As the American population grows increasingly diverse, more nurses and their patients will represent varying backgrounds. With projections pointing to even greater levels of diversity in the coming years (Pew Research Center, 2015), professional nurses need to demonstrate understanding of sensitivity to a variety of cultures. An individual's response to culture is predominantly unconscious and is both intellectual and emotional (Kradin, 2012); nurse preparation programs must train their students with regard to both intellectual and emotional responses to different cultures.
Cultural awareness includes being knowledgeable about one's own thoughts, feelings, and sensations, as well as the ability to reflect on how these can affect one's interactions with others (Giger et al., 2007). Emotional intelligence is a type of social intelligence involving the ability to monitor one's own and others' emotions, to discriminate among them, and to use the information to guide one's thinking and actions (Salovey & Mayer, 1990); two critical components of emotional intelligence are emotional self-awareness and self-regulation. Both cultural awareness and EI can be learned and further developed; they are essential in providing patient-centered care.
Simulation and gaming are effective instructional methods used with students in health professions (Kanthan & Senger, 2011; Stanley & Latimer, 2011). Since 2003, the National League for Nursing (2015) has supported simulation use to facilitate critical thinking and self-reflection and prepare students for the rapidly changing health care environment. Simulated clinical experiences are readily used in nursing programs, but simulation in nonclinical courses is used much less (Jorm et al., 2016). In a nursing leadership course without a clinical component, we offered a low-fidelity simulation class session focusing on cultural awareness, as it relates to learning about diversity and developing emotional intelligence.
THE BAFA BAFA SIMULATION
Bafa Bafa(C), a simulated learning activity, was developed to help individuals understand the influence of culture on the behavior of people and organizations (Simulation Training Systems, 2017). Studies have found Bafa Bafa increased levels of cultural essentialism and intercultural awareness in higher education students (Fisher, 2011), and it has been used effectively in physical therapy and physician assistant programs (Oliveiria, North, Beck, & Hopp, 2015).
The simulation begins with assigning students to one of two groups, each with different values, expectations, and customs in their new culture. The groups are physically separated into two different rooms. Each group receives written instructions on specific behavioral traits of their group norms. The students assume traits of the assigned new culture during a role-play experience with the support of a faculty facilitator. A student representative from each group then visits the other group and silently observes the behaviors of the group members as they role-play their new culture. The two representatives return to their original groups and report their observations. The faculty facilitator for each group generates a list of the observed culture's characteristics, such as who the leader is, how they greet, what the parameters of personal space and physicality of the culture are, and what their focus of interest is.
In the second encounter, the two groups meet in one room and interact as they role-play their new cultural traits. The groups then return to their separate rooms for debriefing and sharing their experiences, perceptions, and interpretations of the information they received from the observer. Each group compiles an updated list of their perceptions of the values and beliefs of the opposite culture and discusses their personal feelings regarding the interaction experience. Finally, the two groups meet together to discuss how each group developed distorted perceptions resulting from one observer's sharing his or her personal perspective.
The faculty-led debriefing sessions are guided by specific questions/prompts designed to stimulate discussion regarding how perceptions and personal interpretation of an experience may impact subsequent behaviors. The idea of cultural bias and how it makes one feel is addressed in the questions, "What does Bafa Bafa teach us about how we judge, represent, understand, and communicate with those who are different from us?" and "What did you learn about yourself and others during the simulation?" Finally, the discussion focuses on the importance of being mindful of our own emotional intelligence as we interact with others who may be different than ourselves, which is the first step of emotional intelligence - the ability to reflect and become self-aware.
LESSONS LEARNED
We have found the simulation activity to be a meaningful and engaging classroom experience. The Bafa Bafa activity elicits intellectual and emotional factors that influence the reaction to cultural differences. In addition, the activity creates "teachable moments" that are not as evident in a case study discussion nor likely to occur during a lecture presentation. Although Bafa Bafa simulation is a fun, safe, nonthreatening classroom activity, this type of activity can be realistic and intense. Thus, the Bafa Bafa simulation is best used during the latter part of the semester, after students get to know and trust each other.
In our experience, students from each group believed their observations of the other group were underpinned in objectivity. However, student responses during the individual group debriefs were emotionally charged with expressions of discomfort, mocking, and laughter. When asked to reflect on how these observed characteristics would translate to a patient care situation, students were reflective and unsettled as to the outcomes of the simulation. The importance of true cultural humility and students' personal responsibility to engage in respectful and judicious behaviors can be stressed creatively in this simulation.
In our experience, this learning activity has been well received by our students. Students have expressed during the whole-class debrief how surprised they were to fall into "group think" mentality. Student feedback also included a heightened self-awareness to having emotional responses to diverse social scenarios. The ability to relate the activity to their life experiences and future profession made the learning activity more meaningful.
CONCLUSION
The changing demographics and health care landscape requires nurse educators to facilitate ways to increase and develop awareness of diverse cultures. A heightened awareness of variations in societal composition may not be sufficient in the establishment of sensitivity to various cultural experiences. Consequently, emotional intelligence is an additional consideration in the development of instructional strategies aimed at development of cultural awareness.
The Bafa Bafa cross-cultural experience impacts the student's emotions and the opinions and behaviors of the two groups. Experiences with our students highlight the ease in which critical thinking and emotional intelligence can be compromised. In addition, the activity demonstrates to students that objectivity in observation is undermined when viewed in the context of one person's unconscious bias reporting. The findings and report by the initial observer illustrate how an individual's interpretation of an event can contribute to "group thinking," the development of assumptions and behavioral bias. The simulated experience, when coupled with faculty reinforcement of the importance and need to engage in self-reflective practice as a professional nurse, has the potential to extend this experience beyond the classroom.
Nursing instructors should strive to use instructional methods that include interactive activities such as gaming and simulation to bridge the nursing theory-practice chasm. The use of the well-established Bafa Bafa learning activity provides a meaningful and relevant situational learning experience supporting emerging emotional intelligence and enhanced cultural awareness.
REFERENCES