percent of Enrollees Who Are Minority/Disadvantaged

Fall 2000

44%

Fall 2001

49%

Fall 2002

32%

59%

Fall 2003

43%

77%

Fall 2004

35%

73%

Fall 2005

22%

55%

Fall 2006

30%

64%

Fall 2007

33%

73%

Journal of Cultural Diversity • Vol. 17, No. 2 Summer 2010

workshops, and frequency with which students social- ized with persons from different racial/ethnic groups, were positively associated with measures of student satisfaction with the undergraduate experience and with measures of academic development, including increased cultural awareness and commitment to promoting racial understanding. The greatest positive impact was based on the frequency with which undergraduate students discussed racial/ethnic issues. Gurin, et al. refers to this type of diversity as informal interactional diversity. This form of diversity involves both the frequency and the quality of inter-group interaction as necessary ways to experience meaningful diversity experiences during college. The focus of tne current study was to examine students' openness to diversity before and after partici- pating in the Diversity Forum where faculty and students were encouraged to discuss a diversity issue occurring in the health care arena.

The Use of the Openness to Diversity and Challenge Scale in Research

In their seminal work, Pascarella et al. (1996) identi- ñed ways in which institutions instilled in students a greater openness to racial, cultural, and value diversity. Using a sample of 2,416 freshman from 18 different universities, openness to diversity was measured in the fall 1992 and Spring 1993 using their Openness to Diver- sity and Challenge Scale that included an assessment of an individual's openness to cultural, racial, and value diversity, the extent to which an individual enjoys be- ing challenged by different ideas, values, and perspec- tives, and an appreciation of racial, cultural, and value diversity (Pascarella et al., p. 179). Forty-five percent of the sample were male and 55% were female; and 59% White, 16% Hispanic, 14% Black, 7% Asian, and 4% Other. This scale was later revised to an 8-item scale and demonstrated an internal consistency of 0.83 for the pre-college measure and 0.84 for the end of the first year follow-up when used with college freshmen. Us- ing a two-stage, least squares regression model, results demonstrated that pre-college variables explained 42% of the variance in the end-of-first-year openness to di- versity / challenge with the precollege measure of open- ness having the strongest effect of any in the prediction model. The net of other influences demonstrated that students fitting the demographics of w ômen, nonw^hite and older students had higher levels of openness than those of men, white and younger students. Controlling for the influence of all other predictors, living on-cam- pus and participating in a racial or cultural awareness workshop had signin^cant net positive effects on open- ness to diversity/ challenge with the greatest impact on whites versus nonwhites. Hours worked per week and student interactions with peers also demonstrated positive net effects. Pascarella et al. predicted the more student interactions focused on controversial or value- laden issues, the greater they developed openness to diversity and challenge.

Summers et al. (2002) administered the ODCS to over 3900 students in one university during the fall and spring semester over a two-year period. Data were analyzed according to three student demographic cat- egories—gender, ethnicity, and class rank. Sixty-five

percent of the respondents were Caucasian, 10% His- panic, 4% African American, 14% Asian American, 4% Native American and 2% designated as other. There were statistically significant differences in the scores based on gender and ethnicity (p< .001) with females scoring higher than males. There was no significant dif- ference in means according to class rank. The net effect revealed that women were more open to diversity than men, regardless of ethnicity.

The ODCS has also been used to measure change in students' opermess to diversity following study abroad experiences. Wortman (2002) measured changes in open- ness that occurred after a semester-long study abroad progran\ of 100 U.S. participants in native English- speaking and non-native English-speaking countries. The average change on the 8 items in diversity/chal- lenge was significant (0.074) with an alpha reliability coefficient of 0.84. Ismail, Morgan, and̂ Hayes (2006) studied changes in openness following a three-week study abroad program of 23 students to China. They used a Mann-Whitney non-parametric test to determine the change in openness to diversity before and after the study abroad program. A significant increase (p = 0.007) in openness to diversity occurred as a result of the three-week study abroad course.

In summary, the literature review provided evidence that institutional structures and educational strategies that intentionally provide opportunities for cross-cul- tural encounters pron\ote both learning outcomes and racial/cultural understanding. Further, while institu- tional structures have a significant impact, providing op- portunities for informal exchanges and dialogue among diverse student groups has the potential to have the greatest impact on learning outcomes, racial/cultural sensitivity, and competency in engaging constructively with diverse populations. Studies using the ODCS also found that cultural workshops, study abroad programs, and informal interactions among diverse peer groups increased students' openness to diversity and challenge with some variations in impact as a result of gender, age and race classifications. The current study is an attempt to determine if a cultural diversity forum that uses both an instructional/lecture format in combination with a small group interaction activity influences the open- ness to diversity/challenge of students matriculating in a University and School of Nursing with a majority minority population.

METHODS A quasi-experimental pretest-posttest design was

used to assess the effect of the Diversity Forum (inde- pendent variable) on participants "openness to diver- sity" (dependent variable). The research hypothesis was: Participants' post-test scores on the ODCS will be significantly higher than their pre-test scores after an eciucational strategy. Sample and Setting

This study took place in a university located in the metropolitan area of a large city in the southeastern United States. Approximately 60% of students attend- ing this university are minority. It was approved by the University's Institutional Review Board̂ . All universit1 u n i v e r s i t y

Journal of Cultural Diversity • Vol. 17, No. 2 Summer 2010

students were invited to attend the Diversity Forum. In- formational flyers and talks conyprised the recruitment activities. Flyers advertising the forum were distributed across campus and multiple informational sessions were held within individual nursing classes. All students who registered to attend the forum were eligible to partici- pate in the study.

Intervention The Diversity Forum took place on-campus and lasted

approximately three hours. The event began with a 45-minute presentation by a nurse educator considered an expert on diversity issues. The title of the keynote address was Eliminating Gaps in Health Outcomes through Gultural Competence. Following the keynote address, student participants, the keynote speaker, and faculty facilitators shared a meal together. After the meal, the speaker facilitated an interactive activity involving all participants. The interactive activity was designed to assist students to apply the concepts presented in the keynote address. The faculty was assigned various health care roles that included insurance company representatives, acute care facility administrators and emergency department employees and assisted in creat- ing scenarios that resulted in unequal treatment of the student participants. Students were assigned to one of several groups that represented a vulnerable population. One group consisted of mentally ill clients, the second group included non-English speaking individuals, and me third group comprised obese individuals. None of the individuals in the vulnerable population groups had health insurance. A fourth group consisted of members of the white majority. The goal of the interactive activity was to have all groups obtain health insurance within a specified time frame. Members of the white major- ity group were treated well and were accommodated by all members of the health care team and the insur- ance company. All members of this group were able to quickly obtain health insurance. Members of the vulnerable population groups encountered assump- tions and prejudices as they tried communicate with members of the health care and insurance facilities. For example, the non-English speaking group experienced the health care team members speaking loudly and fre- quently telling them they could not understand them. Members of the obese group experienced feelings that originated from assumptions made about their health status. For example, one member of the health care team attributed the obese members' health care problems to strictly being obese and assumed that they did not care about their health. Members of the mentally ill group were patronized by members of the health care team or responded to them in fear. One faculty member played the role of grim reaper. She circulated around the room and, after a certain period of time, pulled individuals aside who were unable to obtain health insurance and access to care which resulted in their death. At the con- clusion of the activity, a 15-minute debriefing, reflection and summary period was held. Students shared how it felt to be a member of a vulnerable population as they tried to maneuver through the healtn care system. Nursing student participants shared how the activity

helped them to become more sensitive to the needs of vulnerable populations and how access to quality health care is critical for all members of society.

Instruments A six-item demographic questionnaire was devel-

oped to characterize selected demographic charac- teristics of students attending the forum. These items measured gender, age range, race/ethnicity, year ih college, major, and previous attendance at another col lege/university.

The ODCS is an eight-item, Likert scale with op tions for each item that range from l=strongly disagree to 5=strongly agree. Summed items yield a total score that can range from 8 to 40. Higher scores indicate higher openness to diversity anci challenge; whereas lower scores indicate lower openness to diversity and challenge. This scale had internal consistency (alpha) reliabilities of 0.83 when used to measure of students' pre-college (Pascarella, et al, 1996), 0.84 when used as a follow-up measure at the end of the first year of col- lege (Pascarella, et al., 1996), and 0.84 when used as ä measure of change after a semester-long study abroad program (Wortman, 2002). i

Procedures | At the close of registration, students were approached

via email and askeci to participate in the study. Students were informed that participation required completion of a questionnaire before and after the forum, and were requested to arrive 30 minutes prior to the beginning of the forum.

All students who attended the forum were asked to complete a demographic profile when they arrived. Then, after they checKed in and before the forum began, students who agreed to participate in this study also signed a consent form and completed the ODCS for the first time. The ODCS was re-administered to students participating in the study at the end of the Diversity Forum. !

Statistical Analyses All data were entered into a Microsoft Excel spreadf

sheet and then imported into the Statistical Package for the Social Sciences (SPSS, Version 16.0), and screened foi- completeness. Students who did not complete all items on the ODCS before and after the forum were excluded from the study. The significance level set for this study was p<0.05.

The data were entered and cleaned in Microsoft Of- fice Excel 2003 (Microsoft Corporation, 2003). Univariate statistics were computed to describe the demographic characteristics of all students who attended the forum and the impact of the forum, as measured by the ODCS, of students who participated in this study. Histograms were computed to assess the distribution patterns of the ODCS at both time points. Following tests of normality using the Shapiro-Wilk test statistic, a Wilcoxin Signed̂ f Ranks test was conducted to assess the differences ir\ pretest and posttest scores. i

Journal of Cultural Diversity • Vol. 17, No. 2 Summer 2010

RESULTS One hundred and twenty students registered and

attended the Diversity Forum. Of the attendees, 86 stu- dents completed the demographic form. Demographic data on these 86 attendees indicated that 73 (85%) were female and 13 (15%) male. More students were between 18-24 years old (38%) than were between 25-34 years old (30%) or older than 34 years (32%). Of 70 students report- ing race, the two largest groups were Black students at 43% followed by White students at 28%. Approximately 48% (n=41) were juniors, 38% (n=32) seniors and 13% (n= 11) sophomores; there was only one freshman par- ticipant. Almost 81% of students reporting demographic data had declared nursing as their major and 76% had attended a previous U.S. college or university.

Of the 120 students attending the Diversity Forum, 47 agreed to participate and completed both the ODCS pre-test and post-test. The means and standard devia- tions for the total scores on the pretest and post-test were 33.70/5.718 and 36.34/4.833, respectively. Scores ranged from 16 to 40 on the pretest and 20 to 40 on the posttest. After a review of histograms of total pretest and posttest scores, tests of normality were conducted on the total scores on the pretest and posttest using the Shapiro-Wilk test statistic. The total scores at both time points were not normally distributed; the Shapiro-Wilk test statistic was 0.907 (df=47, p=0.001) and 0.773 (df=47, p=0.000) on the total pretest and posttest scores respectively.

Therefore, a Wilcoxin Signed-Rank test, a nonpara- metric test for two related samples, was calculated to examine the change in scores between the pre-test and post-test times for the 47 students completing the scale at both time points (Table 2). A significant difference was found between participants' pretest and posttest scores (Z = -3.286, p=0.001), thus supporting the research hypothesis that tne students' posttest scores on the ODCS would be significantly higher than their pretest scores.

DISCUSSION AND CONCLUSIONS The results of the study demonstrated that the Di-

versity Forum with its combination of lecture and inter- active sessions had a statistically significant impact on promoting students' openness to diversity/challenge.

' ' d for 86 forumule demographic data were obtained participants, a methodological weakness of the study

was not matching demographic data to the pretest and posttest measurements of openness / challenge to diver- sity. It can be postulated, however, that the attendees completing the pretest/posttest questionnaires, were representative or the larger sample of 86.

The ODCS has largely been used and tested with college freshmen students, generally younger students, and primarily White students. The convenience sample in this study was composed almost entirely of females (85%), mostly students older than 24 years of age (62%), and about half (49%) non-White students. Previous testing of the openness/challenge scale demonstrated that women, non-White and older students had higher levels of openness than men. White and younger students. The results from the study suggest similar findings, namely that educational strategies to promote openness to diversity are more effective with women, students who are older and students who represent mi- nority groups. Most (82%) attendees were majoring in nursing, a major with a strong emphasis on caring and cultural sensitivity woven throughout the curriculum. No study sample from previous studies included a large percent of students declaring nursing as their major. Characteristics of the study sample made this sample unique from those of previous studies. Interpretation of the infiuence of demographic characteristics on the impact of the Diversity Forum, however, was limited by the study design.

Students attended the Diversity Forum for a variety of reasons. As an incentive to encourage participation, approximately 70% earned extra credit within a nursing course for attending. This may have created a selec- tion bias by attracting students who needed the extra credit to succeed in a particular course. No information was collected on a student's academic performance or academic ranking.

Testing of the study sample demonstrated a high mean on total scores for both the pretest and posttest scores. These high scores may have been the result of a ceiling effect, wnere the "true" score could not be ac- curately measured using the ODCS. Thus, the impact of the Diversity Forum may have actually been greater than that demonstrated by the results.

Table 2. Wilcoxin Signed-Ranks Test

TbtalPost - TotalPre

a. TotalPost < TotalPre :b.TotalPost> TotalPre c. TotalPost = TotalPre

Negative Ranks Positive Ranks Ties Total

6= 25" 16= 47

Mean Rank

13.42 16.62

Sum of Ranks

80.50 415.50

Journal of Cultural Diversity • Vol. 17, No. 2 Summer 2010

IMPLICATIONS FOR FUTURE RESEARCH AND PRACTICE

The nursing faculty is currently planning the imple- mentation of tne spring 2009 Diversity Forum. It will provide a new opportunity to demonstrate once more the impact of this strategy on students' openness to diversity/challenge. Furthermore, the 2009 Diversity Forum offers a new opportunity to investigate the rela- tionship between student characteristics, their academic success, and scores as measured by the ODCS. Further testing of the ODCS with this population group will support its usefulness in this setting. The use of ad- ditional tools to measure cultural understanding and competency will serve to validate the impact of the Diversity Forum on students' openness/challenge to diversity. Input from faculty participants can provide evidence of the Diversity Forum's impact on faculty's openness/challenge to diversity, thus supporting ef- forts to create academic environments where cultural understanding; and sensitivity are enhanced among both students and faculty. Once the Diversity Forum has been institutionalized for the University community, explor- ing whether attendance at multiple forums results in a greater, long-term effect may be possible.

The literature supports numerous strategies to pro- mote racial/cultural understanding; one of the most influential strategies being informational interactions. The findings from this study suggest that an educational format sucri as the Diversity Forum can serve to promote such understanding among nursing students. Racial and cultural understanding provides a critical founda- tion in promoting cultural competency among future nurses. With the increasing diversity of patients and healthcare professionals, cultural competency is neces- sary in the delivery of safe and effective health care in the 21'' century.

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feelings of connection to the campus and openness to diver- sity and challenge at a large research university: Evidence of progress? Innovative Higher Education, 27(1), 53-64.

The Sullivan Commission. (2007). Missing persons: minorities in the health professions, a report ofthe Sullivan Commission on diversity in the healthcare workforce, www.sullivancommission.org.

U.S. Census Bureau. (2007). Population. http://www.census. gov / prod / www / abs / popula.html.

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Journal of Cultural Diversity • Vol. 17, No. 2 Summer 2010

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